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A better understanding of temporal relationships between chest CT and labs may provide a reference for disease severity over the disease course. Generalized curves of lung opacity volume and density over time can be used as standardized references from well before symptoms develop to over a month after recovery, when residual lung opacities remain. 739 patients with COVID-19 underwent CT and RT-PCR in an outbreak setting between January 21st and April 12th, 2020. 29 of 739 patients had serial exams (121 CTs and 279 laboratory measurements) over 50 ± 16 days, with an average of 4.2 sequential CTs each. Sequential volumes of total lung, overall opacity and opacity subtypes (ground glass opacity [GGO] and consolidation) were extracted using deep learning and manual segmentation. Generalized temporal curves of CT and laboratory measurements were correlated. Lung opacities appeared 3.4 ± 2.2 days prior to symptom onset. Opacity peaked 1 day after symptom onset. GGO onset was earlier and resolved later than consolidation. Lactate dehydrogenase, and C-reactive protein peaked earlier than procalcitonin and leukopenia. The temporal relationships of quantitative CT features and clinical labs have distinctive patterns and peaks in relation to symptom onset, which may inform early clinical course in patients with mild COVID-19 pneumonia, or may shed light upon chronic lung effects or mechanisms of medical countermeasures in clinical trials.

Liver cirrhosis is a leading cause of death worldwide, with 1-year mortality rates of up to 57% in decompensated patients. Hepatocellular carcinoma (HCC) is the most common primary tumor in cirrhotic livers and the second leading cause of cancer-related mortality worldwide. Annually, up to 8% of patients with cirrhosis develop HCC. The diagnosis of HCC rarely requires histological confirmation: in fact, according to the most recent guidelines, the imaging features of HCC are almost always sufficient for a certain diagnosis. Thus, the role of the radiologist is pivotal because the accurate detection and characterization of focal liver lesions in patients with cirrhosis are essential in improving clinical outcomes. Despite recent technical innovations in liver imaging, several issues remain for radiologists regarding the differentiation of HCC from other hepatic lesions, particularly benign lesions and pseudolesions. It is important to avoid misdiagnosis of benign liver lesions as HCC (false-positive cases) because this diagnostic misinterpretation may lead to ineligibility of a patient for potentially curative treatments or inappropriate assignment of high priority scores to patients on waiting lists for liver transplantation. This review presents a pocket guide that could be useful for the radiologist in the diagnosis of benign lesions and pseudolesions in cirrhotic livers, highlighting the imaging features that help in making the correct diagnosis of macroregenerative nodules; siderotic nodules; arterioportal shunts; hemangiomas, including fast-filling hemangiomas, hemangiomas with pseudowashout, and sclerosed hemangiomas; confluent fibrosis; pseudomasses in chronic portal vein thrombosis; and focal fatty changes.

Background The prognostic role of spontaneous portosystemic shunts (SPSS) has been poorly investigated. Aims To evaluate the impact of the presence of SPSS, as well as their characteristics, on the risk of decompensation. Methods This is a retrospective cohort study of 235 advanced chronic liver disease (ACLD) patients with available imaging examination, transient elastography, and upper endoscopy. ACLD was defined as liver stiffness measurement (LSM) >10 kPa. Competitive risk analyses were performed to identify the factors associated with the main outcome. Results SPSS were reported in 141 (60%) of the patients. Non-viral etiology was independently associated with SPSS presence [Odds-Ratio (OR): 2.743;95%-Interval-of-Confidence (IC):1.129–6.664]. During a follow-up of 37 (20–63) months, SPSS were found predictors of any decompensation type [Subhazard Ratio (SHR):2.264; 95%-IC:1.259–4.071], independently from a history of decompensation or high-risk-varices presence. The risk of complications was higher in patients with large (SHR: 3.775; 95%-IC: 2.016–7.070) and multiple (SHR:3.832; 95%-IC: 2.004–7.330) shunts, and in those with gastrorenal shunts (SHR:2.636; 95%-IC:1.521–4.569). Conclusions The presence, size, and number of SPSS predict not only the risk of hepatic encephalopathy but that of any type of decompensation across all stages of cirrhosis. Future studies should explore the possibility of treating shunts to prevent decompensation.

Heterotopic cervical pregnancy is a rare and potentially dangerous condition where the challenge is the removal of the ectopic pregnancy while preserving the intrauterine one. We present the case of an otherwise healthy 36-year-old woman with heterotopic cervical pregnancy after an IVF cycle for tubal infertility. At 6.5 weeks after a consultation with gynecologists and interventional radiologists, the patient agreed to undergo microwave ablation of the cervical pregnancy. Monthly ultrasound examination showed the persistence of non homogeneous and vascularized tissue in the cervix. Intrauterine pregnancy continued without complications until 37 weeks when a cesarean section was performed for sudden and profuse bleeding, in the presence of uterine contractions. A healthy baby girl was delivered, and the postoperative course was otherwise uncomplicated. Heterotopic cervical pregnancies are rare, and no consolidated and risk-free treatments are available at the moment. Here, we present a case of heterotopic cervical pregnancy treated successfully and without complications with microwave ablation. Electronic supplementary material The online version of this article (10.1007/s43032-020-00270-y) contains supplementary material, which is available to authorized users.

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 Conclusion MVP is a safe and effective embolic agent. While eventual concomitant anticoagulation therapy did not influence the technical outcome, straight course and length of the landing zone are essential parameters to evaluate before deployment.

Simple Summary Cholangiocarcinoma is an aggressive primary cancer of the biliary tree. Combined hepatocellular cholangiocarcinoma is also a primary liver malignancy but displays properties both of cholangiocarcinoma and hepatocellular carcinoma. Liver resection is the mainstay treatment; however, some patients are not surgical candidates. Locoregional therapies have emerged with the goal of providing local cancer treatment and control. We review different locoregional strategies for treating cholangiocarcinoma and combined hepatocellular cholangiocarcinoma. Abstract Cholangiocarcinoma (CCA) is a primary and aggressive cancer of the biliary tree. Combined hepatocellular cholangiocarcinoma (CHC) is a distinctive primary liver malignancy which has properties of both hepatocytic and cholangiocytic differentiation. CHC appears to have a worse prognosis compared to hepatocellular carcinoma, and similar to that of intrahepatic CCA. While significant advances have been made in understanding the pathophysiology and treatment of these two tumor types, their prognosis remains poor. Currently, liver resection is the primary treatment modality; however, only a minority of patients are eligible for surgery. However, the use of locoregional therapies proves an alternative approach to treating locally advanced disease with the aim of converting to resectability or even transplantation. Locoregional therapies such as transarterial chemoembolization (TACE), selective internal radiation therapy (SIRT), radiofrequency ablation (RFA), and photodynamic therapy (PDT) can provide patients with tumor control and increase the chances of survival. In this review, we appraise the evidence surrounding the use of locoregional therapies in treating patients with CCA and CHC.

