Use of a Cutting Balloon Dilation as a Rescue Therapy in Patients with Benign Bilioenteric Anastomotic Strictures Refractory to Conventional Balloon Dilation / 대한췌담도학회지

Percutaneous balloon dilation with or without placement of an external biliary drain is a nonoperative alternative method for treating benign bilioenteric anastomotic strictures. Although this procedure has a high technical success rate, outcomes are less optimal when attempting to dilate refractory tight strictures. For the stricture, cutting balloon can be an option. We present four patients with benign bilioenteric anastomotic strictures refractory to conventional balloon dilation. To the patients, a peripheral cutting balloon over-the-wire system was inflated, following subsequent conventional non-compliant balloon dilation. After the balloon dilation treatment, an external drainage catheter was placed through the stricture site and maintained for up to 30 days. Technical and end-treatment success was achieved in all four patients. In conclusion, the use of cutting balloon dilation may appear to be a safe and effective alternative method of treatment in patients with benign bilioenteric anastomotic strictures refractory to conventional balloon dilation.

Long-Term Clinical and Radiologic Outcomes after Stent-Graft Placement for the Treatment of Late-Onset PostPancreaticoduodenectomy Arterial Hemorrhage

Purpose@#To evaluate the long-term radiologic and clinical outcomes of stent-graft placement for the treatment of post-pancreaticoduodenectomy arterial hemorrhage (PPAH) based on the imaging findings of stent-graft patency and results of liver function tests. @*Materials and Methods@#We retrospectively reviewed the medical records of nine consecutive patients who underwent stent-graft placement for PPAH between June 2012 and May 2017. We analyzed the immediate technical and clinical outcomes and liver function test results. Stentgraft patency was evaluated using serial CT angiography images. @*Results@#All stent-grafts were deployed in the intended position for the immediate cessation of arterial hemorrhage and preservation of hepatic arterial blood flow. Technical success was achieved in all nine patients. Eight patients survived after discharge, and one patient died on postoperative day 28. The median follow-up duration was 781 days (range: 28–1766 days). Follow-up CT angiography revealed stent-graft occlusion in all patients. However, serum aspartate aminotransferase or alanine aminotransferase levels in all patients were well below those observed in hepatic infarction cases. @*Conclusion@#Stent-graft placement is a safe and effective treatment method for acute life-threatening PPAH. Liver function and distal hepatic arterial blood flow were maintained postoperatively despite the high incidence of stent-graft occlusion observed on follow-up CT.

Traumatic Hemothorax Caused by Thoracic Wall and Intrathoracic Injuries:Clinical Outcomes of Transcatheter Systemic Artery Embolization

Purpose@#We aimed to assess the clinical efficacy of transcatheter arterial embolization (TAE) for treating hemothorax caused by chest trauma. @*Materials and Methods@#Between 2015 and 2019, 68 patients (56 male; mean age, 58.2 years) were transferred to our interventional unit for selective TAE to treat thoracic bleeding. We retrospectively investigated their demographics, angiographic findings, embolization techniques, technical and clinical success rates, and complications. @*Results@#Bleeding occurred mostly from the intercostal arteries (50%) and the internal mammary arteries (29.5%). Except one patient, TAE achieved technical success, defined as the immediate cessation of bleeding, in all the other patients. Four patients successfully underwent repeated TAE for delayed bleeding or increasing hematoma after the initial TAE. The clinical success rate, defined as no need for thoracotomy for hemostasis after TAE, was 92.6%. Five patients underwent post-embolization thoracotomy for hemostasis. No patient developed major TAE-related complications, such as cerebral infarction or quadriplegia. @*Conclusion@#TAE is a safe, effective and minimally invasive method for controlling thoracic wall and intrathoracic systemic arterial hemorrhage after thoracic trauma. TAE may be considered for patients with hemothorax without other concomitant injuries which require emergency sur-gery, or those who undergoing emergency TAE for abdominal or pelvic hemostasis.

