Percutaneous transhepatic sclerotherapy for ascending colonic varices due to left-sided portal hypertension

Left-sided portal hypertension (LSPH) causes varices and splenomegaly due to splenic vein issues. Colonic varices are rare and lack standardized treatment. We report the successful treatment of colonic varices caused by LSPH, by addressing both the afferent and efferent veins. A 70-year-old man with distal cholangiocarcinoma had surgery without splenic vein resection, leading to proximal splenic vein stenosis and varices at multiple locations. Percutaneous transhepatic splenic venography revealed that collateral veins flowed into the ascending colonic varices and returned to the portal vein. Complete thrombosis of the varices was achieved by injecting sclerosants and placing coils in both the afferent and efferent veins. The procedure was safe and effective, with no variceal recurrence. This approach provides a minimally invasive option for treating colonic varices associated with LSPH.

A case of percutaneous deep pelvic abscess drainage using CT fluoroscopic guided cranio-caudal puncture technique

A 52-year-old male patient presented with complaints of abdominal and back pain. CT revealed a deep pelvic abscess extending into the anterior sacral space. Since puncture via the conventional transgluteal approach cannot reach a deep abscess, percutaneous pelvic abscess drainage was performed under CT fluoroscopy using the cranio-caudal puncture technique. The cranio-caudal puncture requires needle insertion perpendicular to the CT cross-section. This method advances the CT gantry deeper than the needle tip and follows the CT cross-section with the needle tip. This series of images and movements continues until the needle reaches the target. The procedure was successful without complications, the abscess was reduced in size, and blood test data improved. The cranio-caudal puncture technique provides an alternative for the drainage of deep pelvic abscesses that avoids the complications associated with gluteal muscle puncture. Percutaneous drainage of pelvic abscesses under CT fluoroscopy-guided cranio-caudal puncture offers a safe option as a puncture route for deep pelvic abscesses.

A case of recurrent laryngeal nerve paralysis caused by radiofrequency ablation for mediastinal recurrence of lung cancer

Radiofrequency ablation (RFA) has emerged as a potent therapeutic modality for tumor treatment, and offers benefits such as reduced recovery time and minimal damage to nearby tissues. However, RFA is not devoid of complications, notably nerve damage during intrathoracic lesion treatments, which can significantly impact patients' quality of life. This report describes the unique case of a 71-year-old male who experienced hoarseness attributed to injury to the recurrent nerve after RFA for a locally recurrent lung cancer lesion in the mediastinum near the aortic arch. Although RFA has the advantages of a minimally invasive nature and positive outcomes, its risk of nerve injury, specifically in the thoracic region, highlights the need for improved techniques and preventive measures.

Transparaumbilical Intravariceal Sclerotherapy for Duodenal Varices Using Outflow Embolization

A 55-year-old patient was admitted for variceal treatment, a complication of chronic portal hypertension and liver cirrhosis. Imaging studies revealed prominent duodenal varices, the pancreaticoduodenal vein as its afferent pathway, a drainer vessel into the inferior vena cava, and a paraumbilical vein. We successfully performed complete obliteration of the varix, including its afferent and efferent vessels, via the paraumbilical vein approach.

Repeated rough coiling technique of portosystemic shunt: A novel treatment for hepatic encephalopathy

Hepatic encephalopathy (HE) usually occurs in the end stages of cirrhosis. During these stages, portosystemic shunt (PSS) is one cause of severe HE. Previous reports have demonstrated that shunt embolization is effective in cases involving a large PSS. However, embolization is risky in some patients because severe ascites and esophageal varices may result from aggravation of portal hypertension. Herein, we report a case in which intentional flow reduction was repeatedly performed for spleno-renal shunt using 2 flow reduction methods, debranching and the rough coiling technique, for a patient with severe HE for whom embolization of the whole PSS pathway was risky. Complete embolization was finally achieved by repeated flow reduction over 5 sessions. The patient tolerated treatment well with no ascites for 4 years after total embolization. If embolization of the whole PSS puts the patient at risk for refractory HE, repeatable flow reduction might provide a good alternative path to single-step embolization.

Transcatheter Arterial Chemoembolization for Treatment-Naive Hepatocellular Carcinoma Has Different Treatment Effects Depending on Central or Peripheral Tumor Location

Introduction

The purpose of this study was to evaluate the treatment efficacy of transcatheter arterial chemoembolization (TACE) for treatment-naive hepatocellular carcinoma (HCC) according to tumor location and burden.

Methods

Between 2010 and 2019, consecutive patients who underwent TACE as the first treatment were enrolled. Tumors were classified into two categories based on their location, as central or peripheral tumors. Tumors in the central zone, which is within 1 cm of the main trunk or the first branch of the portal vein, were classified as central tumors, while those located in the peripheral zone were classified as peripheral tumors. Patients were grouped according to the HCC location and up-to-7 criteria. Patients with central tumors were classified into the central arm and those with only peripheral tumors were classified into the peripheral arm. Patients within and beyond the up-to-7 criteria were classified into the up-to-7 in and up-to-7 out-groups, respectively. Local recurrence-free survival (LRFS) and progression-free survival (PFS) were compared per nodule (central tumor vs. peripheral tumor) and per patient (central arm vs. peripheral arm), respectively. The prognostic factors of LRFS and PFS were analyzed by univariate and multivariate analyses.

