Wen-Sheng Tzeng

A comparison of computed tomography, magnetic resonance imaging, and digital subtraction angiography findings in the diagnosis of infected aortic aneurysm.

Purpose: To characterize imaging findings from computed tomography, magnetic resonance imaging, and angiogram in patients with infected aortic aneurysm. Methods: We retrospectively reviewed the records of 21 patients (men, 17; women, 4) with proven infected aortic aneurysms and compared the imaging findings (computed tomography scans, n = 21; magnetic resonance images, n = 2; and angiograms, n = 2). Results: Aneurysms were located in the descending thoracic aorta (n = 10; 47.6%), abdominal aorta (n = 6; 28.6%), aortic arch (n = 3; 14.3%), and thoracoabdominal aorta (n = 2; 9.5%). Aneurysms were saccular in 19 (90%) and fusiform in 2 (10%). Maximal diameters were greater than 10 cm in 2 patients (10%), 5 to 10 cm in 11 (52%), and less than 5 cm in 8 (38%). Average diameters were 6.5 cm in the aortic arch, 5.3 cm in the descending thoracic aorta, and 5.1 cm in the abdominal aorta. Obvious aortic wall calcification occurred in 19 patients (90%). Other features included disrupted calcification (n = 15; 71%), prominent and irregular wall thickening (n = 17; 81%), periaortic soft tissue mass (n = 15; 71%), rim enhancement (n = 18; 86%), periaortic gas (n = 7; 33%), periaortic stranding and fluid retention (n = 14; 67%), periaortic hematoma (n = 3; 14%), adjacent bone destruction (n = 1; 5%), pleural effusion (n = 12; 57%), and associated dissecting aneurysm (n = 2; 10%). Conclusions: Saccular aneurysms, adjacent soft tissue masses, rim enhancement, stranding, fluid, gas, and unusual adjacent bony destruction highly suggest infected aneurysm.

Prediction of Mortality after Emergent Transjugular Intrahepatic Portosystemic Shunt Placement: Use of APACHE II, Child-Pugh and MELD Scores in Asian Patients with Refractory Variceal Hemorrhage

Objective This study was designed to determine if existing methods of grading liver function that have been developed in non-Asian patients with cirrhosis can be used to predict mortality in Asian patients treated for refractory variceal hemorrhage by the use of the transjugular intrahepatic portosystemic shunt (TIPS) procedure. Materials and Methods Data for 107 consecutive patients who underwent an emergency TIPS procedure were retrospectively analyzed. Acute physiology and chronic health evaluation (APACHE II), Child-Pugh and model for end-stage liver disease (MELD) scores were calculated. Survival analyses were performed to evaluate the ability of the various models to predict 30-day, 60-day and 360-day mortality. The ability of stratified APACHE II, Child-Pugh, and MELD scores to predict survival was assessed by the use of Kaplan-Meier analysis with the log-rank test. Results No patient died during the TIPS procedure, but 82 patients died during the follow-up period. Thirty patients died within 30 days after the TIPS procedure; 37 patients died within 60 days and 53 patients died within 360 days. Univariate analysis indicated that hepatorenal syndrome, use of inotropic agents and mechanical ventilation were associated with elevated 30-day mortality (p < 0.05). Multivariate analysis showed that a Child-Pugh score > 11 or an MELD score > 20 predicted increased risk of death at 30, 60 and 360 days (p < 0.05). APACHE II scores could only predict mortality at 360 days (p < 0.05). Conclusion A Child-Pugh score > 11 or an MELD score > 20 are predictive of mortality in Asian patients with refractory variceal hemorrhage treated with the TIPS procedure. An APACHE II score is not predictive of early mortality in this patient population.

CT-guided transthoracic cutting needle biopsy of intrathoracic lesions: Comparison between coaxial and single needle technique

PURPOSE To evaluate the complication rates and diagnostic accuracy of two different CT-guided transthoracic cutting needle biopsy techniques: coaxial method and single needle method. METHODS This study involved 198 consecutive subjects with 198 intrathoracic lesions. The first 98 consecutive subjects received a single needle cutting technique and the next 100 consecutive subjects received a coaxial technique. Both groups were compared in relation the diagnostic accuracy and complication rates. RESULTS No significant difference was found between the two groups concerning patient characteristics, lesions and procedure variables. There was a borderline statistical difference in the incidence of pneumothorax at within 24-h post biopsy between patients in the single needle group (5%) and the coaxial group (13%) (P=0.053). Little difference was found in the pneumothorax rate at immediately post biopsy between the two groups, which was 28% in the single needle group and 31% in the coaxial group. There was no significant difference in the hemoptysis rate between the two groups, which was 9.2% in the single needle group and 11% in the coaxial group. Both techniques yielded an overall diagnostic accuracy of 98% for malignant lesions with similar sensitivity (single needle: 96.9% vs. coaxial: 96.4%) and specificity (single needle: 100% vs. coaxial: 100%). CONCLUSION There is little difference in the pneumothorax rates and bleeding complications between patients who either received a single needle or a coaxial transthoracic cutting biopsy. Both techniques produce an overall diagnostic accuracy of 98% for malignant lesions.