Background: Sarcopenia, defined as low muscle mass with reduced function, is frequently encountered in cirrhotic patients and is a major predictor of adverse events, including post-liver transplant (LT) outcome. Objectives: This study assessed the impact of sarcopenia using computed tomography (CT)-based measurements on post-LT mortality and complications. Methods: From January 2008 to June 2016, 646 adult patients underwent 613 LTs at our institution. We analyzed the postoperative outcome of 287 patients who had pathologically proven cirrhosis on the explanted liver and who had performed a CT examination three months before LT. Psoas muscle density (PMD) was detected for every patient using standard instruments present in the radiological workstation and was related to postoperative survival rates and complications. Statistical analysis was carried out using the appropriate tests. Results: Postoperative mortality was 6.3%. At least one grade III-IV postoperative complication was experienced by 121 patients. Respiratory and infective complications occurred in 30 and 32 patients, respectively. Also, PMD was an independent predictor of postoperative mortality (P = 0.021), respiratory complications (P = 0.015), and infections (P = 0.010). The ROC analysis identified a PMD ≤ 43.72 HU as the best cutoff value for predicting 90-day mortality after LT. Conclusions: Psoas muscle density accurately predicted post-LT mortality and complications. Its ease and low-cost determination can allow widespread use of this parameter to improve clinical care and help with the decision to give these patients some priority on the transplant waiting list.

To evaluate the incidence of in-stent restenosis (ISR) at 12-month follow-up, in patients treated with new dual-layer Roadsaver (Terumo Corp, Tokyo, Japan) carotid artery stent (CAS). Thirteen patients underwent CAS and received a Roadsaver. Neurological examination was performed in all patients. Carotid stenosis was revealed by Doppler ultrasound (DUS) and multidetector CT (MDCT) scan. Four patients presented a peak systolic velocity (PSV) between 130 and 150 cm/s, six a PSV between 150 and 180 cm/s, and three a PSV > 180 cm/s. MDCT gave further anatomic information. Direct stenting was performed in 11 (84.6%) cases, whereas in 2 (15.4%) cases predilatation was required. In all cases postdilatation was performed. Technical and clinical success and safety were evaluated. Stent patency was evaluated during the 12-month follow-up. Technical success was achieved in all cases. In three patients a nonsignificant residual stenosis

Aim: To evaluate dynamic contrast-enhanced (DCE)-MRI and diffusion weighted (DW)-MRI diagnostic value to differentiate Warthin tumors (WT) by pleomorphic adenomas (PA). Materials & methods: Seven WT and seven PA were examined. DCE- and DW-MRI parameters were extracted from volumes of interest; volume of interest-based averages and standard deviations were calculated. Statistical analysis included: linear discriminant analysis, receiver operating characteristic curves, sensitivity and specificity. Results: No single feature was able to differentiate WT by PA (p > 0.05); linear discriminant analysis analysis showed that a combination of all features or combinations of feature pairs (namely: Ktrans(std) & f(std), Ktrans(std) & D(std), kep(std) & D(std), MRE(av) & TTP(av)) might achieve sensitivity (SENS), specificity (SPEC) = 100%, with a slight reduction after cross-validation analysis (SENS = 0.875; SPEC = 1). Conclusion: Although preliminary and not conclusive, our results suggest that differentiation between WT and PA is possible through a multiparametric approach based on combination of DCE- and DW-MRI parameters.

Drug-eluting bead transarterial chemoembolization (DEB-TACE) is a relative new endovascular treatment based on the use of microspheres to release chemotherapeutic agents within a target lesion with controlled pharmacokinetics. This aspect justifies the immediate success of DEB-TACE, that nowadays represents one of the most used treatments for unresectable hepatocellular carcinoma. However, there is no consensus about the choice of the best embolotherapy technique. In this review, we describe the available microspheres and report the results of the main comparative studies, to clarify the role of DEB-TACE in the hepatocellular carcinoma management. We underline that there is no evidence about the superiority of DEB-TACE over conventional TACE in terms of efficacy, but there may be some benefits with respect to safety especially with the improvement of new technologies.

Objectives: To evaluate the efficacy and safety of percutaneous transhepatic lithotripsy (PTL) using an electro-hydraulic (EH) system for difficult bile stones. Methods: We retrospectively evaluated two patients with recurrent cholangitis, jaundice and fever for the presence of difficult bile stones, inaccessible by an endoscopic approach, treated with PTL. Both procedures were conducted using the same protocol, with two different accesses. The treatments were performed using a 10 Fr flexible choledoscopy SpyGlass DSTM for visualization and an EH system for lithotripsy. Results: Technical success, clinical success and complications were evaluated. The two procedures were successfully concluded in both patients without any residual stones in the biliary tree. For both patients, a short follow-up period of six months was available, during which they remained asymptomatic. Neither major nor minor complications were registered. Conclusion: PTL was determined to be an effective and safe technique. This procedure allows a direct visualization of the stone, reducing fluoroscopy time and permitting a less invasive and less traumatic method for the percutaneous management of difficult bile stones. Advances in knowledge: The direct visualization, the high quality of the digital view, the adequate length of the device and the less traumatic approach of EH systems represent advantages compared with other available technologies.

Uterine fibroids are common benign tumors that affect the female reproductive tract. They are responsible for considerable morbidity and deterioration of life quality. The main advantages offered by mini invasive techniques are low grade of invasiveness and short times of hospitalization. The most diffuse technique is uterine artery embolization (UAE). Common concerns with UAE include postprocedural pain, postembolization syndrome, and risk of infection. Image-guided thermal ablation techniques like radiofrequency ablation, percutaneous microwave ablation, and imaging-guided high-intensity focused ultrasound were introduced to overcome the side effects related to UAE and surgery. The aim of this review is to briefly analyze the ablative procedures and their role in the management of symptomatic fibroids, and to describe the safety profile and outcomes of these modalities.

Objective: To report safety and efficacy of interventional radiology procedures in the treatment of gynecologic iatrogenic urinary leaks. Methods: A retrospective analysis of iatrogenic ureteral lesions treated between November 2009 to April 2019 was performed. Under ultrasound (US) and fluoroscopy guidance, an attempt to place a ureteral stent and nephrostomy was carried out in the same session using an anterograde percutaneous approach. At the end of any procedure, a fluoroscopic control and a cone-beam CT scan (CBCT) were performed to check the correct placement and functioning of the nephrostomy and DJ stent. In cases of difficult ureteral stent placement via the single anterograde approach, the collaboration of urologists was requested to perform a rendezvous technique, combined with the retrograde approach. Results: DJ stent placement was achieved using the anterograde approach in 12/15 (80.0%) patients and using the retrograde approach in 3/15 cases (20.0%). Moreover, in 3/15 (20.0%) patients, surgical treatment was needed: in one case because of the persistence of ureteral stenosis at 6 months, and in the other two cases due to ureter-vaginal fistula. No major complications were recorded; overall, minor complications occurred in 4/8 patients. Conclusion: Percutaneous minimally invasive treatment of iatrogenic ureteral lesions after gynecological surgery is a safe and effective option.

