Massimiliano Dizonno

Comparative study of jaws with multislice computed tomography and cone-beam computed tomography

PurposeThe aim of this study was to compare the dosimetric and diagnostic performance of multislice computed tomography (MSCT) and cone-beam computed tomography (CBCT) in the study of the dental arches.Materials and methodsEffective dose and dose to the main organs of the head and neck were evaluated by means of thermoluminescent dosimeters (TLDs) placed in an Alderson Rando anthropomorphic phantom and using a standard CBCT protocol and an optimised MSCT protocol. Five patients with occlusal plane ranging from 54 cm to 59 cm who needed close follow-up (range 1–3 months) underwent both examinations. Image quality obtained with CBCT and MSCT was evaluated.ResultsEffective dose and dose to the main organs of the head and neck were higher for MSCT than for CBCT. Image quality of CBCT was judged to be equivalent to that of MSCT for visualising teeth and bone but inferior for visualising soft tissues. Beam-hardening artefacts due to dental-care material and implants were weaker at CBCT than at MSCT.ConclusionsWhen panoramic radiography is not sufficient in the study of the teeth and jaw bones, CBCT can provide identical information to MSCT, with a considerable dose reduction. MSCT is, however, indicated when evaluation of soft tissue is required.RiassuntoObiettivoScopo di questo lavoro è confrontare le performances dosimetriche e diagnostiche di tomografia computerizzata multidetettore (TCMD) e tomografia computerizzata a fascio conico (TCFC) nello studio delle arcate dentarie.Materiali e metodiSi è provveduto alla misurazione della dose alle strutture di capo e collo e della dose efficace con dosimetri a termoluminescenza (TLD) posti in un fantoccio antropomorfo Alderson Rando utilizzando un protocollo TCFC ed uno TCMD ottimizzato. Sono stati esaminati 5 pazienti, con circonferenza al piano occlusale entro un range prestabilito (54–59 cm) e che avevano necessità di effettuare controlli ravvicinati nel tempo (range 1-3 mesi), con entrambi i sistemi TC ed è stata valutata la qualità delle immagini ottenute.RisultatiLa dose efficace agli organi è superiore per la TCMD rispetto alla TCFC. La qualità delle immagini della TCFC è stata giudicata sovrapponibile alla TCMD nello studio dei denti e dell’osso, inferiore nella valutazione dei tessuti molli. Artefatti da indurimento del fascio dovuti alla presenza di materiale medicamentoso e protesico incidono negativamente sulla qualità dell’immagine maggiormente nel caso della TCMD rispetto alla TCFC.ConclusioniLo studio delle strutture ossee può essere effettuato, se la radiografia ortopanoramica non è sufficiente, mediante TCFC, che fornisce informazioni sovrapponibili a quelle della TCMD con notevole risparmio di dose; la TCMD è indicata qualora sia necessario valutare anche i tessuti molli.

Radiofrequency thermal ablation for pain control in patients with single painful bone metastasis from hepatocellular carcinoma

OBJECTIVE The aim of this study was to assess the safety and the efficacy of radiofrequency thermal ablation (RFA) for pain relief and analgesics use reduction in two patients with painful bone metastases from hepatocellular carcinoma (HCC). MATERIALS AND METHODS Two patients with lytic metastases from HCC located at the left superior ileo-pubic branch and at the middle arch of VII rib, performed RFA displacing a LeVeen Needle (3.5 and 4.0 cm diameter) under US (ultrasonography) and fluoroscopic guidance. Two methods were used to determine the response of both patients: the first method was to measure patients worst pain with a Brief Pain Inventory (BPI) 1 day after the procedure, every week for 1 month, and thereafter at week 8 and 12 (total follow-up 3 months); the second method was to evaluate patients analgesics use recorded at week 1, 4, 8 and 12. Analgesic medication use was translated into a morphine-equivalent dose. RESULTS The RFA were well tolerated by the patients who did not develop any complication. Both patients obtained substantial reduction of pain, which decreased from a mean score of 8 to approximately 2 in 4 weeks. In both patients we observed a reduction in the use of morphine dose-equivalent after a peak at week 1. CT (computed tomography) imaging, performed at 1 month after RFA, demonstrated that both procedures were technically successful and safe because consistent necrosis and no evidence for complications were observed. CONCLUSION RFA provides a potential alternative method for palliation of painful osteolytic metastases from HCC; the procedure is safe, and the pain relief is substantial.

Percutaneous treatment of complete chronic occlusions of the superficial femoral artery.

