Clinical risk factors for portal hypertension-related complications in systemic therapy for hepatocellular carcinoma

BACKGROUND

During systemic therapy, the management of portal hypertension (PH)-related complications is vital. This study aimed to clarify factors associated with the incidence and exacerbation of PH-related complications, including the usefulness of contrast-enhanced computed tomography (CECT) in the management of PH-related complications during systemic therapy.

METHODS

A total of 669 patients who received systemic therapy as first-line treatment (443 patients for sorafenib, 131 for lenvatinib, and 90 for atezolizumab/bevacizumab [ATZ/BEV]) were enrolled in this retrospective study. Additionally, the lower esophageal intramural vessel diameters (EIV) on CECT and endoscopic findings in 358 patients were compared.

RESULTS

The cutoff values of the EIV diameter on CECT were 3.1 mm for small, 5.1 mm for medium, and 7.6 mm for large varices, demonstrating high concordance with the endoscopic findings. esophageal varices (EV) bleeding predictors include EIV ≥ 3.1 mm and portal vein tumor thrombosis (PVTT). In patients without EV before systemic therapy, factors associated with EV exacerbation after 3 months were EIV ≥ 1.9 mm and ATZ/BEV use. Predictors of hepatic encephalopathy (HE) include the ammonia level or portosystemic shunt diameter ≥ 6.8 mm. The incidence of HE within 2 weeks was significantly higher (18%) in patients with an ammonia level ≥ 73 μmol/L and a portosystemic shunt ≥ 6.8 mm. The exacerbating factors for ascites after 3 months were PVTT and low albumin levels.

CONCLUSIONS

Careful management is warranted for patients with risk factors for exacerbation of PH-related complications; moreover, the effective use of CECT is clinically important.

Effects of High-Intensity Inspiratory Muscle Warm-Up on High-Intensity Exercise Performance and Muscle Oxygenation

PURPOSE

An inspiratory muscle warm-up (IMW) improves inspiratory muscle function, but the effects of high-intensity exercise are inconsistent. We aimed to determine the effects of high-intensity IMW on high-intensity exercise performance and muscle oxygenation.

METHODS

Ten healthy men (maximal oxygen uptake [V˙O2max] 52.2 [5.0] mL·kg-1·min-1) performed constant-load exercise to exhaustion on a cycle ergometer at V˙O2max under 2 IMW conditions: a placebo condition (PLA) and a high-intensity IMW condition (HIGH). The inspiratory loads were set at 15% and 80% of maximal inspiratory pressure, respectively. Maximal inspiratory pressure was measured before and after IMW. Oxyhemoglobin was measured in the vastus lateralis by near-infrared spectroscopy during exercise. Rating of perceived exertion (RPE) for a leg was measured after 1 and 2 minutes of exercise.

RESULTS

Exercise tolerance was significantly higher under HIGH than PLA (228 [49] s vs 218 [49] s, P = .003). Maximal inspiratory pressure was significantly increased by IMW under HIGH (from 125 [20] to 136 [25] cm H2O, P = .031). Oxyhemoglobin was significantly higher under HIGH than PLA at 80% of the total duration of exercise (P = .048). RPE for the leg was significantly lower under HIGH than PLA after 2 minutes of exercise (P = .019).

CONCLUSIONS

Given that oxyhemoglobin is an index of local oxygen supply, the results of this study suggest that high-intensity IMW increases the oxygen supply to active limbs. It may also reflect a reduction in RPE in the leg. In addition, high-intensity IMW may improve exercise performance.

Reduced Muscle Mass and Muscle Quality in Patients with Intermittent Claudication due to Peripheral Artery Disease

OBJECTIVE

Peripheral arterial disease (PAD) is associated with reduced muscle mass and quality, but the effects of leg ischemia caused by PAD on muscle quality remain poorly understood. The purpose of this study was to evaluate leg muscle mass and muscle quality in patients with intermittent claudication due to PAD using bioelectrical impedance analysis (BIA).

METHODS

One hundred forty-one patients with intermittent claudication due to PAD who visited Tokyo Medical University Hospital from April 2019 to April 2020 were retrospectively analyzed. Leg ischemia was assessed using ankle-brachial index (ABI). The skeletal muscle mass (SMM) assessed leg muscle mass, while the phase angle (PhA) assessed leg muscle quality using BIA.

RESULTS

A total of 282 legs in 141 patients were included in the analysis. Leg PhA and SMM showed a decreasing trend according to the severity of leg ischemia (borderline/no ischemia: 2.80 ± 0.50 kg/m2, 4.38 ± 0.94°; mild ischemia: 2.83 ± 0.49 kg/m2, 4.33 ± 1.03°; moderate/severe ischemia: 2.50 ± 0.40 kg/m2, 3.89 ± 0. 88°; p<0.001 and p=0.020, respectively). The ABI was moderately correlated with leg SMM (B=0.347, β=0.134, p<0.001) and leg PhA (B=0.577, β=0.111, p=0.013) after adjustment for all significant covariates. Leg PhA was moderately correlated with leg SMM (r = 0.318, p < 0.001).

CONCLUSIONS

Leg ischemia, especially when moderate or severe, has an adverse effect on both muscle mass and quality in the lower extremities and is associated with skeletal muscle myopathy.

The Preoperative Lymphocyte-To-Monocyte Ratio Predicts Mortality Among Patients Undergoing Endovascular Aortic Repair for Abdominal Aortic Aneurysm

PURPOSE

The purpose of this study was to investigate the preoperative lymphocyte-to-monocyte ratio (LMR) as a potential surrogate biomarker predictive of overall mortality in patients undergoing endovascular aortic repair (EVAR) for abdominal aortic aneurysm (AAA).

METHODS

Data on patients with AAA treated by EVAR between March 2012 and December 2016 were obtained from a prospectively maintained EVAR database at Tokyo Medical University Hospital, Tokyo, Japan. The LMR was calculated by dividing the absolute lymphocyte count by the absolute monocyte count.

RESULTS

One hundred seventy-six patients were included in this study after selection based on the exclusion criteria. The subjects consisted of 148 males and 28 females with a mean age of 78.5 years (range, 51-89 years). The median follow-up period was 4.98 years (range, .03-9.28). A receiver operating characteristic curve analysis determined the optimal cut-off value of the preoperative LMR for predicting overall mortality with 3.21 (area under the curve, .71; 95% confidence interval [CI], .62-.79; sensitivity, 57.4%; specificity, 77.0%; P < .001). On univariable and multivariable analyses, octogenarian (hazard ratio [HR], 1.89; 95%CI, 1.10-3.22; P = .020), poor nutritional status (HR, 2.95; 95%CI, 1.73-5.03; P < .001), chronic obstructive pulmonary disease (HR, 1.79; 95%CI, 1.06-3.03; P = .031), active cancer (HR, 2.60; 95%CI, 1.53-4.41; P < .001), and low preoperative LMR (HR, 2.56; 95%CI, 1.53-4.30; P < .001) were identified as independent predictors for overall mortality.

CONCLUSION

This study showed that a low preoperative LMR (<3.21) is an independent predictor of overall mortality after EVAR for AAA. The LMR may help in decision-making regarding the prediction of poor prognosis after EVAR.

