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Abstract The aim of the article is to introduce a new term in post-procedural events related to the procedure itself. All the Societies and Councils report these events as complications and they are divided in mild, moderate and severe or immediate and delayed. On the other hand the term error is known as the application of a wrong plan, or strategy to achieve a goal. For the first time, we are trying to introduce the term “consequence”; assuming that the procedure is the only available and the best fit to clinical indication, a consequence should be seen as an expected and unavoidable occurrence of an “adverse event” despite correct technical execution.

Dual-Energy computed tomography (DECT) with its various advanced techniques, including Virtual Non-Contrast (VNC), effective atomic number (Z-eff) calculation, Z-maps, Iodine Density Index (IDI), and so on, holds great promise in the diagnosis and management of urogenital tumours. In this narrative review, we analyze the current status of knowledge of this technology to provide better lesion characterization, improve the staging accuracy, and give more precise treatment response assessments in relation to urological tumours.

The management of trauma and emergency procedures (i.e., aneurysm repair, visceral and pelvic bleeding, and others) has undergone considerable changes due to the presence of new endovascular and mini-invasive approaches, which have supplanted the surgical approach in some cases. The use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) has been largely used to manage trauma patients, but it is, nowadays, increasingly also being used for other types of bleeding, such as vascular emergencies, post-partum hemorrhages, and gastrointestinal and iatrogenic or spontaneous bleeding. We present a case of an unexpected hemorrhagic shock in a patient with a locally advanced cervix neoplasm involving sacrum and pelvic vessels, where we used a REBOA to manage an intraprocedural massive bleed due to the rupture of the descending branch of the right hypogastric artery.

Background: Traumatic pelvic injuries are associated with high injury severity scores and significant morbidity and mortality. Active bleeding is the most common cause of death among those patients. Due to limitations of surgery for pelvic hematomas, angiographic treatment is at the forefront of pelvic trauma management. Objective: The present article aims to discuss the available endovascular treatment modalities, and common angiographic treatment strategies and techniques. Conclusion: Interventional radiologists plays a key role in the management of patients with pelvic trauma. New standardized protocols are needed to minimize the time spent on deciding the correct treatment for each patient.

Benign Prostatic Hyperplasia (BPH) is the most frequent cause of Lower Urinary Tract Symptoms (LUTSs) in elderly populations. Minimally invasive treatments of BPH are safe and effective and are gaining popularity among both professionals and patients. Prostate Artery Embolization (PAE) has proven to be effective in Trans-Urethral Resection of the Prostate (TURP) in terms of prostate volume reduction and LUTS relief. PAE entails the selective catheterization of the prostatic artery and later embolization of distal vessels with beads of various calibers. Universal consensus regarding the ideal particle size is yet to be defined. We retrospectively evaluated 24 consecutive patients (median age: 75 years; range: 59–86 years) treated with PAE at our institution from October 2015 to November 2022. Particles of different sizes were employed; 12 patients were treated with 40–120 µm particles, 5 with 100 µm, 5 with 100–300 µm and 2 with 250 µm. Technical success, defined as selective prostate artery catheterization and controlled release of embolizing beads, was achieved in all patients. Removal vs. retention of the urinary catheter at the first post-procedural urological visit was the main clinical objective. No major peri-procedural complications were recorded, with 56% of patients successfully removing the urinary catheter.

Computed tomography (CT)-guided lung biopsy is one of the oldest and most widely known minimally invasive percutaneous procedures. Despite being conceptually simple, this procedure needs to be performed rapidly and can be subject to meaningful complications that need to be managed properly. Therefore, knowledge of principles and techniques is required by every general or interventional radiologist who performs the procedure. This review aims to contain all the information that the operator needs to know before performing the procedure. The paper starts with the description of indications, devices, and types of percutaneous CT-guided lung biopsies, along with their reported results in the literature. Then, pre-procedural evaluation and the practical aspects to be considered during procedure (i.e., patient positioning and breathing) are discussed. The subsequent section is dedicated to complications, with their incidence, risk factors, and the evidence-based measures necessary to both prevent or manage them; special attention is given to pneumothorax and hemorrhage. After conventional CT, this review describes other available CT modalities, including CT fluoroscopy and cone-beam CT. At the end, more advanced techniques, which are already used in clinical practice, like fusion imaging, are included.

The liver is the second most common solid organ injured in blunt and penetrating abdominal trauma. Non-operative management (NOM) has become the standard of care for liver injuries in stable patients, where transarterial embolization (TAE) represents the main treatment, increasing success rates and avoiding invasive surgical procedures. In hemodynamically (HD) unstable patients, operative management (OM) is the standard of care. To date, there are no consensus guidelines about the endovascular treatment of patients with HD instability or in ones that responded to initial infusion therapy. A review of the literature was performed for published papers addressing the outcome of using TAE as the primary treatment for HD unstable/transient responder trauma liver patients with hemorrhagic vascular lesions, both as a single treatment and in combination with surgical treatment, focusing additionally on the different definitions used in the literature of unstable and transient responder patients. Our review demonstrated a good outcome in HD unstable/transient responder liver trauma patients treated with TAE but there still remains much debate about the definition of unstable and transient responder patients.

