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Abstract Purpose The purpose of this systematic review and meta-analysis was to evaluate the safety, technical, and clinical effectiveness of percutaneous Transarterial Embolization (TAE) in treating spontaneous retroperitoneal hematomas as well as assess treatment outcomes in patients who underwent target or empirical embolization. Materials and methods Through the PubMed, Embase, and Google Scholar databases, an extensive search was performed in the fields of spontaneous retroperitoneal hematomas treated with transcatheter arterial embolization. We collected pooled data on 141 patients from 6 separate articles selected according to the inclusion and exclusion criteria. Results Technical success rate was 100% in all six studies, for both targeted and empirical embolization. The clinical success rate varied from 56.3 to 89.5%. The total number of complications related to the embolization procedure was 10 events out of 116 procedures analyzed. Empirical or empirical embolization was performed in three studies, where the source of active bleeding was not evident during DSA. A meta-analysis compared the rebleeding rates between targeted and empirical embolization groups. The odds ratio from pooled data from the three assessed studies (72 patients) showed no significant difference in rebleeding rates after empirical TAE compared with targeted TAE. Conclusions TAE is a safe, effective, and potentially life-saving procedure for the treatment of life-threatening spontaneous retroperitoneal hematomas. Empirical and targeted TAE procedures demonstrate a relatively low risk of complications, compared to the high technical and relatively high clinical success rates.

Objectives: This study aims to report on the application of degradable starch microspheres to provide flow diversion by means of temporary embolization of healthy tissues in oncological endovascular procedures when tumor feeding vessels are not selectively accessible. Methods: This is a multicenter retrospective analysis of patients undergoing visceral embolization procedures of malignancies. The inclusion criteria were as follows: flow diversion performed by injection of degradable starch microspheres, visceral embolization procedures with unfeasible superselective catheterism of the target, and a malignant pathology. Technical success was defined as complete flow diversion with temporary exclusion of the non-target district from arterial flow, associated with successful embolization of the target. Clinical success was intended as procedural achievement with patient clinical improvement. Results: Sixteen patients were included in this analysis. Peripheral embolization procedures were performed in the coeliac visceral district all in oncologic patients, including 4 transarterial radioembolization work-up procedures in patients with hepatocarcinoma, 10 chemioembolization procedures in patients with hepatocarcinoma (8) or cholangiocarcinoma (2), and 2 palliative transarterial embolizations in patients with gastric cancer. Technical success was obtained in 100% of the cases, while clinical success was reached in 87.5%: in two chemioembolization procedures, despite technical success, the procedural clinical benefits were partial, with an incomplete target lesion response. Minor complications occurred in five patients (31.2%). Conclusions: In this study, temporary flow diversion with degradable starch microspheres during oncological embolization procedures was safe and effective; this approach is suitable to protect healthy surrounding tissues when vessels feeding the target cannot be selected with the microcatheter.

Abstract Background This retrospective multicentric study aims to report on technical safety and effectiveness of pseudoaneurysms embolization with glue (N-butyl cyanoacrylate) adopting a percutaneous direct puncture approach. Results Fifty-four patients data were collected from five centers. All patients at the time of treatment presented with unruptured PAs and were hemodynamically stable. True aneurysms and lesions treated with embolics other than glue were excluded. Pseudoaneurysms diagnosis was based on CT and anamnestic data; initial investigation with digital-subtracted arteriography was acquired in all cases; then, percutaneous embolizations were performed in the angio-suite (ultrasound, fluoroscopy, ConeBeam CT guidance) or in CT. Technical success was considered as complete pseudoaneurysm embolization at final imaging with sole percutaneous strategy, without need for additional endovascular embolization. Clinical success was intended as pseudoaneurysm resolution within one week follow-up with stabilization or restored clinical conditions. Pseudoaneurysms origins were traumatic (57.4%), inflammatory (24.1%) or spontaneous (18.5%); 39 patients (72.2%) were symptomatic, presenting with pain and/or pulsatile mass. Mean lesions diameter was 19.3 mm (range: 7–30); pseudoaneurysms were located in abdomen (48.1%), limbs (42.6%) and thorax (9.3%). Coagulation function was impaired in 16.6% and 48.1% was under antiplatelets/anticoagulation therapy. In 16.6% the percutaneous approach followed previous treatments failure. The image-guidance modality for percutaneous puncture was most often ultrasound combined with fluoroscopy (38%). Clinical success was obtained in all patients while technical success occurred in 94.4% because 3 patients required an additional endovascular embolization. Complications were registered in 14.8%, all of low grade without clinical sequelae neither prolonged recovery (7 non target embolizations, 1 post-embolization syndrome). Conclusions In this study, pseudoaneurysms embolization with glue via percutaneous direct puncture was safe and effective with a low rate of minor complications.

