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To prospectively evaluate the use of a recently developed expanded polytetrafluoroethylene (PTFE)-covered nitinol stent-graft in preventing the need for repeated intervention after transjugular intrahepatic portosystemic shunt (TIPS) creation.Fifty-three consecutive patients underwent TIPS procedures between January 2000 and February 2002. Minimum patient follow-up was 9 months (mean, 16.3 months). Fifty-six stent-grafts were implanted in 53 patients; eight of the devices were 8 mm in diameter and 48 were 10 mm in diameter. The stent length varied from 4 to 7 cm. Indications for the procedure included recurrence of bleeding after sclerotherapy (28 patients with cirrhosis, one patient without), refractory ascites or hydrothorax (21 patients with cirrhosis, one patient without), and Budd-Chiari syndrome (two patients).A technical success rate of 100% was obtained, with an early clinical success rate of 96.2%. During the follow-up period, the recurrence rate was 3.4% (one of 29 patients) for bleeding and 9.0% (two of 22 patients) for ascites. Shunt malfunction occurred in nine of 53 patients (16.9%); in one of these nine patients, shunt occlusion was evident after revision, and a parallel shunt was created. The 1-year primary and secondary patency rates were 83.8% and 98.1%, respectively. In this series, the incidence of encephalopathy (included even as a single short-lived episode) was 47.1% (25 of 53 patients). The 30-day mortality rate was 3.8% (two of 53), and the late mortality rate was 17.3% (eight of 46), excluding seven patients who underwent transplantation.The new PTFE-covered nitinol stent-graft used appears to be excellent in preventing the need for repeated interventions. A primary patency rate of 83.8% and a secondary patency rate of 98.1% were achieved.

It is widly accepted that Fine Needle Aspiration Biopsy (FNAB) is the main test to distinguish benign from malignant thyroid lesions. Nevertheless, this technique presents some limits such as the possibility of false-negative or inadequate samples and it is unable to cytologically discriminate among adenomathosus goiter, follicular adenoma and well-differentiated follicular carcinoma. The aim of this study was to evaluate the possibility of restricting these limitations using Core Needle biopsy (CN) technique. Therefore we selected for CN, 40 out of 136 patients who underwent FNAB during a one year period; among these patients only 32 agreed a to this technique. Forty-two out of 136 patients underwent surgery; 29 of them were subjected to both biopsies. Sixteen of the diagnostic microbiopsies have been histologically confirmed. We had no discordant cases between cytological and microhistological diagnosis, except for one case which appeared cytologically colloid goiter, microhistologically follicular neoplasm and histologically follicular adenoma. In this case it was not possible to microhistologically discriminate benign from malign follicular lesion. In our experience not all patients accepted CN biopsy as well as FNAB and, moreover, this technique showed no advantage over FNAB diagnosis. On this base we think that actually FNAB should be the main procedure in the diagnosis of the thyroid lesions. It is easily performed, accepted by the patients and has a low cost-benefit ratio. If the sample is not diagnostic it can be easily repeated and false-negative cases could be discovered thanks to an adequate clinical and ultrasonographical follow-up of the patients.

Variceal hemorrhage is a leading cause of death in patients with hepatic cirrhosis. We report the case of two cirrhotic patients with hepatocarcinoma in whom oesophageal varices bled repeatedly. Because the bleeding was not controlled by sclerotherapy, vasopressin or Blakemore balloon, the patients were evaluated for emergency transjugular intrahepatic portosystemic shunt. After the procedure, portal vein pressure decreased from 45.5 mmHg to 18 mmHg and from 44 mmHg to 19 mmHg respectively and no filling of varices was evident at venogram or endoscopy. After 16 and 8 months respectively, bleeding had not recurred, and no episodes of encephalopathy were referred. Transjugular intrahepatic portosystemic shunt should always be considered an effective emergency therapeutic alternative to shunt surgery in patients with active variceal bleeding when traditional management fails.

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.

The role of preoperative staging in the treatment of rectal cancer is emphasized. To this purpose, the use of abdominopelvic angio-C.T., which was carried out in 14 cases, is examined. Preoperative staging obtained by this method is compared with the postoperative one assessed by UYCC classification, modified by AYCC. Its diagnostic and prognostic role is evaluated in relation to the other methods. The validity of abdominopelvic angio-C.T. for a correct therapeutic approach is confirmed.

Objectives: Clinical evidence regarding radiological–endoscopic management of intrahepatic bile duct stones is currently lacking. Our aim is to report our 18-year experience in combined radiological–endoscopic management of intrahepatic difficult bile duct stones. Methods: From June 1994 to June 2012, 299 symptomatic patients with difficult bile duct stones were admitted to our institution. Percutaneous transhepatic cholangiography (PTC)/biliary drainage/s was performed, dilating the PTC track to 10 or 16 French within 3–7 days. Afterward we carried out percutaneous transhepatic cholangioscopy (PTCS) with electrohydraulic lithotripsy (EHL) and/or interventional radiology techniques. Follow up was made with clinical/laboratory tests and ultrasound (US). We retrospectively analyzed our radiological–endoscopic approach and reported our technical and clinical outcomes. Results: Complete stone clearance was achieved in 298 patients after a maximum of 4 consecutive sessions. Most patients (64.6%) were treated with PTCS/EHL alone, while the remaining with radiological techniques alone (26%) or a combination of both techniques (13.3%). Recurrence of stones occurred in 45 cases (15%, Tsunoda class III and class IV) within 2 years and were successfully retreated. Major adverse events were: 5 (1.6%) cases of massive bleeding that required embolisation, 2 (0.66%) perforations of the common bile duct and 31 cases (10.3%) of acute cholangitis managed with medical therapy or intervention. Conclusion: After 18 years of experience we demonstrated that our combined radiological–endoscopic approach to ‘difficult bile duct stones‘ may result in both immediate and long-term clearance of stones with a low rate of adverse events.