Ryota Kawasaki

Endovascular obliteration of bleeding duodenal varices in patients with liver cirrhosis

The purpose of this paper is to describe our experience with endovascular obliteration of duodenal varices in patients with liver cirrhosis and portal hypertension. Balloon-occluded transvenous retrograde and percutaneous transhepatic anterograde embolizations were performed for duodenal varices in five patients with liver cirrhosis, portal hypertension, and decreased liver function. All patients had undergone previous endoscopic treatments that failed to stop bleeding and were poor surgical candidates. Temporary balloon occlusion catheters were used to achieve accumulation of an ethanolamine oleate–iopamidol mixture inside the varices. Elimination of the varices was successful in all patients. Retrograde transvenous obliteration via efferent veins to the inferior vena cava was enough to achieve adequate sclerosant accumulation in three patients. A combined anterograde–retrograde embolization was used in one patient with balloon occlusion of afferent and efferent veins. Transhepatic embolization through the afferent vein was performed in one patient under balloon occlusion of both efferent and afferent veins. There was complete variceal thrombosis and no bleeding was observed at follow-up. No major complications were recorded. Endovascular obliteration of duodenal varices is a feasible and safe alternative procedure for managing patients with portal hypertension and hemorrhage from this source.

Therapeutic Effectiveness of Diagnostic Lymphangiography for Refractory Postoperative Chylothorax and Chylous Ascites: Correlation With Radiologic Findings and Preceding Medical Treatment

OBJECTIVE The purpose of this study was to assess the therapeutic effect of lymphangiography for refractory postoperative chylothorax and chylous ascites and analyze the relation between the clinical outcomes and radiologic findings or response to the preceding medical treatment. MATERIALS AND METHODS Between January 2004 and June 2012, 14 patients underwent lymphangiography. All patients had been unresponsive to at least two medical treatments for 3-62 days (median, 13.5 days) before lymphangiography. Leaks were classified as major, minor, and undetectable on the basis of radiologic findings including CT and conventional radiography after lymphangiography. The clinical outcomes were correlated with the radiologic findings or the changes of the daily chylous output after the preceding medical treatments. RESULTS The leaks were healed in nine of 14 patients (64.3%) by 3-29 days (median, 8 days) after lymphangiography. Healing was achieved for two of seven major leaks, and all of the minor leaks (n=4) and undetectable leaks (n=3) after lymphangiography. The remaining five major leaks were not healed after a median follow-up of 15 days. The daily output decreased more than half after medical treatment in seven of the 14 patients, and the leak was healed in six of these patients (85.7%) by 5-18 days (median, 10 days). CONCLUSION Lymphangiography might be useful for the treatment of refractory postoperative chylothorax and chylous ascites.

N-butyl Cyanoacrylate Embolization for Pseudoaneurysms Complicating Pancreatitis or Pancreatectomy

PURPOSE To evaluate the clinical effectiveness and safety of transcatheter arterial embolization with n-butyl cyanoacrylate (NBCA) for pseudoaneurysms complicating pancreatitis or pancreatectomy. MATERIALS AND METHODS Twelve procedures were performed in nine patients (seven men and two women; mean age, 60.6 years) for pseudoaneurysms that occurred secondary to pancreatitis or as a consequence of pancreatic juice leakage at the site of pancreatectomy. For embolization, NBCA was mixed with iodized oil at a ratio of 1:1-1:4; in one patient with failed selective catheterization of the target vessel, the mixture ratio was 1:9. Technical and clinical success rates, recurrent bleeding, procedural complications, serum amylase level, and clinical outcome were determined for each procedure. RESULTS Embolization was technically successful in all procedures, with no recurrent bleeding documented from the initially treated territory. In three procedures, we encountered additional bleeding vessels at 11, 33, and 49 days after the procedures, which were successfully managed by a second embolization in each case. There were no major complications related to the procedures. As minor complications, in two procedures, the embolized material overflowed beyond the target vessels; however, no clinically significant ischemic events were observed in the embolized territories. Serum amylase did not increase compared with initial levels after any of the procedures. Seven patients were discharged after clinical improvement. Two patients died 2 and 3 weeks after the embolization as a result of multiple organ failure not associated with the procedure. CONCLUSIONS In this limited series, NBCA embolization was found to be feasible and effective for pseudoaneurysms as a complication of pancreatitis or pancreatectomy.

Curved Nitinol Stent-Graft Placement for Treating Blunt Thoracic Aortic Injury: An Early Experience

BACKGROUND Blunt trauma-induced aortic injury traditionally has been treated with early open surgical repair. However, recently endovascular stent-graft technology is considered a less-invasive therapeutic alternative, and flexible stent-grafts, such as the Matsui-Kitamura stent-graft (MKSG), are being used widely. We report our experience with the curved MKSG in treating thoracic aortic injuries. METHODS Nine patients with traumatic thoracic aortic injury underwent endovascular surgery (8, emergency; 1, elective) with curved MKSG. The study variables were Injury Severity Score, endovascular surgery duration, aortic and stent-graft diameter, stay in the intensive care unit, follow-up period, and mortality. An MKSG was constructed using the Matsui-Kitamura stent and a polyester fabric graft. The stent-graft was placed using the transfemoral approach and the wire-tug technique. RESULTS The mean Injury Severity Score was 42.3; 5 patients required 6 emergency procedures before the endovascular procedure (pneumothorax or hemothorax drainage, 5; transarterial embolization, 1). In 8 patients (88.9%), we achieved complete pseudoaneurysm exclusion or hemostasis in the injured portion. There were no postoperative complications; blood loss was minimal, and the intensive care unit stay was 13.4 days. The overall hospital mortality was 22.2% (n = 2; causes of death were unrelated to MKSG placement). Neither intervention-related mortality during follow-up (mean, 237.7 days) nor late endovascular graft-related complications (endoleak or graft migration) were noted. CONCLUSIONS Although this study is limited by a small sample size and short follow-up period, no collapse or stent-graft fractures were noted. Thus, MKSG placement for traumatic thoracic aortic injury appears a safe and effective therapy.

