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We describe the use of ultrasound-guided high-intensity focused ultrasound (HIFU) for ablation of two pancreatic neuroendocrine tumours (NETs; insulinomas) in two inoperable young female patients. Both suffered from episodes of severe nightly hypoglycemia that was not efficiently controlled by medical treatment. After HIFU ablation, local disease control and symptom relief were achieved without postinterventional complications. The patients remained free of symptoms during 9-month follow-up. The lesions appeared to be decreased in volume, and there was decreased enhancing pattern in the multidetector computed tomography control (MDCT). HIFU is likely to be a valid alternative for symptoms control in patients with pancreatic NETs. However, currently the procedure should be reserved for inoperable patients for whom symptoms cannot be controlled by medical therapy. [ABSTRACT FROM AUTHOR]

The purpose of this study was to compare the clinical effectiveness of expanded polytetrafluoroethylene/fluorinated-ethylene-propylene (ePTFE/FEP)-covered stents with that of uncovered nitinol stents for the palliation of malignant jaundice caused by inoperable pancreatic head cancer. Eighty patients were enrolled in a prospective randomized study. Bare nitinol stents were used in half of the patients, and ePTFE/FEP-covered stents were used in the remaining patients. Patency, survival, complications, and mean cost were calculated in both groups. Mean patency was 166.0 ± 13.11 days for the bare-stent group and 234.0 ± 20.87 days for the covered-stent group (p = 0.007). Primary patency rates at 3, 6, and 12 months were 77.5, 69.8, and 69.8% for the bare-stent group and 97.5, 92.2, and 87.6% for the covered-stent group, respectively. Mean secondary patency was 123.7 ± 22.5 days for the bare-stent group and 130.3 ± 21.4 days for the covered-stent group. Tumour ingrowth occurred exclusively in the bare-stent group in 27.5% of cases (p = 0.002). Median survival was 203.2 ± 11.8 days for the bare-stent group and 247.0 ± 20 days for the covered-stent group (p = 0.06). Complications and mean cost were similar in both groups. Regarding primary patency and ingrowth rate, ePTFE/FEP-covered stents have shown to be significantly superior to bare nitinol stents for the palliation of malignant jaundice caused by inoperable pancreatic head cancer and pose comparable cost and complications. Use of a covered stent does not significantly influence overall survival rate; nevertheless, the covered endoprosthesis seems to offer result in fewer reinterventions and better quality of patient life. [ABSTRACT FROM AUTHOR]

The purpose of this study is to report on the feasibility, local response, and 1-year clinical outcome of bland transarterial embolization (TAE) with 40- and 100-mum Embozene microspheres in patients affected by unresectable hepatocellular carcinoma (HCC). Up to January 2009, 53 patients underwent superselective TAE for a total of 74 lesions. Diagnosis of HCC was based on multidetector computed tomography (MDCT), alpha-fetoprotein, and biopsy. MDCT was performed 24 after treatment and repeated at 1 month, 3 months, and then every 6 months. Local efficacy was defined according to RECIST criteria. Technical success was always achieved. Local results at 1-month, 3- to 6-month, and 6- to 12-month follow-up were 62%, 37%, and 16%, respectively, for stable disease and 35%, 56%, and 51%, respectively, for partial response. Complete response (no evidence of lesion) has been observed only at late follow-up (three lesions; 7%). To date, 20 of 53 patients have had at least 1 year of follow-up, with an overall survival rate of 96%. Hepatic progressive disease (i.e., new nodules) was observed in 14 of 20 patients due to underlying liver disease. Minor complications were observed in four patients. A major complication occurred in one patient, who died unexpectedly 24 h after TAE due to pulmonary embolism of necrotic pathologic tissue and passage of particles through a disrupted hepatic vein. Local results as well as 1-year clinical outcome after TAE with Embozene microspheres are veryly encouraging, however, further studies, a larger patient population, and a longer follow-up are mandatory to assess the real clinical impact. [ABSTRACT FROM AUTHOR]

