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Objectives: Cardiac magnetic resonance (CMR) imaging is a key test in the diagnosis of cardiac amyloidosis (CA). Extracardiac involvement is common in light chain (AL) amyloidosis and MRI findings may assist in its diagnosis. We sought to investigate the utility of splenic CMR parameters for the diagnosis of CA. Methods: Thirty-four patients with AL amyloidosis and 32 patients with severe left ventricular hypertrophy in the setting of aortic stenosis (LVH-AS) who completed 3T cardiac MRI at the time of their diagnosis of AL or LVH-AS were assessed with T1, T2 (modified Look-Locker inversion recovery), extracellular volume (ECV) mapping, and late gadolinium enhancement (LGE) imaging of the heart and spleen. Results: Age, left ventricular mass index, wall thickness, ejection fraction, and splenic dimensions did not differ significantly between groups. All AL patients had cardiac involvement. T1 and T2 spleen mapping did not differ significantly between groups but AL patients had higher median ECV in the spleen than in LVH-AS (AL 46.9%, LVH-AS: 31%, p < 0.001), and significantly lower short tau inversion recovery ratio (AL: 1.7, LVH-AS: 2.7, p < 0.001) both with very good diagnostic performance to diagnose AL. We identified 16 AL patients with spleen involvement and 16 without. Spleen ECV and “normalized” spleen ratio, defined as the ratio of spleen LGE to muscle values exhibited strong correlation and had excellent diagnostic performance to discriminate those with spleen involvement. Conclusion: Our findings show that spleen CMR parameters can identify spleen involvement in AL patients and differentiate them from those without AL amyloidosis. © 2022, The Author(s).

Purpose: This study aims to investigate the safety and efficacy of a new device using microwave technology for the endovenous ablation of the great saphenous vein (GSV) causing symptomatic lower limb varicose veins (LLVV). Materials and Methods: This prospective, single-arm, single-center, cohort study investigated the safety and effectiveness of endovenous microwave ablation for the treatment of symptomatic LLVV. Enrollment period was set between January and December 2020. Primary safety endpoint was the occurrence of procedure-related complications and primary efficacy endpoint was anatomical success defined as the duplex ultrasound (DUS)–proven GSV occlusion at 1 year follow-up. Secondary endpoints included 1-year clinical success (CEAP classification improvement), repeat procedures rate due to GSV recanalization, and pain assessment at 24 h post treatment. Results: In total, 50 patients (42 female; mean age: 62 ± 12 years) with 64 limbs were treated. No procedure-related complications were noted. Technical success was 95.3% (61/64 GSVs), as three cases of GSV recanalization were detected. Clinical success was 100%, as in all cases symptoms improvement by at least one grade according to CEAP classification, was achieved. Mean CEAP grade significantly improved from 3.3 ± 0.72 (median: 3) at baseline to 1.8 ± 0.85 (median: 2) at 1-year (p < 0.0001). There were no repeat procedures due to GSC recanalization. The median 24-h VAS value was 2 (mean: 1.9 ± 1.4). Conclusions: Endovenous microwave ablation was safe and effective for the treatment of varicose veins, achieving high 1-year GSV occlusion rates. © The Author(s) 2022.

Objective: To describe, assess the feasibility of, and quantify the long-term patency achieved with percutaneous transhepatic biliary dilation using the anastomotic biliary stricture (ABS) oversized balloon dilation technique as a single-step procedure for the treatment of benign anastomotic biliary strictures following hepatobiliary surgery. Materials and Methods: This was a retrospective, two-center study including 16 consecutive cases of symptomatic benign biliary-enteric strictures. After assessment of the diameter of the bile duct by computed tomography or magnetic resonance imaging, the strictures were dilated with oversized balloons (40–50% larger than the bile duct diameter) and an external biliary-enteric drain was placed. After drain removal, clinical symptoms and laboratory test results were evaluated every three months, whereas follow-up magnetic resonance imaging was performed at 30 days out and follow-up computed tomography was performed at 6 and 12 months out. Results: The mean follow-up time was 31.8 ± 8.15 months. Kaplan-Meier-estimated 1-, 2-, and 3-year patency rates were 88.2%, 82.4%, and 82.4%, respectively. There was one major complication—a small dehiscence of the anastomosis—which extended the catheter dwell time. Minor complications occurred in two cases—one small perihepatic hematoma and one segmental thrombosis of the left portal branch—neither of which required further intervention. Conclusion: The single-step ABS oversized balloon dilation technique is a feasible treatment for benign anastomotic biliaryenteric strictures. The technique appears to be associated with high rates of long-term clinical success and patency. © Colégio Brasileiro de Radiologia e Diagnóstico por Imagem.

Hepatocellular carcinoma is the most common primary malignant liver tumour and is a leading cause of death worldwide. Despite the advent of screening programmes, most cases of hepatocellular carcinoma are diagnosed late (in an advanced stage) which precludes curative treatments such as surgery and ablation. Therefore, intra-arterial locoregional treatments now play a central role in the management of advanced hepatocellular carcinoma, such treatments ranging from trans-arterial chemo-embolisation to the more recently developed trans-arterial radio-embolisation technique. In this essay, we discuss the state of the art of intra-arterial treatment for locally advanced hepatocellular carcinoma and the future directions for such treatment. © 2021, Colegio Brasileiro de Radiologia. All rights reserved.

