Management of portal hypertension derived from uncommon causes

Portal hypertension can arise from any condition interfering with normal blood flow at any level within the portal system. Herein, we presented two uncommon cases of the portal hypertension and its treatment with brief literature review. A 71-year-old man who underwent right hemihepatectomy revealed a tumor recurrence adjacent to the inferior vena cava (IVC). After radiofrequency ablation (RFA) with lymph node dissection, he was referred for abdominal distension. The abdomen computed tomography scan showed severe ascites with a narrowing middle hepatic vein (MHV) and IVC around the RFA site. After insertion of two stents at the IVC and MHV, the ascites disappeared. Another 73-year-old man underwent right trisectionectomy of liver and segmental resection of the portal vein (PV). After operation, he underwent conservative management due to continuous abdominal ascites. The abdomen computed tomography scan showed severe ascites with obliteration of the left PV. After insertion of stent, the ascites disappeared. A decrease of the pressure gradient between the PV and IVC is one of the important treatment strategies for portal hypertension. Vascular stent is useful in the reduction of pressure gradient and thus, can be a treatment option for portal hypertension.

Percutaneous Sclerotherapy of Renal Cysts with a Beta-Emitting Radionuclide, Holmium-166-chitosan Complex

OBJECTIVE: To evaluate the usefulness of a beta-emitting radionuclide (holmium-166-chitosan complex) as a sclerosing agent for the treatment of renal cysts. MATERIALS AND METHODS: Using 10-30 mCi of holmium-166-chitosan complex, 20 renal cysts in 17 patients (14 male and 3 female patients, ranging in age from 47 to 82 years) were treated by percutaneous sclerotherapy under ultrasonographic guidance. The volume of the cysts before and after the sclerotherapy and the percentage change in volume were calculated in order to evaluate the response to therapy, which was classified as either complete regression (invisible), nearly complete regression ( 50 volume%). RESULTS: The follow-up period ranged from 6 to 36 months (mean 28 months). Eighteen cysts (90%) regressed completely (n=11, 55%) or near-completely (n=7, 35%). Partial regression was obtained in one patient (5%) and there was no regression in one patient (5%). No significant complications were encountered. CONCLUSION: The holmium-166-chitosan complex seems to be useful as a new painless sclerosing agent for the treatment of renal cysts with no significant complications.

A Case of Aortobronchial Fistula with Massive Hemoptysis after Aortic Stent Graft / 결핵

Aortobronchial fistula may cause a massive fatal hemoptysis. Recently prosthetic aortic graft insertion or endovascular stent graft is a cause of aortobronchial fistula. We report a rare case of hemoptysis from a fistula between an aortic arch aneurysm and the left main bronchus in a patient who had undergone an endovascular stent graft in pseudoaneurysm of descending thoracic aorta one year before.

Transcaval Transjugular Intrahepatic Portosystemic Shunt: Preliminary Clinical Results

OBJECTIVE: To determine the feasibility of transcaval transjugular intrahepatic portosystemic shunt (TIPS) creation in patients with unusual anatomy between the hepatic veins and portal bifurcation, and inaccessible or inadequate hepatic veins. MATERIALS AND METHODS: Transcaval TIPS, performed in six patients, was indicated by active variceal bleeding (n=2), recurrent variceal bleeding (n=2), intractable ascites (n=1), and as a bridge to liver transplantation (n=1). The main reasons for transcaval rather than classic TIPS were the presence of an unusually acute angle between the hepatic veins and the level of the portal bifurcation (n=3), hepatic venous occlusion (n=2), and inadequate small hepatic veins (n=1). RESULTS: Technical and functional success was achieved in all patients. The entry site into liver parenchyma from the inferior vena cava was within 2 cm of the atriocaval junction. Procedure-related complications included the death of one patient due to hemoperitoneum despite the absence of contrast media spillage at tractography, and another suffered reversible hepatic encephalopathy. CONCLUSION: In patients with unusual anatomy between the hepatic veins and portal bifurcation, and inaccessible or inadequate hepatic veins, transcaval TIPS creation is feasible.

