For over fifteen years, the European Hospital has dedicated special attention to the diagnosis and treatment of cardiovascular diseases. It is home to the Department of Cardiac Surgery and Interventional Cardiology Unit and is fully accredited by the Lazio Region. Since 1990, more than 20,000 patients in the National Health Service have made use of its free healthcare services provided on an inpatient and outpatient basis, as well as its ultra-modern diagnostic equipment, and rapid, high quality clinical treatment and hospitalization services. The Department treats all kinds of cardiovascular disease, from coronary heart disease to heart valves, aortic aneurysms, congenital diseases and arrhythmias. Its cardiology and heart surgery teams are available 24 hours a day.
|WHAT IS CORONARY ARTERY BYPASS GRAFTING?|
Coronary artery bypass grafting (CABG) is a type of surgery that treats ischemic heart disease (IHD).
Ischemic heart disease refers to a variety of diseases of different etiology, the unifying pathophysiologic factor being an imbalance between metabolic demand and the supply of oxygen to the myocardium. In the majority of cases, ischemic heart disease is secondary to obstructive coronary atherosclerosis. The coronary arteries are the blood vessels that supply oxygen-rich blood needed to nourish the myocardium (heart muscle).
The purpose of CABG surgery is to bypass the point at which the affected coronary artery has narrowed or is completely blocked, thus allowing that part of the heart muscle to be revascularized, i.e. receive blood and consequently oxygen. In order to maintain effective cardiac activity, it is essential to supply a constant and uninterrupted flow of oxygen-rich blood through the coronary arteries, as the heart never stops beating and cannot store energy.
|WHEN IS SURGERY NECESSARY?|
Today, there is no doubt, and numerous multicentre studies have demonstrated the advantages, in terms of survival and improvement in the quality of life, of surgery compared medical treatment for patients suffering from diseases of the common trunk of the left coronary artery, or of the whole coronary tree, or with a left ventricular dysfunction.
One should however keep in mind that the type of treatment required varies from patient to patient and that each treatment option (together with its risk-benefit analysis) should be discussed with a trusted specialist.
|HOW IS CABG SURGERY PERFORMED?|
CABG is a procedure performed by a specialist cardiothoracic surgeon. The most frequently used technique is a longitudinal incision in the centre of the front chest wall through the sternum. This incision is called a midline sternotomy.
Through this incision the surgeon accesses the heart and aorta. The patient is connected to a heart-lung machine. At this point the heart is stopped by infusing a cardioplegic solution into the coronary circulation. The surgeon performs the bypass procedure through a small incision downstream from the blocked artery.
As soon as the bypass surgery is completed, the heart is supplied with blood and starts beating again; extracorporeal circulation is cut off and the skin incision is closed. The patient is then transferred to the intensive care unit.
Initially, all bypasses were performed by suturing a segment of the saphenous vein (taken from the patient’s leg) to the obstructed coronary artery; the other end of the vein was then sutured to the ascending aorta. However, the results of venous revascularization soon proved unsatisfactory: saphenous veins were sometimes of poor quality, for example, because of the presence of varicose veins, or the difference in size between the saphenous vein and the coronary vein (this explains why some 10-20% of bypass grafts become blocked), or the high prevalence of atherosclerosis (after about 8 years, 50% of bypass grafts become blocked, and those still functioning have artery walls sometimes in worse condition than the original coronary vein). In order to enhance the duration of post-operative benefits, new ducts have been tested. In the early 1980's, the left mammary artery (also known as the left internal mammary artery or “LIMA”) was used as a graft. It is an artery that runs next to the sternum inside the thoracic cavity.
Bypasses performed using the mammary artery soon proved superior, both in terms of short- and long-term patency, and ultimately, improved short- and long-term patient survival. According to recent publications on the benefits of using both mammary arteries in a series of patients, there has been in recent years a significant increase in total arterial myocardial revascularization.
To increase the long-term benefits of surgery, there is a tendency today to use multiple arterial grafts instead of venous grafts, with the expectation that their longer life span decreases the risk for future surgery. Very recent techniques such as "Y grafts" or the use of the right gastroepiploic artery and the radial artery, are the flagship of revascularization procedures at European Hospital. Depending on the localization of lesions in the coronary arteries, mammary arteries can be utilized in situ, i.e. maintaining their origin in the subclavian artery.
When a complete revascularization of the left coronary territory with two mammary arteries is not possible in situ, this objective can be achieved with T or Y arterial composite grafting. The beating-heart surgery technique (without stopping the heart) has also been used for many years.
|WHAT ARE THE RISKS OR POSSIBLE COMPLICATIONS?|
Myocardial revascularisation is still considered a major operation. When undergoing surgery, the patient is exposed to a number of potential risks which depend on a number of factors related to the patient's overall health. The most common risks include post-operative bleeding, infection, stroke, perioperative myocardial infarction, renal and respiratory failure, and death. The most threatening risk factors for patients are age, left ventricular function, general health and the presence of associated diseases (in particular peripheral vascular disease, diabetes mellitus, renal failure and/or respiratory failure). Statistically, a patient undergoing surgery with a preserved left ventricular function, in generally good condition, and without serious associated diseases, has a low level of risk, oscillating between the 0.8-1.5%.
|WHAT TO EXPECT AFTER SURGICAL REVASCULARIZATION?|
The long-term results of CABG are excellent. Most patients obtain lasting relief from angina symptoms and the risk of ischemic myocardial damage (infarction). Many patients report a better quality of life and recent studies have also shown an increase in life expectancy in patients who underwent CABG surgery.
A small percentage of patients need a second operation (typically about 10 years after the first); but thanks to the exclusive use of arterial conduits, we are convinced that the need for a second operation decreases significantly with time.
|WHAT TO EXPECT AFTER AN OPERATION?|
Chest pain disappears after successful surgery, but the patient may suffer from incisional discomfort. A patient is usually discharged after about a week. Full recovery after surgery can take up to two months because most of the body’s resources are initially utilized for recovery from surgical trauma.
|WHAT IS A MITRAL VALVE?|
The mitral valve is located between the left atrium and left ventricle. Oxygen-rich blood from the lungs flows into the left atrial cavity and reaches the left ventricle through the mitral valve, from where it is pumped throughout the body. During ventricular contraction, the mitral valve normally closes to prevent blood from flowing backwards into the left atrium. The valve has two flaps (cusps), connected to the ventricular papillary muscles by the tendinous chords. These chords generally regulate the perfect closure of the two valve flaps to prevent the backflow of blood. In the diagram below, the red arrow indicates the mitral valve. The valve leaflets, chordae tendineae and papillary muscles, are also visible. During diastole, the mitral valve opens and blood travels from the left atrium to the left ventricle. During systole (when the ventricles contract), the mitral valve closes so that blood can flow into the ascending aorta through the aortic valve, and from there, to the whole body. The mitral valve can become diseased and insufficient (i.e. the valve does not close properly and allows blood to flow backwards from the left ventricle into the left atrium), or the valve may not open properly as in aortic stenosis (a narrowing of the aortic valve opening), or a combination of both defects.
WHAT ARE THE CAUSES OF MITRAL VALVE DISEASE?
Often, mitral valve disease is simply due to degeneration, sometimes associated with excessive weakness of the flaps and of the chordae tendineae, which may stretch and even snap. Ischemic heart disease, by altering the mobility of the ventricular walls, can sometimes alter the alignment of the valve leaflets and cause mitral insufficiency. Diseases such as rheumatic fever can affect the mitral valve, causing retraction, fibrosis and fusion of the valve leaflets. Sometimes the valve develops infective endocarditis when small cauliflower-like masses, called vegetations, form at the site of infection. Mitral valve repair represents around 10-15% of adult cardiac surgery.
|WHAT ARE THE OPTIONS FOR SURGERY?|
Often the mitral valve can be repaired with specific surgical techniques. Mitral valve repair guarantees better performance of the heart muscle, avoids the use of anticoagulants, and provides greater resistance to infection.
Sometimes the mitral valve is seriously damaged and cannot be repaired or the repair of a faulty mitral valve cannot be guaranteed. In such cases, mitral valve replacement surgery is necessary.
A) REPAIRING THE MITRAL VALVE
The easiest corrective surgery is a COMMISSUROTOMY, i.e. surgical separation of the two leaflets of the mitral valve, which are fused together at their "commissures" (points of touching). This fusion is triggered by rheumatic heart disease, which causes scarring, and leads to aortic valve stenosis with a tendency for disease progression. Today, this technique is used less frequently than in the past because it does not give good long-term results. Mitral valvuloplasty is used more frequently when the mitral valve becomes damaged or diseased, for instance, Cleft Mitral Valve, a congenital disorder associated with a particular type of atrial septal defect; prolapse of one or both flaps due to stretching or rupture of the string-like tendons; Floppy Valve Syndrome (literally, a softened valve) where all of the valve components are enlarged and elongated; certain forms of endocarditis; and finally, secondary alterations in ischemic heart disease (an area of the ventricle, a previous infarction site, dilates and pulls down a part of the mitral valve chordae tendineae: the two valve flaps no longer fit together normally and the valve becomes less efficient). However, it is important to remember that, based on preoperative data, the surgeon can estimate the probability of valve repairability, but cannot guarantee its success. Only after having seen the valve and evaluated its structural soundness, can the surgeon decide which strategy to adopt for the patient’s benefit.
Often, the cause is simply valve degeneration, sometimes associated with excessive weakness of the flaps or chordae tendineae structures, which may stretch and even break. Ischemic heart disease, by altering the mobility of the ventricular walls, can sometimes alter the alignment of the valve leaflets and cause mitral insufficiency. Diseases such as rheumatic fever can affect the mitral valve, causing retraction, fibrosis and fusion of the valve leaflets. Sometimes the valve develops infective endocarditis: small cauliflower-like masses, called vegetations, form at the site of infection.
PHASES OF SURGERY
|WHEN IS SURGERY REQUIRED?|
A decision on the timing of surgery requires a careful risk-benefit analysis, but also, as already noted, an evaluation of the risks of delaying surgery in the presence of cardiac dilation and arrhythmias, which, if chronic, require anticoagulation therapy. Indications for surgery are in continuous and constant evolution. In fact, it has recently been shown that surgery performed earlier in the disease process, stops the progression of dilated cardiomyopathy, responsible for degradation of both the ventricular function and the occurrence of arrhythmic disorders (in particular ventricular extrasystole, atrial fibrillation and paroxysmal tachycardia). In general, heart failure symptoms and/or the need to take diuretics to control the symptoms, are considered indications for surgery in the short and medium term. More nuanced situations require careful evaluation and monitoring over time to evaluate the progression of symptoms.
|WHAT ARE THE RESULTS OF MITRAL VALVE REPAIR?|
At the preoperative evaluation stage, the likelihood of repairing a dysfunctional valve can be evaluated, but not fully guaranteed. The valve, if repairable, has a good chance of lasting a long time, and this is especially true for degenerative alterations (ruptured chordae tendineae, prolapsed leaflet, annular dilation). Statistically, a repaired valve has an 85-95% chance of not requiring another operation in the next ten years. If the valve was damaged by rheumatic fever, pathological changes may continue to progress even after surgery making the duration of the repaired valve less predictable. For this reason, many surgeons are reluctant to repair rheumatic valves. Valvuloplasty procedures for secondary alterations in ischemic heart disease are the most difficult to predict because another variable comes into play: the left ventricular segmental function.
|WHAT ARE THE RISKS OF SURGERY?|
The risks of mitral valve replacement are evaluated by the cardiac surgeon and anaesthetist based on multiple factors. The graphs, provided by the American Society of Thoracic Surgeons (STS), show the results of a statistical analysis on a large number of patients operated on in recent years.
|WHAT TO EXPECT AFTER SURGERY?|
After a period of convalescence and rehabilitation, patients who have undergone mitral valve reconstruction surgery typically enjoy a significant reduction in symptoms and a marked improvement in exercise capacity and effort tolerance.
