Fabio Pozzi-Mucelli

Medical treatment of renal and perirenal abscesses: CT evaluation

AIM A retrospective study of our experience of CT evaluation and follow-up of 16 solitary and multiple renal abscesses treated successfully with antibiotics alone and evaluated with CT at the onset of symptoms and after therapy. MATERIALS AND METHODS Seven patients had a solitary renal abscess, five had multiple renal abscesses and four had renal and perinephric abscess. None of the abscesses were larger than 5 cm. RESULTS In all 16 patients, the CT examination showed total renal and extrarenal regression of the abscesses. In four patients, scarring of the renal outline was observed on follow-up. CONCLUSIONS The study demonstrates the opportunity to avoid aggressive interventional or surgical treatment of renal and perirenal abscesses of 5-cm diameter or less which can completely regress after antibiotic therapy of at least 4 weeks. The CT examination results are important both in the diagnostic phase to establish the extent of the lesions and in the follow-up to check the results of medical treatment.

Delayed CT findings in acute renal infection

The computed tomography (CT) findings in twelve patients with acute renal infection examined immediately and 3 h after i.v. contrast medium are reported. Three patients also had delayed scans at 6 h. Three main features were observed on the delayed scans: 1 a delayed nephrogram with streaky, wedge shaped or round high density areas. The areas of high density were at the same sites of the inhomogeneous areas of reduced density on the early scans; 2 focal contrast medium staining or a rim of increased density around abscesses; 3 focal areas of increased density at sites distant from the low density areas seen on the early scans. It is postulated that the delayed areas of increased density replace early areas of reduced density caused by ischemia due to vasospasm and/or compressing oedema of the vascular bed or by tubular obstruction. Delayed CT appears to be useful because it improves diagnostic confidence and gives a more exact evaluation of the extent of infection.

Percutaneous Management of Renal Artery Aneurysm With a Stent-Graft

A 53-year-old woman presented with systemic hypertension that was not responsive to medical treatment with lacidipine 4 mg. daily. The patient had no risk factors for atherosclerosis. Laboratory results were normal. Abdominal color Doppler ultrasound and selective renal angiography showed fibromuscular dysplasia of the main right renal artery consisting of multiple stenoses and 1 cm. saccular aneurysm (fig. 1). The left renal artery was normal. Various therapeutic options were discussed with the patient, and she elected to undergo an endovascular stent-graft procedure to avoid surgery. The procedure was performed percutaneously via the left axillary artery, in order to obtain a better angle while positioning the stent, through a 7Fr introducer sheath. Heparin 5,000 IU was administered. After renal artery selective catheterization with a multipurpose catheter, the lesion was crossed with a 0.014-inch guide wire. The wire was exchanged via the same catheter with a 0.035-inch Amplatz Super Stiff Guide Wire (Boston, Scientific Corp., Natick, Massachusetts). A 28 mm. Jostent Periphel Stent Graft (JOMED, Helsingborg, Sweden) was then mounted on a 5 40 mm. balloon catheter and advanced through the guide wire. The stent was delivered across the lesion and inflated at 8 atm. for 15 seconds. A final right renal arteriogram showed excellent graft position, aneurysmal exclusion and no sign of residual stenosis (fig. 2). There were no complications, and the patient was discharged home on postoperative day 2 on a regimen of aspirin 100 mg. daily for 3 months. The patient remained normotensive for 10 months. At 24month followup blood pressure was observed in the normal range with amlodipine 5 mg. daily, and serum creatinine was 1.2 mg./dl. (normal 0.4 to 1.3). Color Doppler ultrasound showed wide patency of the renal artery, normal renal perfusion and aneurysmal exclusion.

Delayed CT in acute renal infection

CT scans of the kidneys obtained approximately 3 hours after contrast administration often reveal useful information in patients with renal infections. In this article, we discuss three main features of these delayed scans. Feature 1 shows a nephrogram replacing a variable portion of the low density areas present in the early enhanced phase. The nephrogram can be streaky, band-like, cone or horseshoe-shaped; Feature 2 exhibits a focal staining or a hyperdense rim surrounding microabscesses and macroabscesses; Feature 3, very rare, is characterized by hyperdense areas located far from the lesions detected on early scans. These features make it possible to better define the actual extent of infection and the presence of the edema, improving diagnostic confidence.

Cystic renal tumors: US and CT findings

Cystic renal tumors represent a variety of lesions in which both solid and liquid components coexist. These lesions may be either benign or malignant and include the multilocular cystic nephroma (MCN), the renal cell carcinoma (RCC), and the papillary adenocarcinoma (PAC). The MCN is a rare neoplasm formed of multiple loculated cystic masses divided by septa. The tumor is benign, although there are some rare reports of malignant cases. The RCC and the PAC may appear with cystic patterns. This is rather uncommon for the RCC, which inside has a unilocular or multilocular cystic appearance, if the necrotic component is large. PAC is an infrequent renal tumor, which has a greater tendency to appear as a large mass with a unilocular large cystic space. The ultrasonography (US) and computed tomographic (CT) features of 27 cystic tumors are presented. Both US and CT allowed the recognition of the cystic components, the septa, and the vegetations. The two imaging techniques made it possible to distinguish the tumors into “unilocular” and “multilocular” masses: the former correspond to RCC and PAC, the latter to MCN and RCC. CT added some information on calcified or partially calcified tumors. CT more than US enabled the differentiation between the malignant RCC and the benign MCN for which conservative surgery may be indicated. The two techniques did not allow the differentiation between RCC and PAC, which has different prognostic behavior.

