Monica Mangini

Microwave tumors ablation: principles, clinical applications and review of preliminary experiences.

Local ablative techniques have been developed to enable local control of unresectable tumors. Ablation has been performed with several modalities including ethanol ablation, laser ablation, cryoablation, and radiofrequency ablation. Microwave technology is a new thermal ablation technique for different types of tumors, providing all the benefits of radiofrequency and substantial advantages. Microwave ablation has been applied to liver, lung, kidney and more rarely to bone, pancreas and adrenal glands. Preliminary works show that microwave ablation may be a viable alternative to other ablation techniques in selected patients. However further studies are necessary to confirm short- and long-term effectiveness of the methods and to compare it with other ablative techniques, especially RF.

Radiofrequency ablation of intrahepatic cholangiocarcinoma: preliminary experience

The purpose of this study was to evaluate the safety and efficacy of percutaneous ultrasound (US)-guided radiofrequency ablation (RFA) in patients with intrahepatic cholangiocarcinoma (ICCA) in a small, nonrandomized series. From February 2004 to July 2008, six patients (four men and two women; mean age 69.8 years [range 48 to 83]) with ICCA underwent percutaneous US-guided RFA. Preintervetional transarterial embolization was performed in two cases to decrease heat dispersion during RFA in order to increase the area of ablation. The efficacy of RFA was evaluated using contrast-enhanced dynamic computed tomography (CT) 1 month after treatment and then every 3 months thereafter. Nine RFA sessions were performed for six solid hepatic tumors in six patients. The duration of follow-up ranged from 13 to 21 months (mean 17.5). Posttreatment CT showed total necrosis in four of six tumors after one or two RFA sessions. Residual tumor was observed in two patients with larger tumors (5 and 5.8 cm in diameter). All patients tolerated the procedure, and there with no major complications. Only 1 patient developed post-RFA syndrome (pain, fever, malaise, and leukocytosis), which resolved with oral administration of acetaminophen. Percutaneous RFA is a safe and effective treatment for patients with hepatic tumors: It is ideally suited for those who are not eligible for surgery. Long-term follow-up data regarding local and systemic recurrence and survival are still needed.

Complications of microwave and radiofrequency lung ablation: personal experience and review of the literature

PurposeComplications correlated with percutaneous radiofrequency ablation (RFA) and microwave ablation (MWA) of lung tumours were retrospectively reviewed to compare them with data from the literature and to assess risk factors related with the procedures.Materials and methodsFrom January 2003 to January 2009, 29 patients (36 lung lesions) were treated with RFA; from January 2007 to January 2009, 16 patients (17 lung lesions) were treated with MWA. Complications recorded at our institution are reported following the Society of Interventional Radiology guidelines. A systematic review of the literature was performed.ResultsAny major complication of RFA or MWA was recorded. In agreement with the literature, pneumothorax was the most frequent complication, even though the incidence in our series was lower than reported in the literature (3.5% vs. 4.3–18%). Other complications of RFA were pleural effusion and subcutaneous emphysema. No massive haemorrhages, haemoptysis, abscesses, pneumonia, infections or tumour seeding were recorded in our series. The most common complication of MWA was pneumothorax (25% vs. 39% reported in the literature). Pleural effusion was a common reaction, but therapeutic drainage was never required.ConclusionsPneumothorax is the most common complication of both techniques. RFA and MWA are both excellent choices in terms of safety and tolerance.RiassuntoObiettivoScopo del presente studio è stato analizzare retrospettivamente le complicanze registrate nel trattamento termo-ablativo con radiofrequenze (RFA) e con microonde (MWA) di tumori polmonari, confrontarli con i dati riportati in letteratura e valutare i fattori di rischio correlati alle due procedure.Materiali e metodiDa gennaio 2003 a gennaio 2009, 29 pazienti (36 lesioni polmonari) sono stati trattati con RFA; da gennaio 2007 a gennaio 2009, 16 pazienti (17 lesioni polmonari) sono stati trattati con MWA. Le complicanze da noi registrate sono state riportate seguendo le linee guida della Society of Interventional Radiology (SIR). È stata eseguita anche una revisione della letteratura.RisultatiNessuna complicanza maggiore è stata osservata. In accordo con i dati presenti in letteratura, lo pneumotorace è la complicanza più frequente anche se la sua incidenza nella nostra casistica è più bassa (5,8% versus 4,3%–18% in letteratura). Nella nostra casistica, le complicanze post-RFA includono la soffusione pleurica e l’enfisema sottocutaneo. Non è stato osservato nessun caso di emorragia massiva, emottisi, nessuna infezione polmonare, né ascesso né disseminazione tumorale. Anche, nei pazienti trattati con MWA, la complicanza più frequente è stata lo pneumotorace (25% versus 39% riportato in letteratura). La soffusione pleurica è un riscontro frequente, ma in nessun caso è stato necessario il posizionamento di un drenaggio.ConclusioniLo pneumotorace è la complicanza più frequente in entrambe le procedure. La termo-ablazione percutanea, sia RFA che MWA, rappresenta un’ottima opzione terapeutica in termini di sicurezza e tolleranza.

