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Epiphora is a relatively common ophthalmologic affection representing almost 5% of clinical consultations in ophthalmology and it consists in the complete or partial obstruction of nasolacrimal duct, leading to insufficient drainage of tears. The traditional treatment is represented by surgery namely, external dacryocystorhinostomy (DCR). Despite the high success rate DCR has many disadvantages and limitations since it requires general anesthesia, it may arise in a permanent facial scar and it is often affected by the reobstruction of the anastomotic tract by fibrotic scars and osteogenic activity. Fluoroscopically guided interventional procedures are a therapeutic alternative to surgery for lacrimal duct system obstructions that can consist either in balloon dacryocystoplasty or in nasolacrimal stent placement. In both cases, a pre-operative imaging characterization of the occlusion is needed for a correct treatment planning. In this review, we propose to highlight the role of interventional radiology in the treatment of epiphora and the role of computed tomography dacryocystography (CTD) in depiction and the pre-interventional planning.

Background: In oncologic field, thermo-ablative procedures have spread more and more. Percutaneous microwave ablation (MWA) showed same benefits and some advantages over radiofrequency ablation (RFA). To date, a disadvantage of both was the not totally predictable size and shape of ablation volume. The aim of this study was to assess feasibility and safety of MWA in nonresectable pancreatic head cancer using a new technology of MW with high power (100 W) and frequency of 2,450 MH. Methods: Five patients with pancreatic head cancer treated with percutaneous MWA under ultrasound guidance were retrospectively reviewed. Mean lesion diameter was 27.8 mm (range, 25–32 mm). Follow-up was performed by CT after 1, 3, 6 and, when possible, 12 months. The shape of the ablation volume was evaluated with multiplanar reformatting (MPR) using roundness index (RI): a value near 1 represents a more spherical ablation zone shape, and a value distant from 1 implies an oval configuration. Ablation and procedure times were registered, together with hospital stay. The feasibility, safety and quality of life (QoL) were reported. Results: The procedure was feasible in all patients (100%). A spherical shape of ablation zone was achieved in all cases (mean RI =0.97). Mean ablation and procedure time were respectively of 2.48 and 28 minutes. Mean hospital stay was 4 days. No major complications were observed. Minor complications resolved during the hospital stay. An improvement in QoL was observed in all patients despite a tendency to return to preoperative levels in the months following the procedure. Conclusions: Percutaneous MWA is a feasible and safe approach for the palliative treatment of advanced stage tumors of the head of the pancreas, despite its complex anatomic relations. The spherical shape of the ablation volume could be related with an improving of the effectiveness and safety.

Less than 1% of patients with liver metastases from neuroendocrine tumors (NETs) are susceptible to liver transplantation. We report a case of a patient transplanted 13 years ago for NET metastases, with a lesion histologically proved for NET metastasis located at the cava vein anastomosis. He was treated with percutaneous radiofrequency ablation (RFA) after a first failed attempt of endovascular approach. The vascular heat sink, which RFA is susceptible to, was considered an advantage in this case, since it restricted the propagation of heat only to the tissue located in the very proximity of the RFA antenna, protecting the inferior vena cava vessel walls. This positive result may suggest an additional use of RFA in selected challenging cases.

Symptomatic obstruction related to malignant involvement of large veins may occur in central veins both in the thoracic and pelvic regions, and in the abdominal region of the body. Both cases represent a therapeutic challenge, and endovascular revascularization, consisting of angioplasty and stent placement, is safe and effective. Superior vena cava stenting has become widespread in the management of occlusive venous disease. The percutaneous placement of large expandable metal stents allows rapid restoration of normal blood flow in the majority of patients, thus improving symptoms. Published data on the diagnosis and treatment of symptomatic cancer-related iliocaval obstructions are limited and mainly consist of case reports and small case series. The present review reports the current state of endovascular treatment for both superior vena cava occlusion and iliac compression syndrome in cancer patients.

Prostatectomy via open surgery or transurethral resection of the prostate (TURP) is the standard treatment for benign prostatic hyperplasia (BPH). Several patients present contraindication for standard approach, individuals older than 60 years with urinary tract infection, strictures, post-operative pain, incontinence or urinary retention, sexual dysfunction, and blood loss are not good candidates for surgery. Prostatic artery embolization (PAE) is emerging as a viable method for patients unsuitable for surgery. In this article, we report results about technical and clinical success and safety of the procedure to define the current status.

Background: Thyroid nodules are very common in general population. Even if benign, they may require a treatment in case of symptoms or cosmetic concerns. In the last years, minimally invasive treatments alternative to surgery have been developed, in particular ultrasound (US) guided radiofrequency ablation (RFA).\ud \ud Methods: Twenty-four patients (9 males; 15 females; mean age 57.9 years) were treated and divided in two groups (A and B) according to the RFA needle used (18 gauge needle, AMICA; 17 gauge needle, COVIDIEN). Nodules and patients characteristics, together with procedural data were registered pretreatment and at 1-month follow-up. US visibility of the needle, volume of the nodules, symptoms and cosmetic concerns, complications were registered.\ud \ud Results: Visibility of the needle was not significantly different in the two groups (P=0.0787). At 1 month the mean volume of the nodules dropped from 37.1 to 25 mL in group A and from 23.2 to 15.4 mL in group B; shrinkage rate (36.9% and 39.5%, respectively) was not significantly different (P=0.3137). Symptoms decreased from 3.1 to 1.4 in group A and from 4 to 1.6 in group B: no significant differences in reductions were observed (P=0.3305). Cosmetic score decreased from 3.7 to 3.4 in group A and from 3.9 to 3.6 in group B: no significant differences in reductions were observed (P=0.96). Total complication rate (18.2% in group A vs. 23.1% in group B) did not showed significant differences (P=0.5049).\ud \ud Conclusions: The two systems used in our study resulted equivalent in terms of US needle visibility, efficacy, symptom/cosmetic relief, safety. More patients and a longer follow-up are necessary to confirm our results.

