Role of Percutaneous Ablation in the Management of Intrahepatic Cholangiocarcinoma.

Cholangiocarcinoma (CCA) is an invasive cancer accounting for <1% of all cancers and 10-15% of primary liver cancers. Intrahepatic CCA (iCCA) is associated with poor survival rates and high post-surgical recurrence rates whilst most diagnosed patients are not surgical candidates. There is a growing literature suggesting percutaneous ablative techniques for the management of patients with iCCA measuring ≤3 cm with contraindications to surgery as well as for recurrent or residual tumors aiming to provide local cancer treatment and control. Most used ablative therapies for iCCA include radiofrequency and microwave ablation with irreversible electroporation, cryoablation and reversible electroporation (electrochemotherapy) being less commonly encountered techniques. Due to the infiltrative margins of the lesion, there is a need for larger safety margins and ablation zone; multi-apparatus ablation or other variations of the technique such as balloon-assisted approaches can be utilized aiming to increase size of the zone of necrosis. The present review paper focuses upon the current role of percutaneous ablative techniques for the therapeutic management of iCCA. The purpose of this review is to present the current minimally invasive ablative techniques in the treatment of iCCA, including local control and survival rates.

Computed Tomography-Guided Percutaneous Radiofrequency Ablation of the Splanchnic Nerves as a Single Treatment for Pain Reduction in Patients with Pancreatic Cancer.

The aim of this paper is to prospectively evaluate the efficacy and safety of percutaneous computed tomography (CT)-guided radiofrequency (RF) neurolysis of splanchnic nerves as a single treatment for pain reduction in patients with pancreatic cancer. Patients with pancreatic ductal adenocarcinoma suffering from abdominal pain refractory to conservative medication who underwent CT-guided neurolysis of splanchnic nerves by means of continuous radiofrequency were prospectively evaluated for pain and analgesics reduction as well as for survival. In all patients, percutaneous neurolysis was performed with a bilateral retrocrural paravertebral approach at T12 level using a 20 Gauge RF blunt curved cannula with a 1cm active tip electrode. Self-reported pain scores were assessed before and at the last follow-up using a pain inventory with numeric visual scale (NVS) units. The mean patient age was 65.4 ± 10.8 years (male-female: 19-11). The mean pain score prior to RF neurolysis of splanchnic nerves was 9.0 NVS units; this score was reduced to 2.9, 3.1, 3.6, 3.8, and 3.9 NVS units at 1 week, 1, 3, 6, and 12 months respectively (p < 0.001). Significantly reduced analgesic usage was reported in 28/30 patients. Two grade I complications were reported according to the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) classification system. According to the results of the present study, solely performed computed tomography-guided radiofrequency neurolysis of splanchnic nerves can be considered a safe and efficacious single-session technique for pain palliation in patients with pancreatic ductal adenocarcinoma suffering from abdominal pain refractory to conservative medication. Although effective in pain reduction the technique seems to have no effect upon survival improvement.

Clinical outcome and analysis of procedural failure during uterine artery chemoembolisation as a treatment of caesarean scar pregnancy.

INTRODUCTION: Caesarean scar pregnancy (CSP) is a relatively rare yet life-threatening condition in which the embryo is implanted in the scar after caesarean section. Recent studies have reported that uterine artery chemoembolisation (UAC) can be safe and effective method in treating CSP. AIM: To present the clinical outcome of UAC with a mixture of methotrexate and gelatine sponge for the treatment of CSP and analysis of procedural failure. MATERIAL AND METHODS: Forty-one patients diagnosed with CSP were treated with selective endovascular chemoembolisation of uterine arteries. Short- and long-term results, reasons for procedural failure, and clinical outcome were analysed. RESULTS: Primary procedure failed in 7 out of 41 (17%) cases. In 4 cases additional blood supply to the CSP was disclosed; 3 out of 4 from an ovarian artery and one from a superior vesical artery. In other 3 patients, reperfusion of uterine arteries was observed. All these 7 patients underwent successful secondary embolisation. The majority of the followed-up patients reported regular menses after the intervention. Four women suffered from amenorrhoea and 2 from hypomenorrhoea that continued after 90 days. Twelve patients expressed the desire for subsequent pregnancy. From this group, 5 conceived within a year of the procedure. The rest did not achieve a pregnancy. CONCLUSIONS: UAC proved to be a safe and effective method and should be considered as an option for CSP treatment, especially for women hoping to preserve their fertility. However, the presence of collateral blood supply should always be considered.