Tumor ablation is included in several major cancer therapy guidelines. One technical challenge of percutaneous ablation is targeting and verification of complete treatment, which is prone to operator variabilities and human imperfections and are directly related to successful outcomes, risk for residual unablated tumor and local progression. The use of “Prediction Ablation Volume Software” may help the operating Interventional Radiologist to better plan, deliver, and verify before the ablation, via virtual treatment zones fused to target tumor. Fused and superimposed images provide 3-dimensional information from different timepoints, just when that information is most useful. The aim of this study is to evaluate the technical success and efficacy of an ablation treatment flowchart provided by a cone beam computed tomography (CBCT) “Prediction Ablation Volume Software.” This is a single-center retrospective study. From April 2021 to January 2022, 29 nonconsecutive evaluable patients with 32 lesions underwent liver ablation with Prediction Ablation Volume Software. Each patient was discussed in a multidisciplinary tumor board and underwent an enhanced computed tomography or magnetic resonance imaging approximately 1 month before the procedure, as well as ∼1 month after. Technical success was defined as treatment of the tumor according to the protocol, covered completely by the Prediction Ablation Volume. Technical efficacy was defined as assessment of complete ablation of the target tumor at imaging follow up (∼1 month). Technical success, technical efficacy, and procedural factors were studied. Technical success was achieved in 30 of 32 liver lesions (94%), measuring 20 mm mean maximum diameter. The antenna was repositioned in 16 of 30 (53%) evaluable target lesions. Residual tumor was detected at 1 month imaging follow up in only 4 of 30 (13%) of the treated lesion. Technical efficacy was of 87% in this retrospective description of our process. The implementation of a CBCT Prediction Ablation Volume Software and flowchart for the treatment of liver malignancies altered the procedure, and demonstrated high technical success and efficacy. Such tools are potentially useful for procedural prediction and verification of ablation.

Objective The aim of this study is to evaluate the feasibility, safety, and short-term effectiveness of a high-power (150 W) microwave ablation (MWA) device for tumor ablation in the lung, liver, and kidney. Methods Between December 2021 and June 2022, patients underwent high-power MWA for liver, lung, and kidney tumors. A retrospective observational study was conducted in accordance with the Declaration of Helsinki. The MWA system utilized a 150-W, 2.45-GHz microwave generator (Emprint™ HP Ablation System, Medtronic). The study assessed technical success, safety, and effectiveness, considering pre- and post-treatment diameter and volume, lesion location, biopsy and/or cone beam computed tomography (CBCT) usage, MWA ablation time, MWA power, and dose-area product (DAP). Results From December 2021 to June 2022, 16 patients were enrolled for high-power MWA. Treated lesions included hepatocellular carcinoma (10), liver metastasis from colon cancer (1), liver metastasis from pancreatic cancer (1), squamous cell lung carcinoma (2), renal cell carcinoma (1), and renal oncocytoma (1). Technical success rate was 100%. One grade 1 complication (6.25%) was reported according to CIRSE classification. Overall effectiveness was 92.8%. Pre- and post-treatment mean diameters for liver lesions were 19.9 mm and 37.5 mm, respectively; for kidney lesions, 34 mm and 35 mm; for lung lesions, 29.5 mm and 31.5 mm. Pre- and post-treatment mean volumes for liver lesions were 3.4 ml and 24 ml, respectively; for kidney lesions, 8.2 ml and 20.5 ml; for lung lesions, 10.2 ml and 32.7 ml. The mean ablation time was 48 minutes for liver, 42.5 minutes for lung, and 42.5 minutes for renal ablation. The mean DAP for all procedures was 40.83 Gcm 2 . Conclusion This preliminary study demonstrates the feasibility, safety, and effectiveness of the new 150 W MWA device. Additionally, it shows reduced ablation times for large lesions.

Purpose The aim of this study was to describe the safety and efficacy profiles of TACE using DC Beads LUMI. Materials and methods We retrospectively analyzed 90 patients with HCC who underwent TACE with DC Bead LUMI™ between November 2018 and November 2020 at Fondazione IRCCS Cà Granda Policlinico Hospital in Milan, Italy. Patient- and tumour-related factors were registered, including the number of treated lesions, dose of DC Beads LUMI™, dose of Epirubicin, DC Beads LUMI™ target tumour coverage (LC) according to the percentage of target nodule involvement (LC1-0%–25%, LC2-25%–50%, LC3-50%–75%, LC4 75%–100%). Treatment efficacy was obtained through reviewing the follow-up imaging for evidence of response in target lesion(s), according to modified response criteria in solid tumours (mRECIST) criteria with the following outcomes: complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD). Safety assessment was based on the quantitative and qualitative recording of the adverse events, classified according to CIRSE classification. Results Seventy-two patients were enrolled, and 95 procedures were carried out. We observed a target tumour response rate at 1 month with CR in 68%, PR in 10.3% 11.8%, SD in 13%, PD in 7.2%, and an overall tumour(s) (whole liver) response at 1 month with CR in 58.9%, PR in 12.6%, SD in 10.5% and PD in 18%. We found a significant association ( p

Background: Percutaneous Microwave Ablation (MWA) of lung malignancies is a procedure with many technical challenges, among them the risk of residual disease. Recently, dedicated software able to predict the volume of the ablated area was introduced. Cone-beam computed tomography (CBCT) is the imaging guidance of choice for pulmonary ablation in our institution. The volumetric prediction software (VPS) has been installed and used in combination with CBCT to check the correct position of the device. Our study aimed to compare the results of MWA of pulmonary tumours performed using CBCT with and without VPS. Methods: We retrospectively reviewed 1-month follow-up enhanced contrast-enhanced computed tomography (CECT) scans of 10 patients who underwent ablation with the assistance of VPS (group 1) and of 10 patients who were treated without the assistance of VPS (group 2). All patients were treated for curative purposes, the maximum axial diameter of lesions ranged between 5 and 22 mm in group 1 and between 5 and 25 mm in group 2. We compared the presence of residual disease between the two groups. Results: In group 1 residual disease was seen in only 1 patient (10%) in which VPS had ensured complete coverage of the tumour. In group 2 residual disease was found in 3 patients (30%). Conclusions: Using this software during MWA of lung malignancies could improve the efficacy of the treatment compared to the conventional only CBCT guidance.