Endoluminal Placement of Stent-Graft for the Treatment of Peripheral Saccular Aneurysm

PURPOSE: To determine the therapeutic effect of stent grafting in the treatment of saccular aneurysms of the peripheral artery. MATERIALS AND METHODS: Eight patients [M:F=7:1 ; age:22-72(mean, 47) years] with ten saccular aneurysms of the peripheral artery who underwent stent grafting were included in this study. The etiologies of the aneurysms were Behcet's disease in four patients, atherosclerosis in two, trauma in one and 'uncertain' in one; they were located at the common iliac artery in three cases, the renal artery in two, the subclavian artery in two, the anterior tibial artery in one, and at both the proximal and distal anastomotic sites of the common carotid-internal carotid bypass graft. In two cases, stent grafting and coils were used to embolize collateral vessels. Post-procedural evaluations involved the use of computed tomography, Doppler sonography and magnetic resonance imaging. The mean follow-up period was 14.7(range, 4-36) monthes. RESULTS: The saccular aneurysms were successfully excluded in all cases. Post-procedural angiography revealed minor leakage in two cases, but at follow-up these showed complete exclusion. Follow-up evaluation also revealed complete resolution in five cases and complete thrombosis accompanied by size reduction in three. In patients with aneurysms of the proximal and distal ends of a common carotid-internal carotid bypass graft, total occlusion occurred in the stent graft. CONCLUSION: Percutaneous stent-graft insertion is an effective and convenient method for the treatment of peripheral arterial aneurysms, and is an alternative to vascular surgery.

Experimental and Clinical Studies on the Intraarterial Injection of Holmium-166 Chitosan Complex in the Treatment of Hepatocellular Carcinoma

PURPOSE: The purposes of this study were to evaluate the biodistribution and effect of Ho-166 radionuclide by intra-arterial injection of the Ho-166 chitosan complex in dogs and to assess the clinical efficacy and side effects of this complex in the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: In an experimental study, 20 mCi of Ho-166 chitosan complex was injected into the left hepatic artery of six adult dogs. The distribution of radioactivity in each organ was calculated using a gamma camera scan at regular intervals. A beta ray radioactivity count (cpm) of blood and urine was performed periodically, and hematologic and hepatic function were regularly assessed. At 4, 8 and 12 weeks after intra-arterial injection, bone marrow and liver were pathologically evaluated. Twenty-five patients with a single, nodular HCC mass 3 -9 cm in diameter were treated by intra-arterial injection of Ho-166 chitosan complex, and immediately after the procedure a gamma camera scan was obtained. A beta ray radioactivity count(cpm) of blood was performed periodically, hematologic and hepatic function were regularly evaluated, and CT scans and angiograms were obtained 3 months after the procedure. On the basis of the CT and angiographic findings, the treatment effects were classified as complete (CR), partial (PR) or non-response(NR). RESULTS: In the animal study, blood radioactivity peaked immediately after injection and then declined rapidly. Urinary excretion was 0.17%. The proportion of radioactivity in each organ per whole body was 25% in the left lobe of the liver, 7% in the right lobe, 3% in the lung, 1.4 -3% in the bladder, and 2% in bone. WBC and platelet counts declined maximally at 3 -4 weeks and recovered at 12 weeks. The cellularity of bone marrow was 25% at 4 weeks and 55% at 12 weeks, findings which correlated well with the observed hematologic changes. In the clinical study of 25 HCC patients, CR was achieved in 17 (68%) cases, PR in 5 (20%) and NR in 3 (12%). At gamma camera imaging immediately after treatment, tumor radioactivity was localized in 76% of cases. In six cases (24%) WBC and platelet counts decreased 50% or more compared with their pretreatment level. In 67 -75% of cases, SGOT and SGPT were, within 1 -3 days, 2 -3 times higher than their pre-treatment level, and recovered at post 4 weeks. CONCLUSION: Ho-166 chitosan complex administrated intra-arterially localized the target organ with minimal side effects, and we therefore suggest that it may be used in the treatment of nodular and hypervascular HCC. Further study of its dosimetry and possible hematologic side reactions is needed, however.