Ionic versus nonionic contrast media solvents used with an epirubicin-based agent for transarterial chemoembolization of hepatocellular carcinoma.

PURPOSE To compare the stability of epirubicin-iodized oil emulsions prepared with ionic or nonionic contrast medium and to compare the efficacy of these emulsions in a prospective, randomized, controlled trial of transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). MATERIALS AND METHODS Epirubicin-iodized oil emulsions prepared with ionic and nonionic contrast media was evaluated for stability with light microscopy and magnetic resonance imaging. One hundred ninety-seven patients with inoperable HCC were randomized to receive TACE with epirubicin, prepared either with ionic (control group, n = 99) or nonionic (experimental group, n = 98) contrast medium. Tumor response was graded according to iodized oil retention (grade 1 = >90% retention, grade 2 = 50%-90% retention, and grade 3 = <50% retention), as characterized with computed tomography. Survival probabilities were calculated with the Kaplan-Meier method. RESULTS The epirubicin-iodized oil emulsions prepared with ionic contrast medium were less stable, exhibiting rapid separation of the oil and aqueous phases, compared with emulsions prepared with nonionic medium. Ninety-one patients in the control group and 87 in the experimental group underwent follow-up CT. Thirty-seven of the 91 patients in the control group (41%) had grade 1 tumors, 41 (45%) had grade 2 tumors, and 13 (14%) had grade 3 tumors. Forty-eight of the 87 patients in the experimental group (55%) had grade 1 tumors, 22 (25%) had grade 2 tumors, and 17 (20%) had grade 3 tumors. The number of patients with grade 1 tumors was significantly higher in the experimental group than in the control group (P = .02); however, there was no difference in patient survival (P = .94). CONCLUSIONS Epirubicin-iodized oil emulsions prepared with nonionic contrast medium are more stable and are associated with lower tumor grade in patients with inoperable HCC. The choice of solvent, however, does not appear to have an effect on patient survival.

Use of angioplasty balloon-assisted Seldinger technique for complicated small vessel catheterization.

From: Matt Chiung-Yu Chen, MD Shih-Chin Chang, MD Mei-Jui Weng, MD Wen-Sheng Tzeng, MD Reng-Hong Wu, MD Huei-Lung Liang, MD Huay-Ben Pan, MD Department of Diagnostic Radiology (M.C.Y.C., S.C.C., W.S.T., R.H.W.) Chi-Mei Medical Center Yung-Kang Campus Yung-Kang City, Tainan County 806, Taiwan; and Department of Radiology (M.J.W., H.L.L., H.B.P.) Kaohsiung Veterans General Hospital Kaohsiung, and National Yang-Ming University Taipei, Taiwan

Short-term follow-up for percutaneous extra-anatomic intervascular anastomosis in salvage of a thrombosed native arteriovenous fistula.

Percutaneous extra-anatomic intervascular anastomosis (PEIA), i.e., the nonsurgical connection of two anatomically unrelated vascular lumina, has rarely been reported in peripheral applications. Chen et al. [1] recently described a PEIA technique applied in peripheral vascular intervention. Using the same technique, the authors successfully salvaged an occluded native arteriovenous (AV) fistula with obliterated outflow veins. The vascular access has been followed up for more than 6 months and access-related complications are reported here. A 54-year-old woman with a failed and diffusely thrombosed native radiocephalic fistula in the right forearm was referred for shunt salvage. The fistula had been used for about 13 years. Informed consent was obtained. The institutional review board was not required for this retrospective report in our hospital. On physical examination, a hard and dilated forearm cephalic vein was noted, terminating as a venous stump not far below the elbow crease. Using local anesthesia, a 7-Fr introducer sheath was inserted in antegrade fashion in the forearm cephalic vein about 4 cm downstream of the AV anastomosis. A 4.1-Fr angiographic catheter was advanced to the venous stump and a small test bolus of contrast material was injected. No outflow vein from the venous stump could be identified on fluoroscopy. Under sonographic guidance, small thrombosed veins were catheterized, but attempts to get access into the dilated venous stump failed (Fig. 1A). During the search for small thrombosed veins around the venous stump, an upper arm basilic vein near and medial to the venous stump was noted. The patent basilic vein was catheterized under sonographic guidance and the venogram revealed no direct anastomosis with the venous stump (Fig. 1B) and the finding was comfirmed by sonography. A new vascular access creation was therefore suggested but the patient refused surgery after a thorough explanation to her and her family. In order to restore sufficient shunt flow, a good outflow drainage tract from the venous stump was required. Therefore, we attempted to salvage the fistula using the technique reported by Chen et al. [1] by stent-graft insertion between the venous stump and an adjacent patent basilic vein. An 8 · 60-mm stent-graft (Wallgraft; Boston Scientific, Natick, MA) was used to bridge the two ends of the fistulous tract. The stent-graft was dilated with an 8mm ·4-cm PTA balloon catheter. Thrombolysis was performed thereafter using 500,000 IU of urokinase. Thromboaspiration was performed with an 8-Fr Desilets-Hoffman sheath (Cook, Bloomington, IN, USA). Before thrombolysis, a bolus of 5000 IU heparin was given through a peripheral intravenous line. The AV fistula was successfully salvaged and the immediate follow-up fistulography showed brisk flow with presumed compression of a segment of the runoff basilic vein by hematoma (Fig. 1C; arrow). No immediate complications were noted and the patient underwent successful hemodialysis the next morning. The patient was called back for a fistulography 1 month after M. C.-Y. Chen (&) R.-H. Wu W.-S. Tzeng S.-C. Chang Department of Diagnostic Radiology, Chi-Mei Medical Center, Yung-Kang Campus, No. 901, Chung Hwa Road, Yung-Kang City, Tainan County 806, Taiwan e-mail: jjychen@gmail.com

