Endovascular management of fusiform renal artery aneurysm in a patient with refractory hypertension using hydrocoils and embospheres

We are reporting endovascular management of a renal artery aneurysm causing renal hypertension. The aneurysm by mass effect compressed the adjacent artery resulting in a hemodynamically significant stenosis. Endovascular management included embosphere embolization of the renal parenchyma distal to the stenosed segment and hydrocoil embolization of the aneurysm itself.     

Endovascular stenting of veins and grafts: preliminary clinical experience

Stenotic lesions of veins and bypass grafts are often difficult to dilate and have a high frequency of recurrence. In an effort to provide an endoluminal mechanical support, the new concept of transluminal vascular stenting was applied in four patients with stenoses of nonarterial vessels, including two with postoperative venous stenoses, one with a stenosed mesenteric artery graft anastomosis, and one with a long stenosis of the basilic vein distal to a hemodialysis shunt graft. All four were successfully treated with percutaneous transluminal angioplasty followed by endovascular stenting. All but one of the stented segments were patent, with no significant restenosis after a follow-up of 4 1/2-12 months. There have been previous reports of transluminal vascular stenting in the arterial system, and the preliminary results from this study suggest that endovascular stenting also may play an important role in the treatment of venous and graft stenoses. However, further follow-up and careful patient selection will have to be done to establish the long-term benefit of this new procedure.     

MRI-guided radiofrequency ablation of breast cancer: preliminary clinical experience

This study was designed to demonstrate the feasibility of MRI-guided radiofrequency ablation (RFA) of breast cancer. A total of three women diagnosed with invasive ductal breast cancer were treated with percutaneous MRI-guided RFA, according to a treat and resect protocol, in our hospital. RFA procedures were performed in an open 0.5T Signa-SP imager allowing direct patient access and real-time monitoring of the procedure. In all patients ablation was performed with a 15-gauge insulated MRI-compatible multiple needle probe. MRI thermometry and contrast-enhanced postablation MRI were used to evaluate the ablation process. Patients underwent lumpectomy within a week of the RFA procedure. Histopathology confirmed successful (100%) tumor ablation in one patient, and partial tumor destruction (33% and 50%, respectively) in two patients. Challenges of MRI-guided breast RFA that need to be solved to facilitate progress of the technique toward clinical practice are discussed.     

Percutaneous radiofrequency ablation of renal cell carcinoma: preliminary results

PURPOSE: To report early results in percutaneous radiofrequency ablation (RFA) of renal cell carcinoma with an expandable RF probe. MATERIAL AND METHODS: In 14 patients (9 male, mean age 67.9 +/- 9.9 years) CT-guided percutaneous radiofrequency ablation of 15 renal cell carcinomas was performed using an expandable LeVeen probe (diameter 2-4 cm) and a 200-watt generator under general anesthesia and CT control. Tumors exceeding a diameter of 3 cm (n=6) were embolized within 24 h prior to RFA. Average tumor size was 3.0 +/- 1.0 cm. RESULTS: RFA was technically successful in all patients, resulting in a mean size of necrosis of 3.7 +/- 0.7 cm. With the exception of one reno-cutaneous fistula, which was successfully treated conservatively, no major complications were observed. No local recurrence was observed (follow-up: 13.9 +/- 12.4 months) while extrarenal tumor progression occurred in four patients. CONCLUSION: Our preliminary data suggest that nephron sparing percutaneous RFA of renal tumors with an expandable RF probe is safe and effective.     

肾动脉主干加分支射频消融在难治性高血压治疗中的应用

【摘要】 目的 探讨肾动脉分支去神经化在经皮肾交感神经射频消融治疗难治性高血压中的应用。 方法 入选难治性高血压患者60例,完成肾动脉造影后随机分为单纯主支消融组、主支＋分支消融组,各30例。观察分析患者基本资料,手术相关参数（消融点数、温度、平均能量）,术前和术后2年诊室血压、动态血压等。 结果 两组患者年龄、伴发疾病、用药情况差异无统计学意义（P＞0.05）。主支＋分支消融组消融点数与单纯主支消融组相比呈显著增加趋势。两组患者术后诊室血压、动态血压均低于术前（P＜0.05）。术后3～12个月期间主支＋分支消融组诊室血压显著低于单纯主支消融组（P＜0.001）,但术后15～24个月期间两组差异无统计学意义（P＞0.05）。 结论 肾动脉主支＋分支消融术治疗难治性高血压安全有效,但远期随访中与单纯主支消融相比无明显优势。     

Ultrasound-guided percutaneous radiofrequency ablation in elderly breast cancer patients: preliminary institutional experience

