Basic Arterial Anatomy and Interpretation of CT Angiography for Intra-Abdominal or Gastrointestinal Bleeding: Correlation with Conventional Angiographic Findings for Beginners

It is essential to identify the causative artery in case of active intra-abdominal or gastrointestinal bleeding. A thorough understanding of the basic arterial anatomy is required to identify the causative artery on contrast-enhanced CT angiography and conventional catheter angiography. If one is familiar with the basic arterial anatomy, obtaining access to the bleeding artery will be easier, despite the variations in the origin and course of the vessels. We describe the basic arterial anatomy that will help beginners in diagnostic radiology to identify the blood vessels that can cause active intra-abdominal or gastrointestinal bleeding.

Incidentally Found Absence of the Left Brachiocephalic Vein with Venous Return Through the Left Superior Intercostal Vein in an Adult Patient: Venography and CT Findings

A 63-year-old male patient was referred for venography of the thoracic venous system and multidetector computed tomography (CT) due to the unusual location of the left subclavian catheter tip. His venogram and CT images showed an absence of the left brachiocephalic vein (LBCV). Instead of through the LBCV, the usual venous circulation of neck and left upper limb was carried out by the engorged left superior intercostal vein (LSIV); this subsequently drained into the accessory hemiazygos vein and then the azygos vein that drains into the superior vena cava. Here, we report a rare case of an incidentally found absence of the LBCV with venous return through the LSIV in an adult patient, and we present a brief review of the relevant literature.

Clinical Findings and Interventional Treatment of Gastrointestinal Fistulae: Pictorial Essay

Gastrointestinal (GI) fistulae are defined as an abnormal communication between the gastrointestinal tract and the skin and/or the epithelial surface of an adjacent viscus. GI fistulae are the most feared complications caused by a variety of medical conditions including abdominal surgery, inflammatory bowel disease, abscess, radiation, or trauma. The management of GI fistulae is complex and requires a detailed, stepwise approach to achieve successful closure. The ultimate goal of management is to re-establish the continuity of the GI tract, while limiting the morbidity and mortality. Interventional radiology can play an important role in the diagnosis and treatment of GI fistulae. In this article, we review the clinical and radiologic features and interventional treatment of GI fistulae.

Principles for evaluating the clinical implementation of novel digital healthcare devices

With growing interest in novel digital healthcare devices, such as artificial intelligence (AI) software for medical diagnosis and prediction, and their potential impacts on healthcare, discussions have taken place regarding the regulatory approval, coverage, and clinical implementation of these devices. Despite their potential, ‘digital exceptionalism’ (i.e., skipping the rigorous clinical validation of such digital tools) is creating significant concerns for patients and healthcare stakeholders. This white paper presents the positions of the Korean Society of Radiology, a leader in medical imaging and digital medicine, on the clinical validation, regulatory approval, coverage decisions, and clinical implementation of novel digital healthcare devices, especially AI software for medical diagnosis and prediction, and explains the scientific principles underlying those positions. Mere regulatory approval by the Food and Drug Administration of Korea, the United States, or other countries should be distinguished from coverage decisions and widespread clinical implementation, as regulatory approval only indicates that a digital tool is allowed for use in patients, not that the device is beneficial or recommended for patient care. Coverage or widespread clinical adoption of AI software tools should require a thorough clinical validation of safety, high accuracy proven by robust external validation, documented benefits for patient outcomes, and cost-effectiveness. The Korean Society of Radiology puts patients first when considering novel digital healthcare tools, and as an impartial professional organization that follows scientific principles and evidence, strives to provide correct information to the public, make reasonable policy suggestions, and build collaborative partnerships with industry and government for the good of our patients.

