Ultrasound and Fluoroscopy-Guided Placement of Central Venous Ports via Internal Jugular Vein: Retrospective Analysis of 1254 Port Implantations at a Single Center

OBJECTIVE: To assess the technical success and complication rates of the radiologic placement of central venous ports via the internal jugular vein. MATERIALS AND METHODS: We retrospectively reviewed 1254 central venous ports implanted at our institution between August 2002 and October 2009. All procedures were guided by using ultrasound and fluoroscopy. Catheter maintenance days, technical success rates, peri-procedural, as well as early and late complication rates were evaluated based on the interventional radiologic reports and patient medical records. RESULTS: A total of 433386 catheter maintenance days (mean, 350 days; range 0-1165 days) were recorded. The technical success rate was 99.9% and a total of 61 complications occurred (5%), resulting in a post-procedural complication rate of 0.129 of 1000 catheter days. Among them, peri-procedural complications within 24 hours occurred in five patients (0.4%). There were 56 post-procedural complications including 24 (1.9%, 0.055 of 1000 catheter days) early and 32 (2.6%, 0.074 of 1000 catheter days) late complications including, infection (0.6%, 0.018 of 10000 catheter days), thrombotic malfunction (1.4%, 0.040 of 1000 catheter days), nonthrombotic malfunction (0.9%, 0.025 of 1000 catheter days), venous thrombosis (0.5%, 0.014 of 1000 catheter days), as well as wound problems (1.1%, 0.032 of 1000 catheter days). Thirty six CVPs (3%) were removed due to complications. Bloodstream infections and venous thrombosis were the two main adverse events prolonging hospitalization (mean 13 days and 5 days, respectively). CONCLUSION: Radiologic placement of a central venous port via the internal jugular vein is safe and efficient as evidenced by its high technical success rate and a very low complication rate.

The Diagnostic Accuracy, Image Quality and Radiation Dose of 64-Slice Dual-Source CT in Daily Practice: a Single Institution's Experience

OBJECTIVE: We wanted to evaluate the image quality, diagnostic accuracy and radiation exposure of 64-slice dual-source CT (DSCT) coronary angiography according to the heart rate in symptomatic patients during daily clinical practice. MATERIALS AND METHODS: We performed a retrospective search for the DSCT coronary angiography reports of 729 consecutive symptomatic patients. For the 131 patients who underwent invasive coronary angiography, the image quality, the diagnostic performance (sensitivity, specificity, positive predictive value [PPV] and negative predictive value [NPV] for detecting significant stenosis > or = 50% diameter) and the radiation exposure were evaluated. These values were compared between the groups with differing heart rates (HR): mean HR or = 65 and HR variability (HRV) or = 15. RESULTS: Among the 729 patients, the CT reports showed no stenosis or insignificant coronary artery stenosis in 72%, significant stenosis in 26% and non-diagnostic in 2%. For the 131 patients who underwent invasive coronary angiography, 95% of the patients and 97% of the segments were evaluable, and the overall per-patient/per-segment sensitivity, the perpatient/per-segment specificity, the per-patient/per-segment PPV and the per-patient/per-segment NPV were 100%/90%, 71%/98%, 95%/88% and 100%/97%, respectively. The image quality was better in the HR or = 65 group (p = 0.001), but there was no difference in diagnostic performance between the two groups. The mean effective radiation doses were lower in the HR < 65 or HRV < 15 group (p < 0.0001): 5.5 versus 6.7 mSv for the mean HR groups and 5.3 versus 9.3 mSv for the HRV groups. CONCLUSION: Dual-source CT coronary angiography is a highly accurate modality in the clinical setting. Better image quality and a significant radiation reduction are being rendered in the lower HR group.

Three-Dimensional Evaluation of the Anatomic Variations of the Femoral Vein and Popliteal Vein in Relation to the Accompanying Artery by Using CT Venography

OBJECTIVE: We wanted to describe the three-dimensional (3D) anatomic variations of the femoral vein (FV) and popliteal vein (PV) in relation to the accompanying artery using CT venography. MATERIALS AND METHODS: We performed a retrospective review of 445 bilateral (890 limbs) lower limb CT venograms. After the 3D relationship between the FV and PV and accompanying artery was analyzed, the presence or absence of variation was determined and the observed variations were classified. In each patient, the extent and location of the variations and the location of the adductor hiatus were recorded to investigate the regional frequency of the variations. RESULTS: There were four distinct categories of variations: agenesis (3 limbs, 0.3%), multiplication (isolated in the FV: 190 limbs, 21%; isolated in the PV: 14 limbs, 2%; and in both the FV and PV: 51 limbs, 6%), anatomical course variation (75 limbs, 8%) and high union of the tibial veins (737 limbs, 83%). The course variations included medial malposition (60 limbs, 7%), anterior rotation (11 limbs, 1%) and posterior rotation (4 limbs, 0.4%). Mapping the individual variations revealed regional differences in the pattern and frequency of the variations. CONCLUSION: CT venography helps to confirm a high incidence of variations in the lower limb venous anatomy and it also revealed various positional venous anomalies in relation to the respective artery.

