Hiroyuki Tokue

Imaging findings and management of isolated dissection of the visceral arteries

PurposeTo describe clinical and computed tomography (CT) findings of isolated dissection of the visceral arteries (IDVA).Materials and methodsWe retrospectively analyzed clinical presentation and abdominal CT findings of 38 patients who were diagnosed as having an IDVA. IDVA were classified into three types based on CT findings: patent false lumen with re-entry (type I), patent false lumen without re-entry (type II), and completely thrombosed false lumen (type III).ResultsThe dissection was located in the superior mesenteric artery (SMA) in 27 patients, celiac artery (CA) in 6, CA to splenic artery in 2, and common hepatic artery (CHA), CA to CHA, and inferior mesenteric artery (IMA) in 1 patient each. The dissection was classified into type I in 8 patients, type II in 12, and type III in 18. Surgical treatment was performed in 1 patient with type II SMA dissection because of bowel ischemia, although the remaining 37 patients were managed conservatively. Two cases with type II showed a progressive enlargement of the false lumen in follow-up CT. Increased density of the fat tissue around the affected visceral artery was more commonly seen in symptomatic patients compared to asymptomatic ones (P < 0.01).ConclusionBased on our observation, patients with IDVA can be managed conservatively when there are no signs indicating organ ischemia.

Guidelines for the use of NBCA in vascular embolization devised by the Committee of Practice Guidelines of the Japanese Society of Interventional Radiology (CGJSIR), 2012 edition

Abstract Cyanoacrylates are a group of fast-acting adhesives. They form low viscosity liquids in the monomer state and instantly polymerize to become adhesive upon contact with ionic substances. Since the 1950s, they have been used around the world for industrial and household purposes. N-butyl cyanoacrylate (NBCA) is a cyanoacrylate that is commonly used for medical care, and the closure of skin wounds with NBCA has been found to promote hemostasis. However, in Japan, the intravascular injection of NBCA is considered to be off-label use, except during the treatment of gastric varices under endoscopy. The use of NBCA in embolotherapy is considered when the target vessels cannot be cannulated superselectively, for vascular diseases that require long segments of the target vessel to be embolized, or for patients in a hypocoagulable state. NBCA-based embolotherapy can be used to treat vascular malformations, acute hemorrhaging, tumors, and venous disease. The complications associated with NBCA-based embolotherapy include tissue ischemia, hemorrhaging, systemic or local reactions, and catheter adhesion to blood vessels. NBCA is mixed with Lipiodol to make it radiopaque and to adjust its polymerization time. Since there are various technical aspects to performing NBCA-based embolotherapy safely, it should be carried out by, or with the assistance of, proficient interventional radiologists.

Magnetic resonance imaging findings of extrapelvic endometriosis of the round ligament

A 31-year-old woman presented with a mass in her groin accompanied by intense pain during the menstrual period. A poorly circumscribed, elastic, hard mass was palpable in her right inguinal region. Magnetic resonance imaging showed that the mass had continuity with the inguinal course of the round ligament of the uterus. The mass lesion was well enhanced with high intensity on diffusion-weighted imaging. An operation was performed, and the histological diagnosis was endometriosis of the round ligament. After operation, she was completely relieved of pain. It is important to include endometriosis in the differential diagnosis in women with painful inguinal mass lesions at risk for endometriosis.

2-[18 F]fluoro-2-deoxy-d-glucose (FDG) positron-emission tomography (PET) findings of chronic expanding intrapericardial hematoma: a potential interpretive pitfall that mimics a malignant tumor

A 77-year-old man who had undergone mitral valve replacement 5 years previously presented with an intrapericardial mass. Computed tomography and magnetic resonance imaging showed that the mass lesion contained hematoma components. Positron-emission tomography (PET) with 2-[18 F] fluoro-2-deoxy-d-glucose (FDG) revealed uptake in the peripheral rim of the mass. These findings suggested the presence of hematoma associated with a malignant lesion. Surgical resection was performed, and the histological diagnosis was chronic expanding intrapericardial hematoma without neoplastic changes. Chronic expanding intrapericardial hematoma is a rare disease but should be considered when an expanding mass is found in a patient after cardiac surgery. The FDG-PET findings of chronic expanding hematomas, including FDG uptake in the peripheral rim of the mass as a result of inflammation, should be recognized as a potential interpretive pitfall that mimics a malignant tumor.

Safety and Efficacy of Primary Metallic Biliary Stent Placement with Tract Embolization in Patients with Massive Ascites: A Retrospective Analysis of 16 Patients

PURPOSE To evaluate the safety and efficacy of primary metallic biliary stent placement with tract embolization in patients with massive ascites. MATERIALS AND METHODS Sixteen patients with malignant biliary obstruction and massive ascites (age range, 44-79 y; median age, 59 y) were treated with primary percutaneous stent placement with tract embolization. These patients were unsuitable candidates for endoscopic intervention. Etiologies of biliary obstruction were gastric cancer with hilar nodal metastases (n = 9), pancreatic carcinoma (n = 5), cholangiocarcinoma (n = 1), and gallbladder carcinoma (n = 1). Eight patients had nonhilar lesions and the remaining eight had hilar lesions. Percutaneous accesses to the biliary system and stent placements were performed in a one-step procedure, and catheters were removed with tract embolization with metallic coils. RESULTS Stent placement and tract embolization were successful in all patients, without external drainage catheters left in place. Significant reduction of serum bilirubin level was observed in 14 patients (87.5%). No bile peritonitis or intraperitoneal hemorrhage occurred. Major complications included postprocedural cholangitis (12.5%), bloody bowel discharge (6.2%), and right pleural effusion (25.0%). One patient who died 19 days after intervention was deemed to represent a procedure-related mortality. During the survival period (range, 19-175 d; median, 66 d), stent occlusion was noted in two patients at 6 and 159 days after the procedure. Primary stent patency was achieved in 14 patients (87.5%). CONCLUSIONS Primary biliary stent placement with tract embolization is technically safe and offers an effective palliative treatment option for patients with malignant biliary obstruction and massive ascites when endoscopic intervention is not possible.