Long-Term Clinical and Radiologic Outcomes after Stent-Graft Placement for the Treatment of Late-Onset PostPancreaticoduodenectomy Arterial Hemorrhage

Purpose@#To evaluate the long-term radiologic and clinical outcomes of stent-graft placement for the treatment of post-pancreaticoduodenectomy arterial hemorrhage (PPAH) based on the imaging findings of stent-graft patency and results of liver function tests. @*Materials and Methods@#We retrospectively reviewed the medical records of nine consecutive patients who underwent stent-graft placement for PPAH between June 2012 and May 2017. We analyzed the immediate technical and clinical outcomes and liver function test results. Stentgraft patency was evaluated using serial CT angiography images. @*Results@#All stent-grafts were deployed in the intended position for the immediate cessation of arterial hemorrhage and preservation of hepatic arterial blood flow. Technical success was achieved in all nine patients. Eight patients survived after discharge, and one patient died on postoperative day 28. The median follow-up duration was 781 days (range: 28–1766 days). Follow-up CT angiography revealed stent-graft occlusion in all patients. However, serum aspartate aminotransferase or alanine aminotransferase levels in all patients were well below those observed in hepatic infarction cases. @*Conclusion@#Stent-graft placement is a safe and effective treatment method for acute life-threatening PPAH. Liver function and distal hepatic arterial blood flow were maintained postoperatively despite the high incidence of stent-graft occlusion observed on follow-up CT.

Traumatic Hemothorax Caused by Thoracic Wall and Intrathoracic Injuries:Clinical Outcomes of Transcatheter Systemic Artery Embolization

Purpose@#We aimed to assess the clinical efficacy of transcatheter arterial embolization (TAE) for treating hemothorax caused by chest trauma. @*Materials and Methods@#Between 2015 and 2019, 68 patients (56 male; mean age, 58.2 years) were transferred to our interventional unit for selective TAE to treat thoracic bleeding. We retrospectively investigated their demographics, angiographic findings, embolization techniques, technical and clinical success rates, and complications. @*Results@#Bleeding occurred mostly from the intercostal arteries (50%) and the internal mammary arteries (29.5%). Except one patient, TAE achieved technical success, defined as the immediate cessation of bleeding, in all the other patients. Four patients successfully underwent repeated TAE for delayed bleeding or increasing hematoma after the initial TAE. The clinical success rate, defined as no need for thoracotomy for hemostasis after TAE, was 92.6%. Five patients underwent post-embolization thoracotomy for hemostasis. No patient developed major TAE-related complications, such as cerebral infarction or quadriplegia. @*Conclusion@#TAE is a safe, effective and minimally invasive method for controlling thoracic wall and intrathoracic systemic arterial hemorrhage after thoracic trauma. TAE may be considered for patients with hemothorax without other concomitant injuries which require emergency sur-gery, or those who undergoing emergency TAE for abdominal or pelvic hemostasis.

Direct Percutaneous Needle Puncture and Intrapulmonary Lymphatic Embolization for Treatment of Chylothorax in a Patient with Lymphoma

Lymphoma is a common cause of nontraumatic chylothorax. Clinical success rates of thoracic duct embolization are lower in patients with nontraumatic chylothorax compared to patients with traumatic chylothorax. Herein, we report a case of nontraumatic chylothorax and lymphoma in a 77-year-old man managed with thoracic duct embolization. The chest tube drainage decreased but not was sufficient to enable removal of the chest tube. Therefore, a second embolization was performed through a direct puncture of the lymphatic mass in the lung, following which the chyle leakage ceased, and the chest tube was removed. The treatment strategy discussed in this report may be an effective therapeutic option for select patients with nontraumatic chylothorax.

Intervention for Urologic Trauma

Urinary tract injuries occur in up to 10% of patients with abdominal trauma, and the kidney is the most commonly injured structure of the urinary system. The kidney is the third most common abdominal organ to be injured by trauma, following the spleen and liver, in that order. The American Association for the Surgery of Trauma kidney injury scale is the most commonly used classification system for blunt renal injuries, which grades renal injury based on the size of laceration and its proximity to the renal hilum on CT. CT aids in delineating the most important features of urological injury that affect the diagnosis and management, including interventions. The major renal injuries are usually surgical emergencies. The current trend toward a more conservative management of renal trauma and advances in interventional radiology in the field of trauma may increase the use of interventional procedures for patients with renal injury. Urethral injuries can be anterior or posterior depending on the injury site, and interventional urethral realignment plays an important role in the treatment of urethral injury and surgical repair or endoscopic urethral realignment. Therefore, in this paper, we provide a literature review and discuss the efficacy and clinical significance of intervention for urologic trauma.