Efficacy and safety of percutaneous computed tomography-guided microwave ablation for colorectal cancer, oligometastatic liver-only disease: a single center's experience.

BACKGROUND: We retrospectively evaluated the effectiveness and safety of computed tomography-guided percutaneous microwave ablation (MWA) of metastatic liver disease in terms of 5-year overall survival and 5-year disease-free survival. METHODS: Institutional database research identified 32 colorectal cancer patients with oligometastatic liver-only disease who underwent percutaneous computed tomography-guided MWA. Contrast-enhanced computed tomography or magnetic resonance imaging was used for post-ablation follow up. Patient and tumor characteristics, MWA technique and complications were evaluated. In addition, the 5-year overall survival, the 5-year disease-free survival, and the potential factors affecting the survival of these patients were analyzed. RESULTS: Mean patient age was 72 years (male: female 21:11). In total 58 lesions were treated in 45 ablation sessions. Average lesion size was 2 cm (range 0.8-3.9 cm). The primary tumor for the majority of patients was in the colon (n=27), while in 5 patients it was located in the rectum. The majority of patients had 1 liver metastasis (n=16), 11 patients had 2, 4 patients had 3, and 1 patient had 4. Primary local tumor control was achieved in 91.3% (53/58) of the ablated lesions. Overall survival at 1, 3 and 5 years was 96.8%, 68.7% and 34.3%, respectively. CONCLUSION: Computed tomography-guided percutaneous MWA for metastatic liver-only disease in oligometastatic patients is a feasible, safe and effective therapy with satisfactory long-term survival rates.

Retroperitoneal ganglioneuroma causing chronic lower back and leg pain in an 80-year-old man: A case report.

INTRODUCTION: and importance: Retroperitoneal ganglioneuromas that cause lower back and leg pain are extremely rare and are often misdiagnosed. Surgical resection has excellent prognosis in long-term survival. CASE PRESENTATION: We present an 80-year-old man with two-year worsening left lower back and leg pain. He was treated as presumed lumbar spine spondylosis with several courses of physical therapy together with medical treatment. An abdomen CT scan disclosed a tumour in the left retrorenal space. The tumour was resected and the histopathologic examination suggested a completely excised retroperitoneal ganglioneuroma. During one-year follow-up the patient is free of pain without any local recurrence. CLINICAL DISCUSSION: Retroperitoneal ganglioneuromas are rare benign tumors that originate from neural crest-derived cells of the paravertebral sympathetic plexus and sometimes from the adrenal medulla. They are usually asymptomatic and discovered on routine clinical examination or on autopsy. Occasionally they may show symptoms due to local pressure effect or rarely they are hormonally active and present with adrenergic symptoms. Complete resection of the tumor is important in order establish the final diagnosis and alleviate symptoms from pressure effects. CONCLUSION: This case highlights the need for great vigilance among physicians in order to consider any possible retroperitoneal pathology when indicated in the differential diagnosis of lower back and leg pain, before establishing other more common diagnosis, especially in the older population.

Long-term results of super-selective trans-catheter embolization of the vesical arteries for the treatment of intractable bladder haematuria.