To establish the feasibility of performing percutaneous biopsy of lung lesions guided by fusion PET/CT-CBCT and to evaluate whether the metabolic information provided by a prior PET/CT scan add incremental benefits for diagnosis. We retrospectively reviewed data from 180 patients who underwent CBCT-guided lung biopsy (group 1—90 cases) or PET/CT-CBCT fusion-guided lung biopsy (group 2—90 cases). Technical and clinical success was calculated. We also evaluated the agreement between biopsy and definitive histology and the possibility to carrying out immunehistochemical and molecular biology analyses. Technical success was achieved in 84/90 (93.3%) cases for group 1 and 89/90 (98.9%) for group 2 cases (p 0.054). Clinical success was achieved in 80/94 (95.2%) cases for group 1 and 88/89 (98.9%) cases for group 2. Sensitivity, specificity, positive and negative predictive values and accuracy rate were, respectively, 94.5%, 100.0%, 100.0%, 73.3% and 95.2% for group 1 and 98.6%, 100.0%, 100.0%, 94.4% and 98.9% for group 2 (p 0.167). Agreement between biopsy and definitive histology was reached in 85.7% for group 1 and in 96.2% for group 2 (p 0.211). Immunohistochemical and molecular biology investigations were possible in 66.7% for group 1 and in 77.0% for group 2 (p 0.297). No major complication occurred. PET/CT-CBCT-guided lung biopsy is a feasible technique. In our retrospective case series, we found a higher clinical success rate, but no statistical difference was found.

Artificial intelligence (AI) is a branch of Informatics that uses algorithms to tirelessly process data, understand its meaning and provide the desired outcome, continuously redefining its logic. AI was mainly introduced via artificial neural networks, developed in the early 1950s, and with its evolution into "computational learning models." Machine Learning analyzes and extracts features in larger data after exposure to examples; Deep Learning uses neural networks in order to extract meaningful patterns from imaging data, even deciphering that which would otherwise be beyond human perception. Thus, AI has the potential to revolutionize the healthcare systems and clinical practice of doctors all over the world. This is especially true for radiologists, who are integral to diagnostic medicine, helping to customize treatments and triage resources with maximum effectiveness. Related in spirit to Artificial intelligence are Augmented Reality, mixed reality, or Virtual Reality, which are able to enhance accuracy of minimally invasive treatments in image guided therapies by Interventional Radiologists. The potential applications of AI in IR go beyond computer vision and diagnosis, to include screening and modeling of patient selection, predictive tools for treatment planning and navigation, and training tools. Although no new technology is widely embraced, AI may provide opportunities to enhance radiology service and improve patient care, if studied, validated, and applied appropriately.

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We conducted an observational cohort study in adult patients consecutively admitted for the respiratory illness Covid-19 to our hub hospital from March 9 to April 7, 2020. The high observed rate of venous thromboembolism prompted us to increase the prophylactic doses of enoxaparin from 40 mg daily up to 1 mg/kg twice daily in patients admitted to intensive care units (ICU), 0.7 mg/kg twice daily in high-intensity of care wards and 1 mg/kg daily in low-intensity of care wards. Patients on high enoxaparin doses were compared to those who received prophylaxis with the standard dosage. Efficacy endpoints were mortality, clinical deterioration, and the occurrence of venous thromboembolism, safety endpoint was the occurrence of major bleeding. Of 278 patients with Covid-19, 127 received prophylaxis with high enoxaparin doses and 151 with standard dosage. At 21 days, the incidence rate of death and clinical deterioration were lower in patients on higher doses than in those on the standard dosage (hazard ratio 0.39, 95% confidence interval 0.23–0.62), and the incidence of venous thromboembolism was also lower (hazard ratio 0.52, 95% confidence interval 0.26–1.05). Major bleeding occurred in four of 127 patients (3.1%) on the high enoxaparin dosage. In conclusion, in the cohort of patients with Covid-19 treated with high enoxaparin dosages we observed a 60% reduction of mortality and clinical deterioration and a 50% reduction of venous thromboembolism compared to standard dosage prophylaxis. However, 3% of patients on high enoxaparin dosages had non-fatal major bleeding. Supplementary Information The online version contains supplementary material available at 10.1007/s11739-020-02585-9.

This report aims to illustrate how to perform a venous access to a COVID-19 patient at the bedside. The decision on the type of venous access, the selection of the material necessary to perform the procedure, and the preparation of the operators are described. The described approach can reduce costs, speed up execution times, and make the operator’s work safer. Furthermore, these precautions may help control the spread of COVID-19 within the healthcare facility.

Purpose Chest X-ray plays a key role in diagnosis and management of COVID-19 patients and imaging features associated with clinical elements may assist with the development or validation of automated image analysis tools. We aimed to identify associations between clinical and radiographic features as well as to assess the feasibility of deep learning applied to chest X-rays in the setting of an acute COVID-19 outbreak. Methods A retrospective study of X-rays, clinical, and laboratory data was performed from 48 SARS-CoV-2 RT-PCR positive patients (age 60±17 years, 15 women) between February 22 and March 6, 2020 from a tertiary care hospital in Milan, Italy. Sixty-five chest X-rays were reviewed by two radiologists for alveolar and interstitial opacities and classified by severity on a scale from 0 to 3. Clinical factors (age, symptoms, comorbidities) were investigated for association with opacity severity and also with placement of central line or endotracheal tube. Deep learning models were then trained for two tasks: lung segmentation and opacity detection. Imaging characteristics were compared to clinical datapoints using the unpaired student's t-test or Mann-Whitney U test. Cohen's kappa analysis was used to evaluate the concordance of deep learning to conventional radiologist interpretation. Results Fifty-six percent of patients presented with alveolar opacities, 73% had interstitial opacities, and 23% had normal X-rays. The presence of alveolar or interstitial opacities was statistically correlated with age (P = 0.008) and comorbidities (P = 0.005). The extent of alveolar or interstitial opacities on baseline X-ray was significantly associated with the presence of endotracheal tube (P = 0.0008 and P = 0.049) or central line (P = 0.003 and P = 0.007). In comparison to human interpretation, the deep learning model achieved a kappa concordance of 0.51 for alveolar opacities and 0.71 for interstitial opacities. Conclusion Chest X-ray analysis in an acute COVID-19 outbreak showed that the severity of opacities was associated with advanced age, comorbidities, as well as acuity of care. Artificial intelligence tools based upon deep learning of COVID-19 chest X-rays are feasible in the acute outbreak setting.

BACKGROUND. Aim of the study is to evaluate the incidence of DVT in COVID-19 patients and its correlation with the severity of the disease and with clinical and laboratory findings.METHODS. 234 symptomatic patients with COVID-19, diagnosed according to the World Health Organization guidelines, were included in the study. The severity of the disease was classified as moderate, severe and critical. Doppler ultrasound (DUS) was performed in all patients. DUS findings, clinical, laboratory’s and therapeutic variables were investigated by contingency tables, Pearson chi square test and by Student T test and Fisher's exact test. ROC curve analysis was applied to study significant continuous variables.RESULTS. Overall incidence of DVT was 10.7% (25/234): 1.6% (1/60) among moderate cases, 13.8% (24/174) in severely and critically ill patients. Prolonged bedrest and intensive care unit admission were significantly associated with the presence of DVT (19.7%). Fraction of inspired oxygen, P/F ratio, respiratory rate, heparin administration, D-dimer, IL-6, ferritin and CRP showed correlation with DVT. CONCLUSIONS. DUS may be considered a useful and valid tool for early identification of DVT. In less severely affected patients, DUS as screening of DVT might be unnecessary. High rate of DVT found in severe patients and its correlation with respiratory parameters and some significant laboratory findings suggests that these can be used as a screening tool for patients who should be getting DUS.

