Soichiro Hase

Risk Factors for Local Progression After Percutaneous Radiofrequency Ablation of Lung Tumors Evaluation Based on a Preliminary Review of 342 Tumors

The purpose of the study was to retrospectively evaluate the risk factors for local progression after percutaneous radiofrequency (RF) ablation of lung tumors.

Feasibility of percutaneous radiofrequency ablation for intrathoracic malignancies: a large single-center experience.

Radiofrequency ablation (RFA) has become an accepted alternative for treating intrathoracic malignancies; however, the incidence and characteristics of peri‐ and postprocedural complications are not well described. The purpose of the study was to assess the safety and technical feasibility of percutaneous RFA in unresectable intrathoracic malignancies.

Percutaneous Radiofrequency Ablation Combined with Previous Bronchial Arterial Chemoembolization and Followed by Radiation Therapy for Pulmonary Metastasis from Hepatocellular Carcinoma

A 56-year-old man had a lung metastasis from hepatocellular carcinoma 4.7 cm x 3.4 cm in size located directly adjacent to the pulmonary hilar vessels. The tumor was treated with radiofrequency ablation combined with earlier bronchial arterial chemoembolization and subsequent radiation therapy. A complete remission of the tumor has been observed for 6 months since completion of therapy. Considering that complete treatment of such an intermediate-sized tumor adjacent to the large vessels is usually difficult with radiofrequency ablation alone, this result suggests a possible role for combined therapy for pulmonary neoplasms.

Radiofrequency ablation of normal lungs after pulmonary artery embolization with use of degradable starch microspheres : Results in a porcine model

PURPOSE The present study was performed to evaluate the effect of pulmonary artery embolization on radiofrequency (RF) ablation of normal porcine lungs. MATERIALS AND METHODS RF ablation zones (n=34) were created in the normal lungs of five domestic pigs (five zones in each of the first two pigs and eight zones in each of the remaining three pigs) with an expandable multitined electrode with use of bilateral thoracotomy. RF ablation was performed without pulmonary artery embolization (group 1, n=8), immediately after embolization (group 2, n=11), 15 minutes after embolization (group 3, n=7), and 30 minutes after embolization (group 4, n=8) with degradable starch microspheres. Among them, 12 ablation zones were excluded from this study because they were considerably limited by the presence of the pleura or large bronchi. The remaining 22 zones were included (n=7, n=5, n=4, and n=6 in groups 1, 2, 3, and 4, respectively). Coagulation necrosis volumes in the ablation zones were measured and compared among the groups. RESULTS Coagulation necrosis volumes were 0.9+/-0.5 cm3, 2.1+/-0.4 cm3, 2.1+/-1.0 cm3, and 1.9+/-0.6 cm3 in groups 1, 2, 3, and 4, respectively. Groups 2-4 showed significantly larger coagulation volumes than group 1 (P=.012, P=.023, and P=.010 in groups 2, 3, and 4, respectively). CONCLUSION Pulmonary artery embolization contributed to larger volumes of coagulation necrosis after RF ablation of normal lungs.

Dynamic Volumetric CT Angiography for the Detection and Classification of Endoleaks: Application of Cine Imaging Using a 320-Row CT Scanner with 16-cm Detectors

