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This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing percutaneous transhepatic cholangiography, biliary drainage and stenting. It has been developed by an expert writing group established by the CIRSE Standards of Practice Committee.

To investigate the potential of decreasing the number of scans and associated radiation exposure involved in CT liver perfusion (CTLP) dynamic studies for hepatocellular carcinoma (HCC) assessment. Twenty-four CTLP image datasets of patients with HCC were retrospectively analyzed. All examinations were performed on a modern CT system using a standard acquisition protocol involving 35 scans with 1.7 s interval. A deconvolution-based or a standard algorithm was employed to compute ten perfusion parametric maps. 3D ROIs were positioned on 33 confirmed HCCs and non-malignant parenchyma. Analysis was repeated for two subsampled datasets generated from the original dataset by including only the (a) 18 odd-numbered scans with 3.4 s interval and (b) 18 first scans with 1.7 s interval. Standard and modified datasets were compared regarding the (a) accuracy of calculated perfusion parameters, (b) power of parametric maps to discriminate HCCs from liver parenchyma, and (c) associated radiation exposure. When the time interval between successive scans was doubled, perfusion parameters of HCCs were found unaffected (p > 0.05) and the discriminating efficiency of parametric maps was preserved (p

Haemoptysis represents one of the most severe major bleeding manifestations in the clinical course of pulmonary arterial hypertension (PAH) associated with congenital heart disease (CHD). Accumulating evidence indicates that dysfunction of the pulmonary vascular bed in the setting of PAH predisposes patients to increased hemorrhagic diathesis, resulting in mild to massive and life-threatening episodes of haemoptysis. Despite major advances in PAH targeted treatment strategies, haemoptysis is still correlated with substantial morbidity and impaired quality of life, requiring a multidisciplinary approach by adult CHD experts in tertiary centres. Technological innovations in the field of diagnostic and interventional radiology enabled the application of bronchial artery embolization (BAE), a valuable tool to efficiently control haemoptysis in modern clinical practice. However, bleeding recurrences are still prevalent, implying that the optimum management of haemoptysis and its implications remain obscure. Moreover, regarding the use of oral anticoagulation in patients with haemoptysis, current guidelines do not provide a clear therapeutic strategy due to the lack of evidence. This review aims to discuss the main pathophysiological mechanisms of haemoptysis in PAH-CHD, present the clinical spectrum and the available diagnostic tools, summarize current therapeutic challenges, and propose directions for future research in this group of patients.

The aim of this study was to define lower dose parameters (tube load and temporal sampling) for CT perfusion that still preserve the diagnostic efficiency of the derived parametric maps. Ninety stroke CT examinations from four clinical sites with 1 s temporal sampling and a range of tube loads (mAs) (100–180) were studied. Realistic CT noise was retrospectively added to simulate a CT perfusion protocol, with a maximum reduction of 40% tube load (mAs) combined with increased sampling intervals (up to 3 s). Perfusion maps from the original and simulated protocols were compared by: (a) similarity using a voxel-wise Pearson’s correlation coefficient r with in-house software; (b) volumetric analysis of the infarcted and hypoperfused volumes using commercial software. Pearson’s r values varied for the different perfusion metrics from 0.1 to 0.85. The mean slope of increase and cerebral blood volume present the highest r values, remaining consistently above 0.7 for all protocol versions with 2 s sampling interval. Reduction of the sampling rate from 2 s to 1 s had only modest impacts on a TMAX volume of 0.4 mL (IQR −1–3) (p = 0.04) and core volume of −1.1 mL (IQR −4–0) (p < 0.001), indicating dose savings of 50%, with no practical loss of diagnostic accuracy. The lowest possible dose protocol was 2 s temporal sampling and a tube load of 100 mAs.

Percutaneous image-guided thermal ablation is an established form of treatment of small volume hepato-pancreatico-biliary (HPB) tumors with very satisfactory results over the last three decades. Purpose of this article is to offer a brief overview of the history of thermal ablation and the currently available technology that interventional radiologists have in their armamentarium to offer minimally invasive thermally for HPB cancer.

PURPOSE To evaluate foot perfusion in patients with critical limb ischemia (CLI) using quantitative perfusion multi-detector-row CT and estimate perfusion parameter changes before and after percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS This prospective study investigated 13 patients (10 men; median age, 72 y; range, 51-84 y) with CLI who underwent CT foot perfusion examinations with a 128-slice dual-energy CT scanner 1 day before and 1 week after PTA. Key parameters such as permeability surface (PS), blood volume (BV), and blood flow (BF) were analyzed and compared statistically. The studies were also examined by a second observer to determine interobserver reproducibility. RESULTS Revascularization was technically successful in all patients, and mean ankle-brachial index increased from 0.36 ± 0.16 to 0.75 ± 0.22. After revascularization, mean BV increased from 1.55 mL/100 g ± 0.83 to 4.51 mL/100 g ± 1.53, BF increased from 16.28 mL/100 g/min ± 4.97 to 31.49 mL/100 g/min ± 6.86, and PS increased from 3.1 mL/min/100 g ± 1.95 to 8.67 mL/min/100 g ± 3.85 (P < .05). Patients with poor response to revascularization who finally underwent amputation presented lower post-PTA perfusion parameters values than patients with significant clinical improvement (P < .05). All measurements demonstrated very good interobserver reproducibility, and intraclass correlation coefficients were 0.91 for BV, 0.94 for BF, and 0.95 for PS. The mean effective dose of the examination was estimated at 0.29 mSv. CONCLUSIONS CT foot perfusion is a reproducible technique that may be a useful modality for the estimation of PTA outcome. Significant restitution of perfusion parameters was observed after successful revascularization.