Aim of this study was to identify preprocedural parameters, which may predict the application of a complex IVC filter retrieval technique and estimate the procedural outcome by applying two dedicated score systems. In this retrospective multicenter analysis, data concerning patient, filter and procedure characteristics were retrieved from January 2018 to March 2020. Patients were evaluated according to the retrieval technique (standard vs. complex) and the procedural outcome (success vs. failure). Significant differences among these groups were evaluated, and two score systems were developed to predict the application of a complex retrieval technique and the procedural outcome. One hundred and sixteen IVC filters were retrieved in 116 patients. In 98 subjects, the filter was retrieved with a standard procedure (Standard group, 84.5% vs. Complex group, 15.5%), while in 106 patients the procedure was successful (Success group, 91.4% vs. Failure group, 8.6%). Statistically significant differences were noted in terms of embedded filter hook, filter apex tilt, angle between filter axis and IVC, caval wall penetration, dwelling time and procedural time. Two score 0–5 points to predict the need for a complex retrieval technique and the procedural outcome were developed, with a prognostic accuracy of 88.8% and 91.4%, respectively. Significant differences were appreciable analyzing the sample data comparing both the retrieval technique applied and the procedural outcome. Two predictive scores were developed to assess the need for applying a complex retrieval technique and to estimate the procedural outcome.

Chest CT is emerging as a valuable diagnostic tool for clinical management of COVID-19 associated lung disease. Artificial intelligence (AI) has the potential to aid in rapid evaluation of CT scans for differentiation of COVID-19 findings from other clinical entities. Here we show that a series of deep learning algorithms, trained in a diverse multinational cohort of 1280 patients to localize parietal pleura/lung parenchyma followed by classification of COVID-19 pneumonia, can achieve up to 90.8% accuracy, with 84% sensitivity and 93% specificity, as evaluated in an independent test set (not included in training and validation) of 1337 patients. Normal controls included chest CTs from oncology, emergency, and pneumonia-related indications. The false positive rate in 140 patients with laboratory confirmed other (non COVID-19) pneumonias was 10%. AI-based algorithms can readily identify CT scans with COVID-19 associated pneumonia, as well as distinguish non-COVID related pneumonias with high specificity in diverse patient populations., Chest CT is emerging as a valuable diagnostic tool for clinical management of COVID-19 associated lung disease. Here, the authors present a multinational study on the application of deep learning algorithms for COVID-19 diagnosis against multiple lung conditions as controls.

Whilst surgery represents the gold standard for the treatment of adrenal primary malignant tumors, metastatic involvement of the adrenal glands is generally approached conservatively; however, surgery for local control has been controversial, and several reports have described the utility of surgical removal in terms of prolonged survival in selected patients. Different techniques, including radiofrequency ablation (RFA), microwave ablation (MWA), laser induced thermal therapy (LITT), cryoablation (CRA), and chemical ablation, are employed in percutaneous image-guided ablation for primary and metastatic malignancies of the adrenal glands, in case of patients with multiple comorbidities or who refuse surgery. Technical success, clinical success and safety were analysed and discussed in this systematic review. Tumor size was found a significant determinant for local disease control; histology of the primary malignancy and coexistence of tumor elsewhere were correlated with prognosis. These procedures resulted to be feasible and safe, with hypertensive crisis representing the most common complication. Although there is lack of evidence in the literature concerning outcomes compared with surgery, percutaneous ablation may represent a useful therapeutic option for controlling unresectable adrenal metastases, offering patients opportunities for improved survival.

The COVID-19 pandemic has deeply impacted the activity of interventional oncology in cancer centers. Since the first COVID case was diagnosed in Italy on February 21st, our Hospital, located in Milan downtown, has been at the frontline to manage this emergency and to try to ensure essential services. In the present article, we discuss the changes that need to be done for the organization, safety, and patient management in interventional oncology.

To describe radiographic key patterns on Chest X-ray (CXR) in patients with SARS-CoV-2 infection, assessing the prevalence of radiographic signs of interstitial pneumonia. To evaluate pattern variation between a baseline and a follow-up CXR. 1117 patients tested positive for SARS-CoV-2 infection were retrospectively enrolled from four centers in Lombardy region. All patients underwent a CXR at presentation. Follow-up CXR was performed when clinically indicated. Two radiologists in each center reviewed images and classified them as suggestive or not for interstitial pneumonia, recording the presence of ground-glass opacity (GGO), reticular pattern or consolidation and their distribution. Pearson’s χ2 test for categorical variables and McNemar test (χ2 for paired data) were performed. Patients mean age 63.3 years, 767 were males (65.5%). The main result is the large proportion of positive CXR in COVID-19 patients. Baseline CXR was positive in 940 patients (80.3%), with significant differences in age and sex distribution between patients with positive and negative CXR. 382 patients underwent a follow-up CXR. The most frequent pattern on baseline CXR was the GGO (66.1%), on follow-up was consolidation (53.4%). The most common distributions were peripheral and middle-lower lung zone. We described key-patterns and their distribution on CXR in a large cohort of COVID-19 patients: GGO was the most frequent finding on baseline CXR, while we found an increase in the proportion of lung consolidation on follow-up CXR. CXR proved to be a reliable tool in our cohort obtaining positive results in 80.3% of the baseline cases.

Rationale and Objectives The use of chest computed tomography (CT) in the era of the COVID-19 pandemic raises concern regarding the transmission risks to patients and staff caused by CT room contamination. Meanwhile the Center for Disease Control guidance for air exchange in between patients may heavily impact workflows. To design a portable custom isolation device to reduce imaging equipment contamination during a pandemic. Materials and Methods Center for Disease Control air exchange guidelines and requirements were reviewed. Device functional requirements were outlined and designed. Engineering requirements were reviewed. Methods of practice and risk mitigation plans were outlined including donning and doffing procedures and failure modes. Cost impact was assessed in terms of CT patient throughput. Results CT air exchange solutions and alternatives were reviewed. Multiple isolation bag device designs were considered. Several designs were custom fabricated, prototyped and reduced to practice. A final design was tested on volunteers for comfort, test-fit, air seal, and breathability. Less than 14 times enhanced patient throughput was estimated, in an ideal setting, which could more than counterbalance the cost of the device itself. Conclusion A novel isolation bag device is feasible for use in CT and might facilitate containment and reduce contamination in radiology departments during the COVID Pandemic.

Gastric cancer (GC) is a common cancer worldwide. Its incidence and mortality vary depending on geographic area, with the highest rates in Asian countries, particularly in China, Japan, and South Korea. Accurate imaging staging has become crucial for the application of various treatment strategies, especially for curative treatments in early stages. Unfortunately, most GCs are still diagnosed at an advanced stage, with the peritoneum (61–80%), distant lymph nodes (44–50%), and liver (26–38%) as the most common metastatic locations. Metastatic disease is limited to the peritoneum in 58% of cases; in nonperitoneal distant metastases, the most involved GC metastasization site is the liver (82%). The eighth edition of the tumor-node-metastasis staging system is the most commonly used system for determining GC prognosis. Endoscopic ultrasonography, computed tomography, and 18-fluorideoxyglucose positron emission tomography are historically the most accurate imaging techniques for GC staging. However, studies have recently shown renewed interest in magnetic resonance imaging (MRI) as a useful tool in GC staging, especially for distant metastasis assessment. The technical improvement of diffusion-weighted imaging and the increasing use of hepatobiliary contrast agents have been shown to increase the diagnostic performance of MRI, particularly for detecting peritoneal and liver metastasis. However, no principal oncological guidelines have included the use of MRI as a first-line technique for distant metastasis evaluation during the GC staging process, such as the National Comprehensive Cancer Network Guidelines. This review analyzed the role of the principal imaging techniques in GC diagnosis and staging, focusing on the potential role of MRI, especially for assessing peritoneal and liver metastases.