To evaluate safety, technical and clinical success of embolization of type Ia endoleak (T1a EL) using ethylene–vinyl alcohol copolymer as embolic agent alone or in combination with other materials. Five patients presented T1a EL after endovascular repair of aortic aneurysms (EVAR) with radiological evidence of expanding sac size; in particular, three had contained rupture. In one patient, proximal cuff insertion was previously performed, in three patients proximal cuff was urgently inserted but T1a EL persisted; one patient, previously treated with Ovation Abdominal Stent Graft System, was directly proposed for endovascular treatment. In all cases, endovascular embolization was successfully performed and the transfemoral approach was always chosen; in one case it failed and translumbar approach by direct puncture of the sac was required. Used embolization agents were glue, ethylene–vinyl alcohol copolymer (Onyx) and coils in three cases, n-butyl cyanoacrylate and Onyx in one case, Onyx and coils in the last case. Technical success rate was 100% as well as clinical success. No major or minor complication, including non-target embolization, was registered. Clinical success was 100% until today and the sac diameter remained stable in four patients and decreased in one. Onyx may be considered a suitable embolic agent in the treatment of patients with type Ia endoleaks after EVAR, after failure of conventional treatments such as prolonged balloon inflation of the aortic neck or deployment of large bare stent.

Vascular emergencies of the retroperitoneum can arise from traumatic or nontraumatic arterial or venous injuries. Advances in interventional radiology technique have permitted less invasive alternative treatments to surgery for the management of aortic and inferior vena cava acute injuries. In this chapter, the MDCT findings of large-vessel vascular emergencies within the retroperitoneum are discussed, with correlative interventional findings and treatment.

Since the beginning of second decade of last century, when it was introduced in many oncologic scenarios, immunotherapy has become an important tool in the management of a growing number of cancers. Immunotherapy for cancer appears to be useful, improving not only progression free survival but also overall survival, thus achieving the goal that many advanced cancers, previously considered without effective treatment options, have now become successfully treatable. However, considering the relatively recent introduction of these drugs in clinical scenarios and the continuous release of new drugs, there is a lack of large validated clinical experiences and many issues are today debated amongst which the evaluation of the response to immune-therapy. Engaging the host immune system in fighting against cancer is an energy-consuming process, requiring T-cell recruiting; this process, named "pseudo-progression," sometimes produces an increase of both dimensional and metabolic ratio of the lesions, as well as the appearance of "new lesions." This behavior, always considered as undisputed progressive disease when traditional chemotherapy is employed, should be carefully considered in the field of immunotherapy, where the phenomenon of "flare" followed by regression of the disease can occur. In this paper, Authors analyzed the best available evidence in this field, reviewed the most important issues concerning the development of immunotherapy, and addressed evidence and concerns about the evaluation of response when using immunotherapy drugs, in terms of both radiological and nuclear medicine criteria.

Extremity injuries are the second most common traumatic injuries after head injuries and account until 80% of all cases of vascular trauma. Peripheral injuries are usually not immediately lethal, whether due to penetrating or blunt injuries; nevertheless, a prompt identification of the injuries is crucial for a correct management.

Purpose We aimed to report a preliminary single-center experience of elective endovascular aortic repair (EVAR) using ultra-low profile (ULP) endografts of 14 F outer diameter. Methods Data of 67 consecutive patients who underwent EVAR using either Ovation (group A, n=30) or Incraft (group B, n=37) endografts were retrospectively analyzed. Results Aorto-iliac anatomy was significantly different between the two groups, as patients of group A had a greater thrombotic apposition on proximal aortic neck (thrombus thickness: 7.2±1 mm vs. 3.3±1.6 mm, P = 0.042; percentage of the circumference covered by thrombus: 45.2%±10.4% vs. 18.7%±10.6%, P = 0.0003), while patients of group B had a more angulated proximal neck in the coronal axis (35.9°±6.4° vs. 16.7°±5°, P = 0.012). Procedural success was 93.3% and 97.3%, respectively, in groups A and B. One patient in group A required an immediate conversion to open surgery for persistent occlusion of both iliac limbs. Another patient required implantation of a conical endograft with a femoro-femoral right-to-left bypass for occlusion of the contralateral gate during the cannulation. In group B, one intraoperative type Ia endoleak was immediately corrected. Neither deaths nor major adverse events were recorded within 30-days. During a median follow-up of 15.2 months (range, 1-56.7 months) two type Ia endoleaks in group A required open conversion after 12.1 and 40.5 months, respectively. Three patients in group B required a reintervention after 30 days. Neither deaths nor aortic ruptures were recorded during follow-up. Conclusion Both ULP endografts showed satisfying early and mid-term results.

Several techniques and devices are available for urinary drainage. The choice depends on patient’s clinical problem, relevant laboratory data, availability of materials, and preferences and experience of the operator.

Renal and perinephric abscess can result in significant morbidity and mortality with complications including sepsis, renal failure, and fistula formation.

To evaluate the feasibility of image fusion (IF) of pre-procedural arterial-phase CT angiography or MR angiography with intra-procedural fluoroscopy for road-mapping in endovascular treatment of aorto-iliac steno-occlusive disease. Between September and November, 2014, we prospectively evaluated 5 patients with chronic aorto-iliac steno-occlusive disease, who underwent endovascular treatment in the angiography suite. Fusion image road-mapping was performed using angiographic phase CT images or MR images acquired before and intra-procedural unenhanced cone-beam CT. Radiation dose of the procedure, volume of intra-procedural iodinated contrast medium, fluoroscopy time, and overall procedural time were recorded. Reasons for potential fusion imaging inaccuracies were also evaluated. Image co-registration and fusion guidance were feasible in all procedures. Mean radiation dose of the procedure was 60.21 Gycm2 (range 55.02–63.75 Gycm2). The mean total procedure time was 32.2 min (range 27–38 min). The mean fluoroscopy time was 12 min and 3 s. The mean procedural iodinated contrast material dose was 24 mL (range 20–40 mL). IF gives Interventional Radiologists the opportunity to use new technologies in order to improve outcomes with a significant reduction of contrast media administration.