To evaluate the efficacy and safety of an expanded polytetrafluoroethylene-fluorinated ethylene-propylene (ePTFE/FEP)-covered metallic stent in the management of malignant biliary obstruction. Eighty consecutive patients with malignant common bile duct strictures were treated by placement of 83 covered metallic stents. The stent-graft consists of an inner ePTFE/FEP lining and an outer supporting structure of nitinol wire. Clinical evaluation, assessment of serum bilirubin and liver enzyme levels were analyzed before biliary drainage, before stent-graft placement and during the follow-up period at 1, 3, 6, 9 and 12 months. Technical success was obtained in all cases. After a mean follow-up of 6.9+/-4.63 months, the 30-day mortality rate was 14.2%. Survival rates were 40% and 20.2% at 6 and 12 months, respectively. Stent-graft patency rates were 95.5%, 92.6% and 85.7% at 3, 6 and 12 months, respectively. Complications occurred in five patients (6.4%); among these, acute cholecystitis was observed in three patients (3.8%). A stent-graft occlusion rate of 9% was observed. The percentage of patients undergoing lifetime palliation (91%) and the midterm patency rate suggest that placement of this ePTFE/FEP-covered stent-graft is safe and highly effective in achieving biliary drainage in patients with malignant strictures of the common bile duct. [ABSTRACT FROM AUTHOR]

Bariatric surgery may sometimes be challenging and may lead to severe complications. Surgical re-intervention in such cases is not the preferred option due to co-morbidities. When severe bleeding occurs, embolization of the lacerated vessels is the preferred minimal invasive management option and needs to be available if possible. We would like to report a case of young patient who underwent severe bleeding after migration of a gastric band. The patient was successfully embolized and the band was removed. However, on the second post-operative day, the patient complained again for acute abdominal pain and turned haemodynamically unstable. Fresh blood was aspirated from the surgical drain. A new emergency CT scan was performed and a new large pseudoaneurysm was revealed taking origin from the left gastric artery. The second bleeding occurred due to an anastomotic communication and was also successfully embolized. The main take home messages are that bariatric surgery may lead to several complications including bleeding, gastric band may cause vessel erosion but also offer a tamponade effect, endovascular embolization of the lacerated vessels is the preferred management and pseudoaneurysms arising in hepato-splenic or gastroduodenal arteries should be treated with the sandwich embolization technique., (© 2024. Japanese Society of Gastroenterology.)

Pulmonary embolism (PE) is a significant contributor to global cardiovascular-related mortality that mainly depends on the severity of the event. The treatment approach for intermediate and high-risk PE remains a topic of debate due to the fine balance between hemodynamic deterioration and bleeding risk. The initial treatment choice for intermediate-risk PE with hemodynamic deterioration and high-risk PE is historically systemic thrombolysis, but this approach is not always effective and carries a notable risk of severe bleeding. For such patients, various interventional treatments have been introduced to clinical practice, including catheter-directed lysis (CDL), ultrasound-assisted CDL, pharmacomechanical CDL, and aspiration thrombectomy. However, the optimal treatment approach remains uncertain. Encouraging outcomes have been presented assessing the novel endovascular treatments, in terms of reducing right ventricular dysfunction and improving hemodynamic stability, opening the possibility of using these devices to prevent hemodynamic instability in less severe cases. However, ongoing randomized trials that assess the efficacy and the association with mortality, especially for aspiration devices, have not yet published their final results. This article aims to offer a comprehensive update of the available catheter-directed therapies for PE, with a focus on novel mechanical thrombectomy techniques, assessing their safety and efficacy, after comparison to the conventional treatment. CRITICAL RELEVANCE STATEMENT: This is a comprehensive review of the indications of use, techniques, and clinical outcomes of the most novel endovascular devices for the treatment of pulmonary embolism. KEY POINTS: Mechanical thrombectomy is an effective tool for patients with PE. Aspiration devices prevent hemodynamic deterioration. Catheter directed therapy reduces bleeding complications., (© 2024. The Author(s).)