PURPOSE To assess the feasibility and diagnostic performance of dynamic volumetric computed tomography (CT) angiography with large-area detectors in the detection and classification of endoleaks after endovascular aneurysm repair (EVAR). MATERIALS AND METHODS Low-dose dynamic volumetric CT angiography performed with the patient in Fowler position was used to scan the entire stent graft with a 16-cm-area detector during the first follow-up examination after EVAR. There were 39 consecutive patients (36 men and 3 women; mean age, 74 y ± 8.7) examined with approximately 14-20 intermittent scans (temporal resolution, 2 s; scan range, 160 mm). The effective radiation dose, image quality, interobserver and intraobserver agreement for endoleak detection, and time delay between peak enhancement of the aorta and endoleaks were evaluated. RESULTS All examinations with the patient in Fowler position enabled the entire stent graft to be scanned and were rated as diagnostic. The mean effective radiation dose was 13.1 mSv. Endoleaks were detected in eight patients (type Ia, n = 1; type II, n = 6; type III, n = 1). Interobserver agreement (κ = 0.794) and intraobserver agreement (κ = 1.00) for detection of endoleaks were excellent. The mean time delay between peak enhancement of the aorta and the endoleaks was significantly less for type I/III endoleaks (2.0 s ± 0) compared with type II endoleaks (5.3 s ± 1.0; P < .001). CONCLUSIONS Low-dose dynamic volumetric CT angiography performed with the patient in Fowler position is feasible after EVAR. Dynamic information, including cine imaging, the timing of peak enhancement, and the Hounsfield units index, is useful in detecting and classifying endoleaks.

Sloughing of Intraductal Tumor Thrombus of Hepatocellular Carcinoma after Transcatheter Chemoembolization Causing Obstructive Jaundice and Acute Pancreatitis

Editor: A 69-year-old man with liver cirrhosis as a result of hepatitis C virus was admitted to our department. He had a history of surgical resection of hepatocellular carcinoma (HCC) 6 years earlier. Thereafter, two new foci of HCC developed and each was treated with a combination of transcatheter chemoembolization (TACE) and radiofrequency (RF) ablation. At the current admission, another tumor with a diameter of 1.7 cm had developed in the periphery of the medial segment. The patient was admitted in anticipation of RF ablation of this tumor under computed tomographic (CT) fluoroscopic guidance. Our institution does not require an institutional review board approval for retrospective reports such as this. Plain CT images for targeting immediately before RF ablation showed dilation of the intrahepatic bile duct in the left lobe and soft tissue density within the expanded left hepatic duct as the causes of biliary dilation. Because we speculated that cholangitis may possibly develop after RF ablation of the liver with biliary dilation, the scheduled RF ablation was cancelled. Laboratory data obtained the same day showed serum total bilirubin level of 2.18 mg/dL (normal range, 0.33–1.28 mg/dL). Dynamic CT and magnetic resonance imaging were subsequently performed to evaluate the mass within the left hepatic duct. In addition to the tumor in the medial segment, a hypervascular tumor 3.2 cm in diameter directly adjacent to the left hepatic duct was demonstrated in the lateral segment. The mass within the left hepatic duct did not enhance after contrast medium administration, likely indicating hemobilia caused by hemorrhage from the tumor in the lateral segment invading into the left hepatic duct. Six days later, the serum total bilirubin level returned to the previous level and repeat CT images showed that biliary dilation substantially improved, accompanied by spontaneous resolution of hemobilia. Because of limited hepatic function, the patient was not a suitable candidate for surgical resection. RF ablation was also inappropriate because the tumor in the lateral segment involved the left hepatic duct. Therefore, it was selected to perform TACE. On hepatic arteriography, the tumor in the medial segment was supplied by the medial segmental artery and the tumor in the lateral segment was supplied mainly by a branch of the lateral segmental artery. To reduce the possible risk of hepatic failure, hepatic abscess, and biloma after TACE, we performed superselective embolization of each tumor. A microcatheter (Renegade; Boston Scientific, Natick, MA) was selectively introduced into the arteries supplying each tumor, and TACE was performed with injection of a mixture of 1.2 mL iodized oil (Lipiodol; Laboratoire Andre Guerbet, Aulnay-sous-Bois, France) and 12 mg epirubicin (Kyowa-Hakko, Tokyo, Japan), followed by gelatin sponge particles, for the tumor in the medial segment. The tumor in the lateral segment was then treated in the same fashion, but with 0.8 mL iodized oil and 8 mg epirubicin before administration of gelatin sponge particles. On plain CT images immediately after TACE, part of the iodized oil accumulation in the tumor in the lateral segment seemed to protrude into the left hepatic duct (Figure, part a) and dense iodized oil accumulation was seen in the entire tumor in the medial segment (Figure, part a). No immediate complications occurred and the patient was discharged 10 days after TACE. Eighteen days after TACE, the patient returned to our department because with jaundice and severe back pain. Laboratory data on admission showed markedly increased serum total bilirubin and amylase levels of 8.03 mg/dL and 1,000 IU/L (normal range, 38–125 IU/L), respectively. On dynamic CT images, marked dilation of the intrahepatic and common bile duct was demonstrated. Iodized oil accumulation within the left hepatic duct was no longer visible (Figure, part b), and at the bottom of the common bile duct was a high-density deposit (Figure, part c), which was believed to represent sloughed tumor with iodized oil accumulation and the cause of biliary obstruction. Subsequent endoscopic examination revealed the oral protrusion markedly expanding and the sloughed tumor obstructing the ampulla of Vater and protruding into the lumen of the duodenum (Figure, part d). Endoscopic sphincterotomy was then performed and two pieces of tumor migrated into the duodenum. Immediately after the endoscopic therapy, the patient’s back pain resolved. The serum amylase level decreased promptly and returned to normal level 2 days later. The serum total bilirubin level gradually decreased and returned to baseline level 1 month after the endoscopic therapy. Although tumor thrombus into the portal vein is a common feature in the development of HCC, intraductal tumor involvement is not as widely recognized. Kojiro et al (1) reported 24 cases of HCC with prominent tumor growth in the bile duct among 259 autopsy and surgical cases, with a prevalence of approximately 9%. Intraductal tumor is usually associated with large HCC with volumes of more than 40% of the whole liver (1) and associated with varying degree of jaundice at admission or during the course of the disease (1–3). HCC with intraductal tumor involvement is DOI: 10.1097/01.RVI.0000200055.74822.ED Letters to the Editor