Background and aims: Tenecteplase has recently emerged as an alternative thrombolytic agent in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO), possibly superior in achieving early reperfusion compared with alteplase. We aimed to compare the safety and efficacy of intravenous tenecteplase with intravenous alteplase for AIS patients with LVO in everyday clinical practice settings. Methods: We prospectively evaluated patients with AIS due to LVO, treated with intravenous thrombolysis (IVT) with or without mechanical thrombectomy in two tertiary stroke centers. Patients were treated with standard-dose alteplase (0.9 mg/kg) or 0.25 mg/kg tenecteplase. Safety outcomes included prevalence of symptomatic intracranial hemorrhage (sICH) and mortality. Efficacy outcomes included averted thrombectomy, major neurological improvement at 24 h (defined as decrease in baseline NIHSS score of 8 points or greater) and functional status on discharge and on 3 months assessed by modified Rankin Scale (mRS). Results: Nineteen AIS patients with LVO received tenecteplase and 39 received alteplase. We observed a non-significant higher rate of averted thrombectomies (32% versus 18%, p = 0.243) and a non-significant higher rate of sICH (16% versus 5%, p = 0.201) in the tenecteplase group. The rate of 24 h major neurological improvement was higher in the tenecteplase group (64% versus 33%, p = 0.046) but this was marginally attenuated in multivariable analyses (adjusted OR 10.22, 95% CI: 0.73–142.98; p = 0.084). Discharge mRS, 3-months mRS, and 3-month functional independence (mRS scores of 0–2) did not differ (p > 0.2) between the two groups. The rates of 3-month mortality (11% versus 18%, p = 0.703) were similar in the two groups. No independent association between thrombolytic agent and safety or efficacy outcomes emerged in multivariable regression analyses. Conclusion: The present pilot observational study highlights that AIS patients with LVO treated with 0.25 mg/kg bolus administration of tenecteplase had increased likelihood to achieve early neurological improvement compared with AIS patients treated with alteplase, but this association was attenuated after adjustment for potential confounders. There were no significant differences in 3-month functional or safety outcomes between the two groups. This preliminary real-world observation requires independent confirmation in larger, multicenter studies. © The Author(s), 2021.

Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities. © The Author(s), 2021.

PurposeOsteoid osteomas in the spine constitute a challenging group for both surgical and percutaneous approaches. Purpose of the present study is to report a case report of a spinal osteoid osteoma in a challenging spinal location and review literature for safety and efficacy of the technique.MethodsWe report a case of spinal osteoid osteoma extending in the epidural space and abutting the dura in a pediatric patient treated by percutaneous computed tomography-guided radiofrequency ablation. This is not a systematic review of the literature. A number of separate literature searches were performed. Non-English studies and case reports were excluded from the study. All references of the obtained articles were also evaluated for any additional information.ResultsAlthough all prophylactic measures were taken (hydrodissection, thermocouples and neurophysiologic monitoring) and the procedure was uneventful, patient within three hours, was unable to raise or bend the unilateral lower extremity below the knee. Pain reduction was significant from the first morning post-ablation and during the follow-up period of 18 months. MR scan was within normal limits. Dexamethasone was iv injected for 24 h and prescribed per os for 7 days. At follow-up 1 week later mobility of the lower extremity had returned to normal.ConclusionAs far as spine ablation is concerned, all prophylactic measures should be taken; neurophysiologic monitoring seems to be more sensitive than temperature measurement. Intravenous and per os corticosteroids are extremely useful in case of nerve damage.

Purpose: Transarterial chemoembolisation (TACE) using irinotecan-eluting beads is an additional treatment option for colorectal cancer liver metastases (CRLM) patients that are not eligible for curative treatment approaches. This interim analysis focuses on feasibility of the planned statistical analysis regarding data distribution and completeness, treatment intention, safety and health-related quality of life (HRQOL) of the first 50 patients prospectively enrolled in the CIrse REgistry for LifePearl™ microspheres (CIREL), an observational multicentre study conducted across Europe. Methods: In total, 50 patients ≥ 18 years diagnosed with CRLM and decided to be treated with irinotecan-eluting LifePearl™ microspheres TACE (LP-irinotecan TACE) by a multidisciplinary tumour board. There were no further inclusion or exclusion criteria. The primary endpoint is the categorisation of treatment intention, and secondary endpoints presented in this interim analysis are safety, treatment considerations and HRQOL. Results: LP-irinotecan TACE was conducted in 42% of patients as salvage therapy, 20% as an intensification treatment, 16% as a first-line treatment, 14% a consolidation treatment and 8% combination treatment with ablation with curative intent. Grade 3 and 4 adverse events were reported by 4% of patients during procedure and by 10% within 30 days. While 38% reported a worse, 62% reported a stable or better global health score, and 54% of patients with worse global health score were treated as salvage therapy patients. Conclusion: This interim analysis confirms in a prospective analysis the feasibility of the study, with an acceptable toxicity profile. More patients reported a stable or improved HRQOL than deterioration. Deterioration of HRQOL was seen especially in salvage therapy patients. Trial Registration: NCT03086096. © 2020, The Author(s).

