Renal embolization as an alternative to surgical nephrectomy in children.

PURPOSE: Complete renal embolization may be an alternative to surgical nephrectomy. The indications for renal embolization do not differ from those for surgical nephrectomy, but the less invasive nature of the technique is a major advantage. Few case reports are available in the pediatric age group. Our experience showed that complete renal embolization was feasible in pediatric patients with results comparable to those obtained in adults. MATERIALS AND METHODS: Twelve pediatric patients underwent 14 renal embolizations. The indications for embolization were as follows: (1) severe hypertension in 7 patients with end-stage renal failure; in these cases, a unilateral native nephrectomy was recommended prior to renal transplantation; (2) end-stage hydronephrosis in 3 patients with moderate hypertension or recurrent urinary infection; (3) nephrotic syndrome in 1 patient; or (4) ablation of an irreversibly rejected renal allograft in 1 patient. The embolization was performed under epidural anesthesia in 10 patients and under general anesthesia in 2 patients, by means of a polyvinyl alcohol injection with hemostatic gelatin powder and placement of coils. Postembolization course was followed. RESULTS: The embolization was successful in all 12 patients. In 1 patient, the procedure had to be repeated as a small accessory artery had revascularized the upper pole. In another patient, the procedure was bilateral in 2 separate sessions. In 10 patients, severe flank pain required narcotic analgesia. Two patients had fever. None had hypertension peaks. Median hospital stay was 4 days. At mean follow-up of 16 months, the results were stable. CONCLUSION: Renal embolization can avoid surgical nephrectomy also in pediatric patients. The advantages are less morbidity and shorter hospital stay. Our results in the short and medium term were equal to those of surgical removal. The procedure appeared to be safe and minimally invasive.

Dacryocystostenting: technical and long-term results.

PURPOSE: We describe our experience in treating epiphora caused by chronic inflammation and obstruction of the nasolacrimal system by endonasal placement of a polyurethane stent in the nasolacrimal duct, with long-term assessment of patency (4 years). MATERIAL AND METHODS: Between July 1998 and May 2001, 57 stents were inserted using Song's technique. All procedures were carried out in the radiology suite following mild sedation and local anaesthesia of the conjunctival and nasal mucosa. The follow-up investigation concerns 23 stents assessed 24-48 months after placement. RESULTS: At follow-up after 4 years, 20 stents (86.9%) were obstructed. Fifteen of the stents removed underwent histological analysis that showed occlusion of the stent with granulation tissue (eight cases), necrotic material (four cases) and fibrosis (three cases). CONCLUSIONS: Although encouraging in terms of safety, simplicity and reproducibility, the results obtained with the polyurethane stent demonstrate poor long-term efficacy and stimulate the search for new strategies such as programmed stent removal or the development of a more biocompatible material.

Magnetic resonance imaging in the diagnosis of melanoma: in vivo preliminary studies with dynamic contrast-enhanced subtraction.

The aim of this study was to analyse the potential of fast dynamic subtraction magnetic resonance (MR) imaging in differentiating in vivo melanomas from benign melanocytic lesions. Dynamic MR imaging was performed after intravenous administration of gadopentetate dimeglumine (Gd-DTPA) in 18 patients with melanocytic skin lesions. Using a post-processing algorithm, time-signal intensity curves were obtained for the lesions and classified according to their shapes as type I (steady enhancement increase), type II (plateau of signal intensity) or type III (wash-out of signal intensity). Other parameters evaluated for their potential to differentiate melanomas from benign lesions were the enhancement rate (percentage of signal intensity increase) in the first minute after Gd-DTPA administration, the peak value of the enhancement rate, and the wash-out slope. The pigmented lesions were then surgically excised and the MR results compared with the histological assessment. In melanomas, the mean value of the enhancement rate in the first minute was 611%, whereas in benign lesions it was 131% (P = 0.001). The distribution of curve types was also different: seven of the nine naevi showed type I curves, while eight of the nine melanomas displayed a type III curve. In addition, distinctive wash-out dynamics were observed: the enhancement rate began to decrease between the first and third minutes for melanomas, but continued to increase until the sixth minute for naevi (P = 0.000). These findings, which are most likely related to the neoangiogenesis present in melanomas, indicate that dynamic MR imaging can be helpful in the differential diagnosis of pigmented skin lesions.

Combined radiological and surgical treatment of arteriovenous malformations of the head and neck.

Arteriovenous malformations (AVMs) are high-flow lesions. More than 50% of all AVMs are located in the head and neck region. They represent a therapeutic challenge because of their hemodynamic characteristics and their modality of growth. AVMs have a tendency to recur and often require radical resection, making surgical ablation and reconstruction difficult. AVMs require angiography not only for diagnostic purposes but as an initial therapeutic step in the form of embolization. Surgical ablation, which follows a few days after embolization, is facilitated by the reduction in vascularity and shrinkage of the lesion, both of which are afforded by the embolization. These benefits allow for less blood loss at the time of ablation, and less extensive resection. The authors report their experience with 16 patients with extracranial AVMs of the head and neck examined over the last decade.