This review is a brief overview of the current status and the potential role of robotics in interventional radiology. Literature published in the last decades, with an emphasis on the last 5 years, was reviewed and the technical developments in robotics and navigational systems using CT-, MR- and US-image guidance were analyzed. Potential benefits and disadvantages of their current and future use were evaluated. The role of fusion imaging modalities and artificial intelligence was analyzed in both percutaneous and endovascular procedures. A few hundred articles describing results of single or several systems were included in our analysis.

Introduction: The purpose of this study is to evaluate the diagnostic value of positron emission computed tomography-cone beam computed tomography (PET/CT-CBCT) fusion guided percutaneous biopsy, targeted to the maximum standardized uptake value (SUVmax) and minimum standardized uptake value (SUVmin) of large lung lesions. Materials and Methods: Inside a larger cohort of PET/CT-CBCT guided percutaneous lung biopsies, 10 patients with large pulmonary lesions (diameter > 30 mm) were selected retrospectively. These patients have been subjected to double biopsy sampling respectively in the SUVmax area and in the SUVmin area of the lesion. Technical success has been calculated. For each sample, the percentage of neoplastic, inflammatory, and fibrotic cells was reported. Furthermore, the possibility of performing immunohistochemical or molecular biology investigations to specifically define the biomolecular tumor profile was analyzed. Results: Nine lesions were found to be malignant, one benign (inflammation). Technical success was 100% (10/10) in the SUVmax samples and 70% (7/10) in the SUVmin samples ( P-value: .21 ). In the first group, higher percentages of neoplastic cells were found at pathologic evaluation, while in the second group areas of inflammation and fibrosis were more represented. The biomolecular profile was obtained in 100% of cases (9/9) of the first group, while in the second group only in 33.3% of cases (2/6), with a statistically significant difference between the 2 groups ( P-value: .011 ). Conclusion: A correlation between the standardized uptake value value and the technical success of the biopsy sample has been identified. PET/CT-CBCT guidance allows to target the biopsy in the areas of the tumor which are richer in neoplastic cells, thus obtaining more useful information for the planning of patient-tailored cancer treatments.

Purpose: to evaluate the clinical impact of a protocol for the image-guided percutaneous microwave ablation (MWA) of hepatocellular carcinoma (HCC) that includes cone-beam computed tomography (CBCT), fusion imaging and ablation volume prediction in patients with hepatocellular carcinoma unsuitable for standard ultrasound (US) guidance. Materials and Methods: this study included all patients with HCC treated with MWA between January 2021 and June 2022 in a tertiary institution. Patients were divided into two groups: Group A, treated following the protocol, and Group B, treated with standard ultrasound (US) guidance. Follow-up images were reviewed to assess residual disease (RD), local tumor progression (LTP) and intrahepatic distant recurrence (IDR). Ablation response at 1 month was also evaluated according to mRECIST. Baseline variables and outcomes were compared between the groups. For 1-month RD, propensity score weighting (PSW) was performed. Results: 80 consecutive patients with 101 HCCs treated with MWA were divided into two groups. Group A had 41 HCCs in 37 patients, and Group B had 60 HCCs in 43 patients. Among all baseline variables, the groups differed regarding their age (mean of 72 years in Group A and 64 years in Group B, respectively), new vs. residual tumor rates (48% Group A vs. 25% Group B, p < 0.05) and number of subcapsular tumors (56.7% Group B vs. 31.7% Group A, p < 0.05) and perivascular tumors (51.7% Group B vs. 17.1% Group A, p < 0.05). The protocol led to repositioning the antenna in 49% of cases. There was a significant difference in 1-month local response between the groups measured as the RD rate and mRECIST outcomes. LTP rates at 3 and 6 months, and IDR rates at 1, 3 and 6 months, showed no significant differences. Among all variables, logistic regression after PSW demonstrated a protective effect of the protocol against 1-month RD. Conclusions: The use of CBCT, fusion imaging and ablation volume prediction during percutaneous MWA of HCCs provided a better 1-month tumor local control. Further studies with a larger population and longer follow-up are needed.