PURPOSE: To evaluate the feasibility, safety and long-term efficacy of super-selective trans-catheter arterial embolization for the management of intractable bladder bleeding. MATERIALS AND METHODS: The records of 20 patients with intractable haematuria referred urgently for selective arterial embolization after failed conventional therapy, between 2013 and 2018, were retrospectively analyzed. Primary outcomes were technical (cessation of extravasation and/or stasis of flow within the target vessel) and clinical (bleeding control) success. Secondary outcomes included complication and re-intervention rates. RESULTS: Technical success was 90% (18/20 cases), as in 2 cases, embolization was not feasible. Super-selective embolization of the vesical arteries was feasible in 15/18 cases (83.3%). Selective proximal occlusion of the anterior division of the internal iliac artery was performed in two cases (11%) and embolization of the anterior division after coil blockage of the posterior division was performed in one case (5%). Bilateral and unilateral embolization was performed in 10 and 8 cases, respectively. Peri-procedural mortality rate was 5% (1/18 patients). One possible procedure-related death occurred due to myocardial infarction ten days following non-target embolization of the buttocks and the anterior abdominal wall. Mean time follow up was 35 ± 15 months. Bleeding reoccurred in three patients (16.6%), all successfully managed (one conservatively and two with further embolization). Clinical success was 85% (17/20 cases). During follow up 11 more patients died, due to underlying conditions not related to bleeding or the procedure. CONCLUSIONS: Super-selective angiographic embolization is feasible, safe and effective to control refractory, life threatening bladder bleeding and should be considered as a first line treatment, as to obviate the need for emergency surgery.

The role of interventional oncology in the treatment of colorectal cancer liver metastases.

Colorectal cancer is a leading cause of death both in Europe and worldwide. Unfortunately, 20-25% of patients with colorectal cancer already have metastases at the time of diagnosis, while 50-60% of the remainder will develop metastases later during the course of the disease. Although hepatic excision is the first-line treatment for patients with liver-limited colorectal metastases and is reported to prolong the survival of these patients, few patients are candidates. Locoregional therapy encompasses minimally invasive techniques practiced by interventional radiology. Most widely used locoregional therapies include ablative treatments (radiofrequency ablation, microwave ablation) and transcatheter intra-arterial therapies (transarterial chemoembolization, and radioembolization with yttrium-90).

Percutaneous Neurolysis for Pain Management in Oncological Patients.

Cancer pain is most commonly classified as nociceptive (somatic or visceral) or neuropathic. Different types of pain or pain syndromes are present in all phases of cancer (early and metastatic) and are inadequately treated in 56% to 82.3% of patients. Percutaneous neurolysis and neuromodulation are feasible and reproducible, efficient (70-80% success rate) and safe (≈ 0.5% mean complication rate) palliative therapies for pain reduction in oncologic patients with refractory pain. Percutaneous neurolysis can be performed either by injection of a chemical agent (phenol or alcohol) or by application of continuous radiofrequency or cryoablation. During chemical neurolysis nerve damage is achieved by means of Wallerian degeneration. A thorough knowledge of neural anatomy and pain transmission pathways is fundamental to appropriate patient and technique selection. Imaging guidance and strict asepsis are prerequisites. The purpose of this article is to describe the basic concepts of percutaneous neurolysis in oncologic patients. Controversies concerning techniques and products will be addressed. Finally, the necessity for an individually tailored approach for the selection of the different techniques and targets will be emphasized.

Diagnosis and treatment of posttraumatic arteriovenous fistula in the lower leg - a case report.

External injuries are one of the common reasons for reporting to hospital emergency departments. Peripheral vascular injuries occur in up to about 25% of upper and lower extremity injury cases. Arteriovenous fistula is a type of arterial injury. Doppler ultrasound is currently the primary diagnostic method for vascular injuries as it allows for the implementation of appropriately targeted treatment, indicating the potential need for extended diagnosis or patient qualification for endovascular or classical surgery. Endovascular procedures are currently an acknowledged treatment method in peripheral vascular injuries. We present a case of endovascular treatment in a patient with posttraumatic arteriovenous fistula in the lower leg. Patient qualification and treatment efficacy assessment were performed using Doppler ultrasound.

Embolization of iatrogenic renal arteriovenous fistula - a case report.