Objectives: To accurately determine and compare patient radiation burden from routine multi-phase CT (MPCT) and dynamic CT liver perfusion (CTLP) studies taking into account the effect of iodine uptake of exposed tissues/organs. Materials and Methods: 40 consecutive MPCT of upper abdomen and 40 consecutive CTLP studies performed on a modern CT scanner were retrospectively studied. Iodine uptake of radiosensitive tissues at the time of acquisition was calculated through the difference of tissues’ CT numbers between NECT and CECT images. Monte Carlo simulation and mathematical anthropomorphic phantoms were employed to derive patient-size-specific organ dose data from each scan involved taking into account the effect of iodinated contrast uptake on absorbed dose. Effective dose estimates were derived for routine multiphase CT and CTLP by summing up the contribution of NECT and CECT scans involved. Results: The mean underestimation error in organ doses from CECT exposures if iodine uptake is not encountered was found to be 2.2%–38.9%. The effective dose to an average-size patient from routine 3-phase CT, 4-phase CT and CTLP studies was found to be 20.6, 27.7 and 25.8 mSv, respectively. Effective dose from CTLP was found lower than 4-phase CT of upper abdomen irrespective of patient body size. Compared to 3-phase CT, the radiation burden from CTLP was found to be higher for average size-patients but again lower for overweight patients. Conclusions: Modern CT technology allows CTLP studies at comparable or even lower patient radiation burden compared to routine multi-phase liver CT imaging.

Purpose The purpose of this study was to correlate diffusion and perfusion quantitative and semi-quantitative MR parameters, on patients with peripheral arterial disease. In addition, we investigated which perfusion model better describes the behavior of the dynamic contrast-enhanced (DCE) MR data signal on ischemic regions of the lower limb. Methods Linear and nonlinear least squares algorithms, were incorporated for the quantification of the parameters through a variety of widely used models, able to extract physiological information from each imaging technique. All numerical calculations were implemented in Python 3.5 and include the: Intra voxel incoherent motion for diffusion and Patlak's, Extended Toft's and Gamma Capillary Transit time (GCTT) models for perfusion MRI. Results Our initial voxel by voxel correlation analysis didn't show any significant correlation based on the Pearson's Correlation metric between diffusion and perfusion parameters. To account for the inherited noise from the raw data, a Gaussian filter was applied to the parametric maps in order for the data to be comparable. By repeating our analysis in the filtered image maps, a good correlation (>0.5) of diffusion and perfusion parameters was achieved. Conclusions Perfusion and diffusion MRI quantitative and semi-quantitative parameters can be obtained through a variety of physiological-pharmacokinetic models. This paper compares most of the widely-known models and parameters in both techniques with data from patients with peripheral arterial disease. Initial analysis showed no correlation in the perfusion parametric maps of DWI and DCE MRI data but a good correlation was obtained after smoothing the parametric maps indicating that perfusion information could be obtained from diffusion MRI images in patients with peripheral arterial disease.

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer related death worldwide. Radiology has traditionally played a central role in HCC management, ranging from screening of high-risk patients to non-invasive diagnosis, as well as the evaluation of treatment response and post-treatment follow-up. From liver ultrasonography with or without contrast to dynamic multiple phased CT and dynamic MRI with diffusion protocols, great progress has been achieved in the last decade. Throughout the last few years, pathological, biological, genetic, and immune-chemical analyses have revealed several tumoral subtypes with diverse biological behavior, highlighting the need for the re-evaluation of established radiological methods. Considering these changes, novel methods that provide functional and quantitative parameters in addition to morphological information are increasingly incorporated into modern diagnostic protocols for HCC. In this way, differential diagnosis became even more challenging throughout the last few years. Use of liver specific contrast agents, as well as CT/MRI perfusion techniques, seem to not only allow earlier detection and more accurate characterization of HCC lesions, but also make it possible to predict response to treatment and survival. Nevertheless, several limitations and technical considerations still exist. This review will describe and discuss all these imaging modalities and their advances in the imaging of HCC lesions in cirrhotic and non-cirrhotic livers. Sensitivity and specificity rates, method limitations, and technical considerations will be discussed.

Purpose Institutional (local) Diagnostic Reference Levels for Cerebral Angiography (CA), Percutaneous Transhepatic Cholangiography (PTC), Transarterial Chemoembolization (TACE) and Percutaneous Transhepatic Biliary Drainage (PTBD) are reported in this study. Materials and methods Data for air kerma-area product (PKA), air kerma at the patient entrance reference point (Ka,r), fluoroscopy time (FT) and number of images (NI) as well as estimates of Peak Skin Dose (PSD) were collected for 142 patients. Therapeutic procedure complexity was also evaluated, in an attempt to incorporate it into the DRL analysis. Results Local PKA DRL values were 70, 34, 189 and 54 Gy.cm2 for CA, PTC, TACE and PTBD respectively. The corresponding DRL values for Ka,r were 494, 194, 1186 and 400 mGy, for FT they were 9.2, 14.2, 27.5 and 22.9 min, for the NI they were 844, 32, 602 and 13 and for PSD they were 254, 256, 1598 and 540 mGy respectively. PKA for medium complexity PTBD procedures was 2.5 times higher than for simple procedures. For TACE, the corresponding ratio was 1.6. PSD was estimated to be roughly 50% of recorded Ka,r for procedures in the head/neck region and 10% higher than recorded Ka,r for procedures in the body region. In only 5 cases the 2 Gy dose alarm threshold for skin deterministic effects was exceeded. Conclusion Procedure complexity can differentiate DRLs in Interventional Radiology procedures. PSD could be deduced with reasonable accuracy from values of Ka,r that are reported in every angiography system.