Principles for evaluating the clinical implementation of novel digital healthcare devices

With growing interest in novel digital healthcare devices, such as artificial intelligence (AI) software for medical diagnosis and prediction, and their potential impacts on healthcare, discussions have taken place regarding the regulatory approval, coverage, and clinical implementation of these devices. Despite their potential, ‘digital exceptionalism’ (i.e., skipping the rigorous clinical validation of such digital tools) is creating significant concerns for patients and healthcare stakeholders. This white paper presents the positions of the Korean Society of Radiology, a leader in medical imaging and digital medicine, on the clinical validation, regulatory approval, coverage decisions, and clinical implementation of novel digital healthcare devices, especially AI software for medical diagnosis and prediction, and explains the scientific principles underlying those positions. Mere regulatory approval by the Food and Drug Administration of Korea, the United States, or other countries should be distinguished from coverage decisions and widespread clinical implementation, as regulatory approval only indicates that a digital tool is allowed for use in patients, not that the device is beneficial or recommended for patient care. Coverage or widespread clinical adoption of AI software tools should require a thorough clinical validation of safety, high accuracy proven by robust external validation, documented benefits for patient outcomes, and cost-effectiveness. The Korean Society of Radiology puts patients first when considering novel digital healthcare tools, and as an impartial professional organization that follows scientific principles and evidence, strives to provide correct information to the public, make reasonable policy suggestions, and build collaborative partnerships with industry and government for the good of our patients.

Unexpected development of acute abdominal aortic thrombosis during percutaneous coronary intervention

No abstract available.

Percutaneous Placement of Self-Expandable Metallic Stents in Patients with Obstructive Jaundice Secondary to Metastatic Gastric Cancer after Gastrectomy

OBJECTIVE: To evaluate the outcomes of patients undergoing percutaneous placements of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy. MATERIALS AND METHODS: Fifty patients (mean age, 62.4 years; range, 27-86 years) who underwent percutaneous placements of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy were included. The technical success rate, clinical success rate, complication rate, stent patency, patient survival and factors associated with stent patency were being evaluated. RESULTS: The median interval between the gastrectomy and stent placement was 23.1 months (range, 3.9-94.6 months). The 50 patients received a total of 65 stents without any major procedure-related complications. Technical success was achieved in all patients. The mean total serum bilirubin level, which had been 7.19 mg/dL +/- 6.8 before stent insertion, decreased to 4.58 mg/dL +/- 5.4 during the first week of follow-up (p < 0.001). Clinical success was achieved in 42 patients (84%). Percutaneous transhepatic biliary drainage catheters were removed from 45 patients (90%). Infectious complications were noted in two patients (4%), and stent malfunction occurred in seven patients (14%). The median stent patency was 233 +/- 99 days, and the median patient survival was 179 +/- 83 days. Total serum bilirubin level after stenting was an independent factor for stent patency (p = 0.009). CONCLUSION: Percutaneous transhepatic placement of a biliary stent for obstructive jaundice secondary to metastatic gastric cancer after gastrectomy is a technically feasible and clinically effective palliative procedure.

Assessing Primary Percutaneous Aspiration Thrombectomy for the Treatment of Deep Vein Thrombosis

PURPOSE: The aim of this study is to evaluate the role of percutaneous aspiration thrombectomy (AT) for the initial endovascular management of deep vein thrombosis (DVT) and to analyze the success rate and complications according to the symptom duration. METHODS: Forty patients who were diagnosed with DVT from June 2004 to January 2009 were retrospectively examined. The patients were divided into 3 groups; group I, those with symptoms lasting 28 days. All of the patients were initially treated with percutaneous AT using the Pullback technique. The incomplete elimination of large and hard thrombus was managed with overnight catheter directed thrombolysis (CDT) and additional AT. Successful recanalization was defined as successful restoration of antegrade flow in the treated veins with elimination of any underlying obstructive lesion. RESULTS: Initial successful recanalization with only AT was achieved in 24 (60%) patients. CDT was required in 16 (40%) patients who had remaining thrombus. Final successful recanalization was achieved in 37 (92.5%) patients. There were no significant differences in the final recanalization rate, the mean number of ATs and the duration of the procedure among groups I, II and III. There was one case (group I) of procedure-related complication, which was the occurrence of a retroperitoneal hematoma after overnight CDT. CONCLUSION: Percutaneous AT may be an initial therapeutic option for DVT, and it minimizes the risk of hemorrhagic complications. It is an effective treatment method for subacute and chronic DVT, as well as acute DVT.

