Hepatic arterial infusion chemotherapy for hepatocellular carcinoma refractory to transarterial chemoembolization: exploring the influence of prior transarterial chemoembolization and additional transarterial chemoembolization on survival outcomes.

Background: The selection of an efficacious treatment modality for patients with hepatocellular carcinoma (HCC) diagnosed as refractory to transarterial chemoembolization (TACE) presents numerous challenges. In addition to systemic therapies, hepatic arterial infusion chemotherapy (HAIC) may serve as an alternative option. However, it is imperative to identify patients who are appropriate candidates for HAIC to confer a survival benefit. Our study aimed to evaluate the impact of the number of TACE sessions prior to HAIC treatment and the addition of TACE during HAIC on the survival of HCC patient's refractory to TACE. Methods: This retrospective study included 82 patients with HCC refractory to TACE (mean age 60.5 years, 75 males). Survival analysis was conducted using the Kaplan-Meier method, with comparison between two groups via the log-rank test; the Cox regression model was utilized to identify factors influencing survival. Results: The overall response rate (ORR) was observed to be 29.3%, with a disease control rate (DCR) of 56.1%. Patients receiving more than four TACE sessions prior to HAIC exhibited a significantly poorer survival prognosis compared to those receiving fewer than four TACE sessions, with a hazard ratio (HR) of 0.151 (P=0.02). The median overall survival (OS) was markedly different, being 3.4 (range, 0.5-13.6) months for the former group and 14 (range, 8.5-19.5) months for the latter (P=0.01). Furthermore, patients undergoing additional TACE while receiving HAIC treatment demonstrated improved survival outcomes compared to those who did not, with an HR of 0.491 (P=0.02); the respective OS for these groups was 14 (range, 3.6-14.4) and 6.7 (range, 2.8-11) months (P=0.02). Conclusions: HAIC can be a suitable alternative treatment for HCC patient's refractory to TACE. For those with a history of more than 4 TACE sessions, other alternative treatments should be considered. The addition of TACE during HAIC treatment may extend patient OS time, provided it is balanced with maintaining safe liver function.

Arterial-Portal Venous Shunt after Drug-Eluting Bead Transarterial Chemoembolization for Hepatocellular Carcinoma Patients: Risk factors and Impact on Patient Survival.

INTRODUCTION: The effectiveness of transarterial chemoembolization (TACE) in treating hepatocellular carcinoma (HCC) has been well established. The differential impacts of drug-eluting bead TACE (DEB-TACE) as opposed to conventional TACE (cTACE) on vascular changes, such as arterial-portal venous shunts (APS), have been recognized. However, their subsequent effects on treatment outcomes have not been fully explored. This study aims to identify risk factors associated with the occurrence of APS in HCC patients treated with DEB-TACE and to evaluate its impact on patient survival. METHODS: A retrospective analysis was conducted from January 2012 to December 2018 including 74 HCC patients receiving DEB-TACE as initial treatment and a 1:1 conventional cTACE. Kaplan-Meier analysis estimated overall survival (OS) and progression-free survival (PFS). Logistic regression identified significant risk factors for APS occurrence after DEB-TACE. RESULTS: APS incidence was significantly higher after DEB-TACE than cTACE (46.0% vs. 16.2%, p < 0.001). No significant difference in median OS between APS and non-APS groups after DEB-TACE: 50 months (24.6-75.4) vs 26.9 months (19.5-43.2), p = 0.111; median PFS was 15.6 months (4.1-27.1) and 9.5 months (6.8-12.1) for the two groups, respectively, p = 0.065. Risk factors for APS occurrence after DEB-TACE were more than two feeding arteries (OR: 7.25, 95% CI: 1.82-28.95, p = 0.005) and non-selective embolization (OR: 8.02, 95% CI: 2.30-27.95, p = 0.001). CONCLUSION: APS occurrence was higher in DEB-TACE-treated HCC patients, but it did not significantly affect overall survival and progression free survival. More than two feeding arteries and non-selective embolization were significant risk factors for APS occurrence after DEB-TACE.

