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BACKGROUND Fistula between the esophagus and bronchial artery is an extremely rare and potentially life-threatening cause of acute upper gastrointestinal bleeding. Here, we report a case of fistula formation between the esophagus and a nonaneurysmal right bronchial artery (RBA). CASE SUMMARY An 80-year-old woman with previous left pneumonectomy and recent placement of an uncovered self-expandable metallic stent for esophageal adenocarcinoma was admitted due to hematemesis. Emergent computed tomography showed indirect signs of fistulization between the esophagus and a nonaneurysmal RBA, in the absence of active bleeding. Endoscopy revealed the esophageal stent correctly placed and a moderate amount of red blood within the stomach, in the absence of active bleeding or tumor ingrowth/overgrowth. After prompt multidisciplinary evaluation, a step-up approach was planned. The bleeding was successfully controlled by esophageal restenting followed by RBA embolization. No signs of rebleeding were observed and the patient was discharged home with stable hemoglobin level on postoperative day 7. CONCLUSION This was a previously unreported case of an esophageal RBA fistula successfully managed by esophageal restenting followed by RBA embolization.

AIMS: To evaluate the echogenicity of a commercially available needle, modified on the tip, by comparing two groups of patients undergoing to percutaneous biliary drainage. METHODS: In this retrospective analysis 16 percutaneous transhepatic biliary drainage (PTBD) procedures performed on 16 oncologic patients were evaluated. Patients were randomly divided into two groups of eight subjects each; in the first group, a standard needle was adopted (group A); in the second group, the needle was manually modified to create a rough surface (group B), by scrubbing the tip with an 11 scalpel blade for 150 s all around its surface. To objectively quantify US needle tip visibility, the contrast-to-noise ratio (CNR) was calculated analyzing B-mode images by positioning region of interests in correspondence of needle tip and liver parenchyma. RESULTS: Needle tip echogenicity was significantly higher in group B where the needle tip was modified compared to control group A (p value = 0.014). CNR, considered to objectively evaluate differences among needle tip echogenicity, was significantly higher in group B with respect to control group A (p value = 0.018). CONCLUSIONS: The proposed method, scrubbing a 22 gauge commercially available needle tip with a scalpel blade, represents an effective technique to improve needle visibility during US-guided punctures of the liver.

Uterine arteriovenous malformations are rare but may represent a life-threatening cause of vaginal bleeding. The typical patient affected is a multiparous woman during her thirties. The origin can be congenital or acquired, with the latter being more common after uterine surgery and presenting mainly as arteriovenous fistulous connections into the myometrium supplied by uterine arteries. The correct diagnosis of uterine arteriovenous malformations requires imaging findings of tubular and tortuous structures with mixed signal from arterial and venous flows; transvaginal color-Doppler ultrasound is the initial technique applied, then integrated with contrast-enhanced magnetic resonance or computed tomography. Multiple treatment approaches are available, including conservative-medical, endovascular embolization and surgery. Transarterial embolization represents the most applied, preserving childbearing capacity with negligible procedural complications; clinical and technical success rates are elevated, up to 90%. The goal of embolization is to occlude the point of fistula or the nidus and the application of multiple embolizing agents has been reported: despite there is no clear superiority of one over the others, liquids, especially those related to the dymethil-sulfoxide family, present relevant technical advantages. Surgery is nowadays to be considered when the endovascular approach fails and in these cases hysterectomy remains the common recommendation.

Interventional radiology is continuing to reshape current practice in many specialties of clinical care and the fields of gynaecology and obstetrics are no exception. Imaging skills, clinical knowledge as well as vascular and non-vascular interventional technical ability, are essential to practice interventional radiology effectively. Patient safety is of paramount importance in interventional radiology as in all branches of medicine. Potential failures occur throughout successful procedures and are attributed to a spectrum of errors, including equipment unavailability, planning errors, and communication errors. These are mainly preventable by improved preprocedural planning and teamwork. Of all the targeted and effective actions that can be undertaken to reduce adverse events, the use of safety checklists might have a prominent role. The advantage of a safety checklist for interventional radiology is that it guarantees that human error in terms of forgetting key steps in patient preparation, intraprocedural care, and postoperative care are not forgotten.

The strict correlation between abnormal invasive placentation and postpartum hemorrhage suggests that a widespread antenatal diagnosis of placental anomalies would improve the management of these challenging patients; acting preventive solutions at the moment of delivery reduces blood loss and avoid hysterectomies. The role of endovascular procedures in this field has been encouraged by multiple studies reporting prophylactic uterine arteries embolization and iliac/aortic balloon catheters positioning. This paper aims to review the main imaging diagnostic findings of placental implant anomalies and summarize the principal preventive endovascular strategies proposed in literature.

Interventional radiology plays an established role in the management of many conditions of the female reproductive tract. Since in benign gynecological and obstetric pathologies, as myomas and postpartum hemorrhages, uterine arteries embolization has been already evaluated, this manuscript aims to report on a single-center experience concerning the endovascular management of metrorrhagia caused by gynecological malignancies. Single-center retrospective analysis of thirty patients affected by gynecologic cancer treated with endovascular embolization between January 2016 and December 2018 for acute or chronic metrorrhagia. All patients were in advanced oncological stage (III or IV) with loco-regional spread of the tumor or invasion of pelvic structures, with a poor performance status. They were not suitable for surgery. On initial CT angiography, contrast media extravasation was confirmed in two patients (6.6%), while on DSA examination, tumor stain was displayed in 28 patients (93.4%). In two patients (6.6%) a pseudoaneurysm was reported. Endovascular treatment of metrorrhagia in oncologic patients could be a valid therapeutic alternative, especially when in elderly patients with poor clinical conditions not suitable for surgery. A bilateral and superselective embolization using non-resorbable embolic agents should be performed, except for those cases in which there is infiltration of major vessels causing pseudoaneurysms or fistulas that require embolization.