Gastrointestinal bleeding is a potentially life-threatening abdominal emergency that remains a common cause of hospitalisation. Although 80–85% of cases of gastrointestinal bleeding resolve spontaneously, it can result in massive haemorrhage and death. The presentation of gastrointestinal bleeding can range from asymptomatic or mildly ill patients requiring only conservative treatments to severely ill patients requiring immediate intervention. Identifying the source of the bleeding can be difficult due to the wide range of potential causes, the length of the gastrointestinal tract and the intermittent nature of the bleeding. The diagnostic and therapeutic approach is fully dependent on the nature of the bleeding and the patient’s haemodynamic status. Radiologists should be aware of the appropriate uses of computed tomography angiography and other imaging modalities in patients with acute gastrointestinal bleeding, as well as the semiotics of bleeding and diagnostic pitfalls in order to appropriately diagnose and manage these patients. The learning objective of this review is to illustrate the computed tomography angiography technique, including the potential role of dual-energy computed tomography angiography, also highlighting the tips and tricks to identify the most common and uncommon features of acute gastrointestinal bleeding and its obscure form.

Ureteral involvement by a tumor is common, and both partial and complete obstructions can result in symptoms that are distressing and debilitating, especially in cancer patients for whom the resection of the primary tumor is not considered an option. Maintaining ureteric patency in these patients is a challenge. In addition, in cases where a patient has undergone nephroureterectomy due to primary transitional cell cancer, it becomes necessary to decompress the urinary tract to preserve the contralateral kidney from irreversible damage. This is possibly due to ureteral stenting, both retrograde and anterograde, and percutaneous nephrostomy (PCN). Since imaging plays an important role in the routine monitoring of stents, their more and more increasing use requires radiologists to be familiar with these devices, their correct position, their potential complications, and their consequences. The aim of this review is to offer a comprehensive review of the imaging features of some urinary stents and to show the complications encountered in cancer patients as a direct consequence of an invasive diagnostic or therapeutic procedure. Specifically, we focus on ureteral stents and PCN.

Massive hemoptysis represents a distressing and life-threatening condition: 95% of cases originate from the bronchial artery system, with pulmonary arteries accounting for 6%–11% of cases. The most common etiology of hemoptysis from the pulmonary artery system is represented by pulmonary artery pseudoaneurysms (PAPs). PAPs are defined as the focal dilation of a pulmonary artery branch, involving only the adventice, with a higher risk of rupture than a true aneurysm. It constitutes a rare finding, often underdiagnosed by radiologists. However, PAPs can be life-threatening if undiagnosed due to a high mortality rate (50%). They frequently occur in patients affected by erosive inflammatory processes and necrotising infections of the lung or heart, but other etiological factors include trauma, vasculitis, neoplasia, pulmonary hypertension and Hughes–Stovin Syndrome. PAPs due to oncologic etiologies are rare. Among oncologic etiologies, the most frequent are represented by primary lung cancer rather than metastases. Today, CT angiography represents the imaging modality of choice; not only to establish diagnosis, but if performed with an appropriate timing of intravenous contrast, it also helps to plan therapy with an endovascular approach. In fact, endovascular treatment is the preferred therapeutic approach in managing hemoptysis due to PAPs, since a surgical approach is associated with a high risk of morbidity and mortality, especially in patients who are poor surgical candidates. In this article we report the case of massive hemoptysis due to an unusual giant PAP of the posterior lower branch of the right pulmonary artery, in a patient affected by pulmonary colliquated and confluent metastases, successfully treated by endovascular embolisation.

