Giacomo Luppi

Diffusion-weighted lesions after carotid artery stenting are associated with cognitive impairment.

The effect of carotid artery stenting (CAS) on cognitive function is still debated. Cerebral microembolism, detectable by post-procedural diffusion-weighted imaging (DWI) lesions, has been suggested to predispose to cognitive decline. Our study aimed at evaluating the effect of CAS on cognitive profile focusing on the potential role of cerebral microembolic lesions, taking into consideration the impact of factors potentially influencing cognitive status (demographic features, vascular risk profile, neuropsychological evaluation at baseline and magnetic resonance (MR) markers of brain structural damage). Thirty-seven patients with severe carotid artery stenosis were enrolled. Neurological assessment, neuropsychological evaluation and brain MR were performed the day before CAS (E0). Brain MR with DWI was repeated the day after CAS (E1), while neuropsychological evaluation was done after a 14-month median period (E2). Volumes of both white matter hyperintensities and whole brain were estimated at E0 on axial MR FLAIR and T1w-SE sequences, respectively. Unadjusted ANOVA analysis showed a significant CAS*DWI interaction for MMSE (F=7.154(32), p=.012). After adjusting for factors potentially influencing cognitive status CAS*DWI interaction was confirmed for MMSE (F=7.092(13), p=.020). Patients with DWI lesions showed a mean E2-E0 MMSE reduction of -3.1, while group without DWI lesions showed a mean E2-E0 MMSE of +1.1. Our study showed that peri-procedural brain microembolic load impacts negatively on cognitive functions, independently from the influence of patients-related variables.

EUS-guided Nd:YAG laser ablation of a hepatocellular carcinoma in the caudate lobe

Vascular liverinjuries and portobiliary fistulas related to biliary proceduresappear to be a more recognized complication of percutane-ous biliary drainage rather than ERCP. However, this casereport illustrates that if the apparent biliary anatomy looksunusual, particularly if radiographic contrast material washesout from the biliary tree, then entry into the portal vein haslikely occurred, a diagnosis of portobiliary fistula should beconsidered, and stent placement should take place only withcaution. As in this case, if a stent has been placed previously,then further stenting may be needed to occlude the fistula. Inthe occurrence of a portobiliary fistula, biliary stenting viaeither ERCP or percutaneous transhepatic cholangiographyoffers an opportunity to prevent significant hemorrhage andpotential portal sepsis.

Bile Leak Refilling an Intrahepatic Biloma Managed with AMPLATZER Vascular Plug

tumor sizes. Although hysterectomy remains the gold-standard treatment for uterine myomas, it is an unacceptable treatment option for patients who want their uterus to be preserved. For this group of patients, several treatment options exist, including myomectomy and uterine artery embolization. As myomectomy is an invasive surgical procedure, it is associated with the risks of intraoperative blood loss, emergency hysterectomy, cesarean section, and uterine rupture during pregnancy after treatment (3). In patients with submucosal myomas treated with uterine artery embolization, complications of infection and pain during vaginal myoma expulsion have been reported (4). Currently, in cases of submucosal myomas, transvaginal resection with resectoscopy is a good option, but the indications for this technique are limited to small myomas with penetration into the uterine cavity greater than 50% (3). MRgFUS treatment of uterine myomas has clearly demonstrated myoma shrinkage and significant symptom reduction, with only minor complications such as skin burn and nerve heating, which have shown complete improvement with conservative therapy (1). A report of vaginal expulsion of a very large necrotic submucosal myoma after MRgFUS describes removal by hysteroscopy without injury to the uterine endometrium (5). Here we have described successful MRgFUS treatment of an intracavitary submucosal myoma by selective targeting of the stalk connecting it to the uterus, and the resulting disconnection of the myoma, without the need for any additional invasive procedures and without associated complications of infection, pain, or excessive vaginal bleeding during spontaneous expulsion of the myoma. In addition, during the 3-month follow-up period after MRgFUS treatment, the patient experienced decreased menstrual bleeding. In cases of very large submucosal myomas, there may be complications related to the expulsion of the large mass through the vagina, for which a subsequent hysteroscopic resection would be required. The present case suggests the potential exploratory use of MRgFUS for the disconnection of an intracavitary submucosal myoma to the uterine cavity, but further work is required to provide additional knowledge of possible outcomes or complications.