MRI-guided vacuum-assisted breast biopsy (VABB) is used for suspicious breast cancer (BC) lesions which are detectable only with MRI: because the high sensitivity but limited specificity of breast MRI it is a fundamental tool in breast imaging divisions. We analyse our experience of MRI-guided VABB and critically discuss the potentialities of diffusion-weighted imaging (DWI) and artificial intelligence (AI) in this matter. We retrospectively analysed a population of consecutive women underwent VABB at our tertiary referral BC centre from 01/2011 to 01/2019. Reference standard was histological diagnosis or at least 1-year negative follow-up. McNemar, Mann–Whitney and χ2 tests at 95% level of significance were used as statistical exams. 217 women (mean age = 52, 18–72 years) underwent MRI-guided VABB; 11 were excluded and 208 MRI-guided VABB lesions were performed: 34/208 invasive carcinomas, 32/208 DCIS, 8/208 LCIS, 3/208 high-risk lesions and 131/208 benign lesions were reported. Accuracy of MRI-guided VABB was 97%. The predictive features for malignancy were mass with irregular shape (OR 8.4; 95% CI 0.59–31.6), size of the lesion (OR 4.4; 95% CI 1.69–9.7) and mass with irregular/spiculated margins (OR 5.4; 95% CI 6.8–31.1). Six-month follow-up showed 4 false-negative cases (1.9%). Invasive BC showed a statistically significant higher hyperintense signal at DWI compared to benign lesions (p = 0.03). No major complications occurred. MR-guided VABB showed high accuracy. Benign-concordant lesions should be followed up with breast MRI in 6–12 months due to the risk of false-negative results. DWI and AI applications showed potential benefit as support tools for radiologists.

This is a single-center report on coordination of staff and handling of patients during the outbreak of the COVID-19 (coronavirus disease 2019) in a region with high incidence and prevalence of disease. The selection of procedures for interventional radiology (IR), preparation of staff and interventional suite before the arrival of patients, the facility ventilation systems and intra- and post-procedural workflow optimization are described. The control measures described may increase the cost of the equipment, prolong procedural times and increase technical difficulties. However, these precautions may help control the spread of COVID-19 within the healthcare facility.

With increased use of medical imaging, the incidental detection of benign solid liver tumors has become more frequent. Facing with benign disease, the indications for surgery are still object of discussion in light of the stable natural course of most lesions and obvious drawbacks of any surgical intervention; therefore, in most situations, a conservative approach is recommended, and surgery is mainly reserved for those cases with persistent or worsening symptoms, or who are at risk for complications as malignant transformation. The advent of ablative techniques has widened the range of treatment options available to these patients, presenting as a valid alternative to resection in terms of safety and efficacy in selected cases, particularly in patients who are considered poor surgical candidates and with smaller lesions. This review outlines the role of percutaneous ablative methods for benign solid liver tumors that are encountered in adults, providing a per histology analysis of the existing evidence. The up-to-date strategies for management of the most common benign solid tumors are recapitulated.

Radiofrequency ablation is a minimally invasive procedure alternative to surgery to treat benign thyroid nodules causing compressive symptoms. Tolerability of this procedure, aimed at treatment of benign conditions, is fundamental. In this study, we evaluated if local anesthesia should be enough to reduce both hospital costs and sedation-related risks for the patient, avoiding deep sedation and presence of the anesthesiologist. From July 2017 to August 2018, 14 consecutive patients (mean age 60.1 years) were treated and divided in two groups: Group A (7 patients) underwent systemic sedoanalgesia (intravenous remifentanil/fentanyl ± intravenous midazolam ± intravenous acetaminophen/nonsteroidal anti-inflammatory drugs) + subcutaneous anesthesia (lidocaine), with anesthesiologist. Group B (7 patients) underwent mild systemic sedoanalgesia (oral solution morphine sulfate + intravenous midazolam + intravenous acetaminophen) + both subcutaneous and subcapsular anesthesia (mepivacaine + bupivacaine), without anesthesiologist. Tolerability, sedation grade (Ramsay scale), total opioid dose, complications, and results at 12 months were analyzed and compared. Mean tolerability was 9.4 in group A and 8.9 in group B (p: 0.786). Mean sedation grade was 3.86 in group A and 2.71 in group B (p: 0.016). Mean total opioid dose was 70.9 mg in group A and 10 mg in group B (p:0.00015). No complications were observed. At 12 months, mean volume reduction was 56.1% in the group A and 60% in the group B. In thyroid radiofrequency ablation, subcapsular anesthesia can decrease both total opioid dose and level of patient's sedation without significant differences in tolerability, allowing to perform ablation without the anesthesiologist.

The aim of the present study was to identify predictors of outcome and complications in patients with small hepatocellular carcinoma (HCC) treated by percutaneous microwave ablation (MWA). Patients with non-previously treated small (≤ 3 cm) HCCs who underwent ultrasound (US)-guided percutaneous MWA between July 2016 and January 2019 were included. For each patient, the following variables were registered: age, sex, albumin, platelet count, INR/PT, PTT ratio, total bilirubin, liver status, etiology of liver disease, Child–Pugh classification, tumor dimension, margin, and hepatic segment, tumor subcapsular, perihilar or perivascular location, HCC focality, ascites. During follow-up, complications and outcomes were registered. Variables were then analyzed in relation to both outcomes and complications. 74 patients were included. Mean CT follow-up was 6.2 months (range 1–24 months). At least one complication occurred in 48% of patients, the majority being asymptomatic imaging findings not requiring intervention. One major complication was registered (duodenal perforation: 1.3%). The occurrence of complications was associated with HCC multifocality and abnormal INR/PT, duodenal wall edema with tumor dimension, portal vein thrombosis with Child Pugh score, perihepatic free fluid with abnormal platelet count and comorbidities. Incomplete response rate at 1 month was 18.9%. Local tumor progression and new HCC nodules rates were 13.5% and 27%, respectively. Incomplete response at 1 month was associated with both alcoholic etiology of liver disease and II segment tumor location, new HCC nodules with PBC. Despite the small series analyzed, significant factors related with complications and outcomes may be kept in mind when planning the best treatment for each patient.