PurposeThis study was done to evaluate the mid-and long-term patency rates of complete (from the origin to Hunter’s duct) chronic occlusions of the superficial femoral artery (SFA) treated by angioplasty and/or stenting.Materials and methodsFrom February 2002 to March 2005, 21 patients with complete occlusion of the SFA and good distal runoff (two or three patent vessels) were treated with endovascular recanalisation. All patients had severe claudication or critical limb ischaemia. In all cases, recanalisation was performed with a contralateral approach by percutaneous transluminal angioplasty (PTA), with stenting only when PTA provided unsatisfactory results (due to elastic recoil and complications such as dissection). In the case of calcified occlusions and when the true lumen of the SFA could not be crossed, subintimal angioplasty was performed. Follow-up was done at 6 and 12 months and annually thereafter (range 6–55 months, mean 23 months) with clinical evaluation and colour-Doppler ultrasound.ResultsImmediate technical success was achieved in all cases (100%), with postprocedural angiography demonstrating complete recanalisation of the SFA. Two distal embolisations (9.5%) occurred, both treated successfully by local thrombolysis. Primary patency rates at 6, 12, 24, 32 and 44 months were 93.3%, 69.2%, 72.7%, 62.5% and 40%, respectively; secondary patency rates at 6, 12 and 24 months were 100%, 84.6% and 81.8%, respectively.ConclusionsPercutaneous treatment of complete chronic occlusions of the SFA showed good mid-and long-term primary patency rates, with few periprocedural complications. Reocclusions can be treated by a percutaneous technique, which ensures a good secondary patency rate.RiassuntoObiettivoValutare la pervietà a medio-lungo termine delle occlusioni croniche complete (estese dall’origine sino al canale di Hunter) dell’arteria femorale superficiale (AFS) trattate mediante angioplastica (PTA) e/o stenting.Materiali e metodiLo studio include 21 pazienti con occlusione completa dell’AFS e buon run-off distale (2 o 3 vasi pervi) sottoposti a ricanalizzazione endovascolare nel periodo compreso tra febbraio 2002 e marzo 2005. Tutti i pazienti erano sintomatici con claudicatio severa o ischemia critica. In tutti questi casi la ricanalizzazione è stata effettuata con approccio controlaterale cross-over mediante angioplastica transluminale (PTA) e stenting solo nelle evenienze in cui la PTA ha fornito risultati insoddisfacenti, per ritorno elastico di parete (recoil) e complicanze tipo dissezione; nelle occlusioni in prevalenza calcifiche e nei casi in cui non si è guadagnato il lume vero dell’AFS, è stata utilizzata la tecnica di angioplastica subintimale. Il follow-up è stato condotto mediante valutazione clinica ed eco-color-Doppler a 6, 12 mesi, e successivamente annualmente (range da 6 a 55 mesi, valore medio: 23 mesi).RisultatiIl successo tecnico immediato è stato ottenuto in tutti i casi (100%), con ricanalizzazione completa dell’arteria femorale superficiale documentata al controllo angiografico post-procedura. Si sono verificate 2/21 embolie distali (9,5%), trattate con successo mediante trombolisi loco-regionale. Il tasso di pervietà primaria a 6, 12, 24, 32 e 44 mesi è stato, rispettivamente, del 93,3%, 69,2%, 72,7%, 62,5% e 40%; il tasso di pervietà secondaria a 6, 12 e 24 mesi del 100%, 84,6% e 81,8%.ConclusioniLa ricanalizzazione percutanea delle occlusioni croniche complete dell’AFS, nella nostra serie, ha mostrato buoni tassi di pervietà primaria e secondaria a medio e lungo termine con un basso tasso di complicanze periprocedurali; le ri-occlusioni possono essere trattate con tecnica percutanea, che garantisce un soddisfacente tasso di pervietà secondaria.

Fluoroscopically guided retrograde replacement of ureteral stents

PurposeWe assessed the feasibility of fluoroscopically guided transurethral replacement of ureteral stents as an alternative to cystoscopy.Materials and methodsOver the last year, we replaced 27 double-J ureteral stents in 20 patients (10 men and 10 women; mean age 67.7 years, range 43–83); 15/20 patients had a native kidney, 3/20 had a transplanted kidney and 2/20 had a ureteroileal conduit. The procedures were performed in the angiography suite with the patient under sedation. All stents were grasped with a gooseneck snare under fluoroscopic control, and the distal end was withdrawn just outside the urethra; then a wire was advanced through the stent lumen and positioned in the renal pelvis. The stent was then removed and replaced with a new double-J stent.ResultsThe procedures were successful in 26/27 cases. We observed 7 cases of mild haematuria that resolved spontaneously. During follow-up (1–16 months, mean 6.7), stent obstruction occurred in 4 cases, requiring an additional retrograde replacement.ConclusionsTransurethral fluoroscopically guided retrograde replacement of dysfunctioning ureteral stents is an effective and safe alternative to cystoscopy.RiassuntoObiettivoValutare la fattibilità della sostituzione transuretrale con guida fluoroscopica degli stent ureterali, come alternativa alla cistoscopia.Materiali e metodiNel corso dell’ultimo anno abbiamo sostituito 27 stent ureterali in 20 pazienti (10 maschi e 10 femmine; età media 67,7 anni, range 43–83); 15/20 in reni nativi; 3/20 in pazienti portatori di trapianto renale e 2/20 in pazienti con uretero-ileo-cutaneostomia. Le procedure sono state espletate in sala angiografica in sedazione. Tutti gli stent sono stati agganciati per via transuretrale utilizzando un catetere “gooseneck”; l’estremo distale dello stent è stato quindi retratto al di fuori del meato uretrale. Successivamente è stato introdotto un filo guida attraverso lo stent posizionandolo nella pelvi renale. Quindi lo stent è stato rimosso e sostituito con un nuovo stent 8F doppio J.RisultatiLa procedura è riuscita tecnicamente in 26/27 casi. Abbiamo osservato 7 casi di ematuria moderata, a risoluzione spontanea. Durante il follow-up (1–16 mesi, medio 6,7) abbiamo osservato 4 occlusioni di stent, sostituiti sempre per via retrograda con guida fluooscopica.ConclusioniLa procedura è una sicura ed efficace alternativa alla cistoscopia per la sostituzione retrograda degli stent ureterali non funzionanti.