Laparoscopic nephron-sparing surgery (L-NSS) is increasingly performed to treat localised renal lesions. However, the associated morbidity is non-negligible, with a rate of major complications approaching 10 %. This paper provides an overview of indications, surgical techniques and results of L-NSS; explains the incidence, risk factors and manifestations of postoperative complications; discusses the preferred multidetector computed tomography (CT) acquisition techniques; illustrates the appearance of normal postoperative images following L-NSS; and reviews, with example images, the most common and unusual iatrogenic complications. These include haematuria, haemorrhage, vascular injuries, infections and urinary leaks. Most emphasis is placed on CT, which provides rapid, reliable triage and follow-up of iatrogenic complications after L-NSS, identifying occurrences that require transarterial embolisation or repeated surgery. Multidetector CT allows precise assessment of the surgical resection site; detection of pneumoperitoneum and subcutaneous emphysema; quantification of retroperitoneal blood; and identification of active bleeding, pseudoaneurysms, arterio-venous fistulas, abscess collections and extravasated urine. • Laparoscopic nephron-sparing surgery (NSS) is increasingly performed to treat renal lesions. • Radiologists are increasingly requested to investigate suspected post-surgical NSS complications. • Post-NSS complications include haemorrhage, haematuria, vascular injuries, infections and urinary leaks. • Multidetector CT allows choice between conservative treatment, transarterial embolisation or surgery.

Background Recently different software with the ability to plan ablation volumes have been developed in order to minimize the number of attempts of positioning electrodes and to improve a safe overall tumor coverage. Purpose To assess the feasibility of three-dimensional cone beam computed tomography (3D CBCT) fusion imaging with “virtual probe” positioning, to predict ablation volume in lung tumors treated percutaneously. Material and Methods Pre-procedural computed tomography contrast-enhanced scans (CECT) were merged with a CBCT volume obtained to plan the ablation. An offline tumor segmentation was performed to determine the number of antennae and their positioning within the tumor. The volume of ablation obtained, evaluated on CECT performed after 1 month, was compared with the pre-procedural predicted one. Feasibility was assessed on the basis of accuracy evaluation (visual evaluation [VE] and quantitative evaluation [QE]), technical success (TS), and technical effectiveness (TE). Results Seven of the patients with lung tumor treated by percutaneous thermal ablation were selected and treated on the basis of the 3D CBCT fusion imaging. In all cases the volume of ablation predicted was in accordance with that obtained. The difference in volume between predicted ablation volumes and obtained ones on CECT at 1 month was 1.8 cm3 (SD ± 2, min. 0.4, max. 0.9) for MW and 0.9 cm3 (SD ± 1.1, min. 0.1, max. 0.7) for RF. Conclusion Use of pre-procedural 3D CBCT fusion imaging could be useful to define expected ablation volumes. However, more patients are needed to ensure stronger evidence.

The aim of this study was to assess the feasibility of the application of the new system (Emprint Microwave Ablation System, Covidien Boulder, CO, USA) and to identify its advantages. In particular the attention was focused to the spherical ablation zone obtained and its usefulness in terms of effectiveness. The new system is composed of: a 2450 MHz generator that delivers a maximum power of 100 W, a fiberglass antenna and a pump for internally cooled antenna. Ten liver nodules (8 hepatocellular carcinomas and 2 metastasis) were percutaneously treated (mean diameter 24.9 mm, range 16–35 mm). Technical success, ablation duration time, overall procedure time and safety were registered. To define the shape of the ablation zone, multiplanar reformatting (MPR) was performed. Roundness index transverse was calculated: a value near 1 represents a more spherical ablation zone shape, and a value distant from 1 implies an oval configuration. Technical success was 100 %. Mean ablation time was of 3.85 min (range 3–5 min), mean overall procedure time was 30.5 min (range 25–40 min). No major complications were recorded. Roundness index transverse presented a mean value of 0.94, meaning that a spherical shape of ablation zone was achieved. One of the most promising innovations of the new microwave technology is the spherical shape of the ablation volume that could be related with an improving of the effectiveness and safety.

The purpose of this multicentric study is to assess the usefulness of multiphasic Computed tomography in the identification of spontaneous non-traumatic retroperitoneal hematoma (SRH) and its management, with references to the role of interventional radiology. From January 2011 to June 2014, 27 patients with SRH were selected. Patients with aortic, traumatic, or iatrogenic source of bleeding were excluded. All the patients were studied with multiphasic MDCT after injection of intravenous contrast. Digital Subtraction angiography and percutaneous embolization treatment were performed. CT identified SRH in all cases (100 %), showing the source of bleeding in 11 cases (40 %) and pointing out the source of bleeding in 15 cases (55 %). In one case (5 %), the bleeding origin was recognized only at surgery as adrenal source. CT has identified a contrast medium extravasation in the arterial phase in 17 patients (63 %), treated successfully by percutaneous embolization in 13 and by open-surgery in two cases. Two patients died before undergoing intervention and surgery, respectively. Ten patients (37 %) were non-operatively treated successfully with clinical, laboratory, and imaging follow-up. Multiphasic CT is the gold standard for the identification of a SRH. Recognition of CT signs of active bleeding is the crucial feature influencing the timing of therapeutic treatment. Urgent embolization should be performed in cases of arterial bleeding or contained vascular injuries supplying the retroperitoneal hematoma. Surgery is to be addressed in cases of actively bleeding hematomas associated with complication. Finally, an initial more conservative approach can be adopted in patients without signs of contrast extravasation or low-flow active bleeding. Technical skill, expertise, and recognition of CT signs of arterial active bleeding are critical features influencing patients management.

Background Dual-phase cone beam computed tomography (DP-CBCT) and automatic vessel detection (AVD) software are helpful tools for detecting arteries before planned endovascular interventions. Purpose To evaluate the usefulness of DP-CBCT and AVD software in guiding the trans-arterial embolization (TAE) of challenging T2 lumbar endoleaks (T2-L-EL). Material and Methods Ten patients with T2-L-EL were included in this study. The accuracy of DP-CBCT and the AVD software was defined by the ability to detect the endoleak and arterial feeding vessel, respectively. Technical success was defined as the correct positioning of the microcatheter using AVD software and the successful embolization of the endoleak. Clinical success was defined as the absence of recurrent endoleaks during follow-up and the stability of the sac diameter for persistent endoleaks. The total volume of iodinated contrast medium, overall procedure time, mean procedural radiation dose, and mean fluoroscopy time were recorded. Results The EL was detected by DP-CBCT in all patients. The AVD software identified the feeding arterial branch in all cases. In one patient, the nidus of the endoleak was not reached due to the small caliber of the feeding artery, even though the software had clearly identified the vessel route. The mean contrast volume was 109 mL, the mean overall procedural time was 74.3 min. The mean procedural radiation dose was 140.97 Gy cm2, and the mean fluoroscopy time was 29.8 min. Conclusion The use of DP-CBCT and the AVD software is feasible and may facilitate successful embolization in challenging occult T2-L-EL with complex vasculature.