Breast cancer is a major source of morbidity and mortality in the elderly population and the number of patients will increase by 30% in future decades. Surgery and endocrine therapy could be considered as the standard treatment in elderly breast cancer patients, but anaesthesia for surgery requires a specific approach taking into account physiological and psychological alterations secondary to ageing. In cases with major alterations of performance status, percutaneous radiofrequency ablation (RFA) could be substituted for the surgical treatment. The aim of the current study is to evaluate the efficacy and feasibility of this technique. Five tumours in four consecutive patients (aged 79-82 years) contraindicated for surgery with symptomatic cT1-2N0M0, positive oestrogen receptor status, low grade were treated by percutaneous radiofrequency-lump ablation under local analgesia, using percutaneous ultrasound guidance. Thermal lesions were produced with RF power 30 W, at a frequency of 500 kHz. Ultrasound-guided percutaneous biopsy of the RF treated breast was performed during the follow-up. We report a successful RFA lump ablation experience in the treatment of four tumours (4/5). One local recurrence occurred within 4 months after RFA. The other biopsies taken during the follow up showed all fat necrosis within the oil cyst and no malignant cells. One abscess occurred at 9 months within the treated area. After a mean follow up of 29.4 months, all the patients are still alive without any other signs of recurrence or metastases. Ultrasound-guided percutaneous RFA is safe and feasible in the management of breast cancer in elderly patients. Nevertheless, further large comparative studies are needed in order to validate such a minimally invasive procedure in current practice.     

Endovascular treatment of intracranial arterio-venous malformations with Onyx embolization: preliminary experience

PURPOSE: Intracranial arterio-venous malformations (AVM) often represent a complex clinical problem as regards indications to treatment, the choice of treatment and the technical difficulties related to treatment. In the last twenty years, endovascular treatment of intracranial arterio-venous malformations was primarily based on an acrylic glue (Hystoacril) whose endovascular use is not free from risks. A new product for endovascular embolization, named ONYX, has been recently been made commercially available. It is a bio-compatible liquid polymer that precipitates and solidifies in contact with blood, thus forming a soft and spongy embolus. The aim of this study was to evaluate our preliminary results in the endovascular embolization of intracranial AVM with Onyx. MATERIALS AND METHODS: Ten patients were treated (7 men, 3 women; mean age: 29 years, range: 12-48 years) for a total of 37 embolizations, 22 with Onyx and 15 with acrylic resin. RESULTS: Nidus occlusion was complete in 2 cases, >90% in 2 cases, >50 and <90% in 3 cases and <50% in the remaining 3 cases. The following complications were recorded: two transient and one mild permanent neurological deficits, two clinically silent cases of moderate subarachnoid haemorrhage, four catheters glued to the injection site, three cases of treatment discontinuation due to continuous and massive reflux of Onyx into the afferent artery peduncle. CONCLUSIONS: This early experience showed that while Onyx has good embolization potential it also presents some disadvantages, which need to be overcome before this product can be considered easy and safe to use on a large scale.     

Endovascular treatment of intracranial aneurysms with flow-diverter stents: preliminary single-centre experience

Purpose

This paper reports our preliminary experience with the endovascular treatment of intracranial aneurysms using flow-diverter stents (FDs) and compares it with the literature data.

Materials and methods

From May 2009 to April 2012, 28 patients (6 men and 22 women; mean age, 54 years) with a total of 35 aneurysms were treated with FDs. We evaluated postprocedural technical success and long-term efficacy, with follow-up examinations performed at 3–7 days [computed tomography (CT)/magnetic resonance (MR) angiography] and at 3, 6 and 12 months (digital subtraction angiography, DSA). A total of 43 FDs were placed, 36 Pipeline and 7 Silk.

Results

A total of 30 procedures were performed (two patients were treated twice). Technical success was 96.6%, with one case of postprocedural death; the aneurysm exclusion rate at 3, 6 and 12 months was 60%, 73% and 89%, respectively. There was no case of acute stent thrombosis, and only two cases of nonsignificant stenosis. All covered side branches were patent, except one case of steno-occlusion of the ophthalmic artery.

Conclusions

Our results are consistent with the literature and demonstrate the effectiveness and safety of FDs in selected cases of cerebral aneurysm (wide neck, fusiform, blister-like).     

肾交感神经导管消融术治疗难治性高血压临床研究进展

高血压是一个全球性问题,虽然现有的药物治疗取得了一定的成效,但其中的难治性高血压经正规药物治疗后,却仍然无法降至目标值。近年来,随着肾交感神经在高血压发病过程中的深入研究及导管技术的迅速发展,经皮肾动脉交感神经导管射频消融术治疗难治性高血压的尝试,为难治性高血压患者带来了新的疗法,本文就这一新兴技术的临床研究进展作一综述。     

MR angiography of lower-extremity arterial disease: preliminary experience.