Percutaneous Transhepatic Direct Portosystemic Shunt for a Patient With Budd-Chiari Syndrome Using a Balloon as a Target in a Stenotic Inferior Vena Cava

Budd-Chiari syndrome (BCS) patients with portal hypertension are often treated with a direct intrahepatic portosystemic shunt (DIPS) or transjugular intrahepatic portosystemic shunt (TIPS) and angioplasty. DIPS can be problematic, however, due to the technical difficulty of the procedure. To address this problem, we describe a method using the balloon used for inferior vena cava (IVC) dilatation as a puncture target to safely perform DIPS in a BCS patient with complete hepatic vein occlusion and stenosis of the IVC. To perform balloon dilation, the puncture is made through the internal jugular vein, and the guidewire is advanced to the IVC with stenosis. After dilatation of the IVC, the direct left lateral subdistrict branch of the portal vein is percutaneously punctured directly from the cardiac fossa (targeting the inflated balloon in the IVC), and the IVC puncture is done through the portal vein. After creating a pull-through route, a stent is placed between the left portal vein and the IVC. The procedure is completed without any complications. This technique has the potential to form the basis of a safe and reliable DIPS procedure.

Prognostic Value of Nutritional Markers for Long-Term Mortality in Patients Undergoing Endovascular Aortic Repair

Objective: The relationship between nutritional status and morbidity and death in a number of diseases and disorders has garnered considerable attension. In patients having endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAA), we assessed the prognostic value of nutritional markers of albumin (ALB), body mass index (BMI), and geriatric nutritional risk index (GNRI) for long-term mortality. Materials and Methods: Retrospective data analysis was done on patients who had undergone elective EVAR for AAA more than 5 years earlier. Results: A total of 176 patients underwent EVAR for AAA between March 2012 and April 2016. The optimal cutoff value of ALB, BMI, and GNRI for predicting long-term mortality was calculated as 3.75 g/dL (area under the curve [AUC] 0.64), 21.4 kg/m2 (AUC 0.65), and 101.4 (AUC 0.70), respectively. Low ALB, low BMI, and low GNRI as well as age ≥75 years, chronic obstructive pulmonary disease, chronic kidney disease, and active cancer were independent risk factors for long-term mortality. Conclusion: Malnutrition, which is measured by ALB, BMI, and GNRI, is an independent risk factor for long-term mortality in patients receiving EVAR for AAA. Of the nutritional markers, the GNRI can be the most reliable nutritional indicator to identify a potentially high-risk group of mortality after EVAR.

Effects of high-intensity inspiratory muscle warm-up on inspiratory muscle strength and accessory inspiratory muscle activity

This study aimed to determine the effects of work-matched moderate-intensity and high-intensity inspiratory muscle warm-up (IMW) on inspiratory muscle strength and accessory inspiratory muscle activity. Eleven healthy men performed three IMWs at different intensities, namely, placebo, moderate-intensity, and high-intensity, set, respectively, at 15%, 40%, and 80% of maximal inspiratory mouth pressure (MIP). MIP was measured before and after IMW. Electromyography (EMG) was recorded for the sternocleidomastoid muscle (SCM) and intercostal muscles (IC) during IMW. MIP increased significantly in the moderate-intensity condition (104.2 ± 5.1%, p<0.05) and high-intensity condition (106.5 ± 6.2%, p<0.01) after IMW. The EMG amplitudes of the SCM and IC during IMW were significantly higher in the order of high-intensity, moderate-intensity, and placebo conditions. There was a significant correlation between changes in MIP and EMG amplitude of the SCM (r=0.60, p<0.01) and IC (r=0.47, p<0.01) during IMW. These findings suggest that high-intensity IMW increases neuromuscular activity in the accessory inspiratory muscles, which may improve inspiratory muscle strength.

Influence of lower limb ischemia on skeletal muscle mass depletion in patients with peripheral artery disease

OBJECTIVES

The aim of the study was to determine the change in skeletal muscle mass over time by bioelectrical impedance analysis (BIA) in patients with peripheral artery disease (PAD).

METHODS

Patients with symptomatic PAD visiting Tokyo Medical University Hospital between January 2018 and October 2020 were retrospectively analyzed. PAD was diagnosed based on ankle brachial pressure index (ABI) < 0.9 with either leg, and confirmed by duplex scan and/or computed tomography angiography as needed. Patients undergoing endovascular treatment, surgery, or supervised exercise therapy were excluded before and during the study period. Skeletal muscle mass of the extremities was measured using bioelectrical impedance analysis. The sum of skeletal muscle masses in the arms and legs was calculated as skeletal muscle mass index (SMI). Patients were scheduled to undergo BIA at an interval of 1 year.

RESULTS

Of 119 patients, 72 patients were included in the study. All patients were ambulatory and had symptoms of intermittent claudication (Fontaine's satge II). SMI significantly decreased from 6.98 ± 1.30 at baseline to 6.83 ± 1.29 at one-year follow-up. Individual skeletal muscle mass of the ischemic leg was significantly reduced after 1 year, but not in the non-ischemic leg. A decrease in SMI (defined as SMI ≥ 0.1 kg/m² per year) was independently associated with low ABI. The optimal cut-off value of ABI for the decrease in SMI was 0.72.

CONCLUSION

These results suggest that lower limb ischemia due to PAD, especially if ABI is <0.72 or less, may result in a decrease in skeletal muscle mass that affects health and physical function.

First reports of clinical effects of transjugular intrahepatic portosystemic shunt in four patients with cirrhotic ascites refractory to tolvaptan

OBJECTIVE

Ascites in patients with decompensated cirrhosis can lead to abdominal distention and decrease quality of life. Tolvaptan, a vasopressin V2 receptor antagonist, is an effective agent in the treatment of ascites, whereas some patients are refractory to tolvaptan. The efficacy of transjugular intrahepatic portosystemic shunt (TIPS) for these patients is not known. In this study, we performed TIPS for tolvaptan-refractory cirrhotic patients and analysed its efficacy and safety in these patients.

DESIGN

This retrospective analysis included patients with liver cirrhosis who received TIPS for ascites or hydrothorax refractory to tolvaptan therapy along with conventional diuretics between January 2015 and May 2018 at Tokai University Hospital. We evaluated the efficacy and safety of TIPS.

RESULTS

This study included four patients. All patients presented with Child-Pugh class B liver cirrhosis and model for end-stage liver disease-sodium scores were 10/12/14/16. TIPS was generated successfully without any major complications in all patients. The body weight decreased by a mean of 4.7 (SD=1.0) kg and estimated glomerular filtration rate improved from a mean of 38.2 (SD=10.3) to 59.5 (SD=25.0) mL/min/1.73 m² in a month after TIPS procedure.

CONCLUSION

TIPS is an effective potential treatment for ascites in patients with tolvaptan refractory condition. In appropriate patients who can tolerate TIPS, the treatment may lead towards renal function improvement.

Prophylactic Steroids for Preventing Postembolization Syndrome after Transcatheter Arterial Embolization of Renal Angiomyolipoma: A Comparative Study

Purpose

Postembolization syndrome (PES) after renal arterial embolization (RAE) can reduce the patient's tolerance of the procedure and extend the length of hospital stay. We aimed to assess the efficacy of steroid administration in preventing PES in patients undergoing RAE for angiomyolipoma (AML).