Percutaneous low-dose CT-guided lung biopsy with an augmented reality navigation system: validation of the technique on 496 suspected lesions

PURPOSE To validate a CT-navigation system during percutaneous lung biopsy (PLB). METHODS Four hundred-ninety-six patients underwent low-dose CT-guided PLB. Lesion diameter (LD), procedural time (PT), histologic validity, lesion distance from pleural surface (DPS), needle distance travelled during procedure (DTP), complications and radiation exposure were recorded. RESULTS Hysto-patological diagnosis was obtained in 96.2% cases. Mean PT, DPS, DTP, LD were respectively 29.5min, 12.4mm, 17.9mm, 20.7mm. In cases of major complications (4.6%), higher values of DTP were measured. CONCLUSIONS CT-navigation system allowed a good success in terms of diagnosis in small lesions and when a long DTP is required.

Haemorrhoidal disease in severe portal hypertension: a combined approach with transjugular intrahepatic portosystemic shunt (TIPS) and transanal haemorrhoidal dearterialization (THD).

Haemorrhoidal disease is a common finding in cirrhotic patients (40–44%) [1, 2], as haemorrhoidal plexus is a possible site of porto-systemic venous anastomosis. Portal hypertension (PH) can both exacerbate pre-existent essential haemorrhoidal varices (HV) and cause secondary vascular pathologies, called ano-rectal varices (ARV), particularly in conditions of severely increased hepatic vein pressure gradient (HVPG). Coexisting in up to 30% of cases, ARV are different from HV: as they are mainly due to portal pressure, they usually do not benefit from local therapies, requiring instead a corrective strategy for the underlying PH. Here we report a case of a 45-year-old man, known to have alcoholic Child-B liver cirrhosis, who was admitted to our clinic in March 2011 for severe anaemization (haemoglobin 5.8 g/dl) secondary to persistent rectorrhagia. On admission, he was haemodynamically stable and physical examination evidenced pale skin, tachycardia and tachypnoea, while laboratory results showed microcytic anaemia and severe thrombocytopenia (46 000/µl), and mild elevation of hepatic tests. On anamnestic deepening, he underwent an haemorrhoidal prolapsectomy 15 years earlier and a haemorrhoidal ligature 6 years earlier for persistent symptomatic bleeding haemorrhoids. Moreover, he had a 25-year history of severe alcohol consumption but he had been in a relatively good condition until August 2010, when he received the diagnosis of liver cirrhosis because of the first episode of hepatic decompensation (ascites and encephalopathy). Clinical examination evidenced third-degree haemorrhoids and a pancolonoscopy documented ARV excluding other colonic bleeding lesions, while upper endoscopy showed congestive gastropathy in absence of oesophageal varices. Doppler ultrasonography revealed an increased diameter of the main portal tract (13.5 mm), with preserved hepatopetal flow at reduced mean velocity (10 cm/s). An abdominal computed tomography scan with contrast medium detected a patent ectatic superior mesenteric vein with congestion of the rectal venous plexus and mild perihepatic ascites and splenomegaly (Figure 1). Repeated blood transfusions were prescribed to raise haemoglobin and propranolol in increasing dosage was started to reduce portal hypertension. However, severe rectorrhagia continued so we opted for reducing portal system congestion with a transjugular intrahepatic portosystemic shunt (TIPS). The initial portal venous pressure was 22 mm Hg and the estimated HVPG was 18 mm Hg. Despite reduction of the pressure gradient from 18 mm Hg to 4 mm Hg, rectorrhagia persisted, so surgical intervention for haemorrhoids was suggested. Transanal haemorrhoidal dearterialization (THD) was performed through a dedicated proctoscope, which incorporates a Doppler probe that allows one to identify and to ligate haemorrhoidal arteries and arteriovenous shunts. Transanal haemorrhoidal dearterialization is an innovative mini-invasive technique that has gradually gained in popularity among surgeons since the encouraging initial results reported by Morinaga et al. [3] in 1995. It consists of the Doppler-guided ligation of the terminal branches of the superior rectal artery, which solely contribute to the blood supply of the haemorrhoidal plexus [4, 5], thereby reducing the congestion [6]. The postoperative course was uneventful and the patient was discharged after 5 days. After a 15-month follow-up period, the patient is in good clinical condition, complying with his medical treatment, and the ano-rectal blood loss has not recurred. Figure 1 Coronal contrast-enhanced CT image showing ectatic superior mesenteric vein (white arrow) This case highlights how difficult it can be to diagnose and treat haemorrhoidal disease in cirrhotic patients with severe portal hypertension. The presence of persistent bleeding HV, relapsing after previous local therapies, and of endoscopic-evident ARV, suggested that the severely increased portal hypertension was the real cause of bleeding and of persistence of varices. So, we first reduced portal hypertension with both medical (β-blockers) and interventional (TIPS) techniques, probably achieving a reduction in ARV degree and, when we observed that rectorrhagia persisted, it was clear that blood loss was due to coexistent essential HV, this time. Thus, we treated them with a local mini-invasive technique (THD, previously described). Conventional surgical approaches are usually considered unsuitable in this context [7]: they can worsen portal hypertension after surgical removal of the venous porto-caval shunts, as well as having an increased risk of complications in cirrhotic patients. In conclusion, our experience sheds further light on the relevance of managing portal pressure in case of persistent bleeding and relapsing HV in presence of ARV: TIPS could be performed as the first approach in order to reduce the degree of portal hypertension and to plan, in case of ineffective resolution of ano-rectal bleeding, a mini-invasive surgical procedure with reduced operative risk.

