Biomedical subjects

A R Cotroneo

Publications and source records attributed to A R Cotroneo.

49 records · Page 3Linked to original sources

PubMedDate not supplied

Carcinoma of the pancreatic head area. Therapy: nonoperative biliary drainage for palliation.

Jaundice is the dominant symptom in patients with biliary obstruction from carcinomas of the pancreatic head area. The many symptoms usually associated to prolonged biliary stasis (malnutrition, coagulopathy, pruritus hepatocellular failure, renal dysfunction, angiocolitis) is commonly resolved or relieved by biliary drainage. Palliation is frequently the only feasible treatment in these patients due to the biological aggressiveness of these tumors characterized by the early infiltration of adjacent tissues. Endoscopic and percutaneous procedures of biliary recanalization are as effective as those of surgical palliation, are more comfortable to the patients and burdened with a lower morbidity and mortality. In selected patients, palliation of jaundice can be combined with intraluminal radiotherapy or pancreatic drainage the latter aimed at the relief of the "obstructive" pain present in some patients with carcinoma of the area of the head of the pancreas.

Combined Modality Therapy↗

PubMedDate not supplied

[Pulmonary thromboembolism and diagnostic imaging: integration of techniques and methods].

Thromboembolism is presently the third most frequent cardiovascular disease, with an incidence of deep venous thrombosis of 800,000 cases a year in the USA. The clinical diagnosis of the condition is difficult and noninvasive procedures are poorly reliable, which makes the diagnosis and treatment of deep venous thrombosis appropriate in the patient with clinically suspected pulmonary embolism. Color-Doppler US is now replacing phlebography in the diagnosis of deep venous thrombosis. Proximal deep venous thrombosis is always at high risk for embolism (50%). Isolated calf thrombi may spread into proximal veins and thus cause severe embolism. Therefore, the early detection of thrombus site and extent and a timely treatment before embolism are of the utmost importance. Color-Doppler US is a noninvasive technique which can show deep venous thrombosis with 95% sensitivity in the proximal and 55% sensitivity in the distal districts in asymptomatic patients. This examination must be used not only to confirm a diagnostic suspicion of deep venous thrombosis, but also to screen high-risk patient and to monitor distal thrombosis. In the secondary prophylaxis of pulmonary embolism, the radiologist must perform a mechanical interruption of inferior vena cava by positioning a caval filter. Caval filters can be temporary or definitive; standard indications for caval filter positioning are a contraindication to anticoagulant therapy and the onset of pulmonary embolism in spite of anticoagulant drugs. A further indication is the presence of floating thrombi in the femoroiliac-caval trunk. Multidisciplinary groups including the hematologist, the radiologist and the clinician should plan the diagnostic and therapeutic approach and participate in the decision-making process. In our department, from January, 1992, to June, 1995, sixty-five caval filters were positioned in 62 patients selected out of 260 candidates. Three complications only were observed; one patient had recurrent pulmonary embolism and three patient had caval thrombosis spreading beyond the filter. In 198 patients in whom no caval filter was implanted, pulmonary embolism did not recur. At present, the role of the radiologist is markedly changing, especially in the management of this condition. On the one hand, radiologists must diagnose thromboembolism as a whole and not only its pulmonary evidence; on the other hand, they play a major operational and interventional role in the treatment of thromboembolism patients.

Clinical Protocols↗

PubMedDate not supplied

[Aorto-iliac aneurysms and associated gastrointestinal neoplasms. Treatment problems].

In patients affected by aortoiliac aneurysm the concurrent presence of a gastrointestinal tumor is a not infrequent occurrence which poses problems of therapeutic approach (one step operation or prior treatment of one of the two diseases; in the latter case definition of timing and sequence of the surgical treatment). Three cases are reported where an eclectic therapeutic approach has enabled satisfactory results. A patient with an isolated aneurysm of right hypogastric artery associated with rectal cancer was treated with percutaneous embolization of the aneurysm and subsequent excision of the tumor. In a patient with a neoplasm of the left colon and aortic aneurysm, the aneurysm was treated first and after about a month the tumor was resected. In a patient with gastric cancer and aortic aneurysm subtotal gastrectomy was first performed and subsequently, after about 3 months, the aneurysm was treated by extraperitoneal route. Even if an unidirectional approach cannot be defined, it is thought that the two-step treatment of the associated diseases is preferable. In the presence of non stenosed non bleeding colorectal tumors it seems more suitable to treat the aneurysm first (increased postoperative risk for rupture of the aneurysm; more difficult preparation of subrenal aorta in the presence of cicatricial outcomes of colonic surgery; persistence of perianastomotic infections after colonic resection). Gastric tumors should be treated first for their higher biological aggressiveness and unfeasible correct preoperative staging. In particular cases (single unilateral aneurysm of a hypogastric artery associated with gastrointestinal cancer), non surgical treatment of the vascular lesion (embolization during angiography) is the treatment of choice.