It may take two to three months to fully recover after surgery. Once the surgical wound has healed (about forty days), there are generally no significant limitations to physical activity.
B) MITRAL VALVE REPLACEMENT
Today, there are generally two types of prosthetic heart valves: MECHANICAL and BIOPROSTHETIC, each with its advantages and characteristic defects..
Mechanical heart valve prostheses have excellent durability thanks to the hard materials they are made of. In fact, they consist of a steel alloy ring with a carbon coating and two movable carbon leaflets. This type of material does not erode and therefore the life expectancy of a mechanical prosthesis is practically unlimited. The main disadvantage of these valves is that the patient will need to take anticoagulants for life. When blood comes into contact with artificial materials such as carbon, it tends to form clots that may stick to the prosthetic valve preventing it from functioning. The patient will thus have to take a daily dose of anticoagulant medication and undergo regular blood tests (every 3-4 weeks) to check the extent of anticoagulation (if too low, blood will still coagulate; if too high there is a risk of bleeding).
Biological heart valve prostheses are harvested from animal sources, or made from tissues such as the pericardial membrane of animals (cows and pigs). Patients with biological valves require an anticoagulation therapy for only a short period (typically 3 months). In fact, blood does not tend to coagulate when in contact with these tissues. Their main disadvantage is their limited durability, which is inversely proportional to the patient’s age.
In young patients (under 40 years), these valves last a maximum of 8-10 years, while in older patients, they can last 15 years (or even longer in rare cases).
This difference is due to the metabolism of calcium which is more active in younger people but less active in older people. Calcium deposits tend to accumulate in the valve leaflets causing them to become hardened and calcified.
|WHAT ARE THE RISKS OF SURGERY?|
The risks of mitral valve replacement are evaluated by the cardiac surgeon and anaesthetist based on multiple factors.
|WHAT TO EXPECT AFTER SURGERY?|
After a period of convalescence and rehabilitation, patients who have undergone mitral valve reconstruction typically enjoy a significant reduction in symptoms and a marked improvement in exercise capacity and effort tolerance.
Full recovery usually takes up to 2-3 months after surgery. Once the surgical wound has healed (about forty days), there are generally no significant limitations to physical activity. It is good practice to carry a wallet identification card to identify you as a carrier of prosthetic heart valves.
|WHAT IS AORTIC ROOT SURGERY?|
Surgery is necessary in all cases of aortic aneurysms, which may or may not involve aortic valve insufficiency.
Con valvola aortica normofunzionante:
Simple replacement of the aneurysmal aorta with a Dacron tubular graft.
When the aortic valve functions normally:
A. With aortic valve replacement:
Wheat procedure: replacement of the aortic valve (with biological or mechanical valve prosthesis) and replacement of the ascending aorta (with a Dacron graft) without re-implanting the coronary ostia on the tubular prosthesis.
Bentall’s procedure: simultaneous replacement of the ascending aorta and aortic valve with a tubular heart valve prosthesis (mechanical prosthesis) and re-implantation of the coronary ostia on the tubular prosthesis. This surgery is performed when there is aneurysmal dilation of the initial portion of the aorta (aortic root and ascending aorta) and in cases of ascending aorta dissection following aortic valve disease. It consists in using a tube made of synthetic material holding in its interior a mechanical prosthesis valve to replace both the aortic valve and the ascending aorta.
The coronary ostia that originate from this segment of the aorta are re-implanted in the tube. An alternative conduit to replace the aortic valve and the closest ascending aorta segment (aortic root), is the aortic root, removed from a human cadaver (aortic homograft) or a pig’s heart.
B. With aortic valve preservation:
Yacoub technique: substitution of the ascending aorta with a tubular Dacron graft positioned on the three valve leaflets which are suspended inside the prosthesis, and re-implantation of the coronary ostia. This surgery is performed when there is aneurysmal dilatation of the initial portion of the aorta (aortic root and ascending aorta) and in cases of ascending aortic dissection with a morphologically normal aortic valve. It consists in replacing the ascending aorta with a prosthetic tube graft starting from the valvular plane, preserving the native aortic valve. In this type of surgery, the coronary ostia that originate from this segment of the aorta are reimplanted in the tube.
Tirone David technique: replacement of the ascending aorta from the heart base with a prosthetic Dacron tube graft and suspension of the aortic valve within the graft with re-implantation of the coronary ostia. With this technique, also called "re-implantation”, a straight Dacron tube is sutured onto the base of the aortic root, and the native aortic valve is sutured back onto its interior. The coronary arteries, which start at the aortic root, are detached and sutured back onto the prosthetic tube graft.
In cases where aortic aneurysmal dilatation extends distal to the origin of the carotid artery, it is sometimes necessary to perform distal anastomosis of the prosthesis tube to the native aorta under temporary circulatory arrest and cerebral perfusion via selective cannulation of the anonymous arterial trunk and left common carotid artery.
|WHAT IS AN AORTIC VALVE?|
The aortic valve is located between the left ventricle and the aorta. The left ventricle is that part of the heart responsible for pumping oxygenated blood to the whole body along the aorta. The aortic valve opens during ventricular systole (i.e. when the heart contracts to pump blood). It allows blood to flow into the aorta, and when it closes, it prevents blood from flowing back into the ventricle during diastole (i.e. the period during which the ventricles are filling and relaxing before the next contraction). In the diagram, the aorta is coloured in red and the valve is located at the beginning of the aortic bulb.
|WHY REPLACE IT?|
The aortic valve can malfunction for several reasons: there may be a congenital malformation requiring immediate corrective surgery if severe, or the individual may be predisposed to degenerative changes later in life; or may be afflicted with diseases that affect the aortic valve. A bicuspid aortic valve is the most common congenital anomaly.
Typically, the aortic valve has three valve cusps or leaflets, but sometimes there are only two leaflets. A bicuspid valve is present in 1-2% of the population, and is the second most frequent disorder that requires surgery. These valves can function relatively well for many years before becoming stenotic (the orifice becomes too narrow) or insufficient (they are no longer able to close properly).
The most frequent cause of valve disease needing replacement is senile degeneration. This simply means that, with time, calcium deposits harden the valve and prevent it from functioning. The second most common cause is rheumatic heart disease, which causes thickening and scarring of the leaflets, leading to aortic valve stenosis and insufficiency. Other less common causes of aortic valve disease are infections (such as endocarditis), prolapse of one of the leaflets, and diseases such as aortic aneurysms and dissections.
|WHAT ARE THE SYMPTOMS OF AORTIC VALVE DISEASE?|
A diseased aortic valve can cause a number of different symptoms, including fatigue, exertional dyspnea, angina pectoris, palpitations, dizziness and syncope.
A diseased aortic valve can cause a number of different symptoms, including fatigue, exertional dyspnea, angina pectoris, palpitations, dizziness and syncope.
Initially the symptoms are present under strain, but as the disease progresses the symptoms occur as a result of increasingly milder efforts and finally even at rest. This can result in the inability to sleep in a horizontal position or lead to abrupt awakening because of difficulty in breathing. Another sign of failure is the swelling of the ankles, especially in the evening.
Medications may help for a while to relieve the symptoms, but when the valve function fails, your cardiologist will recommend a visit to a cardiac surgeon to schedule surgery. Some tests (echocardiogram, cardiac catheterization with coronary angiography) will help establish the proper timing for surgery and rule out any concomitant diseases (e.g. coronary artery disease).
|WHAT ARE THE CHARACTERISTICS OF PROSTHETIC HEART VALVES AVAILABLE TODAY?|
Today, there are generally two types of prosthetic heart valves: MECHANICAL and BIOPROSTHETIC, each with its advantages and characteristic defects.
Mechanical heart valve prostheses have excellent durability thanks to the hard materials they are made of. In fact, they consist of a steel alloy ring with a carbon coating and two movable carbon leaflets. This type of material does not erode and therefore the life expectancy of a mechanical prosthesis is practically unlimited. The main disadvantage of these valves is that the patient will need to follow an anticoagulant therapy for life. When blood comes into contact with artificial materials such as carbon, it tends to form clots that may stick to the prosthetic valve preventing it from functioning. The patient will thus have to take a daily dose of anticoagulant medication and undergo regular blood tests (every 3-4 weeks) to check the extent of anticoagulation (if too low, the blood will still coagulate, if too high there is a risk of bleeding).
Biological heart valve prostheses are instead harvested from animal sources (or made from tissues such as the pericardial membrane of animals (cows and pigs). Patients with biological valves require an anticoagulation therapy for only a short period (typically 3 months). In fact, blood does not tend to coagulate when in contact with these tissues. Their main disadvantage is their limited durability, which is inversely proportional to the patient’s age. In young patients (under 40 years), these valves last a maximum of 8-10 years, while in older patients, they can last 15 years (or even longer in rare cases). This difference is due to the metabolism of calcium, which is more active in younger people. Calcium tends to accumulate in the valve leaflets causing them to become hardened and calcified.
The latest bioprosthetic heart valves are treated with a particular chemical substance to lower calcification deposits on the surface of valve leaflets. Experimental studies have shown that this treatment can decrease calcification and increase valve durability. In special cases, other types of prosthesis can be used, such aortic homograft (from human cadavers), or a valve taken from the patient’s own body to replace the diseased aortic valve (Ross procedure). The decision on the type of valve to be used is made by the medical team, taking into account the patient's age, general condition, lifestyle and preference.
|WHAT ARE THE RISKS OF SURGERY?|
The risks of aortic valve replacement are evaluated by the cardiac surgeon and anaesthetist based on multiple factors. The graphs show the results of a statistical analysis of a large number of patients operated on in recent years, provided by the American Society of Thoracic Surgeons (STS).
|WHAT TO EXPECT AFTER SURGERY?|
After a period of convalescence and rehabilitation, patients who have undergone valve replacement surgery typically enjoy a significant reduction in symptoms and a marked improvement in exercise capacity and effort tolerance. It may take two to three months to fully recover after surgery. Once the surgical wound has healed (about forty days), there are generally no significant limitations to physical activity, except for the administration of anticoagulants. Antibiotic prophylaxis (as well as the removal of dental tartar) is required before any invasive surgery. It is good practice to carry a wallet identification card that identifies you as a carrier of prosthetic heart valves.
Ventricular restoration surgery is a technique that aims at reshaping the heart.
A heart attack (myocardial infarction), or a series of minor heart attacks over time, can weaken the left ventricular wall. In the long run, this process leads to a progressive thinning of the heart walls, which wear out and begin to dilate, leading to left ventricular aneurysm formation. The left ventricle becomes deformed and acquires a rounded shape.
To restore right ventricular morphology, it is necessary to remove a part of the ventricle wall and remodel the remaining part. This operation is in fact called left ventricular remodelling or restoration. Its importance lies in the fact that when the ventricle loses its original morphology, it also loses some of its pumping ability.
Form and function are in fact two aspects that are closely related in cardiology. So much so that a suitable remodelling of the ventricle can significantly improve the contractile capacity of the myocardium and restore good cardiac functional capacity.
|INTERVENTIONAL CARDIOLOGY DEPARTMENT|
The European Hospital has dedicated special attention to the diagnosis and treatment of cardiovascular diseases for over fifteen years. It is home to the Department of Cardiac Surgery and the Interventional Cardiology Unit, and is fully accredited by the Lazio Region. Since 1990, more than 20,000 patients in the National Health Service have made use of its free healthcare services provided on an inpatient and outpatient basis, as well as its ultra-modern diagnostic equipment, and rapid, high quality clinical treatment and hospitalization services.
