Transcatheter Aortic Valve Implantation (TAVI) Planning with Dual-Layer Spectral CT Using Virtual Monoenergetic Image (VMI) Reconstructions and 20 mL of Contrast Media.

Transcatheter aortic valve implantation (TAVI) is a less invasive alternative to surgical implantation and its implementation is progressively increasing worldwide. We routinely perform pre-procedural aortic angiography CT to assess aortic dimensions and vascular anatomy. This study aims to evaluate the image quality of CTA for TAVI planning using dual-layer spectral CT, with virtual monoenergetic image reconstructions at 40 keV. Thirty-one patients underwent a CTA protocol with the injection of 20 mL of contrast media. Image quality was assessed by measuring the mean density in Hounsfield Units (HU), the signal-to-noise ratio, and the contrast-to-noise ratio in VMI reconstructions. Additionally, a blinded subjective analysis was conducted by two observers. The results showed significant enhancement at all sampled vascular levels with a gradual decrease in HU from proximal to distal regions. Favourable subjective ratings were given for all parameters, with greater variability in the evaluation of iliac axes. A significant negative correlation (p < 0.05) was observed between BMI and CA at all vascular levels, indicating reduced contrast enhancement with increasing BMI. Spectral CT, along with reducing iodine load, allows for obtaining high-quality images without a significant increase in noise. The reduction in iodine load can have positive implications in clinical practice, improving patient safety and resource efficiency.

Dual-Layer Spectral CT as Innovative Imaging Guidance in Lung Biopsies: Could Color-Coded Z-Effective Images Allow More Diagnostic Samplings and Biomarkers Information?

The aim of the study was to try to obtain more information on diagnostic samplings and biomarkers using dual-layer spectral CT in lung biopsies. Lung biopsies were performed by merging images obtained with CBCT with those from spectral CT to use them as functional guidance, experimenting with double sampling to determine the difference between the area with a higher Z-effective number and that with a lower Z-effective number. Ten patients with large lung lesions on spectral CT were selected and underwent percutaneous transthoracic lung mass biopsy. Technical success was calculated. The percentage of neoplastic, inflammatory, fibrotic, necrotic cells, or non-neoplastic lung parenchyma was reported. The possibility of carrying out immunohistochemical or molecular biology investigations was analyzed. All lesions were results malignant in 10/10 samples in the Zmax areas; in the Zmin areas, malignant cells were found in 7/10 samples. Technical success was achieved in 100% of cases for Zmax sampling and in 70% for Zmin sampling (p-value: 0.2105). The biomolecular profile was detected in 9/10 (90%) cases in Zmax areas, while in 4/10 (40%) cases in Zmin areas (p-value: 0.0573). The advantage of Z-effective imaging would be to identify a region of the lesion that is highly vascularized and probably richer in neoplastic cells, thus decreasing the risk of obtaining a non-diagnostic biopsy sample.

Point Shear Wave Elastography of the Spleen: Its Role in Patients with Portal Hypertension.

The goals of the study described here were to evaluate the feasibility and reproducibility of measuring spleen stiffness (SS) using point shear wave elastography in a series of cirrhotic patients and to investigate whether SS, liver stiffness (LS) and other non-invasive parameters are correlated with the presence of esophagogastric varices (EVs). Fifty-four cirrhotic patients with low-grade EVs or without EVs at esophago-gastro-duodenoscopy were enrolled. They underwent abdominal ultrasound and Doppler ultrasound of hepatic vessels simultaneously with p-SWE of the liver and spleen. In 42 patients, the accuracy of LS and SS, as well as of platelet count and spleen longitudinal diameter, in predicting the presence of EVs was evaluated. The technical success was 90.74% for LS (49/54 patients) and 77.78% for SS (42/54 patients). Inter-observer agreement for SS measurement was high. Both LS and SS correlated with esophago-gastro-duodenoscopy: LS had the highest accuracy in predicting the presence of EVs (area under the receiver operating characteristic curve [AUROC] = 0.913); SS had the lowest accuracy (AUROC = 0.675); platelet count and spleen diameter had intermediate accuracy (AUROC = 0.731 and 0.729, respectively). SS did not have an advantage over LS in predicting low-grade EVs and cannot be proposed as a useful tool in the diagnostic process of cirrhotic patients who require screening esophago-gastro-duodenoscopy.

Duplex collecting system in a pelvic kidney - an unusual combination.

