Diagnosis and Treatment of Lower Extremity Deep Vein Thrombosis: Korean Practice Guidelines

Lower extremity deep vein thrombosis is a serious medical condition that can result in death or major disability due to pulmonary embolism or post-thrombotic syndrome. Appropriate diagnosis and treatment are required to improve symptoms and salvage the affected limb. Early thrombus clearance rapidly resolves symptoms related to venous obstruction, restores valve function and reduces the incidence of post-thrombotic syndrome. Recently, endovascular treatment has been established as a standard method for early thrombus removal. However, there are a variety of views regarding the indications and procedures among medical institutions and operators. Therefore, we intend to provide evidence-based guidelines for diagnosis and treatment of lower extremity deep vein thrombosis by multidisciplinary consensus. These guidelines are the result of a close collaboration between interventional radiologists and vascular surgeons. The goals of these guidelines are to improve treatment, to serve as a guide to the clinician, and consequently to contribute to public health care.

Korean Guidelines for Interventional Recanalization of Lower Extremity Arteries

Peripheral arterial occlusive disease caused by atherosclerosis can present with intermittent claudication or critical limb ischemia. Proper diagnosis and management is warranted to improve symptoms and salvage limbs. With the introduction of new techniques and dedicated materials, endovascular recanalization is widely performed for the treatment of peripheral arterial occlusive disease because it is less invasive than surgery. However, there are various opinions regarding the appropriate indications and procedure methods for interventional recanalization according to operator and institution in Korea. Therefore, we intend to provide evidence based guidelines for interventional recanalization by multidisciplinary consensus. These guidelines are the result of a close collaboration between physicians from many different areas of expertise including interventional radiology, interventional cardiology, and vascular surgery. The goal of these guidelines is to ensure better treatment, to serve as a guide to the clinician, and consequently, to contribute to public health care.

Endovascular Revascularization for Patients with Critical Limb Ischemia: Impact on Wound Healing and Long Term Clinical Results in 189 Limbs

OBJECTIVE: To evaluate the impact on wound healing and long-term clinical outcomes of endovascular revascularization in patients with critical limb ischemia (CLI). MATERIALS AND METHODS: This is a retrospective study on 189 limbs with CLI treated with endovascular revascularization between 2008 and 2010 and followed for a mean 21 months. Angiographic outcome was graded to technical success (TS), partial failure (PF) and complete technical failure. The impact on wound healing of revascularization was assessed with univariate analysis and multivariate logistic regression models. Analysis of long-term event-free limb survival, and limb salvage rate (LSR) was performed by Kaplan-Meier method. RESULTS: TS was achieved in 89% of treated limbs, whereas PF and CF were achieved in 9% and 2% of the limbs, respectively. Major complications occurred in 6% of treated limbs. The 30-day mortality was 2%. Wound healing was successful in 85% and failed in 15%. Impact of angiographic outcome on wound healing was statistically significant. The event-free limb survival was 79.3% and 69.5% at 1- and 3-years, respectively. The LSR was 94.8% and 92.0% at 1- and 3-years, respectively. CONCLUSION: Endovascular revascularization improve wound healing rate and provide good long-term LSRs in CLI.

Radiofrequency Ablation of Benign Thyroid Nodules and Recurrent Thyroid Cancers: Consensus Statement and Recommendations

Radiofrequency ablation is a new non-surgical treatment modality for patients with benign thyroid nodules and recurrent thyroid cancers. The Task Force Committee of the Korean Society of Thyroid Radiology has developed recommendations for the treatment of benign thyroid nodules and recurrent thyroid cancers using radiofrequency ablation. These recommendations are based on evidence from the current literature and expert consensus.

Radiofrequency Ablation of Benign Thyroid Nodules and Recurrent Thyroid Cancers: Consensus Statement and Recommendations

Thermal ablation using radiofrequency is a new, minimally invasive modality employed as an alternative to surgery in patients with benign thyroid nodules and recurrent thyroid cancers. The Task Force Committee of the Korean Society of Thyroid Radiology has developed recommendations for the optimal use of radiofrequency ablation for thyroid nodules. These recommendations are based on a comprehensive analysis of the current literature, the results of multicenter studies, and expert consensus.

