Role of transjugular liver biopsy in the diagnostic and therapeutic management of patients with severe liver disease.

PURPOSE: This study sought to assess the diagnostic yield, the impact on treatment and the safety of transjugular liver biopsy. MATERIALS AND METHODS: We reviewed the medical records of 72 patients with severely impaired liver function who underwent transjugular biopsy at our department. Contraindications to percutaneous liver biopsy included thrombocytopenia, severe coagulopathy, marked ascites or a combination of the above. Patients were divided into four groups based on the clinically suspected cause of liver disease. Group 1 included 44 patients (58%) with acute abnormalities of liver function, whereas groups 2, 3 and 4 included patients with chronic abnormalities suspected to be due to infectious cirrhosis (12 patients, 16%), alcoholic cirrhosis (seven patients, 9%) and cirrhosis of unknown origin (13 patients, 17%), respectively. A Quick-Core (Cook, ProAct Ltd., State College, Pennsylvania, USA) needle allowing automated tissue sampling was used for all biopsies. RESULTS: Biopsy specimens were diagnostic in 69 out of 72 patients (91%). Biopsy findings influenced treatment in 34 out of 69 patients (49%). The most significant results were obtained in group 1, where the histological diagnosis differed from clinical suspicion in 25/39 patients. There was only one major complication and four minor complications. The major complication was an arteriovenous and arteriobiliary fistula with haemorrhage and anaemia, which was successfully embolised by the same team of interventional radiologists. CONCLUSIONS: Transjugular liver biopsy proved to be a safe procedure that provided important information for the clinical and therapeutic management of patients in whom treatment would have been either empirical or unfeasible.

[Carbon dioxide angiography. A new injection system]. / Angiografia con anidride carbonica. Nuovo sistema di iniezione.

PURPOSE: To evaluate the usefulness of a new carbon dioxide (CO2) intravascular injection system in digital subtraction angiography. MATERIAL AND METHODS: March 1998 to May 1999, thirty-nine patients were submitted to digital subtraction angiography with CO2 injection by a new delivery system, CO2-Angioset, OptiMed, Ettingen, Germany. The patients were 29 men and 10 women, whose age ranged 32 to 76 (mean: 47), eighteen of them with absolute or relative contraindications to iodinated contrast media and 6 with poor diagnostic findings at previous conventional angiography. CO2 was used for comparison with iodinated contrast agents in 4 patients. We studied the following vascular districts: renal arteries in 9 patients, portal vein in 18, lower limb arteries in 7, upper limb veins in 4. In 1 patient CO2 angiography was carried out for the diagnosis and interventional treatment, by transcatheter embolization, of a postbioptic arteriovenous renal fistula. During the procedure, arterial blood pressure, EKG status and oxygen stauration were monitored, and subjective sensations recorded in all patients. RESULTS: CO2 angiography provided adequate visualization of vascular districts and of abnormal findings in 32 cases (82%), while its results were considered insufficient for correct and complete assessment in 7 cases (18%). In detail, renal arteries studies were adequate in 9/9 cases, providing good depiction of the arterial trunk and main branches but poor demonstration of interlobar and arcuate arteries. The portal trunk was well depicted in 12/18 cases, but CO2 angiography results were insufficient in 3 cases because of poor catheter wedging in the hepatic vein and in 2 cases because of CO2 drainage by an accessory hepatic vein. Peripheral circulation was clearly depicted in 5/7 cases, while there was incomplete filling of the abdominal aorta and of iliac and femoral arteries in 2 cases. We had only one transient complication (2.57%) due to mesenteric ischemia during an aortic injection, with mild abdominal pain and diarrhea which subsided spontaneously in few minutes. CONCLUSIONS: In our experience the CO2-Angioset delivery system has proved to be a simple and safe tool, particularly suitable for use in patients at risk for allergic reactions to iodinated contrast agents and in those with renal function impairment. Also, the system can help carry out some interventional procedures such as arteriovenous fistula embolization and transjugular portosystemic shunting.

Endoluminal repair of infrarenal abdominal aortic aneurysms using a modular stent-graft: one-year clinical results from a European multicentre trial.

This is a report of a prospective study to evaluate the safety and efficacy of the Medtronic AneuRx stent-graft. Patients with an infrarenal aneurysm with a proximal neck length of greater than 10 mm and a neck diameter not greater than 26 mm and iliac artery diameters of at least 6 mm were accepted for endovascular repair using the Medtronic AneuRx modular stent-graft. A total of 104 patients were included in the study. Transfemoral placement of the bifurcated stent-graft was successful in 102 of 104 patients. Two conversions were performed. The mean operating time was 148 min (range 75-480) and the mean blood loss was 605 ml (range 100-2900). The mean follow-up was 15 months (range 12-21). Complications were rare and no kinking or migration occurred. At follow-up, four endoleaks persisted after 12 months. The Medtronic AneuRx stent-graft is a safe and efficacious alternative to open abdominal aortic aneurysm repair with excellent early results.