Policresulen to treat hypergranulation tissue around drainage tubes.

OBJECTIVE: To evaluate the efficacy of policresulen for the treatment of hypergranulation. METHOD: This was a retrospective study of patients with percutaneous catheters. Inpatients from two hospitals and those from outpatient clinics were included. Approximately 2ml of 50% policresulen solution was applied to hypergranulation tissue, which was then immediately pressed with gauze for 1-3 minutes using light pressure. When haemostasis was achieved and the granulation tissue size decreased, the procedure was terminated. RESULTS: A total of eight patients (four females and four males) were included in this study. Effective haemostasis was achieved in all patients. The size of the hypergranulation tissue decreased with policresulen treatment, and resolved completely in one patient. There were no complications. Hypergranulation tissue recurred in one patient. Haemostasis was successfully achieved after repeated procedures. CONCLUSION: The findings of this study showed policresulen to be an inexpensive, easy treatment for hypergranulation at catheter insertion sites.

Usefulness of tumor perfusion on cone-beam CT after hepatic arterial infusion port implantation for evaluating tumor response to hepatic arterial infusion chemotherapy in hepatocellular carcinoma treatment.

PURPOSE: To compare tumor perfusion on cone-beam computed tomography (CBCT) after hepatic artery infusion port implantation with the tumor response to hepatic arterial infusion chemotherapy (HAIC) in patients with hepatocellular carcinoma (HCC). METHODS: This retrospective study was conducted in patients with advanced HCC treated with HAIC from 2015 to 2020. We performed CBCT with contrast injection via a port on the day following implantation. We classified tumor perfusion on CBCT into three groups: hyperperfusion, isoperfusion, and hypoperfusion. We also evaluated tumor response to HAIC on follow-up images using RECIST 1.1 and compared it with tumor perfusion on CBCT. RESULTS: This study included 206 tumors in 193 patients (mean: 60.5 years) with HCC. There were 100 hyperperfusion tumors (48.5%), 92 isoperfusion tumors (44.7%), and 14 hypoperfusion tumors (6.8%). The tumor response to HAIC included 10 tumors with a complete response (CR) (4.9%), 66 tumors with a partial response (32%), 60 tumors with stable disease (29.1%), and 70 tumors with progressive disease (34%). Hyperperfusion tumors had a 65% objective response rate (ORR) and a 92% disease control rate (DCR). Isoperfusion tumors had a 12% ORR and a 46.8% DCR, while hypoperfusion tumors had a 0% ORR and a 7.1% DCR. A CR was shown only in hyperperfusion tumors. The ORR and DCR of the three groups were different, with statistical significance (P < 0.001). CONCLUSION: Hyperperfusion tumors on CBCT showed a better tumor response to HAIC, with a 65% ORR in patients with HCC. Tumor perfusion on CBCT after implantation of the hepatic arterial infusion port was associated with the tumor response to HAIC.

Upper tract heparin instillation for maintenance of ureteral stent patency.

PURPOSE: The study aimed to evaluate the efficacy of heparin packing after antegrade ureteral stent placement in the renal pelvis to protect against early dysfunction. METHOD: From December 2019 to September 2021, 44 double J (DJ) stent placements were performed with heparin packing (heparin packing group). Between February 2008 and March 2014, 250 DJ stent placements without heparin packing were performed (control group). One-week patency and 3-month patency of the two groups were compared. The patency of the DJ stent according to the blood retention grade in the urinary system was also compared by subgroup analysis. RESULT: The 1-week patency rate in the heparin packing group was significantly higher compared to the control group (88.6% and 65.2%, respectively, p = 0.002). There was no significant difference in the 3-month patency rate between the two groups (72.7% and 60.9%, respectively; p = 0.187). In the subgroup analysis, among the patients with high blood retention grades, the 1-week patency rates of the heparin packing group were significantly higher than that of the control group (100% and 60.9%, respectively; p < 0.001). CONCLUSION: Heparin packing through the catheter after DJ stent installation aids in DJ stent patency.