Results

A total of 174 treatment-naive patients with 352 HCCs were retrospectively enrolled. Ninety-six patients and 130 lesions were selected by propensity score matching. Median LRFS was longer for peripheral tumors than central tumors (not reached vs. 3.3 months, p < 0.001). Median PFS was 17.1 months (8.3-24.9) in the peripheral arm and up-to-7 in, 7.0 months (3.3-12.7) in the peripheral arm and up-to-7 out, 8.4 months (4.0-12.6) in the central arm and up-to-7 in, and 3.0 months (1.2-4.9) in the central arm and up-to-7 out-groups. The peripheral arm and up-to-7 in-groups had significantly longer PFS than the other three groups (p = 0.013, p = 0.015, p < 0.001, respectively). Multivariate analysis confirmed that the central zone and central arm were associated with high adjusted hazard ratios for tumor recurrence or death (2.87, p < 0.001; 2.89, p < 0.001, respectively).

Conclusion

Treatment-naive HCCs in the peripheral zone had a longer LRFS and PFS following TACE compared to those in the central zone.

Afferent vein embolization via retrograde approach as a potential treatment strategy for bleeding duodenal varices

The standard treatment for ruptured duodenal varices remains to be established. Emergency balloon-occluded retrograde transvenous obliteration is challenging in patients with bleeding because re-rupture of varices can occur due to increased pressure when using the retrograde approach. Herein, we describe a case in which a catheter was retrogradely advanced to the afferent vein beyond bleeding duodenal varices; however, the varices re-ruptured during coil embolization, and a part of the catheter was deviated into the intestinal tract. The rupture site was embolized by liquid embolic materials from the microcatheter. Embolization via retrograde approach needs to be carefully performed.

Atezolizumab plus bevacizumab-induced intratumoral hemorrhage in a patient with rib metastasis from unresectable hepatocellular carcinoma

Recently, combination therapy with atezolizumab, a humanized monoclonal antiprogrammed death ligand-1 antibody, and bevacizumab, has become available for treatment of unresectable hepatocellular carcinoma (HCC). We herein report a 73-year-old man with advanced stage HCC who developed fatigue during treatment with atezolizumab-bevacizumab combination therapy. Computed tomography identified intratumoral hemorrhage within the HCC metastasis to the right fifth rib metastasis of HCC, which was confirmed on emergency angiography of the right 4th and 5th intercostal arteries and some branches of the subclavian artery confirmed intratumoral hemorrhage, following which transcatheter arterial embolization (TAE) was performed to achieve hemostasis. He continued to receive atezolizumab-bevacizumab combination therapy after TAE, and no rebleeding was seen. Although uncommon, rupture and intratumoral hemorrhage in the HCC metastasis to the ribs can cause life-threatening hemothorax. However, to our knowledge, no previous cases of intratumoral hemorrhage in HCC during atezolizumab-bevacizumab combination therapy have been reported. This is the first report of intratumoral hemorrhage with the combination therapy of atezolizumab and bevacizumab, which was successfully controlled by TAE. Patients receiving this combination therapy should be observed for intratumoral hemorrhage, which can be managed by TAE if it does occur.

Identification of reversed portal flow on 4DCT and of factors contributing to reversed portal flow in patients with liver cirrhosis and portosystemic shunt before interventional radiology procedures

AIM

Patients with liver cirrhosis and portosystemic shunt occasionally develop reversed portal flow in the portal venous system. The factors contributing to reversed portal flow in these patients remain unclear. The aim of this study was to identify factors contributing to reversed portal flow in patients with portosystemic shunts based on four-dimensional computed tomography (4DCT), which visualized flow dynamics in the portal venous system.

METHODS

Data from 34 consecutive patients with portosystemic shunts who had undergone 4DCT before interventional radiology procedures were retrospectively investigated in this study. Uni- and multivariate analyses were performed to identify factors contributing to reversed portal flow.

RESULTS

Flow dynamics could be visualized on 4DCT in 32 of the 34 patients. Fifteen patients had forward portal flow; 17 had reversed portal flow. The main portal, splenic, and superior mesenteric veins displayed reversed portal flow in five, 12, and five vessels, respectively. Portosystemic shunt originating from splenic and superior mesenteric veins, worse albumin-bilirubin score, and small main portal vein diameter were significant factors contributing to reversed portal flow in both univariate (p = 0.049, p = 0.027, and p = 0.002) and multivariate (odds ratio [OR] 6.345, p = 0.012; OR 4.279, p = 0.039; and OR 5.516, p = 0.019) analyses.

CONCLUSIONS

The reversed portal flow was visualized on 4DCT. Portosystemic shunt originating distant to the liver, worse albumin-bilirubin score, and small diameter of the main portal vein were factors contributing to reversed flow in the portal venous system.

Safety and Feasibility of Contrast-Enhanced Computed Tomography with a Nanoparticle Contrast Agent for Evaluation of Diethylnitrosamine-Induced Liver Tumors in a Rat Model

RATIONALE AND OBJECTIVES

Safety and feasibility of contrast-enhanced computed tomography (CECT) with a nanoparticulate contrast agent, ExiTron nano 12000, was evaluated in a rat liver tumor model.