Successful Simultaneous Endovascular Repair of Traumatic Portal Vein Pseudoaneurysm and Aortic Injury

No abstract available.

Prediction of Late Postoperative Hemorrhage after Whipple Procedure Using Computed Tomography Performed During Early Postoperative Period

OBJECTIVE: Postpancreatectomy hemorrhage (PPH) is an uncommon but serious complication of Whipple surgery. To evaluate the radiologic features associated with late PPH at the first postoperative follow up CT, before bleeding. MATERIALS AND METHODS: To evaluate the radiological features associated with late PPH at the first follow-up CT, two radiologists retrospectively reviewed the initial postoperative follow-up CT images of 151 patients, who had undergone Whipple surgery. Twenty patients showed PPH due to vascular problem or anastomotic ulcer. The research compared CT and clinical findings of 20 patients with late PPH and 131 patients without late PPH, including presence of suggestive feature of pancreatic fistula (presence of air at fluid along pancreaticojejunostomy [PJ]), abscess (fluid collection with an enhancing rim or gas), fluid along hepaticojejunostomy or PJ, the density of ascites, and the size of visible gastroduodenal artery (GDA) stump. RESULTS: CT findings including pancreatic fistula, abscess, and large GDA stump were associated with PPH on univariate analysis (p ≤ 0.009). On multivariate analysis, radiological features suggestive of a pancreatic fistula, abscess, and a GDA stump > 4.45 mm were associated with PPH (p ≤ 0.031). CONCLUSION: Early postoperative CT findings including GDA stump size larger than 4.45 mm, fluid collection with an enhancing rim or gas, and air at fluid along PJ, could predict late PPH.

A Comparative Study of Abdominal Aortic Aneurysm: Endovascular Aneurysm Repair versus Open Repair

BACKGROUND: Endovascular aneurysm repair (EVAR) has dramatically changed the management of abdominal aortic aneurysms (AAAs) as the number of open aneurysm repairs have declined over time. This report compares AAA-related demographics, operative data, complications, and mortality after treatment by open aneurysm repair or EVAR. METHODS: We retrospectively reviewed 136 patients with AAAs who were treated over an 8-year time period with open aneurysm repair or EVAR. RESULTS: The mean age of the EVAR group was higher than that of the open repair group (p=0.001), and hospital mortality did not differ significantly between groups (p=0.360). However, overall survival was significantly lower in the EVAR group (p=0.033). CONCLUSION: Although EVAR is the primary treatment modality for elderly patients, it would be ideal to set slightly more stringent criteria within the anatomical guidelines contained in the instructions for use of the EVAR device when treating younger patients.

Gastric Hemangioma Treated with Argon Plasma Coagulation in a Newborn Infant / 대한소아소화기영양학회지

Gastric hemangioma in the neonatal period is a very rare cause of upper gastrointestinal bleeding. We present a case of hemangioma limited to the gastric cavity in a 10-day-old infant. A huge, erythematous mass with bleeding was observed on the lesser curvature side of the upper part of the stomach. Surgical resection was ruled out because the location of the lesion was too close to the gastroesophageal junction. Medical treatment with intravenous H₂ blockers, octreotide, packed red blood cell infusions, local epinephrine injection at the lesion site, application of hemoclip, and gel-form embolization of the left gastric artery did not significantly alter the transfusion requirement. Hemostasis was achieved with endoscopic argon plasma coagulation (APC). After two sessions of APC, complete removal of the lesion was achieved. APC was a simple, safe and effective tool for hemostasis and the ablation of gastric hemangioma without significant complications.

Endovascular stenting of tracheoinnominate fistula after tracheostomy in a 14-year-old boy / 소아과

Tracheoinnominate artery fistula is a rare, fatal complication of tracheostomy, and prompt diagnosis and management are imperative. We report the case of tracheoinnominate artery fistula after tracheostomy in a 14-year-old boy with a history of severe periventricular leukomalacia, hydrocephalus, cerebral palsy, and epilepsy. The tracheoinnominate artery fistula was successfully treated with a stent graft insertion via the right common femoral artery. Endovascular repair of the tracheoinnominate artery fistula via stent grafting is a safe, effective, and minimally invasive treatment for patients in poor clinical conditions and is an alternative to traditional open surgical treatment.