Use of the Endurant stent graft system for ruptured infrarenal aortic aneurysms: short-term experience in nine patients.

PURPOSE To report the early results of use of the Endurant stent graft in the treatment of ruptured abdominal aortic aneurysms (AAAs). MATERIALS AND METHODS Nine consecutive patients (seven men and two women; mean age, 76 y; range, 65-87 y) underwent endovascular aneurysm repair (EVAR) for a ruptured AAA with the Endurant stent graft between April and December 2012. EVAR was emergent in all cases. Early technical success, clinical success, major complication, and mortality rates were analyzed. RESULTS Intraoperative immediate technical success was achieved in all nine patients. The 30-day clinical success rate was 67% (six of nine patients). The 30-day mortality rate was 33% (three of nine patients). During a mean follow-up of 6 months (range, 3-10 mo), none of the cases required reintervention; there was one late death attributed to probable endograft infection. CONCLUSIONS The short-term results of EVAR with the Endurant stent graft in patients with ruptured AAAs are encouraging.

The Upside Down Endurant Iliac Limb Stent Graft for Treatment of a Common Iliac Artery Aneurysm

Endovascular repair of the coverage from the common iliac artery to the external iliac artery after the internal iliac artery embolization has been proven to be a safe and effective treatment in isolated iliac artery aneurysms. But in cases in which the diameter of the proximal sealing zone is larger than that of the distal sealing zone, a reverse-tapered device is needed. We described the off-label use of the Endurant iliac limb stent graft in an upside down configuration to accommodate this diameter mismatch.

Surgical outcomes of aortic repair via transapical cannulation and the adventitial inversion technique for acute Type A aortic dissection