Material and Methods

Between May 2004 and March 2020, 29 RAE procedures in 26 patients with AML were performed. Patient information, including age, sex, tumor size, tuberous sclerosis complex-associated/sporadic AML, hemorrhagic/nonhemorrhagic AML, embolic material, steroid use, medication type, some blood laboratory parameters, hospital stay, and PES occurrence were retrospectively obtained. The prophylactic steroid protocol used in the study was as follows: 250 mg of intravenous methylprednisolone (Solu-Medrol) 2 h before the RAE procedure, followed by 2 days of intravenous prednisolone (Predonine; 2 mg/kg/day), which was tapered by halving the dose every 2 days within the course of 2 weeks. After the discharge, intravenous prednisolone was changed to oral prednisolone (Predonine). PES was defined as the presence of fever, pain, nausea, or vomiting. Data were compared between the steroid and non-steroid groups and between PES and non-PES groups.

Results

The PES incidence rate was 76%, and a comparison between the steroid and non-steroid groups revealed that steroid use significantly decreased the incidence of PES (P < 0.001), including fever (P < 0.001), pain (P = 0.005), and nausea (P = 0.028). The use of anti-inflammatory drugs during the hospital stay was significantly lower in the steroid group (P = 0.019). Moreover, in the steroid group, C-reactive protein level was significantly lower (P = 0.006), whereas white blood cell count was significantly higher (P = 0.004). Conversely, the median length of hospital stay was not significantly shorter in the steroid group (P = 0.292).

Conclusions

The prophylactic use of steroids before and after embolization of renal AML may be effective in preventing PES in this small retrospective study.

Prediction of common hepatic artery catheter insertion based on celiac trunk morphology

PURPOSE

This study aimed to predict the ability to insert a 4-5 French (Fr) catheter insertion with a guidewire into the common hepatic artery (CHA) based on celiac trunk morphology.

METHODS

This retrospective study included 64 patients who underwent balloon-occluded transcatheter arterial chemoembolization (n = 56), transcatheter arterial chemotherapy (n = 2), or were fitted with an implantable port system (n = 6) between June 2019 and December 2019 in our institution. The morphology of the celiac trunk was classified into three types (upward, horizontal, and downward) based on celiac angiography. The aortic-celiac trunk angle was measured on sagittal images of preprocedural contrast-enhanced computed tomography (CT). We reviewed whether a 4-5-Fr shepherd's hook catheter could advance beyond the CHA using a 0.035-inch guidewire (Radifocus® Guidewire M; Terumo). Three patients were diagnosed with median arcuate ligament syndrome (MALS) based on the characteristic hook shape of the celiac artery on sagittal images of contrast-enhanced CT. The predictive ability of celiac angiography and preprocedural CT for CHA insertion success was evaluated. In unsuccessful cases, the balloon anchor technique (BAT) was attempted as follows: (1) a 2.7/2.8-Fr microballoon catheter (Attendant Delta; Terumo) was placed beyond the proper hepatic artery, and (2) the balloon was inflated as an anchor for parent catheter advancement.

RESULTS

Upward, horizontal, and downward celiac trunk types were noted in 42, 9, and 13 patients, respectively. The median CT angle was 122.83° (first quartile-third quartile, 102.88°-136.55°). Insertion in the CHA using the guidewire was successful in 56 of 64 patients (87.50%), and the success rate in the downward type was significantly lower than that in the upward type [42/42 (100%) vs. 7/13 (53.85%), P < 0.001]. The CT angle was significantly larger downward in the unsuccessful group than in the successful group (121.03° vs. 140.70°, P = 0.043). Celiac angiography had a significantly higher area under the curve (AUC) than preprocedural CT (AUC = 0.91 vs. AUC = 0.72, P = 0.040). All three cases of MALS showed unsuccessful CHA insertion. In all eight patients with unsuccessful insertion, the catheter could be advanced using the BAT [8/8 (100%)].

CONCLUSION

Celiac angiography and preprocedural CT could predict CHA catheter insertion using a guidewire, and celiac angiography had high predictability. CT could detect MALS, a risk factor for unsuccessful CHA insertion.

Venous Stent Placement for Malignant Vena Cava Syndrome in a Patient with Liposarcoma

BACKGROUND Reports of venous stenting for inferior vena cava (IVC) syndrome (IVCS) due to sarcoma are limited, and the treatment's efficacy and safety are not clear. CASE REPORT A 36-year-old woman with myxoid liposarcoma was admitted to the Department of Respiratory Medicine for treatment of bilateral lower-leg edema and to be evaluated for acute liver dysfunction. She was 13 years old when she was diagnosed with myxoid liposarcoma. Over the next 18 years, she had 4 tumor resections and 1 round of radiation therapy. She had been on chemotherapy for 4 years and then pazopanib at the age of 35. The edema did not improve after admission despite treatment with diuretics. Computed tomography revealed a huge liposarcoma occupying the right thoracic cavity and a compressed IVC, which caused the edema. Although doxorubicin was administered as fifth-line treatment, there was no response. Since there was no additional chemotherapy regimen, her prognosis was considered to be less than 6 months. She could not be discharged to her home since she was unable to walk due to the edema; therefore, IVC stenting was performed to improve her dysmotility. After IVC stenting, the lower-leg edema improved without any adverse events, enabling her to walk and eventually return home. CONCLUSIONS In patients with IVCS caused by rare malignancies such as myxoid liposarcoma, an IVC stent can be safely implanted and can help to alleviate symptoms. IVC stenting can improve symptoms and allow for home care, resulting in improved quality of life.

Outcomes of embolization procedures for type II endoleaks following endovascular abdominal aortic repair

OBJECTIVE

The objective of this study was to investigate the mid-term outcomes of embolization procedures for type II endoleak after endovascular abdominal aortic repair, and clarify the risk factors for aneurysm enlargement after embolization procedures.

METHODS

This was a retrospective multicenter registry study enrolling patients who underwent embolization procedures for type II endoleaks after EVAR from January 2012 to December 2018 at 19 Japanese centers. The primary end point was the rate of freedom from aneurysm enlargement, more than 5 mm in the aortic maximum diameter, after an embolization procedure. Demographic, procedural, follow-up, and laboratory data were collected. Continuous variables were summarized descriptively, and Kaplan-Meier analyses and a Cox regression model were used for statistical analyses.

RESULTS

A total of 315 patients (248 men and 67 women) were enrolled. The average duration from the initial embolization procedure to the last follow-up was 31.6 ± 24.6 months. The rates of freedom from aneurysm enlargement at 3 and 5 years were 55.4 ± 3.8% and 37.0 ± 5.2%, respectively. A multivariate analysis revealed that a larger aortic diameter at the initial embolization procedure and the presence of a Moyamoya endoleak, defined as heterogeneous contrast opacity with an indistinct faint border, were associated with aneurysm enlargement after embolization management.

CONCLUSIONS

The embolization procedures were generally ineffective in preventing further expansion of abdominal aortic aneurysms in patients with type II endoleaks after EVAR, especially in patients with a large abdominal aortic aneurysm and/or a presence of a Moyamoya endoleak.

