Sung-Yu Chu

Endovascular repair of spontaneous isolated dissection of the superior mesenteric artery

AIM To present our experience of the clinical management of spontaneous isolated dissection of superior mesenteric artery (SIDSMA) and analyse the clinical features, imaging findings, and treatment outcomes. MATERIALS AND METHODS In this retrospective study, eight consecutive patients with symptomatic SIDSMA were treated in Chang Gung Memorial Hospital between April 2007 and April 2010; among these patients, six underwent endovascular stent placement. The clinical manifestations, imaging findings, endovascular stent placement outcome, and follow-up results of the patients were retrospectively analysed. RESULTS Eight patients were diagnosed with SIDSMA by contrast-enhanced computer tomography. One patient died due to comorbidity before angiography. Six patients underwent percutaneous endovascular stent placement in the superior mesenteric artery (SMA): four patients with bare stents and two with stent grafts. Because it was not appropriate to perform stent implantation in the remaining patient, he received only conservative treatment. All seven patients had an uneventful recovery and the follow-up period was 16 month, ranging from 1 to 35 months. CONCLUSION For patients with symptomatic SIDSMA, endovascular repair is a feasible treatment choice with a high success rate and good clinical outcome.

CT-guided percutaneous core-needle biopsy of pancreatic masses: comparison of the standard mesenteric/retroperitoneal versus the trans-organ approaches

AIM To compare the safety and efficacy of percutaneous computed tomography (CT)-guided core-needle biopsy (CNB) of pancreatic masses traversing the gastrointestinal tract or solid viscera versus trans-mesenteric and retroperitoneal approaches. MATERIALS AND METHODS CT-guided CNB of pancreatic lesions performed between May 2004 and December 2014 were retrospectively analysed at a single centre. Biopsies were performed using 18- or 20-G needles with a coaxial system. CT images, histopathology reports, medical records, and procedural details for all patients were reviewed to evaluate the biopsy route, complications, and diagnostic accuracy. According to the routes, biopsies were divided into trans-mesenteric, retroperitoneal and trans-organ approaches for comparison. RESULTS A total of 85 patients, who had undergone 89 CNBs for pancreatic masses were reviewed. The overall sensitivity, specificity, and accuracy of CNB for detecting malignancy via various routes were 88.8%, 100%, and 89.9%, respectively, with a complication rate of 20.2%. Trans-organ biopsies of pancreatic masses (n=22) were performed safely via a direct pathway traversing the stomach (n=14), colon (n=3), small bowel (n=2), liver (n=2), and spleen (n=1). The sensitivity, specificity, and accuracy were 90.5%, 100%, and 90.9%, respectively. In the trans-organ biopsy group, three biopsies (13.6%) resulted in minor haematomas, but no major complications occurred. There were no statistically significant differences in the diagnostic efficacy or complication rate among the different biopsy routes. CONCLUSION Percutaneous CT-guided CNB using a trans-organ approach is a feasible technique for diagnosing pancreatic malignancy; however, as this series was small, more data is required.

Liver metastasis from hepatoid adenocarcinoma of the stomach mimicking hepatocellular carcinoma: Dynamic computed tomography findings.

AIM To evaluate the dynamic computed tomography (CT) findings of liver metastasis from hepatoid adenocarcinoma of the stomach (HAS) and compared them with hepatocellular carcinoma (HCC). METHODS Between January 2000 and January 2015, 8 patients with pathologically proven HAS and liver metastases were enrolled. Basic tumor status was evaluated for the primary tumor location and metastatic sites. The CT findings of the liver metastases were analyzed for tumor number and size, presence of tumor necrosis, hemorrhage, venous tumor thrombosis, and dynamic enhancing pattern. RESULTS The body and antrum were the most common site for primary HAS (n = 7), and observed metastatic sites included the liver (n = 8), lymph nodes (n = 7), peritoneum (n = 4), and lung (n = 2). Most of the liver metastases exhibited tumor necrosis regardless of tumor size. By contrast, tumor hemorrhage was observed only in liver lesions larger than 5 cm (n = 4). Three patterns of venous tumor thrombosis were identified: direct venous invasion by the primary HAS (n = 1), direct venous invasion by the liver metastases (n = 7), and isolated portal vein tumor thrombosis (n = 2). Dynamic CT revealed arterial hyperattenuation and late phase washout in all the liver metastases. CONCLUSION On dynamic CT, liver metastasis from HAS shared many imaging similarities with HCC. For liver nodules, the presence of isolated portal vein tumor thrombosis and a tendency for tumor necrosis are imaging clues that suggest the diagnosis of HAS.