The Department treats all kinds of cardiovascular disease, from coronary heart disease to heart valves, aortic aneurysms, congenital diseases, and arrhythmias. Its cardiology and heart surgery teams are available 24 hours a day.
The Interventional Cardiology Unit has two laboratories with the latest hemodynamic equipment (flat panel detector) where about 1,500 cardiac-catheterization and coronary angiography procedures, as well as 700-800 interventional procedures, are done annually, including coronary angioplasty with stent placement (even in emergencies for patients with acute myocardial infarction), percutaneous mitral valvuloplasty (Italy’s best centre since 2000 - data available on this website: www.gise.it), percutaneous closure of inter-atrial defects and patent foramen ovale, carotid artery stenting, intracoronary pressure and flow measurements and Intravascular ultrasound (IVUS) probes, pericardiocentesis, aortic stent placement, peripheral vascular angioplasty of the iliac-femoral and renal arteries, and Pacemaker (PMK) implantation.
The Interventional Cardiology team is supported 24 hours a day by the Anaesthetic and Resuscitation Service run by specialist cardiac anaesthetists for the treatment of cardiac patients.
|MEDICAL EDUCATIONAL CONFERENCES|
Research activity is documented by major scientific studies at international level. The European Hospital cardiology team is involved in several multicentre randomized trials. Some research results have already been presented at national and international conferences.
For educational purposes, the European Hospital has a closed-circuit television link to classrooms for live transmissions of surgery or diagnostic cardiology and interventional procedures, as well as a well-stocked online electronic cardiology library.
The European Hospital Studies Centre manages and coordinates all congresses, seminars and conferences that take place at the hospital.
Since 2004, the European Hospital has been home to the Scientific Editorship of the Giornale Italiano di Cardiologia Invasiva (Italian Journal of Invasive Cardiology), the official organ of the Società Italiana di Cardiologia Invasiva -SICI (Italian Society of Invasive Cardiology) which has a circulation of 6,200 copies. The journal publishes, by invitation, original and review articles on invasive cardiology. It represents a major reference point for interventional cardiologists all over Italy. The journal is available in printed and electronic form at the following website: www.ilgiornale.gise.it. Articles can be downloaded in pdf format.
|CARDIAC CATHETERIZATION AND DIAGNOSTIC ANGIOGRAPHY|
Cardiac catheterization and hemodynamic monitoring measure arterial pressure via the insertion of a catheter into the heart chamber through vascular access (e.g. the femoral vein).
Coronary angiography, ventriculography, and angiography, refer to the opacification of coronary arteries (arteries that supply blood to the heart), the ventricle or other vascular beds (e.g. carotid arteries), by injecting a contrast agent into the vascular system. To access the coronary arteries, left ventricle and other vascular beds, a catheter is usually inserted in the femoral artery (located in the groin), or more rarely into the radial artery (at the wrist), or the brachial artery (below the elbow crease), and, in special cases, through other vascular access. These catheters are advanced to the area to be studied. A contrast agent is injected allowing opacification and documentation by means of X-rays. These diagnostic tests provide high resolution images of the cardiac and vascular anatomy enabling precise identification of eventual diseases.
Potential risks of diagnostic testing
Some common, albeit rare risks and complications, related to coronary ventriculography and angiography, can be grouped into the following categories:
- Complications related to arterial puncture: Hematoma (collection of blood) or pseudoaneurysm at the puncture site, or, very rarely, arteriovenous fistulas; acute vessel occlusion (closure) due to thrombosis or embolus.
- Complications associated with catheters: Exceptionally, the following complications may occur: heart failure, neurological complications, myocardial infarction and death. These complications occur rarely, usually, but not exclusively, in patients in poor clinical condition, with acute chronic ischaemia, heart failure, kidney failure or respiratory failure.
- Complications related to contrast agents: These are usually due to allergic reactions or kidney damage.
Recovery after diagnostic tests
Patients should stay in bed for 12 hours after tests. If a mechanical closure device was used to close the arterial puncture (that forms a plug on the artery), the patient must stay in bed for six hours. In order to avoid hematomas and blood extravasation, it is essential that the patient always follows the doctor’s orders. For instance, failure to stay in bed after the procedure may cause a hematoma or pseudoaneurysm at the puncture site.
Angioplasty is a procedure, performed with balloon catheters that widen narrowed or obstructed coronary arteries or vascular segments (e.g. peripheral arteries, carotid arteries, etc.). Inflation of the balloon compresses plaque to the artery walls, widening the vessel wall and reducing the risk of artery re-narrowing.
Based on clinical and/or anatomical criteria, the surgeon decides whether to implant one or more stents. A stent is a small mesh metal tube, with a thin wall and a small balloon at its tip. When the balloon is inflated, the stent expands and locks in place in the artery. Within a few weeks/months, a thin layer of tissue will begin to grow over the stent, which will always remain fixed in the same position. The stent’s function is to repair vessel irregularities and keep clogged arteries open in case of refractory occlusion following dilation with a balloon catheter. In particular, it also significantly reduces the likelihood that the vessel will re-narrow (restenosis). In special cases, the surgeon may decide to implant a drug-eluting stent, the latest generation of stents, which markedly reduce risk of restenosis compared to conventional stents.
|MITRAL BALLOON VALVUPLASTY|
Mitral balloon valvuloplasty consists in introducing a balloon catheter on both sides of the mitral valve. The balloon is inflated to widen the stenotic mitral valve. Mitral balloon valvuloplasty is performed using transseptal catheterization, which consists in puncturing the inter-arterial septum of the heart (the structure that separates the left atrium from the right atrium).
|CLOSURE OF ATRIAL SEPTAL DEFECT AND PATENT FORAMEN OVALE|
To close atrial septal defects (ASD) or patent foramen ovale (PFO), a catheter is inserted by peripheral vascular access. The catheter contains a tiny, umbrella-like device folded up inside it. The device is positioned so that it plugs the hole between the right and left atria.
Chances of success and risks
Dilatation of coronary or non-coronary stenosis is a safe and effective procedure. The positive results of coronary angioplasty have been documented for twenty years. The chances of success are about 95%. The risks are low thanks to the use of stents: mortality is currently in the range of 0.2-1.5%. There is a risk, albeit extremely rare, of having to resort to urgent bypass surgery. There is also the risk of myocardial infarction due to necrosis of a secondary vein or part of the downstream vessel being treated.
Angioplasty, starting with the coronary angiogram, presents, in addition to the above risks, the same potential complications as mentioned for cardiac ventriculography.
The potential risks of carotid angioplasty are ischemia or cerebral haemorrhage. In the case of mitral valvuloplasty, transseptal puncture and ASD/PFO closure, possible risks are haemopericardium, cardiac tamponade, complex arrhythmias and death.
Recovery after surgery
After angioplasty, valvuloplasty and closure of ASD/PFO, the patient must stay in bed for about 24 hours. The short tube (sheath) through which the catheter was inserted in the peripheral artery, is removed immediately if the artery was closed with a mechanical haemostasis system, or according to the degree of blood clotting a few hours after the procedure and medications administered. To avoid hematomas and blood extravasation, it is essential that patients follow the doctor's orders regarding rest immediately after the procedure.
An aortic aneurysm is a dilation of the aorta, commonly located in the abdominal aorta. It can reach up to five times the normal diameter of the aorta.
Progressive increase in the size of the aneurysm does not produce any specific symptoms, until its fatal rupture. Ultrasound or CT scans can reveal aortic aneurysms.
Aortic aneurysm repair can be performed with minimally invasive endovascular techniques (positioning of an endoprosthesis inserted percutaneously through the groin), or with traditional surgery (replacing the dilated portion of the aorta with a prosthetic graft) depending on the anatomical characteristics of the aneurysm.
|CAROTID ARTERY STENOSIS|
The internal carotid artery that supplies blood to the brain can be affected by a progressive luminal narrowing of the artery (stenosis), caused by atherosclerotic plaque, with the risk of a disabling stroke and cerebral thrombosis.
An echo-color Doppler can reveal the presence of carotid plaque. This test is necessary especially in the presence of risk factors such as high blood pressure, high cholesterol, heart disease, peripheral artery disease, smoking, obesity, and diabetes.
Surgery usually involves the removal of plaque and remodelling of the obstructed artery segment (arterioplasty) in order to prevent cerebral stroke.
Our surgeons are also able to treat carotid artery stenosis with percutaneous balloon angioplasty. This procedure is particularly useful for elderly patients or patients with high surgical risk.
The presence of arterial atherosclerotic plaque in the lower limbs, which blocks blood flow, can prevent a person from walking uphill or for distances exceeding 200 meters. The progression of obstructive lesions may produce even more severe signs and symptoms, such as “rest pain” or skin ulcers in the lower extremities, especially in persons with diabetes. Following an angiological exam to evaluate circulatory disorders, an echo-color Doppler can provide accurate and precise data on disease severity. More advanced tests, such as traditional or magnetic resonance angiography, are reserved for more severe and complex cases.
Therapeutic measures depend on the severity of the disease. Patients are initially treated with appropriate medications and exercise. In cases of more severe obstructive lesions, which can also be limb threatening, traditional angioplasty or percutaneous surgery (peripheral bypass) is performed.
|VARICOSE VEINS IN THE LOWER LIMBS|
Varicose veins are dilated tortuous veins, which occur in the saphenous vein, and are superficially located on the thigh and leg. Besides the obvious aesthetic disadvantages, varicose veins are a potential health hazard for the leg, causing complications such as thrombophlebitis and venous ulcers. Following an echo-color Doppler exam, minimally invasive treatments are available under local anaesthesia (sclerotherapy, micro-incision, laser and radiofrequency) in a day hospital or short-stay hospitalization.
Diagnostic procedures include:
- Echo-color Doppler of the arteries and veins of the lower limb
- Echo-color Doppler of the carotid and iliac arteries
- Transcranial Doppler
- Digital Subtraction Angiography
- CT Angiogram
- 64-slice CT
- Magnetic Resonance Imaging (MRI)
- Magnetic Resonance Angiography (MRA)
An appointment with Outpatient Diagnostic Services can be fixed by calling: 06.65975180 - 06.65975185.
Therapeutic procedures include:
- Medical treatment of arterial occlusive disease
- Aortic bifemoral bypass and femoral popliteal bypass
- Angioplasty and stent placement
- Bypass for lower limb salvage
- Traditional surgical treatment of aortic aneurysms
- Endoprosthesis for aortic aneurysm repair
- Carotid artery surgery
- Carotid angioplasty and stent placement
- Varicose vein surgery of the lower limbs
- Vascular trauma surgery
- Combined surgery for heart and vascular diseases
Reception desk: 06.65975107 06.65975700
|Intensive care and reanimation|
The team’s areas of activity are:
- Monitored anaesthesia care 24 hours/day, 365 days/year, for patients in intensive care
- Ensure all hospital’s operating rooms are provided with anaesthesia services
- Ensure the prompt internal availability of emergency operating theatres
- Pre-anaesthesia evaluation of the cardiac patient and preparation for surgery
- Intra-operative anaesthetic management, hemodynamics monitoring, coagulation, thromboembolic events (TEE), neurophysiological monitoring, general anaesthesia monitoring combined with epidural and extracorporeal support
- Postoperative monitoring of intensive care patients, and management of postoperative renal failure
- Research efforts aimed at improving cardiac anaesthesia services, especially in terms of myocardial protection and optimum intraoperative inotropic support
- Arranging and conducting courses recognized by the Ministry of Health
|Pain management of intensive care patients|
Management of acute and chronic pain, due to malignant or benign processes, such as malignant neoplasms, neuralgia, joint inflammation, spine diseases, post-amputation pain, vascular disease and diabetes pain, etc. Pain management includes pharmacological treatment, peripheral nerve blocks and epidural nerve blocks.
|Pain management treatment|
The Centre’s clinical activity focuses on multidisciplinary diagnosis and multimodal treatment of acute and chronic pain syndromes.