Stereocontrolled Synthesis of C20S-C26 and C20R-C26 Fragments of Amphidinolide L

Amphidinolide L is a cytotoxic macrolide isolated from marine symbiotic dinoflagellates of the genus Amphidinium. While its planar structure and the absolute stereochemistry of the C21-C26 part have been determined, six stereocenters have remained unassigned. Aiming at structure determination, we have developed a synthetic route to the C20S-C26 and C20R-C26 fragments via the Li-mediated stereocontrolled aldol reaction. Two aldehydes, 16 with the C22-hydroxy group and 19 with the C22-TES ether, were synthesized from lactone 4. The aldol reactions using the Li-enolate of 4-methyl-2-pentanone in THF provided the C20S-C26 fragment 20 from 16 and a 1:3.5 mixture of the C20-C26 fragment 22 favoring the C20R-isomer. Mechanistic studies based on an extensive search of transition states in explicit solvents indicated that the C20S-isomer would be generated via a tri-solvated transition state, while the C20R-isomer would be formed via a di-solvated transition state. The calculation emphasizes the importance of the coordination network as a higher-order complex composed of solvent molecules, aldehyde, enolate, and Li atoms in the reaction of 16 to minimize steric interactions but maximize the stabilizing effect by the coordination of solvents. The presence of the rotationally free aldehyde in the reaction of 19 results in moderate diastereoselectivity.

Trans-arterial Embolization in a Patient with Unilateral Absence of Pulmonary Artery: Treatment Success and the Four-year Prognosis

Unilateral absence of the pulmonary artery (UAPA) with or without other anomalies in the heart is a rare congenital malformation. A 55-year-old Filipino woman without a remarkable medical history was admitted to our hospital for hemoptysis. Contrast-enhanced chest computed tomography revealed the absence of the left pulmonary artery. Echocardiography and right heart catheterization showed no cardiac malformations or pulmonary hypertension. We diagnosed her with isolated left-sided UAPA and performed transarterial embolization of the left inferior phrenic artery. This resolved the hemoptysis, and there was no recurrence during the four-year follow-up period.

The Presence of Simple Renal Cysts Is Associated With Increased Arterial Stiffness in Patients With Abdominal Aortic Aneurysm

Simple renal cysts (SRC) are associated with the development of abdominal aortic aneurysms (AAA). We hypothesized that patients with AAA and SRC have increased arterial stiffness (AS) compared with patients without SRC. Patients (n=223) with an infrarenal AAA undergoing pulse wave analysis were recruited. Brachial-ankle pulse wave velocity (PWV) was measured (automated oscillometric method) as an index of AS. Participants were categorized into those with increased AS and those with normal/borderline AS (threshold: 1800 cm/s); 134 patients (60.1%) had increased AS and 89 (39.9%) patients had normal/borderline AS. Multivariable analyses showed that age ≥75 years (odds ratio [OR], 2.83; 95% confidence interval [CI], 1.51-5.72; P=.002), systolic blood pressure ≥140 mmHg (OR, 5.05; 95% CI, 2.35-10.83; P<.001), hypertension (OR, 2.28; 95% CI, 1.08-4.79; P=.030), and presence of SRC (OR, 1.89; 95% CI, 1.03-3.46; P=.040) were independent risk factors for increased AS. The presence of SRC is an independent risk factor for increased AS in patients with an AAA. This association suggests that patients with SRC may have severe aortic wall degeneration and thus the presence of SRC may be pathologically linked to the development of AAA.

Congenital venous anomalies associated with retrocaval ureter: evaluation using computed tomography

BACKGROUND

Retrocaval ureter is a rare congenital anomaly resulting from anomalous development of inferior vena cava (IVC) and not from anomalous of the ureter. The anomaly always occurs on the right side due to regression of right supracardinal vein and persistence of right posterior cardinal vein. Retrocaval ureter tends to be associated with various vena cava anomalies because of the embryogenesis. We aimed to identify the prevalence of associated congenital venous anomalies (CVA) resulting from cardinal vein development in adults with retrocaval ureter using computed tomography (CT) images.

MATERIALS AND METHODS

The study included 22 adults with retrocaval ureter. We evaluated CT findings and determined the incidence of associated CVA using thin slice data sets from CT scanner with 64 or more detectors. We compared the prevalence of CVA in the retrocaval ureter group (mean age: 57±19 years) and in the control group of 6189 adults with normal ureter (mean age: 66±14 years).

RESULTS

In the retrocaval ureter group, 4 adults (18.2 %) had CVA including double IVC, right double IVC, preisthmic IVC with horseshoe kidney, and preaortic iliac confluence. One of 2 adults with preaortic iliac confluence had right double right IVC. In the control group, 49 adults (0.79%) had CVA including 37 double IVCe, 11 left IVCe, and 1 IVC interruption azygos continuation. Fifteen horseshow kidneys were found. The prevalence of associated CVA in the retrocaval ureter group was higher than that in the control group (p<0.001).

CONCLUSIONS

Retrocaval ureter is frequently associated with CVA. Various CVA with retrocaval ureter could happen because of abnormal development of not only the right posterior or supra cardinal vein but also other cardinal veins.

Celiac Artery Dissection and Retroperitoneal Hemorrhage in Median Arcuate Ligament Syndrome Treated With a Stent and Transcatheter Arterial Embolization: Preprocedural 4-Dimensional Computed Tomography Angiography Assessment

A 61-year-old man presented with retroperitoneal hemorrhage caused by an aneurysm rupture of the pancreaticoduodenal arcade (PDA), and acute celiac artery dissection distal to celiac axis stenosis. Owing to the gradual growth of the false lumen, we planned to deploy a stent to the celiac artery dissection and embolize the PDA aneurysm. Prior to stent placement, we assessed the acute celiac artery dissection distal to the stenosis using four-dimensional computed tomography (CT) angiography through expiration/inspiration/expiration cycle. We diagnosed median arcuate ligament syndrome considering that the celiac axis showed a hooked narrowing at end-expiration, and the compression decreased at end-inspiration. Additionally, the true lumen distal to the stretched axis dilated in the inspiration phase. Therefore, we could advance a catheter into the true lumen during inspiration and successfully deploy a stent. Subsequently, laparoscopic median arcuate ligament release was performed after the stent deployment. A postoperative CT scan showed good patency in the stent, with disappearance of the blood filling the false lumen and with reduced celiac axis stenosis.

Association of preoperative pulse wave velocity to aneurysm sac shrinkage after endovascular aneurysm repair

BACKGROUND

Arterial stiffness may be the underlying cause of the divergent sac behavior after endovascular aortic repair (EVAR). We evaluated arterial stiffness using pulse wave velocity (PWV) in patients undergoing EVAR for abdominal aortic aneurysm (AAA) and demonstrated that arterial stiffness is a predictor for determining sac behavior after EVAR.

METHODS AND RESULTS

One hundred nineteen patients with infrarenal AAA undergoing EVAR between November 2013 and July 2019 were included in this study. Preoperative brachial-ankle PWV was measured using an automated oscillometric method at our vascular laboratory. PWV and other risk factors were assessed with respect to being a risk factor for sac shrinkage at 2 years postoperatively. Univariate and multivariable analyses revealed preoperative PWV (odds ratio [OR] 0.87; 95% confidence interval [CI] 0.79-0.98; p = 0.045) and the incidence of operative type II endoleak (OR 0.68; 95% CI 0.10-0.81; p = 0.048) as an independent risk factor for sac shrinkage at 2 year postoperatively. The receiver-operating characteristic curve analysis showed that the optimal cutoff value for predicting sac shrinkage was 17.79 m/s, and significantly predicted sac shrinkage.

CONCLUSIONS

Preoperative PWV was independently associated with sac shrinkage after EVAR, suggesting that arterial stiffness may be one of the key factors for determining sac behavior after EVAR.