Adenoma, Villous↗

PubMedDate not supplied

Treatment of deep vein thrombosis.

At present, most common initial treatment of deep vein thrombosis is anticoagulant therapy with i.v. heparin. Recently, some reports in literature suggest the efficacy of low molecular weight heparin fractions administered also to outpatients. Thrombolytic therapy as compared to heparin seems to be favorable as for the valvular integrity and function with minor postphlebitic sequels. It is however burdened with a higher incidence of hemorrhagic complications. Probably, it should be reserved for those patients with massive phlebothrombosis or phlebothrombosis associated with relevant clinical signs. At present, it has not definitely been proved that one of the commonly used drugs, streptokinase, urokinase and r-TPA affords substantial advantages in terms of efficacy and safety. Locoregional administration by a catheter inserted into the thrombus with the protection of a caval filter enhances the efficacy of thrombolytic agents, even if data on long-term results of this method are still lacking. Discordant opinions exist on the validity of thrombectomy. As a prophylaxis of pulmonary embolism, thrombus removal has been replaced by caval filters. At present it is commonly indicated for phlegmasia coerulea dolens. In the other forms, even if the vascular patency is restored in a good percentage of cases, it is not similarly effective in preventing the postphlebitic syndrome. For these reasons it should be applied in selected cases.

Anticoagulants↗

PubMedDate not supplied

Interventional radiology in the treatment of pulmonary embolism.

Percutaneous therapy of pulmonary embolism is performed by local administration of thrombolytic agents or by mechanical canalization. The latter is achieved by fragmentation of the embolus with angiographic catheters, or by aspiration or fragmentation of the thrombus with dedicated devices. The pharmacologic basis of locoregional administration of thrombolytic agents, as in the treatment of deep vein thrombosis, is the possibility of reaching a higher concentration of the drug at the level of the embolus by decreasing the activity of systemic fibrinolysis, thus lowering the incidence of hemorrhagic complications. In recent years, locoregional thrombolytic therapy has been used only combined with mechanical canalization. The easiest way is direct fragmentation of the embolus with an angiographic catheter. The system of aspiration of pulmonary emboli, experimented by Greenfield is based on the use of a flexible catheter the tip of which is equipped with a plastic radiopaque cup. Recently, several rotating devices have been designed. Some have already been used for the peripheral arterial system, others are specific for the venous system (Schmitz-Rode-Gunther device). The clinical effectiveness of these devices is however still to be assessed. Other non conventional possibilities for the mechanical canalization of pulmonary arterial system are represented by metal stents and angioplasty with balloon catheters. At present, interventional radiologic procedures represent an additional tool in the medical or surgical therapy of severe pulmonary embolism, when it is contraindicated or ineffective.

Catheter Ablation↗

PubMedDate not supplied

Venous interruption as prophylaxis of pulmonary embolism: vena cava filters.