Background: Hepatocellular carcinoma (HCC) can be treated by local and regional methods of percutaneous interventional radiological techniques. Indications depend on tumor size, type and stage, as well as patient’s condition, liver function and co-morbidities. According to international classification systems such as Barcelona Clinic Liver Cancer (BCLC) classification, very early, early or intermediate staged tumors can be treated either with ablative methods or with transarterial chemoembolization (TACE), depending on tumor characteristics. The combination of both allows for individualized forms of treatment with the ultimate goal of improving response and survival. In recent years, a lot of research has been carried out in combining locoregional approaches with immune therapy. Although recent developments in systemic treatment, especially immunotherapy, seem quite promising and have expanded possible combined treatment options, there is still not enough evidence in their favor. The aim of this review is to provide a comprehensive up-to-date overview of all these techniques, explaining indications, contraindications, technical problems, outcomes, results and complications. Moreover, combinations of percutaneous treatment with each other or with immunotherapy and future options will be discussed. Use of all those methods as down-staging or bridging solutions until surgery or transplantation are taken into consideration will also be reviewed. Conclusion: Local and regional therapies remain a mainstay of curative and palliative treatment of patients with HCC. Currently, evidence on potential combination of the local and regional treatment options with each other as well as with other treatment modalities is growing and has the potential to further individualize HCC therapy. To identify the most suitable treatment option out of these new various options, a repeated interdisciplinary discussion of each case by the tumor board is of utmost importance.

To investigate the potential of decreasing the number of scans and associated radiation exposure involved in CT liver perfusion (CTLP) dynamic studies for hepatocellular carcinoma (HCC) assessment.Twenty-four CTLP image datasets of patients with HCC were retrospectively analyzed. All examinations were performed on a modern CT system using a standard acquisition protocol involving 35 scans with 1.7 s interval. A deconvolution-based or a standard algorithm was employed to compute ten perfusion parametric maps. 3D ROIs were positioned on 33 confirmed HCCs and non-malignant parenchyma. Analysis was repeated for two subsampled datasets generated from the original dataset by including only the (a) 18 odd-numbered scans with 3.4 s interval and (b) 18 first scans with 1.7 s interval. Standard and modified datasets were compared regarding the (a) accuracy of calculated perfusion parameters, (b) power of parametric maps to discriminate HCCs from liver parenchyma, and (c) associated radiation exposure.When the time interval between successive scans was doubled, perfusion parameters of HCCs were found unaffected (p 0.05) and the discriminating efficiency of parametric maps was preserved (p 0.05). In contrast, significant differences were found for all perfusion parameters of HCCs when acquisition duration was reduced to half (p 0.05), while the discriminating efficiency of four parametric maps was significantly deteriorated (p 0.05). Modified CTLP acquisition protocols were found to involve 48.5% less patient exposure.Doubling the interscan time interval may considerably reduce radiation exposure from CTLP studies performed for HCC evaluation without affecting the diagnostic efficiency of perfusion maps generated with either standard or deconvolution-based mathematical model.• CT liver perfusion for HCC diagnosis/assessment is not routinely used in clinical practice mainly due to the associated high radiation exposure. • Two alternative acquisition protocols involving 18 scans of the liver were compared with the standard 35-scan protocol. • Increasing the time interval between successive scans to 3.4 s was found to preserve the accuracy of computed perfusion parameters derived with a standard or a deconvolution-based model and to reduce radiation exposure by 48.5%.

Inferior mesenteric arteriovenous fistula (IMAVF) is a rare condition with 40 reported cases. It can be of congenital, idiopathic or acquired etiology. Acquired IMAVF occurs after trauma or has an iatrogenic origin due to abdominal interventions, mainly operations involving the left hemi-colon. A new case of iatrogenic IMAVF is described, which became symptomatic 13 years after right hemicolectomy and was diagnosed radiologically one year later. This case was treated successfully by means of endovascular arterial embolization. To our knowledge, this is only the second reported case of acquired IMAVF following right hemicolectomy.

Acute pulmonary embolism (PE) is a life-threatening disorder with high mortality. A prompt diagnosis and treatment is essential for reducing the mortality rate. The purpose of the study is to evaluate if lung perfusion scintigraphy (LPS) continues to have a role in the clinical management of patients suspected of pulmonary embolism in the CT pulmonary angiography (CTPA) era. For this study, 1183 patients who had been subjected to LPS were retrospectively evaluated and classified into the following groups: A (positive LPS), B (negative LPS) and C (indeterminate LPS). Patients were further classified into A1 (‘PE likely’ and LPS-negative), B1 (PE unlikely and LPS-positive) and C1 (PE likely and indeterminate LPS) by combining the LPS findings and the clinical pretest probability (cpp). Subgroups A1, B1 and C1 underwent additional CTPA. Groups A, B, and C included 1086/1183, 69/1183 and 28/1183 patients, respectively. The proportion of patients with inconsistent cpp LPS findings who underwent additional CTPA was 106/1183 patients: subgroup A1 (n = 73), B1 (n = 21), and C1 (n = 12). In subgroup A1, CTPA was negative in 61/73, non-diagnostic in 12/73 and positive in 0/73 patients. In subgroup B1, CTPA excluded PE in 2/21, non-diagnostic in 3/21 and positive in 16/21 patients. In group C1, CTPA was negative in 8/12, positive in 2/12 and non-diagnostic in 2/12 patients. In the CTPA era, LPS continues to have a role in the clinical management of patients suspected of PE.