To affirm technical success, clinical success and safety of fluoroscopically guided transurethral replacement of double-J (DJ) ureteral stents. From January 2005 to December 2015, in a follow-up period ranging from 9 to 73 months, we replaced 6167 DJ ureteral stents in 3221 procedures in 1168 patients. All the procedures were performed in the angiography suite under fluoroscopic control. Technical success was achieved in 97.5% of the procedures. In eighty procedures, cystoscopic approach was necessary; time from previous procedure and side were significantly associated with technical success. Clinical success was reached in 95.7% of the procedures and was significantly lower in urological and gynaecological tumours (when compared to fibrosis and other causes) and in bilateral stents. No major complications were reported. In 90 cases, self-limiting transient minor haematuria occurred and in 160 procedures urinary tract infection responding to antibiotics were registered. Overall procedure time was 27 min. Mean fluoroscopic time was 6 min and 45 s. Mean radiation dose of the procedure was 38.40 Gy cm2. In patients that need routine replacement of DJ ureteral stent, transurethral fluoroscopically guided method may be the first choice; only in few cases of technical failure, cystoscopy may be considered.

Thoracic injuries are the third most common traumatic injury. Approximately two thirds of thoracic injuries are due to motor vehicle collisions. They are associated with up to a 20% mortality rate. This is primarily due to the presence of several complex anatomical structures within the thoracic cage such as the heart, great vessels, esophagus, airways, lungs, mediastinum, bones, muscles, diaphragm, and pleura. A chest radiograph is the initial imaging modality in the evaluation of the chest. However, multidetector computer tomography (MDCT) with intravenous contrast is the imaging modality of choice in the assessment of acute thoracic injuries.Endovascular repair is less invasive and has a better outcome than traditional surgical repair. This review article discusses the indications, benefits, and findings of radiographs and MDCT in patients with thoracic injuries, especially with regard to the thoracic aorta.

Purpose The purpose of this study was to assess the effectiveness of anastomotic pseudoaneurysms (APAs) endovascular treatment following aorto-iliac-femoral surgical reconstruction. Basic Procedures We retrospectively evaluated 54 patients who underwent aorto-iliac-femoral bypass (72 APAs). Follow-up was performed with echo-color-Doppler and/or computed tomography angiography at 1, 3, and 6 months after the procedure and then yearly. We compared clinical success in terms of mortality between aortic APAs and nonaortic APAs (iliac-femoral-popliteal). Main Findings Immediate technical success was 100%. No periprocedural complications occurred. Six patients died during follow-up due to causes not related to APA and 5 due to sepsis at 3 months after the procedure. Thirty-day mortality was 9% overall, and we did not register any statistically significant different between aortic APA and nonaortic APA groups. During a mean follow-up of 25.5 months (range: 3–72), we registered 3 occlusions of stent-graft leg, respectively, at 3 days, 7 days, and 24 months after the procedure, 2 type I endoleaks and 1 type III endoleak. Primary clinical success rate was 87.2%, and secondary clinical success was 95.7%. Conclusions Endovascular treatment resulted as a valid alternative to open surgery and could be proposed as the treatment of choice for APAs especially in patients with a high surgical risk.

The aim of this study was to compare the Intravoxel Incoherent Motion (IVIM) parameters between healthy Peripheral Zone (PZ), Benign Prostatic Hyperplasia (BPH) and Prostate Cancer (PCa) and compare them to assess whether there was correlation with Gleason Score (GS) grading system. Thirty-one patients with suspect of PCa underwent 1.5T Multi-Parametric Magnetic Resonance Imaging (MP-MRI) with endorectal coil with a protocol including T2WI, DWI using 10 b values (0, 10, 20, 30, 50, 80, 100, 200, 400, 1000 s/mm2) and DCE. Monoexponential and IVIM model fits were used to calculate both apparent diffusion coefficient (ADC) and the following IVIM parameters: molecular diffusion coefficient (D), perfusion-related diffusion coefficient (D*) and perfusion fraction (f). The ADC and D values were significantly lower in the PCa (0.70 ± 0.16 × 10−3 mm2/s and 0.88 ± 0.31 × 10−3 mm2/s) compared to those found in the PZ (1.22 ± 0.20 × 10−3 mm2/s and 1.78 ± 0.34 × 10−3 mm2/s) and in the BPH (1.53 ± 0.23 × 10−3 mm2/s and 1.11 ± 0.28 × 10−3 mm2/s). The D* parameter was significantly increased in the PCa (5.35 ± 5.12 × 10−3 mm2/s) compare to the healthy PZ (3.02 ± 2.86 × 10−3 mm2/s), instead there was not significantly difference in the PCa compare to the BPH (5.61 ± 6.77 × 10−3 mm2/s). The f was statistically lower in the PCa (9.01 ± 5.20%) compared to PZ (10.57 ± 9.30%), but not significantly different between PCa and BPH (9.29 ± 7.29%). The specificity, sensitivity and accuracy of T2WI associated with DWI and IVIM were higher (100, 98 and 99%, respectively) than for T2WI/DWI and IVIM alone (89, 92 and 90%, respectively). Only for ADC was found a statistical difference between low- and intermediate-/high-grade tumors. Adding IVIM to the MP-MRI could increase the diagnostic performance to detect clinically relevant PCa. ADC values have been found to have a rule to discriminate PCa reliably from normal areas and differed significantly in low- and intermediate-/high-grade PCa. In contrast, IVIM parameters were unable to distinguish between the different GS.

