Type II single coronary artery from right aortic sinus, retro-aortic left coronary artery and dual LAD: a rare association of coronary arterial variations.

PURPOSE: The coronary arterial tree has a wide range of possible benign anatomical variations. It is important to differentiate them from coronary arterial anomalies, which can remain asymptomatic or in some cases lead to sudden death if undiagnosed. METHODS: A 42-year-old female patient with a transient ST depression in right precordial leads performed an ECG-gated computed tomography angiography with dual layer spectral CT (IQon Elite Spectral CT, Philips, Amsterdam, The Netherlands) at Circolo Hospital of Varese. RESULTS: A rare variant was observed and studied: a single common trunk arising from the right sinus of Valsalva which branches into a right coronary artery, a left anterior descending artery with malignant course and a left main with a retroaortic course; the left main gives origin to a dual anterior interventricular artery ("Dual LAD") and a left circumflex artery. CONCLUSIONS: This type of variation was never described in the English literature. Identifying this variant is crucial for potential ischemic complications during sports activities or with the onset of atherosclerotic disease.

Dual-layer spectral CT fusion imaging for lung biopsies: more accurate targets, diagnostic samplings, and biomarker information?

The increasingly widespread use of computed tomography (CT) has increased the number of detected lung lesions, which are then subjected to needle biopsy to obtain histopathological diagnosis. Obtaining high-quality biopsy specimens is fundamental for diagnosis and biomolecular characterisation that guide therapy decision-making. In order to obtain samples with high diagnostic potential, fusion imaging techniques, such as fusion between positron emission tomography and CT, have been introduced to target the biopsy where there more viable neoplastic cells can be sampled. Nowadays, dual-layer spectral CT represents a novel technology enabling an increased tissue characterisation. In particular, Z-effective images, i.e., colour-coded images based on the effective atomic number of tissue components, provide a higher level of discrimination than usual imaged based on x-ray attenuation in Hounsfield units and offer the potential of a better tissue characterisation. Our hypothesis is based on the future use of data provided by spectral CT, in particular by Z-effective images, as a guide for appropriate biopsy sampling for histopathological and biomolecular characterisation in the era of patient tailored-therapy.

Pocket-sized, wireless-Bluetooth ultrasound system to perform diagnostic and low-complexity interventional procedures in bedridden patients during the COVID-19 pandemic: from intensive care unit to domiciliary service?

The use of a pocked-sized, wireless-Bluetooth ultrasound portable system with display images presented on a tablet facilitated the work of our radiologists during the first wave of coronavirus disease 2019 (COVID-19) to perform diagnostic and interventional procedures in bedridden patients. The device is equipped with a battery-powered probe without cables that transmits images to a tablet (or a cell phone) through a dedicated App. We hypothesise in future to extend diagnostic and low-complexity interventional procedures from hospitalised patients to at-home patients who are not able to mobilise out of bed or are difficult to transport. This domiciliary service might also reduce the overhead of hospital accesses.

EVAR Follow-Up with Ultrasound Superb Microvascular Imaging (SMI) Compared to CEUS and CT Angiography for Detection of Type II Endoleak.

The aim of this study was to evaluate the usefulness of superb microvascular imaging (SMI) versus contrast-enhanced ultrasound (CEUS) and compared to computed tomography angiography (CTA) as a reference standard, for detection of type II endoleak during follow-up of endovascular abdominal aortic aneurysm repair (EVAR). Between April 2017 and September 2020, 122 patients underwent post-EVAR follow-up with CTA at 3 months and with ultrasound SMI and CEUS at 4 months from the EVAR procedure. Aneurysmal sac diameter and graft patency were evaluated; endoleaks were assessed and classified. Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy were calculated both for SMI and CEUS and compared to CTA. Furthermore, the percentage of agreement and Cohen's Kappa coefficient were calculated. CTA revealed 54 type II endoleaks. Ultrasound SMI and CEUS presented the same sensitivity (91.5%), specificity (100%), positive (100%), and negative (92.8%) predictive and accuracy (95.9%) value for detecting type II endoleak. The same percentage of agreement of 94.9% was found between SMI/CEUS, and CTA with a Cohen's Kappa coefficient of 0.89. The diagnostic accuracy of SMI is comparable with CEUS in the identification of type II endoleaks after EVAR. Since SMI is less invasive, less expensive, and less time-consuming, this method may be considered to be a potential tool for monitoring patients after EVAR implantation.