This manuscript reports on a preliminary experience concerning emborrhoid in patients affected by cirrhotic portal hypertension; furthermore, a novel customized technique of coils release, named “Spaghetti technique,” is described. Five patients with chronic anemia due to internal hemorrhoidal bleeding and cirrhotic portal hypertension were treated. Clinics and hemoglobin values were evaluated to objectively assess clinical conditions up to 3 months follow-up. Embolizations were performed with fibered coils, oversized, released stretched and not packed. Technical success, intended as occlusion of all superior hemorrhoidal artery branches, was 100%. In two patients, inferior hemorrhoidal arteries were embolized too. No patients reported major or minor complications. At 3-month follow-up, clinical improvement was obtained in four of the five patients; hemoglobin values improved or remained stable in the whole sample. Based on this limited experience, emborrhoid seems to be safe and effective at 3-month follow-up to improve symptoms in patients with cirrhotic portal hypertension and chronic anemia due to hemorroidal bleeding; the stretched fashion to release oversized coils provides effective embolization.

High-flow priapism is an incomplete and painless persistent erection caused by trauma. Its diagnosis is performed thanks to clinic and imaging evaluation with detection of fistula/pseudoaneurysm in the cavernous tissue. This paper aims to retrospectively assess the efficacy and safety of superselective arterial embolization in patients with high-flow priapism. From January 2008 to March 2017, nine patients with high-flow priapism have been treated in a single center with embolization. The main etiology was trauma in eight subjects. The patients were evaluated with laboratory examinations and clinical and imaging findings (color Doppler ultrasonography and angiography). The mean follow-up time after embolization was 24 months. Eleven procedures were performed in nine patients: two of them required a second treatment session because of recurrence after 1–2 weeks. Embolic agents were microcoils, microparticles (300–500 μm) and Spongostan. Restoration of erectile function was monitored by clinical and color Doppler evaluation during follow-up. Superselective embolization should be the procedure of choice in patients affected by high-flow priapism; this technique appears to be successful in preserving erectile function. The choice of the embolic agent is crucial, and it should be tailored for each patient.

Purpose: This paper focuses on the role of interventional radiology embolisations in a series of patients presenting with iatrogenic vascular injuries of the lower limbs following orthopaedic interventions. Material and methods: Fourteen patients (mean age: 64 years, range 23-90 years) were retrospectively analysed. Clinical presentation consisted of palpable pulsatile mass, pain, reduced lower limb motion, or visible haematoma; 11 patients had also anaemia (haemoglobin < 7 g/dl). Results: The time between orthopaedic surgery and embolisation ranged between 0 and 67 days (mean: 15 days). Injured arterial vessels were as follows: inferior gluteal artery (2), superficial external pudendal artery (2), deep femoral artery (1), lateral circumflex femoral artery (3), medial circumflex femoral artery (2), articular branch of descending genicular artery (1), perforating femoral arteries (3), posterior tibial recurrent artery (1), and anterior tibial artery (1). The typologies of vascular lesion were: pseudoaneurysm 57%, bleeding with extraluminal contrast agent blush of the terminal arterial segment 36%, and laceration and bleeding with extraluminal contrast agent blush of the arterial main trunk 7%. Embolising agents adopted were microcoils 57%, glue 14%, microplug 7%, particles 14%, and covered stent 7%. In all cases clinical and procedural technical successes were obtained (100%). Conclusions: For the management of vascular injuries occurring after different orthopaedic interventions of the lower limbs, endovascular embolisations have proven to be safe and effective; orthopaedic surgeons should be aware of the support that interventional radiology could provide in the case of iatrogenic vascular complications.

Aim To describe a 3 years experience of peripheral arterial embolization with Micro Vascular Plug (MVP) (Medtronic, USA). Materials and methods The following parameters were investigated: type of vascular injury, anticoagulation therapy at time of procedure, anatomical district, caliper of the target artery, course of the landing zone, additional embolics, technical and clinical success, device related clinical complications. Technical success was defined as complete embolization without deployment of additional embolics after MVP release. Primary clinical success was considered as hemodynamic stability in emergency setting and resolution of the underlying vascular pathology in elective cases; secondary clinical success was considered clinical success after a second embolization session. Results 116 MVP have been released in 104 patients (67 males and 37 females; mean age 61.3 years). The pullback release technique was adopted in each case. 85 patients were treated in emergent settings while in 19 patients the procedure was scheduled. The overall technical success was 75%. Primary clinical success was 96.1%, secondary clinical success 3% and clinical failure 0.9%. No statistical differences in terms of effectiveness were observed among patients assuming anticoagulation (p-value = 0.6). A straight and longer landing zone were statistically associated with higher technical success compared to curved and shorter ones, (p-values Conclusion MVP is a safe and effective embolic agent. While eventual concomitant anticoagulation therapy did not influence the technical outcome, straight course and length of the landing zone are essential parameters to evaluate before deployment.