RENAL score has been validated on predicting adverse events and relapses in percutaneous treatments of renal lesions. To better fit interventional issues a modified score (mRENAL) has been introduced, but the only difference from the RENAL score is on the dimensional parameter. However, it remains of surgical derivation while a specific interventional score is missing. This study aims to obtain a specific score (ABLATE) to better quantify the risk of complications and relapses in percutaneous kidney ablation procedures compared to the existing surgical scores. Taking inspiration from previous papers, a score was built to quantify the real difficulties faced in percutaneous treatment of renal lesions. The ABLATE score was used on 71 cryoablations to evaluate its predictivity of complications and relapses. Logistic regression was used to predict complication incidence; Cox-regression was used for relapses; ROC analysis was used to evaluate the accuracy of the different scores. Between January 2014 and November 2019, 71 lesions in 68 patients were treated. Overall, malignant histology was found in 62 lesions (87.3%). Mean and median RENAL, mRENAL, and ABLATE scores were 7.04 and 7, 7.19 and 7, and 5.11 and 4, respectively. Out of 71 treatments, we experienced 3 bleeding with anemia (4.2%), only 2 of which needed further treatment (2.82%). The mean and median RENAL, mRENAL, and ABLATE scores in those with complications were 7.66 and 7.01 (p = 0.69), 8.0 and 7.1 (p = 0.54), and 6.6 and 5.0 (p = 0.38), respectively. Out of 62 malignant lesions, we experienced 2 persistent and 6 recurrent lesions (3.2% and 8.4%, respectively). At Cox-regression analyses, mABLATE score outperformed both RENAL and mRENAL scores in predicting recurrences (HR 1.48; p

Artificial intelligence (AI) is revolutionizing healthcare and transforming the clinical practice of physicians across the world. Radiology has a strong affinity for machine learning and is at the forefront of the paradigm shift, as machines compete with humans for cognitive abilities. AI is a computer science simulation of the human mind that utilizes algorithms based on collective human knowledge and the best available evidence to process various forms of inputs and deliver desired outcomes, such as clinical diagnoses and optimal treatment options. Despite the overwhelmingly positive uptake of the technology, warnings have been published about the potential dangers of AI. Concerns have been expressed reflecting opinions that future medicine based on AI will render radiologists irrelevant. Thus, how much of this is based on reality? To answer these questions, it is important to examine the facts, clarify where AI really stands and why many of these speculations are untrue. We aim to debunk the 6 top myths regarding AI in the future of radiologists.

The aim of our study is a retrospective evaluation of effectiveness and safety of Computed Tomography (CT)-guided radiofrequency ablation (RFA) therapy of primary and metastatic lung lesions in patients that cannot be considered surgical candidates. From February 2007 to September 2017, we performed 264 CT-guided ablation sessions on 264 lesions in 174 patients (112M and 62 F; mean age, 68years; range 36–83years) affected by primary and metastatic lung lesions. The 45% of patients was affected by primary lung cancer, with size range lesion of 10–50mm, and the 55% by metastatic lung lesions with size range of 5–49mm. All patients had no more than three metastases in the lung and pulmonary relapses were treated up to three times. Overall Survival (OS), Progression-Free Survival (PFS), Local Progression-Free Survival (LPFS) and Cancer-specific survival (CSS) at 1, 3 and 5years were calculated both in primary lung tumors and in metastatic patients. Immediate and late RFA-related complications were reported. Pulmonary function tests were evaluated after the procedures. The effectiveness of RFA treatment was evaluated by contrast-enhanced CT. In patients affected by primary lung lesions, the OS rates were 66.73% at 1year, 23.13% at 3years and 16.19% at 5years. In patients affected by metastatic lung lesions, the OS rates were 85.11%, 48.86% and 43.33%, respectively, at 1, 3 and 5years. PFS at 1, 3 and 5years were 79.8%, 60.42%, 15.4% in primary lung tumors and 78.59%, 51.8% and 6.07% in metastatic patients. LPFS at 1, 3 and 5years were 79.8%, 64.69%, 18.87% in primary lung tumors and 86.29%, 69.15% and 44.45% in metastatic patients. CSS at 1, 3 and 5years was 95.56%, 71.84%, 56.72% in primary lung tumors and 94.07%, 71% and 71% in metastatic patients. Immediate RFA-related complications (pneumothorax, pleural effusion and subcutaneous emphysema) were observed, respectively, in 42, 53 and 13 of 264 procedures (15.9%, 20% and 5%). There also occurred one major complication (lung abscess, 0.36%). No significant worsening of pulmonary function was noted. Our retrospective evaluation showed long-term effectiveness, safety and imaging features of CT-guided RFA in patients affected by primary and metastatic lung cancer as an alternative therapy in non-surgical candidates.

Hepatocellular carcinoma (HCC) is a frequent tumor that may be treated with radiofrequency thermal ablation (RFA). RFA has been used with success also in treatment of pulmonary metastases from a wide range of primitive tumors, especially colorectal. Previous studies have shown that RFA con be used in treating HCC pulmonary metastases. Purpose of our study was a retrospective evaluation of overall survival and complication rates of percutaneous CT-guided radiofrequency ablation of pulmonary metastases from hepatocellular carcinoma (HCC). Data were collected from 40 CT-guided ablation sessions performed on 42 lesions in 26 patients (16M and 10 F; mean age 62.5years) with pulmonary metastases from HCC (size range 0.3–4cm, mean diameter 1.4 ± 0.98cm) from February 2012 to December 2017. All patients, as in advanced stage of illness (stage C), were treated according to Barcelona Clinic Liver Cancer (BCLC) criteria, with Sorafenib. They had no active HCC foci in the liver and no more than three metastases in the lung. Patients did not discontinue medical therapy with Sorafenib and pulmonary relapses were treated up to three times. In two patients two lesions were treated during the same procedure. Each lesion was ablated under CT guidance. Follow-up contrast-enhanced CT at 1, 3, 6, 12-month and every 6months after treatment were reviewed. A total of 42 metastatic lung lesions from HCC in 26 patients (57% male, 43% female) were treated with CT-guided radiofrequency thermal ablation procedures. Immediate radiofrequency ablation-related complications (subtle pneumothorax) were observed in 9 of 40 procedures (22.5%). Only one patient developed a pneumothorax requiring drainage tube insertion (2.5%). No other major complications occurred. Moreover, no significant worsening of pulmonary function was observed. In all patients the overall survival rates were 88.5% at 1year, 69.8% at 3years and 26.2% at 5years. Our retrospective assessment confirmed that percutaneous CT-guided radiofrequency thermal ablation in 23 patients with pulmonary metastases from HCC represents an effective and safe alternative treatment option in patients not considerable as potential candidates to surgery.

To retrospectively assess the predictive value of the CT performed at 24 h, compared with the CT performed at 1 month, in the evaluation of the technical success of microwave (MW) ablation of hepatic lesions. In a single center, 50 patients with HCC underwent percutaneous MW ablation between November 2016 and March 2019. Each patient underwent a contrast-enhanced CT exam at 24 h and at 1 month after the procedure. For each patient, was assessed the presence or absence of residual disease, the appearance of a new lesion, complications, and the involvement of the hepatic capsule, both at 24-h and at 1 month. Overall correlation between residual disease, appearance of a new nodule and complications was also assessed. A total of 50 hepatic lesions were treated with US-guided MW ablation. Patients’ mean age was 70.9 years (range 28–87 years). Mean nodule diameter was 17.6 mm (range 7–35 mm). Contingency tables and the χ2 test showed a strong association when looking at capsule involvement (accuracy: 100%), residual disease (accuracy: 90%; p-value 0.003), and the appearance of a new HCC nodule (accuracy: 88%; p-value 0.007); regarding complications, the accuracy was 78% (p-value 0.014). Optimal correlation was reached in 62% of cases, moderate correlation in 26%, minimum correlation in 10% of cases; no cases of zero correlation were recorded. CT at 24 h and 1 month showed comparable efficacy in evaluating residual disease after MW thermal ablation of liver lesions. However, further studies are needed to assess which factors may cause false-negative results at the 24-h CT.