Purpose To investigate the effect of scan projection radiography (SPR) coverage on tube current modulation in pediatric and adult thoracic CT examinations. Methods Sixty pediatric and 60 adult chest CT examinations were retrospectively studied to determine the incidence rate of examinations involving SPRs that did not include the entire image volume (IV) or the entire primarily exposed body volume (PEBV). The routine chest CT acquisition procedure on a modern 64-slice CT system was imitated on five anthropomorphic phantoms of different size. SPRs of varying length were successively acquired. The same IV was prescribed each time and the computed tube current modulation plan was recorded. The SPR boundaries were altered symmetrically by several steps of ±10 mm with respect to the IV boundaries. Results The upper IV boundary was found to be excluded from SPR in 52% of pediatric and 40% adult chest CT examinations. The corresponding values for the lower boundary were 15% and 20%, respectively. The computed tube current modulation was found to be considerably affected when the SPR did not encompass the entire IV. SPR deficit of 3 cm was found to induce up to 46% increase in the computed tube current value to be applied during the first tube rotations over lung apex. Conclusions The tube current modulation mechanism functions properly only if the IV set by the operator is entirely included in the localizing SPR image. Operators should cautiously set the SPR boundaries to avoid partial exclusion of prescribed IV from SPRs and thus achieve optimum tube current modulation.

Background Computed tomography liver perfusion (CTLP) has been improved in recent years, offering a variety of perfusion-parametric maps. A map that better discriminates hepatocellular carcinoma (HCC) is still to be found. Purpose To compare different CTLP maps, regarding their ability to differentiate cirrhotic or non-cirrhotic parenchyma from malignant HCC. Material and Methods Twenty-six patients (11 cirrhotic) with 50 diagnosed HCC lesions, underwent CTLP on a 128-row dual-energy CT system. Nine different maps were generated. Regions of interest (ROIs) were positioned on non-tumorous parenchyma and on HCCs found on previous magnetic resonance imaging. Perfusion parameters for non-cirrhotic and cirrhotic livers were compared. Receiver operating characteristic (ROC) analysis was employed to evaluate each map’s ability to discriminate HCCs from non-tumorous livers. Comparison of ROC curves was performed to evaluate statistical significance of differences in the discriminating efficiency of derived perfusion maps. Results Perfusion parameters for non-tumorous liver and HCCs recorded in cirrhotic patients did not significantly differ from corresponding values recorded in non-cirrhotic patients ( P > 0.05). The highest power for HCC discrimination was found for the maximum-slope-of-increase (MSI) parametric map, with estimated the area under ROC curve of 0.997. An MSI cut-off criterion of 2.2 HU/s was found to provide 96% sensitivity and 100% specificity. Time to peak, blood flow, and transit time to peak were also found to have high discriminating power. Conclusion Among available CTLP-derived perfusion parameters, MSI was found to provide the highest diagnostic accuracy in discriminating HCCs from non-tumorous parenchyma. Perfusion parameters for non-tumorous livers and HCCs were not found to significantly differ between cirrhotic and non-cirrhotic patients.

Anomalous origin of the left coronary artery arising from the pulmonary artery (ALCAPA or Bland-White-Garland syndrome) is a rare but serious congenital coronary artery anomaly, with a poor prognosis without surgical repair. There are two types of ALCAPA syndrome: infant type and adult type. We present a rare case of a 63-year-old female patient, with isolated left anterior descending artery origin from the pulmonary artery. Coronary computed tomography angiography revealed giant and tortuous coronary arteries with many collaterals between the left and right coronary system. The patient refused any surgical treatment.

Purpose To assess the underestimation of radiation dose to the thyroid of children undergoing contrast enhanced CT if contrast medium uptake is not taken into account. Methods 161 pediatric head, head & neck and chest CT examinations were retrospectively studied to identify those involving pre- and post-contrast imaging and thyroid inclusion in imaged volume. CT density of thyroid tissue in HU was measured in non-enhanced (NECT) and corresponding contrast-enhanced CT (CECT) images. Resulting CT number increase (ΔHU) was recorded for each patient and corresponded to a % w/w iodine concentration. The relation of %w/w iodine concentration to %dose increase induced by iodinated contrast uptake was derived by Monte Carlo simulation experiments. Results The thyroid gland was visible in 11 chest and 3 neck CT examinations involving both pre- and post-contrast imaging. The %w/w concentration of iodine in the thyroid tissue at the time of CECT acquisition was found to be 0.13%–0.58% w/w (mean = 0.26%). The %increase of dose to thyroid tissue was found to be linearly correlated to%w/w iodine uptake. The increase in radiation dose to thyroid due to contrast uptake ranged from 12% to 44%, with a mean value of 23%. Conclusions The radiation dose to the pediatric thyroid from CECT exposure may be underestimated by up to 44% if contrast medium uptake is not taken into account. Meticulous demarcation of imaged volume in pediatric chest CT examinations is imperative to avoid unnecessary direct exposure of thyroid, especially in CT examinations following intravenous administration of contrast medium.

An 88-year-old male patient of high surgical risk was presented with left sciatic pain symptoms and a palpable pulsatile left lower abdominal mass. He was operated 8 years ago for a large infrarenal aortic aneurysm. Computed tomography angiography (CTA) revealed a giant 161 mm left internal iliac aneurysm with multilocular appearance and left sacral bone erosion causing the symptoms. Endovascular repair was successfully performed using a monotubular iliac stent-graft. Follow-up CTA showed absence of contrast enhancement and a fully thrombosed sac. Patient recovered completely and was discharged 1 month after the procedure in a relatively good condition, nevertheless sciatic symptoms remained.

Background: Erdheim-Chester disease (ECD) is a rare hematopoietic neoplasm of histiocytic origin characterized by an insidious course. The coronavirus disease 2019 (COVID-19) pandemic has put an enormous strain on healthcare systems worldwide both directly and indirectly, resulting in the disruption of healthcare services to prevent, diagnose and manage non-COVID-19 disease. Case Presentation: We describe the case of a 58-year-old male patient with sporadic episodes of self-resolving mild fever and anemia of chronic disease with onset two years before the current presentation. Positron emission/computed tomography scan revealed the presence of moderately hypermetabolic perirenal tissue masses. In order to achieve diagnosis, repeated perirenal tissue biopsies were performed, and the diagnostic evaluation was complicated by the strain put on the healthcare system by the COVID-19 pandemic. The patient contracted SARS-CoV-2 and required hospitalization, but recovered fully. No further ECD target organ involvement was documented. Treatment options were presented, but the patient chose to defer treatment for ECD. Conclusion: A high index of suspicion and multidisciplinary team collaboration is paramount to achieve diagnosis in rare conditions such as ECD. Disruptions in healthcare services in the pandemic milieu may disproportionately affect people with rare diseases and further study and effort is required to better meet their needs in the pandemic setting.

