Motoki Nakai

Evaluation of Transcatheter Arterial Embolization with Gelatin Sponge Particles, Microcoils, and N-butyl Cyanoacrylate for Acute Arterial Bleeding in a Coagulopathic Condition

PURPOSE To evaluate the outcome of transcatheter arterial embolization with gelatin sponge particles, microcoils, and N-butyl cyanoacrylate (NBCA) for acute arterial hemorrhage in the setting of coagulopathy. MATERIALS AND METHODS Coagulopathy is defined by a platelet count less than 5 x 10(4)/microL and/or International Normalized Ratio (INR) greater than 1.5. Forty-six patients (31 male patients; mean age, 62 years) with acute arterial hemorrhage in a coagulopathic condition were treated by transcatheter arterial embolization with gelatin sponge particle, microcoils, and NBCA. RESULTS Because of failure of hemostasis or recurrent hemorrhage, 10 patients who underwent gelatin sponge particle embolization also received transcatheter arterial embolization with microcoils or NBCA embolization and two patients who underwent microcoil embolization also received transcatheter arterial embolization with NBCA. The gelatin sponge particle group consisted of 27 hemorrhagic arteries in 25 patients, the microcoil group had 20 in 20 patients, and the NBCA group had 16 in 13 patients. The mean platelet count and mean INR value were 5.8 x 10(4)/microL +/- 3.5 and 1.81 +/- 0.50, respectively. The primary hemostatic rate, recurrent hemorrhage rate, and mean treatment time for the gelatin sponge particle, microcoil, and NBCA groups were 67%, 23%, and 25 minutes +/- 10; 80%, 0%, and 37 min +/- 19; and 100%, 0%, and 9 min +/- 4, respectively. Primary and secondary hemostasis were achieved in 50 (80%) and 60 (95%) of the 63 hemorrhagic arteries, respectively. Three hemorrhagic arteries in which transcatheter arterial embolization failed were treated with surgical repair. CONCLUSIONS Although transcatheter arterial embolization with microcoils took a greater amount of time, transcatheter arterial embolization with NBCA or microcoils was more effective and feasible than that with gelatin sponge particle in terms of hemostasis and prevention of recurrent hemorrhage in a coagulopathic condition.

Feasibility and efficacy of single photon emission computed tomography-based three-dimensional conformal radiotherapy for hepatocellular carcinoma 8 cm or more with portal vein tumor thrombus in combination with transcatheter arterial chemoembolization.

PURPOSE To assess the feasibility and efficacy of single photon emission computed tomography-based three-dimensional conformal radiotherapy (SPECT-B 3D-CRT) for large hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). METHODS AND MATERIALS HCC patients with PVTT in the first branch or main trunk, 8 cm or greater in size, were admitted to the study. SPECT, using Tc-99m-galactosyl human serum albumin, was used in radiation treatment planning to explore the optimal irradiation beam angle. SPECT enabled the minimum possible irradiation of functional liver (FL). Clinical target volume (CTV) included the main tumor and PVTT. SPECT-B 3D-CRT targeted the CTV to a total dose of 45 Gy/18 fractions. HCC outside the CTV was treated by transcatheter arterial chemoembolization (TACE). RESULTS Nineteen cases were enrolled in this study. The mean maximum dimension, mean CTV, and mean dose to FL were 11.0 cm (range, 8.0-20.0), 435 cm(3) (range, 60-2,535), and 1,102 cGy (range, 691-1,695), respectively. Follow-up SPECT demonstrated radiation-induced dysfunctional liver. Despite the inclusion of 6 cases of Child-Pugh B or C, no patients experienced Grade 3 or worse radiation-induced liver disease. The cumulative non-progression rates of PVTT and PVTT plus main tumor were 78.0 and 43.2%, respectively. Survival rates at 1 and 2 years were 47.4 and 23.7%, respectively. CONCLUSIONS SPECT-B 3D-CRT with TACE appears to be tolerable to cirrhotic liver and to provide promising prognosis for patients with HCC sized 8 cm or more, in comparison with previous treatment methods. A longer follow-up period is required to evaluate these findings.

Prospective comparison of transcatheter arterial chemoembolization with Lipiodol-epirubicin and Lipiodol-cisplatin for treatment of recurrent hepatocellular carcinoma

PurposeThe aim of this study was to compare the safety and short-term efficacy of transcatheter arterial chemoembolization (TACE) using cisplatin-Lipiodol suspension (CP/Lp) with that using epirubicin-Lipiodol emulsion (EP/Lp) in patients with recurrent hepatocellular carcinoma (HCC).Materials and methodsA total of 28 HCC patients were enrolled prospectively and assigned to the CP/Lp group or EP/Lp group. Adverse effects related to TACE were graded; and the treatment effect (TE) on HCC nodules at 3 months and overall tumor response at 6 months were assessed as the endpoint.ResultsNo significant difference was observed between the groups regarding the frequency of adverse effects of grade 3 or less. The TE rates for 100% necrosis plus >50% necrosis in 62 HCC nodules in the CP/Lp group and 75 HCC nodules in the EP/Lp group were 72.6% and 66.7%, respectively (P = 0.894). Overall tumor response revealed that six patients (50.0%) in the CP/Lp group and six patients (37.5%) in the EP/Lp group had a partial response plus a complete response, with no significant difference (P = 0.615). TACE-free control curves for both groups revealed no significant difference (P = 0.513).ConclusionNo significant difference was found with regard to adverse effects, the treatment effect on HCC nodules, or overall tumor response between the CP/Lp and EP/Lp groups.

SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY-BASED THREE-DIMENSIONAL CONFORMAL RADIOTHERAPY FOR HEPATOCELLULAR CARCINOMA WITH PORTAL VEIN TUMOR THROMBUS

PURPOSE To evaluate the safety and efficacy of three-dimensional conformal radiotherapy (3D-CRT) using single photon emission computed tomography (SPECT) in unresectable hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). METHODS AND MATERIALS Patients with HCC with PVTT in the first branch and/or main trunk were selected for this study. The optimal beam directions for 3D-CRT were explored using a Tc-99m-galactosyl human serum albumin SPECT image for guidance. The SPECT image was classified as either wedge type or localized type. The clinical target volume to a total dose of 45 or 50 Gy per 18-20 fractions included the main tumor and PVTT in the wedge type and PVTT alone in the localized type. RESULTS Twenty-six patients were enrolled: 18 with wedge type and 8 with localized type. Mean tumor size was 7.1 cm (range, 4.4-12.3 cm). Clinical target volumes of wedge type vs. localized type were 111.2 cm(3) vs. 48.4 cm(3) (p = 0.010), respectively. Mean dose to normal liver and mean dose to functional liver were 1185 cGy and 988 cGy (p = 0.001) in wedge type and 1046 cGy and 1043 cGy (p = 0.658) in localized type, respectively. Despite an incidence of Child-Pugh B and C of 57.7%, no patients experienced radiation-induced liver disease. The progression of PVTT was inhibited, with an incidence of 92.2%; survival rates at 1 and 2 years were 44% and 30%, respectively. CONCLUSION Single photon emission computed tomography-based 3D-CRT enables irradiation of both the main tumor and PVTT with low toxicity and promising survival.

Preoperative microcoil embolization of the common hepatic artery for pancreatic body cancer

AIM To evaluate safety and feasibility of microcoil embolization of the common hepatic artery under proper or distal balloon inflation in preoperative preparation for en bloc celiac axis resection for pancreatic body cancer. METHODS Fifteen patients (11 males, 4 females; median age, 67 years) with pancreatic body cancer involving the nerve plexus surrounding the celiac artery underwent microcoil embolization. To alter the total hepatic blood flow from superior mesenteric artery (SMA), microcoil embolization of the common hepatic artery (CHA) was conducted in 2 cases under balloon inflation at the proximal end of the CHA and in 13 cases under distal microballoon inflation at the distal end of the CHA. RESULTS Of the first two cases of microcoil embolization with proximal balloon inflation, the first was successful, but there was microcoil migration to the proper hepatic artery in the second. The migrated microcoil was withdrawn to the CHA by an inflated microballoon catheter. Microcoil embolization was successful in the other 13 cases with distal microballoon inflation, with no microcoil migration. Compact microcoil embolization under distal microballoon inflation created sufficient resistance against the vascular wall to prevent migration. Distal balloon inflation achieved the requisite 1 cm patency at the CHA end for vascular clamping. All patients underwent en bloc celiac axis resection without arterial reconstruction or liver ischemia. CONCLUSION To impede microcoil migration to the proper hepatic artery during CHA microcoil embolization, distal microballoon inflation is preferable to proximal balloon inflation.

Effects of hepatic artery chemoembolization using cisplatin-lipiodol suspension with gelatin sponge particles on swine liver.

PURPOSE To define the effects of hepatic artery chemoembolization with cisplatin-lipiodol suspension and gelatin sponge particles on swine liver tissue and estimate the concentration of cisplatin that would have a minimal negative effect on normal liver parenchyma. MATERIALS AND METHODS Twelve pigs were divided into four groups: group A was the control group in which hepatic arteries were embolized with lipiodol and gelatin sponge particle (n = 3); group B animals were embolized with 10 mg/mL cisplatin-lipiodol suspension plus gelatin sponge particle (n = 3), group C with 20 mg/mL cisplatin-lipiodol suspension plus gelatin sponge particle (n = 3), and group D with 30 mg/mL cisplatin-lipiodol suspension plus gelatin sponge particle (n = 3). Pigs were euthanized 1 week after embolization, and the resected livers were cut into 10-mm-thick sections. The livers and necrotic foci were contoured in each section, and the necrosis volume ratio was calculated. RESULTS The necrosis volume ratios of the livers in groups A, B, C, and D were 0.832% +/- 0.334, 2.324% +/- 1.126, 8.056% +/- 3.276, and 11.82% +/- 4.921, respectively. Significant differences (P < .05) in necrosis volume ratio were found between groups A and C, groups A and D, groups B and C, and groups B and D; no significant difference was found between groups A and B. CONCLUSIONS Hepatic artery chemoembolization with higher doses of cisplatin causes greater damage to liver tissue; 10 mg/mL cisplatin-lipiodol suspension causes minimal damage, similar to that without cisplatin, and is related to minimal negative changes in a swine model.