MR angiography versus intra-arterial digital subtraction angiography of the lower extremities: activity-based cost analysis

Purpose.The aim of this study was to analyse the costs pertaining to the radiology department of magnetic resonance angiography (MRA) and intra-arterial digital subtraction angiography (DSA) in the evaluation of arterial disease of the lower limbs.Materials and methods.The differential cost of the two procedures, i. e. the sum of equipment costs (amortisation and service contract), variable costs (supplies and related services) and personnel costs (radiologist, radiographer and nurse) was determined. The common cost (auxiliary personnel and indirect internal costs) was also calculated. Finally, the full cost of the two procedures was obtained (sum of differential and common costs).Results.The differential cost of MRA was 186.14 euro (equipment costs: 50.80 euro, variable costs: 75.04 euro, personnel costs: 60.30 euro) while the differential cost of intra-arterial DSA was 238.18 euro (equipment costs: 57.60 euro, variable costs: 90.13 euro, staff costs: 90.45 euro). The estimated common cost was 5.62 euro. Therefore, the full cost of MRA was 191.76 euro and the full cost of intra-arterial DSA was 243.80 euro (27.1% higher).Discussion and conclusions.Intra-arterial DSA costs more than MRA, mainly because of the higher costs of supplies used during the procedure and higher personnel costs (as a result of the longer duration of intra-arterial DSA). It should be noted that our evaluation considers costs pertaining to the radiology department only. It is evident that an economic analysis considering hospital costs as well would result in much higher costs for DSA if postprocedure hospitalisation is required. Our results cannot be simply exported to other radiology departments since they refer to the technology and organisation adopted in our department. However, our cost analysis model can be easily applied to other environments. MRA provides good diagnostic accuracy in the evaluation of arteries of the lower extremities, and its biological cost is far lower than that of intra-arterial DSA (MRA is noninvasive, it does not use ionising radiation, and the contrast medium is safe). Its lower cost is another argument in favour of the use of MRA instead of intra-arterial DSA in the evaluation of lower-extremity arterial disease.

High-flow priapism (HFP) secondary to Nesbit operation: management by percutaneous embolization and colour Doppler-guided compression

High-flow priapism (HFP) secondary to Nesbit operation: management by percutaneous embolization and colour Doppler-guided compression

Preoperative Vascular Mapping with Multislice CT of Deep Inferior Epigastric Artery Perforators in Planning Breast Reconstruction After Mastectomy

PurposeOur aim was to evaluate the usefulness of computed tomography angiography (CTA) in vascular mapping for planning breast reconstruction after mastectomy using a free flap made with the deep inferior epigastric perforators (DIEP).Materials and methodsWe retrospectively evaluated 41 patients, mean age 57 years, scheduled for mastectomy. CTA was performed with a 64-row scanner (Aquilion 64, Toshiba Medical Systems, Japan), with injection of 100 ml of contrast medium (iomeprol 350 mgI/ml, Bracco, Italy) at 4.5 ml/s. Maximum intensity projection (MIP) and threedimensional volume-rendering (VR) reconstructions were made to mark perforator positions. Presentation frequency, anatomy and artery opacification quality were evaluated.ResultsDIEP were always depicted (n=81) and subdivided according to Taylor’s classification into type I (65%), type II (28%), and type III (7%). We observed a mean of three (range, 1–5) DIEP arteries on the right and two (range, 1–5) on the left side. The superficial inferior epigastric artery (SIEA) was depicted in 6/41 patients, bilaterally in three cases. Opacification was optimal in 30/41 cases, venous contamination due to late arterial phase in eight and low opacification due to early scan in three.ConclusionsStudying DIEP with CTA is useful in the surgical planning of breast reconstruction, even though it requires careful optimisation owing to the critical timing of opacification typical of that vascular district.RiassuntoObiettivoScopo del nostro lavoro è stato valutare l’apporto dell’angio-tomografia computerizzata (angio-TC) nel mapping vascolare per la pianificazione di intervento di ricostruzione mammaria post-mastectomia mediante l’utilizzo di lembo libero confezionato con perforanti dell’arteria epigastrica inferiore profonda (DIEP).Materiali e metodiSono state valutate retrospettivamente 41 pazienti, età media 57 anni, indirizzate alla mastectomia. Le angio-TC sono state effettuate con una TC a 64-detettori durante l’iniezione di 100 ml di mezzo di contrasto (MdC) con flusso di 4,5 ml/s. Sono state effettuate ricostruzioni a proiezione di massima intensità (MIP) e 3D-volume rendering (VR) per individuare le arterie perforanti, delle quali si è valutata la frequenza, l’anatomia e la qualità di opacizzazione.RisultatiLe arterie epigastriche inferiori profonde sono state sempre visualizzate (n=81), classificate secondo Taylor in: tipo I 65%, tipo II 28%, tipo III 7%. Il numero medio di DIEP riscontrato è stato di 3 (range 1–5) a destra e di 2 (range 1–5) a sinistra. L’arteria epigastrica inferiore superficiale (SIEA) è stata visualizzata in 6 pazienti su 41, bilateralmente in 3 casi. La qualità dell’opacizzazione vascolare è stata ottimale in 30 casi su 41, mentre si è registrata sovrapposizione venosa per fase arteriosa tardiva in 8 indagini su 41 ed opacizzazione subottimale per scansione precoce in 3 casi.ConclusioniLo studio dei vasi perforanti con angio-TC rappresenta un utile supporto per la pianificazione dell’intervento di ricostruzione mammaria, ma richiede un’ottimizzazione dell’indagine per la tempistica di opacizzazione critica di tali vasi.