The left common carotid artery usually bifurcates to the internal and external carotids at or near the superior border of thyroid cartilage. In head and neck surgery, the common carotid arteries are important landmarks, defining the plane of dissection during radical neck surgeries. According to the literature, many variations exist regarding the carotid bifurcation. Anatomical knowledge of these variants is important for surgical approaches in the head and neck regions, to avoid devastating complications that may occur, mainly during anterior neck dissections. We report an interesting case of a 75-year-old male patient with low bifurcation of the left common carotid artery, accidentally found during a routine carotid Doppler ultrasonography. Bifurcation was located at the C7-Th1 intervertebral disc height, approximately 4 cm from the aortic arch.

Cytomegalovirus (CMV) rarely causes disease in immunocompetent individuals but may cause severe disease in immunocompromised patients. We report the case of a young woman who had undergone multiple transfusions and splenectomy for homozygous β-thalassemia. She presented with prolonged fever and respiratory distress. Although broad-spectrum antibiotic therapy had initially been administered, the patient had clinically deteriorated. Serology and molecular blood testing established CMV infection and viremia. Computed tomography of the chest demonstrated pneumonitis and she was successfully treated with a 3-week administration of ganciclovir. In β-thalassemia patients who undergo splenectomy necessitating multiple blood transfusions, CMV infection should be considered as a differential diagnosis.

Purpose: To study the necessity of coronary artery screening with computerized tomography coronary angiography (CTCA) in asymptomatic male patients. Material and methods: A total of 226 asymptomatic male patients aged over 50 years were included in this prospective study, according to a clinical protocol approved by the Heraklion University Hospital's Ethics Committee. All participants had at least 3 or more known atherosclerosis risk factors. All patients had none or normal noninvasive cardiological tests in the past and had no contraindications for CTCA. All patients gave their informed consent after being notified regarding contrast medium and radiation dose risks. Results: Significant stenoses were found in 52 asymptomatic males (23%). Out of them, 38 male patients underwent invasive coronography and 14 patients were lost in follow-up. In 18 patients, no lesions were found (47.4%). In the other 20 (52.6%) patients, 28 lesions were found. Stent placement was performed in 11 patients, bypass surgery was proposed in 3 patients, and in another 6 patients conservative treatment was suggested. Patients with findings in CTCA were more likely to have a family history of coronary artery disease, compared to patients with normal CTCA (P < 0.05 by using Fischer's Exact Test). Sensitivity of CTCA for significant stenosis was 74.3% with a specificity of 62%. Conclusion: CTCA may be used to screen for clinically significant coronary artery disease (CAD) in asymptomatic male patients, particularly those with positive family history or potentially high-risk patients with >3 risk factors for CAD.

Early diagnosis of HCC is of paramount importance in order to enable the application of curative treatments. Among these, radiofrequency ablation (RFA) is actually considered the most effective ablative therapy for early stage hepatocellular carcinoma (HCC) not suitable for surgery. On the other hand, transarterial chemoembolization (TACE) represents the standard of care for intermediate stage HCC and compensated liver function. Finally, sorafenib, an oral antiangiogenic targeted drug, is the only approved systemic therapy for advanced HCC with vascular invasion, extrahepatic spread, and well-preserved liver function. Beside traditional radiological techniques, new functional imaging tools have been introduced in order to provide not only morphological information but also quantitative functional data. In this review, we analyze perfusion-CT (pCT) from a technical point of view, describing the main different mathematical analytical models for the quantification of tissue perfusion from acquired CT raw data, the most commonly acquired perfusion parameters, and the technical parameters required to perform a standard pCT examination. Moreover, a systematic review of the literature was performed to assess the role of pCT as an emerging imaging biomarker for HCC diagnosis, response evaluation to RFA, TACE, and sorafenib, and we examine its challenges in HCC management.

Percutaneous cholecystostomy is an established drainage procedure for the management of high-risk patients with acute cholecystitis. However, percutaneous image-guided access to the gallbladder may not be limited to the simple placement of a drain, but may also be used as an alternative approach to the biliary tree through the catheterization of the cystic duct, for a variety of other more complicated conditions. Percutaneous transcholecystic interventions may be performed in both malignant and benign disease. In the case of malignant jaundice, the transcholecystic route may be used when the liver parenchyma is occupied by metastatic lesions and transhepatic access is not possible. In benign conditions, access through the gallbladder may offer a solution if the biliary tree is not dilated. The transcholecystic access may then be route of insertion of large sheaths, internal drainage catheters, lithotripsy devices, stone retrieval baskets, and stents. The purpose of this review is to illustrate the techniques and to discuss the indications, complications, and technical difficulties of this alternative access to the biliary tree.