Bowstring Phenomenon in Renal Artery Aneurysm Exclusion Using a Viabahn Stent Graft

A 77-year-old man presented with an incidental finding of right renal artery aneurysm without symptoms. Computed tomography revealed a 22 mm saccular aneurysm with a wide neck at the main renal artery trunk. An 8 × 100 mm Viabahn stent graft (W. L. Gore, Flagstaff, AZ) was deployed by fully pulling back the guiding sheath. However, the deployment knob was not able to be pulled. We returned the guiding sheath to the original position and confirmed the cause was the bowstring phenomenon. Because avoidance of this phenomenon required straightening of the tortuous vessel, the stent graft was deployed by short pull-back of the guiding sheath. Computed tomography after a year revealed no opacification of the aneurysm and the patency of the stent graft.

Late Nonanastomotic Pseudoaneurysm From the Prosthetic Graft: A Successful Transcatheter Arterial Embolization Using Coils

A 71-year-old man who received a total arch replacement with a knitted Dacron® graft presented aneurysmal sac re-expansion due to leakage at the distal anastomotic site of the graft. He did not tolerate the stress of general anesthesia due to severe pulmonary function impairment. Therefore, thoracic endovascular aortic repair (TEVAR) in zone 3 was performed under epidural anesthesia. Contrast-enhanced computed tomography (CT) revealed another leakage into the aneurysmal sac in zone 1 after performing TEVAR. Because open surgical repair and debranching TEVAR were contraindicated, transcatheter arterial embolization was performed with careful consideration of his comorbidities. Follow-up contrast-enhanced CT performed 2 weeks after embolization indicated no opacification of the aneurysmal sac, and noncontrast-enhanced CT a year after embolization showed no dilatation of the aneurysmal sac.

Successful laparoscopic surgery combined with selective arterial embolization for bleeding due to jejunal angiodysplasia: a case report

Background

Angiodysplasia of the gastrointestinal tract is a rare vascular pathology that sometimes causes massive hemorrhage. Angiodysplasias are particularly difficult to find in the small intestine for anatomical reasons, often impeding their diagnosis and treatment. Lesion localization is a major challenge in cases of small bowel bleeding requiring surgical intervention.

Case presentation

The present case was a 52-year-old woman who was urgently hospitalized with repeated tarry stools. Surgical intervention was chosen after conservative treatment failed to improve her condition. The source of bleeding was suspected to be a vascular lesion discovered in the small intestine during a past double-balloon endoscopy. Abdominal contrast computed tomography revealed a jejunal hemorrhage. We chose selective arterial embolization to stabilize her hemodynamics followed by surgical intervention as her treatment plan. Several embolic and contrast agents (cyanoacrylate, indigo carmine, and Lipiodol) were combined to help identify the location of the lesion during surgery. This multi-pronged approach allowed us to localize the lesion under laparoscopic guidance with high confidence and accuracy, and to excise a 6-cm segment of the small intestine. The lesion was histologically diagnosed as angiodysplasia. No re-bleeding has been observed since the operation.

Conclusion

We report our experience with a case of jejunal angiodysplasia, which was localized with selective arterial embolization using an array of embolic and contrast agents, and then excised laparoscopically. Selective arterial embolization with indigo carmine dye to treat small bowel bleeding preoperatively not only makes the surgery safer by stabilizing the patient’s hemodynamics, but is also very useful for localizing the lesion intraoperatively.

Relationship Between Serum Eicosapentaenoic Acid to Arachidonic Acid Ratio and Atherosclerotic Risk Factors in Patients With Peripheral Artery Disease

BACKGROUND

The eicosapentaenoic acid to arachidonic acid ratio (EPA/AA) is attracting attention as a risk factor for peripheral artery disease (PAD). However, there have been few studies investigating the relationship between the EPA/AA ratio and atherosclerotic risk factors in patients with PAD. The purpose of the present study was to analyze atherosclerotic risk factors in patients with PAD to identify those factors associated with a low EPA/AA ratio.

METHODS.

The data of patients treated for symptomatic PAD at Tokyo Medical University Hospital and Eniwa Midorino Clinic between April 2014 and March 2018 were retrospectively analyzed.

RESULTS.

A total of 149 patients were tested for blood levels of n-3 and n-6 polyunsaturated fatty acids, including EPA and AA. 73 patients had a low EPA/AA ratio (<0.4) and 76 patients had a high EPA/AA ratio (≥ 0.4). Univariate analysis showed that older age (≥ 75 years), female sex, smoking history, body mass index (BMI), and hemoglobin A_1C (HbA_1C) were associated with the low EPA/AA ratio. Multivariable analysis showed that older age (odds ratio [OR], 0.34; 95% confidential interval [CI], 0.15-0.76; p = 0.008), BMI (OR, 0.87; 95% CI, 0.77-0.98; p = 0.027), smoking history (OR, 2.67; 95% CI, 1.09-6.55; p = 0.007), and HbA_1C (OR, 0.46; 95% CI, 0.29-0.72; p = 0.020) were independently associated with the low EPA/AA ratio.

CONCLUSIONS.

The EPA/AA ratio was related to existing arteriosclerotic risk factors in patients with PAD; it was positively correlated with older age, increasing BMI, and higher HbA_1C, whereas it was negatively correlated with smoking history. These results suggest that the EPA/AA ratio may be closely intertwined with other atherosclerotic risk factors and have an influence on cardiovascular health.

Effectiveness of lymphatic cannulation in case of non-applicable intranodal lymphangiography

A 78-year-old man presented with lymphatic fluid collections in bilateral inguinal area after bilateral inguinal lymph node dissections. Because no inguinal or popliteal lymph nodes were observed under ultrasound examination, intranodal lymphangiography was not applicable. Although traditional pedal lymphangiography was required, it was difficult to perform this procedure owing to the decreasing frequency over the past 20 years and being unavailable in not only our institution, but also other in institutions. Therefore, we performed catheterization using the 29-guage Argyle PI catheter into the lymphatic duct in lower legs under a microscope and achieved successful percutaneous embolization using N-butyl cyanoacrylate for inguinal lymphatic leakage.

Influence of Superficial Venous Ablation on Deep Venous Dilation and Reflux in Patients With Saphenous Varicose Veins

BACKGROUND

To investigate the influence of superficial venous ablation on deep venous dilation and reflux in patients with saphenous varicose veins, and to elucidate the association between superficial venous reflux and deep venous morphology and hemodynamics.

METHODS

The data of 154 patients with 223 limbs, who underwent endovenous radiofrequency ablation (RFA) of the great saphenous vein for primary varicose veins between September 2014 and March 2016 in Eniwa Midorino Clinic, were retrospectively analyzed. Overall venous hemodynamics of the leg, including functional venous volume (VV) and venous filling index (VFI), was assessed using air-plethysmography. Saphenous and deep vein reflux and diameter were evaluated with duplex scanning.

RESULTS

Hemodynamic and morphologic changes were evaluated before and 1 month after RFA. The VV and VFI were significantly decreased in postoperative values than in preoperative values (P < .001). Limbs with deep venous reflux significantly decreased postoperatively than preoperatively (P < .001). There were significant differences in the diameter of the common femoral vein (CFV) and popliteal vein (PV) between the preoperative and postoperative values (P < .001). There were strong to moderate correlations between the VV and the diameter of the CFV or PV (CFV, r = 0.47, P < .001; PV, r = 0.35, P < .001), while there were moderate to weak correlations between the VFI and the diameter of the CFV or PV (CFV, r = 0.23, P < .001; PV, r = 0.33, P <.001).