Purpose: To illustrate safety and efficacy of percutaneous vertebroplasty (either solely performed or in combination to alcohol sclerotherapy) for treatment of symptomatic, aggressive vertebral haemangiomas in a series of consecutive patients. Material and Methods: Institutional database research from 1/1/2010 until 31/8/2020 identified 25 patients with 31 symptomatic, aggressive vertebral haemangiomas suffering from pain with or without neurologic compromise underwent percutaneous vertebroplasty either solely performed or in combi- nation to alcohol sclerotherapy. When haemangioma was restrained to the vertebral body, percutaneous vertebroplasty was performed as the only treatment technique. When an epidural component was also present causing pressure effects upon the spinal sac, sclerotherapy was additionally performed with alcohol injection at the level of the vertebral pedicles. CT scan assessed implant distribution the morning post therapy and MRI was performed 6 months post. Numeric Visual pain scores (NVS) prior-and post-treat-ment were compared using Paired Samples t-Test and Wilcoxon Signed Rank Test. Results: Mean pain score prior to any therapy was 8.52 ± 1.388 NVS units. Mean pain score at 12 months post therapy was 1.68 ± 2.445 NVS units. There was a mean reduction of 6.84 ± 3.145 NVS units. The comparison of the patients’ self-reported outcomes concerning pain reduction and mobility improvement prior and post therapy was considered statistically significant (p

Objective: To investigate long-term results of biliary biopsy performed with transluminal forceps in the setting of metastatic biliary involvement. Materials and Methods: Between September 2014 and June 2019, 25 patients—18 males (72%)—with a mean age of 65 ± 15 years, underwent 26 biliary biopsy procedures with a dedicated forceps system. All patients presented with obstructive jaundice that was suspected of being malignant and underwent pre-procedural magnetic resonance cholangiopancreatography. The biopsies were performed during percutaneous placement of an internal-external biliary drainage catheter, under fluoroscopic guidance. Results: The technical success rate was 96% (corresponding to 25 of the 26 procedures). The histological diagnosis was inflammatory biliary stricture in five cases, pancreatic adenocarcinoma in six, liver metastases from colorectal cancer in eight, and hepatocel-lular carcinoma in three, the biliary mucosa being categorized as normal in three cases. In one case, the sample was considered insufficient and the procedure was successfully repeated, after which a diagnosis of pancreatic adenocarcinoma was made. Over a follow-up period of 6–48 months, there were five false-negative results: two findings of inflammatory biliary stricture were later identified as liver metastases from breast and gastric cancer, respectively; and all three patients in which the biliary mucosa was categorized as normal were subsequently diagnosed with metastatic hilar lymph nodes. The procedure was found to have a sensitivity of 77%, a specificity of 100%, and an overall accuracy of 80%. The complication rate was 11.5% (mild, transient hemobilia occurring in three cases). Conclusion: Percutaneous transluminal forceps biopsy is a safe, effective, minimally invasive procedure for histological characterization in patients presenting with obstructive jaundice due to a non-primary biliary tumor. © Colégio Brasileiro de Radiologia e Diagnóstico por Imagem.

The incidence of acute coronary events is increased among people living with HIV (PLWH), but there is no risk estimation score, nor a surrogate biomarker able to predict subclinical coronary artery disease (sCAD). We assessed the performance of: (i) Framingham risk score (FRMs), (ii) peripheral (carotid and femoral) artery atheromatosis, and (iii) coronary artery calcium (CACs) score, to detect the presence of sCAD, in PLWH. In a cohort of PLWH free of cardiovascular disease (CVD), we measured sCAD and CACs by computed tomography, calculated FRMs, and assessed carotid/femoral plaques by ultrasound. In 56 participants (age: 49 ± 10 years, men: 88%, FRMs: 7.2 ± 6.9; mean number of carotid/femoral plaques: 1.4 ± 1.5; CACs >0 present in 59%, median CACs 0.9 [IQR 0-22]): (i) minimal sCAD (stenosis 1%-24%; present in 30%) and mild sCAD (25%-49%, 25%) were effectively detected by FRMs, number of plaques, and CACs [area under the curve (AUC) of CACs was better than that of both FRM and plaques, p < .05]; (ii) moderate sCAD (stenosis 50%-69%; present in 8.9%) was detected by number of plaques and CACs, but similar AUC (0.969 vs. 0.867, respectively, p = NS); and (iii) severe sCAD (70%-99%, present in only 3 [5.4%]) was detected only by CACs. A high prevalence of sCAD in asymptomatic PLWH free of CVD was detected; CACs is a highly efficient biomarker to detect all grades of sCAD, however, the number of carotid/femoral plaques combined is also a very promising - lower cost and radiation free - surrogate biomarker. Future, larger studies are needed to verify these results. © 2021 Mary Ann Liebert Inc.