Nineteen patients underwent magnetic resonance (MR) angiography for evaluation of lower-extremity arterial disease. The underlying conditions included atherosclerotic occlusive disease in 12 patients, femoral or popliteal aneurysms in four, and bypass graft stenoses or occlusion in four. In the patients with occlusive disease, the iliac and femoropopliteal vessels were classified as patent, moderately stenotic, severely stenotic, or occluded. Fifteen of 16 occlusions (accuracy = 94%) were correctly classified. In the one missed case, there was a long delay between MR angiography and x-ray angiography and it is likely that the occlusion occurred during the interval. Three of five severe stenoses were correctly classified with MR angiography. In two cases of iliac artery stenosis, there was a signal void at the point of maximal stenosis, which on the basis of anatomic features could be recognized as severe stenosis rather than an occlusion. Three of four moderate stenoses were correctly classified. Correlation with x-ray angiography or surgery demonstrated the ability of MR angiography to accurately depict the status of runoff vessels.     

Endovascular management of iatrogenic renal arterial lesions and clinical outcomes

PURPOSE

We aimed to evaluate iatrogenic renal arterial lesions, including pseudoaneurysm, arteriovenous fistula, and arteriocaliceal fistula, their management by endovascular embolization, and the clinical results.

METHODS

Fifty-five patients (forty males, fifteen females) with a median age of 40 years (range, 8–85 years), who underwent endovascular embolization of iatrogenic renal arterial lesions between March 2003 and December 2013 were included in this retrospective study. Types of iatrogenic lesions and details of embolization procedures were reported. Estimated glomerular filtration rate (eGFR), renal function tests, hemoglobin, and hematocrit levels before and after embolization were recorded and compared.

RESULTS

Median follow-up was 24 months. We identified 53 pseudoaneurysms, 30 arteriovenous fistulas, and 11 arteriocaliceal fistulas in 55 patients, after percutaneous nephrolithotomy (n=26), renal biopsy (n=21), nephrostomy (n=3), renal surgery (n=3), and extracorporeal shock wave lithotripsy (n=2). Median number of pseudoaneurysms was 1 (range, 1–4) with a median size of 7 mm (range, 1.5–35 mm). Fifty-one patients underwent coil embolization. Median number of coils was 5 (range, 2–21) and median renal parenchymal loss was 5% (range, 1%–50%). There were no significant differences between pre- and postoperative eGFR and serum parameters.

CONCLUSION

Iatrogenic renal arterial lesion can be a life threatening condition. Superselective coil embolization is a safe, minimally invasive treatment option with minimal renal parenchymal loss and without significant change in renal function.Iatrogenic renal arterial lesions including pseudoaneurysm (PA), arteriovenous fistula (AVF), and arteriocaliceal fistula (ACF) are rare, but life-threatening conditions (1). The chief symptom usually includes macroscopic hematuria (2, 3). Catheter angiography is the gold standard for both diagnosis and treatment (1).Previous studies have evaluated the iatrogenic renal arterial lesions following partial nephrectomy (1, 3–7), but there were only a few studies on iatrogenic renal arterial lesions following any iatrogenic renal interventions (2). In the present study, to the best of our knowledge, we report the largest series of iatrogenic renal arterial lesions following various renal interventions such as biopsy, percutaneous nephrolithotomy (PCNL), percutaneous nephrostomy, and partial nephrectomy. We focused on clinical presentations, imaging findings, management, and outcomes.     

Use of an arterial tourniquet to achieve complete radiofrequency ablation of a renal metastasis

Radiofrequency (RF) coagulation of skeletal metastases is usually performed for pain relief. However, patients with solitary skeletal metastasis may benefit from more aggressive attempts to achieve local control. The authors report a case in which an arterial tourniquet was used to enhance the effectiveness of RF treatment of a calcaneal renal cell metastasis, leading to long-lasting local control with preservation of ambulation.     

Flow-diverter treatment for renal artery aneurysms: One-year follow-up of a multicentric preliminary experience

PURPOSERenal artery aneurysms (RAAs) are rare in the general population, although the true incidence and natural history remain elusive. Conventional endovascular therapies such as coil embolization or covered stent graft may cause side branches occlusion, leading to organ infarction. Flow diverters (FDs) have been first designed to treat cerebrovascular aneurysms, but their use may be useful to treat complex RAAs presenting side branches arising from the aneurysmal sac. We aimed to evaluate the mid-term follow-up (FUP) safety and efficacy of FDs during the treatment of complex RAAs.METHODSBetween November 2019 and April 2020, 7 RAAs were identified in 7 patients (4 men, 3 women; age range 55-82 years; median 67 years) and treated by FDs. Procedural details, complications, morbidity and mortality, aneurysm occlusion, and segmental artery patency were retrospectively reviewed. Twelve months of computed tomography angiography (CTA) FUP was evaluated for all cases.RESULTSDeployment of FDs was successful in all cases. One intraprocedural technical complication was encountered with one FD felt down into aneurism sac which requiring additional telescopic stenting. One case at 3 months CTA FUP presented the same complication, requiring the same rescue technique. At 12 months CTA FUP, 5 cases of size shrinkage and 2 cases of stable size were documented. No rescue surgery or major intraprocedural or mid-term FUP complication was seen.CONCLUSIONComplex RAAs with 2 or more side branches can be safely treated by FD. FD efficacy for RAA needs further validation at long-term FUP by additional large prospective studies.