Pancreatic ductal adenocarcinoma (PDAC) is a cancer with one of the highest mortality rates in the world. Several studies have been conductedusing preclinical experiments in mice to find new therapeutic strategies. Experimental ultrasound, in expert hands, is a safe, multifaceted, and relatively not-expensive device that helps researchers in several ways. In this systematic review, we propose a summary of the applications of ultrasonography in a preclinical mouse model of PDAC. Eighty-eight studies met our inclusion criteria. The included studies could be divided into seven main topics: ultrasound in pancreatic cancer diagnosis and progression (n: 21); dynamic contrast-enhanced ultrasound (DCE-US) (n: 5); microbubble ultra-sound-mediated drug delivery; focused ultrasound (n: 23); sonodynamic therapy (SDT) (n: 7); harmonic motion elastography (HME) and shear wave elastography (SWE) (n: 6); ultrasound-guided procedures (n: 9). In six cases, the articles fit into two or more sections. In conclusion, ultrasound can be a really useful, eclectic, and ductile tool in different diagnostic areas, not only regarding diagnosis but also in therapy, pharmacological and interventional treatment, and follow-up. All these multiple possibilities of use certainly represent a good starting point for the effective and wide use of murine ultrasonography in the study and comprehensive evaluation of pancreatic cancer.

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

Chronic mesenteric ischemia (CMI) arises from the inability to achieve adequate intestinal blood flow after meals, leading to an imbalance between oxygen and metabolite supply and demand. The true incidence of CMI remains uncertain. However, the occurrence of mesenteric artery occlusive disease (MAOD) is relatively common among the elderly population. Delays in diagnosing CMI can often be attributed to several factors, including the variability in patient symptoms and the range of potential causes for chronic abdominal pain with weight loss. Mikkelson pioneered the introduction of a surgical treatment for occlusive lesions of the superior mesenteric artery (SMA) in 1957. The inaugural performance of endovascular revascularization (ER) for visceral vessels took place in 1980. The literature has documented two types of endovascular revascularization (ER) methods: percutaneous transluminal angioplasty (PTA) and primary stenting (PMAS). Despite the limited quality of available evidence, the consensus among experts is strongly in favor of PMAS over PTA alone for the treatment of atherosclerotic mesenteric artery stenosis. There are several key areas of focus for chronic mesenteric ischemia (CMI) treatment. Randomized controlled trials comparing different stent types, such as covered stents versus bare metal stents, are needed to evaluate efficacy, patency rates, and long-term outcomes in CMI patients.

Purpose: The present study aims to evaluate the effectiveness and safety of the anti-reflux microcatheter during DEB-TACE with DC Bead LUMITM (radiopaque beads) for the treatment of hepatocellular carcinoma (HCC). Methods: We performed an observational longitudinal prospective monocentric study to analyze all patients with HCC who underwent to DEB-TACE with DC Bead LUMITM and anti-reflux microcatheter. Technical success, the presence of residual disease, and clinical success were evaluated. The performance of the anti-reflux microcatheter on the basis of the percentage of tumor covered and the non-target embolization (NTE) was also evaluated. Results: Twenty patients underwent DEB-TACE with DC Bead LUMITM and an anti-reflux microcatheter. Technical success was achieved in all cases. Residual disease in the target tumor was observed in 11/20 (55%) of cases and no residual disease was found in 9/20 (45%) of cases. The clinical response at 1-month follow-up was of PD 4/20 (20%), SD 7/20 (35%), and CR 9/20 (45%). No major complications were recorded, and 10% of cases had minor complications. The distribution of beads on post-procedural CBCT, classified according to the percentage of target nodule coverage, was ≥50% in 70% (14/20) of cases and between 30–50% in 30% of cases (6/20). NTE was never registered.

Purpose Percutaneous ablative treatments in the kidney are now standard options for local cancer therapy. Multimodality image guidance, combining two 3D image sets, may improve procedural images and interventional strategies. We aimed to assess the value of intra-procedural cone beam computed tomography (CBCT) with magnetic resonance (MR) or CT imaging fusion technique in the guidance of percutaneous microwave ablation (MWA) of renal neoplasms. Materials and methods Fifteen patients (eight males, seven females, median age 65 years, median lesion size 20 mm) underwent percutaneous MWA for 15 renal tumors. All the procedures were performed in a dedicated angiography room setting; CBCT ablation planning capabilities included multimodality image fusion. Preoperative contrast-enhanced CT was available in 12 patients, whereas magnetic resonance imaging in the remaining. All patients were considered inoperable due to comorbidities, advanced age, and/or refusal to undergo surgery. Exclusion criteria were: tumors visible at unenhanced CBCT, metastatic disease, and uncorrected coagulopathy. Technical success and technical effectiveness were calculated. Procedural time, complications and recurrences were registered. Results MWA under CBCT-guidance with fusion technique was technically successful in 14 out of 15 cases (93%). The median procedural time was 45 min. No procedure-related complications were reported. No enhancing tissue was visualized in the area of ablation at 1-month follow-up. All 15 cases were recurrence-free at last follow-up assessment (median follow-up of 12 months); no cancer-specific deaths were registered. Conclusion CBCT-CT/MR image fusion is technically feasible and safe in achieving correct targeting and complete ablation of renal lesions. This approach bears the potential to overcome most of the limitations of unenhanced CBCT guidance alone; larger series are needed to validate this technique.

Breast cancer (BC) is the most frequently diagnosed malignancy among women. In the past two decades, new technologies and BC screening have led to the diagnosis of smaller and earlier-stage BC (ESBC). Therefore, percutaneous minimally invasive techniques (PMIT) were adopted to treat patients unfit for surgery, women who refuse it, or elderly patients with comorbidities that could make surgery a difficult and life-threatening treatment. The target of PMIT is small-size ESBC with the scope of obtaining similar efficacy as surgery. Minimally invasive treatments are convenient alternatives with promising effectiveness, lower morbidity, less cost, less scarring and pain, and more satisfying cosmetic results. Ablative techniques used in BC are cryoablation, radiofrequency ablation, microwave ablation, high-intensity focused ultrasound (US), and laser ablation. The aim of our study is to discuss the current status of percutaneous management of BC, evaluate the clinical outcomes of PMIT in BC, and analyze future perspectives regarding ablation therapy in BC.