Interruption of vena cava for prevention of pulmonary embolism (PE) was achieved in the past with surgical ligation or placement of clips outside the infrarenal vena cava. At present, this procedure is performed with percutaneous insertion of vena cava filters. Vena cava filters can be permanent or temporary, catheter-retrievable. Main indications for placement of a vena cava filter are: contraindication for anticoagulant therapy in patients with severe PE in whom a further embolic episode would be fatal or patients with PE (or its recurrence) undergoing adequate anticoagulant therapy. Temporary filters are reserved to patients where the risk of PE is limited in time as in posttraumatic, post-partum or postoperative thromboembolism. The incidence of recurrence after placement of a vena cava filter varies between 0.5 and 7%. Procedure-associated complications are usually mild. However, severe complications as filter migration into the pulmonary artery or vena cava perforation were described. Our experience concerns the insertion of 61 vena cava filters (47 permanent and 14 temporary). Indications were as follows: iliofemoral thrombosis at embolic risk (37 cases), contraindication for anticoagulant therapy in the presence of deep vein thrombosis with embolic risk (7 cases), protection during fibrinolytic therapy (3 cases), PE during anticoagulant therapy (5 cases) complications of anticoagulant therapy which required discontinuation (5 cases), prophylaxis in view of surgery at high risk for PE (2 cases), protection for surgical venous thrombectomy (2 cases). Mortality was nil. Clinically evident PE was not observed in any patient in whom vena cava filter was inserted. Complications were mild and asymptomatic. Vena cava filters represent an effective prevention of PE together with medical and surgical treatment. At present, problems of this procedure are not technical but rather concern correct indications. Interruption of vena cava is effective if planned within a global strategy for prevention of thromboembolism.

Adolescent↗

PubMedDate not supplied

Multidisciplinary approach to venous thromboembolism.

Venous thromboembolism shows a high incidence and a significant mortality. Even if valid methods are available, thromboembolism is underdiagnosed. There are a number of diagnostic difficulties. They concern the time of the diagnostic suspicion, the patient selection for the various procedures and their combination. These difficulties may be overcome by team work where specialists of different disciplines (surgeons, internists, experts in nuclear medicine, radiologists) integrate their competence to attain the established objectives. The integration results in "synergism", namely an added value greater than the sum of competences of the team components. Thus, an operational unit active 24 hours over 24 must be formed to diagnose and treat the largest number of cases of thromboembolism. To establish the clinical suspicion of thromboembolism is the first indispensable step for patient selection. Thromboembolism should be investigated in all patients with chest pain, dyspnea and tachypnea in the absence of preexisting cardiorespiratory disease. The team should evaluate the impact of signs and symptoms to establish a definitive clinical probability which can direct towards the suitable, least invasive imaging procedure. Perfusion scanning, when highly suggestive or normal, is conclusive. However in 70% of cases it is indeterminate. Thus it should be combined with other procedures and with the clinical assessment. In practice, many dubious cases remain unsolved. The team work represents an organizational response to this diagnostic and therapeutic inadequacy. The real change in strategy which has revolutionized the diagnosis of thromboembolism was the widespread use of color Doppler US in the diagnosis of deep vein thrombosis. Since pulmonary embolism as well as deep vein thrombosis are treated with the same therapy, it is adequate to document the thrombosis also in the absence of a definitive demonstration of embolism. The old-fashioned approach should be reversed and the investigation should be centered on the assessment of deep vein thrombosis: site, emboligenic potential, floating extremity and extension. The integration of the clinical assessment, scanning finding and color Doppler US lowers by about 20% the number of indeterminate cases and indicates the patients for whom pulmonary spiral CT or pulmonary angiography is required. In all patients with cardiorespiratory insufficiency still unsolved after the combination of noninvasive exams, pulmonary angiography or spiral CT is mandatory because of the high risk for death. The remaining ones can be followed with serial color Doppler US exams. The cost/benefit ratio shows that the noninvasive strategy is the least expensive, the least hazardous and the most effective. At present, effective therapies are available for thromboembolism. Standard heparin and low molecular weight heparin fractions, fibrinolytic agents, surgery and recently caval filters are playing a major role in secondary prophylaxis of pulmonary embolism. The therapeutic approach is conditioned by various factors: the features of thrombosis, the presence and entity of pulmonary embolism, the patient cardiorespiratory condition, possible contraindications for anticoagulant and fibrinolytic agents. The presence of such a number of variables makes the use of a therapeutic algorithm, difficult. In this phase, based on our experience we believe that the present solution lies in the activity of an operational team of experts who establish the treatment to be performed.

Cost-Benefit Analysis↗

PubMedDate not supplied

Role of angiography in the evaluation of hepatic perfusion.

