Anna Maria Ierardi

Background: Non-sclerosant liquid embolic agents are safe and effective embolics that have been used in interventional radiology for more than 50 years, in both emergency and elective scenarios. Purpose: This document aims to review the chemical principles and technical considerations involved, to make recommendations regarding clinical indications for the use of non-sclerosant liquid embolic agents, and to review the literature regarding outcomes and complications. CIRSE Standards of Practice documents are not intended to impose a standard of clinical patient care, but to recommend a reasonable approach to, and best practices for, procedural performance, in this instance the use of non-sclerosant liquid embolic agents. Methods: The writing group was established by the CIRSE Standards of Practice Committee and consisted of five clinicians with internationally recognised expertise in non-sclerosant liquid embolic agents and a research assistant (P.R.). The writing group reviewed the existing literature on non-sclerosant liquid embolic agents, performing a pragmatic evidence search using PUBMED and EMBASE focussing on English-language publications, preferably from 2009 up to December 2025, and including more than ten patients. Where clear gaps were evident, older literature was searched and select references included. The final recommendations were formulated through consensus. Results: Non-sclerosant liquid embolic agents are represented by cyanoacrylates and polymers which are safe and effective agents that can be used in a wide range of clinical scenarios, resulting in effective embolization even in patients with impaired coagulation function. Knowing their chemical properties provides understanding of their correct preparation, technical application and clinical indication. Compared to mechanical and particulate agents, non-sclerosant liquid embolic agents present a steeper learning curve, and thus, thorough training in their use is essential.

Background: To evaluate whether quantitative signal intensity (SI) measured on the hepatobiliary phase (HBP) of gadoxetic-acid-enhanced MRI is associated with disease control rate (DCR) after conventional transarterial chemoembolization (cTACE) in patients with hepatocellular carcinoma (HCC). Methods: In this retrospective single-center study, 112 patients with HCC treated with cTACE between April 2018 and September 2020 and with available pre-treatment gadoxetic acid-enhanced MRI were included, with one target HCC lesion analyzed per patient. Mean HBP SI was quantitatively measured using manually drawn regions of interest (ROIs) within the target tumor, adjacent liver parenchyma, and reference tissues. Treatment response was assessed using mRECIST criteria at 1, 3, and 6 months. Logistic regression and receiver operating characteristic analyses were performed to evaluate the association between HBP SI and DCR. Results: Lower tumor HBP SI was associated with DCR at 6 months after cTACE (unadjusted p = 0.010; Bonferroni-adjusted p = 0.030), whereas no significant association was observed at 1 or 3 months. A tumor HBP SI cut-off value of 580 demonstrated moderate discriminatory performance for DCR (AUC = 0.714, 95% CI: 0.585–0.843; p = 0.008), with 69.1% sensitivity and 80.0% specificity. Conclusions: Lower baseline tumor HBP SI was associated with 6-month radiological disease control after cTACE in this exploratory single-center cohort. However, its moderate discriminatory performance, the absence of significant associations at earlier response assessments, and the methodological limitations of the study preclude its use as a stand-alone clinical decision-making tool. HBP SI should therefore be regarded as a potential imaging biomarker, and these findings should be considered hypothesis-generating and require validation in larger, independent cohorts.

Purpose: To evaluate feasibility, technical success, and safety of a fluoroscopy-guided percutaneous technique for central venous catheter (CVC) placement in patients with thoracic central venous obstruction (TCVO). Materials and methods: We retrospectively included 16 adult and pediatric patients with TCVO requiring CVC placement. Technical success was defined as successful venous access and catheter placement; clinical success as functional catheter use without failure. Safety was assessed using CIRSE classification. Procedural metrics were recorded. Descriptive statistics (median, IQR; counts, %) were used. Exploratory comparisons between obstruction type (Type 1–2B vs 3–4) and procedural metrics were performed using Mann–Whitney U test. Results: Seventeen procedures were performed in 16 patients (median age 27.5 years, range 7–61; 11 males). Access and catheter placement succeeded in 16/17 procedures (94.1%) and all patients (100%). In one case, first attempt failed and a second successful procedure was requested. First-attempt per-patient technical success was 93.7%. Clinical success was 100%. No major complications occurred; minor adverse events (CIRSE grade 1) were observed in three patients (18.7%). Median procedure time 52 min, fluoroscopy 12 min and 5 s, contrast 46 mL, and DAP 91.3 Gy/cm ² . Trend toward longer procedure time was noted for Type 3–4 obstructions and collateral snare use. Conclusion: Fluoroscopy-guided percutaneous CVC placement is feasible and safe in TCVO using the described technique and may represent a widely applicable alternative to dedicated inside-out system.