CONCLUSIONS

Superficial venous ablation significantly reduced deep venous dilation and reflux in patients with saphenous varicose veins. Significant correlations existed between the VV or VFI, which reflected superficial venous reflux, and the diameter of the deep veins. These findings reveal that volume overload due to superficial venous reflux is associated with deep venous morphology and hemodynamics.

A mouse model of stenosis distal to an arteriovenous fistula recapitulates human central venous stenosis

Objective

Central venous stenosis (CVS) is a major cause of arteriovenous fistula (AVF) failure. However, central veins are relatively inaccessible to study with conventional Doppler ultrasound methods. To understand mechanisms underlying AVF failure owing to CVS, an animal model was established that creates a stenosis distal to an AVF. We hypothesized that this mouse model will show comparable morphology and physiology to human CVS.

Methods

An aortocaval fistula was created between the distal aorta and inferior vena cava (IVC); a stenosis was then created distal to the fistula by partial IVC ligation. Sham-operated animals, AVF without venous stenosis, and venous stenosis without AVF were used as controls. Physiologic properties of the IVC, both upstream and downstream of the stenosis, or the corresponding sites in models without stenosis, were assessed with ultrasound examination on days 0 to 21. The spectral broadening index was measured to assess the degree of disturbed shear stress. The IVC was harvested at day 21 and specimens were analyzed with immunofluorescence.

Results

The IVC diameter of mice with an AVF and stenosis showed increased upstream (P = .013), but decreased downstream diameter (P = .001) compared with mice with an AVF but without a stenosis, at all postoperative times (days 3-21). IVC wall thickness increased in mice with an AVF, compared with IVC without an AVF (upstream of stenosis: 13.9 μm vs 11.0 μm vs 4.5 μm vs 3.9 μm; P = .020; downstream of stenosis: 6.0 μm vs 6.6 μm vs μm 4.5 μm vs 3.8 μm; P = .002; AVF with stenosis, AVF, stenosis, sham, respectively). AVF patency significantly decreased in mice with an AVF and stenosis by day 21 (50% vs 90%; P = .048). The IVC of mice with AVF and stenosis showed a venous waveform with pulsatility as well as enhanced velocity at and downstream of the stenosis; similar waveforms were observed in a human case of CVS. Downstream to the stenosis, the spectral broadening index was significantly higher compared with mice with AVF alone (1.06 vs 0.78; P = .011; day 21), and there was a trend towards less immunoreactivity of both Krüppel-like factor 2 and phosphorylated-endothelial nitric oxide synthase compared with mice with an AVF alone.

Conclusions

Partial IVC ligation distal to a mouse aortocaval fistula alters the fistula diameter and wall thickness, decreases patency, and increases distal disturbed flow compared with fistulae without a distal stenosis. Our mouse model of stenosis distal to an AVF may be a faithful representation of human CVS that shows similar morphology and physiology, including disturbed shear stress.

A mouse model of venous stenosis distal to an arteriovenous fistula shows similar Doppler waveforms as those observed in a human case of central venous stenosis. These mice retain disturbed shear stress in the vein distal to the fistula, characterized by a sustained increase of the spectral broadening index and diminished expression of proteins upregulated by laminar shear stress. This novel mouse model will enable investigation of the physiology and downstream molecular pathways involved in central venous stenosis in humans.

Altered hemodynamics during arteriovenous fistula remodeling leads to reduced fistula patency in female mice

Objective

The arteriovenous fistula (AVF) is the preferred method of dialysis access because of its proven superior long-term outcomes. However, women have lower rates of AVF patency and utilization than men. We used a novel mouse AVF model that recapitulates human AVF maturation to determine whether there are differences in AVF patency in female and male mice.

Methods

Aortocaval fistulas were created in female and male C57BL/6 mice (9-10 weeks). At days 0, 3, 7, and 21, infrarenal inferior vena cava (IVC) and aortic diameters and flow velocity were monitored by Doppler ultrasound and used to calculate the vessel diameter, blood flow, and shear stress. AVF were harvested, and expression of proteins was examined by proteomic analysis and immunofluorescence and of messenger RNA by quantitative polymerase chain reaction analysis.

Results

At baseline, female mice weighed less and had lower IVC velocity and smaller magnitudes of shear stress, but there was no significant difference in IVC diameter and thickness. After AVF creation, both female and male mice had similar IVC dilation and thickening with no significant differences in IVC wall thickness at day 21. However, female mice had diminished AVF patency by day 42 (25.7% vs 64.3%; P = .039). During fistula remodeling, female mice had lower IVC mean velocity and shear stress magnitude and increased spectral broadening (days 0-21). Messenger RNA and protein expression of Krüppel-like factor 2, endothelial nitric oxide synthase, and vascular cell adhesion molecule 1 was similar at baseline in female and male mice but increased in the AVF only in male mice but not in female mice (day 21). Proteomic analysis of female and male mice detected 56 proteins expressed at significantly higher levels in the IVC of female mice and 67 proteins expressed at significantly higher levels in the IVC of male mice (day 7); function-specific analysis showed that the IVC of male mice overexpressed proteins that belong to pathways implicated in the regulation of vascular function, thrombosis, response to flow, and vascular remodeling.

Conclusions

AVF in female mice have diminished patency, preceded by lower velocity, reduced magnitudes of shear stress, and less laminar flow during remodeling. There is also sex-specific differential expression of proteins involved in thrombosis, response to laminar flow, inflammation, and proliferation. These findings suggest that hemodynamic changes during fistula maturation may play an important role underlying the diminished rates of AVF utilization in women.

Women have lower rates of arteriovenous fistula (AVF) utilization than men. Using a mouse AVF model that recapitulates human AVF maturation, we show that female mice have similar AVF remodeling but diminished patency. AVF remodeling in female mice is associated with reduced shear stress and laminar flow; lack of increased transcription and translation of several anti-inflammatory, antiproliferative, and laminar flow response proteins (endothelial nitric oxide synthase, Krüppel-like factor 2, and vascular cell adhesion molecule 1); and different patterns of expression of pathways that regulate thrombosis and venous remodeling. Identifying downstream targets involved in these mechanisms may improve AVF outcomes in female patients.

Effect of inspiratory resistive training on diaphragm shear modulus and accessory inspiratory muscle activation

This study aimed to elucidate changes in diaphragm and accessory inspiratory muscle (sternocleidomastoid (SCM) muscle and intercostal muscle (IC)) function after a 6-week training program. Nineteen male elite collegiate swimmers were assigned to either a control group (n = 9) or training group (n = 10). The subjects in the training group performed 30 maximum inspirations at a load resistance of 50% of maximum inspiratory mouth pressure (PImax) using an inspiratory muscle training device. These were conducted twice per day and 6 days per week. At baseline and after 6 weeks, PImax, shear modulus of the diaphragm, and electromyograms (EMG) of the SCM and IC during a maximal inspiratory maneuver were evaluated. Relative change in PImax was greater in the training group than in controls. The shear modulus during a PImax maneuver had increased significantly in both groups after 6 weeks. EMG amplitudes of the SCM increased in the training group after 6 weeks, but not in the control group. EMG amplitudes of the IC did not change after 6 weeks in either group. These results suggest that 6-week inspiratory resistive training significantly improves the activation of the SCM, which could be one of the major mechanisms behind increases in inspiratory muscle strength after resistive training. Novelty Six-week inspiratory resistive training increased diaphragm stiffness during maximal inspiration maneuver. Six-week inspiratory resistive training increased electromyogram amplitudes of the sternocleidomastoid during maximal inspiration maneuver.