MATERIALS AND METHODS

This study employed eighteen 8-week-old male F344 rats. Six rats given tap water for 8 weeks further divided into two: Control group and Normal Liver with CECT group. Six rats each were given tap water containing diethylnitrosamine (DEN) at 100 ppm for 8 or 14 weeks; Adenoma group and Hepatocellular carcinoma (HCC) group, respectively. Biochemical marker values and adverse events were evaluated after CT imaging. ExiTron nano 12000 was evaluated for the hepatic contrast enhancement, and the detection and measurement of liver nodules by CECT after 8- and 14-weeks administration of DEN. Post-mortem liver specimens were evaluated by hematoxylin-eosin (HE) staining, and the number and size of liver nodules were measured. The HCC group was evaluated for diagnostic concordance between HE-stained and CECT-detected nodules.

RESULTS

The contrast agent enhanced liver and was tolerated after CECT in 15 rats. Biochemical parameter values did not differ significantly between the Control and Normal Liver groups. The numbers of CECT-detected nodules in the Adenoma and HCC groups were 14.8 ± 5.1, and 32.4 ± 8.1, respectively. The HCC group had 3.6 ± 2.7 of pathological HCCs, which were identified by CECT. The size of CECT-detected HCCs correlated significantly with that of pathological HCCs (r = 0.966, p < 0.0001).

CONCLUSION

CECT with ExiTron nano 12000 is a safe and feasible method to measure tumors in a rat liver tumor model.

Successful treatment of rectal varices with antegrade transvenous sclerotherapy via the splenorenal shunt from the transjugular approach

A 74-year-old patient presented with hematochezia and a history of liver cirrhosis with repeated bleeding from esophageal and rectal varices. Endoscopic examination revealed multiple rectal varices with positive red color signs. Ascites, severe portosystemic thrombosis and a splenorenal shunt were diagnosed on a contrast-enhanced dynamic computed tomography examination. From a transjugular approach, we circumvented thrombosed regions by maneuvering double balloon catheters through the shunt and dilated left colic marginal vein. We managed to successfully obliterate the varices.

Coil-assisted retrograde transvenous obliteration of gastric varices by an inverted catheter tip technique via the pericardiophrenic vein

A 70-year-old woman with liver cirrhosis was admitted to our hospital for treatment of growing gastric varices in the fundus. Computed tomography showed gastric varices continuously draining the pericardiophrenic vein via the inferior phrenic vein. Balloon-occluded retrograde transvenous obliteration by a transjugular approach was planned. However, a conventional balloon catheter or microballoon catheter could not be inserted into the efferent vein near the varices because of the narrowness and tortuosity of the vein. Hence, coil-assisted retrograde transvenous obliteration was performed by an inverted catheter tip technique using a single conventional microcatheter. This technique might be useful for cases in which it is difficult to insert a balloon catheter into the efferent vein.

Efficacy of rechallenge transcatheter arterial chemoembolization after lenvatinib treatment for advanced hepatocellular carcinoma

BACKGROUND AND AIM

We evaluated the efficacy of rechallenge transcatheter arterial chemoembolization (TACE) after lenvatinib (LEN) treatment in patients with previous TACE failure/refractoriness.

METHODS

We enrolled 63 consecutive patients with a history of TACE failure/refractoriness prior to LEN treatment as a first-line systemic therapy. We reviewed the clinical backgrounds and courses of the patients.

RESULTS

In total, 25 patients underwent rechallenge TACE after LEN due to LEN-refractoriness (17 cases) or intolerance (8 cases). A complete or partial response was obtained for 13 (65.0%) of the 20 patients whose therapeutic effects were determined. The survival rate of patients who underwent rechallenge TACE was significantly higher than that of patients who did not undergo rechallenge TACE (median survival time, not reached vs 403 days, P = 0.015). Rechallenge TACE significantly reduced the risk of death in univariate (hazard ratio [HR] 0.24, 95% confidence interval [CI] 0.08-0.69, P = 0.008) and multivariate analyses (HR 0.26, 95% CI 0.08-0.80, P = 0.019). If complete or partial response was obtained by rechallenge TACE, the median survival time of these patients was significantly longer than those of the progressive disease (PD) group (P = 0.05), and the median survival time of the PD group after rechallenge TACE was not different from that of the group who did not undergo rechallenge TACE (P = 0.36). We did not observe a decrease in the ALBI score after TACE.

CONCLUSION

Rechallenge TACE after LEN is an effective treatment that may result in a favorable prognosis.

Visual and quantitative evaluation of microcalcifications in mammograms with deep learning-based super-resolution

PURPOSE

To evaluate visually and quantitatively the performance of a deep-learning-based super-resolution (SR) model for microcalcifications in digital mammography.

METHOD

Mammograms were consecutively collected from 5080 patients who underwent breast cancer screening from January 2015 to March 2017. Of these, 93 patients (136 breasts, mean age, 50 ± 7 years) had microcalcifications in their breasts on mammograms. We applied an artificial intelligence model known as a fast SR convolutional neural network to the mammograms. SR and original mammograms were visually evaluated by four breast radiologists using a 5-point scale (1: original mammograms are strongly preferred, 5: SR mammograms are strongly preferred) for the detection, diagnostic quality, contrast, sharpness, and noise of microcalcifications. Mammograms were quantitatively evaluated using a perception-based image-quality evaluator (PIQE).

RESULTS

All radiologists rated the SR mammograms better than the original ones in terms of detection, diagnostic quality, contrast, and sharpness of microcalcifications. These ratings were significantly different according to the Wilcoxon signed-rank test (p <.001), while the noise score of the three radiologists was significantly lower (p <.001). According to PIQE, SR mammograms were rated better than the original mammograms, showing a significant difference by paired t-test (p <.001).