Visceral artery pseudoaneurysms (VAPAs) are extremely rare and pseudoaneurysms in the superior mesenteric artery (SMA) and its branches, particularly the middle colic artery, are the rarest. These account for 6–8% of all VAPAs with an incidence of 0.01%. They can be associated with an inflammatory disease (such as pancreatitis), infection or arise as a post-surgical complication, but they can also be due to a traumatic damage to the artery caused by a full-thickness slit in the arterial wall. They can be asymptomatic or manifest with symptoms such as abdominal pain, nausea and vomiting, local pressure symptoms (such as a pulsatile mass or a bruit) and gastrointestinal bleeding. Imaging techniques play a key role in the diagnosis of VAPAs and angiography still represents the gold standard, although nowadays it has a pivotal role for treatment with the possibility to perform an endovascular embolisation. In fact, although rare, VAPAs are of clinical importance mainly because they can cause life-threatening intra-abdominal or retroperitoneal haemorrhage and so prompt treatments are crucial, whether they are symptomatic, haemorrhagic or incidentally found. In the past, surgery was the treatment of choice, but in recent years with the improvement and development of interventional vascular techniques, surgery has been replaced by transcatheter endovascular embolisation due to its low morbidity and mortality and high success rate. In this article, we report the case of an unusual giant spontaneous pseudoaneurysm of the middle colic artery in a patient with a scoliotic abdominal aortic aneurysm successfully treated by endovascular embolisation.

Abstract Aim To describe a 3 years experience of peripheral arterial embolization with Micro Vascular Plug (MVP) (Medtronic, USA). Materials and methods The following parameters were investigated: type of vascular injury, anticoagulation therapy at time of procedure, anatomical district, caliper of the target artery, course of the landing zone, additional embolics, technical and clinical success, device related clinical complications. Technical success was defined as complete embolization without deployment of additional embolics after MVP release. Primary clinical success was considered as hemodynamic stability in emergency setting and resolution of the underlying vascular pathology in elective cases; secondary clinical success was considered clinical success after a second embolization session. Results 116 MVP have been released in 104 patients (67 males and 37 females; mean age 61.3 years). The pullback release technique was adopted in each case. 85 patients were treated in emergent settings while in 19 patients the procedure was scheduled. The overall technical success was 75%. Primary clinical success was 96.1%, secondary clinical success 3% and clinical failure 0.9%. No statistical differences in terms of effectiveness were observed among patients assuming anticoagulation (p-value = 0.6). A straight and longer landing zone were statistically associated with higher technical success compared to curved and shorter ones, (p-values

Background: Paratesticular tumors (PTs) are very uncommon, accounting for almost 5% of intrascrotal tumors. Of these, adenomatoid tumors (ATs) represent about 30% and most frequently arise in the tail of the epididymis. Ultrasound (US) examination is the first-choice imaging method employed for the evaluation of the scrotum. Unfortunately, there are no specific US-imaging features useful for distinguishing an AT from a malignant lesion. To increase diagnostic accuracy and confidence, new sonographic techniques have incorporated real-time tissue elastography (RTE) under the assumption that malignant lesions are “harder” than benign lesions. Case report: In our paper, we describe a very rare case of a 60-year-old patient with a giant paratesticular mass mimicking malignancy when examined using RTE, i.e., it was stiffer than the surrounding tissue (a hard pattern), which, upon histologic examination, was identified as an AT. Discussion: Our case underscores that there is also a significant overlap between different types of scrotal lesions when RTE is used for examination. Thus, if a PT is found, the imaging approach should always be supplemented with more definitive diagnostic methods, such as FNAC or FNAB, which are the only diagnostic methods capable of leading to a certain diagnosis. Conclusions: Alongside underlining the importance of pre-operative imaging for making correct diagnoses and selecting the correct therapy, we wish to draw our readers’ attention to this report in order to demonstrate the clinical implications of a giant AT presenting as stiff lesions when examined using SE.

ABSTRACT: Iliopsoas bursitis is characterized by distension of the iliopsoas muscle bursa due to synovial fluid and/or hypertrophic synovium. Hip disease is usually associated with it, however, isolated bursitis is also present. Clinically Diagnosing iliopsoas bursitis can be difficult, and imaging is usually required to differentiate iliopsoas bursitis from other inguinal masses such as lymphadenopathy, hernias, and tumors. We present the case of a 45-year-old athletic patient who underwent diagnostic examination for recurrent right hip pain and a recent development (last 3 months) of a bulky right inguinal mass.