The Image Quality and Radiation Dose of 100-kVp versus 120-kVp ECG-Gated 16-Slice CT Coronary Angiography

OBJECTIVE: This study was conducted to assess the feasibility of performing 100-kVp electrocardiogram (ECG)-gated coronary CT angiography, as compared to 120-kVp ECG-gated coronary CT angiography. MATERIALS AND METHODS: We retrospectively evaluated one hundred eighty five gender- and body mass index-matched 16-slice coronary CT sets of data, which were obtained using either 100 kVp and 620 effective mAs or 120 kVp and 500 effective mAs. The density measurements (image noise, vessel density, signal-to-noise ratio [SNR] and contrast-to-noise ratio [CNR]) and the estimated radiation dose were calculated. As a preference test, two image readers were independently asked to choose one image from each pair of images. The results of both protocols were compared using the paired t-test or the Wilcoxon signed rank test. RESULTS: The 100-kVp images showed significantly more noise and a significantly higher vessel density than did the 120-kVp images. There were no significant differences in the SNR and CNR. The estimated reduction of the radiation dose for the 100-kVp protocol was 24%; 7.8 +/- 0.4 mSV for 100-kVp and 10.1 +/- 1.0 mSV for 120-kVp (p < 0.001). The readers preferred the 100-kVp images for reading (reader 1, p = 0.01; reader 2, p = 0.06), with their preferences being stronger when the subject's body mass index was less than 25. CONCLUSION: Reducing the tube kilovoltage from 120 to 100 kVp allows a significant reduction of the radiation dose without a significant change in the SNR and the CNR.

Transcatheter Arterial Embolization Therapy for a Massive Polycystic Liver in Autosomal Dominant Polycystic Kidney Disease Patients

Polycystic liver is the most common extra-renal manifestation associated with autosomal dominant polycystic kidney disease (ADPKD), comprising up to 80% of all features. Patients with polycystic liver often suffer from abdominal discomfort, dyspepsia, or dyspnea; however, there have been few ways to relieve their symptoms effectively and safely. Therefore, we tried transcatheter arterial embolization (TAE), which has been used in treating hepatocellular carcinoma. We enrolled four patients with ADPKD in Seoul National University Hospital, suffering from enlarged polycystic liver. We embolized the hepatic arteries supplying the dominant hepatic segments replaced by cysts using polyvinyl alcohol particles and micro-coils. The patients were evaluated 12 months after embolization for the change in both liver and cyst volumes. Among four patients, one patient was lost in follow up and 3 patients were included in the analysis. Both liver (33%; 10%) and cyst volume (47.7%; 11.4%) substantially decreased in two patients. Common adverse events were fever, epigastric pain, nausea, and vomiting. We suggest that TAE is effective and safe in treating symptomatic polycystic liver in selected ADPKD patients.

Establishment of a Guideline for the Safe Management of Anatomical Hepatic Artery Variations While Performing Major Hepato-pancreatico-biliary Surgery

PURPOSE: Hepato-pancreatico-biliary (HPB) surgeons often must make decisions regarding hepatic artery (HA) resection while performing major HPB surgery. The purpose of this report was to review and summarize HA resection experience with a focus on vascular preservation during major HPB surgery and to develop a useful algorithm in dealing with these needs. METHODS: We reviewed 1,324 cases that had available computed tomographic and angiographic findings and summarized the problematic HA variations encountered in major HPB surgery. In reviewing our series and previous studies, we have created a set of guidelines that enables a pragmatic approach to the unique variations in HA and the risks of cancer invasion. RESULTS: Challenging HA variations during major HPB surgery were found in 25.7% of the cases and included variations of common HA from superior mesenteric artery (SMA), gastroduodenal artery (GDA), aorta, celiaco-mesenteric (CM) trunk or left gastric artery (LGA) (3.70%), the variations of the right HA from SMA, GDA, aorta, celiac axis (CA) including CM trunk or LGA (12.76%), the variations of the left HA from LGA, CA or GDA (4.46%), and the mixed types of the aberrant left medial HA and/or left lateral HA and/or right anterior HA and/or right posterior HA (2.11%). CONCLUSION: Surgeons should have knowledge of the anatomically variable vasculature of the HA when planning for major HPB surgery. Preoperative imaging studies can aid and should be performed in anticipation of potential HA variations during major HPB surgery.