In the literature, no consensus exists about which CT protocol is to be adopted in patients who underwent high-energy blunt trauma. The aim of the study is to evaluate the additional value of the arterial phase in the CT assessment of vascular injuries of the liver. Admission CT examinations for patients with traumatic injury of the liver due to high-energy blunt trauma, performed between 2011 and 2017 in two major trauma centres, were retrospectively reviewed. Images were analysed for presence or absence of liver parenchymal injury, intrahepatic contained vascular injuries and active bleeding in the arterial and portal venous phase of the CT study. Two hundred twelve patients have been identified. Parenchymal injuries were detected as isolated in 90.6% of cases, whereas they were associated with vascular injuries in 9.4% of cases: contained vascular injuries in 3.3% and active bleeding in 6.1%. Out of all parenchymal injuries detected on the CT portal venous phase, 90.5% were also detectable in the arterial phases (p

Visceral artery aneurysms are very rare and aneurysms of the celiac trunk are the rarest ones: they are in most cases asymptomatic and their detection is frequently incidental. In this article we report the case of a man affected by severe abdominal pain with a huge aneurysm of the celiac trunk, first successfully treated with coil embolization, but, after 10 months, another endovascular embolization was required for deployment of the metallic coils previously released, ahead into the fund of the sac with recanalization of the aneurysm. A second endovascular treatment was performed with other coils and Amplatzer-Plug. The high risk of rupture makes treatment of such aneurysms mandatory and surgery is still considered the gold standard therapy of VAA, but, due to its high morbidity and mortality risks, in the last years, it has been widely replaced by endovascular embolization. An effective endovascular embolization requires not only the complete filling of the aneurysmal sac, but also the complete vascular exclusion of its in-flow and out-flow tracts, to reduce the risk of its anterograde or retrograde reperfusion. Keywords: Celiac artery aneurysm, Visceral artery aneurysm, Endovascular embolization

Accessory spleens are often encountered in radiologic studies and they are not usually associated with symptoms. They could arise from autotransplantation of splenic tissue after splenic trauma or splenectomy (splenosis) [1]. In this case we describe a woman treated for splenectomy 20 years before and subsequently for adhesions, that suffered sudden left upper abdominal quadrant pain, weakness, and pale color. Contrast-enhanced computed tomography revealed free spilling in the abdomen and venous bleeding of a big accessory spleen; thus the patient underwent transcatheter arterial embolization with coils. Due to the 2 previous surgical operations in the splenic loggia, endovascular treatment compared to “open surgery” was the best choice in this case because of determined less complications, a shorter period of hospitalization, and a reduction of health cost. Keywords: Bleeding, Embolization, Accessory spleen, Splenectomy

High-flow arteriovenous malformations (AVMs) are complex vascular lesions for which transcatheter embolization is considered as first-choice treatment nowadays. Multiple embolizing agents have been described, and among them, Onyx® seems to be promising; this is a liquid embolic agent, originally applied in neurointerventional radiology and recently adopted also in peripheral embolizations. The aim of this study is to report on a 10-year experience of transarterial embolization of peripheral high-flow AVM with Onyx® in terms of technical and clinical outcomes. Retrospective analysis was conducted on patients affected by high-flow AVM and treated electively by transarterial embolization with Onyx®. Data collection included: preinterventional clinical radiological evaluations, procedural data and post-procedural clinical radiological assessment. Technical and clinical success was evaluated; follow-up was conducted 30 days after the last treatment session and yearly in case of success. Sixteen patients have been included, totally 38 embolizing procedures. Additional embolizing agents were required in 5 patients. Technical success was obtained in 11 patients; at 30-day follow-up, 15 patients showed improvements in symptoms, even those with incomplete embolization; however, after almost 1 year from treatment accomplishment, 7 patients showed relapse of symptoms and presented radiological signs of AVM recurrence. No clinically relevant complications occurred. In this series, in accordance with previous but limited published data, Onyx® appeared safe and technically effective to embolize high-flow peripheral AVM with transarterial approach. Clinical radiological follow-up is mandatory because new feeder recruitment has to be expected; patients should be informed of the concrete possibility of multiple treatment sessions.

Aim: To describe a three years experience of peripheral arterial embolization with Micro Vascular Plug (MVP) (Medtronic, USA).Materials and methods: 116 MVP have been released in 104 patients (67 males and 37 females; mean age 61.3 years). The pullback release technique was adopted in each case. The following parameters were investigated: angiographic appearance of the vascular injury, anticoagulation therapy at time of procedure, district, caliper of the target artery, course of the landing zone, additional embolics, technical and clinical success.Technical success was defined as complete embolization without deployment of additional embolics.Primary clinical success was considered as hemodynamic stability in emergency setting and resolution of the underlying vascular pathology in elective cases; secondary clinical success was considered clinical success after a second embolization session.Results: Vessel occlusion was achieved in 78 patients after MVP release, while in 26 subjects additional embolics were required; the overall technical success was 75%. Primary clinical success was 96.1%.MVP was oversized between 30% and 40% compared to the target vessel caliper; MVP-3 and MVP-5 were the most frequently adopted in this sampleNo statistical differences in terms of effectiveness were observed among patients assuming anticoagulation. A straight and longer landing zone were statistically associated with higher technical success compared to a curved and a shorter ones, respectively. No clinically adverse events directly related to MVP device occurred; in 3 cases migration was registered without clinical complications.Conclusion: MVP is a safe and effective embolic device. Oversizing is recommended. While eventual concomitant anticoagulation therapy did not influence the technical outcome, straight course and length of the landing zone are essential parameters to evaluate before deployment.

Pseudoaneurysms of the pancreatic and peripancreatic arteries is a well-known complication of chronic or necrotizing pancreatitis due to proteolytic enzymatic digestion of the arterial wall. A major part of peripancreatic pseudoaneurysms involve the splenic artery, but any peripancreatic artery may be involved and bleed. They are potentially life threatening for patients, due to spontaneous intraperitoneal rupture, rupture and fistulization into the surrounding organs, or fistulization into the pancreatic duct. Small ones are usually asymptomatic and are often diagnosed incidentally, while giant (> 5 cm) aneurysms and pseudoaneurysms are symptomatic and may be detected as a pulsatile mass in the upper-left quadrant or epigastrium. Imaging plays a key role in the identification of splenic artery aneurysms and pseudoaneurysms, while angiography still represents the gold standard for the diagnosis, although nowadays it plays a prominent role in treatment. Treatment of splenic artery pseudoaneurysms is mandatory because of the high probability of rupture, with a mortality rate of up to 90%. The gold standard treatment is represented by surgery, with a mortality rate between 16% and 50%. In recent years the endovascular approach has proven to be an effective alternative treatment for splenic artery pseudoaneurysms, and it is currently the method of choice. In this article, we present the case of a ant pseudoaneurysm of the splenic artery due to huge pseudocysts in a young alcoholic patient with recurrent and chronic pancreatitis, complicated by fistulization and invasion of spleen parenchyma and arteriovenous fistula.