N-butyl cyanoacrylate embolization with blood flow control of an arterioportal shunt that developed after radiofrequency ablation of hepatocellular carcinoma.

We present a case of a patient with rapid deterioration of esophageal varices caused by portal hypertension accompanied by a large arterioportal shunt that developed after radiofrequency ablation of hepatocellular carcinoma. We used n-butyl cyanoacrylate (NBCA) as an embolic material to achieve pinpoint embolization of the shunt, because the microcatheter tip was 2 cm away from the shunt site. Under hepatic arterial flow control using a balloon catheter, the arterioportal shunt was successfully embolized with NBCA, which caused an improvement in the esophageal varices.

Basic Study of a Mixture of N-butyl Cyanoacrylate, Ethanol, and Lipiodol as a New Embolic Material

PURPOSE To clarify the configuration change of N-butyl cyanoacrylate (NBCA) polymerization with increasing proportion of ethanol, the properties of a mixture of NBCA with lipiodol plus ethanol (NLE), and the feasibility of use of NLE for aneurysm packing in a swine model. MATERIALS AND METHODS The polymerization configuration of NLE was explored using ratios of 1-4 parts NBCA and 1-3 parts ethanol per 1 part of lipiodol; a 1:1 ratio of NBCA to lipiodol (NLE110) was used as a control. The distance that NLE migrated into saline flowing in a tube was measured. A carotid artery aneurysm was created in each of 18 swine. Aneurysmal packing with three configurations--NLE110, NLE at a ratio of 1:1:2 (NLE112), and NLE at a ratio of 1:1:3 (NLE113)--was attempted in six swine for each configuration. RESULTS Regardless of NBCA composition, medium-sized droplets, a single large droplet, and a noodle-shaped extrusion were observed in NLE with lipiodol versus ethanol ratios of 1:1, 1:2, and 1:3. NLE110 migrated as viscous fluid to 190 cm from the injection site, whereas NLE112 migrated for 81 cm ± 11 and NLE113 migrated for 74 cm ± 9. Instant outflow of NLE110 from the six aneurysms caused occlusion of the parent artery, with adhesion to the microcatheter. Packing was achieved with minimal adhesion for all six of the aneurysms packed with NLE112 or with NLE113. CONCLUSIONS With high ratios of ethanol, the NLE polymerization configuration acquired solid-like properties with potent occlusive ability and negligible adhesion to the microcatheter, suggesting its feasibility for packing of aneurysms.

Differentiation of pancreatic serous cystadenoma from endocrine tumor and intraductal papillary mucinous neoplasm based on washout pattern on multiphase CT.

Objective To evaluate the washout (WO) pattern of serous cystadenomas (SCAs) compared with endocrine tumors (ETs) and intraductal papillary mucinous neoplasm (IPMN). Methods Patients with serous cystadenoma (n = 12), ET (n = 29), and IPMN (n = 35) underwent 4-phase computed tomography CT. Tumors were categorized as hyperdense or hypodense. Computed tomographic values measured were unenhanced attenuation (AU), pancreatic attenuation (A12, 12 seconds), portal attenuation (A35), and equilibrium (A158). Computed tomographic parameters calculated were wash-in (WI) = A12 − AU; WO = A12 − A35; and washout ratio (WOR) = WO/WI × 100/22. Results Hyperdense SCAs had significantly higher WOR than did hyperdense ETs (P = 0.001). Among the 3 hypodense tumors, SCAs had the significantly highest WOR (P < 0.05/3). Relative to the pancreas, the WOR of SCAs were equivalent, whereas the WOR of ETs and IPMNs were significantly lower. Conclusions Hyperdense SCAs had significantly higher WOR than did hyperdense ETs, and hypodense SCAs had the significantly highest WOR among the three.

Pathologic Evaluation of Damage to Bronchial Artery, Bronchial Wall, and Pulmonary Parenchyma After Bronchial Artery Embolization With N-butyl Cyanoacrylate for Massive Hemoptysis

Histologic evidence of safety after bronchial arterial embolization (BAE) with N-butyl cyanoacrylate (NBCA) should be assured. The present report describes a 78-year-old man with massive hemoptysis from lung cancer who underwent surgical lobectomy 23 days after hemostasis had been achieved via BAE with NBCA. Pathologic examination revealed that NBCA filled the lumen of bronchial branch arteries 143-1,094 μm in diameter from the lobar bronchus to subsegmental bronchus but was not seen in the lumen of the pulmonary artery or pulmonary vein. NBCA induced occlusion of bronchial branch arteries but no necrosis of the bronchial wall or pulmonary parenchyma.