Interventional radiology in the treatment of urological vascular complications.

Urological vascular complications (UVC) are largely secondary to percutaneous procedures that are nowadays extensevely used by the urologists and the nephrologists. The major frequency of UVC is observed after the renal biopsy, in a percentage varying from 7 to 17% in different series; UVC are less frequent after a nephrostomic procedure (near 1-3%). UVC consist of artero-venous fistulas (AVF) and pseudoaneurysms (PA), that generally cause haemorrhage, particularly macroscopic hematuria. In the vast majority of cases hematuria resolves spontaneously or with conservative therapy but, in the 4 to 9% of patients persists and requires an adequate therapy, often in emergency. Interventional radiology permits an effective and timely treatment of the lesions, using the techniques of transcatheter embolization that are greatly improved in the last 20 years and that present rate of technical success greater than 80%. Moreover radiological embolization shows a low incidence of complications and lower hospitalization cost with respect to surgical treatment. Herein we describe the different techniques of embolization, the indications and the results as appears from the literature and the personal experience. The latter is based on a series of 31 procedures performed in 26 patients, with a rate of technical and clinical success of 93.5%.

Interventional radiology in the treatment of renal artery stenosis.

Percutaneous transluminal renal angioplasty (PTRA) alone or in combination with stent implantation, is increasingly used as an alternative technique to surgical revascularization for treatment of renal artery stenosis (RAS) wich may cause hypertension or jeopardize renal function. Herein we report the results obtained with 305 PTRAs performed in 242 hypertensive patients, 144 of whom had atherosclerotic RAS, 69 fibromuscolar dysplasia, 15 Ras in transplanted kidneys, 6 restenosis in surgically revascularized kidneys, 4 Takayasu arteritis and 4 neurofibromatosis. Stents were implanted in 68 cases, mostly in atherosclerotic stenoses. The technical success was achieved in 261 arteries (85.6%), with 33 failures (10.8%) and 11 (3.6%) procedures not completed for anatomical reasons. PTRA related complications were observed in 23 cases (7.5%), but no fatalities occurred. An overall benefit on blood pressure control was observed in 41% of patients with atherosclerotic RAS and in 68% of those with fibromuscolar dysplasia. It appears that independently from the ethiology PTRA is technically effective in correcting RAS; yet the position of PTRA with respect to that of medical or surgical treatment needs to be better delineated through randomized, controlled studies aimed at comparing the clinical efficacies of these different approaches.

[Transluminal treatment in aneurysm of the abdominal aorta. Role of diagnostic imaging]. / Trattamento transluminale degli aneurismi dell'aorta addominale. Ruolo della diagnostica per immagini.

PURPOSE: To emphasize the importance of diagnostic imaging: a) in the selection of patients to be treated with the transluminal approach b) during stent-graft positioning c) in the follow-up of treated patients. MATERIAL AND METHODS: From January 1997 to May 1998, twenty-five patients with abdominal aortic aneurysms (AAA) were treated with transfemoral stent-grafts (AneuRx Medtronic). All patients were submitted to a preoperative study including digital angiography (DSA) and Spiral CT. Intraoperatively they underwent DSA and intravascular ultrasound (IVUS). Follow-up was performed with Spiral CT. RESULTS: Twenty-four bifurcated and one straight device were inserted in twenty-five patients with AAA. In two cases it was impossible to position the endoprosthesis due to narrow or tortuous artery access. Following the intention to treat criteria, the technical success rate was 92.5%. All the stents were patent and no dislodgement was observed at follow-up. Partial thrombosis of the stent was observed in three patients. Owing to incomplete distal covering, early endoleak occurred in one patient with an aortoiliac aneurysm; the positioning of two cuffs allowed a successful outcome. CT examination performed 6 months after positioning revealed the presence of endoleaks in three patients, due to persistence of lumbar and inferior mesenteric artery patency. The AAA was no more appreciable in five of the ten patients submitted to CT follow-up one year after the procedure. In three of ten cases it was reduced in size and in two patients there was no change. DISCUSSION: Spiral CT plays a basic role in the selection of patients because it helps assess the length and diameter of the proximal neck, thus permitting to choose the device to be inserted. Preoperative DSA is mandatory in the evaluation of size and tortuosity of the iliac arteries. IVUS allows to monitor the site of delivery during the maneuver and to make the final measurements while DSA plays a role in checking the correct positioning of the device and excluding the presence of endoleaks at the end of the procedure. Late follow-up with Spiral CT aims at demonstrating possible malfunctioning of the endoprosthesis and confirms the definitive exclusion of AAA. CONCLUSIONS: Diagnostic imaging plays a basic role in the endovascular treatment of AAA, much more than that required for traditional surgical treatment. In particular, pretreatment planning is critical and requires sophisticated imaging including Spiral CT with 3D reconstruction and angiographic evaluation using catheters with calibrated markers.