Purpose of this study was to evaluate the employment of MRI-guided Focused Ultrasound (MRgFUS) for treatment of intra-articular benign bone lesions as alternative to surgery, and to monitor the success of the treatment on CT and MRI images. From March 2011 to August 2013, 14 intra-articular benign bone lesions were treated with MRgFUS. All patients were studied by CT and MR imaging. Pain was measured using the visual analogue scale (VAS) before and after treatment (6 and 12Â months). All patients in our series demonstrated regression in painful symptomatology during screening. A significant drop in the mean VAS pain score (from 7.8 to 0.6) was observed at 12-month follow-up, and pain medication was no longer needed after treatment. No complications were observed. Three diagnostic imaging signs were found suggesting absence of biological activity and confirming the clinical findings: calcification of the treated lesion, lack of contrast enhancement and disappearance of bone oedema around the lesions. Conclusion: the employment of MRgFUS is safe and effective in the treatment of intra-articular benign bone lesions. The clinical outcome is satisfactory, and the success of the treatment is confirmed by diagnostic imaging.

To evaluate safety, technical and clinical success of embolization of type II endoleak (T2 EL) using ethylene-vinyl alcohol copolymer as embolic agent alone or in combination with others materials. From March 2007 to March 2015, 104 patients presented T2 EL during follow-up. A total of 21 patients met the criteria for treatment. T2 EL was treated with TAE (n = 18), DPSI (n = 10) or laparoscopic ligature of the inferior mesenteric artery (n = 1). DPSI was considered in case TAE was unsuccessful (8/18 patients). Ethylene–vinyl alcohol copolymer was used as embolic agent in 12 patients: alone in 5 cases, in association with glue and with glue and thrombin in 3 and 2 cases, respectively, during TAE. Onyx was injected in two cases of embolization performed with DPSI: in one case alone and in the other in combination with thrombin and glue. Technical success rate was 100%. Immediate clinical success was 91.7%; in one patient CEUS revealed persistent T2 EL, decreased if compared with that before the procedure. Secondary clinical success was 91.7%; until today, in one patient T2EL is persistent, nevertheless, the sac diameter remained stable. No major or minor complications were registered. Onyx could be an ideal embolic agent for endovascular and percutaneous embolization of T2 EL.

Uterine fibroids are common benign tumors of unclear etiopathology that affect the female reproductive tract. They are responsible for considerable morbidity and deterioration of life quality, and may have a negative impact on the reproductive system as well. Besides surgery aided by uterus-saving techniques, several minimally invasive procedures are now available within the field of interventional radiology that represent a valid solution for women who desire pregnancy and relief from disease-specific symptomatology. The main advantages offered by these techniques are low grade of invasiveness and short times of hospitalization. The most diffuse techniques are uterine artery embolization (UAE) and magnetic resonance-guided high-intensity focused ultrasound (MRgFUS). UAE is an endovascular procedure whose goal is obtained by provoking ischemia of the uterine vessels. MRgFUS is a thermoablation procedure that selectively ablates the symptomatic fibroids. In this review study, both procedures will be described, including a description of technical details, indications, contraindications, complications, and outcomes.

Venous malformations (VMs) are congenital vascular malformations. They are very often misnamed and thus incorrectly managed. The aim of the present paper is to provide the reader with the most updated literature available and to offer a detailed description of each single aspect of this disease. In detail, the paper discusses the epidemiology, the embryological origins and the physiopathology of VMs. Then, the clinical features of sporadic, inherited and syndromic VMs are discussed. The instrumental diagnosis is presented, and the role of US, CT, MRI and phlebography is pointed out. Differential diagnoses with other vascular malformations and tumors are described. The clinical session ends with the staging of VMs relying on MRI and rheological features. All aspects of treatment are described: conservative measures, medical treatment, sclerotherapy, laser and surgery are thoroughly discussed. A section is reserved to bony VMs. Their clinical aspects and the appropriate treatment are presented.

Resume Objectif Evaluer le succes technique, les complications et l’influence de la courbe d’apprentissage sur les resultats de stenting de l’artere carotide (SAC) realises chez des patients ne pouvant etre traites par chirurgie. Patients et methodes Cent neuf mises en place d’un stent carotidien sous protection cerebrale ont ete effectuees chez 103 patients a haut risque. Tous les patients presentaient au moins un facteur qui pouvait accroitre le risque chirurgical lie a une endarteriectomie carotidienne (EAC) selon les criteres SAPPHIRE. Les complications neurologiques ont ete quantifiees au moyen de l’echelle d’accident vasculaire cerebral des National Institutes of Health (National Institutes of Health Stroke Scale ; NIHSS) et le retablissement a ete evalue au moyen de l’echelle de Rankin modifiee (mRS). Dans le but d’evaluer l’influence de l’experience de l’operateur en matiere de realisation de SAC, nous avons realise une analyse retrospective des complications periprocedurales et neurologiques des 50 premieres interventions comparativement aux 59 interventions suivantes. Resultats Le taux de succes technique a ete de 98 %. Des complications neurologiques periprocedurales ont ete decelees chez 4,5 % des patients. Les taux de complications neurologiques en milieu hospitalier et a 30 jours ont ete respectivement de 7,6 % et 2,6 %. Le taux de complications neurologiques a ete plus faible a la suite des 59 dernieres interventions realisees, en accord avec une confiance plus elevee des operateurs. Conclusion Un SAC peut etre effectue a titre d’alternative a une EAC pour le traitement de lesions carotidiennes obstructives severes chez les patients ne pouvant etre traites par chirurgie. La courbe d’apprentissage influence positivement le taux de complications.

Intrahepatic cholangiocarcinoma (ICC) is the second most common primary hepatic malignancy after hepatocellular carcinoma. Complete surgical resection remains the only potentially curative option for patients with ICC. However, until now, early diagnosis with potential surgical intervention has been the exception rather than the rule with only 30% of patients qualifying for attempted surgical cure. Many patients are unresectable because of disease stage, anatomic conditions, medical comorbidities, and small future remnant liver. Interventional radiology procedures are available for these types of patients with intra-arterial therapies and/or ablative treatments both for curative and for palliative treatment. The goals of interventional therapy are to control local tumor growth, to relieve symptoms, and to improve and preserve quality of life. The choice of treatment depends largely on tumor extent and patient performance. No randomized studies exist to compare treatments. The present review describes the current evidence of the interventional treatments in the management of the ICC. Moreover, interventional procedures available to increase the future liver reserve before surgery were analyzed.