Severe postpartum hemorrhage (PPH) occurs in around 1%-2% of deliveries and is a leading cause of maternal mortality and morbidity worldwide. Different treatments of PPH are proposed by the scientific society's guidelines; to date, pelvic artery embolization is an effective therapeutic strategy with the advantages of fast speed, repeatability, and the possibility of future fertility preservation. We compared the different PPH treatments, focusing especially on the role of interventional radiology reviewing pelvic vascular anatomy and emphasizing on the timing of embolization and various clinical conditions of PPH.

The expansion of coronavirus disease 2019 (COVID-19) prompted measures of disease containment by the Italian government with a national lockdown on March 9, 2020. The purpose of this study is to evaluate the rate of hospitalization and mode of in-hospital treatment of patients with chronic limb-threatening ischemia (CLTI) before and during lockdown in the Campania region of Italy. The study population includes all patients with CLTI hospitalized in Campania over a 10-week period: 5 weeks before and 5 weeks during lockdown ( n = 453). Patients were treated medically and/or underwent urgent revascularization and/or major amputation of the lower extremities. Mean age was 69.2 ± 10.6 years and 27.6% of the patients were women. During hospitalization, 21.9% of patients were treated medically, 78.1% underwent revascularization, and 17.4% required amputations. In the weeks during the lockdown, a reduced rate of hospitalization for CLTI was observed compared with the weeks before lockdown (25 vs 74/100,000 inhabitants/year; incidence rate ratio: 0.34, 95% CI 0.32–0.37). This effect persisted to the end of the study period. An increased amputation rate in the weeks during lockdown was observed (29.3% vs 13.4%; p < 0.001). This study reports a reduced rate of CLTI-related hospitalization and an increased in-hospital amputation rate during lockdown in Campania. Ensuring appropriate treatment for patients with CLTI should be prioritized, even during disease containment measures due to the COVID-19 pandemic or other similar conditions.

Purpose: To report our clinical experience with IVUS-guided percutaneous deep vein arterialization (pDVA) to treat chronic critical limb ischemia (cCLI) patients with no-endovascular or surgical options approach due to creation of an arteriovenous fistula (AVF). Materials and Methods: In a 2 years period, 14 no-option cCLI patients were treated with percutaneous deep vein arterialization (pDVA) by creating an AVF with a IVUS-guided system between posterior tibial artery and its satellite deep vein. Technical success was defined as successful AVF creation and venous perfusion of the wound site. Patients’ characteristics, procedure details, mortality and wound outcomes were assessed prospectively. Results: Successful pDVA was successfully performed in all patients (mean age 82 years) without any procedural complications. Clinical improvement was achieved in all patients with resolution of rest pain, tissue formation of granulation tissue or both; only 3 major amputations were performed within the study period with a limb salvage rate of 78%. Median wound healing time was 4.8 months. Conclusion: pDVA is a safe and feasible revascularization technique alternative in no-option cCLI patients.

Background We report our experience in managing iatrogenic renal bleedings after nephrostomic procedures by transarterial embolization using Micro Vascular Plug (MVP) (Medtronic, USA) as single or complementary embolization device with parenchimal sparing. Materials and methods Five patients have been treated in a single center with transarterial embolization because of renal hemorrhages occurring after positioning of nephrostomic drainages. All patients presented with back pain, severe hematuria and/or bright red blood into the nephrostomic bag, with fall in hemoglobin value. After contrast enhanced CT scan confirming arterial active bleeding, rescue embolization was performed using MVP. The renal parenchimal loss was estimated on final postembolization DSA. Creatinine values were monitored before and after the procedure. Results Technical and clinical successes were obtained in all patients. Two patients presented with extraluminal blush, one with multiple pseudoaneurysms, one with pseudoaneurysm with arterovenous fistula, one with extraluminal blush with arterovenous fistula. MVP models were choosen oversized because of vasospasm that would underestimate the effective caliber of target vessel; MVP 3Q and MVP 7Q were adopted in one patient each, while MVP 5Q was released in three cases. MVP was the sole embolizing agent in four patients; in one patient, MVP was employed after microcoils failed to obtain complete embolization. The percentage of renal parenchimal lost was lower than 20%; no increase in Creatinine values was detected at dismission. Conclusions According to proposed data, MVP seems to be a safe, effective and fast embolizing device that interventionalists could consider when facing renal bleedings, even as sole agent.

Pulmonary sequestration is a congenital malformation characterized by dysplastic pulmonary tissue which receives blood supply by arterial systemic system, not in communication with tracheobronchial tree. Although it could be asymptomatic, it can also cause recurrent infections and hemoptysis, rarely massive and fatal. The conventional treatment consists in surgical resection of the pulmonary sequestration, but in the last few years endovascular embolization has been proposed as a valid therapeutic alternative. In this paper, we report the case of a 43–year-old woman affected by recurrent hemoptysis. Computed tomography angiography of the chest, abdomen, and pelvis was performed in emergency setting. Intralobar pulmonary sequestration in the lower lobe of the right lung was found. A bulky aberrant artery originating from the thoracic aorta supplied the pulmonary sequestration. The interventional radiologist performed an endovascular embolization with coils of the vascular malformation. The technical success of the procedure was confirmed by computed tomography angiography of the chest performed on the fourth day after procedure. Further examination performed 6 months later showed no complications. The patient was completely asymptomatic during follow-up. This procedure can demonstrate that arterial embolization is a valid and effective therapeutic alternative to surgical resection in the treatment of pulmonary sequestration.