European multicentre experience with modular device (Medtronic Aneurx) for the endoluminal repair of infrarenal abdominal aortic aneurysms.

OBJECTIVE: Transfemoral endoluminal repair of AAA, introduced for the first time in the early 90's, has become a very promising alternative to conventional open repair and more and more centers are reporting satisfactory postoperative results in a high percentage of cases. Straight and bifurcated grafts represent the devices available on the market at present and aortic, as well as iliac aneurysmal lesions can be safely treated through a transfemoral approach. The possibility to indicate an endovascular AAA repair is related to the configuration (length and size) of the proximal and distal necks, tortuosity and calcification of the access arteries and to vascular and non-vascular comorbidities, which afflict the patients. The objective of our study was to evaluate the early and late postoperative results in a series of patients affected by infrarenal AAA, who underwent endoluminal repair. MATERIALS AND METHODS: From December 1996 to 31 October 1997 in 5 different European Centers, 100 Medtronic AneuRx bifurcated stent grafts were implanted for infrarenal abdominal aortic aneurysms. The diameter of the AAA varied from 33 to 77 mm (average 64 mm) and the mean age of the patients was 70.8 years (51-87 years). In one patient with a 33 mm diameter of the aneurysm, the surgical procedure was indicated because the size of the aneurysm had increased by 5 mm, compared to the previous control made 2 months before. In addition the aneurysm became symptomatic. There were 92 male and 8 female patients. The average time of the surgical procedure was 150 minutes (75-480 minutes) with an average blood loss of 570 ml (100-2,600 ml).

[Degenerative changes in the coxofemoral articulation due to occupational causes. I. Radiological description of a control population]. / Alterazioni degenerative a carico dell'articolazione coxofemorale da cause professionali: I--descrizione radiologica di una popolazione di controllo.

With a view to initiating epidemiological studies aimed at demonstrating the causal or concausal role of certain working activities in degenerative diseases of the coxo-femoral articulations, the authors report data from a radiological study of a reference population and the necessary conditions for their correct use. Statistical analysis of the descriptive features leads to some interesting observations on the evolution with age of the radiological picture of the coxo-femoral joints (and on the aging of these joints). There was an increase with advancing age of some of the alterations that are characteristic of degenerative articular processes, such as sclerosis and osteophytosis. Reduction of articular "rima", however, occurs suddenly between the ages of 36 and 45 and does not seem to subsequently undergo any statistically significant evolution.

[Current role of sialography]. / Ruolo attuale della sialografia.

Computed tomography, ultrasonography and nuclear medicine are morphological techniques widely accepted in clinical practice. They are used together with plain film and sialography in the study of salivary glands pathology. In comparison with these techniques, the efficacy of sialography in different diseases is discussed and the diagnostic value of CT-sialography related to sialography alone is analyzed.

Double-contrast enema in antibiotic-related pseudomembranous colitis.

Pseudomembranous colitis (PMC) is a potentially fatal disease often associated with antibiotic therapy. The condition is now known to be due to an enterotoxin produced by Clostridium difficile. Diagnosis is based on the endoscopic finding of the typical pseudomembranes, stool culture, and assay of the stools for the specific toxin. Radiography with double-contrast medium (DCE), which can be performed in patients not critically ill, often yields pathognomonic findings and permits early diagnosis.

[The solitary pulmonary nodule. A radiologic and clinical approach (author's transl)]. / Approccio radio-clinico al problema del nodulo solitario del polmone.

The cases of pulmonary coin lesions operated at the National Cancer Institute of Milan during the last ten years are presented. Both the disadvantages of early thoracotomy as well as watchful waiting are discussed. Therefore different parameters with the aim to select the patients with the highest probability of cancer are analysed. Finally we tried to identify a diagnostic-therapeutic approach to reduce the complications and risks of thoracotomy in non-oncologic patients.

Pulmonary and mediastinal xerotomography: a critical appraisal.

Xerotomography was performed on 148 patients with proven or suspected tumors of the lung or mediastinum. Retrospectively they were compared to film tomography in 108 cases. In 64 patients, the results of histological examination were also available. Xerotomography proved diagnostically more effective than film tomography in 52 cases (48%), less effective in 6 cases (6%) and about equivalent in the remaining 50 cases (46%). Xerotomography appeared to be more effective in visualization of small peripheral nodes of moderate opacity. Xerotomography has to be a selected second-line technique for special cases, in particular for the study of coin lesions, for the search for cavitations and calcifications and for the study of pulmonary vessels.