Background and aims: Hepatocellular carcinoma (HCC) patients frequently present with comorbidities that limit therapeutic options and increase mortality. This study evaluated the performance of the Charlson Comorbidity Index (CCI) and a modified CCI (mCCI) in stratifying patients with HCC to predict treatment allocation and survival. Methods: A retrospective single-center cohort study analyzed 401 patients with de novo HCC (74% male, median age 68 years, 80% Child–Pugh-Turcotte (CPT) A, 65% viral etiology, 70% Barcelona Clinic Liver Cancer stage (BCLC) 0/A). CCI and mCCI (with points related to HCC and chronic liver disease excluded), were calculated at diagnosis for each patient. The primary endpoint was overall survival (OS) estimated by Kaplan–Meier method and compared across mCCI classes; Cox uni/multivariable models were applied to identify predictors of mortality. The secondary aim was evaluating the association between mCCI and treatment allocation. Results: While CCI classified 94% of patients as “high-risk”, mCCI reclassified patients into “high-risk” (21%), “intermediate-risk” (48%), and “low-risk” (31%), demonstrating better stratification whilst maintaining a strong correlation with CCI (Kendall’s tau-b = 0.57, p < 0.001). BCLC B patients with “high-risk” mCCI exhibited significantly lower access to first-line curative treatment (14% vs. 47%, p = 0.03). Moreover, “high” or “intermediate-risk” patients according to mCCI experienced significantly shorter OS compared to “low-risk” (median OS 36 vs. 49 vs. 74 months, p < 0.001). “High-risk” and “intermediate-risk” mCCI classes were independent predictors of mortality, alongside alpha-fetoprotein, CPT and BCLC stage. Considering the items composing mCCI, age and cardiovascular diseases were independent predictors of mortality. Conclusions: mCCI provides a more accurate assessment of comorbidities than the standard CCI and is associated with survival, hence it can contribute to designing patient-tailored therapeutic strategies.

Background: The role of transarterial chemoembolization (TACE) in hepatocellular carcinoma (HCC) management has evolved over recent years. Although it appears that the overall number of procedures is declining, international guidelines now endorse TACE beyond the Barcelona Clinic Liver Cancer (BCLC) intermediate stage, and multiple TACE platforms allow patient-tailored treatments. In this context, degradable starch microspheres TACE (DSM-TACE) may be valuable when the goal is to preserve liver function and spare healthy parenchyma. This study reports multicenter retrospective Italian data to assess the efficacy and safety of DSM-TACE with EmboCept^® in patients with early-to advanced-stage HCC, and to evaluate whether procedural selectivity (superselective vs. lobar) influences outcomes. Methods: This retrospective multicenter study included 201 patients initially; after applying exclusion criteria, 187 patients (334 HCC nodules) treated across eight centers (2014–2024) were analyzed. Treatment indications were discussed in multidisciplinary tumor boards in all centers. Superselective DSM-TACE was performed in 48 patients (66 nodules, 19.8%), while 139 patients (268 nodules, 80.2%) underwent a lobar approach. Repeated sessions were performed on demand and recorded for lobar treatments. Tumor response was assessed using mRECIST criteria at 1, 3–6, 6–9, and 9–12 months; adverse events were classified according to the Common Terminology Criteria for Adverse Events (CTCAE). efficacy and safety outcomes were compared according to the DSM-TACE approach. Results: In terms of safety, analysis confirmed the overall good tolerability of DSM-TACE, with no grade ≥ 3 adverse events and no major complications or procedure-related deaths. No significant differences were observed in post-embolization syndrome (PES) rates between groups. With regard to efficacy, for the entire cohort, the overall response rate (ORR) was 70% at 1 month, 31.6% at 3–6 months, 20.5% at 6–9 months, and 13.5% at 9–12 months, while the disease control rate (DCR) was 91.4% at 1 month, 69% at 3–6 months, 38.6% at 6–9 months, and 27% at 9–12 months. At intermediate follow-up, superselective DSM-TACE achieved higher ORR than lobar treatment at 3–6 months (53.8% vs. 26.4%; p = 0.009) and 6–9 months (43.8% vs. 15.3%; p = 0.009). Per-nodule analysis confirmed this advantage at 3–6 months (ORR = 66.7% vs. 31.3%; p = 0.0008). Conclusions: DSM-TACE with EmboCept^® provides favorable tumor control and a good safety profile in routine clinical practice. A superselective approach is associated with improved response at intermediate follow-up compared with lobar strategy, supporting DSM-TACE as a flexible therapeutic option for localized HCC.