Demonstrate the role of endovascular management in the treatment of internal mammary artery (IMA) injuries using transcatheter embolization reviewing our 7-year experience. Our retrospective analysis of cases consists of a total of 12 patients (8 M and 4 F; mean age 52 years) who underwent angiographic studies and transcatheter embolization for IMA injuries. Causes of vascular injury were divided in high-energy trauma (n = 6), iatrogenic (n = 3) and penetrating injuries (n = 3). Type of trauma, associated injury, imaging findings, treatments and complications were assessed. Imaging findings included active haemorrhage, pseudoaneurysm and focal dissection. Embolization was performed with microcoils in all patients; complete thrombosis was obtained in four patients by additional injection of Spongostan pledgets and in two patients with 300–500 μm particles. The technical success rate was 100%. No patient died as a direct result of vascular injury; one died of myocardial contusion and one for severe multiorgan failure related to high-energy trauma. No major and minor complications were registered. No patient required emergency surgery or subsequent surgical treatment. Transcatheter embolization offers an effective, efficient and safe alternative to conventional surgical management of IMA injuries.

The aim of this study is to report on a single center experience of managing patients affected by placenta previa major and/or accretism by embolizing uterine arteries immediately before the cesarean delivery to reduce blood loss and secondary the rate of hysterectomies. Sixty-nine patients have been prospectively enrolled. Inclusion criteria were radiological diagnosis of placenta anomalies and risk factors for peri/postpartum hemorrhage. The delivery was electively scheduled between the 35th week and the 36th week of pregnancy. The embolization procedure was performed in the gynecological operating room with a mobile C-arm by injecting calibrated microparticles 500–700 μm. A contrast-enhanced MRI was acquired in a subgroup of 10 patients 6 months after the delivery to evaluate the uterine wall status. Hysterectomy had been performed in 43.5%; 52.2% did not require blood transfusions; 1.2 blood units per patient had been meanly transfused. The mean fluoroscopy beam-on time was 195 s per patient. The mean uterine dose was 26.75 mGy. No pH anomalies were measured from the umbilical cord blood; the Apgar score at 5 min was ≥8. The analysis of the neuro-developmental milestones showed normal cognitive development in all children at 6 months. The uterine wall enhancement evaluated with contrast-enhanced MRI 6 months after the embolization procedure showed preserved myometrial perfusion without area of necrosis. In this series of patients, the predelivery uterine arteries’ embolization was a safe and effective procedure; this may represent a technical alternative that interventional radiologists can consider when facing this challenging scenario.

Uterine arteriovenous fistulas are rare and acquired causes of life-threatening vaginal bleeding. They usually present with intermittent menometrorrhagia in young patients in childbearing age with history of gynecological procedures on uterus. Traditional management is hysterectomy; endovascular embolization represents nowadays an alternative strategy for patients wishing to preserve fertility. Here, the endovascular approach to a 29-year-old woman affected by severe menometrorrhagia caused by a uterine arteriovenous fistula with a concomitant pelvic varicocele is reported; a bilateral uterine arteries embolization with Onyx-18 (ev3, Irvine, CA, USA) has successfully resolved the fistula with clinical success.

This paper reports on the preliminary experience of a single center in the embolization of peripheral AVMs and fistulas with precipitating hydrophobic injectable liquid (PHIL®), focusing on technical aspects and short-term clinical outcomes. Seven males and five females were included in this study, mean age 42.16 years. For ten of them, it was the first embolization treatment; two had been previously treated with Onyx® embolization. PHIL® was injected with a transarterial approach without other embolics during the same procedure. Lesions were localized in small bowel (1), colon (1), head face (5), forefoot (1), uterus (1) and thorax (3); all were symptomatic. After 30-day clinical follow-up, a contrast-enhanced CT or MR was acquired at 3 months from intervention to detect eventual lesion residual. After a single embolization procedure, complete technical success was obtained in 50%, while clinical improvement without additional therapies was appreciable in all patients. No technical failure occurred; in two cases, a small amount of PHIL® proximally refluxed in nontarget vessels without clinical effects. No tattooing effects of superficial lesions neither artifacts at CT and cone-beam CT controls were evident. PHIL® seems to be a safe and effective liquid embolic agent for the treatment of peripheral AVMs and fistulas; although a direct comparison between PHIL and Onyx was not performed, PHIL might present the advantages of reduced artifacts at postprocedural CT scan and no need for shaking time preparation, but it is more expensive due to lower volume of product for each package and slightly less radiopaque at fluoroscopy.

Objective: To evaluate the safety and effectiveness of NOM (nonoperative management) in the treatment of blunt liver trauma, following a standardized treatment protocol. Methods: All the hemodynamically stable patients with computed tomography (CT) diagnosis of blunt liver trauma underwent NOM. It included strict clinical and laboratory observation, 48-72h contrast enhanced ultrasonography (CEUS) or CT follow-up, a primary angioembolization in case of admission CT evidence of vascular injuries and a secondary angioembolization in presence of vascular injuries signs at follow-up CEUS. Results: 181 patients (85.4%) [55 (30.4%) women and 126 (69.6%) men, median age 39 (range 14–71)] were included. Of these, 63 patients (34.8%) had grade I, 48 patients (26.5%) grade II, 39 patients (21.5%) grade III, 21 patients (11.6%) grade IV and 10 patients (5.5%) grade V liver injuries. The overall success rate of NOM was 96.7% (175/181). There was not significant difference in the success rate between the patients with different liver injuries grade. Morbidity rate was 7.4% (13/175). Major complications (2 bilomas, 1 liver hematoma and 2 liver abscesses) were successfully treated by CEUS or CT guided drainage. Eighteen (18/181) patients (9.9%) underwent angioembolization with successful results. Conclusion: Nonoperative management of blunt liver trauma represents a safe and effective treatment for both minor and severe injuries, achieving an high success rate and an acceptable morbidity rate. The angiographic study with embolization, although required only in selected cases of vascular injuries, represents a fundamental therapeutic option in a significant percentage of patients.