Comparison of Contrast-Enhanced Ultrasound and Computed Tomography in Classifying Endoleaks After Endovascular Treatment of Abdominal Aorta Aneurysms: Preliminary Experience

The purpose of the study was to assess the effectiveness of contrast-enhanced ultrasonography (CEUS) in endoleak classification after endovascular treatment of an abdominal aortic aneurysm compared to computed tomography angiography (CTA). From May 2001 to April 2003, 10 patients with endoleaks already detected by CTA underwent CEUS with Sonovue® to confirm the CTA classification or to reclassify the endoleak. In three conflicting cases, the patients were also studied with conventional angiography. CEUS confirmed the CTA classification in seven cases (type II endoleaks). Two CTA type III endoleaks were classified as type II using CEUS and one CTA type II endoleak was classified as type I by CEUS. Regarding the cases with discordant classification, conventional angiography confirmed the ultrasound classification. Additionally, CEUS documented the origin of type II endoleaks in all cases. After CEUS reclassification of endoleaks, a significant change in patient management occurred in three cases. CEUS allows a better attribution of the origin of the endoleak, as it shows the flow in real time. CEUS is more specific than CTA in endoleak classification and gives more accurate information in therapeutic planning.

Predictive factors for endoleaks after thoracic aortic aneurysm endograft repair

BACKGROUND Our prospective investigation aimed to determine and analyze the incidence and the determinants of endoleaks after thoracic stent graft. METHODS Sixty-one patients affected by thoracic aortic aneurysms were treated between January 2000 and March 2008. The study cohort contained 54 men, with a mean age of 63.6 +/- 17.9 years. The follow-up imaging protocol included chest radiographs and triple-phase computed tomographic angiography performed at 1, 4, and 12 postoperative months and annually thereafter. RESULTS Median follow-up was 32.4 months (range: 1-96 months). Endoleaks were detected in 9 (14.7%) patients, of which 7 were type 1. Five endoleaks were detected at 30 postoperative days, and the other 4 developed with a mean delay of 12 months. Endovascular or hybrid interventions were used to treat the endoleaks. Secondary technical success rate was 100%. Multivariate analysis demonstrated that the diameter of the aneurysmal aorta (odds ratio 1.75, 95% confidence interval 1.07-2.86) and the coverage of the left subclavian artery (odds ratio 12.05, 95% confidence interval 1.28-113.30) were independently associated with endoleak development. The percentages of patients in whom reinterventions were unnecessary were 94.6% +/- 3.0%, 88.3% +/- 4.5%, and 85.4% +/- 5.2%, at 1, 2, and 5 years, respectively. The actuarial survival estimates at 1, 2, and 5 years were 85.2% +/- 4.6%, 78.1% +/- 5.4%, and 70.6% +/- 6.4%, respectively. CONCLUSIONS The diameter of the aneurysmal aorta and the position of the landing zone are independent predictors of endoleak occurrence after thoracic stent-graft procedures. A careful follow-up program should be considered in patients in whom these indices are unfavorable, because most of the endoleaks may be successfully and promptly treated by additional endovascular procedures.