Purpose: We aimed to compare the diagnostic yield and procedure-related complications of two different types of systems for percutaneous CT-guided lung biopsy., Material and Methods: All patients with a lung lesion who underwent a CT-guided lung biopsy at our institution, between January 2019 and 2021, were retrospectively analyzed. The inclusion criteria were: (a) Procedures performed using either a fully automated tru-cut or a semi-automated full-core biopsy needle, (b) CT images demonstrating the position of the needles within the lesion, (c) histopathological result of the biopsy and (d) clinical follow-up for at least 12 months and\or surgical histopathological results. A total of 400 biopsy fulfilling the inclusion criteria were selected and enrolled in the study., Results: Overall technical success was 100% and diagnostic accuracy was 84%. Tru-cut needles showed a significantly higher diagnostic accuracy when compared to full-core needles (91% vs. 77%, p = 0.0004) and a lower rate of pneumothorax (31% vs. 41%, p = 0.047). Due to the statistically significant different of nodules size between the two groups, we reiterated the statistical analysis splitting our population around the 20 mm cut-off for nodule size. We still observed a significant difference in diagnostic accuracy between tru-cut and full-core needles favoring the former for both smaller and larger lesions (81% vs. 71%, p = 0.025; and 92% vs. 81%; p = 0.01, respectively)., Conclusion: Our results demonstrated that the use of automated tru-cut needles is associated with higher histopathological diagnostic accuracy compared to semi-automated full-core needles for CTLB., (© 2024. The Author(s).)

Objectives: To investigate whether lesion imaging features may condition the outcome of CT-guided lung biopsy (CTLB) and to develop a scoring system of biopsy outcome prediction., Methods: This is a single center retrospective study on 319 CTLBs that were performed in 319 patients (167 males/152 females, mean age 68 ± 12.2). Uni- and multivariate analysis were performed aiming to assess the imaging features that are likely to be correlated to a negative biopsy outcome and patients were stratified in groups accordingly., Results: Technical success was 100%. 78% of the biopsies (250/319) led to a concrete histology report (218 malignant/32 benign). The remaining lesions led to concrete histology at a second attempt that occurred on a later time. Multivariate analysis revealed increased risk of inconclusive result for nodules with low fludeoxyglucose uptake [odds ration (OR) = 2.64, 95% confidence interval (CI) 1.4-4.97; p = 0.003], for nodules with diameter smaller than 18 mm (OR = 2.03, 95% CI 1.14-3.62; p = 0.017) and for nodules that are located in one of the lung bases (OR = 1.96, 95% CI 1.06-3.62; p = 0.033). Three different groups of patients were identified accordingly with low (<30%), medium (30-50%) and high (>50%) probability of obtaining an inconclusive biopsy sample., Conclusion: This study confirms that percutaneous CT-guided biopsy in nodules that are either small in diameter or present low positron emission tomography-fludeoxyglucose uptake or are in one of the lung bases may lead to inconclusive histology. This information should be factored when planning percutaneous biopsies of such nodules in terms of patient informed consent and biopsy strategy., Advances in Knowledge: Inconclusive histology after lung biopsy may be subject to factors irrelevant to technical success. Lung biopsy histology outcomes may be predicted and avoided after adequate planning.

Endovascular management of small visceral artery aneurysms is an established treatment with satisfactory outcomes. However, when size exceeds 5 cm visceral aneurysms are considered as "giant" (giant visceral artery aneurysms or GVAAs) and management is significantly more complex. Between August 2007 and June 2019 eleven cases of GVAAs that were endovascularly treated were retrospectively reviewed and included in this single center study. Mean size was 80 mm (± 26.3 mm) x 46 mm (+ \-11.8 mm). Nine of the lesions were true aneurysms, and two were pseudoaneurysms. In 8 patients, the lesion was causing compression symptoms in the surrounding organs, one patient developed a contained rupture while 2 patients were completely asymptomatic. However, all patients were hemodynamically stable at the time of treatment. Technical success was defined as immediate complete exclusion of the aneurysmal sac, and clinical success as complete relief from clinical symptoms. Follow-up was performed with CT angiography, ultrasound and clinical examination. Mean follow-up was 45 months (range 6-84). Technical and clinical success were both 91%. Complications were one lack of control of contained rupture that was subsequently operated, one case of self-limiting non-target spleen embolization and one case of splenic abscess. Three patients died, one due to the contained rupture 15 days after procedure, the other two for other causes and occurred during the long-term follow-up. This series suggests that endovascular treatment of giant visceral artery aneurysms and pseudoaneuryms is a valid minimally invasive solution with very satisfactory immediate and long-term outcomes unless the aneurysm is already ruptured. A variety of endovascular tools may be required for successful treatment.

