Pengli Zhou

Initial Imaging Analysis of Budd-Chiari Syndrome in Henan Province of China: Most Cases Have Combined Inferior Vena Cava and Hepatic Veins Involvement

Aim To evaluate the type of venous involvement in Chinese Budd-Chiari syndrome (BCS) patients and the relative diagnostic accuracy of the different imaging modalities. Methods Using digital subtraction angiography (DSA) as a reference standard, color Doppler ultrasound (CDUS), computed tomography angiography (CTA), and magnetic resonance angiography (MRA) were performed on 338 patients with BCS. We analyzed the course of the main and any accessory hepatic veins (HVs) and the inferior vena cava (IVC) to assess the etiology of obstructed segments and diagnostic accuracy of CDUS, CTA and MRA. Results Among the 338 cases, there were 8 cases (2.4%) of isolated IVC membranous obstruction, 45 cases (13.3%) of isolated HV occlusion, and 285 cases (84.3%) with both IVC membranous obstruction and HV occlusion. Comparing with DSA, CDUS, CTA had a diagnostic accuracy of 89.3% and 80.2% in detecting BCS, and 83.4% of cases correctly correlated by MRA. Conclusion In Henan Province, most patients with BCS have complex lesions combining IVC and HV involvement. The combination of CDUS and CTA or MRI is useful for diagnosis of BCS and guiding therapy.

Flat detector C-arm CT-guidance system in performing percutaneous transthoracic needle biopsy of small (≤3 cm) pulmonary lesions.

Background Nowadays, flat detector (FD) equipped angiographic C-arm computed tomography (CACT) systems can be used to acquire CT-like cross-sectional images directly within the interventional suite. The CACT systems offer real time visualization of transthoracic needle biopsy (TNB) procedure and more flexibility in the orientation of the detector system around the patient compared to traditional CT systems. Purpose To evaluate the value of a flat detector C-arm CT-guidance system in performing percutaneous transthoracic needle biopsy (PTNB) for small (≤3 cm) pulmonary lesions in clinical practice. Material and Methods A total of 60 patients with solid lung lesions were retrospectively enrolled to undergo PTNB procedures. The mean diameter of lesions was 2.3 ± 0.6 cm (range, 0.6–3 cm). The needle path was carefully planned and calculated on the C-arm CT system, which acquired three-dimensional CT-like cross-sectional images. The PTNB procedures were performed under needle guidance with fluoroscopic feedbacks. Results Histopathologic tissue was successfully obtained from 59 patients with a puncture success rate of 98.3% (59/60). The diagnostic accuracy rate was found to be 91.5% (54/59). There were only two cases of pneumothorax (3.3%) requiring therapy. The rates of pneumothorax and hemoptysis were low (15.0% [9/60] and 8.3% [5/60], respectively). The overall procedural time was in the range of 12–18 min, resulting in a mean exposure dose of 224.4 ± 4.8 mGy. Conclusion Our study shows that C-arm CT-based needle guidance enables reliable and efficient needle positioning and progression by providing real-time intraoperative guidance for small (≤3 cm) pulmonary lesions in clinical practice.

Endovascular Treatment for Extrahepatic Portal Vein Bifurcation Stenosis after a Whipple Procedure Using the Kissing Stents Technique

A 57-year-old man presented with a rare extrahepatic portal vein bifurcation scar stenosis involving the proximal splenic vein and superior mesenteric vein after a Whipple procedure. He was treated with endovascular coil embolization for the gastroesophageal varices and kissing stents for the portal vein bifurcation stenosis. This case illustrates a rarely seen complication after the Whipple procedure and a novel management strategy that can be considered in the management of this complex disease.

Detection and characterization of Budd-Chiari syndrome with inferior vena cava obstruction: Comparison of fixed and flexible delayed scan time of computed tomography venography

PURPOSE To compare the results of computed tomography venography (CTV) with a fixed and a flexible delayed scan time for Budd-Chiari syndrome (BCS) with inferior vena cava (IVC) obstruction. MATERIAL AND METHODS A total of 209 consecutive BCS patients with IVC obstruction underwent either a CTV with a fixed delayed scan time of 180s (n=87) or a flexible delayed scan time for good image quality according to IVC blood flow in color Doppler ultrasonography (n=122). The IVC blood flow velocity was measured using a color Doppler ultrasound prior to CT scan. Image quality was classified as either good, moderate, or poor. Image quality, surrounding structures and the morphology of the IVC obstruction were compared between the two groups using a χ2-test or paired or unpaired t-tests as appropriate. Inter-observer agreement was assessed using Kappa statistics. RESULTS There was no significant difference in IVC blood flow velocity between the two groups. Overall image quality, surrounding structures and IVC obstruction morphology delineation on the flexible delayed scan time of CTV images were rated better relative to those obtained by fixed delayed scan time of CTV images (p<0.001). Evaluation of CTV data sets was significantly facilitated with flexible delayed scan time of CTV. There were no significant differences in Kappa statistics between Group A and Group B. CONCLUSION The flexible delayed scan time of CTV was associated with better detection and more reliable characterization of BCS with IVC obstruction compared to a fixed delayed scan time.