Pelvic kidney is a relatively common renal malformation as well as duplex kidney; however, the unilateral coexistence of these abnormalities is not frequently found. We present a case of a young woman with a history of hypertension in whom a pelvic and dysmorphic left kidney was discovered during ultrasound examination performed for the study of the renal arteries. Magnetic resonance imaging and computed tomography imaging revealed a duplex pelvic kidney. This combination is very rare; we have not found a similar case reported in the literature.

Analysis of achilles tendon vascularity with second-generation contrast-enhanced ultrasound.

PURPOSE: To compare morphological, power Doppler, and contrast-enhanced ultrasound (CEUS) features of the Achilles tendon between asymptomatic athletes and athletes who had undergone surgical repair of a previous rupture. METHODS: Twenty-four athletes were divided in two groups (A and B). Group A included 14 patients with a median age of 32 years (range 27 to 47 years) who had undergone surgical repair for unilateral Achilles tendon rupture. Group B (control group) included 10 subjects with a median age of 34 years (range 27 to 40 years) with no previous or present history of tendinopathy. All patients were evaluated with ultrasound, power Doppler, and CEUS with second-generation contrast agent. We studied the uninjured Achilles tendon in athletes of group A and either the left or the right Achilles tendon of the athletes in group B. RESULTS: CEUS showed a significantly greater ability to detect a greater number of vascular spots within the uninjured tendon of group A compared to group B (<0.05). CONCLUSIONS: In athletes who had suffered a tear of an Achilles tendon, CEUS detected small vessels that were not identified by power Doppler ultrasound in the uninjured contralateral Achilles tendon. CEUS is useful to evaluate vascularity not detected by other imaging techniques. Vascularity in the uninjured tendon seems to be increased in patients who had a previous rupture.

Percutaneous treatment of traumatic upper-extremity arterial injuries: a single-center experience.

PURPOSE: To assess the feasibility and effectiveness of emergency percutaneous treatment of traumatic injuries of upper-extremity arteries. MATERIALS AND METHODS: Between January 2000 and December 2007, 11 patients (mean age, 49.9 years) with traumatic injuries of upper-extremity arteries were observed: three had pseudoaneurysms, four had dissections, three had transections, and one had mural hematoma. Lesions involved the axillary (n = 6), subclavian (n = 3), or brachial artery (n = 2). Pseudoaneurysms and transections were treated with stent grafts, (n = 6) and dissections and mural hematomas were treated with bare stents (n = 2) or angioplasty (n = 3). Follow-up (mean, 45.1 months; range, 12-84 months) was performed with color Doppler ultrasonography at 1, 3, 6, and 12 months and then, yearly. RESULTS: Immediate technical success was obtained in all cases. No major complications occurred; there was one asymptomatic occlusion of the interosseous artery and one case of incomplete thrombosis of the radial artery (with recanalization after 1 month with systemic medical therapy). During a mean follow-up of 45.1 months, one stent-graft occlusion occurred, which was treated with intraarterial pharmacologic thrombolysis (urokinase 60,000 IU/h for 12 hours). Overall primary clinical success rate was 95.2% and secondary clinical success rate was 100%. CONCLUSIONS: Percutaneous treatment is a feasible and safe tool for injuries of upper-extremity arteries because it can provide a fast and definitive termination of bleeding or a resolution of acute ischemia. This approach, with its low invasiveness, can be proposed as first-line treatment in patients with traumatic lesions of upper-extremity arteries.

Single-antenna microwave ablation under contrast-enhanced ultrasound guidance for treatment of small renal cell carcinoma: preliminary experience.

The purpose of this study was to determine the safety, effectiveness, and feasibility of microwave ablation (MWA) of small renal cell carcinomas (RCCs) in selected patients. Institutional review board and informed consent were obtained. From December 2007 to January 2009, 12 patients (8 male, 4 female) were enrolled in a treatment group, in which percutaneous MWA of small RCCs was performed under contrast-enhanced ultrasound guidance. The tumors were 1.7-2.9 cm in diameter (mean diameter, 2.0 cm).Therapeutic effects were assessed at follow-up with computed tomography. All patients were followed up for 3-14 months (mean, 6 months) to observe the therapeutic effects and complications (according to SIR classification). Assessment was carried out with CT imaging. No severe complications or unexpected side effects were observed after the MWA procedures. In all cases technical success was achieved. Clinical effectiveness was 100%; none of the patients showed recurrence on imaging. In conclusion, our preliminary results support the use of MWA for the treatment of small renal tumors. This technology can be applied in select patients who are not candidates for surgery, as an alternative to other ablative techniques.