Indications for the use of the Amplatzer vascular plug in interventional radiology

PurposeThis study was undertaken to assess the indications and effectiveness of the Amplatzer vascular plug (AVP) system in interventional radiology.Materials and methodsOver the past year, we selected 12 patients (seven men and five women; mean age 65.8 years, range 45–82) for the occlusion of five internal iliac arteries (in three aortoiliac aneurysms, one internal iliac aneurysm and one isolated common iliac artery aneurysm), two common iliac arteries (in two ruptured abdominal aortic aneurysms), two subclavian arteries (in aortic arch aneurysms) and three splenic artery aneurysms. We used 15 AVPs (splenic artery aneurysms were excluded, with one AVP in the feeding vessel and one in the draining vessel).ResultsWe achieved immediate technical success in 12/12 cases. No rupture or dissection of the treated arteries occurred. During the follow-up (mean 4.6 months, range 3–6) computed tomography (CT) angiography and/or contrast-enhanced ultrasound demonstrated complete artery occlusion and aneurysm exclusion.ConclusionsEase and speed of use combined with precise, controlled delivery justify the growing use of the AVP in interventional radiology. No doubt, the system’s versatility will extend its indications, and larger studies with longer follow-up periods will validate the results achieved so far.RiassuntoObiettivoValutare le possibili indicazioni e l’efficacia del sistema Vascular Plug Amplatzer (VPA) in radiologia interventistica.Materiali e metodiNell’ultimo anno abbiamo selezionato 12 pazienti (7 maschi e 5 femmine), (età media 65,8 anni, range 45–82) per l’occlusione di: 5 arterie ipogastriche (in 3 aneurismi aorto-iliaci, 1 aneurisma dell’arteria ipogastrica e 1 aneurisma isolato dell’arteria iliaca comune), 2 arterie iliache comuni (in aneurismi dell’aorta addominale rotti), 2 arterie succlavie (in aneurismi dell’arco aortico) e di 3 aneurismi dell’arteria splenica. Sono stati utilizzati 15 VPA (gli aneurismi splenici sono stati esclusi mediante 2 VPA a monte e a valle).RisultatiÈ stato ottenuto successo tecnico immediato 12/12 casi. Non si sono verificate complicanze maggiori quali rottura, perforazione o dissezione del vaso trattato. Durante il follow-up (medio 4,6 mesi, range 3–6) il controllo con angio-TC e/o ecografia con MdC ha dimostrato la completa occlusione dei vasi trattati e l’esclusione degli aneurismi.ConclusioniLa rapidità e semplicità di utilizzo e il preciso e controllato rilascio dell’AVP, con immediato successo tecnico, ne giustificano la divulgazione in radiologia interventistica. La versatilità del dispositivo ne amplierà sicuramente le indicazioni con risultati avvalorati da pubblicazioni ulteriori e studi numericamente più ampi e con follow-up più protratto.

Radiofrequency ablation of primary and metastatic lung tumors: preliminary experience with a single center device

BackgroundThis study aimed to assess the feasibility and short-term results for percutaneous radiofrequency ablation in the treatment of primary and secondary lung tumors.MethodsBetween May 2003 and July 2004, 15 patients (mean age, 64.9 years; range, 51–80 years) with 18 pulmonary lesions (9 primitive non–small cell lung cancers and 9 metastases) underwent the ablation procedure. All the patients had absolute contraindications to the surgery. The procedure was performed under computed tomography (CT) guidance with anesthesiologic assistance using a coaxial Le Veen needle electrode. The results were evaluated by postprocedural CT scan, and then by clinical and laboratory examination and CT scan 1, 3, 6, 9, and 12 months after the treatment.ResultsA complete ablation was obtained for 16 of 18 lesions (88.9%), and a partial ablation was achieved for the remaining 2 lesions (central tumors). In terms of complications, there were five cases of pneumothorax (2 resolved spontaneously and 3 were drained through a coaxial needle), four middle pleural reactions, and one hemothorax that required draining surgically. Follow-up evaluation was performed for 16 of 18 lesions. Stability was observed in one of two central tumors that received partial ablation. The remaining 15 tumors that received a complete ablation were followed up for a mean of 5 months (range, 1–12 months). All 15 lesions appeared to be hypodense at the CT examination. Dimension reduction with progressive fibrotic scar formation was observed in seven of seven lesions during a follow-up period of 6 months or more. A recurrence at the site of the treatment for two of three lesions was observed during a 12-month follow-up period. One of these received a second radiofrequency ablation. Five patients experienced systemic disease progression. In four of these five patients, this progression was not associated with recurrence at the site of the treatment.ConclusionRadiofrequency ablation seems to be possible for “nonsurgical” patients with primary and secondary lung tumors. Good results in terms of local tumor control were observed during short-term follow-up evaluation.

