Young Soo Do

Peripheral arterial involvement in Behcet’s disease: an analysis of the results from a Korean referral center

The purposes of this study are to review the results of endovascular and surgical interventions and to evaluate clinical appearances of recurrent arterial involvement in patients with peripheral arterial Behçet disease (BD). A total of 28 patients with peripheral arterial BD were identified. There were 24 males (85.7xa0%), with mean age of 40.0xa0±xa09.0xa0years (range 21–59). Arterial involvements were confirmed with computed tomography angiography, magnetic resonance image angiography, or ultrasound. Immunosuppressive agents were administrated to all patients. Indications of intervention were acute symptoms due to arterial occlusion and aneurysmal changes with or without rupture. Among 28 patients with peripheral arterial BD, 10 endovascular and 24 surgical interventions were performed in 21 patients. All 21 patients who underwent endovascular and surgical intervention were followed up for a mean duration of 78.7xa0±xa052.5xa0months (range 0–182xa0months). There was one mortality due to the rupture of pseudoaneurysm in patient who underwent stent-graft insertion for abdominal aortic aneurysm. New arterial involvements of BD occurred in 10 patients. All patients were male, and median age was 33.5xa0years (range 29–59xa0years). Mean time of onset of the new arterial lesion was 32.7xa0±xa032.1xa0months. In conclusion, the result of endovascular and surgical interventions is satisfactory in patients with acute peripheral arterial BD. Accurate diagnosis with immunosuppressive therapy is mandatory to prevent recurrence and activation of peripheral arterial BD.

Ethanol Embolotherapy of Pelvic Arteriovenous Malformations: an Initial Experience

Objective We retrospectively assessed the results of performing ethanol embolization for pelvis arteriovenous malformations (AVMs). Materials and Methods During the past 10 years, eight patients (8 females, age range: 27-52 years) with AVMs in the pelvic wall (n = 3) and uterus (n = 5) underwent staged ethanol embolizations (range: 1-5, mean: 2.5) under general anesthesia. Ethanol embolization was performed by the use of the transcatheter and/or direct puncture techniques. Clinical follow-up was performed for all of the patients, and imaging follow-up was available for seven patients. The therapeutic outcomes were established by evaluating the clinical outcome of the signs and symptoms, as well as the degree of devascularization observed on post-procedural angiography. Results During the 20 sessions of ethanol embolization, the solitary transarterial approach was used 14 times, the transvenous approach was used three times and direct puncture was used once. For two patients, the transarterial and transvenous or direct puncture approaches were used together in one session. For four patients, ethanol and coils were used as embolic agents, and n-butyl cyanoacrylate (NBCA) and ethanol were used in one patient. Seven (88%) of eight patients were cured of their AVMs and one patient (12%) displayed improvement. Major complications were seen in two patients (25%). Conclusion Ethanol embolization is effective for the treatment of pelvic arteriovenous malformations, though there is a chance of a major complication.

Serum Ethanol Levels after Alcohol Sclerotherapy of Arteriovenous Malformations

We analyzed the effects of several factors on the serum ethanol levels after alcohol sclerotherapy in the arteriovenous malformations (AVMs) retrospectively. Blood ethanol level, amounts of given alcohol, location of lesions, methods of flow control, and Doppler resistive index (RI) were analyzed. The results of linear regression analysis showed that the amount of alcohol administered was the predictor of serum ethanol level (r2=0.75, p<0.001). The average amount of injected alcohol was 0.89 mL/kg in the patients with the serum levels above the legal intoxication level (>80 mg/dL). Location of the lesions was not related with the serum ethanol level (p=0.643), and other variables such as forms of flow control and RI were not related to the serum ethanol level after controlling for injected amounts of alcohol (analysis of covariance). It is recommended to keep an eye on the possibility of intoxication when using the amounts of alcohol exceeding 0.89 mL/kg in the sclerotherapy of AVMs.

Clinical outcome and predictors of treatment response in foam sodium tetradecyl sulfate sclerotherapy of venous malformations.

AbstractObjectivesTo evaluate clinical outcomes and their predictors in patients with venous malformation (VM) treated with foam sodium tetradecyl sulfate (STS) sclerotherapy.MethodsWe retrospectively evaluated clinical outcomes of foam STS sclerotherapy in 86 patients with 91 VMs to assess reduction in pain and mass after treatment. Univariate and multivariate analysis was performed to determine possible predictors of clinical outcome with foam STS sclerotherapy.ResultsA positive response of 49.5xa0% in pain reduction and 52.7xa0% in mass reduction was observed. The numerical rating scale (NRS) score improved from 4.36u2009±u20092.64 to 1.74u2009±u20091.57, and VM mass volume decreased to 41.7u2009±u200935.52xa0% of the initial size. On multivariate analysis, a high baseline NRS score (odds ratio: 1.12, 95xa0% confidence interval: 1.09–1.15) and VM location in the trunk versus the head and neck (odds ratio: 1.30, 95xa0% confidence interval: 1.00–1.69) were positive predictors of pain improvement. Minor complications occurred in 11 (12.1xa0%) patients and recurrence in 12 (13.2xa0%) patients.ConclusionsFoam STS sclerotherapy is an effective treatment in venous malformation, with low complication risk. A high baseline NRS score and location in the trunk versus the head and neck were positive predictors in improvement of pain.Key Points• Foam STS sclerotherapy is effective in VM, with low risk of complications.n • Relief of pain tends to be dramatic in patients with severe pain.n • Location of VM is a predictor of pain improvement.n • The presence of a draining vein does not affect foam sclerotherapy.