A Case-Control Study of Risk Factors of Abdominal Aortic Aneurysm.

OBJECTIVE To explore the potential risk factors of abdominal aortic aneurysm (AAA) in the Chinese population. METHODS A matched case-control study was designed for the study. Patients with AAA administrated in the First Affiliated Hospital of Zhengzhou University from January 2005 to December 2007 were included in the study. Sex and age-matched volunteers were selected for the case-control in the same period. A uniform questionnaire was sent to patients and volunteers to collect demographic data, past medical history, and behavioral factors. General physical examination, ultrasound examination of the abdominal aorta, and serological testing were used to collect clinical data. Environmental risk factors of abdominal aortic aneurysms were analyzed by conditional logistic regression. RESULTS A total of 465 subjects including 155 patients were enrolled in the study. Multivariate regression analysis found that people with high blood pressure have high risk of AAA (OR = 1.88, 95% CI 1.12-3.18; P = .02). Smoking is a significant independent risk factor for AAA; the morbidity of AAA in smokers is 5.23-fold of non-smokers (95% CI 2.44-11.23). Dyslipidemia (OR = 2.61, 95% CI 1.45-4.70), serum high sensitivity C-reactive protein (OR = 2.43, 95% CI 1.37-4.31), and homocysteine (OR = 2.73, 95% CI 1.61-4.65) were valuable parameters in detecting AAA. CONCLUSION Hypertension and smoking are risk factors of abdominal aortic aneurysms; dyslipidemia, high-sensitivity C-reactive protein, and homocysteine levels are associated with AAA.

Comment on 'Endovascular Aneurysm Repair and Sealing (EVARS): A Useful Adjunct in Treating Challenging Morphology'.

To the Editor, We enjoyed reading the article entitled ‘‘Endovascular Aneurysm Repair and Sealing (EVARS): A Useful Adjunct in Treating Challenging Morphology’’ by Harrison et al. in the April 2016 issue of the journal [1]. The authors reported an interesting case of pseudoaneurysm after open abdominal aortic aneurysm repair, which was successfully excluded by combining endovascular aneurysm sealing (EVAS) and endovascular aneurysm repair (EVAR). The patient’s iliac vessels were short, and inadequate sealing in iliac vessels could lead to a type Ib endoleak. So, the authors used two Zenith iliac limbs to extend through the distal stents of the Nellix and land at each iliac bifurcation. This combination of elements of EVAS and EVAR has been termed EVARS in this report [1]. Interestingly, Bi et al. first reported the notion of EVARS previously [2, 3], which seemed to be different from this report. EVAS by Nellix device is a fascinating novel concept, which emphasizes the sealing of whole aneurysm rather than the aneurysm shrinkage and thrombosis of the occluded sac lumen [2]. We appreciate this novel concept and hypothesize that EVAS may well be proposed as a novel alternative to EVAR and the second great revolution for aortic aneurysm treatment, if EVAR is regarded as the first revolution compared with open surgical repair. However, Nellix device system has difficulty treating type 1 endoleak due to the two-stent design of the Nellix system [3, 4]. So, Bi et al. previously hypothesized that EVARS could overcome this drawback easily. Aneurysm sealing by a single polymer-filled bag followed by a standard aortic stent-graft EVAR, that is our term of EVARS, may show up with even better fixation and less endoleak than EVAR or EVAS alone does, and can be easily accepted by clinicians who are familiar with standard EVAR operation [2]. In our opinion, single endobag filling is more convenient and effective and can provide a better sealing fixation than the two-endobag filling. Similarly, single stent-graft may show much better regular stent lumen and fewer endoleak than this two-stent design does. Obviously, our notion of EVARS is different from that reported by authors, although we all emphasized the combination of good elements of EVAS and EVAR. According to the authors, in EVARS, the limb lengths were chosen to overlap generously within the 10-mm stents of the Nellix; however, as they pointed out, operators should avoid the dilated stents dwelling within the Nellix stent and risking limb occlusion, if a larger EVAR limb is required. Besides, the volume of polymer required for sealing may not always be estimated accurately if the prefill process is omitted as reported in this case. The authors concluded that EVARS is a feasible treatment of pseudoaneurysms of the anastomoses following open aneurysm repair. In our opinion, EVARS may expand the population of patients who are candidates for endovascular aneurysm repair. & Xinwei Han hanxinwei2006@163.com

Endovascular Treatment of an Unusual Primary Arterioportal Fistula Complicated by Cavernous Transformation of the Portal Vein Caused by Portal Thrombosis

We describe an elderly woman who presented with an unusual primary arterioportal fistula and cavernous transformation of the portal vein caused by portal thrombosis, which were subsequently managed with endovascular coil embolization and transjugular intrahepatic portosystemic shunt using 2 stents after balloon remodeling. This case shows a rarely seen condition in the elderly and a novel management strategy that should be considered in the management of this complex disease.

