Francesco Tiralongo

Background: Percutaneous transhepatic biliary drainage (PTBD) remains a cornerstone in managing obstructive jaundice, particularly when endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful or contraindicated. This study aims to compare ultrasound-guided (US-PTBD) and fluoroscopy-guided (F-PTBD) techniques regarding procedural time, radiation exposure, technical success, and complication rates. Methods: This retrospective, single-center study included patients with malignant obstructive jaundice who underwent PTBD between January 2018 and December 2025. Patients were stratified based on the imaging modality used for the bile duct puncture (US-PTBD vs. F-PTBD). Procedural characteristics, including dose–area product (DAP), fluoroscopy time, complication rates, and technical success, were analyzed using statistical methods appropriate for continuous and categorical data. Results: A total of 133 patients (163 PTBD procedures) were included. US-PTBD demonstrated significantly lower DAP (4.1 ± 1.9 Gy·cm² vs. 6.2 ± 1.5 Gy·cm²; p < 0.001) and shorter procedure time (42 ± 7 min vs. 56.6 ± 6 min; p < 0.001) compared to F-PTBD. Both techniques had comparable technical success rates (91.1% vs. 82.2%; p = 0.158). Complications occurred in 10.2% of patients in the F-PTBD group and 6.7% in the US-PTBD group, with no statistically significant difference between groups (p = 0.489). Major complications, including bleeding and cholangitis, occurred exclusively in the F-PTBD cohort. US-PTBD resulted in fewer Glisson capsule punctures, suggesting reduced procedural trauma. Conclusions: Although a significant access side imbalance was present between cohorts, US-PTBD offers distinct advantages over F-PTBD, including reduced radiation exposure, shorter procedure times, and a comparable safety profile. These findings highlight the potential of US guidance as a safer alternative for PTBD, particularly in patients with coagulopathy or complex anatomy. Further multicenter studies with larger populations are warranted to confirm these benefits and refine patient selection criteria.

Background/Objectives: To provide an updated overview of adrenal incidentaloma evaluation, characterize the principal imaging mimics across pediatric and adult populations, and propose a clinically actionable approach integrating endocrine assessment with conventional and advanced imaging. Methods: A narrative review of recent evidence and major international recommendations was performed, focusing on epidemiology, endocrine work-up, non-contrast computed tomography (CT), washout CT, magnetic resonance imaging (MRI), and dual-energy CT (DECT). Results: The recent literature has questioned a uniformly washout-centered approach and has raised interest in more selective, risk-adapted strategies based on clinical context, endocrine profile, and lesion phenotype; however, these proposals should be distinguished from established guideline recommendations. Non-contrast CT remains the cornerstone of first-line characterization, particularly for identifying lipid-rich adenomas. However, the routine use of adrenal washout CT is increasingly questioned, especially in true incidentalomas, because many benign adenomas are lipid-poor and several non-adenomatous lesions may show overlapping washout behavior. In this setting, MRI maintains a key problem-solving role, mainly through chemical shift imaging. DECT represents the most promising technical advance, enabling multiparametric characterization through virtual non-contrast images, iodine quantification, and material decomposition, with the potential to improve the assessment of indeterminate lesions while reducing unnecessary multiphasic imaging and radiation exposure. Conclusions: Current management should remain grounded in established guideline recommendations. MRI may be selectively used as a problem-solving modality, while DECT and emerging strategies require further validation before they can be considered standards of care.