Impact of aortoceliac angle in implantation of subcutaneous hepatic artery port-catheter system for hepatic arterial infusion chemotherapy via femoral approach.

BACKGROUND: In patients with an acute aortoceliac angle, the diagnostic catheter often fails to enter the common hepatic artery. PURPOSE: To retrospectively evaluate the impact of aortoceliac angle on the implantation of a port-catheter system via a femoral approach for hepatic arterial infusion chemotherapy (HAIC) in patients with advanced hepatocellular carcinoma (HCC). MATERIAL AND METHODS: A total of 399 patients with advanced HCC underwent percutaneous implantation of a port-catheter system for HAIC. Among these patients, 383 underwent successful implantation via a femoral artery approach (success group). In 16 patients, port-catheter systems were implanted via a subclavian artery approach (failure group) after failure of the initial attempt via the femoral artery due to failed catheter tip fixation to the gastroduodenal artery. We statistically analyzed aortoceliac angle, ostial celiac stenosis, sex, age, weight, height, and body mass index (BMI) between groups. RESULTS: The average aortoceliac angle, weight, and BMI were significantly different between the two groups (P < 0.001, P = 0.02, P < 0.001, respectively). Among them, only the aortoceliac angle was a significant risk factor in logistic regression analysis. The smaller the aortoceliac angle, the more often the femoral approach failed (P < 0.001, odds ratio = 0.817, 95% confidence interval = 0.752-0.887). There were no significant differences in ostial celiac stenosis, sex, or age between the two groups (P = 0.549, 0.056, 0.173, and 0.773, respectively). CONCLUSION: For patients with an acute aortoceliac angle, the femoral approach is likely to fail. A subclavian artery approach should be preferentially considered for percutaneous implantation of a port-catheter system in such patients.

Selective arterial embolization of renal angiomyolipoma: comparing ethanol-lipiodol emulsion and polyvinyl alcohol particles as embolic agents.

PURPOSE: To examine the effectiveness and safety of two embolic agents, an ethanol-lipiodol emulsion and polyvinyl alcohol (PVA) particles, for selective arterial embolization (SAE) of renal angiomyolipoma (AML). METHODS: Retrospectively, we reviewed the medical records and imaging data of renal AML patients who received SAE in our hospitals between July 2007 and January 2018. Among those eligible for analysis were patients with complete medical information, preoperative and postoperative contrast-enhanced computed tomography scans, and follow-up data. An ethanol-lipiodol emulsion was used to embolize 15 AMLs, and PVA particles were used to embolize 16 AMLs. We compared the tumor responses and adverse events between the two embolization-agent groups. RESULTS: After embolization, no significant differences were observed in the shrinkage rates: 34.2% ± 3.4% for the ethanol-lipiodol emulsion group and 26.3% ± 3.0% for the PVA particles group (P = 0.090). Minor post-embolization complications were also similar between the groups, and there were no severe adverse events. The length of hospital stay after SAE was 2.5 ± 0.5 days for the ethanol-lipiodol emulsion group and 1.9 ± 0.5 days for the PVA particles group and was not significantly different (P = 0.425). CONCLUSION: The results showed that SAE with ethanol-lipiodol emulsion or PVA particles was safe and efficient in decreasing tumor size and controlling renal AML hemorrhage.

Push-pull monorail technique to overcome a difficult course through the left internal jugular vein.

BACKGROUND: We assessed the outcomes of a push-pull monorail technique to overcome a difficult anatomical course through the left internal jugular vein in implantable port insertions. METHODS: From December 2018 to May 2021, a total of 5326 patients were referred for implantable port insertion in our interventional unit, among which 472 cases were requested for insertion on the left side. Our monorail technique was applied only when the catheter tip entered the azygos vein instead of the superior vena cava (n = 8). The technique consists of a puncture at the distal tip of the port catheter with a 21-gauge micropuncture needle, advancing a 0.018-inch hair-wire to the guide, providing support for the pre-assembled port, and advancing the microsheath over the hair-wire to prevent extrusion of the catheter. RESULTS: The push-pull monorail technique was performed in eight patients, and all cases were technically successful, exhibiting a technical success rate of 100%. There were no immediate or delayed complications. CONCLUSIONS: The push-pull monorail technique is helpful in overcoming the difficult anatomical course through the left internal jugular vein during implantable port insertion.