The Centre studies pain and related disorders in order to provide the most effective pain and suffering relief treatments associated with the disease.
In order to identify the best analgesic treatment, the Centre’s approach to pain syndrome is primarily directed at identifying underlying causes, and initially seeking targeted therapies that focus on the mechanisms that generate acute or chronic pain.
The most painful conditions are:
- Arthritic pain
- Post-traumatic and post-surgical pain
- Lumbar radiculopathy, neck pain or back pain (also post-surgery)
- Neuropathic pain (post shingles, diabetic neuropathy)
- Complex Regional Pain Syndrome
- Orofacial pain (trigeminal neuralgia, temporomandibular joint dysfunction)
- Phantom limb syndrome
- Central Pain Syndrome (multiple sclerosis, post-stroke pain)
- Myofascial pain, fibromyalgia
- Cancer pain in ICU patients
The Centre’s clinical activity is divided into:
- Outpatient visits The Centre’s Clinique is available by appointment Monday to Friday (except for emergencies).
- Inpatient hospitalization The Centre provides beds for the diagnosis and treatment of advanced cancer patients.
The Centre uses the most modern therapeutic techniques and strategies, structured around a multi-modal approach, which aims at providing the best possible pain relief treatment. Even if it can be challenging to eliminate chronic pain, valid treatments are almost always available.
These may include:
- Scrambler Therapy (more information available)
- Drug therapy (anti-inflammatory drugs, opioids, psychotropic drugs, etc.)
- Local anaesthetic infiltration in painful trigger points
- Single-injection or continuous nerve blocks
- Neuromuscular electro stimulation techniques
- Placement of long-term central venous access devices, e.g. Port-a-Cath, peripherally inserted central catheter (PICC)
- 1. Specialist clinic;
- 2. Operating theatre for minimally invasive procedures and invasive ultrasound-guided and radio-guided procedures;
- 3. Ward beds for outpatients and inpatients.
The European Hospital S.p.A. is accredited by the National Health Service exclusively for heart surgery and interventional cardiology. It offers inpatient services for self-pay or patients with private insurance for the following specialist visits:
- Minimally Invasive Surgery
- Plastic, Reconstructive and Aesthetic Surgery
- Gynaecology and Reproductive Medicine
- Internal medicine
- Orthopaedics and Traumatology
- Clinical Neurology
For the provision of services linked to individual specialist units, the European Hospital provides the following outpatient diagnostic services:
- Laboratory for Clinical Chemistry and Microbiology, Immunology, Cytology;
- Histopathology Laboratory
- Diagnostic Imaging Service (fixed and mobile X-ray, 64-slice/sec. multilayer CT scanner, MRI)
- Ultrasound and Echo-Color Doppler Service
- Non-invasive Cardiology Diagnostic Service: ECG, Holter Electrocardiography and blood pressure evaluation, exercise stress test
- Physiokinesitherapy Service
- Endoscopy, Gastroenterology and Urology Service
- Diagnostic Neurophysiology Service (EEG, EMG/ENG)
Outpatient clinics for the following specialist visits are also available only to self-pay patients:
- General Surgery
- Reproductive Medicine
- Laparoscopic Surgery
- Dynamic Holter Electrocardiography
- Specialist outpatient visits
Day hospital surgery and inpatient treatment:
- digestive surgery
- hepatobiliary surgery
- abdominal wall surgery performed laparoscopically
- interventional endoscopy procedures
- rubber band ligation
- PEG tube placement
This discipline corrects congenital physical defects or defects due to accidents or other types of surgery. What matters is that plastic surgery deals with human tissue and the reconstruction of an organ or a lost function, with the aim of obtaining a result that is not only valid but also aesthetically pleasing.
That is why we consider it very important that cosmetic and reconstructive surgery complement each other.
Improving our appearance is certainly very rewarding and can increase our quality of life. A more pleasing appearance helps us feel more confident and content. To obtain real improvement and be satisfied with the results, you must first share your plastic surgeon’s philosophy and appreciate the results.
Consider for example a face: it has a particular shape and dimension. The plastic surgeon must take into account not only technicalities and rules, but also recognize the face’s natural beauty. For example, a big nose in a small face may not be harmonious because it diverts attention away from the eyes. A face with a thin nose, big eyes and prominent cheekbones, can look artificial. A mouth with thin lips can make a face look hard and unfeminine.
Beauty, even after surgery, lies in harmonious and symmetrical facial features. There are some people who have a facial feature that is naturally out of proportion and aesthetically excessive, but sometimes a big mouth, two big eyes or a big nose, look attractive on that particular face. It would be a shame to correct "a gift" of nature that makes a person look unique. That is precisely when the surgeon’s aesthetic sense comes into play. The surgeon must recommend what needs to be surgically corrected and what need not be corrected.
In recent years there has been a clear trend in hand surgery to continuously search for less invasive techniques. The most prominent was endoscopic carpal tunnel surgery for carpal tunnel syndrome which allowed a significant reduction in post-surgical recovery time from a very prevalent pathology.
The ability to dissect only the transverse carpal ligament responsible for nerve compression, without sectioning other structures, has rendered the surgery minimally invasive, not only reducing the surgical scar on the wrist by a centimetre, but especially, significantly reducing postoperative functional recovery time.
The same endoscopic techniques have been used to treat post-traumatic wrist osteoarthritis. Today, complex ligament repairs of wrist injuries and wrist arthritis are possible with endoscopic techniques.
The same carpal bones fractures, such as the scaphoid fracture, can in most cases be repaired by percutaneous osteosynthesis, that is with limited bone exposure, which is minimally invasive for the ligamentous structures and thus permits more rapid postoperative functional recovery.
Other hand diseases treated by our department are:
Dupuytren's disease, rizoarthrosis, , flexor tenosynovitis (trigger finger), la syndactyly and polydactyly, De Quervain's disease.
It is well known that infertility, a couple’s failure to conceive after at least one year of regular unprotected sexual intercourse, is constantly on the rise. Recent studies in France and Great Britain have shown that 15-20% of couples are unable to conceive after one year of regular unprotected intercourse. This reduced fertility rate is largely due to the average age increase of women trying to conceive for the first time and the huge increase in male infertility.
Over the past ten years there have been impressive advances in diagnosic methods but especially in infertility therapy for couples. The Service for Reproductive Medicine and Biology offers a range of infertility and laboratory investigations using the latest equipment. Test results indicate the best medical and surgical treatment for women and men.
In addition to ovulation monitoring, ovulation induction and intrauterine inseminations, the Service offers the latest technology and highly trained staff in the practice of assisted reproduction techniques. In vitro fertilization (IVF) is advised especially for cases of tubal factor infertility, idiopathic infertility and mild to moderate male factor infertility. For patients with severe and very severe oligo-astheno-teratozoospermia, the intracytoplasmic sperm injection (ICSI) is the treatment of choice.
In most cases of azoospermia, it is possible to retrieve sperm directly from the testis or epididymis, using surgical and microsurgical techniques to perform the ICSI procedure.
At the European Hospital Service for Reproductive Medicine and Biology, it is possible to achieve, using the above-mentioned assisted reproductive techniques, pregnancy rates ranging from 25% to 45%, correlated with the woman’s age.
In parallel to clinical and laboratory testing, research programmes are undertaken in collaboration with renowned Italian and foreign researchers.
Finally, a gynaecological diagnostic and operative endoscopy service is available to determine the causes of infertility and if treatment is possible.
The evolution of biomedical research has made available to doctors sophisticated medical diagnostic techniques and complex therapeutic methods.
The vast increase in knowledge in the field of medicine has encouraged the proliferation of different specialties. If, on the one hand, this phenomenon has boosted research, it has, on the other, harmed the common view that the patient functions as an integrated morpho-functional whole rather than as individual parts.
Currently, medical training is giving new attention to the formative role of internal medicine, which has become an indispensable part of specialist activity.
In the different medical specialties, endocrinology and metabolism have a special place in internal medicine as they involve virtually all the body’s organs and systems, as well as a significant impact on pathophysiological aspects, which are important for quality of life factors, such as aging, brain function, osteoporosis, sexual activity, etc.
In Italy, endocrine and metabolic disorders affect 30% of the population. A proper and rigorous, often complex, diagnosis can indicate a suitable treatment.
Based on this concept, the Centre for Endocrinology, Metabolic Diseases and Andrology at the European Hospital was set up to study and treat thyroid diseases, obesity, diabetes, growth and other endocrine diseases.
Modern and sophisticated techniques are also used in the field of andrology to study and treat sexual disorders (male infertility, impotence, etc.).
The Otolaryngology Service provides specialist outpatient services for the diagnosis and treatment of diseases that require special diagnostic tests, which are undertaken at the same healthcare centre. Patients receive a comprehensive assessment for the following diseases together with their medical and surgical treatment.
|Study of the nasal function|
Early detection of abnormalities in nasal breathing can prevent or reveal many nose and paranasal sinus diseases and allow the child to develop a more harmonious craniofacial appearance. It is possible to identify at an early stage damage to the mucous membranes lining the respiratory passages due to exposure to vapours and/or toxic substances. The morphology of the nasal and turbinate cavities, and the sinus ventilation cavity, can be evaluated with endoscopic and radiological investigations. Thanks to a nasal cytology test (simple removal of mucous from the turbinate surface) different forms of vasomotor rhinitis can be identified, and fungal or bacterial infections detected. This test, together with the prick test, provides a complete picture of the reactivity of the mucous membranes of the upper respiratory passages. The following diagnostic clinical investigations aim at studying the respiratory and olfactory functions and providing a detailed and accurate answer on the patient’s current clinical status, as well as monitor the results of both medical and surgical treatment:
- Otolaryngologist (ENT) specialist visit
- Nasal endoscopy
- Cytological examination of nasal mucosa
- Olfactometric examination
- Allergometric test
- CT scan of the nose and paranasal sinuses
|Snoring, sleep-disordered breathing and sleep apnea|
Monitoring cardio-respiratory parameters during sleep assesses the presence of breathing pauses (apneas or hypopneas) and oxygen desaturation. The number and extent of apneas, correlated with the patient's position, heart rhythm changes and thoracoabdominal movements, are studied in order to assess the degree of apnea and its origin (peripheral or central). In the presence of sleep apnea or obstructive sleep apnea, the patient experiences daytime sleepiness, impaired attention and concentration, as well as increased cardiovascular risk in the event of an Apnea Hypopnea Index (AHI) greater than 30 events per hour. In such cases, custom calibration and the prescription of mechanical ventilation is required, or alternatively, surgical treatment of the obstructive site. If the suspicion of chronic snoring or sleep apnea exists, further specific investigations are needed to verify if the following diseases are present: hypertension and cardiac arrhythmias, gastroesophageal reflux disease, headache, obesity, depression, chronic laryngitis, recurrent tracheobronchitis:
- Ear, Nose & Throat (ENT) specialist visit
- Cardiological visit
- Neurological visit
- Nasopharyngoscopy with Müller manoeuvre
- Nasopharyngoscopy under sedation - sleep endoscopy
- Cephalometric analysis
- Polysomnography and trials with bi-level mechanical ventilation
|Dizziness and hearing disorders|
Different types of hearing loss are evaluated by an objective assessment which uses optical endoscopy and otomicroscopy, in addition to instrumental exams such as audiometry, impedance and auditory brainstem response (ABR). Newborn infant hearing screening is also performed in the first weeks of life by studying otoacoustic emissions. Vertigo requires a multidisciplinary approach whereby the ENT specialist determines, with specific vestibular tests, whether the patient has a peripheral or central cause of vertigo. Tinnitus is evaluated by specialist counselling and acufenometry. Currently specific treatments such as Tinnitus Retraining Therapy (TRT), Tinnitus Phase Out Therapy, auditory masking, and supportive therapies are available.