CONCLUSION

An SR model based on deep learning can improve the visibility of microcalcifications in mammography and help detect and diagnose them in mammograms.

The Albumin-bilirubin Score Detects Changes in the Liver Function during Treatment for Budd-Chiari Syndrome: A Retrospective Observational Study

Objective Mapping the long-term prognosis of Budd-Chiari syndrome (BCS) is difficult, as the prognosis is associated with changes in the liver function. The present study evaluated the time course changes in the liver function in a treatment group with percutaneous old balloon angioplasty (POBA) and a non-treatment group using the albumin-bilirubin score (ALBI) and Child-Pugh score during long-term follow-up. Methods In this retrospective study, 13 consecutive patients diagnosed with BCS at our hospital between 2007 and 2020 were categorized into a treatment group (n=8), which received POBA, and a non-treatment group (n=5). Differences in the liver function in the ALBI and Child-Pugh scores between the initial visit and one- and three-year follow-up were calculated and statistically evaluated. We investigated the changes in the liver function during the long-term follow-up, including events such as re-stenosis and re-treatment. Results While the Child-Pugh scores in the treatment group did not differ significantly between the initial visit and 1- or 3-year follow-up, the ALBI scores in this group improved significantly between the initial visit and the 1- or 3-year follow-up visit (p=0.0078 and 0.0156, respectively). The liver function according to the ALBI score in the treatment group showed gradual improvement from the initial value but gradual worsening in the non-treatment group. The ALBI scores also revealed that the liver function varies according to re-stenosis and re-POBA in BCS patients. Conclusion Unlike the Child-Pugh score, the ALBI score was able to capture changes in the liver function of BCS patients during the long-term course of BCS.

Mask-less Two-dimensional Digital Subtraction Angiography Generation Model for Abdominal Vasculature using Deep Learning

PURPOSE

To develop a deep learning model to generate synthetic, two-dimensional subtraction angiography images free of artifacts from native abdominal angiograms.

MATERIALS AND METHODS

In this retrospective study, two-dimensional digital subtraction angiograms (2D-DSA) and native angiograms were consecutively collected from July 2019 to March 2020. Images were divided into motion-free (training, validation, and motion-free test datasets) and containing motion artifacts (motion-artifact test dataset) sets. A total of 3185, 393, 383, and 345 images from 87 patients (mean age, 71 ± 10 years; 64 men, 23 women) were included in the training, validation, motion-free, and motion-artifacts test datasets, respectively. Native angiograms and 2D-DSA image pairs were used to train and validate an image-to-image translation model to generate synthetic deep learning-based subtraction angiography (DLSA) images. DLSA images were quantitatively evaluated by peak signal-to-noise ratio (PSNR) and structural similarity (SSIM) using the motion-free dataset and were qualitatively evaluated by visual assessments by radiologists with a numerical rating scale using the motion-artifacts dataset.

RESULTS

The DLSA images showed mean PSNR (± standard deviation) of 43.05 ± 3.65 dB and mean SSIM of 0.98 ± 0.01, indicating high agreement with the original 2D-DSA images in the motion-free dataset. Qualitative visual evaluation by radiologists on the motion-artifacts dataset showed that DLSA images contained fewer motion artifacts than 2D-DSA. Additionally, DLSA images scored similarly to or higher than 2D-DSA images for vascular visualization and clinical usefulness.

CONCLUSION

The developed deep learning model could generate synthetic, motion-free subtraction images from abdominal angiograms with similar imaging characteristics to 2D-DSA images.

Platelet count and abdominal dynamic CT are useful in predicting and screening for gastroesophageal varices after Fontan surgery

OBJECTIVE

Patients who undergo Fontan surgery for complex cardiac anomalies are prone to developing liver and gastrointestinal complications. In particular, gastroesophageal varices (GEVs) can occur, but their prevalence is unknown. We aimed to elucidate the occurrence of GEVs and the predicting parameters of GEVs in these patients.

MATERIALS AND METHODS

Twenty-seven patients (median age, 14.8 years; median time since surgery, 12.9 years) who had undergone the Fontan surgery and were examined by abdominal dynamic computed tomography (CT) for the routine follow-up were included in the study. Radiological findings including GEVs and extraintestinal complications were retrospectively evaluated by experienced radiologists in a blinded manner. Relationships between blood-biochemical and demographic parameters and the presence of GEVs were statistically analyzed.

RESULTS

Dynamic CT revealed gastric varices (n = 3, 11.1%), esophageal varices (n = 1, 3.7%), and gastrorenal shunts (n = 5, 18.5%). All patients with gastric varices had gastrorenal shunts. All gastric varices were endoscopically confirmed as being isolated and enlarged, with indications for preventive interventional therapy. A platelet count lower than 119 × 109 /L was identified as a predictor of GEV (area under the receiver operating curve, 0.946; sensitivity, 100%; and specificity, 87%).

CONCLUSIONS

GEVs are important complications that should not be ignored in patients who have undergone a Fontan procedure. Platelet counts lower than 119 × 109 /L may help to prompt patient screening by using abdominal dynamic CT to identify GEVs and their draining collateral veins in these patients.