Ultrasound-guided radiofrequency thermal ablation of uterine fibroids: medium-term follow-up.

Previous studies have shown that radiofrequency thermal ablation (RFA) of uterine fibroids through a percutaneous ultrasound (US)-guided procedure is an effective and safe minimally invasive treatment, with encouraging short-term results. The aim of this study was to assess the results in terms of volume reduction and clinical symptoms improvement in the midterm follow-up of fibroids with a diameter of up to 8 cm. Eleven premenopausal females affected by symptomatic fibroids underwent percutaneous US-guided RFA. Symptom severity and reduction in volume were evaluated at 1, 3, 6, 9, and 12 months. The mean symptom score (SSS) before the procedure was 50.30 (range 31.8-67.30), and the average quality of life (QOL) score value was 62 (range 37.20-86.00). The mean basal diameter was 5.5 cm (range 4.4-8) and the mean volume was 101.5 cm(3) (range 44.58-278 cm(3)). The mean follow-up was 9 months (range 3-12 months). The mean SSS value at the end of the follow-up was 13.38 (range 0-67.1) and the QOL 90.4 (range 43.8-100). At follow-up the mean diameter was 3.0 cm (range 1.20-4.5 cm), and the mean volume was 18 cm(3) (range 0.90-47.6 cm(3)). In 10 of 11 patients we obtained total or partial regression of symptoms. In one case the clinical manifestations persisted and it was thus considered unsuccessful. In conclusion, US-guided percutaneous RFA is a safe and effective treatment even for fibroids up to 8 cm.

Emergency endovascular treatment of sac rupture for type IIIa endoleak in thoracic aortic aneurysm previously excluded with endovascular repair.

Elective endovascular treatment of thoracic aortic pathology has been applied in a variety of conditions. The complications of thoracic aortic stenting are also well recognized. Endoleak after endovascular repair of thoracic aortic aneurysms is the most frequent complication; among them, type III is the least frequent. Endovascular treatment of type III endoleak is generally performed under elective conditions; less frequently, in emergency. We report a successful emergency endovascular management of post-thoracic endovascular repair for thoracic aortic aneurysm rupture due to type IIIa endoleak.

Contrast-enhanced ultrasonograpic findings in pancreatic tumors.

OBJECTIVE: The purpose of this article is to present the potentials and limits of contrast-enhanced ultrasonography (CEUS) in the characterization of pancreatic tumors, usually hypoechoic or cystic at B-mode ultrasound. CONCLUSION: As regards hypoechoic lesions at B-mode ultrasound, CEUS often can distinguish among adenocarcinoma, islet cell tumor and serous microcystic adenoma. As regards cystic lesions, CEUS in most cases doesn't add significative diagnostic information; therefore CT, MR or endoscopic US are almost always necessary for their proper characterization.

Radiofrequency ablation of a pancreatic metastasis from renal cell carcinoma: case report.

INTRODUCTION: There is little reported experience of radiofrequency ablation (RFA) of pancreatic tumors. The pancreas is surrounded by structures such as the stomach, duodenum, and colon and concerns regarding the risks of thermal injury to these structures have limited the use of RFA for nonresectable pancreatic tumors. CASE REPORT: This brief report describes the application of this technique for the treatment of a metastasis from renal cell carcinoma localized at the body-tail portion of the pancreas in a 77-year-old man and the outcome of the procedure at 1-year follow-up. CONCLUSIONS: In our experience, RFA is feasible also for metastatic lesion at the pancreas and it was safely carried out in this case. Long-term follow-up and larger series are necessary to assess the spectrum of complications and the true oncologic efficacy.

Ablation of painful metastatic bone tumors: a systematic review.

The pain is the most common problem in patients with bone metastases. It is not related to the characteristics of the tumor (type, location, number or size of metastases). Currently, the bone metastases can be treated with chemotherapy, hormonal therapy, surgery and radiotherapy, but the drugs most used in the treatment of pain are opioids. These drugs give benefit between 8 and 12 weeks and often give non-negligible toxic effects. Percutaneous techniques are varied and, when there is indication, can be used to reduce pain and dose of morphine in these patients, being safe and effective techniques already at 4 weeks of treatment. The choice of a methodical of ablation compared to another depends on the type, size and location of the lesion. Moreover, the combined treatments of ablation and cementoplastic are also useful to stabilize the bone lesion. This review article analyzes techniques and effectiveness of percutaneous treatments of skeletal metastases.