This evolution challenges the traditional dichotomy between non-operative management (NOM) and operative management (OM). In trauma guidelines, angiography and angioembolization are commonly incorporated within NOM. WSES guidelines, for example, describe NOM of splenic injury as ranging from observation to angiography and angioembolization, while liver trauma guidelines recommend angiography and angioembolization as a possible first-line intervention in hemodynamically stable patients with arterial blush [1,2]. Yet embolization is neither observation nor conservative therapy. It represents an active, invasive, image-guided treatment with its own indications, timing, technical endpoints, risks, and rescue pathways. Although current nomenclature often retains embolization within NOM, its functional position in many clinical algorithms lies between observation and surgery.We therefore propose that the term Interventional Management (IM) may better describe this therapeutic space. The intention is not to replace established guideline terminology, but to recognize IR as a distinct therapeutic domain capable of complementing, preceding, avoiding, or following surgery. A three-pillar framework may be useful conceptually: NOM for observation and supportive treatment without procedural intervention; IM for active image-guided treatment; and OM for surgical control. These categories are not mutually exclusive. The same patient may move between them or receive different strategies sequentially within a single resuscitation pathway. Within this framework, Damage Control Interventional Radiology (DCIR) represents perhaps the clearest expression of the changing role of IR in acute care. First introduced within the PRESTO paradigm as a time-conscious approach for severely bleeding trauma patients [3], DCIR applies damage-control principles to endovascular treatment by emphasizing early activation, rapid identification of the dominant bleeding source, simplified, effective hemostatic techniques, and prioritizing physiological stabilization over anatomical perfection. More recently, Ascenti et al. described DCIR as a bridge between NOM and damage control surgery and questioned its classification as simply another component of NOM [4]. This distinction is more than semantic. It places the interventional radiologist within the early treatment strategy alongside emergency physicians, trauma surgeons, anesthesiologists, and intensivists, rather than at the end of an escalation pathway after conservative management has failed. The key question is therefore no longer simply "surgery or no surgery?", but which combination and sequence of supportive, interventional, and operative strategies can achieve the safest and fastest control of a lifethreatening process.Several contributions to this Research Topic illustrate how endovascular treatment is shifting from rescue therapy to earlier, more strategically timed interventions. Martinez et al. challenge the persistent perception of embolization as a last-resort option for posterior epistaxis, emphasizing its feasibility and safety, as well as the need for meticulous angiographic assessment given complex vascular anatomy and potentially dangerous extracranial-intracranial and ophthalmic anastomoses. Zhong et al., in 116 patients with non-variceal gastrointestinal bleeding, compare selective and super-selective transcatheter arterial embolization. In upper gastrointestinal bleeding, superselective embolization was associated with a lower rate of early rebleeding, whereas the lower gastrointestinal subgroup highlighted the ongoing importance of ischemic risk and embolic agent selection. These findings reinforce a central principle of emergency IR: success cannot be reduced to arterial occlusion alone, but requires hemostasis at the appropriate anatomical level while preserving viable tissue whenever possible.The timing and intent of embolization are becoming equally important. Tiralongo et al. examine prophylactic transarterial embolization after successful endoscopic hemostasis in high-risk nonvariceal upper gastrointestinal bleeding. Although the available evidence does not support routine prophylactic embolization, selected patients with unfavorable clinical and anatomical characteristics may benefit from an early strategy aimed at preventing rebleeding and reducing the need for surgical rescue. A comparable preventive concept is explored by Wang et al. in selected patients with small acute epidural hematomas and skull fractures involving meningeal vascular structures. All patients had angiographically demonstrated middle meningeal artery injury; following embolization, no hematoma expansion was observed and craniotomy was avoided. In both settings, IR was deployed before clinical failure rather than in response to it. This shift from reactive rescue toward risk-adapted preventive intervention may become increasingly relevant as patient selection improves.Acute traumatic and iatrogenic hemorrhage remains one of the clearest expressions of emergency IR. Garducci et al. report transcatheter arterial embolization with n-butyl cyanoacrylate metacryloxysulfolane in 54 patients with traumatic or iatrogenic non-visceral arterial bleeding. Technical success was achieved in all procedures and clinical success in 85.2%, with no procedurerelated deaths, major complications, or off-target embolization. Beyond the specific embolic agent, the study reflects the practical demands of emergency embolization: familiarity with different materials, rapid adaptation to vascular anatomy and flow, management of coagulopathy, and the ability to balance selectivity against the urgency of hemorrhage control. From a damage-control perspective, technical sophistication remains important, but should not delay effective hemostasis.A similar balance between anatomy, timing, and treatment burden emerges from the neurovascular contributions. Quiceno-Ramírez et al. compare endovascular...