Main points

• Flow-diverter treatment for bifurcation renal artery aneurysms
• Angio-computed tomography follow-up after renal aneurysms treatment
• Novel endovascular technique for visceral aneurysms

Renal artery aneurysm (RAA) is a rare pathology with an estimated incidence of 0.09% in autopsies and with an incidence estimated in angiographic series of 0.1%-1% in normal population, reaching up to 2.5% in hypertensive population. They account for 22%-25% of all visceral artery aneurysms (VAAs).^1,2RAAs could be classified according to their shape (saccular and fusiform), location (extra- and intra-parenchymal), and wall (dissecting and non-dissecting).²Risk factors associated with the development of a RAA are fibromuscular dysplasia, atherosclerosis/hypertension, and hereditary connective tissue dysplasias (Marfan syndrome) or vasculitis (Behcet disease).³Indication for treatment includes diameter size > 2 cm or volume increase, symptoms, hematuria, hypertension, pregnancy (due to higher risk of rupture during childbearing), and acute rupture.¹ Aneurysmal rupture is noted in up to 5.6% and is considered a life-threatening condition. Increased risk of rupture is seen during pregnancy.²Thanks to technical improvement and accumulation of clinical experience, endovascular treatment represents a safe and successful strategy. Coil embolization and stent grafts are the most tested techniques, reported in numerous studies, where treatment choice is made according to the anatomical characteristics of the aneurysm and the parent arteries.³The aim of the treatment should be the selective occlusion of the aneurysm maintaining normal blood flow to the renal parenchyma; for peripheral lesions, located on a distal branch of the renal artery, as hilar bifurcation or trifurcation, coil embolization or covered stents lead to the sacrifice of parent arteries, determining an increased risk of end-organ ischemia, with possible consequence on the kidney function.^2,4Furthermore, coil embolization in fusiform or wide neck aneurysm cannot be proposed for the potential coil migration or parent vessel occlusion.⁵The application of flow-diversion techniques in the treatment of intracranial aneurysms has represented a revolution in neurovascular interventions: in fact, flow diverters (FDs) are specifically designed to maintain laminar flow in the parent artery and side branches patency, while reducing flow velocity within the aneurysm, thus promoting thrombosis of the sac.^6,7The use of a variety of FD techniques for the treatment of VAA and pseudoaneurysms has recently been reported, with good results in terms of stent patency and aneurysm sac reduction rates.^8-11In this study, a multicentric technical experience and clinical outcomes in 7 patients presenting a hilar RAAs with 2 or 3 arising branches from the sac, treated with FD as an alternative approach to conventional endovascular treatment, in order to preserve renal arteries branches and segmental distal patency was reported.     

B型超声和CT双导向射频消融治疗肝肿瘤15例

目的：探讨B型超声(B超)及CT双导向在经皮肝穿射频消融术(RFA)治疗肝肿瘤的应用价值。方法15例患者的20个肝肿瘤病灶,在B超和CT双导向下行RFA。首先在B超导向下穿入RFA针,使其接近病灶,再于CT导向下精确定位完成RFA。结果20个肝肿瘤病灶均在双导向下精准穿刺成功,顺利完成RFA,而且操作时间短。经治疗的20个肝肿瘤病灶在术后随访复查期间行相关影像学检查未见有明显肿瘤残存。15例患者均未出现RFA治疗的相关并发症。结论 B超和CT双导向下的经皮肝穿RFA,可以更精准地完成在B超下显示欠完整或欠清晰的肝肿瘤RFA,较单CT导向下的RFA,其减少了穿刺步骤及提高了穿刺的精准性,而且并发症少。     

超选择性肝动脉栓塞与射频消融术联合治疗小肝癌

目的评价肝动脉化疗碘油栓塞术(TACE)与射频消融术(RFA)联合介入治疗原发性小肝癌的临床价值。方法21例原发性小肝癌先行超选择性供瘤血管碘油栓塞,对残留癌灶行射频消融术联合介入治疗。结果21例原发性小肝癌治疗后1、2、3年生存率分别为100%、92.7%、77.7%,中位生存期为26.8个月。结论原发性小肝癌行碘油栓塞术与射频消融术联合介入治疗临床效果显著是一项重要的治疗方案。