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Transjugular intrahepatic portosystemic shunt (TIPS) is a nonoperative therapeutic option for the management of portal hypertension, variceal bleeding, recurrent ascites, Budd-Chiari syndrome. In view of the many issues surrounding the use of TIPS, in 1994 the US National Digestive Diseases Advisory Board convened a scientific conference to review the current data available and to establish the indications and controindications for this procedure. However there are still unsolved problems especially short primary patency of the shunt due to intimal hyperplasia, which causes a reduction of the shunt lumen thus favoring a return of the portal hypertension with recurrent variceal bleeding. Several study were performed in the last years to evaluate the efficacy of covered stent in order to reduce shunt disfunction secondary to intimal hyperplasia. PTFE seems to be more efficient in the prevention of restenoses. In our experience more then 100 patients were treated with the Viatorr stent-graft. After a follow-up ranging from 1 to 50 months we reported a 1- year primary patency rate of 83.8%. However the use of the stentgraft is correlate with a high rate of hepatic hencefalopathy (46.6 %). In case of hepatic hencefalopathy refractory to the conventional medical therapy, TIPS reduction should be performed.

Introduction: The development of videolaparoscopic cholecystectomy (VLC) has represented an important achievement in the search for minimally invasive surgical procedures, and especially in the surgical management of such a common and costly disease as cholelithiasis. However, the literature shows that, while VLC carries a similar mortality rate to open surgery, it has a greater incidence (2-5 times) of iatrogenic injury to the biliary tract and hepatic hilum [3, 5, 10, 25, 28]; this incidence further increases in cases of so-called "hard cholecystis" [10, 13, 25, 28, 30]. An equally minimally invasive technique is therefore needed to treat these lesions; this technique should be effective and safe, allow for shorter hospital stays and lower costs, and be made available at all the centres where VLC is performed., Material and Methods: We evaluated 60 patients (28 women and 22 men, age range 41-71) with 24 peritoneal collections (14 bilomas, 10 abscesses), 35 biliary stenosis (clips, chronic-developing lesions), and 2 vascular lesions as direct iatrogenic post-LC injuries. The most frequent clinical symptoms were jaundice, pain, sepsis, abdominal distension, and abdominal colic due to retained common bile duct stones. We carried out 60 percutaneous biliary reconstruction procedures, 44 biliary drainages (4 internal, 4 external), 6 combined radiological-endoscopic approaches with the Rendez-Vous technique, and 2 embolisations., Results: All procedures had 100% technical success; the biliary reconstruction procedures had a 2% morbidity rate (sepsis, cholangitis). The clinical emergencies (choleperitoneum, haemoperitoneum, severe jaundice) resolved in 72 hours for 55 of the 60 patients (92%). The combined percutaneous-endoscopic procedures with the biliary Rendez-Vous technique were successfully performed in 5 out of 6 cases, allowing reconstruction of bile duct continuity and remission of symptoms, without the need to resort to surgical anastomosis. At a recent follow-up of the patients who had been managed only percutaneously, one showed patency of the bile ducts and had the stent removed after 18 months, and two showed optimal functioning of the stent that was still in place after 5 and 8 months respectively; two patients were lost to follow-up. Primary biliary patency at 60 months from biliary reconstruction was 75%. Maximum and immediate dilatation was obtained at the first attempt in most cases. Reoperation was avoided in 59 out of 60 patients. Only one patient with full transection of the common bile duct was reoperated on after insertion of a biliary drainage catheter. The overall length of hospital stays was between 1 and 4 weeks., Conclusions: Interventional radiology carried out according to indications seems to be the most natural way to treat the complications of VLC. It spares the patients, who opted for a minimally invasive technique like VLC, the need to undergo open surgery, and allows for shorter hospital stays and more efficient cost management for the hospital.

Purpose: To evaluate the utility of a trans-brachial access during percutaneous treatment of abdominal aortic aneurysm (AAA)., Material and Methods: Since September 1998, 43 patients with AAA, have been treated using different types of endoprosthesis. A right trans-brachial access was performed in each patient to facilitate catheterization of the controlateral iliac limb and to make the advancement of the aortic device easier and safer. Moreover an angiographic catheter was positioned at renal arteries through the trans-brachial access. Then several angiographic controls were performed to check if the position of the endoprosthesis was correct. The catheterization of the iliac stump was performed using the retrograde technique in 31 cases (72%) and the anterograde one in 12 cases (27.9%)., Results: The percutaneous trans-brachial access was performed successfully in 42/43 patients. Only one case required surgical exposure. The procedure time for the trans-brachial access ranged from 2-12 min (mean 4.5). Trans-brachial access proved extremely useful in facilitating the aortic device advancement when the iliac-femoral axis was sharply angulated. This access allowed an easier catheterization of controlateral iliac limb. It also permitted several angiographic controls to check the correct position of the endoprosthesis. No pseudoaneurysms, no oculo-cerebral disease, no ischemic phenomena were observed during a 29 month follow-up. Only in 2 cases (4.6%) a small hematoma was noticed the day after the procedure., Conclusions: Trans-brachial access proved to be safe and useful during stent-graft positioning.