Introduction: This was a European, multicenter, investigator-initiated and run, single-arm retrospective analysis to assess the safety and the clinical benefit of the use of paclitaxel-coated balloon (PCB) for the treatment of symptomatic central venous stenosis (CVS). Materials and Methods: Eleven centers from 7 countries across Europe, submitted 86 cases performed during the period between October 2015 and June 2018. Minimum follow-up was 6 months. Patient baseline demographics and procedural details were collected. Mean age was 62.6 years (SD 15.2 years). Median vascular access age was 3.0 years (IQR 1.2–4.8 years). A total of 55 were arteriovenous fistulas (64%) the rest arteriovenous grafts (31/86, 36%). Vessels treated were 43 subclavian veins, 42 brachiocephalic veins and 1 superior vena cava. Median drug-coated balloon diameter was 10 mm (IQR 8–12 mm). Primary outcome measures were clinically assessed intervention-free period (IFP) of the treated segment at 6 months and procedure-related minor and major complications. Secondary outcome measures included access circuit survival, patient survival, and the investigation of independent factors that influence the IFP. Results: IFP was 62.7% at 6 months. Median patient follow-up time was 1.0 year (IQR 0.5–2.2 years). There was 1 minor complication (1/86; 1.2%) and no major complications. Access circuit survival was 87.7% at 6 months. Patient survival was 79.7% at 2 years according to Kaplan-Meier survival analysis. Higher balloon diameters significantly favored IFP [HR 0.71 (0.55–0.92), p=0.006; 5–7 mm group vs 8–12 mm group, p=0.025]. Conclusion: In this analysis, use of PCBs for the treatment of symptomatic CVS was safe. Efficacy was comparable to previous trials. Increased balloon size had a significant effect on patency rates. © The Author(s) 2021.

OBJECTIVE: The purpose of this study is to compare the safety and efficacy of the bedside ultrasound (US)-guided trocar technique versus the US- and fluoroscopy-guided Seldinger technique for percutaneous cholecystostomy (PC). SUBJECTS AND METHODS: This prospective noninferiority study compared the bedside US-guided trocar technique for PC (the trocar group; 53 patients [28 men and 25 women]; mean [± SD] age, 74.31 ± 16.19 years) with the US- and fluoroscopy-guided Seldinger technique for PC (the Seldinger group; 52 patients [26 men and 26 women], mean age, 79.92 ± 13.38 years) in consecutive patients undergoing PC at two large tertiary university hospitals. The primary endpoints were technical success and procedure-related complication rates. Secondary endpoints included procedural duration, pain assessment, and clinical success after up to 3 months of follow-up. RESULTS: PC was successfully performed for all 105 patients. The clinical success rate was similar between the two study groups (86.8% in the trocar group vs 76.9% in the Seldinger group; p = 0.09). Mean procedural time was significantly lower in the trocar group than in the Seldinger group (1.77 ± 1.62 vs 4.88 ± 2.68 min; p < 0.0001). Significantly more procedure-related complications were noted in the Seldinger group than in the trocar group (11.5% vs 1.9%; p = 0.02). Among patients in the Seldinger group, bile leak occurred in 7.7%, abscess formation in 1.9%, and gallbladder rupture in 1.9%. No procedure-related death was noted. Minor bleeding occurred in one patient (1.9%) in the trocar group, but the bleeding resolved on its own. The mean pain score during the procedure was significantly lower in the Seldinger group than in the trocar group (3.2 ± 1.77 vs 4.76 ± 2.17; p = 0.01). At 12 hours after the procedure, the mean pain score was significantly lower for patients in the trocar group (0.78 ± 1.0 vs 3.12 ± 1.36; p = 0.0001). CONCLUSION: Use of the bedside US-guided trocar technique for PC was equally effective as the Seldinger technique but was associated with fewer procedure-related complications, required less procedural time, and resulted in decreased postprocedural pain, compared with fluoroscopically guided PC using the Seldinger technique. © American Roentgen Ray Society.

Chronic liver disease (CLD) is currently one of the major causes of death worldwide. If not treated, it may lead to cirrhosis, hepatic carcinoma and death. Ultrasound (US) shear wave elastography (SWE) is a relatively new, popular, non-invasive technique among radiologists. Although many studies have been published validating the SWE technique either in a clinical setting, or by applying machine learning on SWE elastograms, minimal work has been done on comparing the performance of popular pre-trained deep learning networks on CLD assessment. Currently available literature reports suggest technical advancements on specific deep learning structures, with specific inputs and usually on a limited CLD fibrosis stage class group, with limited comparison on competitive deep learning schemes fed with different input types. The aim of the present study is to compare some popular deep learning pre-trained networks using temporally stable and full elastograms, with or without augmentation as well as propose suitable deep learning schemes for CLD diagnosis and progress assessment. 200 liver biopsy validated patients with CLD, underwent US SWE examination. Four images from the same liver area were saved to extract elastograms and processed to exclude areas that were temporally unstable. Then, full and temporally stable masked elastograms for each patient were separately fed into GoogLeNet, AlexNet, VGG16, ResNet50 and DenseNet201 with and without augmentation. The networks were tested for differentiation of CLD stages in seven classification schemes over 30 repetitions using liver biopsy as the reference. All networks achieved maximum mean accuracies ranging from 87.2%-97.4% and area under the receiver operating characteristic curves (AUCs) ranging from 0.979-0.990 while the radiologists had AUCs ranging from 0.800-0.870. ResNet50 and DenseNet201 had better average performance than the other networks. The use of the temporal stability mask led to improved performance on about 50% of inputs and network combinations while augmentation led to lower performance for all networks. These findings can provide potential networks with higher accuracy and better setting in the CLD diagnosis and progress assessment. A larger data set would help identify the best network and settings for CLD assessment in clinical practice. © 2020 Institute of Physics and Engineering in Medicine.