Background: Covered biliary stents have shown significant effectiveness in the palliative management of patients with malignant biliary disease due to prevention of tumour ingrowth. However, stent dysfunction may still occur due to growth of tumour at the borders of the covered stent (tumour overgrowth). The aim of this study is to assess the effectiveness of a bare extension in the prevention of tumour overgrowth when covered stents are used in the palliative treatment of malignant biliary strictures. Methods: This is a prospective, single arm, cohort study. Twenty-two patients with inoperable malignant biliary strictures in the distal common bile duct (Bismuth I−II) and life expectancy more than 6 months were included in the study. The combination of a fully covered biliary stent and a bare proximal and distal extension was used in all cases. All patients were followed-up until death. Primary patency, survival, complication rates and dysfunction cause were assessed. Results: Mean survival was 263.7 days (median 255, SD: 77.6). Mean patency was 240 days (median: 237, SD: 87). The primary patency rate at 3, 6 and 12 months was 90%, 86% and 86% respectively. Tumour in- or overgrowth did not occur in any of the patients. Dysfunction due to sludge formation occurred in three cases; all three were treated with bilioplasty. Conclusions: The combined use of a covered biliary stent and a bare extension appears to be a very effective tool in the palliation of malignant biliary disease, offering long-term patency for patients with inoperable malignant distal common bile duct strictures and increasing the quality of life of such patients.

To investigate the effect of iodine uptake on tissue/organ absorbed doses from CT exposure and its implications in CT dosimetry. The contrast-induced CT number increase of several radiosensitive tissues was retrospectively determined in 120 CT examinations involving both non-enhanced and contrast-enhanced CT imaging. CT images of a phantom containing aqueous solutions of varying iodine concentration were obtained. Plots of the CT number increase against iodine concentration were produced. The clinically occurring iodine tissue uptake was quantified by attributing recorded CT number increase to a certain concentration of aqueous iodine solution. Clinically occurring iodine uptake was represented in mathematical anthropomorphic phantoms. Standard 120 kV CT exposures were simulated using Monte Carlo methods and resulting organ doses were derived for non-enhanced and iodine contrast-enhanced CT imaging. The mean iodine uptake range during contrast-enhanced CT imaging was found to be 0.02-0.46% w/w for the investigated tissues, while the maximum value recorded was 0.82% w/w. For the same CT exposure, iodinated tissues were found to receive higher radiation dose than non-iodinated tissues, with dose increase exceeding 100% for tissues with high iodine uptake. Administration of iodinated contrast medium considerably increases radiation dose to tissues from CT exposure. • Radiation absorption ability of organs/tissues is considerably affected by iodine uptake • Iodinated organ/tissues may absorb up to 100 % higher radiation dose • Compared to non-enhanced, contrast-enhanced CT may deliver higher dose to patient tissues • CT dosimetry of contrast-enhanced CT imaging should encounter tissue iodine uptake

We report the case of a 71-year-old female patient with previous history of rectal cancer. The primary cancer was resected and three cycles of chemotherapy were completed. Excision of metastatic lesions was also performed from the left liver lobe. Due to the presence of new liver lesions on the right lobe, intra-operative microwave ablation was decided. Three hours post ablation the patient bled massively and angiography revealed extravasation from a peripheral branch of the right hepatic artery. Successful embolization was performed; however, the patient died 5 days later on liver failure. We would like to present the case and discuss the technical options and the key points to help avoiding similar complications in the future.

Percutaneous embolization was introduced in the mid-'70s and is now an established therapeutic procedure in current medical practice. With the use of improved imaging techniques, smaller profile catheters and new tools, embolization boundaries are significantly expanded in the last decades. Detachable coils were initially introduced in neuroradiology and are now part of the everyday peripheral embolization armamentarium. Purpose of this review article is to present an overview of the expanded possibilities that this novel material is offering in the field of peripheral embolization procedures.

A 69-year-old man with portal hypertension was admitted with decompensated alcoholic cirrhosis and diuretic resistant ascites. Ultrasound revealed partial portal thrombosis. Due to diuretic intolerance, transjugular intrahepatic portosystemic shunt (TIPS) was decided during which a hepatic arterial branch was inadvertently catheterized. Finally, TIPS was created, but the patient continued gaining weight. Color-Doppler ultrasonography (CDUS) showed upper stent part patency with absence of flow in lower stent portion. Twenty-five days later, the patient presented melena. Endoscopy revealed blood emerging from the Vater papilla. Hepatic angiography revealed arteriovenous shunt between a hepatic arterial branch and the proximal part of the TIPS shunt. Covered stent placement restored sufficient TIPS flow. The patient deteriorated and died 1 month later. We found out that our major technical drawback was that we did not inject a small amount of contrast after puncturing the supposed portal vein, in order to confirm correct position of the needle.

A 32-year-old male with Budd-Chiari syndrome secondary to paroxysmal nocturnal haemoglobinuria (PNH) underwent direct portosystemic shunt (DIPS). The procedure was difficult, and after initial attempts without success via the internal jugular vein, a stent was placed with ultrasound (US) guidance via femoral approach. Unfortunately, following these two prolonged DIPS procedures, two weeks apart, the patient developed contrast-induced nephropathy, precluding further use of conventional contrast media and necessitating an alternative imaging modality to assess stent function. Transabdominal US was unable to clearly visualize the stent, so intravascular ultrasound (IVUS) was utilized. Good quality images were obtained and the stent's patency was accurately evaluated, identifying the presence of thrombus and leading to balloon angioplasty and improved flows. IVUS may be useful for DIPS stent evaluation.

