Katsuhiko Matsuura

Use of intra-arterial nitroglycerin during uterine artery embolization for severe postpartum hemorrhage with uterine artery vasospasm.

OBJECTIVE Uterine artery embolization (UAE) is a standard method for treating postpartum hemorrhage (PPH), although uterine artery vasospasm during UAE may lead to failure of hemostasis. Here, we report our experience with a case of PPH in which the bleeding was successfully controlled by intra-arterial administration of nitroglycerin during the second UAE. CASE REPORT A 30-year-old woman experienced PPH following a successful cesarean section, and a UAE was performed. However, 6 hours later, vaginal bleeding restarted; the reason for unsuccessful embolization during the first UAE was vasoconstriction due to hypovolemic shock. We performed a second UAE, but uterine bleeding continued. After intra-arterial administration of nitroglycerin, hemostasis was confirmed, and there was no reperfusion of the uterine artery. After these two UAE procedures, no recurrence of bleeding was observed. CONCLUSION Thus, use of intra-arterial nitroglycerin was effective for controlling uterine artery vasospasm during UAE. However, larger studies are required to confirm these findings.

Feasibility of Non-contrast-enhanced MR Angiography Using the Time-SLIP Technique for the Assessment of Pulmonary Arteriovenous Malformation.

Purpose: The purpose of this study was to evaluate the diagnostic performance of non-contrast-enhanced magnetic resonance angiography with time-spatial labeling inversion pulse (time-SLIP MRA) in the assessment of pulmonary arteriovenous malformation (PAVM). Methods: Eleven consecutive patients with 38 documented PAVMs underwent time-SLIP MRA with a 3-tesla unit. Eight patients with 25 lesions were examined twice, once before and once after embolotherapy. The lesions were divided into two groups—initial diagnosis (n = 35) and follow-up (n = 28)—corresponding to untreated and treated lesions, respectively, and were evaluated separately. To evaluate the initial diagnosis group, two reviewers assessed image quality for visualization of PAVMs by using a qualitative 4-point scale (1 = not assessable to 4 = excellent). The location and classification of PAVMs were also evaluated. The results were compared with those from digital subtraction angiography. For evaluation of the follow-up group, the reviewers assessed the status of treated PAVMs. Reperfusion and occlusion were defined respectively as visualization or disappearance of the aneurysmal sac. The diagnostic accuracy of time-SLIP MRA was assessed and compared with standard reference images. Interobserver agreement was evaluated with the κ statistic. Results: In the initial diagnosis group, time-SLIP MRA correctly determined the PAVMs in all but one patient with one lesion who had image degradation due to irregular breath. Image quality was considered excellent (median = 4) and the κ coefficient was 0.85. Additionally, both readers could correctly localize and classify the PAVMs on time-SLIP MRA images with both κ coefficient of 1.00. In the follow-up group, the sensitivity and specificity of time-SLIP MRA for reperfusion of PAVMs were both 100%, and the κ coefficient was 1.00. Conclusion: Time-SLIP MRA is technically and clinically feasible and represents a promising technique for noninvasive pre- and post-treatment assessment of PAVMs.

Acquired factor V inhibitor associated with life-threatening bleeding and a mixing test result that indicated coagulation factor deficiency

Abstract A mixing test is useful for distinguishing between coagulation factor deficiency and the presence of inhibitor as the cause of coagulopathy. However, we experienced a patient with acquired factor V (FV) inhibitor whose mixing test showed a coagulation factor deficiency pattern. A 65-year-old man with a tendency for bleeding was referred to our center. The laboratory data showed remarkable prolongation of prothrombin time and activated partial thromboplastin time (APTT). FV activity was less than 3%. A mixing test showed a coagulation factor deficiency pattern. However, neither the tendency for bleeding nor the coagulation tests were corrected by transfusion of fresh frozen plasma. A few days later, a positive test for FV inhibitor of 3 Bethesda units was obtained. Therefore, we started prednisolone and plasma exchange, and the coagulation test results normalized after 6 weeks. Although an incubation period is generally not considered necessary in a mixing test for FV inhibitor, we repeated mixing tests with various incubation periods and confirmed an incubation period-dependent prolongation of the APTT. Therefore, a mixing test with an incubation period is recommended for the detection of FV inhibitor, since a mixing test without an incubation period may show a coagulation factor deficiency pattern when the titer of FV inhibitor is low.

Successful Endovascular Treatment of Iatrogenic Thyrocervical Trunk Pseudoaneurysm with Concomitant Arteriovenous Fistula Using 0.010-Inch Detachable Microcoils

Pseudoaneurysms (PsA) and arteriovenous fistulae (AVF) of the thyrocervical trunk and its branches are rare complications of traumatic or iatrogenic arterial injuries. Most such injuries are iatrogenic and are associated with central venous catheterization. Historically, thyrocervical trunk PsA and AVF have been managed with open surgical repair; however, multiple treatment modalities are now available, including ultrasound-guided compression repair, ultrasound-guided thrombin injection, and endovascular repair with covered stent placement. We report a case of a 65-year-old woman with an iatrogenic thyrocervical trunk PsA with concomitant AVF that developed after attempted internal jugular vein cannulation for hemodialysis access. The PsA was successfully treated by transcatheter coil embolization using 0.010-inch detachable microcoils. Our case is the first published instance of a thyrocervical trunk PsA with concomitant AVF that was successfully treated by endovascular procedure.