Aim To evaluate the effectiveness and safety of the intra-arterial infusion of methotrexate (MTX) followed by uterine arteries embolization (UAE) in women with cesarean scar pregnancy (CSP) in which serum β-HCG levels remained elevated and the gestational sac showed no significant reduction 2 weeks after systemic administration of MTX. Material and methods Twenty-one patients with CSP were enrolled in the study. Technical success, clinical success and complication rates were assessed. Technical success was defined as complete bilateral intra-arterial MTX infusion and successful UAE. Primary clinical outcomes included reduction of gestational sac size, absence of active vaginal re-bleeding, and normalization or steady decline of β-HCG values. Secondary clinical outcomes comprised pregnancy termination, gestational sac expulsion, and reduced or absent bleeding during suction curettage of the uterine cavity. Additionally, the need for uterine cavity revision, time to menstruation recovery, and outcome of subsequent pregnancies were evaluated. Results Technical success, primary clinical outcome, and pregnancy termination were achieved in all cases (100%). Spontaneous expulsion of the gestational sac occurred in five patients (23.9%), while the remaining patients underwent ultrasound-guided suction curettage of the uterine cavity. Two patients (9.5%) required additional hysteroscopy. No major complications were registered. Pain was effectively managed in all patients within 24 h. Menstrual function resumed within 3 months in all women. Among the 12 patients (91.6%) who wished to conceive again, 11 (91.6%) achieved a successful pregnancy. Conclusion Intra-arterial MTX and UAE, following systemic MTX, appear to be a safe and effective treatment for CSP.

Background/Objectives: Chronic pudendal neuralgia is a relatively rare condition in the general population, with an incidence of 1%. Although diagnosis of pudendal neuralgia is mainly clinical, Magnetic Resonance Imaging (MRI) is commonly performed to obtain further information. However, clear criteria and guidelines for MRI diagnosis and the clinical–radiological correlation are still not definite. Methods: We reviewed 81 patients with chronic pudendal neuralgia, studied by an MRI designed protocol for a pelvis and pelvic floor examination. A key element of the protocol was the use of a diffusion-weighted imaging (DWI) technique with echo planar imaging (EPI) sequence (b-values of 0, 100, and 600) for the neurographic evaluation of the nerve. Results: MRI examination revealed DWI abnormalities in 42/81 patients. Pudendal nerve abnormalities were unilateral in 33/42 patients and bilateral in 9/42. Moreover, in 23/42 patients, pathologies related to a high probability of neuropathy have been identified. Conclusions: This study highlights the role of pelvic MRI as a valuable imaging modality in the evaluation of patients with chronic pudendal neuralgia. In the study protocol we propose, an essential role is played by the DWI technique, which improves the visual definition of the pudendal nerve and related anatomical structures. By focusing on anatomical visualization and structured image interpretation, our work provides a practical imaging-oriented contribution to a field in which standardized MRI evaluation is still lacking.