Purpose: To retrospectively assess the efficacy and safety of FemoSeal ® vascular closure device to achieve hemostasis following antegrade common femoral artery puncture after lower limb revascularization using vascular sheaths from 5 to 8 Fr., Methods: We reviewed the hemostatic outcome achieved with FemoSeal in 103 consecutive patients (mean age: 69 ± 8 years, 71 males) that undergone to 111 antegrade common femoral artery accesses for percutaneous lower limbs revascularization using 5- to 8-Fr vascular sheaths. We used FemoSeal in an unselected population, without exclusion criteria. The primary outcome was the technical success, meant as achieving complete hemostasis without immediate complications., Results: Hemostasis was achieved in all 111 puncture sites (100% technical success). We observed eight (7%) puncture site minor complications (hematomas), none of which affecting the patients' outcome or requiring further therapies or increasing the hospital stay. There were no statistically significant differences between the variables potentially related to the occurrence of complications (age, international normalized ratio, platelet count, partial thromboplastin time ratio, body mass index, and common femoral arteries calcification grade) in patients with and without complications. Complications group mean body mass index was 26.4 ± 2.8 kg/m 2 versus non-complications group 26.6 ± 4.4 kg/m 2 , p = 0.92. Mean international normalized ratio and partial thromboplastin time ratio were 1.05 ± 0.01 and 1.05 ± 0.14 versus 1.13 ± 0.2 (p = 0.39) and 1.12 ± 0.23 (p = 0.53), respectively. Common femoral arteries calcification grade was the same (mean: 1, p = 1). Platelet count was 202 × 10 3 /mL ± 66.7 versus 226 × 10 3 /mL ± 91.2, p = 0.55. Mean age was 72.3 ± 10 years versus 72.8 ± 8 years, p = 0.86., Conclusion: The low rate (7%) and grading of the adverse events, combined with the high technical success rate (100%), in an unselected group of patients treated in daily routine, suggest high safety and efficacy of FemoSeal vascular closure device in antegrade common femoral artery puncture site hemostasis when using vascular sheaths ranging from 5 to 8 Fr. Therefore, FemoSeal could be considered as a first-line hemostasis strategy in such cases.

The presence of endoleaks remains one of the main drawbacks of endovascular repair of abdominal aortic aneurysms leading to the increase of the size of the aneurysmal sac and in most of the cases to repeated interventions. A variety of devices and percutaneous techniques have been developed so far to prevent and treat this phenomenon, including sealing of the aneurysmal sac, endovascular embolisation, and direct sac puncture. The aim of this review is to analyse the indications, the effectiveness, and the future perspectives for the prevention and treatment of endoleaks after endovascular repair of abdominal aortic aneurysms.

The combination of percutaneous vertebroplasty with radiofrequency ablation (verteblation) has not shown to be an effective measure of pain management in patients with metastatic lesions of the spine. The use of this novel technique has not been previously described in metastatic disease from thyroid cancer. We would like to report our experience after treating a patient affected by a thyroid carcinoma and an osteolytic spine metastasis. The patient suffered from life-limiting pain and was successfully treated with a combination of vertebroplasty and radiofrequency ablation. This case shows that the indications of verteblation may be expanded in the palliative treatment of metastatic disease from thyroid carcinoma., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

A rare postoperative complication of aortic root replacement is pseudoaneurysm formation. Surgical repair may be rather challenging particularly in patients who are elder and with significant comorbidities. Endovascular approach may also be technically demanding, given the high blood velocity and the anatomical challenges of the area of the aortic root and the ascending aorta. We would like to describe a case of an 85-year-old patient with history of prosthetic graft aortic root replacement who had been developed a 7-cm pseudoaneurysm with sternotomy diastasis and extension in the subcutaneous tissue, 7 years after the initial operation. Given the comorbidities, open repair was not considered a valid option and successful endovascular repair with the use of a ventricular septal occluder plug followed. One-year follow-up confirmed satisfactory exclusion of the pseudoaneurysm with no migration of the endovascular device and no other complication. This is one of the rare cases on endovascular repair of an ascending aorta postoperative pseudoaneurysm.