[Thromboendarterectomy of the superficial femoral artery with a femoro-popliteal endoprosthesis. Technical note on a preliminary experience]. / La Tromboendoarteriectomia (TEA) dell'arteria femorale superficiale (SFA) con posizionamento di endoprotesi femoro-poplitea. Note di tecnica su una esperienza preliminare.

BACKGROUND: The authors report an early experience with a new endovascular approach in the treatment of occlusive superficial femoral artery disease to evaluate the efficacy and the feasibility of the new technique. METHODS AND RESULTS: Four patients with disabling claudication or leg rest pain were treated for long segment occlusion of superficial femoral artery (SFA). A remote endarterectomy (EA) of SFAs has been performed using a single groin incision and a conventional Vollmar ring stripper to remove the entire atheroma core for a length of 20, 10, 9 and 8 cm. In 3 cases following complete extraction of intimal core and a guidewire placement across from the distal endpoint, the endarterectomized segment was lined endoluminally by implanting one or more Self-Expanding Coated Stent (Meadox Passager 6-10 mm); the stent was positioned under fluoroscopic guidance to prevent dissection without any further balloon-dilation. In 1 case a 5 mm diameter thin-walled PTFE endoluminal graft was positioned using a Strecker stent for distal fixation. One patient had an immediate post-operative occlusion of distal stent which required a femoro-popliteal autologous vein bypass. In the remaining 3 cases no postoperative complications were observed and the patients are asymptomatic with normal flow through the stent and the endoluminal PTFE graft at 6 months. CONCLUSIONS: In this report a combined surgical and endovascular procedure has been proposed. A prospective randomized study is carrying on at our Institute to verify if EA+ endovascular grafting of SFA represents an alternative to traditional femoro-popliteal vein bypass.

Treatment of intraosseous arteriovenous fistulas of the extremities.

Intraosseous arteriovenous fistulas of the extremities are rare malformations frequently associated with severe systemic hemodynamic alterations. In many cases, it is quite difficult to eliminate these anomalous vascular structures, but the possibilities for successful treatment are much greater when surgery is combined with interventional radiology. Selective embolization of the malformed vessels can be produced with a variety of agents that are injected into afferent arteries, via percutaneous puncture or through direct surgical access. The intraosseous portion of the fistula should be resected at the time of embolization or later. The authors describe the successful treatment of three patients having intraosseous arteriovenous fistulas of the upper extremities, who have had follow-up for 2 to 10 years.

[Preoperative ultrasonographic measurement of melanoma thickness with 20 MHz probe]. / Misurazione ecografica preoperatoria dello spessore del melanoma con sonda da 20 MHz.

The authors report on the preoperative evaluation of melanoma thickness with very high frequency US probes (20 MHz). Thirty patients with clinical suspicion of melanoma were examined preoperatively with US. The high quality of the images obtained with 20-MHz US probes allowed the lesions involving the superficial derma or, in more advanced cases, all derma, to be demonstrated and tumor thickness to be measured accurately. The latter is a major prognostic factor and indeed Breslow's classification is based on tumor thickness. The preoperative US study of melanoma thickness allows the surgeon to plan excision depth, which is necessary for accurate and safe tumor resection, that is, whose margins are proportionate to melanoma thickness. In the 30 patients submitted to preoperative US measurements of tumor thickness, US and histologic findings were in agreement. US overestimated melanoma thickness by 7 to 11%, which however had no impact on prognosis and surgical planning. While US can differentiate melanomas from other types of benign or malignant pigmented skin lesions such as blue nevus, pigmented basalioma or pigmented seborroic cheraosis, no unquestionable US signs have been found yet to differentiate melanoma from nevus, which makes US useless for the differential diagnosis. Nonetheless, surgeons can use preoperative US to adapt the exeresis of melanoma to its actual severity and to reduce scars to a minimum. Possible skin metastases can also be detected by US and thus removed.

[Gastric lymphoma: diagnostic radiology in the staging of the disease]. / Il linfoma gastrico: la diagnostica radiologica nello staging della malattia.

In the staging of gastric lymphoma, the radiologist has very important role, because he has many means to define correctly the stage. Conventional radiology is useful for detection of the lesion. Moreover, Ultrasound, Computed Tomography, and Magnetic Resonance are useful to define parietal extension and eventual nodal involvement. Lymphography remains a study kept to negative or doubt cases. In the future, the Magnetic Resonance will have a bigger role than now, in the definition of abdominal and pelvis nodal involvement.

[Percutaneous transluminal renal angioplasty. Italian experience at 13 centers]. / L'angioplastica renale percutanea transluminale. Esperienza italiana in 13 centri.