Spontaneous Intrahepatic Portosystemic Shunt in Budd–Chiari Syndrome

Budd-Chiari syndrome (BCS) caused by hepatic venous outflow obstruction may result in portal hypertension and the development of intrahepatic collaterals that bypass the obstruction. Spontaneous intrahepatic portosystemic venous shunt (SIPSVS) is uncommon and may be associated with portal hypertension. SIPSVS is extremely rare in patients with BCS and has not been well documented. We report a case of SIPSVS in a 42-year-old woman with BCS caused by membranous obstruction and chronic thrombosis in the inferior vena cava (IVC). A direct vascular communication between the left portal vein and IVC was confirmed by sonography and a computed tomography angiography scan. The patient underwent successful percutaneous balloon angioplasty of the IVC. Surgical or endovascular treatment for SIPSVS was not carried out because the patient was asymptomatic and remained asymptomatic in terms of encephalopathy at a 1-year follow-up.

Long-term Outcomes of Endoluminal Sharp Recanalization of Occluded Inferior Vena Cava in Budd-Chiari Syndrome

PURPOSE To report the long-term results of endoluminal sharp recanalization of occluded inferior vena cava (IVC) in patients with the Budd-Chiari syndrome (BCS). PATIENTS AND METHODS Seventy-two consecutive patients with BCS and IVC occlusion underwent endoluminal recanalization of the IVC occlusion during a 6-year period. BCS with occlusive IVC was detected by reviewing patient history and color Doppler ultrasonography. Data on technical success, morbidity, mortality, complications, and color Doppler sonographic outcome were collected and analyzed. RESULTS Seventy-seven recanalizations were performed in 72 patients. Technical success (patent IVC with good blood flow) was achieved in 70 (97.4%) patients. No perioperative death was observed. Six complications were found during recanalization, and 10 complications were found for total interventional procedures. The complication rates were 7.8% and 7.3% for recanalization and total procedure, respectively. Bleeding of access veins was the most common complication, and 2 patients showed slight rupture of IVC. The postoperative IVC diameter and blood speed of IVC increased significantly. Fifty-seven patients (79.2%) were clinical cured, and 2 patients (2.8%) showed no improvement. The 1-year, 3-year, and 5-year primary patency rates were 92.5%, 86.8%, and 77.3%, respectively. The second patency rates were 100.0%, 97.8%, and 91.8% for 1, 3, and 5 years, respectively. There were 2 deaths during follow-up. CONCLUSION Endoluminal sharp recanalization of occluded IVC in patients with BCS is safe and effective with good long-term outcomes.

Percutaneous Transhepatic Hepatic Vein Angioplasty in Budd–Chiari Syndrome After Transvenous Failure

PURPOSE To evaluate the safety and efficacy of percutaneous transhepatic route creation for hepatic vein (HV) angioplasty in Budd-Chiari syndrome (BCS). PATIENTS AND METHODS Between April 2012 and August 2016, a total of 19 BCS patients underwent percutaneous transhepatic route creation for HV angioplasty after transvenous catheterization failure in this study. Color Doppler ultrasonography was required in all patients after admission and during follow-up. Data were retrospectively collected, and follow-up observations were performed. RESULTS Technical and clinical success was achieved in 18 patients. Except for 1 failure of route creation, 19 routes were successfully created in 18 patients, with a technology success rate of 95.0%. Twenty-two balloon angioplasties were performed in 18 patients, with a mean balloon diameter of 13.6 ± 0.5 mm. Blood pressure and length of occlusive HV decreased significantly, and blood flow velocity and diameter of HV increased significantly after procedure. Abdominal distension/pain and ascites decreased significantly after procedure. One procedure-related death occurred, who died of gastrointestinal bleeding 6 days later. Except for the failure case, the rest of 18 patients were successfully followed up. The remaining 18 patients survived during follow-up, with a 5-year survival rate of 94.9%. One patient had a restenosis of HV after 47 days, and had undergone successful dilation. The 5-year primary and second patency rates were 94.1% and 100%, respectively. CONCLUSION Percutaneous transhepatic route creation is safe and effective for HV angioplasty, and can be used to treat BCS patients after transvenous catheterization failure.