A case of venous aneurysm of a splenorenal shunt

A 66-year-old man presented with liver cirrhosis due to non-alcoholic steatohepatitis and hyperammonemia. Contrast-enhanced CT showed a dilated and tortuous splenorenal shunt and a large venous aneurysm in the shunt. The venous aneurysm showed gradual enlargement over 10 years and worsening hyperammonemia, so balloon-occluded retrograde transvenous obliteration was performed. Under balloon occlusion, 5% ethanolamine oleate was injected from a microcatheter into the venous aneurysm, which was subsequently embolized with microcoils. Contrast-enhanced CT after the procedure showed complete thrombosis of the venous aneurysm. 10 months later, the venous aneurysm reduced in size, and hyperammonemia had improved.

Assessing liver stiffness with conventional cut-off values overestimates liver fibrosis staging in patients who received the Fontan procedure

AIM

Patients who undergo the Fontan procedure for complex congenital heart disease are prone to liver cirrhosis. Liver stiffness (LS) reflects liver fibrosis stage in patients with chronic viral hepatitis; however, its accuracy in predicting liver fibrosis stage in Fontan patients is controversial. We aimed to clarify the correlation between LS and liver fibrosis stage in Fontan patients.

METHODS

Fifty-eight Fontan patients were prospectively measured for LS with transient elastography. We undertook liver biopsy, cardiac catheterization, and laboratory tests in 22 of these patients (median age, 14.7 years; range, 9.9-32.1 years) with LS > 11.0 kPa (median, 19.2 kPa; range, 12.2-39.8 kPa); these elevated LS values suggest liver cirrhosis.

RESULTS

Histologically, all patients showed mild-to-severe portal and sinusoidal fibrosis but no cirrhosis. Statistically, LS did not predict histological liver fibrosis scores (p = 0.175). Liver stiffness was not correlated with central venous pressure (p = 0.456) or with the hepatic venous pressure gradient (HVPG; p = 0.062), although the p value for HVPG was only slightly above the threshold for significance.

CONCLUSIONS

Fontan patients are prone to developing both portal and sinusoidal fibrosis. Liver stiffness could be influenced by HVPG, and using the conventional cut-off values for LS overestimates and overtreats liver fibrosis in these patients.

Transcatheter embolization for stomal varices: A report of three patients

Stomal varices are rare and ectopic varices defined as dilated portosystemic collateral veins located in sites other than the gastro-esophageal region. These sometimes cause recurrent bleedings and can be life-threatening. Optimal treatments have yet to be established. We report 3 cases of repetitive bleeding stomal varices in which resolution of bleeding was obtained over the medium term with minimally invasive approaches including balloon-occluded retrograde transvenous obliteration and variceal embolization by ultrasound-guided direct puncture. Rebleeding did not occur in any patients within 2-15 months of follow-up. Serious complications over Clavien-Dindo grade I were not found.

Splenic Vein Diameter is a Risk Factor for the Portal Venous System Thrombosis After Partial Splenic Artery Embolization

Purpose

Portal venous system thrombosis is a complication of partial splenic artery embolization, and pre-treatment risk assessment is thus important. The purpose of this study was to identify the risk factors for portal venous system thrombosis after partial splenic artery embolization.

Materials and methods

We retrospectively analyzed 67 consecutive patients who underwent contrast-enhanced computed tomography before and after first partial splenic artery embolization between July 2007 and October 2018. As risk factors, we investigated age, sex, hematological data, liver function, steroid use, heparin use, and findings from pre- and post-treatment computed tomography. Uni- and multivariate analyses were performed to evaluate the relationship between thrombus appearance or growth and these factors. Values of p < 0.05 were considered significant.

Results

Partial splenic artery embolization was technically successful in all 67 patients. Nine patients showed appearance or growth of thrombus. Univariate analysis showed maximum diameter of the splenic vein before treatment (p = 0.0076), percentage of infarcted spleen (p = 0.017), and volume of infarcted spleen (p = 0.022) as significant risk factors. Multivariate analysis showed significant differences in maximum diameter of the splenic vein before treatment (p = 0.041) and percentage of infarcted spleen (p = 0.023). According to receiver operating characteristic analysis, cutoffs for maximum diameter of the splenic vein and percentage of infarcted spleen for distinguishing the appearance or growth of thrombus were 17 mm and 58.2%.

Conclusion

Large maximum diameter of the splenic vein before partial splenic artery embolization and high percentage of infarcted spleen after partial splenic artery embolization were identified as risk factors for portal venous system thrombosis.

Level of Evidence

Level 4, Case Series

Visualization of flow dynamics in the portal circulation using 320-detector-row computed tomography: a feasibility study

Multidetector row computed tomography (CT) scanners perform dynamic scanning and have a wide scan range. Time-resolved three-dimensional CT (i.e., 4D CT) has recently enabled visualization of flow in neurovascular vessels. We hypothesized that 4D CT technology would be a useful and non-invasive method for visualizing the flow dynamics of the portal circulation. The aim of this study was to evaluate the technical feasibility of 4D CT for visualizing flow dynamics in the portal circulation using 320-detector-row CT. 4D CT images of 18 consecutive patients with portal circulation including gastrorenal shunt were retrospectively evaluated for their ability to generate flow dynamics of the portal circulation. Flow dynamics could be visualized by 4D CT in 68 of the 72 vessels in the portal vein, splenic vein, superior mesenteric vein, and gastrorenal shunt. Flow direction could not be identified in four vessels, all of them being superior mesenteric veins. Flow direction was recognized on 4D CT in the 68 vessels of the portal circulation. A preliminary validation study revealed that flow direction of all 19 vessels in the portal circulation had concordance between 4D CT and color Doppler ultrasound. 4D CT could visualize flow dynamics of the portal circulation.