Application of manual aspiration thrombectomy in the treatment of deep vein thrombosis in cancer patients: Descriptive retrospective cohort study.

OBJECTIVES: To determine the outcomes and feasibility of endovascular treatment, mainly based on manual aspiration thrombectomy (MAT) with adjunctive percutaneous balloon angioplasty with or without stent deployment, for treatment of symptomatic ilio-femoral deep vein thrombosis (IFDVT) in cancer patients. MATERIALS AND METHODS: In this retrospective cohort study, 135 consecutive patients (56 men; mean age, 63 years; 149 limbs) with acute (n = 113; 83.7%) and subacute to chronic (n = 22; 16.3%) symptomatic IFDVT underwent MAT-based endovascular treatment. Among them, adjunctive balloon angioplasty and stent placement was performed in 94 patients. Technical and clinical success regarding stage and cause of DVT was assessed. RESULTS: Technical success (complete thrombus removal without residual thrombus or stenosis) was achieved in 89.6%, and subjective symptom improvement was stated by 71.5% of treated patients. The primary patency rates were 88.1%, 81.6%, 76.0%, 74.1% and 69.1% at 1, 3, 6, 12, and 30 months, respectively. Recurrent IFDVT occurred in 19.3% (26/135) of patients, 0.79 cases per patients-years of follow up. According to the analysis by causes of IFDVT, recurrence rate was 19.3% (11/57), 21.2% (12/57), and 14.3% (3/21) in unknown, compression/invasion of the vein by cancerous mass, and May-Thurner syndrome groups, respectively (p = 0.798). No procedure-related complication developed. CONCLUSIONS: Endovascular treatment based on MAT is a feasible treatment option with favorable outcomes and minimal risk of complication in cancer patients with symptomatic IFDVT.

Toxicity assessment of Gryllus bimaculatus (a type of cricket) glycosaminoglycan.

We performed general toxicity studies of Gryllus bimaculatus (two-spotted cricket) glycosaminoglycan (GbG), including a single, 4-week repeated oral dose toxicity test in ICR mice, and short-term genotoxicity tests. The mutagenic potential of the purified GbG was non-genotoxic when it was evaluated using short-term genotoxicity tests, namely Ames, chromosome aberration (CA), and micronuclei (MN) tests. In Salmonella typhimurium and Escherichia coli assays, GbG did not produce any mutagenic response in the absence or presence of S9 mix with five bacterial strains (TA98, TA100, TA1535, TA1537, and WP2uvrA). Chromosome aberration test showed that GbG had no significant effect on Chinese hamster ovary (CHO) cells. In mouse micronuclei tests after twice oral treatments per day for two days, no significant alteration in the occurrence of micronucleated polychromatic erythrocytes was observed in ICR male mice intraperitoneally administered with GbG at doses of 15.63, 31.25, or 62.50 mg/kg. These results indicate that GbG has no mutagenic potential in these in vitro and in vivo systems. After GbG was orally administered at doses of 20, 40, 80, and 160 mg/kg for a single oral dose toxicity study and at 0, 40, 80, and 160 mg/kg bw/day for 4-week oral dose toxicity study, there were no observed clinical signs or deaths related to treatment in any group tested. Therefore, the approximate lethal oral dose of GbG was considered to be higher than 160 mg/kg in mice. Throughout the administration period, no significant changes in diet consumption, ophthalmologic findings, organ weight, clinical pathology (hematology, clinical chemistry, coagulation, and urinalysis), or gross pathology were detected. Microscopic examination did not identify any treatment-related histopathologic changes in organs of GbG-treated mice in the high dose group. These results indicate that the no-observed adverse effect level (NOAEL) of GbG is higher than 160 mg/kg bw/day in mice.