Percutaneous radiofrequency thermal ablation of renal cell carcinoma: is it possible a day-hospital treatment?

PURPOSE: The aim of this study is to evaluate the feasibility of the procedure in day-hospital and discuss prognostic factors, efficacy and complications of percutaneous radiofrequency ablation in the treatment of renal cell carcinoma. MATERIALS AND METHODS: Between January 2003 and August 2008, 26 patients (mean age 79, range 70-87 years, 15 men and 11 women) affected by 27 kidney tumoral lesions, 25 RCC and two renal oncocitome (one patient was affected by two RCC), undergo 29 treatments of RFA (three patients underwent two treatments due to residual tumor at the CT performed 1 month after the first treatment). Three out of 26 patients had only one kidney due to progressed nephrectomy because of RCC; three/26 patients were carriers of oncological comorbidity while four/26 patients were carriers of medical comorbidity. The remaining 16/26 patients refused the surgical option. The lesions had a diameter between 1 and 4 cm (average diameter 2.4 cm). Seventeen of the 27 lesions were exophytic, five/27 parenchymal, three/27 was central while two/27 was mixed. All the lesions had been characterized either by CT or MRI. On the basis of the same investigation the feasibility of the radiofrequency procedure was verified. For all the procedures the RF type 3000 radiofrequency generator system was used together with the LeVeen ago-electrode. Twenty-one lesions out of 27 were treated under ultrasound guidance while six/27 lesions under the CT guide. After the procedure a US control was performed to exclude early complications and the same day the patients were discharged from hospital: the procedure was performed in day-hospital. RESULTS: The technical success of the procedure was obtained in all cases (100%). After the procedure, 18 patients, without complications and comorbidity, were discharged from hospital the same day, seven patients with comorbidity were kept under observation for one night while one patient was hospitalized. The primary success of the treatment, rated with CT or MRI after 1 month, was obtained in 25/27 of the cases. In two/27 lesion, an incomplete ablation was obtained; for this reason these patients underwent a second treatment and after 6 month of a regular follow-up, no more neoplastic tissue was identified. During the follow-up there were no signs of disease in any patients. No major peri-procedural complications were recorded; only one patient had to be assisted for the appearance of a peri renal liquid (urinoma) and a thin pneumothorax layer that resolved completely in few days after the procedure. CONCLUSIONS: Preliminary results with RFA of RCC are promising. Radiofrequency thermal ablation could prove to be a useful treatment for patients who are unsuitable for surgery; in this study we demonstrate the feasibility of the treatment in day-hospital for selected patients.

Endoleak detection and classification after endovascular treatment of abdominal aortic aneurysm: value of CEUS over CTA.

This paper focuses on the diagnostic value of CEUS in the detection and characterization of endoleaks in comparison with other imaging modalities, primary CDUS and CTA in the follow-up of endovascular abdominal aortic aneurysm repair. CEUS is an interesting alternative technique because of its limited costs and lack of exposure to ionizing radiation. However, CTA cannot currently be substituted because it enables a more precise evaluation of aneurysm morphologic changes, aneurysm sac diameter, graft anchorage and integrity. CEUS could be used along with CTA when the latter reveals the presence of endoleak, to provide a better characterization of it taking advantage of the angiodynamic behavior of the contrast agent that permits an easier visualization of the agent flow into the sac. It could also be indicated when aneurysm diameter increases and CTA did not show sac reperfusion or to monitor type II endoleaks reducing the use of CTA with consequent reduction of costs and exposure to radiation.

Percutaneous sonographically guided radiofrequency ablation of medium-sized fibroids: feasibility study.