Usefulness of coil-assisted retrograde transvenous obliteration II (CARTO-II) for the treatment of ascending colonic varix: a case report

Background

Colonic varices are rare among ectopic varices. A previous report demonstrated that once bleeding from colonic varices occurs, it can be fatal. Several treatments for colonic varices exist, including surgical, endoscopic, and endovascular treatments; however, management of colonic varices has not been standardized. For colonic varices, minimally invasive therapies would be desirable. Balloon-occluded retrograde transvenous obliteration (B-RTO) is one of the treatment options for colonic varices to prevent their rupture. Two cases of successful conventional B-RTO for these varices have already been reported. However, B-RTO using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure for these varices has not been reported.

Case presentation

A 71-year-old male patient had liver cirrhosis caused by hepatitis C virus infection. A varix was located at the ascending colon, which was coincidentally found on colonic endoscopy. Contrast-enhanced computed tomography (CT) showed that the feeder vein was the ileocolic vein and that the main draining vein was the right renal vein. Physicians concluded that treatment was required to avoid the risk of death from massive bleeding due to varix rupture. However, endoscopic and surgical treatments were difficult due to the anatomical location of the varix and the high risk of operative compilations, respectively. This ascending colonic varix was treated by balloon-occluded retrograde transvenous obliteration (B-RTO) using coil-assisted retrograde transvenous obliteration II (CARTO-II) procedure via the right renal vein. There were no complications during the procedure and no recurrences for 36 months during long-term follow-up.

Conclusions

CARTO-II can be one of the effective treatment techniques for ascending colonic varices.

Survival Benefit of Radiofrequency Ablation with Intratumoral Cisplatin Administration in a Rabbit VX2 Lung Tumor Model

PURPOSE

This study evaluated the survival benefit of a combination therapy with radiofrequency ablation (RFA) and intratumoral cisplatin (ITC) administration for lung tumors by using a rabbit VX2 tumor model.

MATERIALS AND METHODS

Experiments were approved by the institutional animal care committee. VX2 tumor suspension was injected into the lungs of Japanese white rabbits under CT guidance to create a lung tumor model. Thirty-two rabbits bearing a transplanted VX2 lung tumor were randomly assigned to four groups of eight: control (untreated); RFA alone; ITC alone; and RFA with ITC. All treatments were performed one week after tumor transplantation. Kaplan-Meier survival curves were compared by the log-rank test.

RESULTS

The median survival time was 24.5 days (range 17-33 days) in the control group, 40 days (30-80 days) in the RFA alone group, 31.0 days (24-80 days) in the ITC alone group, and not reached (53-80 days) in the RFA with ITC group. The median survival was significantly longer with the RFA/ITC combination compared to the control group (P < 0.001), RFA alone (P = 0.034), and ITC alone (P = 0.004). The survival time after RFA alone was also significantly longer than that of the control group (P < 0.001). There was no significant difference in tumor size or the rate of pneumothorax between each group.

CONCLUSION

RFA prolonged the survival of rabbits with lung VX2 tumors when combined with ITC.

Utility of low-dose gelatin sponge particles and 5% ethanolamine oleate iopamidol mixture in retrograde transvenous obliteration (GERTO) for gastric varices

OBJECTIVE

To determine the utility of low-dose gelatin sponge particles and 5% ethanolamine oleate iopamidol (EOI) mixture in retrograde transvenous obliteration (GERTO) for gastric varices (GV).

METHODS

57 consecutive patients who underwent balloon-occluded retrograde transvenous obliteration (B-RTO) for GV were divided into three groups with Hirota's grade by balloon-occluded retrograde transvenous venography. Hirota's Grade 1 patients were assigned to G1 group and underwent treatment with 5% EOI. Grade ≥ 2 patients prior to August 2015 were G ≥ 2 group treated with 5% EOI, and those treated thereafter were GERTO group. The amount of EOI used per unit GV volume (EOI/GV ratio), the times to embolization and recurrence rate of GV were evaluated.

RESULTS

The EOI/GV ratio was 0.66 ± 0.19 in G1, 1.5 ± 0.8 in G ≥ 2, and 0.58 ± 0.23 in GERTO (G ≥ 2 vs GERTO, p < 0.0001). The times to embolization were 26.5 ± 10.5 min for G1, 39.2 ± 26.8 for G ≥ 2, and 21.4 ± 9.4 for GERTO (G ≥ 2 vs GERTO, p = 0.005). The recurrence rate was not significantly different in any of the groups.

CONCLUSION

GERTO was performed in lower amount of sclerosants and in less time compared to conventional B-RTO in Hirota's grade ≥2.

ADVANCES IN KNOWLEDGE

Feasibility of low-dose gelatin sponge particles and 5% EOI mixture as sclerosants for GV.

Utility of Coil-Assisted Retrograde Transvenous Obliteration II (CARTO-II) for the Treatment of Gastric Varices

Purpose

To investigate the technical feasibility, safety and clinical outcomes of coil-assisted retrograde transvenous obliteration II (CARTO-II) for gastric varices (GV).