The purpose of our study is to report safety, technical success, effectiveness, local progression-free survival (LPFS) and overall survival of percutaneous microwave ablation (MWA) to treat lung tumours unsuitable for surgery. Nineteen patients with thirty-one tumours (mean diameter 2.4 cm) underwent percutaneous MWA in 28 sessions. Microwave ablation was carried out using a 2450-MHz generator (Emprint/Covidien, Boulder, CO, USA). Procedures were performed under cone-beam CT (CBCT) and under fluoro-CT (one session) guidance. Safety, technical success, effectiveness, LPFS and overall survival (OS) were evaluated. Safety was defined as the frequency of major and minor complications. The efficacy was evaluated on the basis of imaging characteristics, using RECIST criteria. CT follow-up was performed at 1, 3 and 6 months and yearly. LPFS was defined as the interval between MWA treatment and evidence of local recurrence, if there was any. OS was defined as the percentage of patients who were still alive. We registered one major complication (purulent hydro-pneumothorax). Minor complications were spontaneously resolved (pneumothorax and perilesional haemorrhagic effusion). Technical success was 100%. Residual disease was registered in two cases, one of whom was retreated. Complete ablation was obtained in the remaining cases (90.3%). During available follow-up (mean 9.6 months), 9/31 tumours demonstrated local recurrence. Five tumours were retreated, and none of them presented residual disease during follow-up (LPFS 22.6%). Overall survival was 93.8%. Percutaneous high-energy MWA is a safe, effective and confident technique to treat lung tumours not suitable for surgery.

Purpose of the study To report our experience in treating complicated biliary calculi by percutaneous transhepatic endoscopic biliary holmium laser lithotripsy (PTBL). Patients and Methods Ten symptomatic patients with intrahepatic or common bile duct calculi underwent PTBL. Six of these patients had previously undergone unsuccessful endoscopic treatment; four patients were declared not suitable for endoscopic procedure. PTBL was performed with a flexible choledochoscopy inserted by way of the percutaneous access sheath. A holmium laser was used to fragment the biliary stones. Sphincteroplasty was performed when considered necessary and an occlusion balloon for the clearance of common bile duct (CBD) calculi was used when continuous warm saline irrigation at high pressure was not sufficient. Clinical follow up was performed by the referring physician. Technical success, clinical success and complications were evaluated. Main findings Technical success rate was 100%. The overall clinical success rate was 100%. No patients underwent additional procedures for retained stones or developed de novo strictures or other complications related to the procedure. Hospital stay was no more than 4 days after the procedure. Duration of follow-up was 6–25 months (mean 12.6). One patient died from unrelated causes. During this period, no recurrence and/or complications related to procedure were observed. No major complications were registered. Minor complications like temporary abdominal pain were considered not significant by the patients. Conclusions Complicated or large biliary calculi can be treated successfully using PTBL. In selected patients, this approach should become the first choice of treatment after other treatments are rejected.

Purpose of the study The aim of the study was to assess the efficacy, safety and effectiveness of percutaneous image-guided microwave ablation (MWA) in Bosniak category III or IV cystic renal lesions after 24 months follow-up duration. Methods Between May 2008 and December 2012, computed tomography (CT)- or ultrasound (US)-guided MWA was performed in 6 patients with 7 cystic renal lesions (range 13.8–27 mm, mean 17.02 mm, SD 8.5 mm) Bosniak catgegory III or IV. The number of treatment sessions, treatment results, lesion size changes and complications were evaluated. Technical success (TS), technical effectiveness (TE), local tumor progression rate (LTPR), cancer-specific survival rate (CSSR) and overall survival rate (OSR) were computed. Main findings TS was 100% (7/7) and TE was 100%; LTPR was 0%; CSSR and OSR were 100%. No major complications were observed. Conclusion Our preliminary experience with MWA shows a potential role for US/CT-guided percutaneous MWA in treating Bosniak category III or IV cystic renal lesions, as a safe approach to treat selected patients not suitable for surgery.

This study was done to evaluate the feasibility, effectiveness and safety of microwave (MW) ablation of lung tumours.Twenty-four patients underwent percutaneous MW ablation of 26 intraparenchymal pulmonary masses. All patients were judged to be inoperable on the basis of tumour stage, comorbidities, advanced age and/or refusal to undergo surgery. Ablation was performed using a microwave generator (Evident Microwave Ablation System, Covidien Ltd., Dublin). Lesions with a diameter ≤ 3 cm were treated with a single antenna, lesions with a diameter3 cm were treated by positioning two or more antennae, simultaneously. All patients underwent computed tomography (CT) follow-up with and without contrast administration at 1, 3 and 6 months and then yearly in combination with complete blood and metabolic tests.Technical success was 100 %. No major complications were recorded. Asymptomatic grade-1 pneumothorax was recorded in 9 patients (37.5 %). One case of asymptomatic pleural effusion and one of haemoptysis, not requiring transfusion, were observed. No patients were diagnosed with a post-ablation syndrome. Complete necrosis was observed in 16 of 26 lesions (61.6 %). Partial necrosis was obtained in 30.8 % (8/26 lesions); in one case (3.8 %) a progression of the disease was recorded and in another case (3.8 %) a stability was observed.Our preliminary experience may be considered in accordance with literature dates, in terms of efficacy and safety.

Several substances have been used in an attempt to sclerose biliary ducts associated with persistent biliary-cutaneous fistula (BCF). The AMPLATZER Vascular Plug (AVP; AGA Medical, USA) system is a recently developed endovascular occlusion device, introduced as an alternative to permanent embolic materials (metallic coils or acrylic glue), in the occlusion of large and medium-calibre arteries and veins. We report a successful use of the AVP to embolize BCF, developed after the removal of an internal-external biliary drainage.