Use of double-occlusion balloon catheter: preoperative portal vein embolization for induction of future remnant liver hypertrophy.

AbstractPurpose: To evaluate the efficacy andnsafety of using double-occlusion balloon catheters in preoperativenportal vein embolization (PVE) to induce future remnant livernhypertrophy. Materials and Methods: PVE was achievednwith gelatin sponges by using double-occlusion balloon catheter innseventeen patients with hepatobiliary malignant tumors. The ipsilateralnapproach was used in thirteen patients and the contralateral approachnin four patients due to large size of tumor in the right hepatic lobe.nSurgery was performed in 15 patients, 14–27 days (mean, 21.9 days)nafter PVE. Computed tomographic liver volumetric studies were performednbefore embolization and before surgery. The changes in aspartatenaminotransferase (AST), alanine aminotransferase (ALT), prothrombinntime (PT), and total bilirubin levels before and after the PVE werenevaluated. Complications were evaluated after PVE. nResults: PVE using double-occlusion balloon catheter wasnsuccessful in all cases, irrespective of approach technique. The futurenremnant liver (FRL) volumes were 251–920 cm3 (mean, 437ncm3) before PVE and 281–1042 cm3 (mean, 555ncm3) after PVE. The mean increase in the volume of the FRLnwas 28.6%; this represented 37% of the preresection volume of thenliver. Clinical and biologic tolerance of PVE was mandatory. There werenno complications. nConclusions: PVE using thendouble-occlusion balloon catheter is safe and well-tolerated and can benperformed technically with ease. This hypertrophy allows hepatectomy tonbe performed safely when the FRL volume is initially insufficient innpatients with hepatobiliary tumors.

Early Stage Hepatocellular Carcinomas Not Feasible for Ultrasound-Guided Radiofrequency Ablation: Comparison of Transarterial Chemoembolization Alone and Combined Therapy with Transarterial Chemoembolization and Radiofrequency Ablation

PurposeTo report the results of combined therapy with transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) for early stage hepatocellular carcinoma (HCC) considered infeasible for ultrasound (US)-guided RFA in comparison with those of TACE monotherapy.MethodsFrom January 2007 through December 2010, 91 patients with early or very early stage HCC infeasible for US-guided RFA received either TACE alone (TACE group; nxa0=xa054) or TACE immediately followed by RFA (TACE–RFA group; nxa0=xa037) as a first-line treatment. 1-month tumor response, time to progression (TTP), and overall survival (OS) rates were calculated. Univariate and multivariate analyses were performed to identify prognostic factors.ResultsTACE–RFA group showed a better 1-month tumor response than TACE group (Pxa0<xa0.001). The mean TTP was 29.7xa0±xa03.4xa0months (95xa0% confidence intervals [CIs] 23.0–36.5) in TACE group and 34.9xa0±xa02.8xa0months (95xa0% CIs 29.4–40.4) in TACE–RFA group. TACE–RFA group had a significantly longer TTP (Pxa0=xa0.014). Cumulative 1-, 2-, and 3-year OS rates in the TACE and TACE–RFA groups were 91, 79, and 71xa0% and 100, 97, and 93xa0%, respectively (Pxa0=xa0.008). Initial treatment of TACE was found to be the only significant risk factor for tumor progression and OS in multivariate analysis.ConclusionTACE–RFA combination therapy appears superior to TACE monotherapy in terms of 1-month tumor response, TTP, and OS when performed for early stage HCC infeasible for US-guided RFA.

Iatrogenic Aorto-Cisterna Chyli Fistula During Percutaneous Balloon Aortoplasty in a Patient with Takayasu’s Arteritis: A Case Report

We present a case of iatrogenic aorto-cisterna chyli fistula that developed during percutaneous transluminal aortoplasty in a 16-year old girl with Takayasu’s arteritis. The aorto-cisterna chyli fistula was angiographically confirmed and treated using a stent-graft, which successfully occluded the fistula. Her claudication then improved, although follow-up CT angiography at 10 months revealed mild recurrent aortic stenosis.