OBJECTIVES To evaluate the surgical outcomes of aortic repair via transapical cannulation and the adventitial inversion technique for acute Type A aortic dissection. METHODS Between 2008 and 2015, a total of 300 patients with acute Type A aortic dissection underwent emergency surgery, consisting of 271 hemiarch repairs and 29 total aortic arch replacements, using transapical cannulation and the adventitial inversion technique at a distal anastomosis. The mean follow-up periods were 31.7 ± 25.2 months. Overall, 18% (54/300) of the patients were octogenarians, and 21.7% (65/300) had cardiac tamponade; 25% (75/300) had preoperative malperfusion. RESULTS The in-hospital and 30-day mortality rates were 8.3% (25/300) and 6.7% (20/300), respectively. The 30-day mortality rate was 2.7% (6/225) among patients without preoperative malperfusion and 18.7% (14/75) among patients with malperfusion (P < 0.0001), 7.4% (4/54) among octogenarians and 6.5% (16/246) among patients aged less than 80 years (P = 0.81), and 6.3% (17/271) among patients treated with hemiarch repair and 10.3% (3/29) among patients treated with total aortic arch replacement (P = 0.403). Preoperative malperfusion was an independent predictor of perioperative mortality in a multivariable analysis. During the follow-up period, distal reintervention was performed in 11% (33/300) of the patients. The rates of freedom from reintervention at 1, 3 and 5 years were 95.9%, 88.9% and 80.0%, respectively. The overall survival rates at 1, 3 and 5 years were 88.7%, 86.7% and 82.0%, respectively. The in-hospital mortality rate for elective reintervention was 3.0% (1/33). CONCLUSIONS Aortic repair via transapical cannulation and the adventitial inversion technique for acute Type A aortic dissection provides good early and mid-term results. The safety of elective distal reintervention can be guaranteed. To obtain better operative outcomes, effective treatment for cases with malperfusion is mandatory.

Which dose abdominal compartment syndrome occur after endovascular repair of ruptured infra-renal abdominal aortic aneurysm or not?

No. 349 Which dose abdominal compartment syndrome occur after endovascular repair of ruptured infrarenal abdominal aortic aneurysm or not? J. Nishimura, Y. Koike, S. Hase, N. Hosaka, M. Yamasaki, N. Moriya, H. Nishimaki; Department of Interventiona Radiology, Kawasaki Saiwai Hospital, Kawasaki, Japan; Department of Cardiovascular surgery, St. Marianna Medical University, Kawasaki, Japan Purpose: Abdominal compartment syndrome (ACS) have been increasingly recognized as significant causes of mortality in patients with endovascular repair (EVAR) of ruptured infrarenal abdominal aortic aneurysms (rAAAs). If there is high rate of falling into the ACS in the patient with rAAA, EVAR with the procedure of leak reduction and continuous decompression surgery of intra-abdominal pressure are able to be performed. Otherwise, the shock index (SI), defined as the ratio of heart rate to systolic blood pressure, is a simple marker for situation in emergent patients. This study is presented to determine whether the SI is a useful marker for ACS in patients with EVAR of rAAAs. Materials and Methods: In 14 cases with rAAAs, 12 Men and 2 women, mean age 77.2 6.5, EVAR were performed emergency in our institution between March in 2012 and July in 2013. SI calculated from heart rate and systolic blood pressure just before putting the patients under an anesthetic. SI was analyzed between patients with ACS and without ACS. Results: Intraoperative immediate technical success were obtained in all cases. 4 patients fall into the ACS, 2 patients of them died, and reminded 2 patients could leave hospital on foot. SI of patients with ACS and without ACS were 1.86 0.30 (1.44 2.08) and 1.28 0.45 (0.67 1.86), respectively. There is significant difference between SI with ACS and without ASC (P o 0.05). 4 patients died in our hospital after EVAR. SI of the death and survive cases were 1.86 0.23 (1.55 2.08) and 1.29 0.43 (0.67-1.86), respectively. Also, there is significant difference between SI with death and survive cases (P o 0.05). All patients with SI less than 1.4 could be survive, and all patient more than 2.0 died. There is the same trend about ACS between patients in our institusion with EVAR of rAAA and ruptured solitary iliac artery’s aneurysm. Conclusion: SI is simple and useful marker for ACS in patients with EVAR of rAAAs. When SI is over 1.4, there is possibility patient falling into ACS, the procedure for leak control during EVAR and decompression of the abdomen after EVAR are considered to be prepared.