Background: The complexity of the case, including the rarefied simultaneous occurrence of complications—iatrogenic, as well as reperfusion injury, invite reporting and publication. Case presentation: A 39-year-old woman with a single-functioning left kidney, previous left renal artery stenting (RAS), and known hypercoagulopathy was hospitalized for flash pulmonary edema, elevated serum creatinine (9.7 mg/dl), and refractory hypertension. She was subsequently referred to our center [2] for endovascular treatment of acute renal ischemia (AKI) due to RAS occlusion. Periprocedural complications of guide-wire arterial perforation and reperfusion injury resulted in life-threatening hemorrhage. Conclusions: Following more than 48 h of hypoperfusion of the left kidney, revascularization of the thrombosed RAS was successfully attempted with selective, trans-catheter thrombolysis, and balloon angioplasty. Ultra-selective, nephron-sparing coil embolization was successfully performed. The patient’s creatinine level decreased to 2.8 mg/dl at 12 days and to 1.5 mg/dl at 3 months. After 1 year of follow-up, the stent remains patent, and the patient is asymptomatic with stable renal function. © 2020, The Author(s).

Budd-Chiari syndrome (BCS) is a relatively rare clinical condition with a wide range of symptomatology, caused by the obstruction of the hepatic venous outflow. If left untreated, it has got an high mortality rate. Its management is based on a step-wise approach, depending on the clinical presentation, and includes different treatment from anticoagulation therapy up to Interventional Radiology techniques, such as transjugular intrahepatic portosystemic shunt (TIPS). TIPS is today considered a safe and highly effective treatment and should be recommended for BCS patients, including those awaiting orthotopic liver transplantation. In this review the pathophysiology, diagnosis and treatment options of BCS are presented, with a special focus on published data regarding the techniques and outcomes of TIPS for the treatment of BCS. Moreover, unresolved issues and future research will be discussed. © The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.

Background: We retrospectively investigated outcomes of emergency TAE for the management of life-threatening haemorrhage in patients with uncorrected bleeding diathesis. Materials and methods: This multicenter, retrospective, study, was designed to investigate the safety and efficacy of percutaneous TAE for the management of life-threatening haemorrhage in patients with uncorrected bleeding disorder at the time of embolization. All consecutive patients with uncorrected coagulation who underwent TAE for the treatment of haemorrhage, between January 1st and December 31th 2019 in three European centers were included. Inclusion criteria were thrombocytopenia (platelet count < 50,000/mL) and/or International Normalized Ratio (INR) ≥2.0, and/or activated partial thromboplastin time (aPTT) > 45 s, and/or a pre-existing underlying blood-clotting disorder such as factor VIII, Von Willebrand disease, hepatic cirrhosis with abnormal liver function tests. Primary outcome measures were technical success, rebleeding rate and clinical success. Secondary outcome measures included patients’ 30-day survival rate, and procedure-related complications. Results: In total, 134 patients underwent TAE for bleeding control. A subgroup of 17 patients with 18 procedures [11 female, mean age 70.5 ± 15 years] which represent 12.7% of the total number of patients, presented with pathological coagulation parameters at the time of TAE (haemophilia n = 3, thrombocytopenia n = 1, cirrhosis n = 5, anticoagulants n = 7, secondary to bleeding n = 1) and were analyzed. Technical success was 100%, as in all procedures the bleeding site was detected and successfully embolised. Clinical success was 100%, as none of the patients died of bleeding during hospitalization, nor was surgically treated for bleeding relapse. Only one rebleeding case was noted (5.9%) that was successfully treated with a second TAE. No procedure-related complications were noted. According to Kaplan-Meier analysis the estimated 30-day survival rate was 84.2%. Conclusion: TAE in selected patients with uncorrected bleeding diathesis should be considered as a suitable individualized management approach. Emergency TAE for life threatening haemorrhage in patients with coagulation cascade disorders should be used as an aid in realistic clinical decision making. © 2020, The Author(s).

Purpose: Recent randomized-controlled clinical trials have provided preliminary evidence for expanding the time window of intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients by applying certain neuroimaging criteria. We prospectively assessed the potential eligibility for IVT in the extended time window (4.5–9 h) among consecutive AIS patients treated in a comprehensive stroke center during a nine-month period. Methods: Potential eligibility for IVT in the extended time window was evaluated by using inclusion criteria from the EXTEND trial. All patients were underwent baseline emergent neurovascular imaging using either computed tomography angiography/computed tomography perfusion (CTA/CTP) or magnetic resonance angiography/magnetic resonance perfusion (MRA/MRP). Images were post processed by the automated software RAPID. Results: Our study population consisted of 317 AIS patients, and, among them, 31 (9.8 %) patients were presented in the time window of 4.5–9 h. Seven patients (2.2 %) fulfilled the EXTEND neuroimaging criteria. Four patients (1.3 %) were treated with IVT because they fulfilled both clinical and neuroimaging EXTEND criteria. Patients eligible for EXTEND neuroimaging criteria had no ischemic core lesion, whereas the mean volume of critical hypoperfusion was relatively small (17.0 ± 11.8 ml). There was no hemorrhagic complication in any of the patients treated with IVT. The median mRS score at three months was 0 (range: 0–3) among patients who were eligible for EXTEND neuroimaging criteria. Conclusion: Our everyday clinical practice experience suggests 9.8 % of consecutive AIS patients present in the 4.5–9 h window and 2.2 % adhere to EXTEND neuroimaging eligibility criteria for IVT. Only 1.3% of AIS is eligible for IVT according to EXTEND neuroimaging and clinical eligibility criteria. © 2020, Springer-Verlag GmbH Germany, part of Springer Nature.