The purpose of this study was to compare the clinical effectiveness of expanded polytetrafluoroethylene/fluorinated-ethylene-propylene (ePTFE/FEP)-covered stents with that of uncovered nitinol stents for the palliation of malignant jaundice caused by inoperable pancreatic head cancer. Eighty patients were enrolled in a prospective randomized study. Bare nitinol stents were used in half of the patients, and ePTFE/FEP-covered stents were used in the remaining patients. Patency, survival, complications, and mean cost were calculated in both groups. Mean patency was 166.0 ± 13.11 days for the bare-stent group and 234.0 ± 20.87 days for the covered-stent group (p = 0.007). Primary patency rates at 3, 6, and 12 months were 77.5, 69.8, and 69.8% for the bare-stent group and 97.5, 92.2, and 87.6% for the covered-stent group, respectively. Mean secondary patency was 123.7 ± 22.5 days for the bare-stent group and 130.3 ± 21.4 days for the covered-stent group. Tumour ingrowth occurred exclusively in the bare-stent group in 27.5% of cases (p = 0.002). Median survival was 203.2 ± 11.8 days for the bare-stent group and 247.0 ± 20 days for the covered-stent group (p = 0.06). Complications and mean cost were similar in both groups. Regarding primary patency and ingrowth rate, ePTFE/FEP-covered stents have shown to be significantly superior to bare nitinol stents for the palliation of malignant jaundice caused by inoperable pancreatic head cancer and pose comparable cost and complications. Use of a covered stent does not significantly influence overall survival rate; nevertheless, the covered endoprosthesis seems to offer result in fewer reinterventions and better quality of patient life.

To compare clinical effectiveness of Viabil-covered stents versus uncovered metallic Wallstents, for palliation of malignant jaundice due to extrahepatic cholangiocarcinoma, 60 patients were enrolled in a prospective and randomized study. In half of the patients a bare Wallstent was used, and in the other half a Viabil biliary stent. Patients were followed up until death. Primary patency, survival, complication rates, and mean cost were calculated in both groups. Stent dysfunction occurred in 9 (30%) patients in the bare stent group after a mean period of 133.1 days and in 4 (13.3%) patients in the covered stent group after a mean of 179.5 days. The incidence of stent dysfunction was significantly lower in the covered stent group (P = 0.046). Tumor ingrowth occurred exclusively in the bare stent group (P = 0.007). Median survival was 180.5 days for the Wallstent and 243.5 days for the Viabil group (P = 0.039). Complications and mean cost were similar in the two groups. Viabil stent-grafts proved to be significantly superior to Wallstents for the palliation of malignant jaundice due to extrahepatic cholangiocarcinoma, with comparable cost and complication rates. Appropriate patient selection should be performed prior to stent placement.

We report the case of a 78-year-old male patient with obstructive jaundice due to a pancreatic head neoplasm. The patient's general condition did not permit an endoscopic approach and the presence of diffuse liver metastases prohibited hepatic puncture for percutaneous biliary drainage, therefore the transcolecystic transperitoneal approach was decided to be the safest decompression route. Through a gallbladder access, a Viabil-covered stent with a mesh extension was placed in the distal common bile duct, without complications. The patient died 8 months later without signs of stent dysfunction or necessity of reintervention. Transcholecystic transperitoneal access is a safe option when diffuse liver metastases prohibit the transhepatic approach, even in cases where placement of a covered stent is considered necessary.

We report a case of a 33-year-old female patient with Budd-Chiari syndrome because of polycythemia vera. A transjugular intrahepatic portal-systemic shunt was performed because of refractory ascites 7 months after diagnosis. She had a stable hepatic function receiving anticoagulants until 3 years later when she presented with bloody diarrheas, liver function deterioration with prolonged prothrombin time and hypoalbuminemia, encephalopathy, and ascites. Colonoscopy revealed ulcerative pancolitis and the patient was treated with corticosteroids and antibiotics. Hepatic function was stabilized in parallel to controlling ulcerative colitis and the patient is in good health until now receiving maintenance therapy for ulcerative colitis and anticoagulants for Budd-Chiari syndrome.

We report a case of simultaneous late migration of two ePTFE-FEP covered biliary endoprostheses (Viabil, W.L. Gore, Flagstaff, AZ, USA) that were percutaneously implanted for the treatment of malignant obstructive jaundice. The first Viabil covered stent was placed successfully without any evidence of dislocation or other complication during follow-up. Occlusion of the stent occurred 4 months later and was treated with the placement of a second stent of the same type. Thirteen months later the patient became symptomatic. Percutaneous transhepatic cholangiography (PTC) revealed the presence of a choledocho-duodenal fistula and the disappearance of the two endoprostheses previously implanted. A third metallic stent was then percutaneously positioned through the bilioenteric fistula. The computed tomography scan that followed for the detection of the metallic bodies did not reveal the dislocated metallic stents. Stent migration is a well-known complication of uncovered metallic stents, though Viabil stent migration is assumed to be most unlikely to happen due to the stent's anchoring barbs. Furthermore, the stent had already been tightly fixed by tumor over- and ingrowth, as recognized in previous imaging. This is a very unusual case, describing the disappearance of two metallic foreign bodies encapsulated by tumor.

The vast majority of cases of malignant jaundice are due to a non-operable tumour. Palliation is of paramount importance for the quality of life of such patients. Stents have an established role in the palliation of malignant biliary disease, aiming for drainage of bile towards the duodenum and the resolution of jaundice. The first stents that were introduced in clinical practice were plastic; these were soon replaced by self-expandable metallic stents because of their longer patency. However, bare metallic stents tend to become occluded by tumour in-growth and therefore covered metallic stents were developed. We describe a case where a covered metallic stent was used for the palliation of a patient with malignant jaundice due to a pancreatic adenocarcinoma, and we review the current evidence in the literature.

We report a case of an 80-year-old man, who underwent an endovascular repair of an abdominal aortic aneurysm. Surgical access was obtained from both common femoral arteries, and the procedure was uneventful. One month computed tomography (CT) follow-up was without findings. Two months after endovascular aortic aneurysm repair (EVAR), the patient complained of claudication on the left side associated with persistent pain, rigid swelling on the left groin area, and occasional febrile episodes within the last month. Ultrasonography showed fluid collection, and needle aspiration gained pus. It was thought to be local postsurgical infection, and the patient got antibiotics, but he did worse. One month later, computed tomography revealed focal left common femoral artery (CFA) stenosis, edematous appearance of subcutaneous soft tissue in the left groin area, and anterior displacement of the ipsilateral CFA in relation to the right side. Surgical exploration of the region revealed retained, uncapsuled, and partially destroyed surgical gauze, lying just behind the left CFA, which was removed.