Percutaneous Biliary Drainage Using Open Cell Stents for Malignant Biliary Hilar Obstruction

OBJECTIVE: To evaluate the feasibility, safety and the effectiveness of the complex assembly of open cell nitinol stents for biliary hilar malignancy. MATERIALS AND METHODS: During the 10 month period between January and October 2007, 26 consecutive patients with malignant biliary hilar obstruction underwent percutaneous insertion of open cell design nitinol stents. Four types of stent placement methods were used according to the patients' ductal anatomy of the hilum. We evaluated the technical feasibility of stent placement, complications, patient survival, and the duration of stent patency. RESULTS: Bilobar biliary stent placement was conducted in 26 patients with malignant biliary obstruction-T (n = 9), Y (n = 7), crisscross (n = 6) and multiple intersecting types (n = 4). Primary technical success was obtained in 24 of 26 (93%) patients. The crushing of the 1st stent during insertion of the 2nd stent occurred in two cases. Major complications occurred in 2 of 26 patients (7.7%). One case of active bleeding from hepatic segmental artery and one case of sepsis after procedure occurred. Clinical success was achieved in 21 of 24 (87.5%) patients, who were followed for a mean of 141.5 days (range 25-354 days). The mean primary stent patency period was 191.8 days and the mean patient survival period was 299 days. CONCLUSION: Applying an open cell stent in the biliary system is feasible, and can be effective, especially in multiple intersecting stent insertions in the hepatic hilum.

Insertion and Management of Central Venous Catheters / 한양의대학술지

The indications for placement of central venous catheters are continually expanding. The rapid growth of hemodialysis services, transplantation programs, and oncologic centers has contributed to the need for maintaining patients who require parenteral nutrition, hemodialysis, plasmapheresis, blood transfusion, blood sampling, and long-term chemotherapy for various neoplastic and infections disease. There are three basic categories of venous catheters: non-tunneled catheters, tunneled catheters and implantable ports. Each category of non-tunneled and tunneled catheter divided to infusion and high flow hemodialysis catheter. Peripherally inserted central catheter is a unique long non-tunneled catheter inserted through an arm vein. All physicians should have a deep understanding of each central venous catheters and ability to select the most appropriate one for each patient. Central venous catheterization should be performed by experts with imaging guidance. The high failure rate and high complication rate in the landmark bedside technique was revealed due to anatomical variance of veins. Appropriate management of the catheter is one of the most important parts should be understood by nurses as well as physician in central venous catheterization.

Effects of Physical Diseases Including Nocturia on Sleep Disturbance in the Urban Elderly

BACKGROUND: Nocturia is a common event among the elderly that is often understood to be a potential cause of sleep disorder. However, only a few such studies have been reported in Korea. The purpose of this study was to investigate physical diseases including nocturia as a risk factor for sleep disturbance in the Korean elderly. METHODS: Subjects included 433 patients older than 60 years (average age, 69.7 years) who had completed a structured questionnaire from June to August 2009. The questionnaire asked about the quality of their sleep, nocturia and physical diseases such as hypertension, diabetes mellitus, gastrointestinal problems, arthralgia and chronic obstructive pulmonary disease. Logistic regression analysis was used to evaluate the nocturia and the physical diseases associated with sleep. RESULTS: Incidence of nocturia increased with age and showed a significant variation among the different age groups (p<0.05): 35.7% in their 60s, 41.5% in their 70s and 60.4% in their 80s and older. Nocturia (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.10 to 2.58) and arthralgia (OR, 1.69; 95% CI, 1.10 to 2.60) were two important factors causing sleep disorder. CONCLUSION: In conclusion, nocturia and arthralgia were the main causes of sleep disorder. As the elderly population is continually increasing, further studies are needed to improve our understanding of this subject and to find a potential cure.

