Biomedical subjects
Publications and source records attributed to G Simonetti.
The authors present the results achieved with angiographic evaluation of 34 patients suffering from extremity injuries. In spite of the improvements of various diagnostic techniques, especially ultrasound studies, they believe that emergency arteriography is the only way to obtain an ultimate answer in vascular traumas caused by extremity injuries.
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Current procedures to determine the clinical staging of disease in patients with lung cancer are lacking in accuracy, particularly regarding the presence of metastatic disease. We have evaluated the use of computed tomography (CT) of the chest, brain, and upper abdomen for clinical staging of the extent of disease in 113 consecutive patients with histologically confirmed carcinoma of the lung. Comparisons with mediastinoscopy and surgical findings were made regarding the extent of primary tumor in 47 patients and nodal involvement in 41 patients. The CT scan showed a sensitivity of 86.9%, a specificity of 91.6%, and an accuracy of 89.3% for extrapulmonary extension of the primary tumor and a sensitivity of 50%, a specificity of 96.5% and an accuracy of 82.9% for mediastinal node involvement. Thirty-two of the 85 patients studied by total body CT scan had distant metastasis, of which 24 (75%) were clinically silent. Thus 28.2% of the 85 patients studied had asymptomatic metastatic disease. We conclude that CT of the chest, brain, and upper abdomen is a reliable procedure for staging lung cancer.
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The computed tomographic (CT) findings in Budd-Chiari syndrome are described. With repeated injections of contrast medium, using an angio-CT technique, the authors consistently obtained a good and homogeneous enhancement of the liver parenchyma and vascular structures. The portal and hepatic veins were routinely seen. In Budd-Chiari syndrome, the authors found patchy enhancement of the involved section of the liver and absence of visualization of the hepatic veins. The latter is considered characteristic of hepatic vein obstruction and should not be misinterpreted as a consequence of neoplastic lesion.
Angio-CT consists in a rapid bolus intravenous injection of contrast medium followed by serial sequential fast scanning to include the arterial and the venous phases. Injection of contrast medium of 50 cm3 are made 3 or 4 times for a total of 150 divided by 200 cm3 of contrast medium at an iodine concentration of 29 g/100 cm3. At the beginning, scans are intercalated with injections, until the total amount of contrast medium is reached. Thereafter, the scans are rapidly continued to cover the whole organ under study. The scanning during the vascular enhancement has considerably helped our diagnostic accuracy and has a made the drip-infusion technique out-moded.
In 20 patients with a clinical picture of primary hyperaldosteronism (5 patients were later found to be suffering from hypertension of other origin), CT showed diagnostic precision higher than 90% in the localization of adrenal adenoma (11 out of 12). On the other hand, this examination scarcely helped in the diagnosis of uncommon gland hyperplasias (1 out of 3). In CT doubtful or negative cases, hormonal measurement in blood samples taken selectively from adrenal veins was more indicative than selective phlebography. CT can therefore be considered as an alternative to iodocholesterol scintigraphy in early diagnostic investigation in this field of pathology.
A technique consisting of repeated injections of contrast medium has been used in 530 cases of upper abdominal CT studies for evaluation of hepatic and pancreatic disease. Out of 530 cases, 105 patients had hepatic lesions, 62 metastatic, 3 adenomas, 4 haemangiomas and 6 hepatomas. The remaining 30 patients had cystic lesions involving the liver. Using a repeat dose technique and rapid scanning, the accuracy rate ranged about 90%. Th authors feel that this technique should be employed routinely for evaluation of hepatic problems and that other techniques should be abandoned.
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The presence of superior mesenteric artery aneurysms may be suspected on the basis of clinical and ultrasound findings. These lesions have a suggestive appearance on computed tomography, but for a preoperative assessment angiography is always indicated. Two cases are presented.