Emergency Endovascular Treatment of Abdominal Aortic Aneurysms: Feasibility and Results

PurposeTo assess the feasibility and effectiveness of emergency endovascular treatment of abdominal aortic aneurysms (AAAs).MethodsDuring 36 months we treated, on an emergency basis, 30 AAAs with endovascular exclusion. In 21 hemodynamically stable patients preoperative CT angiography (CTA) was performed to confirm the diagnosis and to plan the treatment; 9 patients with hemorrhagic shock were evaluated with angiography performed in the operating room. Twenty-two Excluder (Gore) and 8 Zenith (Cook) stent-grafts (25 bifurcated and 5 aorto-uni-iliac) were used. The follow-up was performed by CTA at 1, 3, 6, and 12 months.ResultsTechnical success was achieved in 100% of cases with a 10% mortality rate. The total complication rate was 23% (5 increases in serum creatinine level and 2 wound infections). During the follow-up, performed in 27 patients (1–36 months, mean 15.2 months), 4 secondary endoleaks (15%) (3 type II, 2 spontaneously thrombosed and 1 under observation, and 1 type III treated by iliac extender insertion) and 1 iliac leg occlusion (treated with femoro-femoral bypass) occurred. We observed a shrinkage of the aneurysmal sac in 8 of 27 cases and stability in 19 of 27 cases; we did not observe any endotension.ConclusionsEndovascular repair is a good option for emergency treatment of AAAs. The team’s experience allows correct planning of the procedure in emergency situations also, with technical results comparable with elective repair. In our experience the bifurcated stent-graft is the device of choice in patients with suitable anatomy because the procedure is less time-consuming than aorto-uni-iliac stent-grafting with surgical crossover, allowing faster aneurysm exclusion. However, further studies are required to demonstrate the long-term efficacy of endovascular repair compared with surgical treatment.

Treatment of secondary hyperparathyroidism with ultrasonographically guided percutaneous radiofrequency thermoablation.

We present a case of a 63-year-old woman with a recurrent secondary hyperparathyroidism hyperplasia with absolute contraindication for surgery, treated in 2 sessions with percutaneous ultrasonographically guided radiofrequency tissue ablation. The complete pathologic tissue ablation was confirmed by contrast-enhanced ultrasonography performed before and after the treatment and by clinical and laboratory follow-up. Furthermore in work progress, the percutaneous ultrasonographically guided radiofrequency tissue ablation can be considered a feasible and effective nonsurgical alternative treatment for symptomatic secondary hyperparathyroidism in high-risk patients.

Endovascular treatment of steno-occlusions of the infrarenal abdominal aorta.

Purpose.Our aim is to report our experience in the endovascular treatment of steno-occlusions of the infrarenal abdominal aorta.Materials and methods.We selected 19 patients (mean age 66.3 years, range 45–80): five with complete occlusion of the infrarenal aorta and both common iliac arteries (CIAs), four of which were associated with occlusion of the external iliac arteries (EIAs); three with complete occlusion and three with severe stenosis of the distal aorta with occlusion or stenosis of the CIAs and EIAs; and eight with focal severe stenosis of the infrarenal aorta. All patients were treated with direct stenting.Results.Immediate technical success was 94.7% (18/19 cases). We observed two cases of distal embolism treated with thrombolysis, one case of mild renal failure and one case of transient angina abdominis. During the follow-up (mean 19.6 months; range 6–48), 2/18 (11.1%) occlusions of an iliac stent occurred 1 and 3 months after the procedure (treated with local intra-arterial thrombolysis). The primary patency rate was 88.8% and the secondary patency rate was 100%.Conclusions.Direct stenting is a feasible and safe option for the treatment of infrarenal abdominal aortic steno-occlusions, especially in patients at high surgical risk, with good early and late clinical results.