Technical and Clinical Considerations for Successful Management of Postoperative Bowel Perforation by Percutaneous Foley Catheter Placement.

Purpose: The aim of this study was to analyze several technical and clinical factors associated with the successful management of postoperative leakage by percutaneous Foley catheter placement. Materials and Methods: Thirty-two patients were included in this retrospective study. Postoperative gastrointestinal leakage was diagnosed by computed tomography (CT) and the patients underwent percutaneous Foley catheter placement into the leakage site through Jackson-Pratt tubes or imaging-guided methods. Clinical success was defined as successful Foley catheter removal without symptom recurrence within 1 week and the risk factors for clinical failure were analyzed. Results: In all patients, percutaneous Foley catheter placement was successfully achieved without complications. Foley catheter was placed at a median of 10 days (range, 1-68) after the confirmation of leakage on CT. Clinical success was achieved in 26 of the 32 patients (81%). Systemic comorbidity (p < 0.001) and failed oral intake (p = 0.015) were the statistically significant risk factors for clinical failure. Conclusion: Percutaneous Foley catheter placement can be considered an effective approach for the management of postoperative bowel leakage. The presence of systemic comorbidity and successful oral diet after Foley catheter placement are significant factors for successful clinical recovery.

Dual-Port versus Mono-Port Implantation for Intra-Arterial Chemoinfusion Therapy for Treatment of Hepatocellular Carcinoma in Patients with Anatomic Hepatic Artery Variation.

PURPOSE: To compare the feasibility and safety of mono-port catheter system and dual-port catheter system for advanced hepatocellular carcinoma (HCC) in patients with anatomic hepatic artery variation and portal vein tumor thrombosis. MATERIALS AND METHODS: This retrospective study consisted of 22 patients with infiltrative or multiple HCC with unilateral or bilateral portal vein thrombosis who had hepatic artery variation. A mono-port or dual-port catheter system was determined according to the degree of blood supply to the entire tumor through the common hepatic and variant hepatic arteries. Intrahepatic perfusion pattern, hepatic toxicity, and tumor response were investigated on computed tomography, medical records, and follow-up imaging study. RESULTS: The most common hepatic arterial variation was replaced right hepatic artery arising from the superior mesenteric artery (n = 16), followed by replaced left hepatic artery (n = 5) and replaced right posterior segmental artery (n = 1). Twelve patients were treated with mono-port catheter system, and 10 patients were treated with dual-port catheter system. All 10 patients in the dual-port group showed homogeneous distribution of contrast material in the entire liver after port implantation, and 6 patients (50%, n = 6/12) in the mono-port group showed heterogeneous distribution (P = .018). The objective tumor response rates (P = .361) were 18.2% and 40%, and the disease control rates (P = .395) were 36.4% and 60% in the mono-port and dual-port groups, respectively. CONCLUSIONS: The dual-port catheter system is a safe and effective technique that allows the even distribution of hepatic arterial infusion chemotherapy without hemodynamic modification of anatomic variation in the hepatic arteries.

Para-Axial Central Venous Stent Placement in Patients with Malignant Central Venous Obstruction with a Venous Port.

The authors performed a para-axial central venous stent (p-CVS) placement in 38 patients and implanted the stent without having to remove the functioning port. No difficulties were experienced in catheter function with p-CVS. In-stent stenosis was seen in 6 of 24 patients in the p-CVS group and in 6 of 18 patients in the intrastent venous stent placement group (P = .333). No complications occurred in any patient with p-CVS when the venous port was removed. Thus, p-CVS can be an alternative way to insert a CVS in patients who already have a functioning venous port.

Usefulness of fusion images of unenhanced and contrast-enhanced arterial phase cone-beam CT in the detection of viable hepatocellular carcinoma during transarterial chemoembolization.