Successful interventional management for subclavian artery injury secondary to internal jugular catheterization: a report of two cases.

Central venous cannulation through the right internal jugular vein is a widely used technique, and complications due to this procedure are very rare. We report two cases of right massive hemothorax due to inadvertent puncture of a right subclavian artery. Digital subtraction angiography demonstrated a perforated subclavian artery in both cases. These were successfully treated with transcatheter arterial embolization for the bleeding points of the right subclavian arteries.

Characteristic of computed tomography and magnetic resonance imaging finding of thrombosed varices of the round ligament of the uterus: a case report.

A 37-year-old woman presented with a painful mass lesion in her right inguinal region, 6 days after normal vaginal delivery. Computed tomography and magnetic resonance imaging showed a serpentine mass lesion containing blood elements along the inguinal course of the round ligament continuous to the labium majus. Although thrombosed varices of the round ligament is a rare condition, it should be distinguished from other inguinal masses to prevent unnecessary surgical treatments.

Combination of postmortem mass spectrometry imaging and genetic analysis reveals very long-chain acyl-CoA dehydrogenase deficiency in a case of infant death with liver steatosis

CASE HISTORY A 3-month-old infant was found dead in his bed. A postmortem computed tomography (CT) scan suggested fatty attenuation in the liver parenchyma, but no other potentially fatal changes were found. To clarify the cause of death, a medicolegal autopsy was carried out. AUTOPSY FINDINGS Internal examination confirmed the presence of liver steatosis as well as hepatomegaly. There were no other significant findings including encephalitis or brain edema. MASS SPECTROMETRY ANALYSIS To clarify the mechanism underlying lipid accumulation in the liver, matrix-assisted laser desorption/ionization imaging mass spectrometry (MALDI-IMS) analysis was conducted. This indicated a significant accumulation of C14:1 acylcarnitine in the liver of the deceased, suggesting very long-chain acyl-CoA dehydrogenase (VLCAD) deficiency. GENETIC ANALYSIS To find the cause of the VLCAD deficiency, genetic analysis of the responsible gene, acyl-CoA dehydrogenase, very long chain (ACADVL), was performed. This revealed two novel mutations that may have accounted for the disease. CONCLUSION A combination of these data revealed that the liver steatosis in this case might have been caused by VLCAD deficiency based on genetic mutations of ACADVL. Thus, the deceased might have been vulnerable to energy crisis and sudden infant death. The present findings show that MALDI-IMS analysis as well as genetic analysis can be useful for elucidating the cause of death.

Postmortem computed tomography evaluation of fatal gas embolism due to connection of an intravenous cannula to an oxygen supply

An 84-year-old man who had suffered from chronic obstructive pulmonary disease accompanied by moderate pneumonia as well as gastric cancer with liver metastasis was found dead by a nurse, who noticed that the patients intravenous catheter in the left forearm had been erroneously connected to an oxygen supply in his hospital room, leading to infusion of oxygen into a vein. Postmortem CT scanning demonstrated multiple accumulations of gas in the pulmonary artery, the right atrium and ventricle, as well as the left subclavian and brachiocephalic veins, corresponding to the route that the infused gas would have taken to the heart and pulmonary artery. Conventional autopsy revealed the presence of gas in the right ventricle. These findings suggested that the immediate cause of death was a gas embolus due to oxygen that had entered the cardiopulmonary circulation via the intravenous catheter. This case highlights the usefulness of postmortem imaging as an aid to conventional autopsy for demonstrating gas embolism.

Transcatheter arterial embolization with N- butyl cyanoacrylate for arterial esophageal bleeding in esophageal cancer patients

BackgroundThe aim of this study is to evaluate the clinical efficacy and safety of transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) for the treatment of arterial esophageal bleeding in esophageal cancer patients.MethodsBetween November 2008 and December 2014, five esophageal cancer patients underwent TAE with NBCA for the treatment of arterial esophageal bleeding. We retrospectively evaluated the technical and clinical success, recurrent bleeding, and procedure-related complications.ResultsAll of the patients had bleeding from the esophageal artery and were in shock at the beginning of TAE. Four patients had a coagulopathy at the time of TAE; however, the TAE could successfully arrest bleeding in all five patients. After TAE, they immediately recovered from the shock state. Two patients were discharged without event, one patient is currently hospitalized for another complication, and the other two patients died due to multiorgan failure. In addition, no procedure-related complications such as esophageal infarction and recurrence of arterial esophageal bleeding were observed during this study.ConclusionsTAE with NBCA can arrest bleeding in esophageal cancer patients with active arterial esophageal bleeding, even in those with a pre-existing coagulopathy.