Effects of Physical Diseases Including Nocturia on Sleep Disturbance in the Urban Elderly

BACKGROUND: Nocturia is a common event among the elderly that is often understood to be a potential cause of sleep disorder. However, only a few such studies have been reported in Korea. The purpose of this study was to investigate physical diseases including nocturia as a risk factor for sleep disturbance in the Korean elderly. METHODS: Subjects included 433 patients older than 60 years (average age, 69.7 years) who had completed a structured questionnaire from June to August 2009. The questionnaire asked about the quality of their sleep, nocturia and physical diseases such as hypertension, diabetes mellitus, gastrointestinal problems, arthralgia and chronic obstructive pulmonary disease. Logistic regression analysis was used to evaluate the nocturia and the physical diseases associated with sleep. RESULTS: Incidence of nocturia increased with age and showed a significant variation among the different age groups (p<0.05): 35.7% in their 60s, 41.5% in their 70s and 60.4% in their 80s and older. Nocturia (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.10 to 2.58) and arthralgia (OR, 1.69; 95% CI, 1.10 to 2.60) were two important factors causing sleep disorder. CONCLUSION: In conclusion, nocturia and arthralgia were the main causes of sleep disorder. As the elderly population is continually increasing, further studies are needed to improve our understanding of this subject and to find a potential cure.

Living donor liver transplantation for Patients with beyond Milan hepatocellular carcinoma

BACKGROUND: To find the patients who have a significant chance of cure with living donor liver transplantation (LDLT) among the patients suffering with beyond-Milan hepatocellular carcinoma (HCC), we retrospectively analyzed the tumor factors that could affect a good prognosis after LDLT for patients who suffer with beyond Milan HCC. METHODS: Between March 2005 and May 2007, 18 cases of LDLT for beyond Milan HCC were performed. None of the patients had preoperative radiological evidence of vascular invasion. Excluding the 3 cases of in-hospital mortality, we analyzed the survival, the disease-free survival and the prognostic factors for recurrence in 15 beyond Milan HCC patients. The mean follow-up period was 18.8degrees +/- 8.8 months (range: 4-34 months). RESULTS: The two-year survival and disease-free survival rates after LDLT were 61.7% and 31.1%, respectively, in 15 beyond-Milan patients. Among them, 9 patients had recurrence of HCC during follow-up. The one-year survival rate after tumor recurrence was 55.5%. An alphafetoprotein (AFP) level < 400 ng/mL, Edmonson-Steiner histology grade I and II and the presence of graft rejection were analyzed as the good prognostic factors of disease-free survival after LDLT for beyond-Milan HCC (p < .05). The patients with negative preoperative positron emission tomography (PET) findings (n = 5) showed a better prognosis than the PET-positive patients (n = 10) with statistical significance (p = .05). CONCLUSION: Allowing that HCC patients exceed the Milan criteria, we can find the potentially curable candidates for LDLT with using tumor biologic markers such as a serum AFP level < 400 ng/mL, negative PET uptake or low grade histology, as assessed by preoperative needle biopsy. Further investigation is needed to evaluate the relation between graft rejection and tumor recurrence after liver transplantation.

Performance of Interventional Procedures in a Day-hospital System

PURPOSE: We wanted to describe the practice and results of applying the day-hospital system in an interventional radiology clinic. MATERIALS AND METHODS: From Oct. 2004 to Dec. 2005, the day-hospital system was applied to various interventional procedures with using a part of the recovery room of an angiography suite as a facility for hospital admission. The study included 91 cases in 73 patients. The source of the patient referral, the procedures, hospital courses and complications were analyzed and questionnaire surveys were conducted for the available 55 patients. RESULTS: Among the patients, 70% (n=64) were referred from other departments, 5% (n=5) from other hospitals, 5% (n=4) were new patients and 20% (n=18) were re-admissions. The procedures included gastrointestinal, biliary, urinary, hemodialysis related- and implantable port related interventions. 96% (n=87) of the patients were successfully discharged in a day and admission to the general ward was only 4% (n=4). Minor complications occurred after discharges in 3% (n=3). The questionnaire survey revealed that 96% (n=53) of the patients were satisfied with the service and they were not anxious after discharge. CONCLUSION: Most of common interventional procedures were safely done under the day-hospital system with the patients being highly satisfied. The day-hospital system can be a good tool for establishing admitting privileges for an interventional radiology clinic.