Purpose: The safety of liquid embolics over the conventional coils for the treatment of non-variceal upper gastrointestinal bleeding (UGIB) approach is still unclear. Purpose of this study is to assess the safety of ethylene-vinyl alcohol copolymer (EVOH 6%) over coils in the treatment of UGIB., Materials and Methods: All the upper gastrointestinal tract embolization procedures performed in a single center in a 6-year period were reviewed. Patients embolised with coils (Group A) versus those embolised with EVOH 6% (Group B) were compared. Technical/clinical success, bleeding recurrence, complication and mortality rates were analyzed., Results: A total 71 patients were included in the study (41 Group A and 30 Group B). Coagulopathy was present in 21% of Group A and 46% of Group B patients (p < 0.05). Technical and clinical success was 97.6 and 92.7% for Group A, and 100 and 93.3% for Group B respectively, (p > 0.05). Ten patients (17% Group A; 10% Group B) re-bled within the first 36 h and all of them were re-treated successfully with a second embolization. In Group A one major complication (bowel ischemia) occurred. No complication occurred in Group B. The survival rate in the first 30 days was 90.3% for group A and 90% for group B (p > 0.05)., Conclusion: This study demonstrated EVOH 6% appears to be as safe and effective as coils in the treatment of non-variceal UGIB.

Background: Atherosclerosis is a multifactorial disease characterized by an immune-inflammatory remodeling of the arterial wall. Treg and Th17 subpopulations are detectable inside atherosclerotic plaque; however, their behavior in symptomatic carotid artery stenosis (CAS) is not fully elucidated. The aim of this study was to evaluate Th17 and Treg subsets and their ratio in patients affected by symptomatic and asymptomatic CAS., Methods: 14 patients with symptomatic CAS (CAS-S group), 41 patients with asymptomatic CAS (CAS-A group), 32 subjects with traditional cardiovascular risk factors (RF group), and 10 healthy subjects (HS group) were enrolled. Th17 and Treg frequency was determined by flow cytometry and by histology and immunohistochemistry. Interleukin (IL)-10, IL-17, and metalloproteinase (MMP)-12 levels were measured by ELISA., Results: Th17 were significantly increased in CAS-A versus RF and versus HS. Tregs were significantly increased in CAS-S versus CAS-A. Tregs/Th17 ratio was significantly reduced in CAS-A versus RF and versus HS, whereas it was significantly increased in CAS-S versus CAS-A., Conclusions: The results of this study suggest that Th17 are related to the late stages of CAS but not to plaque instability. Moreover, Treg expansion seems to represent a specific cellular pattern displayed by patients with symptomatic CAS and associated with brain injury. KEY MESSAGES Tregs expansion seems to represent a specific cellular pattern displayed by patients with symptomatic CAS and associated with CD4+ effector depletion and brain ischemic injury. Th17 lymphocytes are related to the late stages of CAS but not to plaque instability.

Introduction: The aim of this study is to analyze the safety and efficacy of stent-graft endovascular treatment for visceral artery aneurysms and pseudoaneurysms., Methods: Multicentric retrospective series of patients with visceral aneurysms and pseudoaneurysms treated by means of stent graft. The following variables were analyzed: Age, sex, type of lesion (aneurysms/pseudoaneurysms), localization, rate of success, intraprocedural and long term complication rate (SIR classification). Follow-up was performed under clinical and radiological assessment., Results: Twenty-five patients (16 men), with a mean age of 59 (range 27-79), were treated. The indication was aneurysm in 19 patients and pseudoaneurysms in 6. The localizations were: splenic artery (12), hepatic artery (5), renal artery (4), celiac trunk (3) and gastroduodenal artery (1). Successful treatment rate was 96% (24/25 patients). Intraprocedural complication rate was 12% (4% major; 8% minor). Complete occlusion was demonstrated during follow up (mean 33 months, range 6-72) in the 24 patients with technical success. Two stent migrations (2/24; 8%) and 4stent thrombosis (4/24; 16%) were detected. Mortality rate was 0%., Conclusion: In our study, stent-graft endovascular treatment of visceral aneurysmns and pseudoaneurysms has demonstrated to be safe and is effective in the long-term in both elective and emergent cases, with a high rate of successful treatment and a low complication rate., (Copyright © 2017 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Transradial access for percutaneous coronary and non-coronary intervention has gained worldwide acceptance. This approach has demonstrated less bleeding and vascular events with a reduced in-hospital stay, and an improvement in clinical outcomes when compared to the traditional transfemoral approach. However, this strategy may occasionally lead to severe catheter kinking and further manipulation may be required to unravel the catheter and avoid complication. Purpose of this review article is to present the current knowledge and evidence in preventing and potentially resolving issues related to radial access catheter knots.