Stand up paddle (SUP) surfing, a variant of ocean surfing, is becoming very popular because it can be performed at any level of difficulty and thus attracts athletes from a wide range of ages. Unlike ocean surfing, limited data exist on injuries related to SUP surfing. We report the first case of a 28-year-old athlete who developed myelopathy during his first SUP surfing session. Clinical examination revealed severe neurological deficit, which had not subsided fully at the 28-month follow-up.

Arteriovenous malformations of the head and neck are rare lesions with unclear pathogenesis. They usually present during childhood, growing proportionately to the child. Although preoperative superselective embolization followed by surgical resection is the treatment of choice, complete removal is often not feasible, leading to high recurrence rates. The case of a patient with an arteriovenous malformation of the floor of the mouth diagnosed late in her adulthood and its management are presented.

Hepatic involvement in hereditary hemorrhagic telangiectasia is infrequent and poorly studied. We describe a 62-year-old woman with Rendu-Osler-Weber (ROW) disease and recurrent gastrointestinal bleeding episodes. Blood chemistry was consistent with the presence of cholestasis. Imaging studies revealed prominent vascular abnormalities in the liver and focal intrahepatic bile duct dilatations. The intimate anatomic relationship of the vascular abnormalities to the dilated bile ducts suggests that external vascular compression could have caused their dilatation. To our knowledge, this mechanism has not been proposed in the literature as a possible explanation of biliary dilatation in patients with ROW.

We report a case of an 86-year-old female patient who presented with a septic, right ureteric obstruction, caused by a symptomatic Bochdalek hernia. The patient was initially managed with percutaneous nephrostomy and final treatment was achieved by placement of an external-internal nephroureteral double pigtail.

To evaluate the necessity of metallic stenting of the sphincter of Oddi in malignant obstructive jaundice when the tumor is more than 2 cm from the papilla of Vater.Sixty-seven self-expandable biliary stents were used in 60 patients with extrahepatic lesions of the common hepatic or common bile duct and with the distal margin of the tumor located more than 2 cm from the papilla of Vater. Stents were placed above the papilla in 30 cases (group A) and in another 30 with their distal part protruding into the duodenum (group B).The 30-day mortality was 15%, due to the underlying disease. The stent occlusion rate was 17% after a mean period of 4.3 months. No major complications were noted. Average survival was 132 days for group A and 140 days for group B. In group A, 19 patients survivedor = 90 days and in eight of these, cholangitis occurred at least once. Of 11 patients in group A with survival90 days, only two developed cholangitis. In group B, 13 patients who survivedor = 90 days had no episodes of cholangitis and in 17 with survival90 days, cholangitis occurred in three. There is a statistically significant difference (p0.05) regarding the incidence of cholangitis in favor of group A.In patients with extrahepatic lesions more than 2 cm from the papilla and with a relative poor prognosis (or = 3 months), due to more advanced disease or to a worse general condition, the sphincter of Oddi should also be stented in order to reduce the postprocedural morbidity.

A solid pseudopapillary neoplasm (SPN) is an extremely rare tumour of the pancreas that frequently occurs in young females and is mostly benign. SPN is a low-grade malignant tumour that may evolve years before symptoms start. However, the pathogenesis of this tumour remains unclear and there are no adequate reports of long-term results to evaluate the management and the long-term surgical control. We describe a new case of SPN with a 10-year follow-up, and review the world literature that accounts for approximately 322 cases. Moreover, a review of the current management and surgical tendencies in the treatment of SPN is considered. An SPN pancreatic tumour occurred in a 24-year-old female who complained of episodic mild abdominal pain sustained by a palpable epigastric mass. The tumour mass was detected by ultrasound and computer tomography and was localised at the tail of the pancreas adherent to the spleen. The preoperative diagnosis was uncertain and en-block distal pancreatectomy and splenectomy were performed. The size of the mass which weighed 300 g was 11 x 12 x 8 cm, and the tumour was strictly adherent and invaded the splenic hilum. Histologic examination confirmed a complete resection of the primary SPN that locally invaded spleen. The postoperative period was uneventful and after a 10-year follow-up the patient is free of symptoms. SPN should be considered in the differential diagnosis of large pancreatic masses, especially in young females. Radical resection, where technically feasible, should be considered the therapy of choice as it is a safe and effective control of the disease.

To present our experience performing percutaneous cholangioscopy in the management of 25 patients with biliary disease.During the last 3 years, 26 percutaneous cholangioscopies were performed in 25 patients with common bile duct disease (n = 16), intrahepatic ducts disease (n = 6), and gallbladder disease (n = 4). Our patient population group included seven with common bile duct stones, three with intrahepatic lithiasis, and eight with benign strictures (six iatrogenic and two postinflammatory). In four patients malignancy was to be excluded, in two the tumor extent was to be evaluated, whereas in one case the correct placement of a metallic stent needed to be controlled. A 9.9 Fr flexible endoscope URF-P (Olympus, 1.2 mm working channel, 70-cm length) was used.In total, percutaneous cholangioscopy answered 30 diagnostic questions, was technically helpful in 19 cases (performing lithotripsy or biopsy or guiding a wire), and of therapeutic help in 12 (performing stone retrieval). In 24 of 26 cases the therapeutic decision and the patient management changed because of the findings or because of the help of the method. In two cases biliary intervention failed to treat the cause of the disease. No major complication due to the use of the endoscopy was noted.Percutaneous cholangioscopy is a very useful tool in the management of patients with biliary disease. The method can help in diagnosis, in performing complex interventional procedures, and in making or changing therapeutic decisions.