Bilateral transrenal ureteral occlusion by means of n-butyl cyanoacrylate and AMPLATZER vascular plug.

AMPLATZER vascular plug is a widely used embolic agent. In the present paper, we present a case of an 86-year-old female patient who underwent bilateral ureteral occlusion by means of AMPLATZER vascular plug II coupled to n-butyl cyanoacrylate (NBCA) because of recurring pyelonephritis following cystectomy with subsequent bilateral ureterosigmoidostomy (sec. Mainz type II).

Radiofrequency ablation of renal cell carcinoma in patients with a solitary kidney: a retrospective analysis of our experience

PurposeThis study was done to evaluate the feasibility and safety of radiofrequency ablation (RFA) of renal cell carcinomas (RCCs) in patients with solitary kidney.Materials and methodsSeven patients (two men, five women; age range 52–70 years; mean age 59.7 years) were treated under computed tomography (CT) and ultrasound (US) guidance. Three patients had single lesions, and the remaining four had multiple lesions. Seventeen lesions (4 cortical, 13 exophytic, maximum diameter range 12–40 mm, mean 21.0 mm) not located close to the renal pelvis were treated. CT or magnetic resonance (MR) imaging follow-up studies were obtained for all patients at the end of the procedure and at 1, 3, 6 and 12 months; serum creatinine was also monitored.ResultsTen ablation sessions were performed. In two patients, a perinephric haematoma was detected, and one of these patients had two episodes of self-limiting haematuria. Contrast-enhanced CT and MR imaging at the end of the procedure and at 1 month demonstrated 100% technical success; these results were confirmed at 3, 6 and 12 month. Fisher’s test comparing serum creatinine obtained 1 day before and 1 day after the procedure showed no case of acute renal failure (mean serum creatinine 24 h before the procedure 1.02 mg/dl; mean serum creatinine 24 h after the procedure 0.95 mg/dl; p=0.114; not significant). Serum creatinine at follow-up was always within the normal range.ConclusionsRadiofrequency ablation in the solitary kidney is a safe and effective procedure for treating RCC.RiassuntoObiettivoScopo del nostro lavoro è stato valutare l’efficacia e la sicurezza dell’ablazione a radiofrequenza (RFA) del carcinoma renale (RCC) in pazienti con rene solitario.Materiali e metodiSette pazienti (2 uomini e 5 donne; età compresa tra 52 e 70 anni; età media 59,7 anni) sono stati trattati sotto guida tomografica computerizzata (TC) ed ecografica. Tre pazienti avevano una lesione singola; i restanti quattro presentavano multiple localizzazioni. Complessivamente diciassette lesioni (4 corticali e 13 esofitiche, con diametro massimo compreso tra 12 e 40 mm, in media 21 mm) non adiacenti alla pelvi renale sono state trattate. TC e risonanza magnetica (RM) sono state le metodiche scelte per il follow-up al termine di ogni procedura e a distanza di 1, 3, 6 e 12 mesi; sono stati monitorati anche i valori di creatinina sierica.RisultatiIn totale sono state condotte 10 sedute ablative. In 2 pazienti abbiamo riscontrato la presenza di un ematoma peri-renale ed in uno di questi due pazienti sono stati riportati anche 2 episodi di ematuria, regrediti spontaneamente. Il successo tecnico, raggiunto nel 100% dei casi, è stato dimostrato grazie al controllo mediante TC o RM con somministrazione di agente di contrasto al termine di ogni procedura e a distanza di un mese; i follow-up a 3, 6 e 12 mesi hanno confermato questo dato. Nessun caso di insufficienza renale acuta è stato riscontrato dopo aver applicato il test di Fisher comparando i valori di creatinina sierica misurati il giorno prima e il giorno dopo la procedura, (valore medio di creatinina sierica 24 ore prima della procedura: 1,02 mg/dl; valore medio di creatinina sierica il giorno dopo: 0,95 mg/dl; p=0,114, non significativo). I valori di creatinina sierica nei successivi controlli a distanza sono sempre stati nei limiti della norma.ConclusioniLa RFA si è rivelata una procedura sicura ed efficace nel trattamento dei carcinomi a cellule renali nei pazienti con rene solitario.