OBJECTIVE: The purpose of this study was to assess the feasibility and safety of percutaneous radiofrequency ablation under sonographic guidance as a unique procedure in the management of symptomatic uterine myomas. SUBJECTS AND METHODS: Six premenopausal women with symptomatic submucosal or intramural uterine myomas underwent percutaneous radiofrequency ablation under suprapubic sonographic guidance. Relief of symptoms and reduction in the diameter and volume of the myomas were measured every 3 months. RESULTS: The location of myomas was anterior and submucosal in one of the six patients and intramural in the other five (one posterior, one anterior, two fundal, and one on the left side). Five of the patients had pelvic pain, and four had menorrhagia. The median baseline diameter was 4.8 cm (range, 4.4-5.2 cm), and the mean volume was 58.57 cm3 (range, 44.58-73.58 cm3). The mean follow-up time was 9 months (range, 3-12 months). At follow-up, the median diameter was 2.3 cm (range, 1.20-3.2 cm), and the median volume was 8.97 cm3 (range, 0.90-18.81 cm3). The median preoperative symptom score was 47.2 (31.8-67.30), and the median health-related quality of life (QOL) score was 63.92 (37.20-86.00). The median symptom score during follow-up was 5.15 (range, 0-26), and the mean QOL score was 96.2 (range, 86.30-100). Four of six patients were symptom-free at the last follow-up visit. CONCLUSION: Percutaneous sonographically guided radiofrequency ablation alone is a feasible and efficient procedure in the management of medium-sized uterine myomas.

Laparoscopic resection of a primary hydatid cyst of the adrenal gland: a case report.

BACKGROUND: Echinococcosis rates vary in different parts of the world. Italy is regarded as a middle to high risk country with over 1,000 cases requiring surgery each year. Liver (45-75%) and lung (10-50%) are the most frequent locations of this parasitosis. CASE PRESENTATION: The authors report a clinical case of a 62 year old woman, admitted to hospital with left flank pain. Plain radiographs of the abdomen, ultrasound, CT and MRI scans were performed and the presence of a 3-cm lesion of the left adrenal gland was demonstrated. A diagnosis of hydatid cyst was made. The patient underwent transabdominal laparoscopic left adrenalectomy. Histopathological examination confirmed the presence of a hydatid cyst in the left adrenal gland. CONCLUSION: A hydatid cyst was correctly diagnosed on the basis of radiologic findings. The uncomplicated cyst was successfully resected using a laparoscopic approach. The pathological features of this case are presented in this paper.

Preoperative assessment of rectal cancer stage: state of the art.

Rectal cancer is one of the most common tumors worldwide; it accounts for approximately 25-30% of cancers arising in the large bowel. Owing to greater distribution of screening programs and better attention from both patients and General Practitioners to this disease, in recent years we have observed an increasing number of cases diagnosed in the early stages, with a consequent better prognosis. The improved 5-year survival is also partially due to better, and more accurate, diagnostic techniques and to more curative treatments. In this review, the authors analyze and discuss the more recent diagnostic techniques for an accurate preoperative staging of rectal cancer, highlighting each method's advantages and limits for their routine use in clinical practice.

Endovascular treatment of anastomotic pseudoaneurysms after aorto-iliac surgical reconstruction.

PURPOSE: To assess the effectiveness of endovascular treatment of anastomotic pseudoaneurysms (APAs) following aorto-iliac surgical reconstruction. MATERIALS: We retrospectively evaluated 21 men who, between July 2000 and March 2006, were observed with 30 APAs, 13 to the proximal anastomosis and 17 to the distal anastomosis. The patients had had previous aorto-iliac reconstructive surgery with a bypass due to aneurysm (15/21) or obstructive disease (6/21). The following devices were used: 12 bifurcated endoprostheses, 2 aorto-monoiliac, 4 aortic extenders, 1 stent-graft leg, and 2 covered stents. Follow-up was performed with CT angiography at 1, 3, and 6 months after the procedure and yearly thereafter. RESULTS: Immediate technical success was 100%. No periprocedural complications occurred. Four patients died during follow-up from causes not related to APA, and 1 (treated for prosthetic-enteric fistula) from sepsis 3 months after the procedure. During a mean follow-up of 19.7 months (range 1-72 months), 2 of 21 occlusions of stent-graft legs occurred 3 and 24 months after the procedure (treated with thrombolysis and percutaneous transluminal angioplasty and femorofemoral bypass, respectively) and 1 type I endoleak. Primary clinical success rate was 81% and secondary clinical success was 91%. CONCLUSION: Endovascular treatment is a valid alternative to open surgery and can be proposed as the treatment of choice for APAs, especially in patients who are a high surgical risk. Further studies with larger series and longer follow-up are necessary to confirm the long-term effectiveness of this approach.