Eleven patients, included in a series of 105 orthotopic liver transplant recipients, underwent interventional radiologic procedures for post-operative complications. Seven patients had obstructive jaundice, three patients had sepsis, and one patient was bleeding from the T-tube. Cholangiography, performed in 9/11 patients, demonstrated stenosis of the anastomosis in six cases, stenosis of the intrahepatic biliary tree in one case, and stenosis of both tracts in the remaining two cases. Four patients were treated with bilioplasty (from 1 to 5 sessions), using balloon catheters (8-10 mm) followed by stones removal in one case, and by the placement of a metallic stent in another case. The follow-up ranged from one to three years: no biliary stasis occurred, during that period, in these patients. Another patient with recurrent cholangiocarcinoma of the biliary anastomosis, treated with Carey-Coons endoprosthesis and brachytherapy, died four months later without jaundice. In the three patients with sepsis and in the patient with bleeding from the T-tube, intra- or extra-hepatic (in one case) multiple abscesses were demonstrated. The conservative treatment with the placement of percutaneous drainage catheters, associated with internal biliary drainage in two cases, allowed complete symptoms resolution. The technical success obtained in all patients confirmed the effectiveness of interventional radiology in the treatment of biliary complications after liver transplant, thus avoiding the need of surgical reintervention.

This paper reports on an original method to prepare a contrast agent consisting of CO2 microbubbles to be injected i.a. during ultrasound examinations (ultrasound angiography-USA), whose value was investigated in the study of tumor neovascularity in HCC patients. Thirty-five HCC patients underwent USA. CO2 was drawn out from a gas container under pressure and, through a sublimation process, made available in predetermined quantities in test tubes. USA was performed during angiography in 9 cases and immediately before arterial chemoembolization in the other 26 cases. In 51 lesions vascularity was evaluated with conventional angiography, USA and lipiodol CT. USA demonstrated lesion hypervascularity in 91% of cases, as confirmed by lipiodol CT (88%), versus 72.4% of angiography. In 3 of 35 patients USA demonstrated 6 more lesions undetected by other modalities: two of them were proved to be HCC and adenomatous hyperplasia at percutaneous biopsy. USA is a cost-effective procedure, which is easy to perform during conventional angiography: it is more sensitive than conventional angiography in the study of lesion neovascularity and can help plan lesion management, anticipating the results of chemoembolization. The role of USA in the diagnosis and treatment of HCC is, however, still to be defined.

December 1991 through November 1993, fifty-five patients underwent TIPS with the following indications: failed sclerotherapy or surgery (25 patients), bleeding from gastric varices (3 patients), patients waiting for liver transplantation (11 patients) and refractory ascites (9 patients). Seven patients were included in a randomized TIPS vs sclerotherapy trial. The average follow-up of living patients is 4.6 months (range: 1-16 months). The technical success rate was 100%. The portosystemic gradient decreased from 22 mmHg to 10.7 mmHg. After TIPS all patients were followed-up with endoscopic, angiographic and color Doppler examinations and underwent periodic clinical checks. Early (5-day) angiographic follow-up exams showed partial stent thrombosis in 5/32 cases (15.5%) and complete stent thrombosis in 3 cases (9.3%). Late angiographic follow-up exams (1-9 months) showed complete stent occlusion in 2 cases, stent stenosis in 8 cases and hepatic vein stenosis in 5 cases. At present, 37 patients are alive (67%); 5 patients have undergone liver transplantation (9%), and 13 patients died (24%)--3 within 48-72 hours after the procedure and 10 in 1-8 months. Five patients had recurrent bleeding (9%). Ascites was reduced or disappeared in 8/9 cases. Early clinical complications occurred in 12% of cases and were treated with medical therapy. Within one year, signs of encephalopathy developed in 13 patients (23%) and were successfully treated with medical therapy.

The percutaneous treatment of symptomatic renal cysts has grown in therapeutic importance over the last years. The international literature includes many reports on the sclerotherapy of renal cysts with different sclerosing agents. The authors report their experience with the percutaneous treatment of renal cysts by combining pure alcohol and fibrin glue. The glue serves the purpose to seal the walls of the cyst already damaged by alcohol. The results of the combined treatment show that relief of symptoms was obtained in all patients, with no major or minor complications. Complete cyst ablation was obtained only in 16% of cases, while a partial recurrence was seen in 80% of patients, with an average regrowth < 35% of the initial cyst volume. None of these patients presented further symptoms. At present, the follow-up time ranges 3 to 34 months.