Background and purpose: The purpose was to investigate our centre’s experience on computed-tomography-guided (CT-guided), transforaminal, intrathecal administration of nusinersen in adult subjects with spinal muscular atrophy (SMA) type 2 and severe spinal deformity. Method: This is a retrospective, single-centre study investigating the feasibility and safety of CT-guided, transforaminal, lumbar puncture for the intrathecal administration of nusinersen (Spinranza®; Biogen; Cambridge, MA, USA) in a cohort of adult subjects with SMA type 2, severe neuromuscular scoliosis and previous spinal surgery. Between January 2019 and October 2019, five male, adult, SMA type 2 subjects were eligible to be treated in our centre with nusinersen. The mean age of the patients was 31 ± 9 years (range 19–43 years). The study’s outcome measures were technical success, adverse events and radiation exposure. Results: In total, four patients completed the four loading doses, whilst the fifth patient received only one loading dose; two patients also received their first maintenance doses. Overall, 20 consecutive transforaminal, intrathecal treatments were analysed. Technical success was 100% (20/20 intrathecal infusions). No adverse events were documented following the procedures. Mean dose–length product (DLP) value per injection was 665.4 ± 715.5 mGy*cm. Estimated mean effective dose per injection was 12.7 ± 12.9 mSv. Subgroup analysis between the chronologically first 10 versus subsequent 10 procedures demonstrated a clear trend towards less radiation exposure in the latter, although this difference did not reach statistical significance (DLP: 984.7 ± 903.3 vs. 436.7 ± 321.5 mGy*cm, P = 0.165; respectively). Conclusions: In this retrospective series, CT-guided transforaminal access for intrathecal injection of nusinersen was proven feasible and safe. A decrease in radiation dose over time was noted. Protocols to minimize radiation exposure are essential. © 2020 European Academy of Neurology

An amendment to this paper has been published and can be accessed via the original article.

Objectives: The purposes of the study were to evaluate the safety and long-term efficacy of augmented vertebroplasty using a polyether ether ketone (PEEK) implant, for the treatment of lumbar or thoracic vertebral fractures (A2 according to the Magerl’s AO classification) and to analyze pain reduction, height restoration, and complications during a 2-year follow-up period. Methods: Prospective non-randomized evaluation was performed for 21 painful split vertebral fractures (20 patients, 14 females, 6 males; mean age 72.80 ± 10.991) treated with percutaneous vertebral augmentation using a PEEK device, under fluoroscopic guidance. Pain before the procedure and after 6, 12, and 24 months was evaluated using a numeric visual scale (NVS) questionnaire. Imaging was performed by CT and X-rays. The minimum craniocaudal diameter at the level of the fracture and the maximum craniocaudal diameter at the middle of the fractured vertebra were measured. Statistical analysis was performed to evaluate pain decrease and height restoration. Results: Successful implant positioning was achieved in all cases. No major clinical complications were observed. Comparing the mean pain scores at baseline (8.69 ± 1.138) and the first day after the treatment (1.19 ± 1.424), there was a decrease of 7.50 NVS units (p < 0.001). Minimum and maximum vertebral body heights were increased after the procedure 56.58% and 13.7% respectively (p < 0.001). Both pain relief and height restoration remained statistically significant (p < 0.001) during the follow-up period. Conclusion: A2 Magerl thoracic or lumbar fractures could be successfully treated with PEEK implant-assisted vertebral augmentation. Randomized studies with larger sample sizes should be done to confirm the effectiveness of the technique. Key Points: • Vertebral augmentation using a PEEK implant for the treatment of A2 Magerl lumbar or thoracic vertebral fractures seems to be effective both in terms of pain reduction and height restoration. • Effects on pain reduction and height restoration have a long-term duration. • The technique seems to be safe for the treatment of A2 Magerl fractures, without major complications in our study group. © 2018, European Society of Radiology.