The Incidence of Giacomini Vein and Its Association with Lower Extremity venous Insufficiency: An Ultrasonographic Study

PURPOSE: We wanted to evaluate the incidence of Giacomini vein and its association with lower extremity venous insufficiency by performing US. MATERIALS AND METHODS: From September 2006 to July 2007, 173 patients (58 males and 115 females, mean age: 52.7 years, age range: 22-72 years) who had been diagnosed with unilateral/bilateral varicose veins or telangiectasias were evaluated with duplex Doppler ultrasonography. The presence of Giacomini vein, superficial/deep vein reflux, the anatomical sites of the venous reflux and the abnormal perforating veins was investigated in 346 legs. RESULTS: Giacomini veins were found in 33 limbs (9.5%) of 21 patients (12.1%). Bilateral Giacomini veins were found in 12 patients. Of the 33 limbs that had Giacomini veins, 20 limbs had great saphenous vein (GSV) reflux and 4 limbs had small saphenous vein (SSV) reflux. The patients with Giacomini veins were classified into two groups according to the presence of Giacomini vein. There was no significant difference of the GSV reflux (p = 0.155), the SSV reflux (p = 0.760) and the mean velocity of the GSV reflux or the SSV reflux (p = 0.685, p = 0.431, respectively) between the two groups. CONCLUSIONS: Our results indicated that Giacomini vein is not associated with either GSV or SSV reflux, and this is contrary to conventional belief.

Interventional Management of Gastrointestinal Fistulas

Gastrointestinal (GI) fistulas are frequently very serious complications that are associated with high morbidity and mortality. GI fistulas can cause a wide array of pathophysiological effects by allowing abnormal diversion of the GI contents, including digestive fluid, water, electrolytes, and nutrients, from either one intestine to another or from the intestine to the skin. As an alternative to surgery, recent technical advances in interventional radiology and percutaneous techniques have been shown as advantageous to lower the morbidity and mortality rate, and allow for superior accessibility to the fistulous tracts via the use of fistulography. In addition, new interventional management techniques continue to emerge. We describe the clinical and imaging features of GI fistulas and outline the interventional management of GI fistulas.

Early Results of Endovascular Aneurysm Repair in Abdominal Aortic Aneurysms

PURPOSE: We report early experiences on endovascular abdominal aortic aneurysm repair (EVAR). METHOD: We reviewed the results of 15 patients underwent EVAR between 2003 and 2007 in the Kyung Hee University Medical Center, retrospectively. RESULT: Mean age of patients was 71.2 years (range, 51~85 years). 14 patients (93.3%) had comorbidities. All of AAAs were infrarenal types. The mean size of AAA was 58.5 mm (38~91 mm), and the mean length, diameter, and angle of neck was 26.4 mm, 19.9 mm, and 37.7degrees, respectively. Ten patients were accompanied with iliac aneurysm. 14 were bifurcated grafts and 1 was straight tubular graft. Mean procedure time was 100.6 minutes. Mean length of hospitalization was 6.5 days (2~10 days). There was no need of transfusion or use of an intensive care unit. Fever of unknown origin occurred in 7 cases but resolved spontaneously. Device deployment was successful in 100% (primary 9 cases, assisted-primary 6 cases). There were seven endoleaks during interventions. One patient with secondary type II endoleak and suprarenal enlargement of AAA sac died from aortoenteric fistula. In one patient with perigraft abscess after EVAR, surgical drainage was performed. Decrease of AAA diameter > or =5 mm in two patients, newly developed suprarenal aortic aneurysm in one patient were detected on CT scan during mean follow-up of 11.4 months (2-29 months) and remained unchanged in other twelve cases. CONCLUSION: These early results suggest that EVAR offers considerable benefits for appropriate patients, but is thought to need more experiences and long-term outcomes.

Primary Stent Placement for Chronic Spontaneous Infrarenal Abdominal Aortic Dissection: A Case Report

Spontaneous infrarenal abdominal aortic dissection (SIAAD) is a rare entity with various clinical presentations. We recently encountered the even rarer condition of a female patient suffering from chronic SIAAD with multiple intimal flaps and prominent lumbar artery collaterals; this all caused stenotic changes of the infrarenal abdominal aorta and produced progressive lower extremity pain and claudication in both her legs. This patient's condition was successfully managed by primary stent placement followed by balloon angioplasty.