Non-Adhesive Liquid Embolic Agents in Extra-Cranial District: State of the Art and Review of the Literature.

This review focuses on the use of "new" generation of non-adhesive liquid embolic agents (NALEA). In literature, non-adhesive liquid embolic agents have mainly been used in the cerebral district; however, multiple papers describing the use of NALEA in the extracranial district have been published recently and the aim of this review is to explore and analyze this field of application. There are a few NALEA liquids such as Onyx, Squid, and Phil currently available in the market, and they are used in the following applications: mainly arteriovenous malformations, endoleaks, visceral aneurysm or pseudoaneurysm, presurgical and hypervascular lesions embolization, and a niche of percutaneous approaches. These types of embolizing fluids can be used alone or in combination with other embolizing agents (such as coils or particles) so as to enhance its embolizing effect or improve its possible defects. The primary purpose of this paper is to evaluate the use of NALEAs, predominantly used alone, in elective embolization procedures. We did not attempt a meta-analysis due to the data heterogeneity, high number of case reports, and the lack of a consistent follow-up time period.

Transcatheter Arterial Embolization in Acute Non-Variceal Gastrointestinal Bleedings: A Ten-Year Single-Center Experience in 91 Patients and Review of the Literature.

OBJECTIVE: To report the safety and efficacy of trans-arterial embolization (TAE) for upper gastrointestinal bleeding (UGIB) and lower gastrointestinal bleeding (LGIB) due to different etiologies in 91 patients for ten years. METHODS: A retrospective analysis of GIB treated between January 2010 and December 2020 was performed. TAE was performed using different embolic agents (coils, particles, glue, gelatin sponge, and EVOH-based agents). Technical success, secondary technical success, clinical success, and complications were evaluated. RESULTS: Technical success was achieved in 74/91 (81.32%) patients. Seventeen patients (18.68%) required re-intervention. Secondary technical success was achieved in all cases (100.0%). Clinical success was achieved in 81/91 patients (89.01%). No major complications were recorded; overall, minor complications occurred in 20/91 patients. CONCLUSIONS: TAE is a technically feasible and safe therapeutic option for patients with GIB from a known or blind anatomic source where endoscopic therapy has failed or is deemed unfeasible.

Gangliocytic paraganglioma leading to duodeno-jejunal intussusception: A case report.

The intussusception of the small bowel is rarely encountered in adult patients and is frequently associated with a lead point that is often malignant. In a 69-year-old female patient with an episode of gastrointestinal (GI) bleeding, computed tomography (CT) showed a duodenal-jejunal intussusception caused by an intraluminal mass. Open polypectomy and reduction of intussusception were performed and the diagnosis of gangliocytic paraganglioma was made at pathological evaluation. It would be important to consider neoplasms like gangliocytic paraganglioma in the setting of adult small bowel intussusception.

Successful endovascular management with a covered stent of an external iliac pseudoaneurysm following allograft nephrectomy using CO2 as contrast medium: a case report.

Iodinated contrast agents for angiography in chronic kidney disease (CKD) patients could further deteriorate their renal function leading to adverse sequelae. The use of carbon dioxide (CO2) is reported in the literature and has been safely used for a variety of angiographic procedures, particularly to guide aortic and renal interventions. We report the case of the successful endovascular treatment with a covered stent of a right external iliac artery pseudoaneurysm following graft nephrectomy in a CKD patient, using CO2 as contrast medium.

MR- arthrography: anatomic variant from link between lateral meniscus and anterior and posterior cruciate ligaments. A case report and review of the literature.