Percutaneous implantation of intra-arterial port system for regional drug infusion: Results and complications in 110 cases

PURPOSE: To investigate the feasibility and complications of a percutaneously implantable port system for regional drug infusion. MATERIALS AND METHODS: For intra-arterial drug infusion, a 5.8 or 5-F pediatric venous port system was implanted in 110 patients with hepatocelluar carcinoma (n = 79), liver metastasis (n = 16), gallbladder cancer (n = 4), stomach cancer (n = 3), pancreatic cancer (n = 3), Burger's disease (n = 2), diabetes mellitus (n = 2), or lymphoma (n = 1). All intra-arterial port implantations were performed percutaneously in an angiographic ward through the common femoral artery (n = 98), left subclavian artery (n = 10), or left superficial femoral artery (n = 2). Complications were evaluated during the follow-up period, which ranged from 21 to 530 (mean, 163) RESULTS: The technical success rate for percutaneous implantation of the system was 97.3% (107 of 110 patients). The tips of the port catheter were located in the common hepatic artery (n = 34), proper hepatic artery (n = 49), right hepatic artery (n = 8), left hepatic artery (n = 1), descending aorta at T9 level (n = 10), left popliteal artery (n = 2), right external iliac artery (n = 1), left external iliac artery (n = 1), or left deep femoral artery (n = 1). Complications were encountered in 24 patients(22.4%), namely chamber site infection (n = 7), catheter dislodgement (n = 7), catheter occlusion (n = 3), migration of coil (n = 2), disconnection between chamber and catheter (n = 1), kinking of catheter (n = 1), arterial occlusion (n = 1), necrosis of overlying skin (n = 1), and leakage around port chamber (n = 1). Outcomes of complications included removal of port systems or cessation of therapy in 12 cases (11.2%), correction of catheter location using a guide wire in five (4.7%), thrombolysis with urokinase in three (2.8%), and straightening using a snare in one (0.9%). In three patients, the port system was used without reintervention. CONCLUSION: Percutaneous implantation of an intra-arterial port system showed a high technical success rate and a low rate of serious complications. The method may be useful for regional drug infusion in various

Renal Artery Embolization Using a New Liquid Embolic Material Obtained by Partial Hydrolysis of Polyvinyl Acetate (Embol):Initial Experience in Six Patients

OBJECTIVE: To evaluate the therapeutic efficacy of a new liquid embolic materi-al,Embol, in embolization of the renal artery. MATERIALS AND METHODS: Embol is a new embolic material obtained by partial hydrolysis of polyvinyl acetate mixed in absolute ethanol and Iopromide 370 and manufactured by Schering Korea, Kyonggido, Korea. Six patients who underwent embolization of the renal artery using Embol were evaluated. Four were male and two were female and their ages ranged from 11 to 70 (mean, 53) years. Clinical and radiologic diagnoses referred for renal artery embolization were renal cell carcinoma (n = 3), renal angiomyolipoma (n = 2) and pseudoaneurysm of the renal artery (n = 1). After selective renal angiography, Embol was injected through various catheters, either with or without a balloon occlusion catheter. Changes in symptoms and blood chemistry which may have been related to renal artery embolization with Embol were analyzed. RESULTS: The six patients showed immediate total occlusion of their renal vas-cular lesions. One of the three in whom renal cell carcinoma was embolized with Embol underwent radical nephrectomy, and the specimen thus obtained revealed 40% tumor necrosis. In the two patients with angiomyolipomas, the tumors decreased in size and abdominal pain subsided. Bleeding from pseudoaneurysm of the renal artery was successfully controlled. Four patients showed symptoms of post-embolization syndrome, and one of these also showed increased levels of blood urea nitrogen and creatinine. One patient experienced transient hyperten-sion. CONCLUSION: Embol is easy to use, its radiopacity is adequate and it is a safe and effective embolic material which provides immediate and total occlusion of renal vascular lesions.