Aims: Aim of this study is to describe a multicenter experience on percutaneous transhepatic biliary drainage (PTBD) performed with ultrasound-guidance to access the biliary tree, focusing on safety, effectiveness and radiation dose exposure; differences between right- and left-sided approaches have been also evaluated. Methods: This is a multicenter prospective single-arm observational study conducted on patients affected by biliary tree stenosis/occlusion with jaundice and endoscopically inaccessible. The procedures have been performed puncturing the biliary system under US guidance and crossing the stenosis/occlusion under fluoroscopy. Beam-on time and X-ray dose have been evaluated. Results: 117 patients affected by biliary tree stenosis/occlusion not manageable with an endoscopic approach have been included in this analysis. The biliary stenosis/occlusion was malignant in 90.8% and benign in 9.2%. Technical success, considered as positioning of a drainage tube into the biliary tree, was 100%. Overall clinical success, considered as decrease in total bilirubin level after a single procedure, was 95.7%. The overall mean number of liver punctures to catheterize the biliary tree was 1.57. The mean total beam-on time was 570.4s; the mean dose-area product was 37.25Gycm2. No statistical significant differences were observed in terms of technical and dosimetry results according to right-sided and left-sided procedures. Complications rate recorded up to 30days follow-up was 10.8%, all of minor grades. Conclusions: In this series US guidance to access the biliary tree for PTBD was a safe and effective technique with an acceptable low-grade complications rate; the reported radiation dose is low. Graphic abstract: [Figure not available: see fulltext.].

Purpose: To report on the endovascular management of a patient affected by concomitant left common iliac artery and right superficial femoral artery (SFA) pseudoaneurysms after stent positioning. Case Report: A 77-year-old man affected by severe lower limb atherosclerosis was previously treated with iliac and femoropopliteal Supera stenting procedures; he presented to our emergency department because of bilateral severe claudication recurrence, back pain, and right groin region swelling. Angio-computed tomography (CT) depicted 2 pseudoaneurysms of the left common iliac artery and right SFA, due to stent fracture and stent intussusception, respectively. A 2-step endovascular treatment was planned using bilaterally covered stent-grafts to exclude vascular lesions from blood flow. The devices were successfully deployed without any complication. At 1 month, angio-CT confirmed patency of the implanted stent-grafts showing complete pseudoaneurysm exclusion without leaks. Conclusion: Endovascular approach can be a valid option in the treatment of pseudoaneurysms due to stenting procedure complications.

Background Vascular blowout syndrome (VBOS) is a life-threatening condition secondary to direct tumor encasement or invasion in advanced stage malignancies. Endovascular management can be used as an alternative to surgical treatment in this fragile patient population, providing a minimally invasive measure both acutely and prophylactically. Methods Three patients with peripheral VBOS secondary to advanced stage malignancies underwent successful endovascular treatment. Technical success was obtained in all patients with nonsignificant perioperative complications. Results Endovascular management controlled immediate life-threatening hemorrhage and enabled these high-risk patients to undergo other adjunctive therapeutic modalities. Conclusions Endovascular treatment can offer a safe and effective palliative measure of peripheral VBOS secondary to neoplastic erosion in patients with advanced stage malignancies.

Interventional radiology provides local management of bone metastases (BM) with a palliative intent in most cases, or with a curative intent in selected patients. Its role has rapidly expanded in the last decade, offering new treatment solutions often in combination with surgery, radiation therapy and medical treatments. The aim of the present paper is to increase awareness, acceptance and adoption of interventional radiology procedures for the treatment of BM; and to present the joint position of the Italian College of Musculoskeletal Radiology and the Italian College of Interventional Radiology.

The therapeutical management of low-flow vascular malformations (LFVMs) is challenging because of high recurrence rate; multiple strategies have been proposed. This paper aims to report a single-center experience of direct puncture sclerotherapy of peripheral LFVMs, focusing on technical aspects and clinical outcome in mid-term follow-up. 16 patients have been treated for peripheral LFVMs (mean age 36.1 years), complaining mild pain, swelling of the region of interest, and cosmetic nuisance. Preprocedural US and MR were acquired; angiography performed only in doubt vascular supply. Standard procedure consisted of direct puncture of the nidus using 20–23 gauge needles under US guidance and injection of up to 15 ml foam of sodium tetradecyl sulphate under fluoroscopic guidance. Clinical and radiological follow-up were assessed at 1, 3, and 6 months. Lesions were localized: 8 in the upper and 5 the in lower limbs, 2 in the cheeks, and 1 in the vaginal labia. All procedures have been technically accomplished (100%). At 6 month follow-up, technical and clinical success were obtained in all cases, while radiological follow-up showed 81.2% (13 patients) complete vessels thrombosis after multiple sclerotherapy sessions. No major complications have been recorded; five patients (31.2%) referred minor complications. Sclerotherapy via direct puncture of LFVMs is a clinically effective procedure, well tolerated by patients, with reduced costs and mild minor complications rate; interventionalists should always clarify to the patients that multiple sessions would be performed and recurrences are expected at imaging follow-up despite clinical improvement.