Performance of Interventional Procedures in a Day-hospital System

PURPOSE: We wanted to describe the practice and results of applying the day-hospital system in an interventional radiology clinic. MATERIALS AND METHODS: From Oct. 2004 to Dec. 2005, the day-hospital system was applied to various interventional procedures with using a part of the recovery room of an angiography suite as a facility for hospital admission. The study included 91 cases in 73 patients. The source of the patient referral, the procedures, hospital courses and complications were analyzed and questionnaire surveys were conducted for the available 55 patients. RESULTS: Among the patients, 70% (n=64) were referred from other departments, 5% (n=5) from other hospitals, 5% (n=4) were new patients and 20% (n=18) were re-admissions. The procedures included gastrointestinal, biliary, urinary, hemodialysis related- and implantable port related interventions. 96% (n=87) of the patients were successfully discharged in a day and admission to the general ward was only 4% (n=4). Minor complications occurred after discharges in 3% (n=3). The questionnaire survey revealed that 96% (n=53) of the patients were satisfied with the service and they were not anxious after discharge. CONCLUSION: Most of common interventional procedures were safely done under the day-hospital system with the patients being highly satisfied. The day-hospital system can be a good tool for establishing admitting privileges for an interventional radiology clinic.

A Case of a Dieulafoy Lesion Treated usingCoil Embolization in a Child / 대한소아소화기영양학회지

A dieulafoy lesion, which is an unusual cause of gastrointestinal bleeding that can be fatal in children. Dieulafoy lesions are characterized by an abnormally large eroded submucosal artery that is commonly located in the lesser curvature of the proximal stomach. In most cases, permanent hemostasis is achieved by endoscopic epinephrine injection, however, some patients require other endoscopic treatment modalities, embolization or surgery. We report here a case of a Dieulafoy lesion in an 11-year-old boy who had recurrent bleeding from the lesion in the duodenal bulb after endoscopic epinephrine injection and surgical ligation, that was successfully treated using coil embolization.

A Case of a Dieulafoy Lesion Treated usingCoil Embolization in a Child / 대한소아소화기영양학회지

A dieulafoy lesion, which is an unusual cause of gastrointestinal bleeding that can be fatal in children. Dieulafoy lesions are characterized by an abnormally large eroded submucosal artery that is commonly located in the lesser curvature of the proximal stomach. In most cases, permanent hemostasis is achieved by endoscopic epinephrine injection, however, some patients require other endoscopic treatment modalities, embolization or surgery. We report here a case of a Dieulafoy lesion in an 11-year-old boy who had recurrent bleeding from the lesion in the duodenal bulb after endoscopic epinephrine injection and surgical ligation, that was successfully treated using coil embolization.

Metastatic Spinal Epidural Leiomyoma: A Case Report

We report here on a case of a spinal extradural leiomyoma in a 67-year-old woman, and this tumor was in a very unusual location for a leiomyoma. Because the patient underwent hysterectomy for a uterine leiomyoma 20 years ago, we can speculate that the spinal lesion was a metastatic leiomyoma.

Transarterial Embolization of Acute Intercostal Artery Bleeding

PURPOSE: To report our experiences of transarterial embolization for acute intercostal artery bleeding. MATERIALS AND METHODS: A retrospectively analysis of the causes, clinical manifestations, angiographic findings and transarterial embolization technique in 8 patients with acute intercostal artery bleeding, with a review of the anatomical basis. RESULTS:The causes of intercostal artery bleeding were iatrogenic and traumatic in 88 and 12% of cases, respectively. Active bleeding from the collateral intercostal or posterior intercostal arteries was angiographically demonstrated in 75 and 25% of cases, respectively. Transarterial embolization successfully achieved hemostasis in all cases. However, two patient with hypovolemic shock expired due to a massive hemothorax, despite successful transarterial embolization. CONCLUSION: Intercostal access should be performed through the middle of the intercostal space to avoid injury to the collateral intercostal artery. Transarterial embolization is an effective method for the control of intercostal artery bleeding.