Menisci congenital anomalies are rare morphologic abnormalities including accessory meniscus, discoid meniscus, double-layered meniscus, hypoplastic meniscus and ring-shaped meniscus (RSM). In a 35 year-old male patient, MR arthrography showed a bridging accessory bundle connecting the anterior cruciate ligament and posterior cruciate ligament with the posterior horn of the lateral meniscus. Arthroscopic examination showed a fan-like obstacle embracing the posterior horn of the lateral meniscus. It would be important to correctly identify this anatomical variant, because the bundle connecting the external meniscus to the ligaments of the central pivot can be misinterpreted as a meniscal fragment.

Role of ultrasound and magnetic resonance imaging in the prognosis and classification of muscle injuries in professional football players: correlation between imaging and return to sport time.

PURPOSE: To study distractive muscle injuries applying US and MRI specific classifications and to find if any correlation exists between the results and the return to sport (RTS) time. The second purpose is to evaluate which classification has the best prognostic value and if the lesions extension correlates with the RTS time. METHODS: A total of 26 male, professional soccer players (age 21.3 ± 5.6), diagnosed with traumatic muscle injury of the lower limbs, received ultrasound and MRI evaluation within 2 days from the trauma. Concordance between US and MRI findings was investigated. The relationships between MRI and US based injury grading scales and RTS time were evaluated. Correlation between injuries' longitudinal extension and RTS time was also investigated. RESULTS: The correlation between US and MRI measurements returned a Spearman value of rs = 0.61 (p = .001). Peetrons and Mueller-Wohlfahrt grading scales correlations with RTS time were r = 0.43 (p = .02) and r = 0.83 (p = < .001). The lesion's extension correlation with RTS time was r = 0.63 (p < .001). The correlation between the site of the lesion and its location with the RTS time were rs = 0.2 and rs = 0.25. CONCLUSIONS: Both US and MRI can be used as prognostic indicators along with the Peetrons (US) and the Mueller-Wohlfahrt (MRI) classifications. MRI is more precise and generates more reproducible results. The lesion craniocaudal extension must be considered as a prognostic indicator, while the injury location inside the muscle or along its major axis has doubtful significance.

Visceral Artery Aneurysms Embolization and Other Interventional Options: State of the Art and New Perspectives.

Visceral artery aneurysms (VAAs) are rare, usually asymptomatic and incidentally discovered during a routine radiological examination. Shared guidelines suggest their treatment in the following conditions: VAAs with diameter larger than 2 cm, or 3 times exceeding the target artery; VAAs with a progressive growth of at least 0.5 cm per year; symptomatic or ruptured VAAs. Endovascular treatment, less burdened by morbidity and mortality than surgery, is generally the preferred option. Selection of the best strategy depends on the visceral artery involved, aneurysm characteristics, the clinical scenario and the operator's experience. Tortuosity of VAAs almost always makes embolization the only technically feasible option. The present narrative review reports state of the art and new perspectives on the main endovascular and other interventional options in the treatment of VAAs. Embolization techniques and materials, use of covered and flow-diverting stents and percutaneous approaches are accurately analyzed based on the current literature. Visceral artery-related considerations and targeted approaches are also provided and discussed.

Knee articular cartilage injury treatment with matrix-induced autologous chondrocyte implantation (MACI): correlation at 24 and 120 months between clinical and radiological findings using MR arthrography.

OBJECTIVE: To evaluate the long-term evolution of matrix-induced autologous chondrocyte implantation (MACI) with magnetic resonance (MR) arthrography and verify the correlation between radiological and clinical findings. MATERIALS AND METHODS: Twenty-six patients (20 m/6f) were diagnosed with knee chondral injuries and treated with MACI implantation. Each patient received MR arthrography and clinical examination at mid-term (range 22-36 months) and long term (range 96-194 months) after surgery. MR arthrography was performed with dedicated coil and a 1.5-Tesla MR unit. The modified MOCART scale was used to evaluate the status of chondral implants. Implant coating, integration to the border zone, and the surface and structure of the repaired tissue were evaluated. Presence of bone marrow oedema was evaluated. The Cincinnati Knee Rating System (CKRS) was used for clinical assessment. RESULTS: At long term, 4/26 patients had complete alignment; 5/26 had a complete integration of the margins; in 4/26 cases, the implant surface was undamaged; in 14/26 cases, the reparative tissue was homogeneous. In 9/26 cases, the implant showed isointense signal compared to articular cartilage, while the presence of subchondral bone oedema was documented in 19/26 cases. The average radiological score decreased from 59.2 (mid-term) to 38.6 (long term). The average clinical score decreased from 8.9 to 8.3. CONCLUSIONS: Decrease in clinical results was not significant (0.6 points p = .06), but mMOCART scores decreased significantly (p = .00003). Although imaging studies showed deterioration of the grafts, the patients did not have significant clinical deterioration (231/250).

