Endovascular treatment of visceral artery aneurysms and pseudoaneurysms: our experience.

PURPOSE: The aim of this study was to analyse our 8 years of experience with endovascular treatment of visceral aneurysms and pseudoaneurysms. MATERIALS AND METHODS: From January 2002 to September 2009, we used an endovascular approach to treat 30 patients (22 men, eight women) affected by aneurysm (n=18) or pseudoaneurysm (n=13) of the splenic (n=11), hepatic (n=6), renal (n=5), pancreaticoduodenal (n=3), left gastric (n=2), gastroduodenal (n=1), rectal (n=1) or middle colic (n=1) arteries and the coeliac axis (n=1). Of these, 26/31 were treated with metal coils, 3/31 with Cardiatis multilayer stent, 1/31 with a coated stent and 1/31 with coils and Amplatzer plug. Procedures were performed electively in 10/30 cases and during haemorrhage in 20/30 cases. Follow-up was performed clinically (cessation of bleeding) and at 1, 6 and 12 months by colour-Doppler ultrasound (CDUS) and computed tomography (CT) angiography. RESULTS: In 31/31 aneurysms and pseudoaneurysms we obtained immediate exclusion. In four patients with aneurysm and in four with pseudoaneurysm, parenchymal ischaemia occurred; one was treated with surgical splenectomy. One patient with pseudoaneurysm of the coeliac axis died 10 days later because of new bleeding. During follow-up, all aneurysms and pseudoaneurysms remained excluded. CONCLUSIONS: Percutaneous treatment is effective and safe, with a small number of complications, especially when compared with traditional surgery.

Pulmonary arteriovenous malformations: percutaneous treatment preserving parenchyma in high-flow fistulae.

PURPOSE: The aim of our study was to illustrate the benefits of percutaneous treatment by embolisation of high-flow pulmonary arteriovenous malformations (PAVM) in patients suffering from hereditary haemorrhagic telangiectasia (HHT; Rendu-Osler-Weber disease). MATERIALS AND METHODS: From December 2001 to February 2007, we embolised 60 PAVMS in 35 procedures performed on 30 patients, all referred by the HHT centre in Crema, and enrolled in a screening programme of HHT families. All patients underwent clinical evaluation, contrast-enhanced ultrasound (CEUS) and spiral computed tomography (CT). Embolisation was made with nonmagnetic metallic coils via femoral venous access; an endovascular Amplatzer device was used in one patient only. RESULTS: All embolisations were performed without difficulty. One patient only developed partial temporary aphasia, which resolved in 72 H. At spiral-CT follow-up, we generally demonstrated exclusion from circulation of treated PAVMS and regression of clinical symptoms. In the case of new lesions or recanalisation, further embolisation was possible: CONCLUSIONS: Percutaneous embolisation has recently become the initial treatment option in PAVM owing to its good results and minimal invasiveness compared with thoracotomy. Our experience is in agreement with the literature: the procedure has a low complication rate, provides very good technical and clinical results and avoids resection of healthy pulmonary parenchyma.

Intra-arterial hepatic chemotherapy: management of liver tumors by percutaneous port-a-cath positioning.

In the past, intrahepatic arterial locoregional chemotherapy was performed by surgical approach via gastroduodenal artery; early use of percutaneously placed arterial port was complicated by clotting and bleeding in 50% of pts. More recently, permanent catheters were positioned percutaneously in GDA by Japanese group and fixed to the artery by means of bucrylate in order to reduce dislocation. We present the technique and the preliminary results of percutaneous implantation of intraarterial catheters connected to a subcutaneous infusion reservoir for prolonged regional chemotherapy of hepatic tumors. Two hundred patients underwent to percutaneous arterial port implant, for loco-regional chemotherapy for liver primary or metastatic tumors. Catheter dislodgments were observed in 14,5%, but in 90% the catheters could be reinserted. No case of catheter related mortality was registered. Percutaneous positioning of arterial port is a safe and effective technique to deliver loco-regional treatment for hepatic tumors. Complication rates are similar to the surgical series and to other percutaneous interventional radiological reports. This percutaneous approach in the hands of a skilled team allows intra-arterial infusion in a wide percentage of pts, improving the accuracy of clinical trials by a faster and optimal balanced comparison between systemic and arterial arm.

[Transjugular intrahepatic portasystemic shunt (TIPS). Role of ultrasonographic methods]. / Anastomosi porto-sistemica intraepatica per via transgiugulare (TIPS). Ruolo delle metodiche ultrasonografiche.

The transjugular intrahepatic portosystemic shunt (TIPS) is a new interventional radiology procedure which may be assisted by modern ultrasound techniques (US). Color-Doppler US can be used for patients selection, during TIPS and in the follow-up. In a 20-month period, 71 patients were examined: 3 of them were excluded because of the absolute contraindications shown by US; in 14 of the remaining 68 patients, US demonstrated relative contraindications, such as hepatocellular carcinoma, partial portal vein thrombosis and right internal jugular vein occlusion. During the maneuver, US helped to select the most adequate veins for shunt creation and was especially useful in guiding portal vein puncture, thus allowing technical success to be achieved in 65/68 patients. The mean number of passes per patient was 2.7 and no procedure-related complications were observed. US was also used to investigate TIPS patency the day after the maneuver and to monitor shunt function during the follow-up. Color-Doppler US correctly diagnosed both 3/65 early occlusions and 9/65 late stenoses; in particular, in 18/65 patients US showed gradual flow reduction through TIPS, but clinical and endoscopic findings of malfunction appeared only in 9/65 patients whose mean reduction rates exceeded 50% at Doppler US.