Efficacy of a Paclitaxel-Eluting Nitinol Stent on the Inhibition of Pseudointimal Hyperplasia in a Transjugular Intrahepatic Portosystemic Shunt: An Experimental Study in a Swine Model

PURPOSE: To evaluate the efficacy of a paclitaxel-eluting nitinol stent on the inhibition of pseudointimal hyperplasia in a transjugular intrahepatic portosystemic shunt. MATERIALS AND METHODS: Twelve pigs were used in this study. Two types of 10-mm diameter and 60-mm long nitinol stents were made for a transjugular intrahepatic portosystemic shunt by coating them with a polyurethane solution, with and without paclitaxel. Each transjugular intrahepatic portosystemic shunt was created successfully in the 12 swine with 7 paclitaxel-eluting stents and 5 polyurethane stents. Five swine in each group were followed-up for 14 days due to the death of 2 swine given the paclitaxel-eluting stents. The proliferation of the pseudointima was evaluated on both follow-up portograms and histopathology examinations. The mean maximum pseudointimal hyperplasia is expressed as the percentage of the stent radius. RESULTS: On the portograms, all the transjugular intrahepatic portosystemic shunts using the paclitaxel-eluting stents maintained patency despite there being a complete occlusion of the polyurethane stents in all the animals. The histopathology analysis revealed the mean maximum pseudointimal hyperplasia to be 25% and 76% in the paclitaxel-eluting and control stents, respectively. CONCLUSION: A transjugular intrahepatic portosystemic shunt with a paclitaxel-eluting nitinol stent appears to significantly inhibit the formation of pseudointimal hyperplasia.

Effects of Intraluminal Irradiation with Holmium-166 for TIPS Stenosis: Experimental Study in a Swine Model

OBJECTIVE: We wanted to evaluate the effectiveness of intraluminal irradiation with Holmium-166 (166Ho) for reducing the pseudointimal hyperplasia (PIH) in the transjugular intrahepatic portosystemic shunt (TIPS) tract in a swine model. MATERIALS AND METHODS: TIPS was performed in 12 domestic pigs, after the creation of portal hypertension by intraportal injection of a mixture of N-butyl-2-cyanoacrylate (NBCA) and lipiodol. Five pigs first underwent intraluminal irradiation (30 Gy) in the parenchymal tract with using a 166Ho solution-filled balloon catheter, and this was followed by the placement of a nitinol stent in the TIPS tract. For the seven control pigs, the balloon was filled with saline and contrast media mixture. Two weeks later, follow-up portography and histological analysis were performed. RESULTS: TIPS was successfully performed in all twelve pigs with achieving artificially induced portal hypertension. Portography performed two weeks after TIPS showed the patent tracts in the TIPS tracts that were irradiated with 166Ho (5/5, 100%), whereas either completely (5/6, 83.3%) or partially (1/6, 16.7%) occluded TIPS were seen in the seven pigs of the nonirradiated control group, except in one pig that experienced periprocedural death due to bleeding. Histological analysis showed a statistically significant difference for the maximal PIH (irradiated: 32.8%, nonirradiated: 76.0%, p < 0.001) between the two groups. CONCLUSION: Intraluminal irradiation with 30 Gy of 166Ho for TIPS significantly improved the TIPS patency in a swine model of portal hypertension during a 2-week period of follow-up.

Efficacy of a Dexamethasone-Eluting Nitinol Stent on the Inhibition of Pseudointimal Hyperplasia in a Transjugular Intrahepatic Portosystemic Shunt: An Experimental Study in a Swine Model