Angiography was the first method to be used for a morphofunctional study of hepatic perfusion. It can be performed with direct puncture of portal system or indirect opacification after contrast injection into the splenic artery or superior mesenteric artery. At present, direct angiographic procedures have only a historical value in the diagnostic approach while they have a preliminary role in interventional maneuvers on the portal system (TIPSS, embolization of portal branches or left gastric vein). Indirect angiographic procedures allow the study of arteries, parenchymas and portal system. Much of the information on arterial hepatic and portal circulation is now supplied by noninvasive procedures (US,CT,MRI); however in selected cases, angiography can be performed. Furthermore, the knowledge of angiographic findings of hepatic circulation is basic to the interpretation of "functional" information supplied by color-Doppler US, spiral CT and MR angiography.

Angiography↗

PubMedDate not supplied

New perspectives on the clinical applications of functional radiology of the liver.

Preliminary results of "new clinical applications" of functional imaging of the liver are reported. In 20 healthy volunteers portal flow measurement with Doppler US at the level of right, left portal branch and main portal trunk, showed the preferential distribution in baseline conditions of portal flow to the right liver (about 68%) as compared to the left portal branch. This influenced MRI volumetry of right liver as compared to left liver. After meal intake, flow increase was significantly higher at the level of left portal branch suggestive for a "functional reserve" in left liver. Portal flow physiology was examined in preparation of portal imaging before and after portal vein embolization, a procedure performed preoperatively before enlarged hepatectomies.

Diagnostic Imaging↗

PubMedDate not supplied

The diabetic foot: role of color-Doppler US.

Color Doppler US is a first choice instrumental exam for the diagnosis and staging of peripheral arterial occlusive disease in diabetic patients. Normal and pathological findings are analyzed to establish the potential and limitations of the procedure. Color Doppler US is a noninvasive, reproducible and cost-effective procedure. Direct morphologic and flowmetric evaluations of stenotic-occlusive alterations, and indirect evaluations based on the interpretation of velocimetry findings proximal and distal to the lesions, are feasible. The conventional basic exam can be enhanced with the power module. Encouraging experimental results are observed with the use of echographic contrast media. Disadvantages of the procedure are related to the poor panoramic view, subjective (operator-dependent) interpretation and limitations related to the physics of ultrasound.

Diabetic Foot↗

PubMedDate not supplied

Angiography and MR-angiography in the diagnosis of peripheral arterial occlusive disease in diabetic patients.

An invasive diagnostic procedure as angiography which involves direct arterial injection of contrast through suitable catheters, is still considered the gold standard in the evaluation of diabetic patients with peripheral arterial occlusive disease. The accuracy of anatomical details is combined on angiography with a pan view, indispensable for correct therapeutic planning. MR-angiography, with the 2D time of flight sequences in particular, supplies images of great anatomical accuracy and very sensitive in the detection of occlusive lesions which compare well with angiography and superior in the assessment of the length of occluded tracts. This noninvasive, cost-effective procedure seems bound to replace angiography in the pretreatment evaluation of diabetic patients with peripheral arterial occlusive disease.

Angiography↗

PubMedDate not supplied

The role of interventional radiology in the treatment of the diabetic foot.

Although the pathologic features of arterial disease in diabetes do not differ from those of simple atheromatous lesions, the plurisegmental involvement, the predominant subpopliteal location of lesions and the association with impaired cardiac and renal function in these patients imply peculiar problems in the selection of an adequate therapy. At present, in interventional radiology a number of procedures are available for intravascular therapy (angioplasty, stent, locoregional fibrinolisis, mechanical atherectomy), particularly suitable for diabetics who are affected by multisystem impairment. These procedures are not in opposition to the conventional ones (surgical and medical) but rather integrate them, allowing to extend the indications and improve the results in the treatment of the vasculogenic diabetic foot. Based on the personal experience the potential of intravascular procedures in this disease, is analyzed.

Aged↗

PubMedDate not supplied

The foot clinic. Multidisciplinary management of the patient with diabetic foot.

Treatment of a complex disease as the diabetic foot requires a multidisciplinary management with the close collaboration of a team for care. The most important members of the team are the diabetologist as coordinator, the vascular surgeon, the orthopedist, the radiologist, the orthopedic technician, the podiatrist and the nurse specialist. The care based on this arrangement should be carried out in dedicated rooms and times to exploit at best the organizational potential in the patient's interest, implemented in the foot clinic.

Diabetic Foot↗