Endovascular Treatment of Abdominal Aortic Aneurysm by Bifurcated Stent Graft

PURPOSE: To evaluate the effectiveness and safety of endoluminal bifurcated stent graft for the treatment of AAA. MATERIALS AND METHODS: Between August 1997 and August 1998, 20 patients with AAA underwent treatment involving the use of a bifurcated stent graft. Fourteen in whom the aneurysm involved only bifurcation and six patients in whom the common iliac arteries were involved. For one patient, a stent with a short proximal neck measuring 12 mm was used. The stent graft was inserted by means of a unilateral surgical femoral arteriotomy. After the procedure, follow up involving CT and aortography was performed between month 3 and month 12. RESULTS: The primary success rate with the first trial was 79 percent (15 of 19 patients), and the overall success rate was 84 percent; one perigraft leak was successfully corrected. In one case, technical failure occurred due to a tortuous iliac vessel and spasm. Procedure-related complications occurred in 16% of patients (3 of 19), one of whom died due to acute renal failure following a contrast overdose. CONCLUSION: Endovascular treatment of infrarenal AAA by means of a bifurcated stent graft was effective and safe. In particular, if the proximal neck measured more than 1cm, any AAA could be treated using bifurcated stent graft. Further investigation of the outcome and complications arising during long-term follow-up are needed, however.

MR Imaging and IVIR Angiography in Patients with Hemifacial Spasm

PURPOSE: To determine the usefulness of MR imaging and MR angiography (MRA) in the evaluation of patients with hemifacial spasm. MATERIAL AND METHODS: One hundred and twenty-five patients with hemifacial spasm were included in this study. Axial T1-, T2-weighted images, proton density image (3mm thickness, 256 x 192) and 3-D TOF MRA were performed. Relation between facial nerve and adjacent arterial structures was carefully evaluated, which was correlated with surgical findings. RESULTS: MRA identified the presen(~e of offending vessels at the root exit zone of facial nerve and its origin in 117 patients(52 PICA, 50 AICA, 6 vertebral artery, 9 dual vessels). There were 4 false negatives and 4 false positives. Vascular groove at the root exit zone was identified in 52 cases, but there was no positive correlation between severity and duration of symptoms. The presence of ipsilateral or contralateral distal loop formation of vertebral artery were noted in 63 patients. In addition, 4 cases of neoplastic and vascular lesions were also demonstrated on MR imaging. CONCLUSION: Combination of MR imaging and MRA is an useful screening modality in the presurgical evaluation of hemifacial spasm, which can demonstrate the offending vessels as well as other pathologic lesions.

Rotator Cuff Injury: Fat Suppression MR Image

PURPOSE: We performed the study prospectively to evaluate the advantage of fat suppression MR in the diagnosis of rotator cuff injury. MATERIALS AND METHODS: Ten symptomatic patients were studied with both conventional T2WI and FST2WI using chemical shift technique. Each image was analyzed for the assessnent of injuries, conspicuity of the lesion, the presence of effusion in subacromial bursae and joint space, and presence of humeral head injury. Arthroscopy was done in 4 patients following MRI. RESULTS: We could made presumptive diagnoses on FSMR as identical as on conventional MR in six cases(1 normal, 2 tendinitis, 2 partial thickness tear, 1 full thickness tear), two of them were confirmed by arthroscopic procedures. Two cases of partial thickness tear proved by arthroscopy were detected on FST2WI, whereas they were considered tendinitis on conventional T2Wl. There were another 2 cases who showed tendinitis on FSMR, but normal on conventional T2Wl. They, however, were not confirmed by either arthroscopy or surgical procedure. CONCLUSION: We found the FSMR were superior to conventional T2Wl in the conspicuity of lesions and detection of joint effusion and abnormalities on the humeral head. We think FSMR of the shoulder could have significant diagnostic advantages over the conventional spin-echo MR imaging.

Breast Parenchymal Change on Mammography Following Postmenopausal Hormone Replacement Therapy

PURPOSE: To determine the frequency and distribution of parenchymal changes on mammography before and after hormone replacement therapy. MATERIALS AND METHODS: Mammograms of 100 postmenopausal women who underwent hormone replacement therapy without breast disease were evaluated. Mammograms obtained annually after hormone replacement were analysed and compared with that of pretreatment. In addition, mammograms of control group and treatment group were compared. RESULTS: An increase in density of breast parenchyma was seen on the mammogram of 20 women(20%) receiving therapy. The mammograms from the control group showed no change. Mammographic changes were detected at first year in 13 women, 2nd year in 4 women, 3rd year in 2 women, and 4th year in 1 woman (average,19 months). CONCLUSION: We conclude that increase in mammographic density following postmenopausal hormone replacement therapy is not uncommon(20%).