“Full metal jacket” with direct stenting of complete chronic occlusions of the superficial femoral artery

PurposeThis study evaluated the short- and midterm patency of complete total occlusions of the superficial femoral artery (SFA) treated with direct stenting.Materials and methodsFifty-two consecutive patients (36 men and 16 women; mean age 73.6 years; range 58–85) with chronic complete SFA occlusion and good distal run-off (two or three patent vessels) underwent endovascular recanalisation by direct stenting. All patients were symptomatic (severe claudication or critical ischaemia). Recanalisation was achieved by using a contralateral approach in 44 patients and an ipsilateral antegrade access in eight patients. A total of 152 nitinol stents were used: three stents in 32 cases, four stents in eight cases and two stents in 12 cases. Follow-up consisted of clinical evaluation and colour Doppler ultrasound at 6, 12, 18 and 24 months.ResultsThe immediate technical success rate was 100%, with complete SFA recanalisation documented on postprocedural angiography. Four cases of distal embolism occurred, which were treated successfully with intra-arterial thrombolysis. During the follow-up, 12 reocclusions were observed: eight were treated with mechanical thrombectomy and in-stent angioplasty, and four were converted into femoropopliteal bypasses. The primary patency rates at 6, 12, 18 and 24 months were 92.3%, 76.9%, 69.2% and 69.2%, respectively. The secondary patency rates at 6, 12, 18 and 24 months were 100%, 100%, 92.3% and 92.3%.ConclusionsThe percutaneous treatment of chronic complete SFA occlusions yielded good primary and secondary patency rates in the short and medium term, with few periprocedural complications. Reocclusions were treated using the percutaneous technique, which guarantees a good secondary patency rate.RiassuntoObiettivoScopo del nostro lavoro è stato valutare la pervietà a breve-medio termine delle occlusioni complete e totali dell’arteria femorale superficiale (AFS) trattate mediante direct stenting.Materiali e metodiCinquantadue pazienti consecutivi (36 uomini e 16 donne; età media 76,3 anni; range 58–85) con occlusione completa dell’AFS e buon run-off distale (2 o 3 vasi pervi) sono stati sottoposti a ricanalizzazione endovascolare mediante direct stenting. Tutti i pazienti erano sintomatici (claudicatio severa o ischemia critica). In 44 casi è stato utilizzato l’approccio controlaterale; in 8 casi è stato utilizzato l’approccio anterogrado. Sono stati utilizzati 152 stents in nitinol: in 32 casi 3 stents, in 8 casi 4, in 12 casi 2. Il follow-up è stato condotto tramite valutazione clinica ed eco-color doppler a 6, 12, 18 e 24 mesi.RisultatiIl successo tecnico immediato è stato del 100% con ricanalizzazione completa dell’AFS documentata al controllo angiografico post-procedura. Si sono verificat 4 casi di embolia distale, trattati mediante trombolisi locoregionale. Durante il follow-up sono state riscontrate 12 riocclusioni: 8 trattate con trombectomia meccanica ed angioplastica intrastent, 4 convertite in by-pass femoropopliteo. Il tasso di pervietà primaria a 6, 12, 18 e 24 mesi è stato, rispettivamente, del 92,3%, 76,9%, 69,2% e 69,2%. Il tasso di pervietà secondaria a 6, 12, 18 e 24 mesi è stato del 100%, 100%, 92,3% e 92,3%.ConclusioniIl trattamento percutaneo delle occlusioni croniche complete dell’AFS, nella nostra serie, mostra buoni tassi di pervietà primaria e secondaria a brevemedio termine con un basso tasso di complicanze periprocedurali. Le riocclusioni possono essere trattate con tecnica percutanea, che garantisce un buon tasso di pervietà secondaria.