Purpose of reviewTo present the latest evidence about carotid artery stenting (CAS) including indications, safety, efficacy, and available equipment.Recent findingsThe micromesh stent, a new stent design which offers excellent flexibility and embolic protection, has been associated with promising outcomes.SummaryCAS has emerged as a minimally invasive treatment method for carotid artery stenosis with comparable outcomes with surgical management. The implementation of new technology combined with operator experience has led to a paradigm shift; however, to date, no robust evidence exists about patient and lesion selection. Many studies are underway to clarify the technical aspects of CAS as well as the optimal treatment of carotid artery stenosis for each patient population. © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Purpose: To automatically detect and isolate areas of low and high stiffness temporal stability in shear wave elastography (SWE) image sequences and define their impact in chronic liver disease (CLD) diagnosis improvement by means of clinical examination study and deep learning algorithm employing convolutional neural networks (CNNs). Materials and Methods: Two hundred SWE image sequences from 88 healthy individuals (F0 fibrosis stage) and 112 CLD patients (46 with mild fibrosis (F1), 16 with significant fibrosis (F2), 22 with severe fibrosis (F3), and 28 with cirrhosis (F4)) were analyzed to detect temporal stiffness stability between frames. An inverse Red, Green, Blue (RGB) colormap-to-stiffness process was performed for each image sequence, followed by a wavelet transform and fuzzy c-means clustering algorithm. This resulted in a binary mask depicting areas of high and low stiffness temporal stability. The mask was then applied to the first image of the SWE sequence, and the derived, masked SWE image was used to estimate its impact in standard clinical examination and CNN classification. Regarding the impact of the masked SWE image in clinical examination, one measurement by two radiologists was performed in each SWE image and two in the corresponding masked image measuring areas with high and low stiffness temporal stability. Then, stiffness stability parameters, interobserver variability evaluation and diagnostic performance by means of ROC analysis were assessed. The masked and unmasked sets of SWE images were fed into a CNN scheme for comparison. Results: The clinical impact evaluation study showed that the masked SWE images decreased the interobserver variability of the radiologists’ measurements in the high stiffness temporal stability areas (interclass correlation coefficient (ICC) = 0.92) compared to the corresponding unmasked ones (ICC = 0.76). In terms of diagnostic accuracy, measurements in the high-stability areas of the masked SWE images (area-under-the-curve (AUC) ranging from 0.800 to 0.851) performed similarly to those in the unmasked SWE images (AUC ranging from 0.805 to 0.893). Regarding the measurements in the low stiffness temporal stability areas of the masked SWE images, results for interobserver variability (ICC = 0.63) and diagnostic accuracy (AUC ranging from 0.622 to 0.791) were poor. Regarding the CNN classification, the masked SWE images showed improved accuracy (ranging from 82.5% to 95.5%) compared to the unmasked ones (ranging from 79.5% to 93.2%) for various CLD stage combinations. Conclusion: Our detection algorithm excludes unreliable areas in SWE images, reduces interobserver variability, and augments CNN's accuracy scores for many combinations of fibrosis stages. © 2019 American Association of Physicists in Medicine

Background: Distinction between benign and malignant biliary obstruction is always challenging. Purpose: To evaluate outcomes of percutaneous transluminal biopsy of biliary strictures using a dedicated forceps system. Material and Methods: This prospective, single-center, single-arm study, included 29 consecutive patients (17 men [56.6%]; mean age = 60 ± 9 years), who underwent 30 transluminal biopsies during percutaneous transhepatic biliary drainage (PTBD) due to obstructive jaundice, between September 2014 and January 2017, using a transluminal biliary access and biopsy forceps set. The study’s primary efficacy endpoint was technical success and the primary safety endpoint was the procedure-related major complications rate. The study’s secondary endpoints were procedure-related minor complication rate, sensitivity, specificity, and diagnostic accuracy for the characterization of malignancy. Results: Tissue samples allowed histological diagnosis in 27/30 procedures (technical success rate 90.0%), as in three cases (10.0%) the sample was characterized as non-diagnostic: one case was suspicious for pancreatic cancer and two cases were cholangiocarcinoma. In one case, biopsy was successfully repeated. The diagnosis was cholangiocarcinoma in 16 cases (53.3%), colorectal metastasis in three cases (10%), pancreatic adenocarcinoma in three cases (10.0%), and inflammation in five cases (16.6%). There were two false-negative cases of inflammation proven to be cholangiocarcinoma, resulting in sensitivity of 91.67%, specificity of 100%, and accuracy of 92.59%. No major complications were noted. There were four cases of hemobilia (13%) which auto-resolved within 48 h. Conclusion: Percutaneous transluminal biopsy of biliary strictures during PTBD using the specific forceps system was proven safe and resulted in high technical success and diagnostic accuracy rates. © The Foundation Acta Radiologica 2018.

Purpose: To investigate the bleeding complications associated with endovascular therapy (EVT) for peripheral artery disease (PAD) and develop a dedicated peripheral bleeding score (PBS). Materials and Methods: This prospective, single-center study enrolled 530 patients (mean age 67.6±9.8 years; 396 men) undergoing endovascular procedures between August 2016 and July 2018 for chronic PAD. Primary endpoints were the incidence of 30-day bleeding complications [minor and major (prolonging hospitalization, causing permanent sequelae, or resulting in death)], the identification of factors associated with bleeding events, and the development of a dedicated PBS based on univariate and multivariate analysis. Hazard ratios (HR) and 95% confidence intervals (CI) are reported. The HAS-BLED score was compared with the PBS. Results: The overall peripheral bleeding complication rate was 3.8% (20/530), of which 3.2% (17/530) were major and included 4 (0.7%) active retroperitoneal bleeding events and 13 (2.4%) pseudoaneurysms. The annualized incidences of overall bleeding and major bleeding complications were 1.9% and 1.6%, respectively. Multivariable regression analysis identified age ≥75 as a correlate of significantly increased bleeding risk (HR 3.32, 95% CI 1.12 to 9.80, p