Background: Visceral pseudoaneurysms (PSAs) are usually treated endovascularly. No official guidelines exist regarding the correct management when this management option fails. The aim of this study is to assess the efficacy and safety of percutaneous imaging guided puncture of visceral PSAs in patients where intra-arterial embolization was unsuccessful or unfeasible. Methods: Five patients with visceral artery pseudoaneurysms (VAPAs) were enrolled in the study. The diagnosis was made using a 64-slice multi-detector computed tomography (MDCT) scanner and all patients were previously considered unsuitable for the procedure or underwent the procedure unsuccessfully; all patients had anemia with hemoglobin loss greater than 2 g/dL in the last 24 hours. A 22-gauge Chiba needle was used to get percutaneous access to the lesion, where N-butyl cyanoacrylate (NBCA) and lipiodol or coils and onyx were subsequently injected. Results: Four patients received a mixture of NBCA and lipiodol in a 1:2 ratio (80%, n = 4), and only one participant received coils and onyx. Primary clinical success was 100% and embolization was not repeated in any cases. No life-threatening secondary conditions or major complications were observed throughout the follow-up period; in one patient an asymptomatic embolic agent migration was reported. Secondary clinical success was also obtained in the current study. None of the remaining four participants experienced re-bleeding episodes or any procedure-related problems. Conclusions: Percutaneous embolization of visceral PSAs is a safe and effective treatment alternative that should be considered when the trans-arterial method cannot be used.

Imaging-guided percutaneous ablative treatments, such as radiofrequency ablation (RFA), cryoablation and microwave ablation (MWA), have been developed for the treatment of unresectable primary and secondary lung tumors in patients with advanced-stage disease or comorbidities contraindicating surgery. Among these therapies, MWA has recently shown promising results in the treatment of pulmonary neoplasms. The potential advantages of MWA over RFA include faster ablation times, higher intra-tumoral temperatures, larger ablation zones and lower susceptibility to the heat sink effect, resulting in greater efficacy in proximity to vascular structures. Despite encouraging results supporting its efficacy, there is a relative paucity of data in the literature regarding the role of computer tomography (CT) to monitor MWA-treated lesions, and the CT appearance of their morphologic evolution and complications. For both interventional and non-interventional radiologists, it is crucial to be familiar with the CT features of such treated lesions in order to detect incomplete therapy or recurrent disease at early stage, as well as to recognize initial signs of complications. The aim of this pictorial essay is to describe the typical CT features during follow-up of lung lesions treated with percutaneous MWA and how to interpret and differentiate them from other radiological findings, such as recurrence and complications, that are commonly encountered in this setting.

Despite the advances made in treatment, the prognosis of pancreatic ductal adenocarcinoma (PDAC) remains dismal, even in the locoregional and locally advanced stages, with high relapse rates after surgery. PDAC exhibits a chemoresistant and immunosuppressive phenotype, and the tumor microenvironment (TME) surrounding cancer cells actively participates in creating a stromal barrier to chemotherapy and an immunosuppressive environment. Recently, there has been an increasing use of interventional radiology techniques for the treatment of PDAC, although they do not represent a standard of care and are not included in clinical guidelines. Local approaches such as radiation therapy, hyperthermia, microwave or radiofrequency ablation, irreversible electroporation and high-intensity focused ultrasound exert their action on the tumor tissue, altering the composition and structure of TME and potentially enhancing the action of chemotherapy. Moreover, their action can increase antigen release and presentation with T-cell activation and reduction tumor-induced immune suppression. This review summarizes the current evidence on locoregional therapies in PDAC and their effect on remodeling TME to make it more susceptible to the action of antitumor agents.

Percutaneous image-guided thermal ablation is included in most society guidelines for treatment of hepatocellular carcinoma (HCC). The results of this treatment in terms of efficacy depend on the ability to precisely place the device into the target tumor. Ultrasound (US) is a commonly used imaging guidance modality for its real-time feedback. However, an accurate device deployment remains challenging in some clinical scenarios, including cases of tumors that are undetectable or not clearly visible by US. To overcome this problem, fusion imaging techniques have been developed, which combine images from different modalities. The most widely known technique combines pre-procedural contrast-enhanced computed tomography (CT) or magnetic resonance imaging (MRI) with real-time US scans. Cone beam CT (CBCT) is a technology that can provide intra-procedural cross-sectional images, which can be registered to images from other modalities, including preprocedural CT/MR scans. The aim of our study is to report the preliminary experience on percutaneous microwave ablation (MWA) of patients with HCC that were treated using the “double fusion“ technique, which combines the use of US fusion imaging and CBCT fusion imaging. We describe the technical details, feasibility, safety and short-term efficacy of this technique in a small series of eight patients with 11 HCCs.