Abstract Background Omental infarction is a rare disease that affects the entire omentum or a segment of the greater omentum. It presents as acute abdominal pain mainly in the right lower quadrant or right flank. Left-sided omental torsion is infrequent and it is rarely preoperatively diagnosed. Omental infarction is a differential diagnosis in the acute abdomen. As most cases of omental infarction can be adequately diagnosed via computed tomography, a conservative treatment strategy for patients without complications should be considered in order to avoid any unnecessary surgical intervention. Case presentation We herein report a case of a surgically proved left-sided infarction of the greater omentum presenting with abdominal pain, tenderness of the left flank. Specifically, we describe the ultrasound (US) and computed tomography (CT) findings of this rare disease providing a radiological-pathological correlation of them. To date, there are few similar correlation reports in literature. Conclusions Although the classical treatment of omental infarction is surgery, more recently the conservative management has been suggested. Thus, we believe that the knowledge of the characteristic imaging findings is essential for establish a correct preoperative diagnosis, which can avoid unnecessary surgical intervention.

Abstract Background We report our experience in managing iatrogenic renal bleedings after nephrostomic procedures by transarterial embolization using Micro Vascular Plug (MVP) (Medtronic, USA) as single or complementary embolization device with parenchimal sparing. Materials and methods Five patients have been treated in a single center with transarterial embolization because of renal hemorrhages occurring after positioning of nephrostomic drainages. All patients presented with back pain, severe hematuria and/or bright red blood into the nephrostomic bag, with fall in hemoglobin value. After contrast enhanced CT scan confirming arterial active bleeding, rescue embolization was performed using MVP. The renal parenchimal loss was estimated on final postembolization DSA. Creatinine values were monitored before and after the procedure. Results Technical and clinical successes were obtained in all patients. Two patients presented with extraluminal blush, one with multiple pseudoaneurysms, one with pseudoaneurysm with arterovenous fistula, one with extraluminal blush with arterovenous fistula. MVP models were choosen oversized because of vasospasm that would underestimate the effective caliber of target vessel; MVP 3Q and MVP 7Q were adopted in one patient each, while MVP 5Q was released in three cases. MVP was the sole embolizing agent in four patients; in one patient, MVP was employed after microcoils failed to obtain complete embolization. The percentage of renal parenchimal lost was lower than 20%; no increase in Creatinine values was detected at dismission. Conclusions According to proposed data, MVP seems to be a safe, effective and fast embolizing device that interventionalists could consider when facing renal bleedings, even as sole agent.

Accessory spleens are often encountered in radiologic studies and they are not usually associated with symptoms. They could arise from autotransplantation of splenic tissue after splenic trauma or splenectomy (splenosis) [1]. In this case we describe a woman treated for splenectomy 20 years before and subsequently for adhesions, that suffered sudden left upper abdominal quadrant pain, weakness, and pale color. Contrast-enhanced computed tomography revealed free spilling in the abdomen and venous bleeding of a big accessory spleen; thus the patient underwent transcatheter arterial embolization with coils. Due to the 2 previous surgical operations in the splenic loggia, endovascular treatment compared to “open surgery” was the best choice in this case because of determined less complications, a shorter period of hospitalization, and a reduction of health cost. Keywords: Bleeding, Embolization, Accessory spleen, Splenectomy

Objective: To evaluate the safety and effectiveness of NOM (nonoperative management) in the treatment of blunt liver trauma, following a standardized treatment protocol.Methods: All the hemodynamically stable patients with computed tomography (CT) diagnosis of blunt liver trauma underwent NOM. It included strict clinical and laboratory observation, 48-72h contrast enhanced ultrasonography (CEUS) or CT follow-up, a primary angioembolization in case of admission CT evidence of vascular injuries and a secondary angioembolization in presence of vascular injuries signs at follow-up CEUS.Results: 181 patients (85.4%) [55 (30.4%) women and 126 (69.6%) men, median age 39 (range 14–71)] were included. Of these, 63 patients (34.8%) had grade I, 48 patients (26.5%) grade II, 39 patients (21.5%) grade III, 21 patients (11.6%) grade IV and 10 patients (5.5%) grade V liver injuries. The overall success rate of NOM was 96.7% (175/181). There was not significant difference in the success rate between the patients with different liver injuries grade. Morbidity rate was 7.4% (13/175). Major complications (2 bilomas, 1 liver hematoma and 2 liver abscesses) were successfully treated by CEUS or CT guided drainage. Eighteen (18/181) patients (9.9%) underwent angioembolization with successful results.Conclusion: Nonoperative management of blunt liver trauma represents a safe and effective treatment for both minor and severe injuries, achieving an high success rate and an acceptable morbidity rate. The angiographic study with embolization, although required only in selected cases of vascular injuries, represents a fundamental therapeutic option in a significant percentage of patients.