- Ear, Nose & Throat (ENT) specialist visit
- Endoscopy and otomicroscopy
- Audiometric and impedance testing
- Auditory Evoked Potential
- Otoacoustic emissions
- Vestibular testing and involuntary eye movement (nystagmus) measurement with videooculoscopy, also for medicolegal purposes
- Medicated endotympanic insufflations
- Eustachian tube rehabilitation
|Newborn hearing screening with otoacuostic emissions|
(First level screening)
Voice disorders can be of functional or organic origin. Functional disorders result from improper use of the vocal mechanism, which includes voice misuse by professional voice users, while organic disorders are caused by inflammatory processes or the presence of laryngeal tumours. All specialist visits are supported by an endoscopic voice assessment and computerized voice analysis which allow an objective quantification of certain voice parameters. Once a diagnosis has been established, treatment should proceed with either medical treatment, rehabilitation therapy (speech therapy) or surgical treatment. The following services are available:
- Ear, Nose & Throat Specialist visit
- Flexible Endoscopy of the nose, pharynx and larynx
- Computerized voice analysis with Multidimensional Voice Program (MDVP)
- FonoLogopedia speech therapy
- Adenotonsillar hypertrophy, sleep respiratory disorders and chronic or recurrent inflammation (phlogosis) in adults and children
- Tonsillectomy and adenoidectomy
- Functional Rhinoplasty
- Turbinate decongestion surgery with radiofrequency performed under local anaesthesia
- Functional endoscopic sinus surgery (FESS)
- Voice disorder and dysphonia
- Diagnostic and operative microsurgery of the vocal cords and larynx
- Ear Surgery
- Roncopathy (snoring) and sleep apnea
- Minor and major surgery of the palate and pharynx
- Combined surgical techniques (nose - palate - pharynx)
The constant evolution of modern technology has provided the urologist with sophisticated tools to efficiently perform minimally invasive surgery, which has become more and more common today. Rapid progress in a fast-moving field is making current techniques obsolete.
In around 1970, urological endoscopy became a surgical technique and gradually replaced traditional methods. Prostate resection, resection of bladder tumours, and management of urethral stricture by transurethral resection, were the first steps towards minimally invasive surgery.
In 1980, extracorporeal shock wave lithotripsy enabled treatment of kidney stones without surgery. In 1987, the kidney stone centre (Stone Centre) was one of the first in Italy and the second in Rome to possess an extracorporeal lithotripter. Ureteral calculi were quickly removed with the insertion of an endoscope (a thin, rigid or flexible tube) known as the ureteroscope. The energy sources for fragmenting ureteric calculi were initially electrohydraulic, and then ballistic. Today the Holmium/YAG laser guarantees a “stone-free” outcome in one sitting.
The last two decades have been characterized by laparoscopic surgery. Its impact on multiple surgical disciplines has further accelerated minimally invasive surgery. Today, the value and importance of urologic laparoscopic surgery is well known. With high-performance optical systems, cameras and high definition (HD) monitors, surgical procedures are much more accurate and therefore a priori superior.
Postoperative recovery and resumption of normal activities are faster. Postoperative pain is significantly less and transfusion requirements are rare compared to open surgery. Laparoscopic surgery avoids large incisions, in particular, muscle plane incisions. Laparoscopic surgery has also led to the development of robotic urologic surgery. Radical Prostatectomy for prostate cancer has increased thanks to laparoscopic surgery. Initiated in France, it quickly spread around the world and is now the preferred technique for prostate cancer.
In addition to endoscopy, a routine exam today, and extracorporeal shock wave lithotripsy, our group has also developed laparoscopic surgery in urological oncology for the early treatment of bladder, prostate and kidney cancers.
The early detection of urological tumours has today led to standard methods that quickly help the surgeon select the most appropriate therapy or surgery for the patient.
Cancer patients receive regular follow-up testing and are closely monitored. This monitoring activity is important because of the tendency for these tumours to reoccur without treatment and without following the appropriate protocol.
We use a new generation lithotripter, capable of crushing stones without anaesthesia, available both in day hospital and ambulatory care. The latest technological advances in our possession are flexible ureteroscopes, such as the holmium: YAG laser that effectively fragments stones.
Today we correct urinary incontinence in women with genitourinary prolapse with laparoscopic promontofixation using the transobturator tape (TOT) procedure. For Peyronie’s disease also known as Induratio Penis Plastica (IPP) we use a specific lithotripter (a new frontier in the treatment of this disease) in addition to traditional methods.
Finally, benign prostatic hypertrophy (BPH) is treated both surgically and with transurethral resection using the Gyrus PK system that allows a bloodless operative field with the patient discharged 36 hours later.
More details are available on our website: www.chirurgiaurologicaroma.com. The information is clearly presented and easy to understand. It enables readers to become familiar with technical terms and methods of treatment, diagnosis and therapy. The objective of this site is to provide the patient with information on the various techniques available, or not available.
The neurosurgery service, headed by Prof. Romano Greco, relies on the clinic’s high level diagnostic, instrumental and organizational capacity.
The more complex neurosurgery procedures are performed in a completely safe, comfortable and pleasant setting.
High-quality, technically advanced and continuously updated diagnostic tests include, among others:
- Multilayer spiral CT
- NMR and cerebral angiography
- Morphodynamic and radiological analysis
These tests are routinely performed to obtain detailed information prior to surgical procedures and for serial postoperative monitoring.
All neurological, brain and spinal disorders are treated at the European Hospital: from cranial and spinal trauma to cerebral aneurysms; from spinal tumours to intracranial neoplasms. Microsurgical techniques are used for the excision of tumours that are difficult to reach, eliminating or greatly reducing possible damage to nervous tissue. This also applies to spinal tumours, such as meningiomas or schwannomas, which, if operated on in time, permit the complete disappearance of serious paralysis, such as quadriplegia or paraplegia, and recovery of normal motility and ambulation. Microsurgical treatment of intracranial aneurysms and angiomas, as well as microsurgery of lumbar disc herniation, allows surgery to be performed with maximum safety for the patient.
The surgical treatment of lumbar herniated disc is a standard microsurgical procedure, usually performed without general anaesthesia and allows the patient to be discharged on the same day as surgery.
Herniated cervical discs are treated with microsurgical approaches. An artificial disc implant can restore normal movement to the cervical spine: extension (left), flexion (right) and help avoid grafts or mechanical fixation. However, when the cervical disc is not 'recoverable' it can be replaced with a fully functional artificial disc to maintain or restore normal kinematics of the cervical spine (Bryan disc). Our neurosurgery in this field is well known for its extensive experience and expertise nationally and internationally, and can be considered the centre of excellence for herniated disc microsurgery, and for all cervical, dorsal and lumbar spinal diseases. In spinal disease treatment, we routinely perform the most advanced bone grafts, to stabilize the spinal bones, with continuously and systematically updated medical equipment.
Trigeminal neuralgia and hemifacial spasm (facial twitching) are treated with microsurgery that eliminates the cause of the disorder (neurovascular conflict).
Hydrocephalus is treated with variable pressure valves, which can be adjusted electronically from outside the body; or, based on the doctor’s indications, a neuroendoscopic approach can be used to establish a new pathway for cerebrospinal fluid circulation without the use of extraneous materials.
Prof. Steiner, University of Virginia (USA), works closely with our Neurosurgery Service, placing at the disposal of patients his experience in the Radiosurgery field, perhaps best known to the public as 'neurosurgery without scars'. Finally, one must not forget the favourable psychological dimension created by our friendly environment and reassuring, efficient and collaborative medical staff. This may contribute to reducing the hospital stay of patients after brain surgery and leave them with good memories of their surgical experience.
Prof. Romano Greco, Dr. Marco Brunori, Dr.ssa Anna Maria Vitale
Welcome to this site.
My name Othello Poli. I graduated in Medicine and Surgery in 1984 and specialized in Neurology in 1989. I further specialized in Pain Therapy in 1991 (Hospital Medical School, Lazio Region). I initially attended the Postgraduate School of Neurology at the University of La Sapienza in Rome. I began as a Neurologist with a strictly intensivist footprint (acute cerebrovascular disease, stroke and epilepsy).
At the European Hospital, I am responsible for the Division of Clinical Neurology and Instrumental Diagnosis of Neurophysiopathology. The Division’s collaboration with colleagues from the Department of Cardio-Vascular Sciences, Intensive Care Unit and other operating units, allows optimum treatment of all neurological disorders, from acute to chronic neurodegenerative conditions (Alzheimer's disease, Parkinson’s disease, tremor and other movement disorders), either as outpatient or, if necessary, with brief hospitalization.
The treatment of pain also deserves attention (headache, migraine, trigeminal neuralgia, post herpetic neuralgia and all other forms of neuropathic pain). In this respect, I collaborate with the Pain Treatment Centre of this Hospital.
My Division provides the following clinical and instrumental diagnostic services:
- clinical neurology
- elettroneurography of the upper and lower limbs
- elettroneurography of the facial muscles and blink reflex (particularly indicated for facial palsy and trigeminal neuralgia)
with the possibility for further investigation, after a preliminary clinical evaluation by this Division, in selected cases, such as drug resistant epilepsy, sleep-wake disorders, sleep disorders (nocturnal/morpheic epilepsies, narcolepsy, parasomnias, sleep apnea treatment for stroke prevention) with:
- dynamic Holter electroencephalography
- possibility of camera video recording
Among my collaborators, it is certainly worth mentioning the fundamental professional activity performed by Dr. Eleonora Bottoni, who graduated in Neurophysiology techniques at the University of La Sapienza in Rome in 2009. In addition to her high level of professionalism, she can boast of extensive study and work-related experiences abroad.
The Department of Coloproctology, a complex care unit, was founded in 1992. It is currently directed by Dr. Attilio Nicastro and is at the forefront of benign proctological diseases (haemorrhoids, fissures, fistulas, warts, etc.). Its techniques aim at resolving post-operative pain, and the prevention and treatment of colorectal cancer and inflammatory diseases.
The Department has a section dedicated to research and experimentation of new technologies and the implementation of new surgical and medical techniques, thanks to which a new diagnostic instrument for anorectal disorders, the Digital Videoproctoscopy©, has been designed, tested and patented. Numerous studies published in important national and international medical surgical journals have resulted from this research.
The diagnostic section, in collaboration with the entire structure of the European Hospital, uses modern radiological methods (Dynamic MRI, Virtual Colonoscopy, Ecotomography, Video Defecography), functional methods (Urodynamics and Anorectal Manometry), and diagnostic and operative endoscopy. The Department has a care centre for patients who have undergone digestive and urinary ostomy and provides oncological follow-up care, stoma care and management, as well as stomal therapy.