OBJECTIVE: We wanted to evaluate the feasibility and efficacy of using a dexamethasone (DM) -eluting nitinol stent to inhibit the pseudointimal hyperplasia following stent placement in the transjugular intrahepatic portosystemic shunt tract (TIPS) of a swine. MATERIALS AND METHODS: Fifteen stents were constructed using 0.15 mm-thick nitinol wire; they were 60 mm in length and 10 mm in diameter. The metallic stents were then classified into three types; type 1 and 2 was coated with the mixture of 12% and 20%, respectively, of DM solution and polyurethane (PU), while type 3 was a bare stent that was used for control study. In fifteen swine, each type of stent was implanted in the TIPS tract of 5 swine, and each animal was sacrificed 2 weeks after TIPS creation. The proliferation of the pseudointima was evaluated both on follow-up portogram and pathologic examination. RESULTS: One TIPS case, using the type 1 stent, and two TIPS cases, using the type 2 stent, maintained their luminal patency while the others were all occluded. On the histopathologic analysis, the mean of the maximum pseudointimal hyperplasia was expressed as the percentage of the stent radius that was patent, and these values were 51.2%, 50% and 76% for the type 1, 2, and 3 stents, respectively. CONCLUSION: The DM-eluting stent showed a tendency to reduce the development of pseudointimal hyperplasia in the TIPS tract of a swine model with induced-portal hypertension.

An Iliac Arteriovenous Malformation Causes Bladder Outlet Obstruction with Voiding Difficulty / 대한비뇨기과학회지

No abstract available.

Evaluation of Percutaneous Radiologic Placement of Peritoneal Dialysis Catheters: Technical Aspects, Results, and Complications

PURPOSE: To evaluate the technical aspects, results and complications of the percutaneous radiologic placement of peritoneal dialysis catheters. MATERIALS AND METHODS: Between December1999 and April 2001, 26 peritoneal dialysis catheters were placed percutaneously in 26 consecutive patients by interventional radiologists. The patient group consisted of 16 men and ten women with a mean age of 55 (range, 30-77) years. The results and complications arising were reviewed, and the expected patency of the catheters was determined by means of Kaplan-Meier survival analysis. RESULTS: The technical success rate for catheter placement was 100% (26/26 patients). Severe local bleeding occurred in one patient due to by inferior epigastric artery puncture, and was treated by compression and electronic cautery. The duration of catheter implantation ranged from 1 to 510 days and the patency rate was 416+/-45 days. Catheter malfunction occurred in four patients. In two, this was restored by manipulation in the intervention room, and in one, through the use of urokinase. In three patients, peritonitis occurred. Catheters were removed from four patients due to malfunction (n=2), peritonitis (n=1), and death (n=1). CONCLUSION: Percutaneous radiologic placement of a peritoneal dialysis catheter is a relatively simple procedure that reduces the complication rate and improves catheter patency.

A Case Report of Synchronous Double Primary Liver Cancers Combined with Early Gastric Cancer

Combined hepatocellular carcinoma and cholangiocarcinoma is found at a frequency of 1.0~6.3% in resected primary hepatic tumors. However, the case of double cancers of hepatocellular carcinoma and cholangiocarcinoma that are discovered synchronously in different lobes of a liver is very rare. We experienced a case of a 74-year-old man who was found to have hepatocellular carcinoma and cholangiocarcinoma in different lobes of the liver, which were accompanied by early gastric cancer. To our knowledge, this is the first case report of double primary hepatic cancers accompanied with early gastric cancer. The pathogenesis and previous related reports of these lesions are discussed.

Hepatic Metastasis from Choriocarcinoma: Angiographic Findings in Two Cases

We report two cases of hepatic metastases from choriocarcinoma in women of childbearing age in whom imaging studies performed at presentation revealed the presence of liver masses, and who had clinically progressive anemia or intraabdominal hemorrhage. CT demonstrated heterogeneously enhanced liver masses. Characteristic angiographic findings included hypervascular hepatic masses with aneurysmal dilatations of the peripheral hepatic arteries at the arterial phase and persistent vascular lakes at the venous phase.

Interventional Radiology for the Urogenital System

Several procedures in the interventional radiology for the urogenital system are reviewed herein. Interventional radiology has advanced rapidly in recent years as new technologies have become available. Arterial embolization of uterine fibroids is an example. Pelvic varices are frequently encountered in the general population and can be directly associated with a significant morbidity. The affected venous axes can be easily catheterized in a selective, retrograde manner and then can be occluded through this minimally invasive route, avoiding major surgical complications while giving comparable results. Interventional uroradiologic techniques have had a major impact on the care of the urologic patients by allowing non-operative treatment in many diseases. This article also reviews percutaneous nephrostomy with an emphasis on urologic calculi, interventional therapy for neoplasms and trauma to the urinary tract, treatment of renovascular hypertension, and the management of renal cysts.