Background: Non-variceal upper gastrointestinal bleeding (NVUGIB) continues to present a significant clinical burden due to rebleeding after apparently successful endoscopic hemostasis, particularly in ulcers overlying large-caliber arterial territories. Prophylactic transarterial embolization (pTAE) has been proposed as a strategy to prevent rebleeding in high-risk patients. This mini-review evaluates the evidence for pTAE after successful endoscopic control in NVUGIB, focusing on patient selection, technical approaches, outcomes, and complications. Methods: A literature search of PubMed and Scopus (January 2010–September 2025) was conducted, yielding 10 studies (two randomized trials, three prospective, and five retrospective) evaluating pTAE. Only studies addressing prophylactic, not empiric, embolization were included. Results: Evidence suggests that pTAE is technically feasible and generally safe when guided by ulcer location, size (≥15–20 mm), Rockall score (≥5), and arterial territory (GDA or LGA). While randomized trials did not show overall superiority in intention-to-treat analyses, per-protocol data and observational studies suggest reduced rebleeding and a lower need for surgical rescue in well-selected patients. Complications are infrequent when standardized techniques and early timing (≤24 h) are applied. Conclusion: Routine pTAE is not supported by current guidelines or RCT-level evidence. However, in anatomically and clinically high-risk ulcers, pTAE may offer meaningful benefits. Further multicenter randomized trials with uniform protocols are warranted to clarify its role and optimize patient selection.

This review aims to provide a comprehensive pictorial review of low-flow vascular malformations (LFVMs) of the central nervous system (CNS) without arteriovenous shunting, focusing on their epidemiology, pathophysiology, imaging features, and associations with other vascular anomalies. LFVMs - developmental venous anomalies (DVAs), cavernous malformations (CMs), brain capillary telangiectasias (BCTs), and sinus pericranii (SP) - are typically benign and incidental but may cause symptoms or hemorrhage. Differentiating LFVMs from neoplastic, inflammatory, or high-flow vascular lesions is critical to avoid misdiagnosis and inappropriate treatment. MRI is the reference technique. DVAs show a “caput medusae” venous pattern; CMs have a mulberry-like core with a complete hemosiderin rim on T2*/SWI; BCTs are often occult on routine MRI but may display brush-like enhancement and subtle SWI hypointensity; SP consists of an extracranial venous mass communicating with a dural sinus through a transosseous vein. Familiarity with the imaging spectrum and typical associations of CNS LFVMs enables confident diagnosis and helps avoid unnecessary invasive procedures. Critical relevance statement: By illustrating key imaging features of low-flow CNS vascular malformations, this article critically addresses frequent diagnostic pitfalls. It advances radiological practice by guiding differentiation from neoplastic or high-flow lesions and improving multidisciplinary patient care. Key Points: LFVMs (DVAs, CMs, capillary telangiectasia, SP) are frequently incidental but may cause hemorrhage, seizures, or neurological deficits. DVAs are typically benign drainage variants; hemodynamic congestion on perfusion weighted imaging explains occasional symptoms and the frequent association with acquired CMs. CMS presents as “mulberry-shaped” lesions with a hemosiderin rim on SWI sequences, reflecting microhemorrhages and the absence of intervening brain parenchyma. Capillary telangiectasia most often occurs in the pons; recognition of the characteristic SWI hypointensity with faint enhancement prevents misdiagnosis as a neoplasm or ischemia. AP shows trans‑osseous venous channels connecting dural sinuses to epicranial varices; CT characterizes bony defects, and MRI depicts venous communication. Graphical