The Department has a section dedicated to the diagnosis and treatment of pelvic floor dysfunction, particularly constipation, faecal and urinary incontinence and sexual dysfunction. In addition to surgical techniques, rehabilitation treatment is provided such as pelviperineal electrostimulation, biofeedback and Extracorporeal Magnetic Innervation.
The European Hospital has a Physical Therapy and Rehabilitation Department run by highly specialized staff.
Its highly skilled labour force and technical staff offer the following treatment:
- postural gymnastics
- low-intensity exercise
- static and dynamic equilibrium techniques
- proprioceptive re-education
- relaxation techniques
- neuromotor rehabilitation
- respiratory gymnastics
- massage therapy
- lymphatic drainage
Recovery time following injuries and surgery is reduced thanks to the wide variety of exercise equipment available.
The centre also provides all types of commonly used physiotherapy such as hyperthermia therapy, pressure therapy and laser therapy.
The centre also boasts modern Shock Wave Therapy Equipment.
This is a new minimally invasive and extremely effective therapy that promotes faster soft tissue healing and bone injury healing.
Its main purpose is to effectively cure joint pain and heal bones in cases of non-union, avoid surgery, reduce costs and healing time.
Tendinopathies and Enthesopathies: inflammatory or degenerative diseases, related to tendons and their insertion sites on bone segments.
Muscle injuries: spasticity, contractures, sprains, partial tears, bruises, Peyronie disease (IPP), pseudoarthrosis and non-union, para-osteo-arthropathy (POA), ischemia and necrosis.
|Multi-slice TC Scan (64 slice)|
A new Computer Tomography Unit has been set up at the European Hospital’s Diagnostic Imaging Service, based on the most advanced, high-performance technical solutions currently available.
The new Brilliance 64 CT Scanner produced by Philips Medical System uses a 64-row detector and is capable of simultaneously gathering high-resolution images in 0.4 seconds, 64 body slices, with a spatial resolution of 0.34 mm (gathering a Total Body scan in 6-8 seconds). It represents the latest product in recent multi-layer technology and offers excellent and stimulating opportunities for the most sophisticated clinical and diagnostic applications.
The CT investigations we carry out include neuro, body, bone and joint scans with three-dimensional reconstructions:
- CT of Skull, Neck, Thorax, Abdomen, Pelvis
- CT of joints and spine
- CT of Feet (patellofemoral joint, TT-TG calculation, the femoral anteversion angle, tibial torsion assessment)
As well as unique and innovative imaging methods:
- Cardiac CT (Coronary CT)
- Quantitative Coronary Artery Calcification test (Calcium Scoring)
- Advanced Vessel Analysis (AVA) and CT Pan-angiography
- Qualitative evaluation of carotid plaque
- CT urography
- Pulmonary nodule imaging
- CT virtual endoscopy (rhinosinusitis imaging, cystoscopy, bronchoscopy, colonoscopy, endovascular navigation)
- Functional imaging
- Dentalscan, QCT bone Densitometry
|1,5 Tesla MRI Scanner|
The equipment at our disposal guarantees excellent quality diagnostic examinations of each body part thanks to its high intensity magnetic field,. Magnetic resonance imaging (MRI) has a high spatial resolution, an excellent tissue contrast and the advantage of not emitting ionizing radiation. The contrast agent, used in specific cases, increases the contrast between tissues. It allows characterization of the type and degree of vascularity of solid masses, and an angiographic assessment of the various anatomical regions. Finally, a multiplanar study completes the spatial information.
The magnetic resonance (MR) investigations we offer cover neurological, body and osteoarticular examinations:
- Dynamic 3D studies of ears, orbits, sella, APC, ATM
- MR Angiography, neck and intracranial
- MR Angiography, visceral and peripheral
- Dynamic parenchymal study
- MR Cholangiography
- Breast MRI
- MR Spinal column and meninges
- MR Arthrography
- Skeletal system
- Respiratory System
- Gastro-intestinal radiological exam
- Urogenital system
- Paediatric Radiology
- Morphometric examination
- Osteoarticular ultrasound
- Varicoceles treatment
|What is CT?|
Computed tomography, abbreviated CT, is a radiodiagnostic technique that uses beams of ionizing radiation (X-ray) that traverse the body and produce, with the aid of a computer, cross sectional images (tomography) of body structures. It is also known as computed axial tomography or CT scan. The adjective "axial" has become obsolete: modern equipment produce scans on an axial plane, but the resulting images can be reformatted in different planes. In the Seventies, the earliest state-of-art clinical applications only allowed the structures of the skull to be studied (the first tomographic computer was installed at Atkinson Morley Hospital in London in 1971). Today, any part of the body, from head to chest, to abdomen, can be studied in detail, as well as the skeleton, soft tissue, parenchyma and blood vessels. Thanks to rapid technological progress, CT is used today in cardiology diagnostics to analyse heart and coronary health (Cardiac CT).
|Spiral CT? Single-slice? Multislice? Spiral CT image acquisition|
In computed tomography an X-ray tube (source of the X-ray beam) rotates around the patient, and a detector, on the opposite side, picks up cross-sectional images of the patient. The patient table slides inside a tunnel where the scanning takes place. During each round, different sectional views of the patient’s body are generated. Helical (spiral) CT image acquisition takes place by means of continuous rotation of the X-ray tube while the patient table moves on a sliding surface: the X-ray tube and detector perform a ‘spiral’ or ‘helical’ movement with respect to the patient, thus producing a spiral scan. Spiral CT scanners can obtain single- or multiple-slice images of a body section in a single rotation. Current technology allows 64 submillimetre body slices (64-slice CT) per rotation lasting 0.4 seconds: approximately 8 seconds are sufficient to analyse the whole body.
|When and how to perform a CT scan?|
A CT scan is required when doubt exists concerning a diagnosis, and when simpler, less expensive preliminary examinations (X-rays and ultrasounds) are unable to provide a definitive answer.
For skeletal and articular evaluation, there is generally no need to prepare the patient nor use a contrast agent (CA). CAs are administered orally or intravenously, and are generally used for the study of parenchyma. They are indispensable for vascular investigations.
|Before the exam|
If the clinical investigation requires the use of a contrast agent, specific laboratory tests are necessary, in particular to measure the renal function. The patient must fast for at least six hours prior to the exam and must also complete and sign a legal consent form. The patient must not fail to inform the Radiology Specialist of any past adverse reactions to contrast agents or any history of allergies. It is extremely important that the patient provides all health records related to the clinical investigation, including, of course, previous radiological examinations (ultrasound, CT, etc.). Women of childbearing age must be certain they are not pregnant. If in doubt, all tests involving the use of contrast agents and X-ray irradiation of the body, or parts of the body, must be avoided. For intravenous administration of the contrast agent, a small cannula is inserted into a superficial vein of the arm through which the contrast agent is injected. If necessary, especially for abdominal CT scans, the patient will be asked to drink the contrast agent in order to opacify the intestinal loops.
|During the examination|
Currently, CT exams are fast and painless. The patient lies on a small bed. During image acquisition, the bed slides into a large donut shaped device (technically called a gantry which houses the X-ray tube and detection system). It usually does not cause a sense of claustrophobia. Patients may be requested to hold their breath for a few seconds. The body must be absolutely still during the exam. In general, a CT scan, especially with multi-slice technology, does not last more than 15-20 minutes, including the preparation phase.
|After the exam|
After the exam, if a contrast agent was administered, the cannula used for the injection will be removed after an appropriate period of observation (at least 30 minutes after the injection). No special needs or dietary requirements are necessary and the patient can immediately resume normal activities after the exam.
|What is MRI?|
Magnetic Resonance Imaging (MRI) is a more recent diagnostic technique than CT. It differs in that it does not use ionizing radiation (X-rays), but radio frequency waves and magnetic fields. Externally, CT and MRI equipment look similar (but their imaging techniques are completely different). The main difference is the length of the tunnel in which the patient is positioned: small for CT, but larger for MRI. In general, MRI is better suited than CT to distinguish between the different types of normal or diseased tissues.
|How does it work?|
The basic working principle is simple: water makes up about two-thirds of the human body. The amount of water varies depending on the type of tissue and its pathological condition. A powerful external magnetic field ("magnetic effect") forces the body’s water molecules to change their energy state. When a radio frequency wave is generated and passes through the body, the energy of protons, in the water molecules, is altered. They subsequently return to their original equilibrium orientation. The oscillations induced in the protons can be detected externally by measuring the density of molecules at that point. This information, processed by a computer, eventually provides a multiple-slice image of the organ.
|What is MRI used for?|
It is particularly useful for the diagnosis of diseases of the brain, spine, and musculoskeletal system (joints, bone, soft tissue) but also abdomen, pelvis and blood vessels.
Before the exam
No special preparation is required. It is preferable to avoid the exam in the first trimester of pregnancy, except in special cases, as recommended by the doctor. Prior to the exam, each patient is given a questionnaire that must be completed and signed. In particular, cardiac pacemakers must be declared, as well as internal infusion pumps, neurostimulators, and inner ear implants, which can be damaged by the magnetic field action.
Similarly, the following may constitute a contraindication: the presence of metallic chips within the body, particularly in the vicinity of the eyes, and metal clips after brain or heart surgery. Ferromagnetic objects will experience an attractive force when placed in an intense magnetic field. This can cause them to shift position with consequent tissue damage, for example, in the case of chips that may be lodged near blood vessels. Even in the absence of this risk, the presence of ferromagnetic objects may also degrade image quality by altering the magnetic field to which tissues are exposed. Metal objects, watches, magnetic cards (credit cards, ATM cards), facial makeup, contact lenses, keys, coins and any metal object worn must be removed before the exam. Claustrophobia represents a relative contraindication for MRI exams, especially in "closed" devices. In such cases, alternative diagnostic tests should be considered. A more or less deep sedation will be administered, in consultation with the Anaesthesia and Reanimation Unit.
How is an MRI exam performed?
After consultation with the radiologist, you will be taken to a dressing room, where you will undress down to your underwear as long as it does not contain metal. You will be given a hospital gown and will enter the exam room. A nurse will help you enter the MRI scanner, and depending on the organ to be studied, surface coils may be positioned on specific parts of your body. As the MRI cylinder is quite narrow and the exam period fairly long (about 30 minutes), those who suffer from claustrophobia (fear of being enclosed in small places) should try to relax, and perhaps think of something else. While in the magnetic tube, the patient will hear a loud thumping sound due to radio wave emissions (headsets may be worn to reduce noise). Even if patients are alone in the examination room, they will be able to communicate with the technicians and doctor via a microphone.
Sometimes, at the discretion of the doctor and radiologist, depending on the type of pathology being studied, a contrast agent containing gadolinium may be administered intravenously (through a cannula positioned in a superficial vein).
|After the exam|
After the exam, no special needs or dietary requirements are necessary and the patient may immediately resume normal activities.
|What are they?|
The human body is made up of different organs and structures that can be analysed in their natural or diseased state, based on different tissue densities (X-ray and CT) or molecular tissue structure (MRI). This density contrast, detectable by direct or baseline exams, may be artificially accentuated, directly or indirectly, with the use of substances called “contrast agents” (CA).
|Different types of CA?|
Contrast agents differ according to the technique used (CT, MRI, X-ray, ultrasound) and the organ/structure in which the contrast agent will be injected (vessels, gastrointestinal tract, biliary tract, etc.). Ordinary air or water, if introduced into the intestinal tract, will behave like real contrastographic agents. For simplicity and speed, I will briefly discuss intravenously injected contrast agents (a small cannula is inserted in a superficial vein of the arm) and divide them into 1) iodinated contrast agents in CT exams; and 2) paramagnetic contrast agents in MRI exams. The former, also called contrast media for uro-angiography, are used not only for CT but also in some radiological diagnostic procedures (which use X-Ray angiography, urography, etc.).
|1) Iodinated contrast agents for CT|
Iodinated CAs are a class of substances made up of sometimes complex molecules containing iodine atoms. When introduced into the bloodstream, they spread in interstitial spaces and are excreted through the kidneys. These substances, used to evaluate vessels, permeate the body’s parenchymatous structures, enhancing the visibility of vascular structures at both macro- and micro-circulation levels; thus highlighting alterations in solid or liquid organs and clarifying its vascularization and nature. Based on these criteria, contrast agents are essential for the characterization of neoplasms, generally with a developed vascular architecture (neoangiogenesis), which are distinguishable by their abnormal and often non-homogeneous accumulation of contrast medium.