Man With Sudden Onset of Bilateral Flank Pain

A 68-year-old man complained of the sudden onset of bilateral flank pain on emergency department evaluation for fever of uncertain origin. Physical examination revealed a blood pressure of 145/81 mm Hg and a peak temperature of 38.5°C (101.3°F), Blood tests showed anemia (hemoglobin 56 g/L) and leukocytosis (white blood cell count 21.2 109/L). Heterogeneous echogenic Figure 1. Abdominal ultrasonograph demonstrating mixed hyperand hypoechoic lesions at the right perirenal space (indicated by caliper marking). The contralateral kidney (not shown) demonstrated a similar sonographic appearance.

The Role of Transjugular Intrahepatic Portosystemic Shunt in Acute Variceal Bleding: Diferential Survival Owing to Diferent Cirhosis Etiology

Background and Aim: Transjugular intrahepatic portosystemic shunt (TIPS) procedures are increasingly used to treat severe complications of portal hypertension, while its efficacy in treating acute variceal bleeding caused by different etiology of liver cirrhosis has not yet being evaluated. This study aims to evaluate whether different etiology of liver cirrhosis may influence the outcome of TIPS treatment for acute variceal bleeding. Materials and Methods: A total of 74 patients with acute variceal bleeding receiving TIPS treatment from March 2004 to December 2006 were enrolled for the analysis. They were divided into four groups: HBV-related (Group Ⅰ, n=22), HCV-related (Group Ⅱ, n=25) and Alcohol-related (Group Ⅲ, n=19) as well as Others (Group Ⅳ, n=8). The hepatic venous pressure gradient (HVPG) was measured before (pre-TIPS) and after (post-TIPS) the procedure and immediate stop bleeding was assessed. Survival curves were constructed by the Kaplan-Meier method, and compared by log-rank test. Results: Survival for the whole patient group after TIPS was short with a mean of 9.6±14.5 months and with a median survival time of 3.0 months. Patient group Ⅳ(Others) had the best outcome with a median survival time of 24 months after TIPS (overall P＜0.05), while alcohol liver cirrhosis patients (Group Ⅲ) had the worst outcome after TIPS with a median survival time of 2.0 months. HCC patients receiving the TIPS therapy for acute variceal bleeding survived shorter than those without HCC (P=0.008, log-rank test). Conclusions: Different etiology of liver cirrhosis may influence the outcome of TIPS treatment for acute variceal bleeding. Despite its apparent efficacy for emergent conditions, TIPS procedure should be limited to salvage therapy as a transition to liver transplantation.

Hepatic artery infusion catheter implantation without embolization of the gastroduodenal artery in cases of retrograde blood flow.

Between January 2007 and January 2008, a port/catheter system for hepatic arterial infusion chemotherapy was implanted in seven patients with retrograde blood flow in the gastroduodenal artery (GDA). The GDA was not coil-embolized when the catheter tip was positioned in the right gastroepiploic artery. In all cases, implantation of the port/catheter system was successful, and there were no complications. Interventionalists can economize on expensive microcoils by using this simple and time-saving method.

Peliosis Hepatis Presenting as Pseudotumors: Report of a Case

Peliosis hepatis: (1) is an uncommon condition characterized by multiple blood-filled cavities in the liver; (2) whose difference from hemangioma lied in presence of portal tracts within the fibrous stroma; (3) was usually identified incidentally past mortem, but the chance of pre-mortal diagnosis was increased with the advance of modern radiology. The 44-year-old healthy female of peliosis hepatis: (1) was referred to our hospital fir a 2.8cm hypoechoic tumor-like lesion at the dame area incidentally-discovered by ultrasonography far abdominal distention and investigated herein; (2) whose subsequent computed tomography (CT) showed multiple nodules in the bilateral lobes with changes in hemangioma-like enhancement; (3) whose magnetic resonance imaging (MRI) divulged these lesions were hardly recognized on T1-weighted images and were with hyerintense signals on T2-weighted images; (4) whose echo-guided percutaneous biopsy was thus done and peliosis was proved pathologically Although it is very scanty, peliosis hepatis can he part of the differential diagnosis of focal hepatic lesions.