Background The aim of this study was to evaluate the diagnosis and management of postoperative bile leaks, reporting typical diagnostic findings and available percutaneous techniques in association with other diagnostic and management methods. Methods Thirty-six patients (28 male) were treated for postoperative bile leaks. A biliary leak was clinically suspected in case of persistent leakage of bilious material from a surgical drain, or in the presence of non-specific symptoms such as abdominal pain, fever and anorexia, with or without laboratory alteration of liver enzymes. Radiological confirmation was mainly based on noninvasive methods such as ultrasound, computed tomography, and magnetic resonance cholangiopancreatography. We assessed each treatment by evaluating multiple factors, including technical success (TS) and clinical effectiveness (CE), defined as primary or secondary. We also evaluated overall CE (OCE), defined as leak control with either single or multiple procedures. Results TS and OCE were achieved in all patients (36/36; 100%) with a grade A or B biliary leak. No grade C was observed. There were no major complications. Minor complications were observed in 7/36 (19.4%) patients. No procedure-related deaths occurred. Conclusions In our study, considering all percutaneous techniques, leak healing was achieved in all the patients with a grade A or B biliary leak. These procedures provide a less invasive approach and are increasingly recognized as having a significant role in the management of complications and should be considered as an integral component in the postoperative management of these patients.

Renal cell carcinoma (RCC) local recurrence after radical nephrectomy is uncommon. When feasible, surgical removal remains the primary treatment strategy; nevertheless, local RCC relapse management is controversial, and less invasive procedures may represent an attractive option to achieve oncologic control. The aim of our study was to assess the feasibility, safety, and clinical outcomes of image-guided percutaneous microwave ablation (MWA) for RCC local recurrence in patients initially treated with nephrectomy with curative intent. 10 consecutive patients underwent CT-guided percutaneous MWA of a total of 10 retroperitoneal nodules. Inclusion criteria were: histologically verified retroperitoneal metastases, previous radical nephrectomy, lesion no larger than 3cm, no other metastatic site elsewhere. All the procedures were performed under moderate sedation choosing the most favorable patient decubitus. If deemed necessary, pneumodissection was induced before ablation. After the antenna placement inside the target lesion, thermal ablation was achieved by maintenance of a power of 100W for a total time between 2 and 4min. All patients were observed overnight and discharged the following day if clinically stable. Technical success was obtained in 100% of patients. One patient was re-treated to complete oncologic response with repeat MWA. No major complications were observed. No patients demonstrated local recurrence at a mean follow-up of 26months. MWA is a safe and effective treatment strategy for loco-regional relapse of RCC following radical nephrectomy. This technique may represent a valuable approach for patients who are not eligible for surgery.

To compare clinical success and patient satisfaction of percutaneous cervical nucleoplasty (PCN) and percutaneous cervical discectomy (PCD) in contained cervical disc herniation treatment. We retrospectively identified 50 consecutive patients in our institution: 24 underwent the PCD treatment and 26 patients were treated by the PCN procedure. All patients complained of radicular pain with or without neck pain; diagnosis of contained cervical disc herniation was obtained by MRI; all patients had received conservative therapy which did not result in symptom improvement. Exclusion from our series consisted of patients who had undergone previous surgery at the indicated level, or those with myelopathy, or those in whom more than a sole herniation was treated in the same session. Overall procedure time, fluoroscopy time, radiation dose and complications were recorded. The MacNab scale score was used to assess clinical success in terms of pain relief at 2- and 6-month follow-up. After 4–6 months, a cervical MRI was obtained in 24 patients. Neither major nor minor complications were reported. Regarding patient satisfaction, overall median modified MacNab score was excellent both at 2 and 6 months after treatment. No significant statistical difference was found in mean modified MacNab score at 2 and 6 months among patients grouped by treatment choice (p = 0.319 and 0.847, respectively); radiation dose was inferior in PCN group than in PCD, with no significant statistical difference. PCD and PCN were found to be safe and effective in terms of pain relief in contained cervical herniation treatment.

Background: The aim of this study was to investigate the effect of the time interval from clinical presentation of arteriovenous graft thrombosis and the thrombectomy procedure by the AngioJet system in terms of technical and clinical success and to identify factors influencing success. Methods: A total of 60 consecutive patients (35 men and 25 women; mean age = 52 ± 7.89 years) who had undergone percutaneous thrombectomy by the AngioJet device from 2016 to 2019 were retrospectively enrolled. Demographics and fistula data, previous treatments, time from clinical onset of thrombosis to intervention, procedural details and complications were recorded. Technical and clinical success and primary and secondary patency rates were calculated. One-way analysis of variance was performed to test any correlation between patient-related and fistula/procedure-related variables and technical/clinical success. Odds ratio and relative risk were also calculated when necessary. Results: Technical success and clinical success were 95% and 91.7%, respectively. Post-interventional primary and secondary patency rates at 1 year were 72.5% and 84.3%, respectively. Complication rate was 6.7%. One-way analysis of variance showed that clinical success was higher in patients with no previous treatment (p = 0.015). Furthermore, clinical success was significantly associated with door to angiographic bed time (p = 0.002): p-value for the 24-h and the 72-h cut-off was 0.012 and 0.006, respectively. Conclusion: Percutaneous rheolytic thrombectomy is safe and effective for thrombosed arteriovenous grafts, with acceptable primary and secondary patency rates. Higher clinical success was found in patients never treated before and when the procedure was carried out within 24 h from the clinical onset of thrombosis.

This is an illustrated case about CT ventilation and perfusion in Covid patient.

Background The herniation of the ureter into the inguinal canal is a rare condition, but probably underreported. Acquired nephroptosis could cause herniation of the ureter and, therefore, when diagnosed, a full study of the urinary tract should be performed especially in patients with inguinal hernia. Case presentation We present the case of an 86-year-old white man with a herniated ureter likely caused by acquired nephroptosis presenting with acute urinary retention, documented with magnetic resonance imaging for the first time. Conclusions The Fast Imaging Employing Steady State Acquisition sequence on magnetic resonance imaging, for many reasons, could allow correct evaluation of the urinary tract, especially in cases of renal dysfunction that contraindicate the use of intravenous contrast agents.

OBJECTIVES Arteriovenous malformations (AVM) are the most troublesome vascular malformations to deal with. They tend to behave like low-grade malignancies with infiltrative and disruptive growth. Crucially, the clinical course of an AVM that has been improperly managed is usually characterized by a recurrence that is much more aggressive than the original disease. As in oncology, a comprehensive staging system is highly desirable and is to date lacking in the literature. The authors present a new comprehensive staging system. METHODS A multicentric multidisciplinary team of experts in the field of vascular anomalies has created this new staging system. The SECg staging system defines the local extension of the disease (S1-S4), the vascular architecture of the malformation (E1, E2, E3), the severity of the symptoms (C0-C3) and the presence or absence of growth of the AVM (g+, g-). RESULTS This staging system allows to address all the aspects of AVMs and, more importantly, to help building an appropriate, individualized treatment plan for affected patients. After being staged an AVM can be defined as (a) healable, (b) healable with predicted sequelae, or (c) unhealable. Then, the SECg system allows to outline (a) absolute indications, (b) relative indications, and (c) no indications for treatment. The purpose of the treatment (radical, palliative) is furthermore taken into consideration. CONCLUSIONS This multicentric, the SECg staging system that this multidisciplinary group of Authors has defined allows for a comprehensive staging of the disease which in turn has enabled to outline an algorithm to properly manage AVMs.