Successful Balloon-Occluded Retrograde Transvenous Obliteration for Gastric Varices Using Foam Sclerosant Followed by Glue Embolization of Gastrorenal Shunt via the Brachial Vein Approach in a Severely Obese Patient

Balloon-occluded retrograde transvenous obliteration is an effective treatment for gastric varices. In this report, we illustrate a consecutive treatment strategy via brachial vein approach and n-butyl cyanoacrylate (NBCA) packing of the gastrorenal shunt (GRS) after injecting sclerosing agent in a severely obese patient. The brachial vein approach reduced the burden on the patient, and the closure of the GRS using NBCA shortened the procedure time. These techniques may improve patient comfort as well as reduce medical costs and the risks of several complications.

Murine Model of Central Venous Stenosis using Aortocaval Fistula with an Outflow Stenosis

Central venous stenosis is an important entity contributing to arteriovenous fistula (AVF) failure. A murine AVF model was modified to create a partial ligation of the inferior vena cava (IVC) in the outflow of the fistula, mimicking central venous stenosis. Technical aspects of this model are introduced. The aorta and IVC are exposed, following an abdominal incision. The infra-renal aorta and IVC are dissected for proximal clamping, and the distal aorta is exposed for puncture. The IVC at the midpoint between the left renal vein and the aortic bifurcation is carefully dissected to place an 8-0 suture beneath the IVC. After clamping the aorta and IVC, an AVF is created by puncturing the infra-renal aorta through both walls into the IVC with a 25 G needle, followed by ligating a 22 G intra-venous (IV) catheter and IVC together. The catheter is then removed, creating a reproducible venous stenosis without occlusion. The aorta and IVC are unclamped after confirming primary hemostasis. This novel model of central vein stenosis is easy to perform, reproducible, and will facilitate studies on AVF failure.

Type IIIb Endoleak After Endovascular Aneurysm Repair Using the Zenith Stent Graft

We present 3 cases of type IIIb endoleak after endovascular aneurysm repair (EVAR) using the Zenith stent graft system. Type III endoleak, like type I endoleak, is a high-pressure, high-risk leak that increases sac pressure up to or even above arterial pressure, and is associated with an increased frequency of open conversions or risk of aneurysm rupture. Type IIIb endoleak is rare but there is much concern that the incidence of type IIIb endoleak is likely to increase hereafter; the mechanism of type IIIb endoleak is deterioration of graft fabric in conjunction with stent sutures. Type IIIb endoleak is difficult to diagnose before rupture. The possibility of type IIIb endoleak should be highly suspected when the continued growth of an excluded aneurysm sac without direct radiologic evidence is observed during follow-up. Type IIIb endoleak can be repaired by relining of the stent graft with additional stent grafts.

Endovascular Catheter Biopsy for the Diagnosis of Pulmonary Artery Sarcoma

The diagnosis of pulmonary artery sarcoma (PAS) is challenging, and its definitive diagnosis is mainly confirmed using specimens obtained during surgery or autopsy. Endovascular catheter biopsy was performed in five patients with suspected PAS to establish a definitive diagnosis. Aspiration biopsy was performed in all patients, and forceps biopsy was performed in one patient. Three patients were diagnosed with PAS, and no definitive diagnosis was obtained in two patients with squamous cell lung carcinoma with pulmonary artery infiltration. Endovascular catheter biopsy is helpful in the diagnosis of PAS and should be performed when a tumor is suspected.

Respiratory changes in the length of the vena cava: implications for optimal positioning of inferior vena cava filter

BACKGROUND

A transjugular temporary inferior vena cava (IVC) filter may change position with respiration, leading to serious complications such as filter migration to the right atrium (RA) or renal veins. We therefore evaluated respiratory changes in the length and diameter of the vena cava using MRI.

METHODS

In 20 volunteers, the length and diameter of the vascular segments from the right brachiocephalic vein (BCV) to infrarenal IVC were measured with MRI.

RESULTS

The mean lengths in mm of the BCV, superior vena cava (SVC), RA, suprarenal IVC, and infrarenal IVC during expiration vs. inspiration were 32.7±7.3 vs. 43.0±8.0, 44.6±9.6 vs. 58.5±12.7, 77.8±12.4 vs. 98.9±10.0, 104.6±19.1 vs. 85.0±14.9, and 49.0±8.7 vs. 33.8±9.7, respectively (all P<0.01). The distances in mm from the BCV to RA, upper confluence of the renal vein, and lower confluence of the renal vein during expiration vs. inspiration were 155.2±18.5 vs. 200.4±20.1, 259.7±28.5 vs. 285.4±23.5, and 308.7±31.6 vs. 319.1±24.9, respectively (all P<0.01). The diameter of the SVC decreased with inspiration, while that of the infrarenal IVC increased. The diameter of the suprarenal IVC did not change significantly with respiration.

CONCLUSIONS

The distances from the BCV to RA, upper, and lower confluences of the renal vein were 4.5, 2.6, and 1.0 cm longer on average at inspiration than at expiration, respectively. These respiratory-associated changes of the vena cava length should be taken into account when deploying an IVC filter to prevent its migration.

Aberrant Left Brachiocephalic Vein versus Persistent Left Superior Vena Cava without Bridging Vein in Adults: Evaluation on Computed Tomography

Objective: Persistent left superior vena cava without bringing vein (PLSVC w/o BV) is a common thoracic venous anomaly, while aberrant left brachiocephalic vein (ALBCV) is an uncommon condition. We compared the incidences of the two venous anomalies and assessed congenital cardiovascular diseases (CCDs) in adults using computed tomography (CT).

Materials and Methods: We reviewed the recorded reports or CT images of 49,494 adults for PLSVC w/o BV and ALBCV in two hospitals. We determined incidences of two venous anomalies and the rate of associated CCDs.

Results: 76 PLSVCs w/o BV and 27 ALBCVs were found. The incidence of PLSVC w/o BV was 0.15% and the incidence of ALBCV was 0.055%. PLSVC w/o BV had higher incidence than ALBCV (p<0.001). Four PLSVCs w/o BV and one ALBCV were associated with congenital heart diseases. Two PLSVCs w/o BV and four ALBCVs were associated with congenital aortic arch anomaly (CAAA). ALBCV had higher incidence of associated CAAA than PLSVC w/o BV (P=0.02).

Conclusion: The incidence of ALBCV was <50% that of PLSVC w/o BV. The two venous anomalies found on CT during adulthood were rarely associated with CCDs.

Right Aortic Arch with Mirror-image Branching in Adults: Evaluation Using CT

OBJECTIVE

We evaluated radiological findings and clinical significance of right aortic arch with mirror-image branching (RAMI) in adults using data from computed tomography (CT) examinations.

MATERIAL AND METHODS

We reviewed recorded reports and CT images obtained from university and branch hospitals for RAMI in adults. The RAMI incidence in adults found on CT was assessed. Associated congenital and acquired cardiovascular diseases were evaluated.

RESULTS

A total of 27 cases (14 men, 13 women; mean age, 59.4 ± 18.3 years) of RAMI were found. Among 107,014 cases in three hospitals, the RAMI incidence in the first, second, and third Tokai University hospitals were 0.018%, 0.012%, and 0.012%, respectively. Eight cases had high aortic arches and four cases had aortic diverticulum (AD) in proximal descending aorta. Three cases had a history of tetralogy of Fallot. One case with an absent left pulmonary artery and three cases with an aberrant left brachiocephalic vein were found incidentally. Two cases were associated with AD aneurysm and vascular ring formation. One case had stenosis of the left subclavian artery due to injury.