Anomalous Unilateral Single Pulmonary Vein Mimicking Pulmonary Arteriovenous Malformation

Anomalies involving the pulmonary vein are so rare that most of them have been reported as a case or a series of several cases. Some of them often simulate pulmonary arteriovenous malformation (AVM), and patients undergo pulmonary angiography for embolization. Herein we report a case of anomalous unilateral single pulmonary vein that was confirmed on pulmonary angiography after initial diagnosis of pulmonary AVM on contrast medium-enhanced chest computed tomography.

Combined transarterial chemoembolization of the right inferior phrenic artery and radiofrequency ablation for small hepatocellular carcinoma near the diaphragm: its efficacy and safety

PurposeThe purpose of the study is to report the efficacy and safety of combined transarterial chemoembolization (TACE) of the right inferior phrenic artery (IPA) and radiofrequency ablation (RFA) for small hepatocellular carcinoma (HCC) near the diaphragm supplied by the right IPA.MethodsFrom July 2009 through April 2015, 11 patients with small (≤xa03xa0cm) HCC near the diaphragm, which was infeasible for ultrasound-guided RFA and supplied by the right IPA, received TACE of the right IPA and subsequent RFA in one session. The safety and therapeutic efficacy, including technique effectiveness and local tumor progression (LTP), were evaluated.ResultsTechnique effectiveness was achieved in all the 11 patients (100%). During average follow-up period of 39.2xa0months (range 13–89xa0months), LTP occurred in none of the 11 patients. There were twelve minor complications in eight patients, including right shoulder pain (nxa0=xa04), right pleural effusion (nxa0=xa02), diaphragmatic thickening (nxa0=xa02), transient lung change (nxa0=xa02), subsegmental intrahepatic bile duct stricture (nxa0=xa01), and subsegmental hepatic infarction (nxa0=xa01). No major complications were encounteredConclusionCombined TACE of the right IPA and RFA can be a safe and effective treatment for small HCC near the diaphragm that is supplied by the right IPA.

Transcatheter Arterial Embolization for Life-Long Urinary Incontinence Associated with Bilateral Ureteral Duplication with Ectopia.

To the Editor, Urinary incontinence associated with duplicated collecting system with ureteral ectopia is a rare disease [1]. An ectopic ureter that inserts into the urethra distal to the external sphincter or into the vagina results in continuous leakage of urine. The mainstay of treatment for the symptomatic ectopic ureter is invasive surgical heminephrectomy of upper poles associated with the ectopic ureter [2]. With the advance of interventional techniques, several cases of successful endovascular treatment of ectopic ureter have been reported in pediatric patients [3, 4]. Herein, we report a case of life-long urinary incontinence which was successfully treated with selective embolization. A 60-year-old woman with urinary incontinence between normal voids was diagnosed as left ectopic ureter insertion into vaginal wall 30 years ago. At the time, simple suture of vaginal opening of the ectopic ureter was performed by a gynecologist at another hospital. However, urinary incontinence had continued for another 30 years. She recently visited our hospital and had a retrograde pyelogram (RGP) and cystoscopy. However, both bilateral RGP and cystoscopy failed to demonstrate ureteral duplication. On admission, physical examination was unremarkable and vital signs were stable. Serum creatinine and creatinine clearance were within the normal range. The amount of urinary incontinence in pad test was approximately 30 g/day. For further evaluation, she underwent CT urography and multiplanar reconstruction (MPR) images, and maximum intensity projection (MIP) images were reconstructed. CT images of nephrogenic phase demonstrated dysplastic upper poles in both kidneys (Fig. 1A, B). Excretory phase images clearly depicted insertion of left ectopic ureter into left upper vagina (Fig. 1C). The physician recommended surgical correction, but she was reluctant to undergo radical surgery. As an alternative, transcatheter arterial embolization of the dysplastic upper poles was attempted. On a careful review of CT images before embolization, small arteries were traced from the proximal portions of both renal arteries to the dysplastic upper poles of both kidneys. After right femoral approach, both renal arteries were selected with a 5-Fr catheter (Michaelson, Cook, Bloomington, IN, USA) for selective renal angiography. Renal angiograms depicted a small feeding artery originating from the main renal artery (Fig. 2A, B), which were identified on CT images. A 2.0-Fr microcatheter (Masters Parkway; Asahi Intecc, Nagoya, Japan) was advanced into the feeders of the dysplastic upper poles of both kidneys. Embolization was performed with a total of 4 ml of absolute ethanol (99 %) at both feeders and additionally a 2-mm microcoil (Micronester coils; Cook, Bloomington, IN, USA) only at the left feeder. Completion angiogram showed successful embolization of the feeders (Fig. 3A, B). During and after the embolization, vital signs were stable. After successful embolization of the dysplastic upper poles of both kidneys, urinary incontinence stopped immediately. Follow-up serum creatinine was normal. There has been no recurrence of urinary incontinence. & Dongho Hyun mesentery.hyun@samsung.com