Splenic artery pseudoaneurysm (PSA) is a contained vascular wall lesion associated with a high mortality rate, generally related to pancreatitis, trauma, malignancy, iatrogenic injury, and segmental arterial mediolysis. Computed tomography angiography allows us to visualize the vascular anatomy, differentiate a PSA from an aneurysm, and provide adequate information for endovascular/surgical treatment. The present review reports on the main state-of-the-art splenic artery PSA diagnosis, differentiating between the pros and cons of the imaging methods and about the endovascular treatment.

Pulmonary sequestration is a congenital malformation characterized by dysplastic pulmonary tissue which receives blood supply by arterial systemic system, not in communication with tracheobronchial tree. Although it could be asymptomatic, it can also cause recurrent infections and hemoptysis, rarely massive and fatal. The conventional treatment consists in surgical resection of the pulmonary sequestration, but in the last few years endovascular embolization has been proposed as a valid therapeutic alternative. In this paper, we report the case of a 43–year-old woman affected by recurrent hemoptysis. Computed tomography angiography of the chest, abdomen, and pelvis was performed in emergency setting. Intralobar pulmonary sequestration in the lower lobe of the right lung was found. A bulky aberrant artery originating from the thoracic aorta supplied the pulmonary sequestration. The interventional radiologist performed an endovascular embolization with coils of the vascular malformation. The technical success of the procedure was confirmed by computed tomography angiography of the chest performed on the fourth day after procedure. Further examination performed 6 months later showed no complications. The patient was completely asymptomatic during follow-up. This procedure can demonstrate that arterial embolization is a valid and effective therapeutic alternative to surgical resection in the treatment of pulmonary sequestration.

Background: This study aims to investigate the correlation between computed tomography (CT) and digital subtraction angiography (DSA) findings in patients affected by acute post-traumatic intraparenchymal renal hemorrhages and evaluate their conservative management with superselective embolization. Methods: This retrospective multicenter analysis focuses on patients affected by renal bleedings detected by contrast-enhanced CT and treated with superselective endovascular embolization. CT findings were compared to DSA. Embolization procedural data were analyzed and renal function was evaluated before and after the intervention. Results: Twenty-seven patients were retrospectively evaluated in one year. Compared to DSA, CT showed 96.3% diagnostic accuracy in terms of hemorrhage recognition; concerning the type of vascular lesion, there was discrepancy between CT and DSA in five cases. The technical success rate of embolization was 100%, while primary clinical success was 88.9%. The inferior parenchymal third was the most frequent site of renal injury. Microcoils were the most adopted embolics. Renal function did not change significantly before and after embolization. Conclusions: CT has elevated diagnostic accuracy in detecting post-traumatic intraparenchymal renal hemorrhages; in a small percentage, the type of vascular lesion may differ from the findings observed at DSA. In this scenario, superselective embolization presents high clinical success with a low complication rate.

Pulmonary arteriovenous malformations (PAVMs) are vascular anomalies of the lung and carry the risk of cerebral thromboembolism, brain abscess, or pulmonary hemorrhage. We describe a 64-year-old male with hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) who presented with a five-year history of progressive effort dyspnea and a PAVM in the right upper lobe successfully treated by transcatheter embolization of feeding arteries using a new occlusion device, the ArtVentive Endoluminal Occlusion System™.

Uterine arteriovenous fistulas are rare and acquired causes of life-threatening vaginal bleeding. They usually present with intermittent menometrorrhagia in young patients in childbearing age with history of gynecological procedures on uterus. Traditional management is hysterectomy; endovascular embolization represents nowadays an alternative strategy for patients wishing to preserve fertility. Here, the endovascular approach to a 29-year-old woman affected by severe menometrorrhagia caused by a uterine arteriovenous fistula with a concomitant pelvic varicocele is reported; a bilateral uterine arteries embolization with Onyx-18 (ev3, Irvine, CA, USA) has successfully resolved the fistula with clinical success.

This paper outlines an original approach to e-learning systems which integrates the most recent results in the feld of human-computer interaction. Notably it will show the applicability of multimodal, attentive, affective and perceptual user interfaces to monitor the students’ behavior during their interaction with an e-learning system, in order to measure their attention level and involvement and promptly provide the necessary support to carry out an effective learning process.