Diagnostic yield of CT-guided lung biopsies: how can we limit negative sampling?

OBJECTIVES: To investigate whether lesion imaging features may condition the outcome of CT-guided lung biopsy (CTLB) and to develop a scoring system of biopsy outcome prediction. METHODS: This is a single center retrospective study on 319 CTLBs that were performed in 319 patients (167 males/152 females, mean age 68 ± 12.2). Uni- and multivariate analysis were performed aiming to assess the imaging features that are likely to be correlated to a negative biopsy outcome and patients were stratified in groups accordingly. RESULTS: Technical success was 100%. 78% of the biopsies (250/319) led to a concrete histology report (218 malignant/32 benign). The remaining lesions led to concrete histology at a second attempt that occurred on a later time. Multivariate analysis revealed increased risk of inconclusive result for nodules with low fludeoxyglucose uptake [odds ration (OR) = 2.64, 95% confidence interval (CI) 1.4-4.97; p = 0.003], for nodules with diameter smaller than 18 mm (OR = 2.03, 95% CI 1.14-3.62; p = 0.017) and for nodules that are located in one of the lung bases (OR = 1.96, 95% CI 1.06-3.62; p = 0.033). Three different groups of patients were identified accordingly with low (<30%), medium (30-50%) and high (>50%) probability of obtaining an inconclusive biopsy sample. CONCLUSION: This study confirms that percutaneous CT-guided biopsy in nodules that are either small in diameter or present low positron emission tomography-fludeoxyglucose uptake or are in one of the lung bases may lead to inconclusive histology. This information should be factored when planning percutaneous biopsies of such nodules in terms of patient informed consent and biopsy strategy. ADVANCES IN KNOWLEDGE: Inconclusive histology after lung biopsy may be subject to factors irrelevant to technical success. Lung biopsy histology outcomes may be predicted and avoided after adequate planning.

Image-guided minimally invasive treatment for small renal cell carcinoma.

Surgical partial nephrectomy is still considered as the "gold standard" for the definitive management of small malignant renal masses, whereas treatment with image-guided percutaneous ablation is still mainly reserved for those patients who cannot undergo nephron-sparing surgical resection due to advanced age, underlying comorbidities or compromised renal function. Nonetheless, the recent evidence that underlines the long-term oncological equipoise of percutaneous ablation methods with surgical resection in combination with the reduced complication rate and cost supports the use of an image-guided minimally invasive approach as a first-line treatment. The purpose of this review is to offer an overview of the most widely used percutaneous renal ablation treatments (radiofrequency, microwave and cryoablation) with a focus on their main technical aspects and application techniques for curative ablation of small renal cell carcinoma (stage cT1a). The authors also provide a critical narrative of the relevant medical literature with an emphasis on outcomes of comparative effectiveness research, and appraise the percutaneous methods compared to surgery in the context of evidence-based practice and future research studies. TEACHING POINTS: • RCC is a common cancer and is increasingly detected incidentally at early stages. • There is long-term oncological equipoise of percutaneous ablation compared to surgical resection. • Large-scale trials are required to produce Level 1a evidence.

Postoperative ascending aortic gigantic pseudoaneurysm: Endovascular treatment with the use of a septal occluder plug.

A rare postoperative complication of aortic root replacement is pseudoaneurysm formation. Surgical repair may be rather challenging particularly in patients who are elder and with significant comorbidities. Endovascular approach may also be technically demanding, given the high blood velocity and the anatomical challenges of the area of the aortic root and the ascending aorta. We would like to describe a case of an 85-year-old patient with history of prosthetic graft aortic root replacement who had been developed a 7-cm pseudoaneurysm with sternotomy diastasis and extension in the subcutaneous tissue, 7 years after the initial operation. Given the comorbidities, open repair was not considered a valid option and successful endovascular repair with the use of a ventricular septal occluder plug followed. One-year follow-up confirmed satisfactory exclusion of the pseudoaneurysm with no migration of the endovascular device and no other complication. This is one of the rare cases on endovascular repair of an ascending aorta postoperative pseudoaneurysm.

Peripheral Non-atherosclerotic Arterial Disorders: What Radiologists Need to Know.

Peripheral non-atherosclerotic arterial disorders (NAADs) are a heterogeneous group of rather uncommon conditions that tend to manifest in subjects without atherosclerosis. Each of these conditions has distinctive pathophysiology; however, there are some common clinical and radiological characteristics and in some cases a common treatment approach that unifies these conditions to a specific group, hence the NAADs. Clinicians and radiologists often fail to recognize NAADs, and there might be a delay in the management of such patients; this may result in seriously adverse outcomes that could otherwise have been avoided or minimized. Knowledge of these conditions and of their radiological appearances is therefore important to help establish a correct diagnosis to allow the prompt initiation of treatment. The purpose of this pictorial review is to present a selection of NAADs cases and to discuss the radiological characteristics and the most common lines of therapeutic approaches.

Peripheral use of detachable coils: expanding the boundaries of embolization.

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.

Open and Endovascular Treatment of Trans-Atlantic Inter-Society Consensus II D Aortoiliac Occlusive Lesions: What Determines the Rate of Restenosis?