Computed tomography (CT), magnetic resonance imaging (MRI), and 18-fluorideoxyglucose positron emission tomography (18FDG-PET) are historically the most accurate imaging techniques for diagnosing liver metastases. Recently, the combination of diffusion-weighted imaging and hepatospecific contrast media, such as gadoxetic acid in MRI, have been demonstrated to have the highest diagnostic accuracy, sensitivity, and specificity for detecting liver metastases. Various recent meta-analyses have confirmed the diagnostic superiority of this combination (diffusion-weighted imaging and gadoxetic acid-enhanced MRI), especially in terms of per lesion sensitivity, as compared with CT and 18FDG-PET, even for smaller lesions (≤1 cm). However, none of the oncological guidelines have suggested the use of MRI as a first-line technique for liver metastasis detection during the staging process of oncological patients. This review analyzes the history of the principal imaging techniques for the diagnosis of liver metastases, in particular of colorectal liver metastases, focusing on the most accurate method (diffusion-weighted imaging combined with gadoxetic acid-enhanced MRI), possible reasons for the lack of its diffusion in the guidelines, and possible future scenarios.

Paragangliomas (PGLs) are catecholamine-secreting neoplasms of chromaffin cells and represent a rare but curable cause of secondary hypertension. Surgery is the treatment of choice for symptomatic PGLs. A small (7 mm) extra-adrenal PGL was diagnosed in the right retroperitoneal space in a 19-year-old patient affected by symptomatic hypertension unresponsive to medical treatment. Indication to percutaneous radiofrequency ablation (RFA) was given by a multidisciplinary team on the basis of the size of the nodule, the surgical risks, the young age of the patient, and his wish to reduce as much as possible the post-interventional rehabilitation. To our knowledge, the use of percutaneous RFA in the treatment of retroperitoneal extra-adrenal primary paragangliomas has never been described. We describe its feasibility and the patient's clinical outcome.

Pancreatico-duodenectomy (PD) represents the standard surgical treatment for resectable malignancies of the pancreatic head, distal common bile duct, periampullary region and duodenum, and is also performed to manage selected benign tumours and refractory chronic pancreatitis. Despite improved surgical techniques and acceptable mortality, PD remains a technically demanding, high-risk operation burdened with high morbidity (complication rates 40–50% of patients). Multidetector computed tomography (CT) represents the mainstay modality to rapidly investigate the postoperative abdomen, and to provide a consistent basis for an appropriate choice between conservative, interventional or surgical treatment. However, radiologists require familiarity with the surgically altered anatomy, awareness of expected imaging appearances and possible complications to correctly interpret early post-PD CT studies. This paper provides an overview of surgical indications and techniques, discusses risk factors and clinical manifestations of the usual postsurgical complications, and suggests appropriate techniques and indications for early postoperative CT imaging. Afterwards, the usual, normal early post-PD CT findings are presented, including transient fluid, pneumobilia, delayed gastric emptying, identification of pancreatic gland remnant and of surgical anastomoses. Finally, several imaging examples review the most common and some unusual complications such as pancreatic fistula, bile leaks, abscesses, intraluminal and extraluminal haemorrhage, and acute pancreatitis. • Pancreatico-duodenectomy (PD) is a technically demanding surgery burdened with high morbidity (40–50%). • Multidetector CT is the mainstay technique to investigate suspected complications following PD. • Interpreting post-PD CT requires knowledge of surgically altered anatomy and expected findings. • CT showing collection at surgical site supports clinico-biological diagnosis of pancreatic fistula. • Other complications include biliary leaks, haemorrhage, abscesses and venous thrombosis.

The number and complexity of endovascular procedures performed via either arterial or venous access are steadily increasing. Albeit associated with higher morbidity compared to the radial approach, the traditional common femoral artery remains the preferred access site in a variety of cardiac, aortic, oncologic and peripheral vascular procedures. Both transarterial and venous cannulation (for electrophysiology, intravenous laser ablation and central catheterisation) at the groin may result in potentially severe vascular access site complications (VASC). Furthermore, vascular and soft-tissue groin infections may develop after untreated VASC or secondarily to non-sterile injections for recreational drug use. VASC and groin infections require rapid diagnosis and appropriate treatment to avoid further, potentially devastating harm. Whereas in the past colour Doppler ultrasound was generally used, in recent years cardiologists, vascular surgeons and interventional radiologists increasingly rely on pelvic and femoral CT angiography. Despite drawbacks of ionising radiation and the need for intravenous contrast, multidetector CT rapidly and consistently provides a panoramic, comprehensive visualisation, which is crucial for correct choice between conservative, endovascular and surgical management. This paper aims to provide radiologists with an increased familiarity with iatrogenic and self-inflicted VASC and infections at the groin by presenting examples of haematomas, active bleeding, pseudoaneurysms, arterial occlusion, arterio-venous fistula, endovenous heat-induced thrombosis, septic thrombophlebitis, soft-tissue infections at the groin, and late sequelae of venous injuries. Teaching Points • Complications may develop after femoral arterial or venous access for interventional procedures. • Arterial injuries include bleeding, pseudoaneurysm, occlusion, arteriovenous fistula, dissection. • Endovenous heat-induced thrombosis is a specific form of iatrogenic venous complication. • Iatrogenic infections include groin cellulitis, abscesses and septic thrombophlebitis. • CT angiography reliably triages vascular access site complications and groin infections.

Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm (AAA), occurring in less than 1% of all AAAs. Paradoxical embolism can rarely be associated with ACF, pulmonary embolism may originate from dislodgment of thrombotic material from the AAA in the inferior vena cava (IVC) through the ACF. We report a case of a patient admitted to the emergency department with abdominal pain and shortness of breath who immediately underwent thoraco-abdominal CT. Imaging allowed a prompt pre-operative diagnosis of an ACF between an AAA and the IVC, also identifying CT signs of right heart overload and the presence of a paradoxical pulmonary embolism.

To evaluate outcomes of uterine conserving surgery with occlusion balloon technique. A critical review of the complications was performed. Between 2010 and 2016, pregnant women, with a prenatal diagnosis of morbidly adherent placenta (MAP), were treated with occlusion balloon catheters in both internal iliac arteries. Parameters such as need for hysterectomy, incidence of PPH, grade of MAP, estimated blood loss during delivery (EBL) and transfusion requirements, mean recovery time and duration of the balloon inflation, were collected and reviewed. Complications requiring further management were analysed. Thirty-seven women with MAP underwent prophylactic occlusion balloon placement (POBC). Mean recovery was 4.48 days (range 2–10). Catheters were successfully positioned and balloons inflated in obstetric theatre following caesarean delivery in 100% of the cases. The uterus was conserved in every case. The MAP grades were 20 percreta, 3 increta and 14 accreta. The EBL was not statistically different between the different grades of placentation. There was a statistically significant association in the number of patients requiring blood transfusions and the degree of placental invasion (p = 0. 0119). PPH occurred in 5 patients (13.5%) and arterial thrombosis in 4 patients (11%). The EBL during delivery was significantly higher (2811 mL) in patients with complications (p = 0.0102). Furthermore, the group of patients that had complications required statistically significant more blood transfusions compared to those without complications (p = 0.0001). No maternal mortality or foetal morbidity occurred. The utilisation of Prophylactic occlusion balloon catheters allows uterine conserving surgery to be performed safely with few maternal complications.