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.

The Factors Affecting Recurrence of Symptoms after Infrainguinal Arterial Endovascular Angioplasty

BACKGROUND: This study reports the result of endovascular treatment for arterial occlusive disease limited to femoropopliteal lesions, focusing on the recurrence of symptoms instead of patency. METHODS: This was a retrospective, single-center study. From April 2007 to November 2011, 48 limbs in 38 patients underwent endovascular stenting or balloon angioplasty to treat femoropopliteal arterial occlusive disease. The factors affecting the recurrence of symptoms were analyzed. RESULTS: The mean age of the patients was 69.60+/-7.62 years. Among the baseline characteristics of the patients, initial hyperlipidemia was the most important factor affecting the recurrence of symptoms (relative risk=5.810, p=0.031). The presence of a dorsal arch was also a significant factor (relative risk=0.675, p=0.047). CONCLUSION: The major factors that affect the recurrence of symptoms after endovascular treatment for femoropopliteal arterial occlusive lesions are hyperlipidemia and the presence of a dorsal arch. Therefore, the usage of lipid-lowering agents after endovascular treatment and taking the presence of a dorsal arch into consideration are important elements of managing the recurrence of symptoms.

A Comparison of the Short-Term Effects of a Botulinum Toxin Type A and Triamcinolone Acetate Injection on Adhesive Capsulitis of the Shoulder

OBJECTIVE: To evaluate the short-term clinical effects of the intra-articular injection of botulinum toxin type A (BoNT-A) for the treatment of adhesive capsulitis. METHODS: A prospective, controlled trial compared the effects of intra-articular BoNT-A (Dysport; 200 IU, n=15) with the steroid triamcinolone acetate (TA; 20 mg, n=13) in patients suffering from adhesive capsulitis of the shoulder. All patients were evaluated using a Numeric Rating Scale (NRS) of the pain intensity and a measurement of the range of motion (ROM) at baseline (before treatment) and at 2, 4, and 8 weeks post-treatment. RESULTS: The NRS at 2 weeks (BoNT-A vs. TA; 5.0 vs. 5.2), 4 weeks (4.1 vs. 4.9) and 8 weeks (3.8 vs. 4.6) of both treatment groups were significantly lower than that measured at baseline (7.4 vs. 7.6). The ROM of patients' shoulders increased significantly from baseline in both treatment groups. There was no significant difference in the NRS of pain intensity or the ROM between the two groups. Reduction in the pain intensity score was maintained for 8 weeks post-injection in both groups. There were no significant adverse events in either treatment group. CONCLUSION: The results suggest that there are no significant short-term differences between the intra-articular injections of BoNT-A and TA. Although BoNT-A has a high cost, it may be used as a safe alternative of TA to avoid the steroid-induced side effects or as a second-line agent, for patients who have failed to respond to the current treatments.

Factors Affecting the Postoperative Mortality in the Ruptured Abdominal Aortic Aneurysm

BACKGROUND: Although patients with a ruptured abdominal aortic aneurysm (RAAA) often reach the hospital alive, the perioperative mortality is still very high. We retrospectively reviewed thirty patients who underwent repair of RAAA to identify the factors affecting postoperative mortality in a single hospital. MATERIALS AND METHODS: Between September 2007 and May 2011, thirty patients with RAAA underwent emergent surgery (n=27) or endovascular aneurysm repair (n=3). Their medical records were retrospectively reviewed regarding three categories: 1) preoperative patient status: age, gender, vital signs, serum creatinine, blood urea nitrogen, hematocrit, and hemoglobin level: 2) aneurysmal status: size, type, and rupture status; and 3) operative factors: interval time to operating room, operative duration, and amount of perioperative transfusion. RESULTS: The 30-day postoperative mortality rate was 13.3% (4/30); later mortality was 3.3% (1/30). On multivariate analysis, the initial diastolic blood pressure (BP), interval time to operating room and amount of preoperative packed cell transfusion were statistically significantly linked with postoperative mortality (p<0.05). CONCLUSION: In this study, preoperative diastolic BP, preoperative packed cell transfusion amount and interval time between arrival and entry to operating room were significantly associated with postoperative mortality. It is important to prevent hemorrhage as quickly as possible.