Abstract Trauma accounts for a third of the deaths in Western countries, exceeded only by cardiovascular disease and cancer. The high risk of massive bleeding, which depends not only on the type of fractures, but also on the severity of any associated parenchymal injuries, makes pelvic fractures one of the most life-threatening skeletal injuries, with a high mortality rate. Therefore, pelvic trauma represents an important condition to correctly and early recognize, manage, and treat. For this reason, a multidisciplinary approach involving trauma surgeons, orthopedic surgeons, emergency room physicians and interventional radiologists is needed to promptly manage the resuscitation of pelvic trauma patients and ensure the best outcomes, both in terms of time and costs. Over the years, the role of interventional radiology in the management of patient bleeding due to pelvic trauma has been increasing. However, the current guidelines on the management of these patients do not adequately reflect or address the varied nature of injuries faced by the interventional radiologist. In fact, in the therapeutic algorithm of these patients, after the word “ANGIO”, there are no reports on the different possibilities that an interventional radiologist has to face during the procedure. Furthermore, variations exist in the techniques and materials for performing angioembolization in bleeding patients with pelvic trauma. Due to these differences, the outcomes differ among different published series. This article has the aim to review the recent literature on optimal imaging assessment and management of pelvic trauma, defining the role of the interventional radiologist within the multidisciplinary team, suggesting the introduction of common and unequivocal terminology in every step of the angiographic procedure. Moreover, according to these suggestions, the present paper tries to expand the previously drafted algorithm exploring the role of the interventional radiologist in pelvic trauma, especially given the multidisciplinary setting.

Rapid-paced development and adaptability of artificial intelligence algorithms have secured their almost ubiquitous presence in the field of oncological imaging. Artificial intelligence models have been created for a variety of tasks, including risk stratification, automated detection and segmentation of lesions, characterization, grading and staging, prediction of prognosis, and treatment response. Soon, artificial intelligence could become an essential part of every step of oncological workup and patient management. Integration of neural networks and deep learning into radiological artificial intelligence algorithms allow for extrapolating imaging features otherwise inaccessible to human operators and pave the way to truly personalized management of oncological patients. Although a significant proportion of currently available artificial intelligence solutions belong to basic and translational cancer imaging research, their progressive transfer to clinical routine is imminent, contributing to the development of a personalized approach in oncology. We thereby review the main applications of artificial intelligence in oncological imaging, describe the example of their successful integration into research and clinical practice, and highlight the challenges and future perspectives that will shape the field of oncological radiology.

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

The purpose of this bicentric case series was to report the safety, efficacy, and clinical outcome of transcatheter embolization in pulmonary artery pseudoaneurysms (PAPAs). Between January 2016 and June 2021, eight patients with PAPA were subjected to transcatheter embolization. The total number of patients was eight, of which five were female, with a mean age of 62 ± 14 years (average ± standard deviation). Etiology was traumatic in 2/8 cases and iatrogenic in 6/8 cases (after positioning a Swan-Ganz catheter in 5/6 cases and a temporary pacemaker in the latter case). In a single case, the PAPA was incidentally discovered during a routine X-ray, in the remaining 7 cases, the procedure was performed in emergency settings. PAPA embolization was performed using detachable coils alone in 3 cases; coils and glue in 1 case; coils, glue, and vascular plug in 1 case; coils and non-adhesive liquid embolic agents (Onyx and Squid respectively) in 2 cases; and non-adhesive liquid embolic agent alone (Onyx) in 1 case. No peri-procedural or post-procedural complications were recorded. Both the technical and clinical success rates were 100.0%. In conclusion, endovascular embolization is a technically feasible and safe therapeutic option for patients with PAPAs.

Abstract 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.

PURPOSEChest 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.METHODSA 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.RESULTSFifty-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.CONCLUSIONChest 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.

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.

PURPOSEWe aimed to evaluate the safety and effectiveness of percutaneous sclerotherapy using gelified ethanol in patients with low-flow malformations (LFMs).METHODSA retrospective study was performed, analyzing treatment and outcome data of 6 patients that presented with 7 LFMs (3 lymphatic and 3 venous). Median diameter of LFMs was 6 cm (interquartile range [IQR], 4.5–8.5 cm). Data regarding pain, functional and/or cosmetic issues were assessed. Diagnosis was performed clinically and confirmed by Doppler ultrasound, while extension of disease was assessed by magnetic resonance imaging (MRI). Percutaneous puncture was performed with 23G needle directly or with ultrasound guidance. All the LFMs were treated with gelified ethanol injection. The median volume injected per treatment session was 4.4 mL.RESULTSTechnical and clinical success were obtained in all cases. No recurrences were recorded during a median follow up of 17 months (IQR, 12–19 months). Among the 6 patients, 5 had complete relief (83%) and one showed improvement of symptoms. The median VAS score was 7 (IQR, 6–7.5) before and 0 (IQR, 0–0) after treatment. All patients had functional and esthetic improvement (100%). Four patients (66.7%) revealed very good acceptance and two patients (33.3%) good acceptance. No major complications or systemic side effects were observed.CONCLUSIONGelified ethanol percutaneous sclerotherapy was easy to handle, well-tolerated, safe and effective in the short-term follow-up. Longer follow-up of efficacy is mandatory for further conclusions.