BACKGROUND: Open surgery is the preferred approach for the treatment of type D lesions according to the Trans-Atlantic Inter-Society Consensus (TASC) II guideline, but endovascular solutions also appear to be a valid option in selected patients. The study aimed to identify the risk factors of restenosis after open and endovascular reconstruction of symptomatic TASC II D aortoiliac occlusive lesions (AIOLs). METHODS: Fifty-six patients (82 limbs) who underwent open repair and endovascular treatment (ET) for symptomatic TASC ΙΙ D AIOLs between March 2005 and December 2012 were retrospectively reviewed. Baseline characteristics, preoperative and postoperative imaging, and operation procedure reports were reviewed and analyzed. Restenosis after revascularization was assessed by duplex ultrasound or computed tomography angiogram. Kaplan-Meier survival analysis, Log-rank test, and multivariate Cox regression were used to evaluate the relevance between risk factors and patency. RESULTS: The mean duration of follow-up was 42.8 ± 23.5 months (ranging from 3 to 90 months). Primary patency rates at 1-, 3-, 5-, and 7-year were 93.6%, 89.3%, 87.0%, and 70.3%, respectively. Restenosis after revascularization occurred in 11 limbs. Kaplan-Meier survival analysis and the Log-rank test revealed that diabetes, Rutherford classification ≥5 th and concurrent femoropopliteal TASC II type C/D lesions were significantly related to the duration of primary patency. According to the result of Cox regression, diabetes and femoropopliteal TASC ΙΙ type C/D lesions were identified as the risk factors for restenosis after revascularization. CONCLUSION: This study demonstrated that diabetes and femoropopliteal TASC ΙΙ type C/D lesions are risk factors associated with restenosis after open and ET of TASC II D AIOLs.

Textiloma formation post endovascular repair of abdominal aortic aneurysm.

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.

Bioresorbable scaffolds in peripheral arterial disease.

The risk of in-stent restenosis has been dramatically reduced with the use of thin-strut nitinol and balloon-expandable drug-eluting stents in the peripheral arterial territory. However, the presence of a permanent endovascular device is linked to a series of events that can lead to restenosis and stent thrombosis. Significant advances in the technology of bioresorbable materials have delivered the potential for fully bioresorbable scaffolds (BRS), which are able to mechanically support the artery wall and elute an anti-restenotic drug for a predetermined time period after which the scaffold becomes fully absorbed into the vascular wall. Currently, several vascular BRS are available, undergoing evaluation either in clinical trials or in preclinical settings. The aim of this review is to present the new developments in BRS technology, describe the mechanisms involved in the resorption process, and discuss the current and potential future prospects of this innovative treatment option for peripheral arterial disease.

Palliation of esophageal cancer with a double-layered covered nitinol stent: long-term outcomes and predictors of stent migration and patient survival.

PURPOSE: To evaluate the long-term clinical outcomes and the negative predictors after the deployment of double-layered stents in malignant esophageal strictures. METHODS: This is a single-center study of patients who received a double-layered covered stent for the palliation of dysphagia due to malignant esophageal strictures in a 3-year period. 56 patients fulfilled the inclusion criteria. The study's primary end points were technical success, dysphagia improvement, stent migration, and complication rates; secondary end points were the stent's primary patency and overall survival. Cox regression analysis was used to adjust for confounding variables and to identify predictors of survival outcomes. RESULTS: Technical success was 95%. Median dysphagia score improved significantly after stenting (p < 0.0001). Stent migration rate was 7.1% and occurred exclusively in the group of patients who received chemoradiotherapy (p < 0.01). The median stent patency was 87 days (range 5-444 days). Dysphagia reoccurred in 39.3% and was successfully managed with restenting in 98.2%. The median survival was 127 days (range 15-1480 days). Chemoradiotherapy and baseline histology did not influence survival outcomes. Survival was adversely affected by metastases (p = 0.005) and poor oral intake (p = 0.048). Patient survival was improved by repeat stenting in case of tissue overgrowth (p = 0.06). CONCLUSION: The device is safe and effective for the treatment of patients with dysphagia due to esophageal cancer. Migration rate is zero for patients who do not receive chemoradiotherapy. Reintervention when required is a positive survival predictor.

Descement's Membrane Detachment Diagnosis Using a Very High Frequency Ultrasound Scanning System.

A 74-year-old woman was referred to our institute due to persistent corneal edema after cataract surgery. Slit-lamp examination revealed severe total corneal edema (obscuring anterior chamber and iris). Using a very high frequency (VHF) ultrasound scanning system (Artemis 2, Ultralink LLC) descement's membrane detachment (DMD) was diagnosed. VHF ultrasound scanning system could be a useful instrument in detecting post-cataract surgery DMD especially in patients in which diagnosis is difficult due to significant corneal clouding.

Percutaneous transcholecystic placement of an ePTFE/FEP-covered stent in the common bile duct.

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.

Late migration of two covered biliary stents through a spontaneous bilioenteric fistula in a patient with malignant biliary obstruction.

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.