The Role of White Matter Damage in the Risk of Periprocedural Diffusion-Weighted Lesions after Carotid Artery Stenting

Background: White matter hyperintensities (WMH) are a common finding in aged individuals affected by carotid artery disease and are a risk factor for first-ever and recurrent stroke. We investigated if white matter damage increases the risk of brain microembolism during carotid artery stenting (CAS), as evaluated by the appearance of new areas of restricted diffusion on diffusion-weighted images (DWI). Methods: We evaluated 47 patients with severe internal carotid artery (ICA) stenosis undergoing CAS, comparing preprocedural clinical, ultrasound and radiological characteristics. WMH volume was computed on FLAIR images before CAS. After CAS, the DWI scan was looked over for areas of restricted diffusion (DWI lesions). A first univariate analysis was adopted to compare groups according to the occurrence of DWI lesions. Then, the variable DWI lesion was modelled by means of a logistic regression model. Results: Seventeen patients developed at least 1 DWI lesion after CAS. Compared with non-DWI, DWI patients were more commonly treated in the left ICA (p = 0.007) and had a more severe WMH damage (p = 0.027). Indeed, the risk of a DWI lesion was higher in left versus right stenosis (OR = 9.0, 95% CI 1.9-42.7, p = 0.005) and increased for each log-unit of WMH lesion load (OR = 7.05, 95% CI 1.07-46.49, p = 0.042). A WMH lesion load of at least 5.25 cm3 had a 50% probability of occurrence of a new DWI lesion. Conclusions: Treated side and preexisting white matter damage are risk conditions for brain microembolism during CAS. This should be taken into account to optimize severe carotid artery disease management.

Percutaneous radiofrequency ablation of a bleeding pseudoaneurysm during CT-guided renal cancer treatment. A case report.

We describe a new emergency interventional radiology approach in percutaneous procedure complications. We present the case of an 81-year-old male with small renal cancer, approached with percutaneous radiofrequency ablation (RTA) and complicated by pseudoaneurysm bleeding of a renal artery branch. In the emergency setting, pseudoaneurysm was treated in the CT room by the same RTA needle, without any complications or local tumor recurrence during the next 6-month follow-up.

The Liver as Another Possible Target Organ for Bacillus cereus Infection

A case of liver abscess due to Bacillus cereus infection in an immunocompetent 59-year-old man is reported. Percutaneous drainage and antimicrobial therapy, with vancomycin and levofloxacin afterwards, have been demonstrated to be an appropriate treatment, leading to clinical and radiological cure.