Evaluation of hypervascular hepatocellular carcinoma in cirrhotic liver: comparison of different concentrations of contrast material with multi-detector row helical CT--a prospective randomized study.

PURPOSE To evaluate two different iodine concentrations of contrast material for detecting hypervascular hepatocellular carcinomas (HCCs) in cirrhotic liver by multi-detector row helical CT (MDCT) when a fixed contrast material volume and injection rate is used. MATERIALS AND METHODS Institutional Review Board approval was obtained, and informed consent was obtained from all patients. In this prospective study, 105 patients were randomly assigned a group A (an iodine concentration of 300 mg I/mL), and a group B (an iodine concentration of 370 mg I/mL). In both groups the volume of contrast material was 100 mL and the injection rate was 4 mL/s. Fifty-two patients had 122 hypervascular HCCs. The diagnosis of HCCs was established histopathologically (n=24) and by imaging findings (n=98). Three readers independently analyzed four image sets: an arterial phase (AP), a portal phase (PP), an equilibrium phase (EP), and combined all three phase images set. Sensitivity, specificity, and diagnostic accuracy were calculated by receiver operating characteristic (ROC) analysis. RESULTS The mean sensitivity for detecting hypervascular HCCs of the AP set, EP set, and combination set in group B (0.94, 0.81, and 0.93) was significantly higher than in group A (0.84, 0.69, and 0.80). Area under the ROC curve of the AP set and the combination set in group B (0.974 and 0.981) was significantly higher than in group A (0.939 and 0.958). CONCLUSION At the same contrast material volume and injection rate, higher iodine concentration of contrast material was effective for detecting hypervascular HCCs by MDCT.

Atypical hemangioma mimicking hepatocellular carcinoma with a special note on radiological and pathological findings.

We report a case of hemangioma with an atypical vascular enhancement pattern. The hemangioma showed peripheral rim enhancement at the arterial phase during dynamic magnetic resonance imaging, and the peripheral enhanced zone was still apparent during the delayed phase, as shown on double-phase computed tomography hepatic arteriography. The rim enhancement pattern of this case, mimicking that of hepatocellular carcinoma, may be due to the surrounding liver parenchymal fibrotic change caused by an active hepatitis C viral infection.

Flow-preserved coil embolization using a side-holed indwelling catheter for common hepatic artery pseudoaneurysm: report of three cases

We report three cases of hepatic artery pseudoaneurysm, which were all treated successfully using a combination of coil embolization and a side-holed 5F indwelling catheter for maintaining minimal hepatic artery blood flow with exclusion of the pseudoaneurysm. The tip of an infusion catheter was placed in the right hepatic artery and a side hole was positioned at the celiac axis. Coil embolization was then performed from the proper to the common hepatic artery using detachable coils. Hemostasis was achieved in all patients, with a final angiogram showing the hepatic arteries through the indwelling catheter. One major hepatic infarction and one focal liver abscess caused by reflux cholangitis manifested on postoperative days (PODs) 11 and 87, respectively. All patients survived and the indwelling catheter was removed on POD 136–382 without complication.

Endovascular Treatment for Visceral Vessel Complication After Branched Graft Replacement : Initial Results

OBJECTIVE The objective of our study was to retrospectively assess the safety and efficacy of endovascular treatment for branch stenosis or obstruction after branched graft replacement in patients with thoracoabdominal aortic aneurysm or aortic arch aneurysm. MATERIALS AND METHODS Seven patients (all men; median age, 62 years; age range, 19-79 years) who had undergone aortic surgery using branched grafts between March 2004 and January 2007 were treated. Diagnosis was established on dynamic contrast-enhanced CT or angiography. A self- or balloon-expandable stent was placed after predilatation with a balloon catheter and, if necessary, thrombolysis was also performed. Stent patency was assessed on thin-slice axial images obtained during the arterial phase on dynamic contrast-enhanced CT. RESULTS Seven lesions (one celiac artery, two left subclavian arteries, and four renal arteries) were treated. The time between the surgery and treatment was 0-3 days for patients with abdominal lesions and 20-41 days for those with thoracic lesions. Stent placement was successful in five of the seven patients. In one patient, insertion of the stent delivery system was unsuccessful; in the other patient, the stent was not completely expanded. The clinical symptoms and abnormal laboratory data improved in all patients with successful procedures. No restenosis was observed on imaging follow-up, with a median patency of 104 days (range, 5-1,218 days) during clinical follow-up (range, 37-1,218 days; median, 135 days). CONCLUSION Endovascular repair can be an alternative treatment for visceral vessel complications of branched grafts, especially in obstructed but peripherally patent branches.

Percutaneous retrograde recanalization of an occluded celiac artery complicating acute aortic dissection

Abstract A 79-year-old woman with a complaint of persistent upper abdominal pain was admitted to our hospital for the treatment of thrombosed acute type B aortic dissection. Computed tomography showed the complete static occlusion of the celiac artery. Because of progressive symptom with elevation of liver enzymes and metabolic acidosis 11 h after admission, endovascular revascularization was attempted on an emergent basis. After a failed catheterization of the celiac ostium in an antegrade fashion due to a hard occlusion, we succeeded in a retrograde recanalization through the pancreaticoduodenal arcade via the superior mesenteric artery with stent placement using a pull-through technique. This technique is useful and safe when an antegrade approach seems difficult.