In arterio-venous malformations, arterial trans-catheter embolization can be considered as a definitive treatment, a pre-operative devascularizing technique, and a palliative treatment of those not surgically operable malformations. A very important point is choosing the correct way where to introduce the catheter and the embolizing devices. The most known devices are: synthetic fibrin foam (Gelfoam, Spongostan), Gianturco coils, and among the non reabsorbable devices a polyvinylic alcohol foam (Ivalon), the isobutyl-2-cyanoacrylate and silicone. Furthermore detachable balloons and bristle-brushes can be used. Many parameters must be taken into consideration: hemodynamic fluxes of the lesion, type of vascularization, extension of the lesion, aim of the embolization, possible risks. When embolizing large territories, the protocol must foresee several performances for the control of the embolized vessels, the presence of collateral circulation, the extension of the embolization and other afferent arteries to the lesion. Regarding the permanent occlusions it is preferable to utilize fragments of Ivalon, small silicone spheres or liquid silicone; finally, reabsorbable device must be used in the distal embolizations and non reabsorptible in the proximal embolizations. The best results have been achieved in the traumatic lesions where a direct communication exists between an artery and a vein. Among the arterio-venous malformations the best results have been achieved in cranio-facial angiomas with low flux. The possible complications are consequences of ischemia: necrotic musculo-cutaneous, cerebral or troncular changes.
We used the transhepatic approach to the portal system to obliterate bleeding gastroesophageal varices as an alternative to portosystemic shunt performed as an emergency. In eight of 13 patients, we obtained complete arrest of bleeding, while rebleeding was observed in five patients. The shunt was performed upon six patients, and only one patient died. Transhepatic obliteration of varices seems to be the more useful method for the control of untractable hemorrhage and to prepare the patient for an elective operation.
The authors present their experience with 18 cases of hepatic arterial embolization: 9 for neoplasm, 8 for hemorrhage and 1 for vascular malformation. Aside from contral of acute arterial bleeding, this angiographic technique has extended its indications to the preoperative or palliative treatment of hepatic primary and secondary tumors and also to non surgical treatment of arterovenous and malformations. Compared to surgical ligation, embolization, being highly selective, produces less damage to the normal parenchyma. In case of inoperable tumors embolization produces some improvement of general conditions and has analgesic effect; while when operation is possible it may act as a preoperative devascularization procedure. Finally with employment of non absorbable material embolization may substitute surgery in presence of arterovenous malformation. The procedure has no controindications but it is essential that hepatic function is preserved and that portal flow dynamics are not altered. Among laboratory data to be investigated blood glucose level is particularly important since it may reveal ischemic damage. Possible complications due to reflux of emboli can be avoided with a correct technique and with some simple acquirements.
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A series of 24 patients affected by hepatic abscess have been examined by means of CT. The localization observed was: 12 intrahepatic abscesses, 5 subdiaphragmatic, 7 subhepatic and 1 both intrahepatic and subdiaphragmatic. The advantages and disadvantages of the method are described, beside considerations on the examination technique.
In a series of patients affected by hepatic metastases, the authors have found a diagnostic accuracy of 84% by means of CT, poorly inferior to that of angiography: 163 patients were studied by means of angiography, 88 by CT, 12 with both techniques besides scintigraphy, echotomography and other investigations. In many patients when scintigraphy and echotomography do not lead to a diagnosis, CT can avoid an angiographic investigation. Nevertheless angiography must be performed in all those patients in which the investigations suggest a possible surgical intervention. Despite employing all possible investigations, there are some cases in which the hystological diagnosis of the lesion can be reached only by optic by means.
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The authors present their experience with 38 cases of renal tumors which had angiographic embolization. Embolization is electively indicated as a preoperative procedure: the 4 divided by 5 days time lapse before the operation give rise to tissue modifications which permit a better resectability of the mass. Thus embolization achieves a good demarcation of the neoplastic mass from the surrounding tissues and reduces intraoperative bleeding. Emboli may be made of different materials like: fibrin sponge (Gelfoam), acrylic resin (Bucrylate) or steel (Gianturco coil). The association of both the steel coil and one of the other two types of emboli may be the method of choice. The metallic device is indicated for main vessel occlusion, while the others are more suitable for more peripheral branches. Selective or superselective catheterization in required for emboli introduction and care must be taken when occluding the renal artery to avoid reflux and to permit surgical clamping.