Renal artery pseudoaneurysms and arteriovenous fistulae most often occur as an iatrogenic complication. The article discusses a case of a patient diagnosed with an arteriovenous fistula and a pseudoaneurysm. A 64-year-old woman was admitted to the hospital due to nonspecific pain in the lumbar region. Imaging showed a typical picture of clear cell renal carcinoma. The patient was qualified for surgical treatment. After tumor resection, the patient developed microhematuria. Arteriovenous fistula and renal pseudoaneurysm were diagnosed using Doppler and computed tomography scans. The patient was qualified for arteriography with simultaneous embolization of the lesion. A follow-up evaluation confirmed the exclusion of aneurysm and fistula. Treatment outcomes were monitored using Doppler ultrasound. Doppler ultrasonography is the first method of choice in detecting and monitoring renal artery irregularities. Safety, non-invasiveness and easy access to this tool make it play a key role in the diagnosis of renal artery fistulas and pseudoaneurysms.

Recanalization of Occluded Transjugular Intrahepatic Portosystemic Shunts Using the Rösch-Uchida Stiffening Cannula.

PURPOSE: To report the safety and efficacy of occluded transjugular intrahepatic portosystemic shunts (TIPS) recanalization using the stiffening cannula (SC) technique. MATERIALS AND METHODS: This is a retrospective, single-centre, single-arm study, investigating the safety and efficacy of transjugular recanalization of occluded TIPS using the SC (Cook, Ind. USA), in cases of failure to cross the occlusion with standard angiographic catheters and balloons. Between October 2015 and October 2017, a total of 15 TIPS revisions have been performed due to shunt occlusion. In all cases in which the initial standard approach to cross the lesion failed, the SC technique was used. The study's primary efficacy outcome measure was technical success, and primary safety outcome measure was immediate procedure-related complications rate. Secondary outcome measures included restenosis and peri-procedural adverse events rates. RESULTS: Among 15 patients with shunt occlusion, seven (7/15; 46.5%) were successfully crossed via transjugular access, using standard angiographic catheters. In the remaining eight patients (nine procedures), recanalization with the SC technique was performed. Technical success was 100%. No complications or peri-procedural adverse events were noted. Restenosis rate was 11.1% (1/9 cases) as only one case of re-occlusion was noted, 3 months following recanalization using sole balloon angioplasty and successfully retreated using the SC technique and stent graft deployment. CONCLUSIONS: The SC technique is a safe and efficient option for the recanalization of occluded TIPS, in cases in which conventional lesion crossing is not feasible, in order to avoid percutaneous transhepatic access or new TIPS creation.

CT-Guided, Ethanol Sympatholysis for Primary Axillary-Palmar Hyperhidrosis.

PURPOSE: Primary hyperhidrosis is an excessive sweating due to an overactive sympathetic system. Our objective was to test the feasibility and provide early data on the safety/efficacy of CT-guided sympatholysis, for primary hyperhidrosis. MATERIALS AND METHODS: Nine consecutive patients with axillary-palmar hyperhidrosis were treated between 2013 and 2015. CT-guided sympathetic block was performed in the outpatients at T-2, T-3, and T-4, bilaterally using alcohol under local anesthesia. Immediate postprocedure CT was obtained to assess the complications as per Common Terminology Criteria for Adverse Events, version 4. Technical success and clinical success were recorded. Primary and secondary efficacy were assessed by phone and clinical visits; mean follow-up was 12 months (6-26 months). Descriptive statistics was used to report the outcomes. RESULTS: One procedure was aborted due to eyelid ptosis after lidocaine injection. All other eight patients (5:3, F:M) (median age 32) had immediate cessation of sweating. Two major complications (pneumothorax, one requiring a chest tube) occurred. Two patients recurred with unilateral and one with bilateral symptoms. One of the unilateral recurrence and the bilateral recurrence patients was retreated successfully. Median follow-up was 1 year. No cases of Horner's or compensatory hyperhidrosis were observed. CONCLUSIONS: CT-guided EtOH sympatholysis for axillary/palmar primary hyperhidrosis is feasible. Technical failure rate was 11 %. Primary and secondary efficacy are 75 and 94 %, respectively, to a median follow-up of 1 year. Risk profile appears favorable. Despite a small sample size, results confirm feasibility and encourage a larger study.