[Intrahepatic portosystemic shunts]. / Derivazioni porto-sistemiche intraepatiche.

We want to present our experience performed at the Institute of Radiology of Turin: 98 TIPS in 97 patients (in 1 patient, twice). METHODS. From March 1992, 97 cirrhotic patients (18 Child A, 48 Child B, 31 Child C) underwent the TIPS procedure for portal hypertension. The indications were digestive hemorrhage in 81 patients (20 of which performed in emergency for acute bleeding), intractable ascites in 13 patients and bleeding prevention in 3 patients. RESULTS. Immediate technical success was obtained in 95/98 cases (96.9%). Patients were monitored by US-Doppler at 24 hours, 2 months and every 6 months and by esophagogastroscopy at 2 and 6 months. Major clinical complications included CID (2 cases), hepatic failure (3 cases), renal insufficiency (2 cases), heart failure (1 case), recurrent bleeding (6 cases) and encephalopathy (15 cases). We had 5 early occlusion and 17 late stenosis of the shunt; 21 patients in this group were successfully treated either by PTA or restenting; one patient underwent a surgical shunt. Mortality rate follow-up was 0/17 among Child A patients, 7/48 (14.5%) among Child B patients and 12/29 (41.3%) among Child C patients. CONCLUSIONS. TIPS is a safe and valuable method for the treatment of portal hypertension. Though shunt stenosis may occur with a certain frequency (22/95, 23.1% in our study), a second intervention is usually effective in reducing gastro-oesophageal varices and ascites.

[Prolonged angina after the administration of a synthetic PGE2 derivative]. / Angina prolungata dopo somministrazione di un derivato sintetico di PGE2.

We describe the case of a 39-year-old woman, heavy smoker, who received 500 micrograms i.m. of Sulprostone, a synthetic PGE2-derivative, to induce pregnancy termination. Sulprostone is usually administered either to cause abortion in preparation of an instrumental operation or to induce delivery after the intrauterine death of the fetus. This drug has a dilating effect on the cervix uteri and stimulates the uterus muscles. After about fifteen minutes the patient experienced a constrictive chest pain which progressively worsened and spread to the upper limbs. The pain disappeared for a short period and then recurred with greater intensity, accompanied by bradycardia and hypotension. The ECG showed sinus bradycardia, second- and third-degree atrioventricular block, S-T segment elevation in the inferior leads and reciprocal depression in the anterior leads. Intravenous nitroglycerin therapy induced a rapid reduction of the clinical symptoms and changes in the ECG. There was no increase in cardiac enzymes. The exercise test, the cold pressor test and the ECO-dipyridamole test were negative. The patient refused to undergo the ergonovine test and coronary angiography. We hypothesize that the Sulprostone either had a dipyridamole-like effect or that it induced a paradoxal coronary spasm.

[Lipids and serum apoproteins in subjects with slight or mild coronary atherosclerosis evaluated with angiography]. / Lipidi ed apoproteine sieriche in soggetti con aterosclerosi coronarica di grado lieve o moderata valutata angiograficamente.

In this study 126 subjects (91 males and 35 females, range of age 43-65 years) were studied by coronary angiography. We considered positive for coronary atherosclerosis also patients showing mild or moderate stenosis (> or = 25%). In all subjects we have evaluated serum lipid and apoprotein A-I, B, C-II, C-III and E levels; therefore also cholesterol concentrations in all lipoprotein fractions, separated by sequential ultracentrifugation (VLDL d < 1.006, LDL d 1.006-1.063, HDL d > 1.063 g/ml) and apoprotein B in LDL have been measured. Subjects with coronary atherosclerosis have shown significantly higher levels of total cholesterol, LDL-cholesterol, total cholesterol/HDL-cholesterol and LDL-cholesterol/HDL-cholesterol ratios than controls. Therefore, a lower apo A-I/apo B ratio in males and a higher LDL-apo B levels in females has been found in subjects with coronary atherosclerosis in comparison with controls. The stepwise multiple analysis has demonstrated that LDL-cholesterol levels is the parameter that best correlates with the presence of coronary atherosclerosis. These data confirm the importance of the reduction of LDL-cholesterol levels in primary and secondary prevention of coronary heart disease.

[Possibility of evaluation of chest pain at the time of hospitalization]. / Possibilità di valutazione del dolore toracico al momento del ricovero in ospedale.

A series of 140 patients admitted to an Internal Medicine or a Cardiology Department for an acute chest pain is examined in order to evaluate the possibility of reaching a quick diagnosis, particularly for coronaric heart diseases, according with history, physical examination, electrocardiogram. In most of cases it was possible an immediate, correct evaluation of the patients, but in some cases a right diagnosis was achieved only after a period of observation and different investigations.

[Myocardial infarction and diabetes (author's transl)]. / L'infarto miocardico nel diabete

30 diabetic patients with myocardial infarction were compared with 30 non-diabetic myocardial infarction patients during their hospitalization in an Intensive Care Unit, to observe possible differences at the onset and throughout the course of the infarction syndrome. Myocardial infarction in diabetic cases has an oligosymptomatic onset, often painless, which evolves towards cardiocirculatory decompensation. The frequence of arrhythmias is higher, especially in serious or mortal arrhythmias. Possible pathogenetic reasons for this are briefly discussed.