Percutaneous embolization was introduced in the mid-'70s and is now an established therapeutic procedure in current medical practice. With the use of improved imaging techniques, smaller profile catheters and new tools, embolization boundaries are significantly expanded in the last decades. Detachable coils were initially introduced in neuroradiology and are now part of the everyday peripheral embolization armamentarium. Purpose of this review article is to present an overview of the expanded possibilities that this novel material is offering in the field of peripheral embolization procedures.

Objectives: To retrospectively evaluate safety and efficacy of pelvic artery embolisation (PAE) in post-partum haemorrhage (PPH) in abnormal placental implantation (API) deliveries., Methods: From January 2009 to November 2013, 12 patients with API and intractable intraoperative PPH underwent PAE after caesarean delivery to control a haemorrhage (in four of these cases after hysterectomy). Arterial access was obtained prior to the delivery; PAE was performed in the obstetrics operating room by an interventional radiologist that was present with an interventional radiology (IR) team during the delivery., Results: PAE was successful in preventing bleeding and avoid hysterectomy in four cases (group A). Uterine atony and disseminated intravascular coagulation caused failure of PAE requiring hysterectomy in four patients (group B). PAE prevented bleeding post-hysterectomy in the remaining four cases (group C). Technical success (cessation of contrast extravasation on angiography or occlusion of the selected artery) was 100 %. Maternal and foetal mortality and morbidity were 0 %., Conclusions: PAE is a minimal invasive technique that may help to prevent hysterectomy and control PPH in API pregnancies without complications. Embolisation should be performed on an emergency basis. For such cases, an IR team on standby in the obstetrics theatre may be useful to prevent hysterectomy, blood loss and limit morbidity., Key Points: • Endovascular treatment is a validated technique in post-partum haemorrhage. • Abnormal placental implantation is a risk factor for post-partum haemorrhage. • We propose an interventional radiologist standby in the delivery room.

Within the group of Gastro-Entero-Pancreatic Neuroendocrine tumours (GEP-NETs), several heterogeneous malignancies are included with a variety of clinical manifestations and imaging characteristics. Often these cases are inoperable and minimal invasive treatment offered by image-guided procedures appears to be the only option. Interventional radiology offers a valid solution in the management of primary and metastatic GEP-NETs. The purpose of this review article is to describe the current status of the role of Interventional Radiology in the management of GEP-NETs.

Hepatitis E virus (HEV) is the most important causative agent of acute hepatitis in developing countries. The disease is usually characterized by a self-limiting, benign course. However, when particular conditions coexist (pregnancy, old age, pre-existing liver disease) it may run an unfavourable course. To date, 4 HEV genotypes have been described. Historically, in the Western world, HEV infection was considered a travel-related disease, however in the last 2 decades a great number of non-travel-related autochthonous cases have been described, more often related to genotype 3 or 4 and in the context of zoonosis. We report the case of an elderly Italian man with an acute fulminant HEV infection genotype 3e that developed in the context of pre-existing liver disease; this is the first case of an unfavourable outcome associated with subgenotype 3e. The potential pathogenicity of this subgenotype together with the influence of host-related risk factors are discussed.

Background: Arteriovenous malformations (AVMs) are communications between an artery and a vein outside the capillary level. This pathologic communication may be either a fistula, a simple communication between a single artery and a dilated vein, or a more complex communication, a nidus of tortuous channels between one or more arteries/arterioles and one or more draining veins. The latter type of lesion is most frequently seen in the extremities; in the kidney they tend to appear more rarely. The most common clinical presentation of renal arteriovenous malformations (RAVMs) is haematuria. Percutaneous treatment with selective endovascular techniques offers a minimally invasive, nephron-sparing option in comparison to the more invasive surgical approaches. The purpose of this pictorial review is to highlight the general lines of management and to show the range of imaging findings of the percutaneous treatment of RAVMs., Methods: The imaging characteristics of a selection of cases of percutaneously managed congenital RAVMs are presented and the most common lines of approach are discussed., Conclusion: The imaging spectrum of diagnosis and percutaneous treatment of RAVMs is presented in order to aid interpretation and endovascular management., Teaching Points: • Renal arteriovenous malformations are very rare lesions. • Clinical expression is usually haematuria. • Diagnosis is made with CT or MRI but the gold standard is digital subtraction angiography. • Catheter-directed treatment with the use of coils or liquid embolics is minimally invasive, safe and effective.