Safety and efficacy of image-guided percutaneous biopsies in the diagnosis of gastrointestinal stromal tumors

BACKGROUND After the invention of effective target agent therapy for gastrointestinal stromal tumors (GISTs), percutaneous biopsies may be indicated for unresectable diseases or before neoadjuvant chemotherapy. The purpose of this study was to evaluate the safety and efficacy of percutaneous biopsies for GISTs. MATERIAL AND METHODS Fifty-eight procedures of transluminal biopsies or image-guided percutaneous biopsies in 49 patients at our Institution from 1999 to 2010 were retrospectively reviewed. RESULT Twenty-three transluminal biopsies, 20 ultrasonography-guided biopsies, and 15 CT-guided biopsies were performed. Failure rate was higher in the group of transluminal biopsies (17%). There is no major procedure-related complication in patients who underwent percutaneous biopsy. However, life-threatening bleeding after transluminal biopsies happened in two patients. CONCLUSION Image-guided percutaneous biopsy is a safe and efficient alternative tool for the diagnosis of patients with GISTs.

Trans-organ versus trans-mesenteric computed tomography-guided percutaneous fine-needle aspiration biopsy of pancreatic masses: Feasibility and safety

AIM To evaluate the safety and efficacy of computed tomography (CT)-guided percutaneous fine-needle aspiration biopsy (FNAB) of pancreatic masses that traverses the gastrointestinal tract or solid viscera. MATERIALS AND METHODS From January 2002 to December 2012, 144 patients underwent 165 CT-guided biopsies of pancreatic masses. Biopsies were performed using a 21 or 22 G needle. Cytology reports, medical records, and procedure details for all patients were retrospectively reviewed to evaluate the biopsy route, complications, and diagnostic accuracy. RESULTS Trans-organ biopsies of pancreatic masses were safely performed via a direct pathway traversing the stomach (n = 45), colon (n = 14), jejunum (n = 4), or liver (n = 5). There were five self-limiting mesenteric haematomas along the biopsy route on immediate post-procedure CT and all patients remained asymptomatic. All haematomas occurred after a trans-mesenteric approach rather than passage through abdominal organs. Three patients had acute pancreatitis. There was no significant difference in complications and diagnostic yields between the groups. The sensitivity, specificity, positive predictive value, and negative predictive value of final FNAB cytology for malignancy were 98.3%, 100%, 100% and 71.4%, respectively. The overall accuracy was 98.4%. CONCLUSION Percutaneous FNAB using the trans-organ approach is a safe and effective technique to diagnose pancreatic malignancy.

Predictive Factors for Additional ProGlide Deployment in Percutaneous Endovascular Aortic Repair

PURPOSE To evaluate outcomes and predictive factors for additional ProGlide device deployment in percutaneous endovascular aortic repair (PEVAR) with the preclose technique. MATERIALS AND METHODS Clinical data of patients who underwent PEVAR with the preclose technique from February 2012 to January 2015 were retrospectively reviewed. A total of 268 patients (229 men, 39 women) who underwent PEVAR (thoracic endovascular aortic repair [TEVAR], n = 113; endovascular abdominal aortic repair [EVAR], n = 152; simultaneous TEVAR and EVAR, n = 3) with 418 femoral access sites were enrolled. The mean age of the patients was 69 years ± 14. Univariate and multivariate analyses were performed to identify predictive factors associated with additional ProGlide device deployment. RESULTS Primary technical success with adequate hemostasis and two ProGlide devices was 87.6%, and 48 femoral arterial access sites (11.5%) required additional ProGlide device deployment. The secondary technical success rate was 99.0%. Four femoral access sites (1.0%) needed surgical repair. Anterior wall calcification near the arteriotomy increased the risk of additional ProGlide device deployment (adjusted odds ratio, 6.19; 95% confidence interval, 2.81-13.64; P < .001), whereas larger sheath size, common femoral artery (CFA) diameter, and depth from the skin to the arteriotomy did not. CONCLUSIONS Additional ProGlide device deployment reduces the rate of surgical repair after primary hemostasis failure in PEVAR. Anterior CFA wall calcification is a significant predictor for additional ProGlide device deployment.

Management of Type II Endoleak From Internal Iliac Artery Immediately After Endovascular Aneurysm Repair

Inadvertent coverage of origin of internal iliac artery (IIA) during endovascular aneurysm repair may lead to type II endoleak. Except for open surgery, the endovascular solution is limited. We report a case with such complication that was successfully treated with coil embolization using retrograde extrastent approach. This is a new technique that has not been reported before, and as such, had been useful in the treatment of type II endoleak from IIA as an alternative to open ligation of IIA origin.

Pancreatic Acinar Cell Carcinoma with Diffuse Whole-Organ Involvement: An Unusual Presenting Pattern

Pancreatic acinar cell carcinoma is a rare tumor arising from exocrine components of pancreas. Several case reports and case series studies have reported the imaging characteristics of the pancreatic acinar cell carcinoma, including computed tomography (CT) and magnetic resonance imaging (MRI). It is generally considered to be an exophytic, well-circumscribed mass arising from pancreas without pancreatic ductal dilatation. We report an unusual case of pancreatic acinar cell carcinoma with diffuse organ involvement initially mimicking a duodenal tumor. The diagnosis was confirmed histologically after a total pancreatectomy and the specimen showed diffuse pancreatic involvement of the tumor. To the best of our knowledge, diffuse whole-organ involvement of pancreatic acinar cell carcinoma has never been reported in the scientific literature.