Pancreatic surgery still remains burdened by high levels of morbidity and mortality with a relevant incidence of complications, even in high volume centers. This review highlights the interventional radiological management of complications after pancreatic surgery. The current literature regarding the percutaneous drainage of fluid collections due to pancreatic fistulas, percutaneous transhepatic biliary drainage due to biliary leaks and transcatheter embolization (or stent–graft) due to arterial bleeding is analyzed. Moreover, also, percutaneous intra-portal islet auto-transplantation for the prevention of pancreatogenic diabetes in case of extended pancreatic resection is also examined. Moreover, a topic not usually treated in other similar reviewsas percutaneous intra-portal islet auto-transplantation for the prevention of pancreatogenic diabetes in case of extended pancreatic resection is also one of our areas of focus. In islet auto-transplantation, the patient is simultaneously donor and recipient. Differently from islet allo-transplantation, it does not require immunosuppression, has no risk of rejection and is usually efficient with a small number of transplanted islets.

Abstract 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.

Background: The aim of the present study is to determine the feasibility of biopsy for atypical liver nodules in patients under surveillance for hepatocellular carcinoma (HCC), assessing which factors influence the decision to perform it. Methods: A total of 128 atypical liver nodules in 108 patients under surveillance for HCC, who underwent CT between September 2018 and September 2019, were included. All the images were saved digitally (on CD-ROM) and the two most representative images in the arterial and delayed phases were selected for each lesion and inserted into a digital atlas (on PDF). Two experienced radiologists (Readers 1 and 2) reviewed both the CD-ROM and the PDF to define the feasibility of biopsy in both scenarios, specifying the reasons for the unfeasibility of biopsy. The intra-observer variability and inter-observer variability were assessed. Results: When reviewing the PDF, 76 (59.4%) and 68 (53.1%) nodules were deemed unfeasible for biopsy by the less experienced radiologist (Reader 1) and the more experienced radiologist (Reader 2), respectively (p = 0.604). When reviewing the entire CT study, both percentages decreased slightly (Reader 1 = 70/128 (54.7%); Reader 2 = 61/128 (47.6%); p = 0.591). The intra-reader agreement on the PDF was substantial (k = 0.648 (95% CI = 0.513–0.783)). The inter-reader agreement on the PDF was slight (k = 0.185 (95% CI = 0.021–0.348)) and moderate on the entire CT study (k = 0.424 (95% CI = 0.269–0.579)). When assessing the PDF, the nodule size (10–20 mm) and location in segments six and eight were negatively and positively associated with the feasibility of liver biopsy, respectively. When assessing the CD-ROM, only the nodule dimension was associated with the unfeasibility of liver biopsy. Conclusions: The unfeasibility of liver biopsy is mainly due to the small size of the lesions and their location.

Visceral artery pseudoaneurysms (VAPAs) are the most frequently diagnosed pseudoaneurysms (PSAs). PSAs can be asymptomatic or symptomatic. The aim of our study was to evaluate the safety and effectiveness of percutaneous embolization of VAPAs performed on patients with an unfeasible trans-arterial approach. Fifteen patients with fifteen visceral PSAs, with a median dimension of 21 mm (IQR 20–24 mm), were retrospectively analyzed. No patients were suitable for trans-arterial catheterization and therefore a percutaneous approach was chosen. During percutaneous treatments, two embolic agents were used, either N-butyl cyanoacrylate (NBCA) (Glubran II, GEM Milan, Italy) mixed with Lipiodol (Lipiodol, Guerbet, France) or thrombin. The outcomes of this study were technical success, primary clinical success, and secondary clinical success. In our population the 15 PSA were located as follows: 2 in the left gastric artery, 1 in the right gastric artery, 3 in the right hepatic artery, 2 in a jejunal artery, 1 in left colic artery branch, 1 in a right colic artery branch, 1 in the gastroepiploic artery, 1 in the dorsal pancreatic artery, 1 in an ileocolic artery branch, 1 in an iliac artery branch, and 1 in a sigmoid artery branch. 80% of PSAs (12/15) were treated with a NBCA:lipiodol mixture and 20% of PSAs (3/15) were treated with thrombin. Technical, primary, and secondary clinical successes were obtained in 100% of the cases. No harmful or life-threatening complications were observed. Minor complications were registered in 26.6% (4/15) of the patients. Percutaneous embolization of visceral PSA is a safe and effective treatment and should be considered as an option when the endovascular approach is unsuccessful or unfeasible.

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.

Abstract Performed on either an elective or urgent basis, cholecystectomy currently represents the most common abdominal operation due to the widespread use of laparoscopy and the progressively expanded indications. Compared to traditional open surgery, laparoscopic cholecystectomy minimised the duration of hospitalisation and perioperative mortality. Albeit generally considered safe, cholecystectomy may result in adverse outcomes with non-negligible morbidity. Furthermore, the incidence of worrisome haemorrhages and biliary complications has not been influenced by the technique shift. Due to the growing medico-legal concerns and the vast number of cholecystectomies, radiologists are increasingly requested to investigate recently operated patients. Aiming to increase familiarity with post-cholecystectomy cross-sectional imaging, this paper provides a brief overview of indications and surgical techniques and illustrates the expected early postoperative imaging findings. Afterwards, most iatrogenic complications following open, converted, laparoscopic and laparo-endoscopic rendezvous cholecystectomy are reviewed with examples, including infections, haematoma and active bleeding, residual choledocholithiasis, pancreatitis, biliary obstruction and leakage. Multidetector computed tomography (CT) represents the “workhorse” modality to rapidly investigate the postoperative abdomen in order to provide a reliable basis for an appropriate choice between conservative, interventional or surgical treatment. Emphasis is placed on the role of early magnetic resonance cholangiopancreatography (MRCP) and additional gadoxetic acid-enhanced MRCP to provide a non-invasive anatomic and functional assessment of the operated biliary tract. Teaching Points • Having minimised perioperative mortality and hospital stay, laparoscopy has now become the first-line approach to performing cholecystectomy, even in patients with acute cholecystitis. • Laparoscopic, laparo-endoscopic rendezvous, converted and open cholecystectomy remain associated with non-negligible morbidity, including surgical site infections, haemorrhage, residual lithiasis, pancreatitis, biliary obstruction and leakage. • Contrast-enhanced multidetector computed tomography (CT) is increasingly requested early after cholecystectomy and represents the “workhorse” modality that rapidly provides a comprehensive assessment of the operated biliary tract and abdomen. • Magnetic resonance cholangiopancreatography (MRCP) is the best modality to provide anatomic visualisation of the operated biliary tract and is indicated when biliary complications are suspected. • Additional gadoxetic acid (Gd-EOB-DTPA)-enhanced MRCP non-invasively provides functional biliary assessment, in order to confirm and visualise bile leakage.