Ruptured Abdominal Aortic Aneurysm after Endovascular Aortic Aneurysm Repair

In treating uncomplicated abdominal aortic aenurysm, endovascular aortic aneurysm repair (EVAR) has been employed as a good alternative to open repair with low perioperative morbidity and mortality. However, the aneurysm can enlarge or rupture even after EVAR as a result of device failure, endoleak, or graft migration. We experienced two cases of aneurismal rupture after EVAR, which were successfully treated by surgical extra-anatomic bypass.

Clinical Efficacy of Endovascular Abdominal Aortic Aneurysm Repair

BACKGROUND: Endovascular aortic aneurysm repair (EVAR) has come into use and been widely extended because of the low complication rate and less-invasiveness. This article aimed to describe our experience in the treatment of abdominal aortic aneurysm with EVAR. MATERIALS AND METHODS: A retrospective review was conducted for the 22 patients who underwent EVAR in a single hospital December 2001 to June 2009. RESULTS: The mean age of the patients was 68.5+/-7.6 years. There were several risk factors and comorbidities in 20 patients (90.9%). The mean diameter of the aortic aneurysms was 61.2+/-12.9 mm. The mean length, diameter, and angle of the aneurysmal neck were 30.5+/-15.5 mm, 24.0+/-4.5 mm, and 43.9+/-16.0degrees, respectively. The mean follow-up period of the patients was 28.8+/-29.5 months. The 30-day postoperative mortality was none. Seven patients (31.8%) had endoleaks during the hospital stay and three patients (13.6%) had endoleaks during the follow-up period. One patient (4.5%) died due to a ruptured aortic aneurysm. The cumulative patient survival rates were 88.2%, 88.2%, and 70.6% at 1, 3, and 5 years of follow-up, respectively. CONCLUSION: EVAR is currently a safe, feasible procedure for high risk patients with abdominal aortic aneurysm because of low postoperative complication and mortality if patients are selected properly and followed up carefully.

The Efficacy of Endovascular Treatment for Deep Vein Thrombosis / 대한흉부외과학회지

BACKGROUND: Deep vein thrombosis (DVT) is a serious disease that causes life-threatening pulmonary embolism and chronic venous insufficiency. Anticoagulation is the standard therapy for DVT. However, the results of standard anticoagulation for treating DVT have been disappointing, so endovascular treatment is commonly performed nowadays. The aim of this study was to evaluate the efficacy of an endovascular procedure for treating patients with DVT. MATERIAL AND METHOD: We retrospectively evaluated the clinical data of 29 DVT patients who underwent an endovascular procedure between December 2006 and July 2008. We compared the results of the 29 patients with the results of another 45 patients who were treated with only aspirin and heparin. RESULT: The patient's mean age was 55.4 years in the intervention group and 53.7 years in the control group. DVT occurred more frequently in the females. Catheter-directed thrombolysis was performed in 22 patients (75.8%). Aspiration thrombectomy was performed in 18 patients (62%) and a endovascular stent was placed in 25 patients (86.2%). Fifteen patients (51.7%) underwent percutaneous insertion of a retrievable IVC filter for the prevention of pulmonary embolism. In the control group, thirty nine patients (86.7%) were treated with low-molecular heparin, and seven patients (15.6%) who were contraindicated for warfarin were treated with aspirin. No bleeding complications occurred during thrombolysis or anticoagulation. We analyzed the statistical data according to recurrence of DVT and the incidence of post-thrombotic syndrome (PTS) during the follow-up period. The intervention group had a significantly lower incidence of PTS (p-value=0.008), but they had the same result as the control group for the recurrence of DVT. In addition, death from the DVT did not occur in the intervention group. Thus, we obtained better clinical outcomes in the intervention group as compared to those in the anticoagulation only group. CONCLUSION: Endovascular procedures are effective alternative modalities, as compared to systemic anticoagulation, for the treatment of DVT. But more studies are needed to determine the specific indications and to validate the long-term efficacy of endovascular procedures for the treatment of DVT.