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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.

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).

Il management del trauma renale ha registrato continue innovazioni grazie al progressivo sviluppo di metodiche di imaging sempre piu accurate; puo variare dal trattamento conservativo — associato o meno a trattamenti adiuvanti, quali embolizzazione o applicazione di cateteri nefrostomici — fino alla nefrectomia.

Intestinal ischemia of the small bowel represents an important diagnostic question to answer in an emergency. Although some findings could be appreciated with basic imaging methods, the MDCT as a modern noninvasive imaging method could be effective in evaluating intestinal disease caused by superior mesenteric artery or vein occlusion and making a diagnosis of ischemia from low-flow states. Looking at the features of the parietal layers with knowledge of the pathologic mechanism underlying the changes from the "normality" could be helpful in making a correct, prompt, and effective diagnosis of intestinal ischemia or disease from impaired venous drainage.

We investigated the role of multidetector-row computed tomography (MDCT) in identifying active bleeding and its source in polytrauma patients with pelvic vascular injuries with or without associated fractures of the pelvis. From January 2003 to December 2007, 28 patients (19 men and nine women, age range 16–80 years) with acute symptoms from blunt pelvic trauma and a drop in haematocrit underwent MDCT and angiography. Conventional radiography of the pelvis was performed in all patients at the time of admission to the emergency department. MDCT was performed with a four-row unit in 15 patients and a 16-row unit in the remaining 13 patients. The study included whole-body CT to identify craniocerebral, vertebral, thoracic, abdominal and pelvic injuries. CT was performed before and after rapid infusion (4–5 ml/s) of intravenous contrast material (120 ml) using a power injector. A triphasic contrast-enhanced study was performed in all patients. MDCT images were transferred to a workstation to assess pelvic fracture, site of haematoma and active extravasation of contrast material, visibility of possible vascular injuries and associated traumatic lesions. At angiography, an abdominal and pelvic aortogram was obtained in all cases before selective catheterisation of the internal iliac arteries and superselective catheterisation of their branches for embolisation purposes. Results related to identifying the source of bleeding at MDCT were compared with sites of bleeding or vascular injury identified by selective pelvic angiography. The sensitivity and positive predictive value (PPV) of MDCT were determined. MDCT allowed us to identify pelvic bleeding in 21/28 patients (75%), with most cases being detected in the delayed contrast-enhanced phase (13/21 cases, 61.9%). Injured arteries were identified on MDCT in 12/21 cases (57%): the obturator artery (n=9), internal iliac artery (n=6), internal pudendal artery (n=6) and superior gluteal artery (n=5) were most frequently injured. In 8/21 patients (28.6%), more than one artery was injured. Among the 12 patients in whom MDCT showed the presence of pelvic haemorrhage, there was agreement between MDCT and angiography in ten cases. Angiography confirmed the site of bleeding detected on MDCT and identified a second arterial haemorrhage in one patient. There was no agreement between MDCT and angiography in the last patient. MDCT showed a sensitivity of 42.85% and a PPV of 100% in identifying the injured arteries. Arterial haemorrhage is one of the most serious problems associated with pelvic fracture, and it remains the leading cause of death attributable to such fractures. MDCT provides diagnostic information regarding the presence of small pelvic fractures and, thanks to the contrast-enhanced angiographic technique, it is capable of identifying pelvic bleeding, with the demonstration in some cases of it source. The presence of contrast material extravasation is an indicator of injury to a specific artery passing through the region of the pelvis where the extravasation is noted on MDCT. Urgent angiography and subsequent transcatheter embolisation are the most effective methods for controlling ongoing arterial bleeding in pelvic injuries.

1. Sanguinamento di pertinenza dell’arteria gastrica sinistra in paziente affetto da neoplasia gastrica. 2. Un cateterismo selettivo dell’arteria gastrica sinistra. 3. Dell’avvenuta embolizzazione dell’arteria gastrica sinistra (“stampo” da bucrilato). 4. L’arteria frenica sinistra.

1. Arteriografia selettiva dell’arteria epatica. 2. Areole di spandimento di mdc a carico dei rami dell’arteria epatica, indice di sanguinamento attivo. 3. Lesione iatrogena di rami dell’arteria epatica durante le manovre di puntura-cateterismo della via biliare per apposizione di drenaggio interno-esterno in paziente itterico per neoplasia della via biliare. 4. Un’embolizzazione selettiva dell’arteria epatica con microspirali attraverso un catetere coassiale.

1. Arteriografia selettiva dell’arteria ipogastrica sinistra in fase precoce, che non evidenzia chiare e definite immagini di sanguinamento attivo. 2. Nella fase tardiva dell’angiogramma lo spandimento di mdc e dovuto ad uno pseudo-aneurisma dell’arteria glutea sinistra. 3. Lo pseudo-aneurisma e intensamente radiopaco per l’accumulo di materiale embolizzante (colla acrilica) misto a Lipiodol. 4. Per evidenziare l’avvenuta esclusione vascolare della lesione al fine di proseguire la procedura, ove necessario.

1. L’arteria ipogastrica destra. 2. La branca ischiopubica, vasi otturatori. 3. Il vasospasmo. 4. L’esclusione vascolare del ramo sanguinante.

1. II porzione duodenale. 2. Arteria epatica destra, originatasi dalla mesenterica superiore. 3. Arcata pancreatico-duodenale. 4. Devascolarizzazione preoperatoria.

1. Aneurisma della branca sinistra dell’arteria polmonare. 2. Angiopneumografia panoramica e successivamente selettiva. 3. Occlusione percutanea con anime metalliche di guide retraibili. 4. La TC.

1. Arteria tiroidea superiore sinistra, che prende origine dalla carotide esterna; tiroidea inferiore, che prende origine dal terzo medio-distale della succlavia; tiroidea ima, che prende origine (quando presente, 6%) tra il tronco brachio-cefalico e la succlavia sinistra (1%) dal tronco brachio-cefalico (3%), dalla carotide comune destra (1%), dalla mammaria interna, succlavia o tiroidea inferiore (1%). 2. Spandimento emorragico nel contesto del parenchima ghiandolare tiroideo. 3. Cateterismo superselettivo dell’arteria tiroidea superiore sinistra con catetere coassiale. 4. Lo “stampo” di colla acrilica dell’arteria tiroidea sinistra.

1. Irregolarita morfologica vascolare dei rami digiunali dell’arteria mesenterica superiore da angiodisplasia. 2. Cateterismo superselettivo di ramo digiunale con tecnica coassiale. 3. Acquisizione senza sottrazione, molto utile per rilevare sanguinamenti. 4. Dell’embolizzazione della malformazione vascolare ottenuta con colla acrilica.

1. Gravidanza ectopica localizzata nella cervice uterina. 2. Ipertrofia dei vasi uterini con una ipervascolarizzazione locale. 3. E stata effettuata un’embolizzazione selettiva delle arterie uterine che ha reso rapida la revisione chirurgica in assenza di perdite ematiche. 4. La successiva infertilita.