CONCLUSION

Cases of RAMI found in CT examinations in adults were extremely rare. Some cases were associated with congenital anomalies and/or acquired cardiovascular disease.

Utility of a 3D Roadmap During Balloon-occluded Retrograde Transvenous Obliteration for Gastric Varices

OBJECTIVE

We describe our initial clinical experience regarding the use of a 3D roadmap during balloon-occluded retrograde transvenous obliteration (BRTO) in three patients.

METHODS

Between June 2016 and July 2016, three BRTO procedures were performed in three patients with gastric varices. Preprocedural intravenous dynamic CT was performed, and portal venous phase CT images were postprocessed to obtain volume rendering (VR) images. A 3D roadmap was developed by overlaying the VR images onto the real-time X-ray fluoroscopy images. This 3D roadmap was used for interventional guidance during the BRTO procedure.

RESULTS

Using a 3D roadmap, the catheterization of the gastrorenal shunt was successfully accomplished. In addition, in all three patients, the sclerosant could reach the gastric varices without the administration of iodinated contrast medium. Fluoroscopy time and the iodinated contrast dose administered in the present cohort were also substantially lower than in our previous cohorts that did not use a 3D roadmap.

CONCLUSION

Using a 3D roadmap during BRTO enables easier and faster catheter manipulation, thereby helping to reduce both radiation exposure and the need to administer iodinated contrast medium.

Current status of portal vein thrombosis in Japan: Results of a questionnaire survey by the Japan Society for Portal Hypertension

AIM

To investigate the current status of portal vein thrombosis (PVT) in Japan, the Clinical Research Committee of the Japan Society of Portal Hypertension undertook a questionnaire survey.

METHODS

A questionnaire survey of 539 cases of PVT over the previous 10 years was carried out at institutions affiliated with the Board of Trustees of the Japan Society of Portal Hypertension.

RESULTS

The most frequent underlying etiology of PVT was liver cirrhosis in 75.3% of patients. Other causes included inflammatory diseases of the hepatobiliary system and the pancreas, malignant tumors, and hematologic diseases. The most frequent site was the main trunk of the portal vein (MPV) in 70.5%, and complete obstruction of the MPV was present in 11.5%. Among the medications for PVT, danaparoid was given to 45.8%, warfarin to 26.2%, heparin to 17.3%, and anti-thrombin III to 16.9%. Observation of the course was practiced in 22.4%. Factors contributing to therapeutic efficacy were implementation of various medications, thrombi localized to either the right or left portal vein only, non-complete obstruction of the MPV and Child-Pugh class A liver function. A survival analysis showed that the prognosis was favorable with PVT disappearance regardless of treatment.

CONCLUSION

The questionnaire survey showed the current status of PVT in Japan. Any appropriate medication should be given to a patient with PVT when PVT is recognized. It is necessary to compile a large amount of information and reach a consensus on safe and highly effective management of PVT.

Magnetic resonance thoracic ductography assessment of serial changes in the thoracic duct after the intake of a fatty meal

The thoracic duct, a terminal lymph vessel, is thought to dilate after the intake of a fatty meal. However, this physiological change has not been well explored in vivo. Therefore, the present study aimed to assess serial changes in the thoracic duct after the intake of a fatty meal using magnetic resonance thoracic ductography (MRTD). Eight healthy volunteers were subjected to one MRTD scan before a fatty meal and eight serial MRTD scans every hour thereafter. The cross-sectional areas of the thoracic duct were estimated using MRTD measurements of the diameters of the thoracic duct at the upper edge of the aortic arch, the tracheal bifurcation, the mid-point between the tracheal bifurcation and the left part of the diaphragm and the left part of the diaphragm. The change-rates in these areas were calculated before and after the fatty meal intake, and the maximal change-rate and timing of its achievement were determined for each subject. The summed change-rates in the four portions of the thoracic duct ranged from -40.1 to 81.3%, with maximal change-rates for each subject ranging from 22.8 to 81.3% (mean, 50.4%). Although individual variations were observed, most subjects (88.9%) exhibited a maximal change-rate at 4-6 h after meal intake, with subsequent decreases at 7-8 h. In conclusion, MRTD revealed a tendency toward thoracic duct enlargement at 4-6 h after the intake of a fatty meal, followed by contraction.

Congenital anomalies of the left brachiocephalic vein detected in adults on computed tomography

PURPOSE

Anomalous left brachiocephalic vein (BCV) is a rare and less known systemic venous anomaly. We evaluated congenital anomalies of the left BCV in adults detected during computed tomography (CT) examinations.

MATERIALS AND METHODS

This retrospective study included 81,425 patients without congenital heart disease who underwent chest CT. We reviewed the recorded reports and CT images for congenital anomalies of the left BCV including aberrant and supernumerary BCVs. The associated congenital aortic anomalies were assessed.

RESULTS

Among 73,407 cases at a university hospital, 22 (16 males, 6 females; mean age, 59 years) with aberrant left BCVs were found using keyword research on recorded reports (0.03%). Among 8018 cases at the branch hospital, 5 (4 males, 1 female; mean age, 67 years) with aberrant left BCVs were found using CT image review (0.062%). There were no significant differences in incidences of aberrant left BCV between the two groups. Two cases had double left BCVs. Eleven cases showed high aortic arches. Two cases had the right aortic arch, one case had an incomplete double aortic arch, and one case was associated with coarctation.

CONCLUSION

Aberrant left BCV on CT examination in adults was extremely rare. Some cases were associated with aortic arch anomalies.

Risk factors for adverse outcomes after endovascular therapy for critical limb ischemia with tissue loss due to infrainguinal artery disease

BACKGROUND

The purpose of this study was to analyze the risk factors for an adverse outcome after endovascular therapy (EVT) for critical limb ischemia (CLI) with tissue loss due to infrainguinal artery disease.

METHODS

We retrospectively reviewed the charts of patients with tissue loss (Rutherford class 5 and 6) due to infrainguinal artery disease who were managed with endovascular therapy (EVT) between January 2006 and December 2013. The primary endpoint was amputation-free survival (AFS), while the secondary endpoints were freedom from a major adverse limb event (MALE) plus perioperative (30 days) death (POD), limb salvage, and survival rates at one year. Multivariable perioperative predictors of AFS were identified using the stepwise Cox proportional hazards regression model.

RESULTS

A total of 65 patients underwent EVT for infrainguinal artery disease on 72 limbs. The technical success rate was 94% (68/72), while the clinical success was attained in 54 of 72 limbs (72%). The AFS, MALE + POD, limb salvage, and survival rates at one year were 76%, 86%, 91%, and 81%, respectively. The multivariate analysis demonstrated that major tissue loss classified as Rutherford class 6 (HR, 5.68; 95% CI, 2.29-14.13; P<0.05) was negatively associated with decreased AFS, while clinical success (HR, 0.25; 95% CI, 0.11-0.60; P<0.05) was positively associated with increased AFS.

CONCLUSIONS

EVT resulted in an acceptable rate of AFS, MALE+POD, limb salvage, and survival. However, we must keep in mind that there are significant limitations to be considered for EVT in patients with major tissue loss, and that, even if revascularization could be successfully performed, a significant number of the treated limbs are still in a critical situation, such as major amputation or death.