A new detachable microvascular plug (MVP, Reverse Medical®, Irvine, CA, USA) has been recently developed; three models are available according to the size (MVP3–MVP5–MVP7). MVP3 and MVP5 are released through a 0.027″ microcatheter, MVP7 through a 4 Fr catheter. This series aims to describe an initial single-center experience examining intraprocedural safety and technical success of MVP. Ten patients (mean age 55.1 years) have been treated for arterial embolization using MVP; eight extracranial and two intracranial arterial embolizations have been performed. The embolizations were because of: four bleedings, three aneurysms, two pseudoaneurysms, and one presurgical nephrectomy. MVP3 was used in five cases, MVP5 in four cases, and MVP 7 once. In all cases, the MVP was successfully released in

Biliary leakage is a challenging complication when managing the bile duct strictures. The etiology of benign strictures of the biliary tree may have different etiologies but iatrogenic is the most common, with relevant increase after introduction of laparoscopic procedures. Interventional radiologist plays a key role, both in diagnosis and treatment of biliary strictures and leakage. We report on a case of a 39-year-old woman affected by abdominal pain and jaundice after laparoscopic cholecystectomy; jaundice was caused by surgical clipping of the common bile duct. The combined management by surgeon and interventional radiologist, consisting of removal of surgical clip and percutaneous management of biliary leakage, successfully resolved the leakage with clinical success.

Postpartum hemorrhages occur in 5 % of all deliveries. Open surgery and endovascular embolization techniques are the options commonly applied to face this life-threatening scenario. A cost analysis has been performed to compare the standard embolization endovascular approach, performed postpartum in emergency settlement, with a novel proposed preventive embolization approach, and performed in election in selected high-risk patients before the delivery. Two groups have been compared: 46 patients (non-preventive group) and 67 patients (preventive group). The computation of the detailed costs derived from the real costs supported by the hospital, based on the regional tariff in the period considered. The total expense for the 46 patients of the non-preventive group was 640.551,84€ (13.925,04€/patient); all of them received transfusions and 43.4 % underwent to hysterectomy; the total expense for the 67 patients of the preventive group was 509.720,59€ (7.607,77€/ patient); 36 % required transfusions and 26 % underwent to hysterectomy. Overall, in the preventive group, there is a mean saving of 45 %, it else 6.317€/patient. In this sample, predelivery uterine artery embolization has proved to be a cost-effective procedure, reducing the length of the hospital stay and the number of transfers to the intensive care unit, in pregnants with placental implant anomalies.

Pelvic bone fractures in female patients are a result of high-energy trauma and are a significant cause of morbidity and mortality. Their classification is based on the mechanism of the traumatic impact force and the evaluation of stability or instability of pelvic ring fracture. Vascular hemorrhage is frequently associated with pelvic bone disruption and is the main cause of death in polytrauma female patients. At many trauma centers, multidetector computed tomography (MDCT) has been considered the best modality in the trauma setting as it is also useful in characterizing multiple-body traumatic lesions. Specifically, MDCT angiography can lead to fast recognition of pelvic vascular injuries to triage patients with blunt pelvic trauma and to send those with ongoing arterial hemorrhage to appropriate emergent treatment. At contrast medium enhanced MDCT, extravasation of contrast material is an accurate finding of active bleeding and enables the interventional radiologist to selectively investigate the arteries most likely to be involved with prompt angiographic embolization. The potential sites of hemorrhage include the pelvic bone, the pelvic venous plexus, the major iliac veins, the major iliac arteries, and their peripheral branches. MDCT multiphase protocol can accurately differentiate arterial from venous hemorrhage. This article discusses the use of multiphase contrast medium enhanced MDCT in detecting and characterizing vascular pelvic injuries associated with pelvic fractures in trauma female patients.

Purpose To assess the safety and outcomes of uterine artery embolization (UAE) performed before delivery in patients with placental implant anomalies at high risk for peripartum or postpartum hemorrhage. Materials and Methods From January 2013 to January 2015, 50 consecutive patients with placental implant anomalies at 35–36 weeks of pregnancy were recruited. UAE was performed superselectively by injecting reabsorbable pledgets. We applied 5 dosimeters to patients' backs to measure the uterine radiation dose, considered to be the same radiation dose that the fetus received. Newborns were assessed immediately after birth and at 6-month follow-up. Results All procedures were technically successful. Of patients, 64% did not require transfusions. Mean blood units transfused was 0.7 U (range, 0–4 U). No patient was transferred to the intensive care unit. Hysterectomy was performed in 13 patients (26%). Mean fluoroscopy operative time was 3 minutes 42 seconds (range, 1 min 21 s–6 min 58 s), and mean uterine radiation dose was 15.61 mGy (range, 8.15–38.18 mGy). Mean time between embolization and delivery was 6 minutes 4 seconds (range, 4 min 18 s–8 min 12 s). The 1-minute and 5-minute Apgar scores were 8–9 in all newborns; 8 newborns were lost to follow-up at 6 months. A normal cognitive outcome was evident in all 42 children studied. Conclusions UAE before delivery appeared to reduce bleeding during cesarean sections in this consecutive series of patients with placental implant anomalies. In the hands of experienced staff, radiation dose to the fetus was minimal.