Cesarean scar pregnancy (CSP) carries a high risk of severe hemorrhage and potential loss of fertility. This narrative review summarizes current evidence on uterine artery embolization (UAE) using absorbable gelatin sponge (GS), focusing on GS preparation, procedural approaches, and reported outcomes. PubMed/MEDLINE, Scopus, and Google Scholar were searched from January 2015 to 31 December 2024 for peer-reviewed studies reporting UAE with GS for CSP (GS alone or combined with intra-arterial methotrexate and/or adjunct particles). Fifty studies (N = 3139) were included. Technical success was 3133/3139 (~99.8%) and clinical success was 2975/3139 (~94.8%), with most cohorts reporting high clinical control. Severe complications were infrequently reported (typically ~2–4% in most series). Menstrual function, when assessed, generally recovered within ~1–2 months. Subsequent pregnancy outcomes were inconsistently reported and follow-up durations were heterogeneous, predominantly in retrospective designs. Overall, UAE with GS appears effective for hemostasis in CSP and may reduce escalation to hysterectomy in appropriately selected patients. Standardized reporting of GS preparation and outcomes, as well as prospective multicenter registries/studies, are needed to refine best practices.

Background/Objectives : The D-dimer/fibrinogen ratio (D-d/F) has been proposed as a composite marker of fibrinolysis–coagulation balance. Whether D-d/F reflects CT-quantified thrombus burden and right ventricular dysfunction (RVD) in acute pulmonary embolism (PE) remains uncertain. Methods: Single-center retrospective cohort of consecutive adults with CTPA-confirmed PE (January 2022–October 2024). D-d/F = D-dimer (µg/mL)/fibrinogen (mg/dL). Thrombus burden: Qanadli and Mastora indices. RVD: RV/LV ratio, septal bowing, and IVC reflux. Associations: Spearman’s ρ with Steiger’s Z for between-marker comparisons. Discrimination for Qanadli ≥ 40% and RV/LV ≥ 1.0 by ROC. Two exploratory logistic models predicted Qanadli ≥ 40%: Model-1 (age, sex, D-d/F) and Model-2 adding RV/LV. Results: Among 112 patients (mean age 65.4 ± 15.6; 60% men), D-d/F correlated modestly with Qanadli (ρ = 0.233, p = 0.013) and Mastora (ρ = 0.274, p = 0.0034); strengths were similar to D-dimer (no between-marker difference: Steiger’s Z both p > 0.5). D-d/F correlated with RV/LV (ρ = 0.335, p < 0.001) and with IVC reflux (ρ = 0.247, p = 0.0085). CT indices related more strongly to hemodynamic markers (e.g., Qanadli with RV/LV ρ = 0.571, p < 0.0001; Mastora with RV/LV ρ = 0.620, p < 0.0001). Patients with septal bowing had higher D-dimer (median 4.65 vs. 2.74 µg/mL, p = 0.0037), higher D-d/F (1.04 vs. 0.61, p = 0.0018), and higher clot-burden scores (both p < 0.0001). For Qanadli ≥ 40%, AUCs were 0.621 for D-d/F (cut-off > 0.795; sens 58.8%, spec 62.3%) and 0.618 for D-dimer (>1.894 µg/mL; 84.3%, 37.7%); AUCs did not differ (p = 0.93). For RV/LV ≥ 1.0, AUCs were 0.693 for D-d/F (>0.607; 83.8%, 52.0%) and 0.684 for D-dimer (>2.849 µg/mL; 75.7%, 54.7%); p = 0.72. In Model-1, D-d/F predicted Qanadli ≥ 40% (OR = 1.43 per unit, p = 0.043; AUC = 0.64). After adding RV/LV (Model-2), discrimination improved (AUC = 0.796), RV/LV remained a strong predictor (p < 0.0001), and D-d/F was not retained (p = 0.287). Conclusions: In acute PE, D-d/F tracks thrombus burden and RVD to a degree comparable to D-dimer, but effects are modest. CT-based markers—particularly RV/LV—better reflect disease severity and are more predictive of high clot burden. Risk prediction and incremental utility of D-d/F were not assessed and warrant prospective evaluation.