Materials and Methods

Thirty-six consecutive patients who had undergone CARTO-II between June 2016 and April 2018 were included in the study. In the CARTO procedure, coil embolization of the drainage vein is performed “before” injection of the sclerosant to replace the use of balloon catheter. In the CARTO-II procedure, coil embolization of the drainage vein was performed “after” injection of the sclerosant to prevent migration of the sclerosant. CARTO-II was performed with ethanolamine oleate iopamidol, and the balloon catheter was immediately removed after coil placement. Technical and clinical success rates, number of coils used, presence or absence of severe complications, timing of the procedure, and rate of GV recurrence after the procedure were analyzed retrospectively.

Results

In all patients, GV sclerosis, coil placement and removal of the balloon catheter were successfully completed. The technical success rate was 100%. No patients experienced severe complications such as coil migration or pulmonary embolization. The mean number of metallic coils used per procedure was 3.36. Mean length of the procedure was 132.8 min. Contrast-enhanced computed tomography after CARTO-II confirmed complete variceal thrombosis in all cases. The recurrence rate of GV during follow-up was 2.8% (mean follow-up, 207 days).

Conclusion

CARTO-II was feasible and safe and could be performed relatively quickly. The number of coils used and the rate of GV recurrence were both low. CARTO-II may have an important role to play in the management of GV.

Usefulness of Venous Pressure Measurement in Endovascular Treatment of Budd-Chiari Syndrome: A Retrospective Cohort Study

Objective Therapeutic predictors derived from the venous pressure before therapy have not been identified for Budd-Chiari syndrome (BCS). The aim of this study was to determine whether or not measuring the distal pressure or pressure gradient was useful for predicting treatment efficacy in BCS. Methods We retrospectively analyzed seven consecutive patients diagnosed with symptomatic BCS at our hospital between 2008 and 2017. Distal and proximal venous pressures at occlusion sites of BCS were measured before treatment in all cases. The pressure gradient was defined as the difference between distal and proximal venous pressures. A receiver operating characteristics (ROC) analysis was performed for venous pressures. Results Percutaneous old balloon angioplasty (POBA) was performed in seven cases, with technical success achieved in all cases (100%). No complications were encountered. The median primary patency was 574 (interquartile range, 439.5-1,056.5) days. The 1-year primary patency rate was 71.73%. Six cases (85.7%) showed resolution of symptoms, representing clinical success. The ROC analysis revealed a high distal pressure (area under the ROC curve = 0.83, cut-off=12 mmHg) as a predictor of treatment efficacy of POBA for symptomatic BCS. In addition, the pressure gradient was considered significant from a clinical perspective, because the 6 successful cases with resolution of symptoms showed a large pressure gradient (range, 8-21 mmHg) before treatment, whereas the failed case showed a relatively small pressure gradient (7 mmHg). Conclusion High distal pressure and a large pressure gradient might predict the treatment efficacy of balloon angioplasty for symptomatic BCS.

Selective Balloon-occluded Retrograde Transvenous Obliteration for Gastric Varices

Objective Balloon-occluded retrograde transvenous obliteration (B-RTO) for gastric varices (GV) is associated with drawbacks including a postoperative increase in portal pressure and the risk of subsequent worsening of esophageal varices (EV). Selective B-RTO that embolizes only the varices may have the potential to minimize such risks. The aim of this study is to retrospectively compare the postoperative course of patients after selective B-RTO (Group S) and conventional B-RTO (Group B). Methods One hundred four patients treated from January 2007 to April 2012 were classified into Groups S (n=5) and B (n=99). In the univariate analysis, the volume of 5% ethanolamine oleate iopamiodol (EOI) administered at baseline and the GV blood flow on endoscopic ultrasound after B-RTO were considered as covariates. The rates of GV recurrence and EV aggravation was also compared between Groups B and S. Results In Group S, the volume of 5% EOI was significantly lower (Group S vs. Group B: 14.6±5.5 vs. 28.5±16.4 mL; p=0.0012) and the rate of EV aggravation was lower in comparison to Group B (p=0.045). However, in Group S, the rate of complete eradication of GV blood flow was significantly lower (Group S vs. Group B: 0% vs. 89.9%; p<0.001) and the rate of re-treatment for GV was higher in comparison to Group B (Group S vs. Group B: 60% vs. 1.0%; p<0.001). Conclusion Selective B-RTO for GV could minimize the risk of a worsening of EV or reduce the amount of sclerosants; however, the rate of recurrence was high in comparison to conventional B-RTO.

Prediction for Improvement of Liver Function after Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varices to Manage Portosystemic Shunt Syndrome

PURPOSE

To investigate predictive factors and cutoff value of transient elastography (TE) measurements for assessing improvement in liver function after balloon-occluded retrograde transvenous obliteration (BRTO) for gastric varices (GV).

MATERIALS AND METHODS

Retrospective analysis was performed of 50 consecutive patients followed for > 3 months after BRTO, who had undergone TE before BRTO between January 2011 and February 2015. The correlation between change in liver function (total bilirubin, albumin, and prothrombin time) and baseline liver function values and liver stiffness measurement (LSM) by TE was evaluated by Pearson correlation test. Receiver operating characteristic curves were used to determine cutoff values for discriminating between patients who had improved liver function and patients who did not. The time interval from BRTO to aggravation of esophageal varices (EV) (worsening morphology, development of new varices, or variceal rupture) grouped by cutoff values was also analyzed.