Pancreatic adenocarcinoma is an aggressive tumour with an extremely poor prognosis, which has not changed significantly during the last 30 years. Prolonged survival is achieved only by R0 resection with macroscopic tumour clearance. However, the majority of the cases are considered inoperable at diagnosis due to local spread or presence of metastatic disease. Chemoradiotherapy is not tolerated by all patients and still fails to prolong survival significantly; neoadjuvant treatment also has limited results on pain control or tumour downstaging. In recent years, there has been a growing interest in the use of ablation therapy for the treatment of nonresectable tumours in various organs. Ablation techniques are based on direct application of chemical, thermal, or electrical energy to a tumour, which leads to cellular necrosis. With ablation, tumour cytoreduction, local control, and relief from symptoms are obtained in the majority of the patients. Inoperable cases of pancreatic adenocarcinoma have been treated by various ablation techniques in the last few years with promising results. The purpose of this review is to present the current status of local ablative therapies in the treatment of pancreatic adenocarcinoma and to investigate on the efficiency and the future trends.

Background: Renal artery aneurysm is a rare disorder with a high mortality rate in the event of rupture, the most frequent complication, which can also occur in lesions smaller than those indicated for treatment by current criteria. Surgery is still the first-line treatment, although a growing trend toward endovascular management of visceral artery aneurysms has emerged because of the high efficacy and low invasiveness that has been demonstrated by several authors. Treatment of wide-necked aneurysms and, depending on location, those at renal artery bifurcations or distal branches is more complex and may require invasive surgical techniques, such as bench surgery., Case Presentation: We describe the successful use of a new neurointerventional coil to treat an enlarging wide-necked segmental-branch renal aneurysm in an elderly woman who was not a candidate for surgery because of several comorbidities., Conclusions: The technique described allowed safe, successful treatment of a wide-necked aneurysm in an unfavorable vascular territory, reducing the risk of downstream artery embolization and consequent parenchymal damage and decreased renal function. In similar cases, other endovascular devices have often proven to be ineffective at nephron sparing. To validate the safety and efficacy of this system, more cases treated in this manner should be studied.

Purpose: This study was designed to investigate the added role of radiofrequency ablation (RFA) to vertebroplasty on the pain management of patients with multiple myeloma (MM)., Methods: Thirty-six patients (51-82 years) with vertebral localization of MM were randomly divided into two groups: 18 patients (group A) who underwent RFA and then vertebroplasty, and 18 patients (group B) who underwent only vertebroplasty. Primary endpoints were technical success and pain relief score rate measured by the visual analogue pain scores (VAS) and Roland-Morris Questionnaire (RMQ); secondary endpoint was the amount of administered analgesia. Survival and complications were compared., Results: Technical success was 100 % in both groups. The VAS score (at 24 h and 6 weeks postprocedure) decreased in equal manner for both groups from a mean of 9.1-3.4 and 2.0 for group A and from a mean of 9.3-3.0 and 2.3 for group B; RMQ mean score was 19.8 for group A and 19.9 for group B and decreased to a mean of 9.6 and 8.2 for group A and 9.5 and 8.7 for group B. The amount of medication was equally decreased in the two groups. No statistically significant difference was noted. No major complication occurred and two patients died from other causes., Conclusions: The use of percutaneous vertebroplasty alone appears to be effective for the pain management of the patients with vertebral involvement of multiple myeloma. The use of RFA that includes cost and time does not offer any clear added benefit on the midterm pain management of such patients.