Our objective is to describe the results of a multicenter prospective trial on the safety and efficacy of transjugular intrahepatic portosystemic shunts (TIPS) using the Viatorr stent-graft.From 2001 to 2003, 114 patients (75 men and 39 women; mean age, 59.3 years) with portal hypertension underwent TIPS with the Viatorr stent-graft. Indications for treatment were variceal bleeding (n = 49, 43.0%), refractory ascites (n = 52, 45.6%), hypertensive gastropathy (n = 10, 8.8%), Budd-Chiari syndrome (n = 1, 0.9%), and hepatorenal syndrome (n = 2, 1.7%). Eight patients (7.0%) had Child-Pugh class A cirrhosis; 60 (52.6%), Child-Pugh class B; and 46 (40.4%), Child-Pugh class C. Patients were monitored by color Doppler sonography and phlebography.The procedure was successful in 113 (99.1%) of 114 patients; in one patient, creation of the track was not feasible. The mean portosystemic pressure gradient decreased from 21.8 to 8.7 mm Hg. Three minor immediate complications (2.6%) occurred (two cases of self-limiting hemoperitoneum and one extrahepatic portal puncture requiring covered stenting). At a mean follow-up of 11.9 months, the overall mortality rate was 31.0% (35/113), with a 30-day mortality rate of 8.8% (10/113). Mortality was significantly higher in patients in Child-Pugh class C with refractory ascites and with post-procedural encephalopathy. Cumulative primary patency rates were 91.9%, 79.9%, and 75.9% at 6, 12, and 24 months' follow-up, respectively. Restenosis occurred in 15 patients (13.3%) within the stent (n = 8, 53.3%) or at the ends of the portal (n = 1, 6.7%) or hepatic (n = 6, 40%) veins and was solved by percutaneous transluminal angioplasty (n = 11), stenting (n = 3), or parallel TIPS (n = 1). The secondary patency rate was 98.2%. Post-procedural encephalopathy occurred in 27 patients (23.9%).The Viatorr stent-graft is safe and effective in TIPS creation, with high primary patency rates. Covering the entire track up to the inferior vena cava can increase patency.

Gastroduodenal perforation is an emergency clinical situation that usually requires prompt diagnosis and well-timed surgical treatment. An early and precise diagnosis is usually based on detecting the causes and site of gastroduodenal tract perforation. MDCT is now considered the most accurate imaging technique to identify and evaluate gastrointestinal perforation. Several authors have illustrated the direct and indirect CT findings of gastrointestinal perforation, and free extraluminal air has been identified as a major imaging finding for diagnosis of perforation. MDCT is more sensitive than plain radiography in this respect as it can display even very small amounts of extraluminal, intraperitoneal, or retroperitoneal free air. In addition to defining the presence of perforation, MDCT with multiplanar reformation images can localize the perforation site with higher accuracy than CT. In this chapter, we illustrate the characteristic CT findings indicating the presence, localization, and causes of gastroduodenal tract perforation, and we describe the advantages of MDCT with thin-section images and multiplanar reformations in diagnosis of perforation.

In recent years, interest in endovascular foreign bodies (IFB) has greatly increased, as evidenced by the increasingly high casuistry and the growing number of publications on this subject. Surely the increase in interventional procedures can be correlated either as the cause, due to the increasingly higher number of IFB iatrogenic, or to the increasing introduction into clinical practice of a number of techniques for the recovery of these.

The liver is one of the most frequently injured abdominal organs in trauma (about 35–45% of blunt abdominal trauma, 40% of stab wounds, and 30% of gunshot wounds); about 80% occur in men between 20 and 40 years of age [1]. Liver trauma is classified according to the Liver Injury Scale from the American Association for the Surgery of Trauma (AAST), which lists six grades with progressive severity depending above all on two parameters: depth of parenchyma laceration, and the area of hematoma with or without vascular involvement. The diagnostic and therapeutic approach to abdominal and liver trauma has evolved in recent decades, leading to a reduction in deaths [1, 2].

The aim of this study was to evaluate the efficacy and the safety of selective uterine artery embolisation in patients with a high risk of haemorrhage due to obstetric issues. We retrospectively reviewed the angiographic examinations of 63 patients (average age ± SD, 32.6 years ± 4.8), affected by an obstetric disease with a high risk of haemorrhage (22 cases of ectopic pregnancy, 41 of postpartum haemorrhage) and treated with an interventional approach. In particular, we considered the rate of second treatment with interventional technique or conservative or radical surgery, the incidence of postprocedural complications, and the absorbed radiation dose. Immediate technical success, defined as the cessation of active bleeding, was achieved in all cases. Uterine artery embolisation was able alone to control the haemorrhage in 95.24 % of cases. Three patients required a second treatment to achieve haemostasis. No peri- or postprocedural complications were observed. At the 12-month follow-up after embolisation, 22/49 conservatively treated patients were found to be pregnant and successfully completed their pregnancy. Selective uterine artery embolisation allows for safe and complete control of haemorrhage in patients with obstetric disease, with a very low incidence of complications and preservation of fertility.

Postpartum hemorrhage is among the most common causes of maternal morbidity and mortality. Postpartum hemorrhage is defined as a blood loss of greater than 500 mL or any amount that, if not replaced, could cause shock or death in the mother. The most common cause of postpartum hemorrhage is uterine atony. This occurs when the normal myometrium fails to contract after delivery of the placenta. The initial treatment involves the administration of intravenous oxytocin and uterine massage. If the initial maneuvers fail to stop the postpartum hemorrhage, other techniques, such as uterine packing, suture techniques, uterine or hypogastric artery ligation, can be considered. In the last 30 years, a new angiographic approach for treatment of postpartum hemorrhage has emerged. Pelvic arterial embolization, after emerging as a treatment option to control and prevent pregnancy-related hemorrhage, has been established to be safe and effective. The goal of treatment for all causes of postpartum hemorrhage is cessation of bleeding in a timely fashion, before the onset of consumptive coagulopathy and end organ damage.

Vascular injuries are a major source of morbidity and mortality in patients with blunt pelvic trauma. Up to 40% of patients with pelvic fractures related to blunt traumatic injury experience intra-abdominal or intrapelvic bleeding, which is the major determining factor of mortality. Sources of hemorrhage within the pelvis include injuries to major pelvic arterial and venous structures and vascular damage related to osseous fractures. Among patients with pelvic fractures, up to 20% require emergent transcatheter embolization, depending on the type of injury. Angiography is the gold standard for the treatment of pelvic arterial hemorrhage associated with pelvic fractures. Transcatheter techniques provide direct identification of sources of bleeding. Selective catheterization and flow-directed particulate emboli can control bleeding from small arteries at sites of injury.

“You land a million planes safely, then you have one little mid-air and you never hear the end of it” (Air Traffic Controller, New York TRACON, Westbury Long Island).