PURPOSE: We aimed to evaluate the diagnostic efficacy of fusion imaging of unenhanced and arterial phase contrast-enhanced cone-beam computed tomography (CBCT) by comparing with multidetector computed tomography (MDCT) in detection of viable hepatocellular carcinoma (HCC) in patients who have been previously treated with transarterial chemoembolization (TACE). METHODS: In this retrospective study, a total of 173 tumors in 33 known HCC patients (21 men, 12 women; mean age, 64±7.6 years; mean tumor size, 2.15±1.70 cm) who had been previously treated with TACE and underwent additional session of TACE were included. The sensitivity and positive predictive values of preprocedural MDCT and fusion CBCT for detection of viable tumor were analyzed with follow-up MDCT images performed 3-4 weeks after TACE, as reference standard. RESULTS: A total of 141 remote and 32 marginal viable tumors were included. The sensitivities for detection of remote, marginal, and total viable tumors were 80.9%, 68.8%, and 78.6% for MDCT and 96.5%, 96.9%, and 96.5% for fusion CBCT, respectively. The positive predictive values for detection of remote, marginal, and total viable tumors were 95.0%, 78.6%, and 95.8% for MDCT, and 97.1%, 88.6%, and 97.7% for fusion CBCT, respectively. Fusion CBCT showed statistically higher sensitivity and positive predictive value for detection of viable tumors (P < 0.001). CONCLUSION: The diagnostic performance of fusion imaging of unenhanced and contrast-enhanced arterial phase CBCT was superior to MDCT for detection of viable HCCs.

Extraluminal Recanalization of Bile Duct Anastomosis Obstruction after Liver Transplantation.

This report describes extraluminal recanalization of bile duct anastomosis obstruction after living donor liver transplantation. The procedure was performed in 5 patients in whom negotiation of the biliary anastomotic obstruction by retrograde endoscopic approach and percutaneous intraluminal recanalization had failed. Extraluminal puncture from the donor bile duct to the recipient side bile duct was made with the stiff back end of a 0.035-inch hydrophilic guide wire. After recanalization, a percutaneous transhepatic biliary drainage catheter was placed through the created tract. In all 5 patients, extraluminal recanalization was achieved without major complication, and endoscopic plastic stents were subsequently placed along the tract.

Primary and Secondary Percutaneous Ureteral Stent Placement: Comparison of Stent Patency and Clinical Outcome.

OBJECTIVES: To compare early double J ureteral stent (DJUS) dysfunction rate and long-term patency between two percutaneous ureteral stent placement methods: single-stage (primary) or two-stage (secondary) procedures. METHODS: A total of 250 (176 primary and 74 secondary) DJUS placements performed on interventional unit were retrospectively reviewed between February 2008 and March 2014. Early DJUS dysfunction was defined as no passage of contrast media into the urinary bladder in 2-3 days after placement. Long-term patency was considered if the ureteral stent functioned for 3 months (time point for a first routine DJUS change). Amount of blood retained in the collecting system was scored on nephrostogram immediately after DJUS placement with three levels of score. RESULTS: The overall early DJUS dysfunction rate and long-term patency rate were 30.8 and 96.7%. The early DJUS dysfunction rates were similar in primary and secondary DJUS placements (30.7 and 31.1%, P = 0.950). The long-term patency rates were similar in primary and secondary groups (96.2 and 97.9%, P = 0.928). The amount of blood retained in the collecting system between primary and secondary groups was not significantly different. The early DJUS dysfunction rate significantly increased with increasing blood retention. CONCLUSIONS: The early DJUS dysfunction rates and long-term patency are similar in primary and secondary DJUS placement. However, the early DJUS dysfunction rate can be increased by increasing the blood retention in the collecting system.

The Monorail Technique to Overcome Difficult Anatomical Course During Implantation of Central Venous Port via the Left Internal Jugular Vein.