Gd(DTPA)2--enhanced, and Quantitative MR Imaging in Articular Cartilage

PURPOSE: Early degeneration of articular cartilage is accompanied by a loss of glycosaminoglycan (GAG) and the consequent change of the integrity. The purpose of this study was to biochemically quantify the loss of GAG, and to evaluate the Gd(DTPA)2--enhanced, and T1, T2, rho relaxation map for detection of the early degeneration of cartilage. MATERIALS AND METHODS: A cartilage-bone block in size of 8mmx10 mm was acquired from the patella in each of three pigs. Quantitative analysis of GAG of cartilage was performed at spectrophotometry by use of dimethylmethylene blue. Each of cartilage blocks was cultured in one of three different media: two different culture media (0.2 mg/ml trypsin solution, 1mM Gd (DTPA)2- mixed trypsin solution) and the control media (phosphate buffered saline (PBS)). The cartilage blocks were cultured for 5 hrs, during which MR images of the blocks were obtained at one hour interval (0 hr, 1 hr, 2 hr, 3 hr, 4 hr, 5 hr). And then, additional culture was done for 24 hrs and 48 hrs. Both T1-weighted image (TR/TE, 450/22 ms), and mixed-echo sequence (TR/TE, 760/21-168ms; 8 echoes) were obtained at all times using field of view 50 mm, slice thickness 2 mm, and matrix 256x512. The MRI data were analyzed with pixel-by-pixel comparisons. The cultured cartilage-bone blocks were microscopically observed using hematoxylin & eosin, toluidine blue, alcian blue, and trichrome stains. RESULTS: At quantitation analysis, GAG concentration in the culture solutions was proportional to the culture durations. The T1-signal of the cartilage-bone block cultured in the Gd(DTPA)2- mixed solution was significantly higher (42% in average, p0.05). However the focal increase in T1 relaxation time at superficial and transitional layers of cartilage was seen in Gd(DTPA)2- mixed culture. Toluidine blue and alcian blue stains revealed multiple defects in whole thickness of the cartilage cultured in trypsin media. CONCLUSION: The quantitative analysis showed gradual loss of GAG proportional to the culture duration. Microimagings of cartilage with Gd(DTPA)2--enhancement, relaxation maps were available by pixel size of 97.9x195 micrometer. Loss of GAG over time better demonstrated with Gd(DTPA)2--enhanced images than with T1, T2, rho relaxation maps. Therefore Gd(DTPA)2--enhanced T1-weighted image is superior for detection of early degeneration of cartilage.

Management patterns of upper gastrointestinal symptoms

BACKGROUND: Upper gastrointestinal symptoms is the one of the most frequent symptom in primary medicine, those manifestations are various and can not find the cause in many cases. In Korea the management patterns for upper gastrointestinal symptoms are using drug store, oriental medicine, folk methods, diet therapy in addition to medical service. We have investigated the behavioral patterns for the control of upper gastrointestinal symptoms. METHODS: The authors surveyed the patients who had visited Dong guk university Kyung ju hospital with upper gastrointestinal symptoms from April 1 to June 30 in 2000. RESULTS: 269 questionnaires were collected and among them 247 completed ones were analysed. 112 subjects were used medical service only(45.3%), 135 subjects were used alternative methods also(54.7%). Among the 135 subjects who used alternative methods, 60 visited to drug store(44.4%), 36 took oriental medicine(26.7%), 18 used folk herbal remedy(26.7%), 5 used diet therapy(3.7%), 16 used folk manual therapy(11.9%), most commonly. Women more commonly used alternative methods(P<0.01). By occupation, housewives more commonly used alternative methods and specialists less commonly used alternative methods. There were no significant difference between two groups in other general characteristics, most severe symptom, cost, satisfaction. CONCLUSION: We find the behavioral patterns for relieving upper gastrointestinal symptoms are using alternative methods(drug store, oriental medicine, folk herbal remedy, folk manual therapy, diet therapy) in addition to using medical service. Women and housewives more commonly used alternative methods, and specialist less commonly used alternative methods.