The data relative to 13 years' experience with percutaneous transluminal renal angioplasty (PTRA) in the 13 major interventional radiology centers in Italy were collected and analyzed to evaluate technical and clinical results. Our aim was to collect homogeneous results in a large series of patients, evaluating both the technical and the clinical success with a long-term follow-up (1 month-13 years). One thousand three hundred forty seven PTRA procedures (including 42 restenoses) in 1,073 patients were retrospectively reviewed. In 807 cases the cause of stenosis was atherosclerosis, in 442 cases fibromuscular dysplasia and in 24 cases arteritis in 12 cases, stenoses were present in patients that had undergone a surgical by-pass. Sixty-two stenoses in patients with solitary kidney and 102 in patients with renal failure were studied separately. The technical success (based on the morphology of the dilated tract) obtained in 91% of cases was considered, together with the clinical success (in 81% of cases), based on the decrease in blood pressure evaluated according to Martin's classification. The blood pressure values collected after the maneuver were also evaluated separately for the different types of stenosis etiology: atherosclerosis, fibromuscular dysplasia or arteritis; moreover, blood pressure was studied in solitary kidney patients and in those with renal failure. Complications were classified as major (4.2%) and minor (4.9%). The high success rate and the low incidence of complications we observed in our series suggest PTRA as the procedure of choice for high blood pressure patients with renal artery stenosis > 50% of the normal caliber.

[The origin of the arteria sigmoidea ima]. / Sull'insorgenza dell'a. sigmoidea ima.

The authors report the results of their observations on the lowest sigmoid artery, carried out on 92 anatomical specimens coming from surgical operations on the sigmoid and rectum. The specimens were injected and radiographed immediately after their removal . The observations were often preceded by pre-operative angiographies performed for diagnostic reasons. The AA. document all the variational patterns of this artery. They confirm the poor functional value of this artery more known by the old surgeons than by the anatomists.

[Connections between the phrenic arteries and various visceral arteries]. / Sulle connessioni fra le arterie freniche ed alcune arterie viscerali.

During an angiographic research carried out over more than 1100 cases, some connections between the phrenic arteries and the arteries of the hepatic, superior mesenteric and renal districts were observed. The AA. point out the presence of these connections even of thin calibre, their right prevalence (71%), and their uncertain embryologic origin.

Arterial thrombosis as clinical manifestation of congenital protein C deficiency.

A 49-year-old man was hospitalized for slight paresis of the upper left limb. Thrombosis of the right internal carotid artery was documented by arteriography and digital angiography, which showed evidence of an anastomotic blood flow. He went on anticoagulation treatment. Five years later, after an uneventful period, he was referred to our center for the occurrence of a superficial thrombophlebitis: diagnosis of congenital protein C deficiency was possible in the patient as well as in two of his relatives. Two other subjects with congenital protein C deficiency belonging to two different kindreds, whose illness was diagnosed in our center, suffered from myocardial infarction and TIA, respectively, as the only clinical manifestation; a fourth case, previously described, with recurrent superficial thrombophlebitis, suffered from a TIA when on treatment with stanozolol. These cases indicate that arterial thrombosis or TIA is not an uncommon event in congenital protein C deficiency, even in patients without other risk factors for arterial thrombosis.

[Integrated imaging of hepatocarcinoma. Personal experience]. / Imaging integrato dell'epatocarcinoma. Esperienza personale.

Hepatocellular carcinoma (HCC) is the commonest primary tumor of the liver; of late, its incidence has increased in the Western world. The authors report their experience with 42 patients affected with HCC; 36 cases were confirmed by fine-needle biopsy (FNAB), and 2 by surgery. All patients were studied with US and CT; 25 of them underwent color-Doppler US, and 30 angiography. In 9 patients, Lipiodol-CT was performed after hepatic arterial chemo-embolization. Thirty-six expansive and expansive-infiltrative lesions were observed, 4 infiltrative ones, and 1 neoplastic thrombosis of the portal vein with no evidence of parenchymal mass; 28 cases were multinodular in nature. US showed the primary lesion in all cases, while CT missed 2 lesions of 15 mm in diameter. In 19 of 25 cases studied with color-Doppler US, arterial pathologic signals were observed. Angiography confirmed all the primary lesions diagnosed by US in 30 patients and was found to be the most sensitive method to reveal multinodular lesions 8-15 mm phi, whereas Lipiodol-CT had higher resolution in detecting nodules up to 3 mm phi. The retrospective review of our results pointed out the capabilities of diagnostic imaging techniques in characterizing and staging HCCs--which is the reason why the role of biopsy has not been emphasized. The whole of the morphofunctional data obtained with the different techniques allowed lesion tissue characterization.

[The termination of the superior hemorrhoidal artery. An anatomicoradiological study]. / Sulla terminazione della a. emorroidale superiore. Studio anatomo-radiologico.

The author report the observations carried out on the distal part of the hemorrhoidal artery, obtained with a research on the vascularization of the large intestine, studied by the angiographic method and injection of the c.m. in the anatomical specimen immediately after surgical extirpation. The study was based on 92 anatomical specimens and reveals a variability of the terminal arterial distribution which can be summarized in few more frequent models, but cannot be given an absolute rule.