Rupture of a Small Hepatocellular Carcinoma in a Stable Disease State in a Patient Receiving Sorafenib Treatment

A 72‐year‐old man presented with upper abdominal pain. When he was 65‐years old, he was diagnosed with HCC and underwent subsegmentectomy of S6 and S8 of the liver. Thereafter, he had repeated HCC recurrences and underwent transcatheter arterial chemoembolization (TACE) nine times and radiofrequency ablation twice. He had undergone the last TACE against segment 5 at 15 months before the rupture. When his HCC became refractory to the treatments, he started taking sorafenib 400–600 mg/day since 14 months before the rupture. The vascularity of HCC was decreased by sorafenib, and there was no significant change in size. Dynamic computed tomography (CT, Canon Medical Systems, Tokyo, Japan) revealed six small HCCs a month before, and stable disease indicated therapeutic efficacy. He has no history of abdominal trauma. He had hypertension since he was 60 years old, and his blood pressure was usually controlled to about 130/80 mmHg (1 mmHg = 0.133 kPa) with amlodipine 10 mg orally. He did not take antiplatelet drugs or anticoagulants.

Non–contrast-enhanced magnetic resonance angiography using time-spatial labeling inversion pulse technique for differentiation between pulmonary varix and arteriovenous malformation

Pulmonary varix is a rare entity that presents as a focal aneurysmal dilatation of the pulmonary vein and is frequently mistaken for a pulmonary arteriovenous malformation (PAVM). It is important to distinguish between pulmonary varix and PAVM because the former does not usually require treatment. We present the findings of non–contrast-enhanced magnetic resonance angiography with the time-spatial labeling inversion pulse technique in case of pulmonary varix and PAVM and the utility of this method for differentiating between these diseases.

Chronic unilateral leg swelling caused by iliac vein compression (Cockett's) syndrome in an elderly patient

The causes of chronic unilateral leg swelling include common manifestations such as venous insufficiency, varicosis, deep vein thrombosis, and persistent cellulitis, less commonly are secondary lymphedema (tumor, radiation, and surgery), pelvic tumors or lymphoma causing pressure on the veins, and reflex sympathetic dystrophy, and rarely congenital venous malformation, pregnancy, and iliac vein compression syndrome.1,2 Here, we describe a 78yearold nonsmoking man with history of type 2 diabetes mellitus, dyslipidemia, and hypertension presented with left leg swelling that had been getting worse over several months. On the physical examination, the patient was alert in no acute distress, and 165 cm tall, weighing 50 kg with a body mass index of 18.4 kg/m2. His temperature was 36.7°C, blood pressure 120/54 mm Hg, pulse rate 90 beats/min (regular), respiratory rate 12 breaths/min, and oxygen saturation 97% on room air. There were right lateral inguinal hernia, bilateral hydrocele testis, superficial venous varicosity in left inguinal area, and painless nonpitting left leg swelling with localized redness, warmth, and several small blisters on the lower left leg. The bilateral differences of circumference of the thigh and lower leg were 9 cm and 11 cm around, respectively. The palpation of posterior tibial arteries was good, and anklebrachial index was as follows: right 1.03 and left 0.94. Digital rectal examination revealed an enlarged prostate. The remainder of the physical examination was unremarkable. Laboratory findings were as follows: white blood cell count, 4080/μL; hemoglobin (Hb), 14.0 g/dL; platelet count, 140 000/μL; HbA1c, 6.0%; blood urea nitrogen, 19 mg/dL; creatinine, 1.01 mg/ dL; lowdensity lipoprotein cholesterol, 124 mg/dL; triglyceride, 124 mg/dL; Creactive protein, 2.12 mg/dL; occasional plasma glucose, 124 mg/dL; Ddimer, less than 1.0 μg/mL; and no proteinuria. Chest radiograph showed cardiomegaly, and the cardiothoracic ratio was 56% with bilateral sharp costophrenic angles. Electrocardiogram showed normal sinus rhythm without STT segment abnormalities. Contrastenhanced wholebody computed tomography (Figure 1) demonstrated complete compression with calcification of the left common iliac vein (LCIV) between the overlying right common iliac artery (RCIA) anteriorly and the fifth lumbar vertebra posteriorly, known as iliac vein compression syndrome, resulting in both obstruction of venous outflow and twisting venous dilatations distal from the LCIV (white arrowheads) and venous thrombosis only in the left soleus veins with no evidence of pulmonary embolism. Iliac vein compression syndrome was clinically overviewed as one of the causes for postphlebitic syndrome by Cockett.3 We do not confuse iliac vein compression syndrome with the original MayThurner description4 which indicates anatomical spurlike formations at the lesion of the LCIV by the overlying RCIA.5 Iliac vein compression syndrome could cause left unilateral leg swelling and leftsided deep venous thrombosis in elderly patients.6

Ultra-short echo time magnetic resonance imaging for detection of pulmonary arteriovenous malformation recanalization after coil embolization: a case report and a phantom study

A pulmonary arteriovenous malformation (PAVM) is a direct connection between the pulmonary arteries and veins for which metallic coil transcatheter embolization is the standard of care. Detecting recanalization after PAVM treatment is crucial, but direct visualization with computed tomography or magnetic resonance imaging (MRI) is generally difficult. Here, we report a case of a recanalized PAVM that was directly detected with ultra-short echo time MRI. The detection of these signals in the coils was confirmed in a phantom study.