Liver cancers are the second most frequent cause of global cancer-related mortality of which 90% are attributable to hepatocellular carcinoma (HCC). Despite the advent of screening programmes for patients with known risk factors, a substantial number of patients are ineligible for curative surgery at presentation with limited outcomes achievable with systemic chemotherapy/external radiotherapy. This has led to the advent of numerous minimally invasive options including but not limited to trans-arterial chemoembolization, radiofrequency/microwave ablation and more recently selective internal radiation therapy many of which are often the first-line treatment for select stages of HCC or serve as a conduit to liver transplant. The authors aim to provide a comprehensive overview of these various image guided minimally invasive therapies with a brief focus on the technical aspects accompanied by a critical analysis of the literature to assess the most up-to-date evidence from comparative systematic reviews and meta-analyses finishing with an assessment of novel combination regimens and future directions of travel. © The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.

Iodinated Contrast Media (CM) has a plethora of applications in routine non-invasive or percutaneous invasive imaging examinations and therapeutic interventions. Unfortunately, the use of CM is not without complications, with contrast-induced acute kidney injury (CI-AKI) being among the most severe. CI-AKI is a syndrome defined as a rapid development of renal impairment after a few days of CM endovascular injection, without the presence of any other underlying related pathologies. Although mostly transient and reversible, for a subgroup of patients with comorbidities related to renal failure, CI-AKI is directly leading to longer hospitalization, elevated rates of morbidity and mortality, as well as the increased cost of funding. Thus, a need for classification in accordance with clinical and peri-procedural criteria is emerged. This would be very useful for CI-AKI patients in order to predict the ones who would have the greatest advantage from the application of preventive strategies. This article provides a practical review of the recent evidence concerning CI-AKI incidence, diagnosis, and sheds light on prevention methods for reducing contrast use and avoiding AKI during endovascular procedures. In conclusion, despite the lack of a specific treatment protocol, cautious screening, assessment, identification of the high-risk patients, and thus the application of simple interventions-concerning modifiable risk factors-can significantly reduce CI-AKI risk. © 2019 Bentham Science Publishers.

Introduction: Ischemic stroke is becoming a primary cause of disability and death worldwide. To date, therapeutic options remain limited focusing on mechanical thrombolysis or administration of thrombolytic agents. However, these therapies do not promote neuroprotection and neuro-restoration of the ischemic area of the brain. Areas covered: This review highlights the option of minimal invasive, intra-arterial, administration of biological agents for stroke therapy. The authors provide an update of all available studies, discuss issues that influence outcomes and describe future perspectives which aim to improve clinical outcomes. New therapeutic options based on cellular and molecular interactions following an ischemic brain event, will be highlighted. Expert opinion: Intra-arterial administration of biological agents during trans-catheter thrombolysis or thrombectomy could limit neuronal cell death and facilitate regeneration or neurogenesis following ischemic brain injury. Despite the initial progress, further meticulous studies are needed in order to establish the clinical use of stem cell-induced neuroprotection and neuroregeneration. © 2019, © 2019 Informa UK Limited, trading as Taylor & Francis Group.

Objectives: To investigate the incidence and endovascular treatment of severe spontaneous non-cerebral hemorrhage (SSNCH) in a high-volume, tertiary university hospital. Methods: All patients diagnosed with SSNCH between January 2016 and June 2017 were retrospectively analyzed. Endovascular treatment (group EVT) was offered only in patients demonstrating active bleeding at CT angiography (CTA). In cases without active bleeding at CTA, conservative management was decided (group CM). Outcome measures included the incidence of SSNCH, 6-month rebleeding, and survival rates in the two groups as well as EVT technical success and related complications. Results: Within the 18-month period, 44 SSNCH cases were identified, resulting in an annual incidence of 29.3 cases. In 37/44 cases (84.1%), bleeding was attributed to the antithrombotic therapy. In total, 19/44 patients underwent EVT (43.2%), and 25/44 patients (56.8%) were managed conservatively. Two patients who were initially treated conservatively finally underwent EVT due to rebleeding (7.4%). The technical success of EVT was 100%, while rebleeding occurred in 1 case (5.2%) following lumbar artery embolization and was successfully re-embolized. According to the Kaplan-Meier analysis, the 1-, 3-, and 6-month survival rates were 68.4%, 63.2%, and 42.1% for group EVT and 87.5%, 75.0%, and 58.3% for group CM, respectively. There were no EVT-related complications. Conclusions: The annual incidence of SSNCH in our institution is substantial. EVT resulted in uncomplicated, high bleeding control rates. The mortality rate was similarly high following either EVT or conservative treatment and was mainly attributed to severe comorbidities. Key Points: • This study demonstrates that the incidence of severe spontaneous non-cerebral hemorrhage (SSNCH) in our institution is substantial. • Endovascular treatment was offered only in patients with clinical signs of ongoing hemorrhage and active bleeding at CT angiography and resulted in effective and uncomplicated, minimal invasive hemostasis, in a population with severe comorbidities. • This is the first study to evaluate the outcomes of both endovascular hemostasis and conservative management. Rebleeding following either conservative or endovascular treatment was minimal. © 2018, European Society of Radiology.