Background: Benign biliary postoperative stenoses and biliary leaks and fistulas usually occur due to injury after laparoscopic cholecystectomy, gastric or hepatic resection, bilio-enteric anastomoses and after liver transplantation. In most of the cases a new surgical intervention is not possible and the percutaneous trans-hepatic approach is of paramount importance in the diagnosis and treatment of the problem. This review aims to highlight the spectrum of percutaneous cholangiographic findings and methods of treatment of postoperative benign biliary stenoses and biliary leaks and fistulas. In the case of stenosis, dilation of the narrow tract is the usually the first approach, whereas in the case of leaks and fistulas bile diversion with drainage is usually attempted in order to seal the fistulous tract. However, a great variety of combination of materials and techniques may be used on a "case-by case" approach, Methods: A selection of cases of benign biliary postoperative stenoses and biliary leaks and fistulas that were managed percutaneously are presented and the most common lines of approach are discussed., Conclusion: The imaging spectrum of percutaneous treatment of benign biliary postoperative stenoses and biliary leaks and fistulas is presented in order to aid interpretation and management with image guided procedures. TEACHING POINTS : • Treatment of benign biliary stenosis is performed with cholangioplasty and stents. • The main goal of fistula treatment is to divert the bile away from the site of bile wall defect. • Drain collection and tract embolisation are the other options for bile leak percutaneous treatment.

Objective: The aim of this study was to evaluate the safety and efficacy of ultrasound-guided high-intensity focused ultrasound therapeutic ablation of solid tumors in difficult locations., Subjects and Methods: A procedure was performed with a focused ultrasound tumor therapeutic system which provides real-time ultrasound guidance. All patients underwent MDCT or MRI, and some patients underwent PET/CT. From November 2007 through April 2009, 31 patients with 38 lesions of the liver and pancreas in difficult locations were treated. Six patients had hepatocellular carcinoma, 13 patients had hepatic metastasis from colorectal cancer, two had hepatic metastases of breast cancer, two had hepatic metastasis of neuroendocrine tumors, one patient had lymph node metastasis of breast cancer at the hepatic hilum, six patients had pancreatic cancer, and one patient had a neuroendocrine tumor. Difficult location was defined as tumor adjacent to a main blood vessel, the heart, the gallbladder and bile ducts, the bowel, or the stomach., Results: The mean diameter of tumors was 2.7 +/- 1.4 cm. PET/CT, MDCT, or both on the day after one session of high-intensity focused ultrasound treatment showed complete response in all six patients with hepatocellular carcinoma, the patient with lymph node metastasis, and 22 of 24 patients with hepatic metastasis. The symptoms of all seven patients with pancreatic caner or neuroendocrine tumors were palliated, and PET/CT or MRI showed complete response of six of seven lesions. Portal vein thrombosis occurred after high-intensity focused ultrasound ablation in one patient with pancreatic cancer. No other side effects were detected in a median follow-up period of 12 months., Conclusion: According to our short- and long-term follow-up results, ultrasound-guided high-intensity focused ultrasound ablation can be considered a safe and feasible approach to the management of solid tumors in difficult locations.

Purpose: To review the outcomes with the use of balloon-expandable covered iliac kissing stents as compared with bare metal stents in the treatment of atherosclerotic disease at the aortic bifurcation., Materials and Methods: A review of consecutive patients from a single institution with atherosclerotic occlusive disease at the aortic bifurcation treated with balloon-expandable kissing stents was performed between January 1, 2002, and September 1, 2007. Fifty-four patients were identified and divided into two groups: those with bare metal stents and those with covered stents. Technical and clinical success (Fontaine classification), complications, and patency at follow-up were documented., Results: Twenty-six patients (17 men, nine women; mean age, 61 years; age range, 39-79 years) received covered stents and 28 patients (15 men, 13 women; mean age, 61 years; age range, 38-82 years) received bare metal stents. Technical success was achieved in 100% of patients in both groups. Major complications occurred in three of the 26 (11%) with covered stents (P = .66) and two of the 28 patients (7%) with bare metal stents. The median follow-up was 21 months (20 months for covered stents vs 25 months for bare metal stents; range, 1-62 months). Twenty-two of the 26 patients (85%) with covered stents had sustained improvement in clinical symptoms during the follow-up period compared with 15 of the 28 patients (54%) with bare metal stents (P = .02). Primary patency rates at 1 and 2 years were 92% and 92%, respectively, for covered stents and 78% and 62% for bare metal stents (P = .023)., Conclusions: The use of covered balloon-expandable kissing stents for atherosclerotic aortic bifurcation occlusive disease provides superior patency at 2 years as compared with bare metal balloon-expandable stents., (Copyright 2010 SIR. Published by Elsevier Inc. All rights reserved.)