In the last decade, pharmacological research has invested considerable effort to introduce, in diagnostic and interventional radiology, contrastographic agents that reduce or cancel the incidence of adverse reactions.
|What are the adverse reactions?|
Iodinated contrast agents are real pharmaceutical substances, generally well tolerated and almost completely devoid of adverse effects, sometimes caused by an immunological mechanism. Currently, the older high-osmolality contrast agents have been completely replaced by low-osmolality formulations, which have a comparable diagnostic efficacy and a lower incidence of adverse reactions. Urticarial reactions, itching and a sense of warmth are the most common reactions and usually resolve spontaneously without treatment or with the administration of a single dose of antihistamines, based on severity.
It is important that the Medical Radiologist carefully evaluates the patient’s medical history to reduce risk factors, in particular:
- allergic predispositions and especially previous adverse reactions to contrast agents as well as a history of allergic problems
- organ decompensation or failure
- renal insufficiency, especially if severe
- diabetes with severe renal insufficiency
In this respect, for preventive purposes, laboratory tests are necessary before the contrast-enhanced CT exam, in particular: serum creatinine, blood urea nitrogen and blood sugar (preferably recent, but still valid if performed within three months prior to the CT exam).
|2) MRI Paramagnetic contrast agents|
MRI uses contrast agents that contain gadolinium. Gadolinium-based substances, administered intravenously, are distributed in vessels and organs in the same way as iodinated contrast agents in CT. Gadolinium molecules become temporarily magnetized when placed in an external magnetic field, thus modifying the signal and consequently the MR image. This enables image acquisition of vessel and organ malformations as differences in tissues and vasculature are accentuated.
|What are the adverse reactions?|
Paramagnetic contrast media are better tolerated than iodinated contrast media, because of the reduced volume and reduced molar amount of substance injected. They also have a very low risk of toxic reaction and negligible immuno-allergic reaction. Their unique character and rare adverse reaction after administration justify the relative "tranquillity" with which they are employed.
The incidence of severe anaphylactic reaction is very low, with an estimated frequency of 0.01-0.0003% (Niendorf et al. 1991; Murphy et al. 1996).
Studies have shown that only one fatal reaction attributable to gadolinium has been reported (Jordan, AJR, 1995).
The only counter indication for paramagnetic CAs, as well as for iodinated contrast agents, is for individuals with pre-existing adverse reactions to the CA.
Some manufacturers have recently cautioned against the use of gadolinium-based contrast agents for patients with severe renal impairment or for those who have had a liver transplant
In such cases, and for the use of paramagnetic contrast agents, laboratory tests are required to assess the renal function (serum creatinine and blood urea nitrogen).
|What is it?|
Virtual colonoscopy, introduced in 1994, is a diagnostic method, similar to endoscopy of the colon (colonoscopy), for non-invasive navigation inside the colon lumen.
The data necessary for a virtual colonoscopy exam is derived from CT acquisition of the abdomen and pelvis after rectal insufflation of air. Dedicated computer software is used to generate images.
|Differences with conventional colonoscopy|
As in conventional endoscopy, the mucosal surface of the colon is evaluated (by viewing the inside of the colon). However, in virtual colonoscopy, biopsies or the removal of polyps is not possible.
Virtual colonoscopy has, however, the advantage of being minimally invasive, well tolerated by the patient and rapidly executed. It is also not limited by organic and clinical conditions, or difficulties that would prevent the execution of a full conventional colonoscopy.
1. Virtual colonoscopy is useful when a traditional colonoscopy was incomplete owing to postsurgical adhesions, anatomical abnormalities or the patient’s intolerance.
2. It represents a viable alternative if the patient’s clinical condition does not permit a traditional colonoscopy (allergic reaction to anaesthesia, severe coagulopathy, respiratory failure).
3. 1. It can be used in cases when advancing the endoscope probe in the bowel is risky because of diverticulitis with peritonitis.
4. It can evaluate the intestinal tract upstream from an obstruction (stenosis or obstruction of the colon), which is not possible with conventional endoscopy, and identify any synchronous lesions (polyps/tumours) in other areas of the colon.
5. It can be used in cases of extracolonic invasion by colon cancer (bowel wall infiltration, lymph node metastasis and parenchymal), and provide important pre-operative information.
6. Virtual colonoscopy can be proposed as a screening method for individuals over 50 years of age with a family history of colorectal cancer (especially in very close relatives), or for a periodic evaluation of patients who have undergone an endoscopic polypectomy or colorectal neoplasia surgery.
ALL INSTRUCTIONS FOR VIRTUAL COLONOSCOPY MUST BE FOLLOWED CLOSELY FOR EACH EXAM IN CLOSE COLLABORATION WITH THE PATIENT’S DOCTOR AND THE RADIOLOGIST.
|Before the exam|
The exam can only be taken after adequate colon cleansing. When booking an exam, the patient will be given all the necessary information and an exam preparation module for CT Virtual Colonoscopy for colorectal cancer.
The patient lies on a small bed in the CT room. A balloon catheter, connected to a pump, is inserted through the rectum. Air is insufflated through a Foley type catheter to adequately distend the colon and carefully assess intestinal wall abnormalities. Between 1000-1500 cc of air is insufflated, according to the patient’s maximum tolerance. A preliminary CT scout image is taken to confirm adequate colon distension.
Patients are asked to hold their breath during the CT scan which lasts an average of 5-10 seconds. They are either in the supine (lying face upward) or prone (lying face down) decubitus position.
Both decubitus positions are used for optimal air and fluid redistribution in the various intestinal segments and to identify the presence of faecal fluid and/or faecal residues in the intestinal wall.
The administration of an intravenous contrast agent (see link in this site) is used for preoperative evaluation of stenosing colorectal cancers, in patients with a prior history of cancer, and in some cases, to increase diagnostic certainty in technically difficult cases and define the extension of inflammatory processes in cases of diverticulitis. Spasmolytic agents (Buscopan), administered intravenously before image acquisition, are used in the absence of contraindications to relax the intestinal muscles, distend the colon and enhance tolerance for the exam.
|After the exam|
The catheter is extracted from the rectum and the patient can resume normal activities. If a contrast agent was used, a short observation period is necessary.
The images obtained are sent to a computer workstation where a specific virtual endoscopy software programme provides different projections in 2D images of the bowel lumen to examine the parenchyma, the abdominal cavity and vessels of the domino-pelvic region.
|What is it?|
A Dentascan (Dentalscan or CT Dentascan) is a dedicated reconstruction software for the study of dental arches by acquiring CT images of the jaw.
It has become an indispensable tool for therapeutic planning, evaluation and follow-up of both conventional and advanced implant rehabilitation procedures. Conventional implantology uses Computed Tomography with a software reconstruction programme dedicated to the study of dental arches (Dentascan) for maxillary sinus floor elevation.
With the aid of 3D and multiplanar reconstruction programmes, it is the most effective tool to accurately evaluate the quantity and quality of bone on which to perform implants. Even in advanced implantology, computed tomography is the best technical method for studying bone structure and offers the possibility of optimally assessing, thanks to post-processing procedures (reconstruction by Volume Rendering and Virtual Navigation methods) the preparation procedures for implants such as the elevation of the maxillary sinus floor and distraction osteogenesis. Dentascan should also be considered, among the different diagnostic exams of the jaw, as the one that enables the best anatomical definition and greatest accuracy in the study of expansive and inflammatory processes, especially at the mandibular canal level. In periradicular inflammatory diseases, it is the most effective method to diagnose a maxillary sinusitis of odontogenic origin and the presence of oro-antral fistula. Another important advantage is the study of dental abnormalities (supernumerary teeth, including dysodontiasis) by obtaining more precise anatomical and topographical images compared to radiographic exams.
Images are acquired with the use of an interdental spacer with the patient in the supine position and completely immobile. The maxillary bones are studied separately, as they have different angles with respect to the axial plane. The acquisition time for each arch is 3-5 seconds, performed with a 64-slice volume rendering technique, with a slice thickness of 0.625 mm. Dentascan exams for paediatric patients require specific low-dose exposure protocols.
For the purpose of implants, a lateral scan projection, done with a scanogramme, is essential. This will clearly determine, and cannot be modified by normal Dentascan programmes, coronal and parasagittal plane reconstructions, perpendicular to the axial scan.
The acquired data is then processed according to indications provided by the operator, who can determine the position, number and distance between reconstructions, directly with the equipment programme, or by transferring it to a workstation for further processing. The latter allows enhancement of the exam’s demonstrative capacity by making it possible, for example, to visualize the colour display of the mandibular canal and to simulate implant placement.
The selected axial image is generally placed at the level of the tooth roots and must show, in its entirety, the contour of the maxilla or mandible. Reconstruction of part or all of the maxilla can then be carried out.
A full set of images usually includes 20-40 reconstructions according to the axial plane (Transaxial), 40-100 sagittal oblique reconstructions (cross-sectional) perpendicular to the long axis of the maxillary, and 5-9 coronal images, similar to Panoramic Dental X-ray (Panorex) on a curved path traced along the long axis of the maxilla.
The following are also possible:
- 2D Multiplanar Reconstruction (MPR) according to the plane orientation selected by the operator;
- three-dimensional reconstructions (3D SSD, VR) according to various angles (front, back, side, transverse, oblique) also in bone sections with transparent visualization;
- endosinusial virtual navigation (Navigator);
- tomodensitometric bone density analysis expressed in Hounsfield units (HU).
The exam is conducted by wearing a resin mask with radiopaque landmarks provided by the dentist to facilitate referencing of the implant sites in the different images, both with regard to the position and orientation of the implants. With regard to the superior dental arch, Dentascan coronal reconstructions provide images similar to those produced by panoramic X-ray, as well as a wealth of information regarding teeth, alveolar process, maxillary sinuses and nasal cavities (Dysodontiasis VIII).
Oblique sagittal reconstructions show optimal morphology of the alveolar processes, in particular with regard to the structure, thickness and height of the cortical and cancellous bone. They also highlight the morphology of nasopalatine canals.
In the lower dental arch, Dentascan reconstructions effectively display the horizontal branch, chin region, alveolar process, mandibular canal and the chin channel, which represents the mesial extension. Anatomical abnormalities such as double or triple mandibular canal and the relationship between the mandibular canal and teeth (dysodontiasis of the Wisdom teeth) can be recognized with extreme precision thanks to simultaneous display according to coronal and sagittal oblique reconstruction planes.
Cardiac CT is a non-invasive heart-imaging test for the diagnosis of coronary heart disease. It allows thin-slice volume acquisition of the lower portion of the chest in a single breath hold. ECG-synchronized cardiac investigations permit the reconstruction of data during the same phase as the cardiac cycle so as to avoid heart motion artefacts.