Multimodal approach to the endovascular treatment of embolisation or exclusion of the renal arteries and their distal and/or polar branches: personal experience

PurposeThis study reviews our experience over the last 10 years with procedures of embolisation and/or exclusion of the renal arteries, their parenchymal branches and the polar arteries [renal artery embolisation (RAE)].Materials and methodsTwenty-seven patients (19 men and eight women; age range 37–93 years; mean 74 years) underwent RAE. The indications were: symptomatic gross haematuria in nine patients (33.3%) (tumour-related in seven and iatrogenic in two), symptomatic inoperable renal tumour in five (18.5%), large subcapsular or perirenal haematoma in three (11.1%) and aneurysm of the main renal artery in two (7.4%). Eight patients (29.6%) scheduled for endovascular aneurysm repair (EVAR) of the abdominal aorta underwent prophylactic embolisation of the renal polar branch arising from the aneurysmal sac or the subrenal aortic neck to prevent the possible revascularisation of the sac. Different embolisation agents were used: coils (17 cases), embolisation particles (14 cases), glue (one case), coated stent (two cases) and mechanical occlusion devices (two cases). In 11 cases, two to three different embolisation agents were used together.ResultsTechnical success was achieved in 26/27 patients (96.3%); in one case, embolisation of a polar artery arising from the aneurysmal sac was not possible. One case of gross haematuria recurred 13 months after the procedure and was re-treated with success. There were no cases of major or minor complications.ConclusionsRAE is an effective and minimally invasive procedure in the treatment of neoplastic/iatrogenic symptomatic gross haematuria and in the palliative treatment of inoperable renal tumours. One possible new indication is the prophylactic exclusion of the polar artery arising from the neck or the sac of an abdominal aortic aneurysm in patients who are candidates for EVAR. In our experience, we observed very low morbidity and a short hospital stay. This procedure requires the availability of various materials for performing embolisation and experience in their use.RiassuntoObiettivoScopo di questo lavoro è rivalutare la nostra esperienza degli ultimi 10 anni nelle procedure di embolizzazione o esclusione delle arterie renali (EAR), dei suoi rami parenchimali e delle arterie polari.Materiali e metodiVentisette pazienti (19 maschi e 8 femmine; età 37–93 anni, media 74 anni) sono stati sottoposti a procedura di EAR. Le indicazioni sono state: macroematuria sintomatica in 9 pazienti (33,3%) (tumorale in 7 casi e iatrogena in 2), tumore renale sintomatico inoperabile in 5 pazienti (18,5%), voluminoso ematoma sottocapsulare o perirenale in 3 casi (11,1%) ed aneurisma dell’arteria renale principale in 2 casi (7,4%). In 8 pazienti (29,6%) candidati a posizionamento di endoprotesi aortica addominale (EVAR) si è proceduto alla preventiva embolizzazione del ramo renale polare originantesi dalla sacca aneurismatica o dal colletto sottorenale aortico per prevenire la possibile rivascolarizzazione della sacca. Sono stati utilizzati diversi agenti embolizzanti: spirali (17 casi), particelle embolizzanti (14 casi), colla (1 caso), stent ricoperto (2 casi), occlusore meccanico (2 casi). In 11 casi sono stati utilizzati insieme 2–3 diversi agenti embolizzanti.RisultatiIl successo tecnico è stato ottenuto in 26/27 pazienti (96,3%); in un caso non è stato possibile embolizzare un’arteria polare originante dalla sacca aneurismatica. Un caso di macroematuria ha recidivato a distanza di 13 mesi ed è stato ritrattato con successo. Non si sono verificate complicanze maggiori o minori.ConclusioniL’EAR è una terapia efficace e minimamente invasiva nel trattamento della macroematuria sintomatica neoplastica/iatrogena e nella palliazione di tumori renali inoperabili. Una possibile nuova indicazione è l’esclusione preventiva dell’arteria polare originantesi dal colletto o dalla sacca di un aneurisma dell’aorta addominale in pazienti candidati ad EVAR. Nella nostra esperienza abbiamo osservato scarsa morbilità e breve degenza intraospedaliera. Questa procedura richiede la disponibilità di diversi materiali per effettuare l’embolizzazione ed esperienza nel loro utilizzo.