From October 1988 to September 1989, 29 self-expanding biliary metallic stents were positioned in 18 patients with recurrent benign biliary strictures, who were no longer candidates to surgical repair and did not respond to percutaneous balloon dilatation. "Z" stent were used in 17 patients and a Wallstent in one case. At four years' follow-up (range: 39-50, average: 46 months), 10 patients remain asymptomatic, without signs of bile stasis (55.5%), five patients had recurrence of symptoms and were subsequently retreated (27.7%) and three patients died from severe underlying diseases, two of them with stent obstruction, one without signs of bile stasis. Recurrences were caused by stent obstruction in three cases. At four years' follow-up the overall patency rate is 68.7%. According to the type of stricture treated, patency is 100% in the group of patients with single CBD stenosis and in the patients with single anastomotic strictures, whereas in all patients with multiple or complicated strictures the stents completely occluded within 4-22 months.

Fifteen patients with squamous cell carcinoma of the uterine cervix--7 in stage II, 6 in stage III and 2 in stage IV--were considered not to respond at the end of radiotherapy. Therefore, the whole patient population underwent bilateral intraarterial chemotherapy with Mitomycin-C (3 cycles, 3-4 weeks' intervals). Patients' responses were evaluated with clinical and CT examinations following irradiation and after completing chemotherapy. Pelvic irradiation was administered by external beams (6 Mv), for a 50-Gy dosage (200 cGy/day for 5 weeks); in 4 cases treatment was completed by means of brachytherapy (192 Ir), with 20-25 Gy dosage. Intraarterial infusion was carried out after positioning the catheters in both uterine arteries; in 5 cases, the internal iliac artery alone was cannulated. At the end of the combined treatment, 2 patients (13%) responded completely, 9 (60%) partially and 4 (27%) not at all. Mean survival was 24 months. No hematologic complication was so severe that treatment had to be discontinued. In 4 patients chemotherapy caused a partially ulcerated skin erythema in the buttocks, which was completely cured in all cases.

We reviewed our personal experience in 46 patients with biliary strictures, who underwent percutaneous balloon dilatation between 1983 and 1988. The strictures were iatrogenic in 24% of the cases, anastomotic in 52%, inflammatory in 17%, and associated with sclerosing cholangitis in 7%. The treatment consisted in dilating the bile ducts with balloon catheters of different kinds and sizes ("bilioplasty") and placing an internal drainage catheter for a varying period of time ("stenting"). In 22 patients the catheter was removed after an average time of 7.7 months. The rate of stricture recurrence was 13.5% (average follow-up: 20 months). In the remaining 24 patients the stents are still in situ, waiting for removing. Major complication rate was 6.4% (2 pleural effusions and 1 hepatic artery bleeding). We also report our initial experience with metallic self-expanding stents which appear as a promising tool in the management of recurring strictures.

Transluminal angioplasty represents an alternative to operation in treatment of arteriosclerotic stenosing and obstructive lesions. The authors report their experience since 1973 with 64 cases treated in the iliac, femoral or popliteal region and 2 cases of stenosis of the renal artery. Arterial tract may be dilated or recanalized depending on stage of the lesion. Patient's follow up with angiography and flow controls showed 70% of success for dilatation and 60% for recanalization at 5 and 4 years respectively. The rate of success and low incidence of complications are particularly encouraging and suggest this type of treatment not only for inoperable high risk patients but also as an elective procedure in well selected patients. Moreover technical facilities and skill of the operator may extend the applicability of angioplasty to treatment of other stenosed segments at the level of renal, coronary and visceral arteries and of iliac veins.

Chemoembolization by selective intra-arterial injection of lipiodol--chemotherapeutic agents (mitomycin and/or adriamycin)--followed by terminal embolization with gelfoam was performed on 20 inoperable patients with hepatic tumors: 13 hepatocellular carcinomas (HCC), 6 metastases from colorectal cancer, and one adenoma. A total of 29 embolizations were performed, 17 of them followed by gelfoam embolization. Significant decrease in tumor size or no tumor increase was shown in 8 patients--6 capsulated and well-limited HCC's, and 2 multinodular HCC's. Apart from occasional episodes of post-embolization syndrome (fever, vomit, abdominal pain), no significant complications were observed. Nine patients died at intervals ranging from 2 weeks to 37 months after the first embolization; in 6 patients the cause of death was not related to the advancing of the cancer, but to the complications of the underlying cirrhosis. In cirrhotic patients, damage to the rest of liver parenchyma can be limited by using superselective catheterization. Of the 6 patients with greater than 12 months follow-up, 4 are alive and 2 have died; 2 more patients are still alive 18 months after the first embolization. Finally, lipiodol was useful as radiopaque marker to detect lesion changes during the follow-up.

Interventional angiography has greatly developed recently, as a consequence of a better definition of clinical indications, the progress and the diffusion of the angiographic techniques and finally as a consequence of the technological improvements of angiographic material and accessories. A synthetic study of the actual technical knowledge and of the perspectives of further improvement, is presented, on the basis of a 10 years' experience, during which more than 500 therapeutical interventions have been performed by means of angiographic techniques.