1) NATIVE CORONARY ARTERY DISEASE: screening of patients with low- or medium-risk of severe coronary atheroma. In the presence of coronary heart disease risk factors (hypercholesterolemia, hypertension...) and after cardiac stress testing with negative or doubtful results, Cardiac CT can replace conventional coronary angiography thanks to its high negative predictive value (ability to rule out severe coronary artery disease).
2) CORONARY STENTS, especially if positioned at the level of the main artery branches, because of their high calibre and being less prone to beam hardening artefacts, makes it difficult to evaluate intra-stent lumen.
3) CORONARY ARTERY BYPASS SURGERY has for years recognized the value of Cardiac-CT compared to conventional coronary angiography thanks to its diagnostic accuracy and panoramic visualization.
4) ACUTE CHEST PAIN is a clinical condition brought about by various diseases (such as myocardial ischemia). Many of these diseases are easily identifiable with CT. For this reason, Cardiac CT is currently the focus of a lively debate on the possibility of using it in emergency situations because of its speedy execution.
5) OTHER AREAS: Cardiac CT is able to evaluate cardiac morphology in considerable anatomical detail. However, kinetic evaluation and assessment of perfusion defects of the ventricular walls are still limited compared to other non-invasive techniques currently in use.
Cardiac CT makes use of ionizing radiation and intravenously injected contrast agents.
Cardiac CT is specifically indicated for non-invasive heart imaging, while MRI is considered superior for the evaluation of kinetic and parietal contractility, valve function and myocardial tissue characterization.
In Cardiac CT, a contrast agent is injected in a peripheral vein of the arm. Whereas in conventional coronary angiography, arterial access is necessary via a catheter introduced into the aorta at the point where the coronary arteries originate. Because the different invasive nature of the exam, Cardiac CT can be performed on an outpatient basis without the need for hospitalization. The risk is comparable to that of a regular CT exam using a contrast agent.
Conventional coronary angiography provides higher diagnostic accuracy when evaluating the calibre of coronary artery lumen, especially in the presence of diffuse calcification of parietal atheromasia, while Cardiac CT is also able to provide accurate information on the coronary vessel wall. The characterization of atheromatous plaque is currently of considerable interest for pathogenesis of acute coronary syndromes.
Biochemical blood tests (carried out not more than three months prior to the exam) are required (serum creatinine, blood urea nitrogen, blood sugar level and electrophoretic protidogram) to evaluate the renal function and to exclude conditions that contraindicate intravenous administration of iodinated contrast material.
The patient must fast for at least four hours prior to the exam.
To achieve optimal ECG synchronization, the heart rate must be between 60-65 bpm. To this end, a preliminary medical visit is necessary to measure the heart rate and medication may be prescribed to slow the heart rate. An unusually high heart rate or abnormal heart rhythms (extrasystoles) may interfere with the image quality of the test. The exam will hence be cancelled as it may not be of acceptable diagnostic quality.
Volume Rendering 3D reconstruction of the heart.
The patient lies on a small bed in the supine position. Electrodes are positioned to perform the ECG synchronized CT and then a needle-cannula is inserted inside an antecubital vein of the arm and connected to an automatic injector.
During the exam, patients must remain as still as possible and must hold their breath for about 15 seconds during each image acquisition period.
The exam lasts about 15 minutes.
Patients stay under observation for a short period after which they can resume normal activities in the absence of special precautions.
The images obtained are processed to assess the calcium score (amount of calcium in the artery walls). An angiographic and parietal analysis of the main coronary branches is undertaken and the cardiac chambers evaluated.
Varicoceles are abnormally dilated testicular veins (pampiniform plexus) of the scrotum which appear swollen and twisted. They may cause pain and impair spermatogenesis.
Currently there are two treatments available for patients with varicoceles: percutaneous sclero-embolization and surgery. Both procedures result in the interruption of reflux.
Who to consult? Couples usually see an andrologist to monitor their infertility.
The problem can sometimes also be handled by a urologist, more often in the case of pain. The interventional radiologist performs sclero-embolization procedures, usually in an angiographic suite. An anaesthetist is rarely present during the procedure, only in cases of previous allergic reactions to contrast agents.
A varicocele diagnosis supported by a recent (two months) Colour Doppler ultrasound of the spermatic vessels together with the degree of incontinence classification (treatment recommended for Grade 2 and up).
Request from the clinic confirming the varicocele diagnosis, specifying the grade and the motive for treatment (pain or altered spermatogenesis).
Blood tests: blood urea nitrogen, blood sugar and serum creatinine. Patients must fast on the exam day.
After local anaesthesia is injected into the brachial (at elbow level) or inguinal vein, a cannula is placed inside the vein. A guidewire is then introduced to guide the placement of the catheter which passes from the vein of the arm, through the right heart atrium, into the inferior vena cava, and then into the renal vein. A small amount of contrast agent is injected into the renal vein to allow visualization of the spermatic vein, usually the left vein.
The venography will determine the degree of reflux and anatomical connections of the spermatic vein. At this point, the varicocele is graded.
The next stage involves selective catheterization of the spermatic vein with a guidewire, usually easy to perform in the absence of anatomic variants.
At this point, after injecting a small amount of sclerosing agent with the patient in a contracted abdominal position, occlusion of the vein is evaluated within a few minutes. The same technique can also be used successfully for the treatment of pelvic congestion syndrome in women.
There are no particular contraindications to the treatment. A relative contraindication may be the patient’s previous allergic reactions to contrast material. In such cases, the anaesthetist should consider alternative imaging modalities or the use of other contrast agents. Patients with diabetes, kidney failure, myeloma or allergies should consult the radiologist prior to the use of contrast agents. Patients suffering from recurrent varicoceles after surgical treatment must provide their relative medical record, and based on which surgical approach was used (inguinal or subinguinal), a decision will be made on whether or not to proceed with the percutaneous treatment.
The radiation dose administered is very low (less than a common X-ray of the spine) as digital X-ray equipment is used.
Complications are infrequent. They may be general or local, such as allergic reactions to the contrast agent, drop in blood pressure, feeling of pain or discomfort in the groin area, scrotal swelling, redness and/or testicular pain, and small hematoma. There is a possibility of feeling pain or discomfort in the groin area immediately after treatment. This is due to the irritating action of the sclerosing agent and can last for several days. In the treatment of pelvic congestion syndrome in women, pelvic pain may persist for the first few days and is often felt as a "colic".
Patients are discharged the same day as the procedure and must be accompanied home. They will require absolute rest for two days and must refrain from all sport, sexual and stressful activities for at least a week. Antibiotics are prescribed and given to the patient for about 3-5 days. In case of pain, an intramuscular nonsteroidal anti-inflammatory is recommended.
There is worldwide unanimity regarding percutaneous sclero-embolization as being the treatment that offers the best results (60-80% success rate).
The percentage of complications is low. Usually, no further treatment is required. The Percutaneous arm-vein approach, the absence of hospitalization and serious complications, and finally the excellent results, make this procedure effective, reliable and well tolerated by patients.
How soon can I get back to normal activities?
After sclero-embolization therapy, patients are generally discharged on the same day and can resume light activity after three days. It is advisable to refrain from strenuous effort and sexual activity for a week in order not to alter normal cellular and tissue processes triggered by occlusion of the vein.
Are the results similar to surgical treatment?
Yes. Scientific studies have shown a clear improvement in functionality and the number of sperm as well as a reduction in pain without statistically significant differences between sclero-embolization and surgery. The main differences are that the hospitalization period and recurrence rates are lower for percutaneous sclero-embolization.
Is radiology for sclero-embolization less invasive than surgery?
Yes. In sclero-embolization a surgical incision is not necessary and hospitalization is shorter.
Is a relapse possible?
Yes, a relapse is possible. Approximately 5-24% of patients have a recurrence of varicocele.
Who is an Interventional Radiologist?
Interventional Radiologists are physicians who use X-rays, ultrasound, CAT scan and MRI to perform minimally invasive percutaneous procedures aimed at diagnosis (biopsy) or treatment (angioplasty, sclero-embolization, etc.) of a disease.
- Modulo clinico-anamnestico per esami TC o RM
- Consenso informato all'utilizzo del mezzo di contrasto
- Questionario per l'esecuzione di esami RM
- Preparazione all'esame di colonscopia virtuale con TC
- Informativa sullo stato di gravidanza
In order to provide patients with timely and comprehensive information, forms in PDF format may be downloaded in this section and completed for the various diagnostic procedures.
The informed consent tool is an integral part of health care practice, promoting individual autonomy in medical decisions. Patients can decide whether they wish to be treated for an illness. They have the right/duty to receive all the available information about their health, and may ask the doctor for further clarification. Patients also have the freedom to decide, in an informed way, whether to undergo a particular treatment or diagnostic test.
Consent must be given in writing in cases where clinical exams or medical treatment can have serious consequences for the person’s health and safety. If consent is refused, the doctor has the obligation not to perform or to terminate the relevant clinical exam or therapy. Written consent is required when giving or receiving blood, when participating in a clinical trial, or in the detection of HIV infection.
In other cases, when a trusting relationship exists between doctor and patient, consent may be given verbally but must be expressed to the doctor directly. In any case, informed consent must be recent, i.e. it must relate to the present situation and not a future one.
Informed consent can be expressed by another person only if it was clearly delegated by the patient. If the patient is a minor, delegation of parental consent is required. The minor, however, has the right to be informed and to express his/her wishes, which must be taken into consideration.
Exceptions from informed consent
- the patient has explicitly expressed the desire not to be informed;
- presumed consent: the patient’s condition is so serious and life threatening that it requires immediate action and emergency care;
- implied consent: for routine medical care or prescription drugs for known diseases;
- mandatory health treatment;
- mandatory vaccinations decreed by national health programmes
MONDAY - FRIDAY: 08:00 - 18:20
Phone number: 06.65 975180
Phone number: 06.65 32665
Phone number: 06.65 975675
Phone number: 06.65 975604
The clinical analysis laboratory performs clinical diagnostic tests, microbiology, seroimmunological and enzyme immunoassay. It has cutting-edge and high precision tools for routine and more complex laboratory analysis, ensuring fast, reliable and accurate results.
Staff consist of laboratory technicians and biologists, specialists in clinical pathology, microbiology and virology, who regularly attend ECM (continuing medical education) courses and advanced medical education courses to improve their knowledge and keep their professional skills up to date due to the continuous evolution of bio-diagnostic techniques and methods.
Staff scrupulously observe all applicable procedures in full compliance with Law 626 in relation to risk prevention and the protection of workers.
The laboratory premises are ventilated and equipped with microclimate standards according to current legislation.
The laboratory is able to perform the following tests:
- Basic general clinical investigations: metabolites, enzymes, proteins
- Early detection of myocardial damage
- Detection of monoclonal gammopathies
- Laboratory assessment of thyroid function
- Tumour marker tests
- Measurement markers of viral hepatitis A, B, C
- Serological testing for HIV
- Hormone tests
- Microbiological analysis and pathogen detection
Outpatient services are available only to self-pay patients and/or in agreement with all private medical aid companies for the following specialties:
|Medically Assisted Procreation|
|Pulmonary - Allergy|
|Pain management service|
|Colour Doppler Ultrasound|
|Cardiovascular stress test|
The imaging diagnostics service is available only to self-pay and/or private medical aid patients for the following specialties:
|Digital diagnostic radiology|
|Multislice Spiral Computed Tomography|
|Magnetic Resonance Imaging – brain, body, joints|
|Ultrasound: bones and joints|
For the provision of services linked to individual specialist units, The European Hospital has the following outpatient diagnostic services:
|Laboratory for Clinical Chemistry and Microbiology, Immunology, Cytology;|