Comparative prospective study of load distribution projection among patients with vertebral fractures treated with percutaneous vertebroplasty and a control group of healthy volunteers.

PURPOSE: Through a prospective comparison of patients with vertebral fractures and normal population, we illustrate effect of percutaneous vertebroplasty (PV) upon projection of load distribution changes. METHODS: Vertebroplasty group (36 symptomatic patients with osteoporotic vertebral fractures) was evaluated on an electronic baropodometer registering projection of weight bearing areas on feet. Load distribution between right and left foot (including rear-front of the same foot) during standing and walking was recorded and compared before (group V1) and the day after (group V2) PV. Control group (30 healthy asymptomatic volunteers-no surgery record) were evaluated on the same baropodometer. RESULTS: Mean value of load distribution difference between rear-front of the same foot was 9.45 ± 6.79 % (54.72-45.28 %) upon standing and 14.76 ± 7.09 % (57.38-42.62 %) upon walking in the control group. Respective load distribution values before PV were 16.52 ± 11.23 and 30.91 ± 19.26 % and after PV were 10.08 ± 6.26 and 14.25 ± 7.68 % upon standing and walking respectively. Mean value of load distribution variation between the two feet was 6.36 and 14.6 % before and 4.62 and 10.4 % after PV upon standing and walking respectively. Comparison of load distribution variation (group V1-V2, group V1-control group) is statistically significant. Comparison of load distribution variation (group V2-control group) is not statistically significant. Comparison of load distribution variation among the two feet is statistically significant during walking but not statistically significant during standing. CONCLUSIONS: There is a statistically significant difference when comparing load distribution variation prior vertebroplasty and that of normal population. After vertebroplasty, this difference normalizes in a statistically significant way. PV is efficient on equilibrium-load distribution improvement as well.

Transjugular intrahepatic portosystemic shunt for the treatment of Budd-Chiari syndrome patients: results from a single center.

PURPOSE: To evaluate the outcome of transjugular intrahepatic portosystemic shunt (TIPS) in patients with Budd-Chiari syndrome (BCS). PATIENTS AND METHODS: Fourteen patients (11 female, mean age 45.8 years), with symptomatic BCS refractory to conventional therapy, were treated with TIPS placement in our department within a period of 9 years. Stent grafts were primarily used in 12 patients. Mean follow-up time was 38.1 ± 36.1 months (range 7-114). Model for end-stage liver disease (MELD) score, BCS Rotterdam index, and Child-Pugh score were calculated for all patients. In addition, the recently suggested BCS-TIPS prognostic index score (BSC-TIPS PI) was applied. RESULTS: BCS-TIPS PI score was ≤7 in all patients. Most of our patients (12 of 14) had good or intermediate prognosis according to MELD, Rotterdam and Child-Pugh scores. Technical success was achieved in all 14 patients and was accompanied by complete resolution of the symptoms. In 3 patients, the procedure was complicated by hemoperitoneum, which was successfully treated in two patients with coils or stent-graft placement, whereas 1 patient was managed in the operating room. Thirteen patients are symptom and orthotopic liver transplantation-free. Primary patency was 92.8, 84.7, and 58.7 % at 6, 12, and 24 months, respectively. Secondary patency was 100, 100 and 84.6 % at 6, 12, and 24 months respectively. CONCLUSION: In symptomatic BCS patients with moderate prognosis according to MELD, Child-Pugh, and BCS Rotterdam scores, as well as BCS-TIPS PI score ≤7, TIPS has high clinical success, low morbidity, and no mortality, and it offers durable mid-term resolution of the symptoms and OLT-free survival.