The aim of this study was to evaluate the usefulness of superb microvascular imaging (SMI) versus contrast-enhanced ultrasound (CEUS) and compared to computed tomography angiography (CTA) as a reference standard, for detection of type II endoleak during follow-up of endovascular abdominal aortic aneurysm repair (EVAR). Between April 2017 and September 2020, 122 patients underwent post-EVAR follow-up with CTA at 3 months and with ultrasound SMI and CEUS at 4 months from the EVAR procedure. Aneurysmal sac diameter and graft patency were evaluated; endoleaks were assessed and classified. Sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy were calculated both for SMI and CEUS and compared to CTA. Furthermore, the percentage of agreement and Cohen’s Kappa coefficient were calculated. CTA revealed 54 type II endoleaks. Ultrasound SMI and CEUS presented the same sensitivity (91.5%), specificity (100%), positive (100%), and negative (92.8%) predictive and accuracy (95.9%) value for detecting type II endoleak. The same percentage of agreement of 94.9% was found between SMI/CEUS, and CTA with a Cohen’s Kappa coefficient of 0.89. The diagnostic accuracy of SMI is comparable with CEUS in the identification of type II endoleaks after EVAR. Since SMI is less invasive, less expensive, and less time-consuming, this method may be considered to be a potential tool for monitoring patients after EVAR implantation.

Background: Our aim was to assess the safety and efficacy of transcatheter embolization in the treatment of post-partum bleedings. Methods: In a single institution, the outcome of 15 patients who underwent transarterial embolization (TAE) for post-partum hemorrhages (PPH) were retrospectively reviewed. Eleven patients presented with hemodynamic instability requiring blood transfusion (73%) and four patients were hemodynamically stable (27%). Arterial embolization was performed with gelatin sponge, particles, and coils. Results: Mean follow-up time was 21.2 months (range 12–48 months). Technical success rate was 100%. The overall clinical success rate was 100%. No major complications that required intensive care treatment were registered during or after the procedures. No patient required emergency surgery and subsequent hysterectomy. During follow-up, four patients became pregnant after transcatheter arterial embolization and delivered full-term, healthy infants. Conclusions: TAE is a safe method that allows for the avoidance of surgery and hysterectomy for uncontrollable PPH; a future normal pregnancy after embolization may be hypothesized.

It is imperative to ensure the safety of health-care workers in the angiographic room during the outbreak of the coronavirus disease 2019 (COVID-19). The selection criteria for interventional radiology (IR) procedures, the preparation of the staff and angiographic suite, ventilation systems, and intra- and post-procedural workflow optimization methods are detailed. The specific measures needed to protect occupational safety and health may result in higher costs, longer procedural times, and greater technical problems. However, these precautions may help to minimize the spread of COVID-19 among IR practitioners.

Glue and Onyx are two liquid embolic agents. They have different characteristics and applications, so it is essential to know how to choose between them. The main aims of this article are to describe the principles and features of these embolic agents, to highlight the advantages and limitations of both the materials, and to provide optimal indications of each agent during endovascular arterial embolization procedures.

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

Abstract 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. Teaching Points • 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.

Abstract 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.

Image-guided locoregional therapies (LRTs) are a crucial asset in the treatment of hepatocellular carcinoma (HCC), which has proven to be characterized by an impaired antitumor immune status. LRTs not only directly destroy tumor cells but also have an immunomodulating role, altering the tumor microenvironment with potential systemic effects. Nevertheless, the immune activation against HCC induced by LRTs is not strong enough on its own to generate a systemic significant antitumor response, and it is incapable of preventing tumor recurrence. Currently, there is great interest in the possibility of combining LRTs with immunotherapy for HCC, as this combination may result in a mutually beneficial and synergistic relationship. On the one hand, immunotherapy could amplify and prolong the antitumoral immune response of LRTs, reducing recurrence cases and improving outcome. On the other hand, LTRs counteract the typical immunosuppressive HCC microenvironment and status and could therefore enhance the efficacy of immunotherapy. Here, after reviewing the current therapeutic options for HCC, we focus on LRTs, describing for each of them the technique and data on its effect on the immune system. Then, we describe the current status of immunotherapy and finally report the recently published and ongoing clinical studies testing this combination.