PURPOSE: The study aimed to introduce a monorail technique to overcome difficult anatomical course via left internal jugular vein in implantable port insertion. METHODS: From 2007 to 2016, a total of 9346 patients were referred for implantable port insertion in our interventional unit, among which 79 cases were requested to insert on the left side. Our monorail technique was applied only when the technical challenge of the catheter tip entering the azygos vein instead of the superior vena cava occurred (n = 7). The technique consists of puncturing at the distal tip of the port catheter with a 21-gauge micropuncture needle and advancing a 0.018-in. hair-wire to guide and provide support for pre-assembled port. RESULTS: The monorail technique was performed in seven patients and all but one case were technically successful, showing a technical success rate of 85.7%. There were no immediate or delayed complications. CONCLUSIONS: The monorail technique is helpful to overcome the difficult anatomical course via left internal jugular vein in implantable port insertion.

A side-hole catheter for catheterization of a difficult internal mammary artery.

Background The internal mammary artery (IMA) can be a source of hemoptysis in patients with chronic lung disease. Intervention via the IMA can be a challenge due to anatomic variations and lead to excessive contrast use and radiation exposure. Purpose To evaluate safety and efficiency of a new side-hole catheter for the catheterization of the IMA in patients with hemoptysis. Material and Methods From January 2011 to August 2014, a total of 96 transarterial embolization procedures required exact evaluation of the IMA due to chronic lung disease involving the anterior thorax. In 17 cases (18%) of these 96 procedures, the conventional selective IMA angiography failed and instead a novel side-hole catheter as a modification of a cobra-type curved catheter was used. The side hole allowed passage of a micro-wire and catheter. Results Failed catheterizations were due to severe vascular tortuosity, acutely angulated subclavian artery, or abnormal takeoff of the IMA. The Cobra shaped catheter with the microcatheter through the side-hole catheter yielded a technical success rate of 100%. Longer time was required to catheterize the IMA with the Cobra shaped catheter than with the side-hole catheter (17 vs. 2 min, P < 0.05). There were no procedure-related complications. Conclusion Side-hole catheter technique is useful in patients whose internal mammary artery is difficult to access. Further design revisions are needed to improve the ease and speed of IMA catheterization and angiography.

Factors Related to Radiation Exposure during Lumbar Spine Intervention.

Fluoroscopy guidance is useful to confirm anatomical landmark and needle location for spine intervention; however, it can lead to radiation exposure in patients, physicians, and medical staff. Physicians who used fluoroscopy should be cognizant of radiation exposure and intend to minimize radiation dose. We retrospectively reviewed three lumbar spine intervention procedures (nerve root block, medial branch block, and facet joint block) at our institution between June and December, 2014. We performed 268 procedures on 220 patients and found significant difference in radiation dose between two groups classified by performing physicians. The physician who controlled the fluoroscopy unit directly used significantly shorter fluoroscopy (6 seconds) that resulted in a smaller radiation dose (dose area product [DAP] 0.59 Gy∙cm(2)) than the physician supervising the radiographer controlling the fluoroscopy unit (72 seconds, DAP 5.31 Gy∙cm(2), P < 0.001). The analysis indicates that the difference in fluoroscopy time depends on whether a physician or a radiographer controls the fluoroscopy unit.

Reversal of Hypoglycemia Unawareness with a Single-donor, Marginal Dose Allogeneic Islet Transplantation in Korea: A Case Report.

Pancreatic islet transplantation is a physiologically advantageous and minimally invasive procedure for the treatment of type 1 diabetes mellitus. Here, we describe the first reported case of successful allogeneic islet transplantation alone, using single-donor, marginal-dose islets in a Korean patient. A 59-yr-old patient with type 1 diabetes mellitus, who suffered from recurrent severe hypoglycemia, received 4,163 islet equivalents/kg from a single brain-death donor. Isolated islets were infused intraportally without any complications. The immunosuppressive regimen was based on the Edmonton protocol, but the maintenance dosage was reduced because of mucositis and leukopenia. Although insulin independence was not achieved, the patient showed stabilized blood glucose concentration, reduced insulin dosage and reversal of hypoglycemic unawareness, even with marginal dose of islets and reduced immunosuppressant. Islet transplantation may successfully improve endogenous insulin production and glycemic stability in subjects with type 1 diabetes mellitus.