The purpose of our study was to evaluate technical success, effectiveness and safety of microwave ablation (MWA) in patients with unresectable liver metastases, where radiofrequency ablation (RFA) presents some limits.Twenty-five patients (17 men, 8 women) with 31 liver metastases3 cm or located near vessels (3 mm) were treated in a total of 29 sessions. Tumours were subdivided as follows: colorectal metastases (n=21) and no colorectal metastases (n=10). All procedures were performed percutaneously under ultrasound (US) guidance. Follow-up was performed with computed tomography (CT) scan at 1, 3, 6 and 12 months after treatment; mean follow-up period was 12.04 (range, 3-36) months. Technical success, mean disease-free survival, effectiveness and safety were evaluated.Technical success was obtained in all cases. Mean disease-free survival was of 20.5 months. Local recurrence was recorded in 12.9% of metastases treated (4/31). No major complications were recorded. The rate of minor complications was 44.8% (13/29 sessions). Mortality at 30 days was 0%.Percutaneous MWA of liver metastases3 cm or located near vessels (3 mm) can be considered a valid and safe option, probably preferable to RFA. Further studies are required to confirm these encouraging initial results.

To compare the efficacy of intravesical electrostimulation (IVES) versus sacral neuromodulation (SNM) in patients with incomplete spinal cord lesions (SCL) and neurogenic non-obstructive urinary retention (N-NOR).In this retrospective study, 77 N-NOR patients underwent IVES (minimum 28 sessions), then after returning to voiding baseline symptoms, percutaneous first stage of SNM (lasting for minimum 4 weeks). After the two neuromodulation treatments, responders were categorized as patients experiencing both a 50% reduction of volume per catheterization per ml and a 50% reduction in number of catheterizations per day when comparing the 7-day voiding diaries at the end of both procedures to baselines. New urodynamics were performed subsequently. Responders to first stage of SNM underwent permanent SNM.Forty-eight patients responded to neither of the treatments, whereas 29 responded to both IVES and first-stage SNM. No significant statistical differences (P0.05) were detected in the voiding diaries. Following the two procedures, the first sensation of bladder filling was either maintained or recovered by all responders, whereas the same 11 patients reached a bladder contractility index of100. The 29 IVES responders lost their clinical benefits in a mean follow-up of 9.6 months. Only 10 out of the 29 patients became nonresponsive to permanent SNM, in a mean follow-up of 54 months.A strict correlation in terms of clinical and urodynamic patterns was demonstrated in patients with incomplete SCL and N-NOR, following IVES and first stage of SNM. However, voiding improvement through IVES was short-term when compared with the effects of permanent SNM.

Acute vascular injuries are the second most common cause of fatalities in patients with multiple traumatic injuries; thus, prompt identification and management is essential for patient survival. Over the past few years, multidetector CT (MDCT) using dual-phase scanning protocol has become the imaging modality of choice in high-energy deceleration traumas. The objective of this article was to review the role of dual-phase MDCT in the identification and management of acute vascular injuries, particularly in the chest and abdomen following multiple traumatic injuries. In addition, this article will provide examples of MDCT features of acute vascular injuries with correlative surgical and interventional findings.

Interventional radiological procedures may be performed to treat different types of complications after digestive and biliopancreatic endoscopy.

To demonstrate the feasibility of percutaneous nucleoplasty procedures at L5/S1 level using cone beam CT (CBCT) and its associated image guidance technology for the treatment of lumbar disc herniation (LDH). We retrospectively reviewed 25 cases (20 men, 5 women) of LDH at L5/S1 levels. CBCT as guidance imaging was chosen after a first unsuccessful fluoroscopy attempt that was related to complex anatomy (n = 15), rapid pathological changes due to degenerative diseases (n = 7) or both (n = 3). Technical success, defined as correct needle positioning in the target LDH, and safety were evaluated; overall procedure time and radiation dose were registered. A visual analog scale (VAS) was used to evaluate pain and discomfort pre-intervention after 1 week and 1, 3, and 6 months after the procedure. Technical success was 100 %; using CBCT as guidance imaging the needle was correctly positioned at the first attempt in 20 out of 25 patients. Neither major nor minor complications were registered during or after the procedure. The average procedure time was 11 min and 56 s (range, 9–15 min), whereas mean procedural radiation dose was 46.25 Gy.cm2 (range 38.10–52.84 Gy.cm2), and mean fluoroscopy time was 5 min 34 s (range 3 min 40 s to 6 min 55 s). The VAS pain score decreased significantly from 7.6 preoperatively to 3.9 at 1 week, 2.8 at 1 month, 2.1 at 3 months, and 1.6 at 6 months postoperatively. CBCT-guided percutaneous nucleoplasty is a highly effective technique for LDH with acceptable procedure time and radiation dose.

The management of trauma patients has evolved in recent decades owing to increasing availability of advanced imaging modalities such as CT. Nowadays, CT has replaced the diagnostic function of angiography. The latter is considered when a therapeutic option is hypothesized. Arterial embolization is a life-saving procedure in abdominopelvic haemorrhagic patients, reducing relevant mortality rates and ensuring haemodynamic stabilization of the patient. Percutaneous transarterial embolization has been shown to be effective for controlling ongoing bleeding for patients with high-grade abdominopelvic injuries, thereby reducing the failure rate of non-operative management, preserving maximal organ function. Surgery is not always the optimal solution for stabilization of a patient with polytrauma. Mini-invasivity and repeatability may be considered as relevant advantages. We review technical considerations, efficacy and complication rates of hepatic, splenic, renal and pelvic embolization to extrapolate current evidence about transarterial embolization in traumatic patients.

Percutaneous radiofrequency ablation (RFA) can be as effective as surgical resection in terms of overall survival and recurrence-free survival rates in patients with small hepatocellular carcinoma (HCC). Effectiveness of RFA is adversely influenced by heat-sink effect. Other ablative therapies could be considered for larger tumors or for tumors located near the vessels. In this regard, recent improvements in microwave energy delivery systems seem to open interesting perspectives to percutaneous ablation, which could become the ablation technique of choice in the near future. Microwave ablation (MWA) has the advantages of possessing a higher thermal efficiency. It has high efficacy in coagulating blood vessels and is a relatively fast procedure. The time required for ablation is short and the shape of necrosis is elliptical with the older systems and spherical with the new one. There is no heat-sink effect and it can be used to ablate tumors adjacent to major vessels. These factors yield a large ablation volume, and result in good local control and fewer complications. This review highlights the most relevant updates on MWA in the treatment of small (

We describe a man who presented with a traumatic portal vein pseudoaneurysm, which was subsequently managed with a percutaneous transhepatic stent graft. This case demonstrates a rarely seen condition in the traumatic population and a novel management strategy, which should be considered in the management of this challenging injury.