A hospital based case control study on the risk factors of stomach cancer

BACKGROUND: For gastric cancer, primary prevention by risk factor modification might have some important roles. However, previous studies having investigated the factors associated with stomach cancer reported various results. In addition, there were only a few studies based on Korean population. METHODS: A case control study was carried out on 106 cases matched for age and sex with 106 controls in a tertiary care hospital. In patients who were aged 75 years or less and had been newly diagnosed as adenocarcinoma of stomach between July 1996 and January 1997 were included into the case group. Information on baseline characteristics, health habits, dietary habits of study subjects was obtained through an interview using structured questionnaire. Conditional logistic regression analysis was used to evaluate the factors associated with stomach cancer. RESULTS: Salt preference was associated with significantly increased risk of stomach cancer (odds ratio[OR]=9.81, 95% confidence interval[CI]=2.28 42.2). Eating broiled food more than three times a week significantly increased the risk of stomach cancer (OR=3.33, 95% CI=1.16 9.55) compared to eating it less than once a week. Blood type, family history of stomach cancer, smoking, and alcohol consumption were not associated with stomach cancer. CONCLUSION: Salt preference and frequent eating of broiled food are the risk factors significantly associated with stomach cancer in this study subjects.

Malignant Pulmonary Neoplasms Causing Airspace Consolidation: CT Findings

PURPOSE: To determine the CT findings of consolidative malignant neoplasms of the lung. MATERIALS AND METHODS: Seventeen patients in whom pulmonary consolidation was seen on chest radiography were involved in this study. In all cases malignancy was subsequently proven; the neoplasms involved were bronchioloalveolar carcinoma (n = 9), malignant lymphoma (n = 4), mucoepidermoid tumor (n = 1), metastasis from colon cancer (n = 2), and metastasis from pancreatic mucinous adenocarcinoma (n =1). CT images were retrospectively analyzed in terms of enhancement pattern of the consolidation, morphologic appearance of an air-bronchogram, CT angiogram sign, pseudocavitation, and lymphadenopathy. RESULTS: Visually assessed enhancement pattern of the consolidation showed lower attenuation than adjacent muscles in bronchioloalveolar carcinoma (8/9) and metastasis (1/3); isoattenuation in malignant lymphoma (3/4), mucoepidermoid carcinoma (1/1), and metastasis (1/3); and higher attenuation in bronchioloalveolar carcinoma (1/9), malignant lymphoma (1/4), and metastasis (1/3). Among the 15 of 17 patients for whom an air-bronchogram was available, a stretching and squeezing pattern was seen in bronchioloalveolar carcinoma (4/9), malignant lymphoma (3/4), and metastasis (1/3). CT angiogram sign was identified in bronchioloalveolar carcinoma (5/9), malignant lymphoma (2/4), and metastasis (3/3). Pseudocavitation was observed in two patients with bronchioloalveolar carcinoma, while lymphadenopathy was seen in bronchioloalveolar carcinoma (4/9), malignant lymphoma (3/4), and metastasis (1/3). Conglomerate and extrathoracic lymphadenopathy are commonly associated with malignant lymphoma. CONCLUSION: Malignant neoplasms which apper as consolidative lung lesions appear not only as bronchioloalveolar carcinoma, which is well known, but also in other forms. Although these lesions cannot be differentiated on the basis of air-bronchography and CT angiography, poor enhancement of consolidative lesion and pseudocavitation are characteristic findings of bronchioloalveolar carcinoma, and conglomerate or extrathoracic lymphadenopathy are also characteristic of malignant lymphoma.