RESULTS

Serum albumin was significantly improved at 3 months after BRTO (3.57 g/dL vs 3.74 g/dL, P < .001). There was a significant negative correlation between change in albumin and baseline LSM (r = -0.50, P < .001). The best cutoff point for LSM was ≤ 22.9 kPa, with sensitivity and specificity of 78.4% and 69.2%, respectively, for predicting which patients would have improved albumin after BRTO. Among 33 patients, 29 (88%) patients had improved albumin. The 1-year progression rate of EV after BRTO was 13.6% in patients with LSM ≤ 22.9 kPa.

CONCLUSIONS

The predictive factor for improvement in albumin after BRTO was lower LSM (≤ 22.9 kPa) using TE.

Three-dimensional conformal radiotherapy for locally advanced hepatocellular carcinoma with portal vein tumour thrombosis: evaluating effectiveness of the model for end-stage liver disease (MELD) score compared with the Child-Pugh classification

OBJECTIVE

The purpose of this study was to retrospectively evaluate the effectiveness of the model for end-stage liver disease (MELD) score compared with the Child-Pugh classification in patients who received three-dimensional conformal radiotherapy (3D CRT) for hepatocellular carcinoma (HCC) with portal vein tumour thrombosis (PVTT) by analyzing toxicity and prognostic factors.

METHODS

56 consecutive patients who had locally advanced HCC with PVTT treated by 3D CRT between September 2007 and April 2013 were retrospectively reviewed.

RESULTS

The median survival time of all patients was 6.4 months. Receiver-operating characteristic (ROC) analysis identified MELD score = 7.5 [area under the curve (AUC) 0.81] and Child-Pugh score = 6.5 (AUC 0.86) as the best cut-off values for predicting the incidence of complications over Common Terminology Criteria for Adverse Events grade 2. There was no significant difference in the discrimination power between the MELD score and the Child-Pugh score on comparison of the two ROC curves (p = 0.17). On multivariate analysis, age, MELD score and radiotherapy dose were significant prognostic factors for overall survival (p = 0.021, 0.038 and 0.006, respectively). In contrast, the Child-Pugh classification, tumour response, PVTT response and the number of prior interventional radiologic treatments were not significant on multivariate analysis.

CONCLUSION

This study showed that the best MELD score cut-off value is 7.5 and that the MELD score is a better prognostic factor than the Child-Pugh classification in 3D CRT for HCC with PVTT.

ADVANCES IN KNOWLEDGE

The MELD score is useful for predicting the risk of severe toxicities and the prognosis of patients treated with 3D CRT for PVTT.

Mid-term Results of Endovascular Treatment for Infrarenal Aortic Stenosis and Occlusion

BACKGROUND

Focal stenosis or occlusion of the infrarenal aorta is rare, and treatment is usually conventional bypass or endarterectomy. However, endovascular treatment has advanced in recent years. The purpose of this retrospective study is to report the results of primary stenting for focal infrarenal aortic occlusive disease and clarify the usefulness of endovascular treatment.

METHODS

This study includes 6 consecutive patients (3 men, 3 women; mean age, 59.3 years) with infrarenal aortic stenosis or occlusion who underwent endovascular intervention at our hospital between April 2009 and February 2014. All patients had bilateral intermittent claudication. The mean preoperative ankle-brachial index (ABI) showed a slight to moderate decrease: right 0.668 and left 0.636. The mean lesion site length was 12.5 mm, the percent stenosis was 90.7%, and calcification was present in 3 patients. Primary stenting was performed in all patients. The stent selected was generally a self-expanding stent (SES). For patients with severe calcification, the stent selected was a balloon-expandable stent (BES).

RESULTS

Four patients received an SES and two patients received a BES. The technical success rate was 100%, no complications occurred, and the mean pressure gradient disappeared or decreased. Symptoms resolved in all patients and the postoperative ABI improved: right 0.923 and left 0.968. During a mean follow-up period of 27 months, there were no recurrent symptoms and no restenosis on CT angiography.

CONCLUSIONS

Endovascular treatment should be considered as a first line treatment for focal infrarenal aortic stenosis and occlusion.

Usefulness of CT volumetry for gastric varix before balloon-occluded retrograde transvenous obliteration

BACKGROUND/AIMS

To evaluate the feasibility of gastric variceal (GV) volumetry using computed tomography (CT) images taken before balloon-occluded retrograde transvenous obliteration (B-RTO) and to assess its correlation with the actual amount of 5% ethanolamine oleate and iodinated contrast medium (EOI) injected in B-RTO.

METHODOLOGY

Forty-seven consecutive patients with GV underwent B-RTO of the gastrorenal shunt. GV volume was measured with preoperative CT images by three radiologists. Statistical significance was examined by intraclass correlation coefficient (ICC) for concordance among three radiologists and by Pearson correlation test for correlation between GV volume and the amount of 5% EOI injected.

RESULTS

GV volumes measured by three radiologists significantly correlated with each other (ICC=0.959). Combining all patients and all measurements, the mean GV volume and the mean amount of 5% EOI were 27.02±16.67cm3 and 28.72±17.72mL, respectively. There was a significant correlation between GV volume, calculated as a mean of the three values measured by the three radiologists, and the amount of EOI (r2=0.706, p<0.001).

CONCLUSIONS

GV volume measured on CT showed a significant correlation with the amount of 5% EOI injected. CT volumetry of GV has the potential to determine an amount of the sclerosing agent to be injected in B-RTO.