CT Angiography for Living Kidney Donors: Accuracy, Cause of Misinterpretation and Prevalence of Variation

OBJECTIVE: To determine the accuracy of the use of multi-detector row CT (MDCT) to predict vascular anatomy in living kidney donors and to reveal the prevalence of vascular variations in a Korean population. MATERIALS AND METHODS: A total of 153 living kidney donors that had undergone preoperative CT and nephrectomy, either with open or laparoscopic surgery, were selected retrospectively. The initial CT results were compared with the surgical findings and repeated review sessions of CT scans were performed to determine the causes of mismatches in discordant cases. RESULTS: The accuracy of CT angiography was 95% to predict the number of renal vessels. Four arteries and two veins were missed during the initial CT interpretation due to perception errors (for two arteries and two veins) and technical limitations (two arteries). The prevalence of multiple renal arteries and veins, early branching of a renal artery and late confluence of a renal vein were 31%, 5%, 12%, 17%, respectively. The circumaortic renal vein and the bilateral inferior vena cava were found in two cases each (1.3%). One case (0.7%) each of a retroaortic renal vein and a supradiaphragmatic originated renal artery were found. CONCLUSION: MDCT provides a reliable method to evaluate the vascular anatomy and variations of living kidney donors.

A New and Simple Practical Plane Dividing Hepatic Segment 2 and 3 of the Liver: Evaluation of Its Validity

OBJECTIVE: The conventional method of dividing hepatic segment 2 (S2) and 3 (S3) is subjective and CT interpretation is unclear. The purpose of our study was to test the validity of our hypothesis that the actual plane dividing S2 and S3 is a vertical plane of equal distance from the S2 and S3 portal veins in clinical situations. MATERIALS AND METHODS: We prospectively performed thin-section iodized-oil CT immediately after segmental chemoembolization of S2 or S3 in 27 consecutive patients and measured the angle of intersegmental plane on sagittal multiplanar reformation (MPR) images to verify its vertical nature. Our hypothetical plane dividing S2 and S3 is vertical and equidistant from the S2 and S3 portal veins (vertical method). To clinically validate this, we retrospectively collected 102 patients with small solitary hepatocellular carcinomas (HCC) on S2 or S3 the segmental location of which was confirmed angiographically. Two reviewers predicted the segmental location of each tumor at CT using the vertical method independently in blind trials. The agreement between CT interpretation and angiographic results was analyzed with Kappa values. We also compared the vertical method with the horizontal one. RESULTS: In MPR images, the average angle of the intersegmental plane was slanted 15 degrees anteriorly from the vertical plane. In predicting the segmental location of small HCC with the vertical method, the Kappa value between CT interpretation and angiographic result was 0.838 for reviewer 1 and 0.756 for reviewer 2. Inter-observer agreement was 0.918. The vertical method was superior to the horizontal method for localization of HCC in the left lobe (p < 0.0001 for reviewers 1 and 2). CONCLUSION: The proposed vertical plane equidistant from S2 and S3 portal vein is simple to use and useful for dividing S2 and S3 of the liver.

Role of CT Venography in the Diagnosis and Treatment of Benign Thoracic Central Venous Obstruction

OBJECTIVE: To evaluate the role of CT venography in the diagnosis and treatment of benign thoracic central venous obstruction. MATERIALS AND METHODS: Eighteen patients who had undergone both CT venography and digital subtraction venography were prospectively enrolled in this study. The following features were analyzed by two observers: the cause, degree, and extent of venous obstruction; associated thrombosis; and implications for the planning of treatment. CT venography and digital subtraction venography were compared in defined venous segments, and the degree of obstruction, and correlation was expressed using Spearman's rank correlation coefficient. RESULTS: In all patients, CT venography depicted the causes of obstruction, including extrinsic compression of the left brachiocephalic vein, and mediastinal inflammatory pseudotumor. Interobserver agreement regarding classification of the degree of obstruction was judged as good for CT venography (k=0.864), and in evaluating this, there was significant correlation between CT venography and digital subtraction venography (reader 1: Rs = 0.58, p < 0.01; reader 2: Rs = 0.56, p < 0.01). In evaluating the status of central veins proximal to long segmental obstruction, and associated thrombosis, CT venography was superior to digital subtraction venography. In half of all patients, the findings of CT venography led to changes in the treatment plan. CONCLUSION: The findings of CT venography correlated closely with those of digital subtraction venography, and the former accurately depicted the degree and extent of benign venous obstruction.