Diagnostic and Interventional Radiology Management of Ureteral Iatrogenic Leakage after Gynecologic Surgery.

OBJECTIVE: To report safety and efficacy of interventional radiology procedures in the treatment of gynecologic iatrogenic urinary leaks. METHODS: A retrospective analysis of iatrogenic ureteral lesions treated between November 2009 to April 2019 was performed. Under ultrasound (US) and fluoroscopy guidance, an attempt to place a ureteral stent and nephrostomy was carried out in the same session using an anterograde percutaneous approach. At the end of any procedure, a fluoroscopic control and a cone-beam CT scan (CBCT) were performed to check the correct placement and functioning of the nephrostomy and DJ stent. In cases of difficult ureteral stent placement via the single anterograde approach, the collaboration of urologists was requested to perform a rendezvous technique, combined with the retrograde approach. RESULTS: DJ stent placement was achieved using the anterograde approach in 12/15 (80.0%) patients and using the retrograde approach in 3/15 cases (20.0%). Moreover, in 3/15 (20.0%) patients, surgical treatment was needed: in one case because of the persistence of ureteral stenosis at 6 months, and in the other two cases due to ureter-vaginal fistula. No major complications were recorded; overall, minor complications occurred in 4/8 patients. CONCLUSION: Percutaneous minimally invasive treatment of iatrogenic ureteral lesions after gynecological surgery is a safe and effective option.

Vacuum-assisted mechanical thrombectomy in extensively occlusive thrombosis of dialysis arteriovenous grafts with indigo system.

PURPOSE: To present a selected series of extensively occlusive thrombosis of arteriovenous graft treated with the Penumbra's Indigo System. MATERIALS AND METHODS: Ten patients with acute (within 72 h) extensively occlusive thrombosis of arteriovenous graft (mean extension = 30.1 (range = 15-45) cm) were treated at our institution with the Indigo System. Of the 10 cases, thrombosis was extended to venous outflow in 7 cases and to both arterial inflow and venous outflow in 3 cases. RESULTS: Both anatomic and clinical success were achieved in 8 of the 10 procedures (80.0%). In the 2 cases of technical failure, the patients underwent surgical thrombectomy with the finding of arteriovenous graft exhaustion, which was then replaced. The 6-month primary patency, primary-assisted patency, and secondary patency rates were 37.5% (3/8), 50.0% (4/8), and 62.5% (5/8). We reported 2 complications (one minor and one major adverse event). CONCLUSION: Percutaneous mechanical thrombectomy aspiration with Indigo System is a relatively safe and effective procedure and can be used even in extensively thrombosed arteriovenous graft.

Hypoplasia of right renal vein with aberrant drainage into ipsilateral spermatic vein: Case report.

The objective of this study was to describe a case of marked hypoplasia of the right renal vein with drainage into ipsilateral gonadal vein. A 66-year-old man, known for hypertension and previous smoking, underwent an abdominal ultrasound exam, which detected a juxtarenal aortic aneurysm. Computed tomography scan confirmed the presence of the aortic aneurysm; furthermore it showed an abnormal right kidney venous drainage consistent in a dilated and tortuous vein, which originated at the hilar region, heading caudally and joining the right spermatic vein at level of aortic carrefour. A thin vein-located more cranially with mild and late contrast enhancement-was also demonstrated from right kidney hilum to inferior vena cava, probably representing a remnant of the right main renal vein. To our knowledge, this anatomic variant was never reported in the peer-reviewed literature.