Primary intraosseous arteriovenous malformations are rare. Many minimally invasive procedures can be considered preoperative steps and/or definitive treatment. The case reported regards a young woman with a voluminous arteriovenous extratroncular infiltrating malformation of the humerus. She underwent several treatments, but none of them was completely occlusive. The last treatment consisted of direct percutaneous puncture of the intraosseous alteration and injection of polymethylmethacrylate (PMMA), which is normally used in percutaneous vertebroplasty. We obtained complete occlusion of the humerus lytic lesion. To the best of our knowledge, this represents the first case of intraosseous AVM treated by percutaneous injection of PMMA.

This study was designed to evaluate the utility of dual phase cone beam computed tomography (DP-CBCT) and automatic vessel detection (AVD) software to guide transarterial embolization (TAE) of angiographically challenging arterial bleedings in emergency settings. Twenty patients with an arterial bleeding at computed tomography angiography and an inconclusive identification of the bleeding vessel at the initial 2D angiographic series were included. Accuracy of DP-CBCT and AVD software were defined as the ability to detect the bleeding site and the culprit arterial bleeder, respectively. Technical success was defined as the correct positioning of the microcatheter using AVD software. Clinical success was defined as the successful embolization. Total volume of iodinated contrast medium and overall procedure time were registered. The bleeding site was not detected by initial angiogram in 20 % of cases, while impossibility to identify the bleeding vessel was the reason for inclusion in the remaining cases. The bleeding site was detected by DP-CBCT in 19 of 20 (95 %) patients; in one case CBCT-CT fusion was required. AVD software identified the culprit arterial branch in 18 of 20 (90 %) cases. In two cases, vessel tracking required manual marking of the candidate arterial bleeder. Technical success was 95 %. Successful embolization was achieved in all patients. Mean contrast volume injected for each patient was 77.5 ml, and mean overall procedural time was 50 min. C-arm CBCT and AVD software during TAE of angiographically challenging arterial bleedings is feasible and may facilitate successful embolization. Staff training in CBCT imaging and software manipulation is necessary.

The intravascular foreign bodies (IFBs) can originate from many sources both iatrogenic and noniatrogenic; as the frequency of endovascular therapies increases, the incidence of lost or embolized iatrogenic foreign bodies is also increasing. As IFB can cause significant complications such as thrombosis, pulmonary and peripheral embolism, etc. It is therefore necessary to remove them, and this may be accomplished through surgery or by means of percutaneous radiologic techniques. Percutaneous approach is widely perceived as the best way to retrieve IFB. We provide an overview of recent literature, clarifying what devices are being lost, what symptoms occur as a result, and how retrieval is being performed.

Introduction We report on the successful endovascular treatment of a ruptured splenic artery pseudoaneurysm. Our patient had acute pancreatitis superimposed on chronic calcific pancreatitis and chronic renal impairment. Contrast-enhanced ultrasonography was used to assess post-embolization results. Case presentation Our patient was a 67-year-old white Caucasian man with recurrent pancreatitis. Computed tomography angiography showed a pancreatic pseudocyst with a ruptured pseudoaneurysm, which was successfully embolized using an endovascular percutaneous approach. At six months, persistent renal failure led to contrast-enhanced ultrasonography. This confirmed the absence of turbulent blood flow and extravasation of contrast medium in the pseudocyst. Conclusion Our experience with this case leads us to support the role of interventional radiology as a first-line treatment tool. Contrast-enhanced ultrasonography can be used to follow-up embolization procedures in patients with impaired renal function.

We present the case of a 49-year-old woman diagnosed with Sneddon's syndrome and previous endovascular embolization for cerebral and left renal artery aneurysms. The aneurysm was asymptomatic and incidentally detected as coin opacity at a preoperative X-ray performed for breast surgery. The 13-mm saccular left internal thoracic artery aneurysm engaged through a percutaneous left brachial artery access was successfully excluded with a stent graft. A 6-month follow-up computed tomography angiography confirmed the exclusion of the aneurysm, the patency of the internal thoracic artery, and the absence of endoleak or edge stenoses. True aneurysm of the internal thoracic artery is a rare entity. Stent-graft repair is a viable end effective alternative treatment for the exclusion of this lesion.

To evaluate the role of endovascular treatment for controlling haemorrhage in haemodynamically unstable patients with pelvic bone fractures and to relate clinical efficacy to pre-procedural variables.From March 2009 through April 2013, 168 patients with major pelvic trauma associated with high-flow haemorrhage were referred to our emergency department and were retrospectively reviewed. Pelvic arteries involved were one or more per patient. Embolisation was performed using various materials (micro-coils, Spongostan, plug, glue, covered stent), and technical success, complications, treatment success, clinical efficacy, rebleeding, and mortality rates were assessed. Factors influencing clinical efficacy were also evaluated.The technical success rate was 100%; no complications occurred during the procedures. Treatment was successful in 94.6% cases, and clinical efficacy was 85.7%. Three patients had to undergo a second arteriography due to recurrent haemorrhage. Fifteen patients died. Pre-embolisation transfusion demand was significantly associated with clinical efficacy.Percutaneous embolisation of pelvic bleeding may be considered a safe, effective, and minimally invasive therapeutic option. As haemodynamic stability is the first objective with traumatic haemorrhagic patient, arterial embolisation can assume a primary role. On the basis of our results, pre-procedural transfusion status may be considered a prognostic factor.• The series presented is one of the largest in a single centre. • Arterial embolisation is a life-saving procedure in patients with pelvic haemorrhage. • In pelvic traumas associated with haemorrhage, prognosis is dependent upon prompt treatment. • Transfusion status is significantly related to clinical efficacy.

Initial studies about ablation therapies of the pancreas were associated with significant morbidity and mortality, which limited widespread adoption. Development of techniques with high quality imaging used as guidance improve outcomes reducing complications. Moreover, only few experiences of percutaneous pancreatic ablations are reported. They are performed by very skilled operators in highly specialized centers. This review presents the current status of percutaneous local ablative therapies in the treatment of advanced pancreatic cancer.