Analysis of the origin of the right inferior phrenic artery in 178 patients with hepatocellular carcinoma treated by chemoembolization via the right inferior phrenic artery.

BACKGROUND: No previous report has described the level of the origin of the right inferior phrenic artery (RIPA) based on an analysis of the relationships between the level of the RIPA, the celiac artery (CA), the superior mesenteric artery (SMA), and the right renal artery (RRA) in a series of cases. PURPOSE: To evaluate the origin of the RIPA by retrospectively analyzing angiographic findings in 178 patients with hepatocellular carcinoma (HCC) who underwent transcatheter arterial chemoembolization (TACE) via the RIPA. MATERIAL AND METHODS: In patients treated with intraarterial chemoembolization for HCC, additional superselective chemoembolization of the RIPA branches was necessary in 178 cases. We analyzed the level of the origin of the RIPA in these patients according to the relationships between the level of the origin of the RIPA, the CA, the SMA, and the RRA on angiography. RESULTS: Among the 178 cases, the RIPA arose from 1) the aorta directly in 102 cases (57%), 2) the CA in 53 (30%), 3) the left gastric artery (LGA) in three (2%), 4) the dorsal pancreatic artery (DPA) in one (1%), and 5) the RRA in 19 (11%). The level of the origin of the RIPA that originated directly from the aorta was supraceliac in 56 cases (32%), between the CA and the SMA in 31 (17%), and between the SMA and the RRA in 15 (8%). CONCLUSION: In our study, the RIPA originated from the aorta between the CA and the SMA directly in 17% of cases. When it is difficult to identify the origin of the RIPA, we must keep in mind that the RIPA may originate from the right part of the aorta within the small distance between the SMA and the CA.

[Colonic varices; a case report].

Colonic varices is a rare entity that is caused by portal hypertension in most instances. In the case reported here, barium enema and colonoscopy showed multiple tortuous polypoid lesions with intact mucosal surface. Inferior mesenteric angiography showed arteriovenous malformation in the sigmoid colon, complete obstruction of the inferior mesenteric vein, and tortuous dilated marginal veins. We assume that the colonic varices of this case was secondary to complete obstruction of the inferior mesenteric vein following AVM of the sigmoid colon. Close follow-up should is warranted in cases of colonic varices because of the risk of bleeding.

Combination of transileocolic vein obliteration and balloon-occluded retrograde transvenous obliteration is effective for ruptured duodenal varices.

Duodenal varices are a rare site of hemorrhage in patients with portal hypertension, but their rupture is a serious and often fatal event. We report a 65-year-old woman who presented with hematemesis and melena. She was admitted to our department because of prolonged shock, despite having received transfusion of a large volume of blood. Upper gastrointestinal endoscopy revealed nodular varices with active bleeding in the second portion of the duodenum. Endoscopic injection sclerotherapy (EIS) was performed using a tissue adhesive agent, alpha-cyanoacrylate monomer, with only temporary benefit. However, anemia continued to progress after the procedure. Therefore, we combined transileocolic vein obliteration (TIO) with balloon-occluded retrograde transvenous obliteration (B-RIO), using 5% ethanolamine oleate with iopamidol to obliterate the varices. Complete hemostasis was achieved without complications. Neither recurrence of varices nor further bleeding has occurred for over 3 years. We conclude that combined TIO and B-RTO, which can obstruct both the feeding and the draining vessels of duodenal varices to retain the sclerosing agent completely in the varices, is a safe and effective hemostatic measure for ruptured duodenal varices, when EIS has failed to accomplish complete hemostasis.

Saline-jet aspiration thrombectomy catheter. Clinical results in patients with venous thrombosis.

PURPOSE: To evaluate hydraulic thrombectomy using a saline-jet aspiration thrombectomy catheter in the treatment of venous thrombosis. MATERIAL AND METHODS: Ten patients underwent 12 hydraulic thrombectomy procedures using 2.7 or 4.0 mm catheters. The site of the thrombus was either central, peripheral or in portal veins. The age of the thrombi was between 2 and 60 days (mean 19.7 days). The efficacy of hydraulic thrombectomy was evaluated based on the aspirated thrombus ratio (ATR), i.e. the volume of the thrombus aspirated divided by the volume of the thrombus before thrombectomy. ATR was estimated by comparing the angiograms of the lesion before and after thrombectomy. RESULTS: Soft thrombi were usually rapidly removed. ATR was >2/3 in 3, 2/3-1/3 in 2, 1/3-0 in 4, and 0 in 1 patient. The activation time of the injector was 23-224 s (mean 102 s) and the volume of aspirated blood was 30-680 ml (mean 250 ml). Compensatory infusion of saline was performed for blood loss, and 400 ml of packed red blood cells was transfused in 1 patient. No complications of the hydraulic thrombectomy were observed. Thrombolysis or additional treatment were performed in 9 patients. CONCLUSION: Hydraulic thrombectomy using this catheter can contribute to the treatment of venous thrombosis.

Endoscopic injection sclerotherapy with n-butyl-2-cyanoacrylate for ruptured duodenal varices.

Duodenal varices are a rare site of hemorrhage in patients with portal hypertension, but their rupture is a serious and often fatal event. We report the case of a 77-year-old woman with cirrhosis who presented with melena. She was admitted to our Department because of prolonged shock although she had received a large blood transfusion. Upper gastrointestinal endoscopy revealed nodular varices in the third portion of the duodenum which were considered to be the source of the bleeding. Endoscopic injection sclerotherapy (EIS) with n-butyl-2-cyanoacrylate (Histoacryl; Braun-Melsungen, Germany), an adhesive agent, was performed. We injected 1.5 ml of Histoacryl with Lipiodol (Laboratoire-Guerbet, France) intravariceally and achieved successful hemostasis. This patient's duodenal varices had almost completely resolved 1 month after EIS. We conclude that EIS with Histoacryl is an effective hemostatic measure for ruptured duodenal varices.

Hemorrhage from abdominal non-Hodgkin's lymphoma treated successfully by emergency transcatheter arterial embolization.

A 49-year-old Japanese woman with follicular lymphoma who presented with severe abdominal and back pain is reported. She was known to have malignant lymphoma and had been previously treated with combination chemotherapy. An abdominal tumor occurring at the root of the mesentery and involving the superior mesenteric artery (SMA) had been diagnosed by computed tomography (CT), magnetic resonance imaging, and abdominal angiography. Emergent ultrasonography and CT findings showed intraperitoneal bleeding from the abdominal tumor. Selective SMA angiography revealed extravasation from a small branch originating from the dorsal pancreatic artery, which was embolized through a catheter by using platinum coils. It should be noted that a large tumor of malignant lymphoma, involving large vessels, may bleed, and in such a case selective transcatheter arterial embolization may be one of the effective modalities for hemostasis.

Adult hepatoblastoma: case report and review of the literature.

We report a case of hepatoblastoma in a 24-year-old woman. The tumour was removed by an extended right lobectomy after transcatheter hepatic arterial embolization. A survey of the literature revealed 31 cases of adult hepatoblastoma. According to these reports there are no characteristic clinical features of the tumour, making a correct diagnosis before surgery or autopsy extremely difficult. Complete removal of the tumour is the only treatment which is potentially curative provided that lesion is confined within the liver capsule.

Chemoembolotherapy for recurrent hepatocellular carcinoma in the residual liver after hepatectomy.

The efficacy of transcatheter arterial chemoembolization using Lipiodol (TACE) to treat recurrent hepatocellular carcinoma (r-HCC) in the residual liver after radical hepatic resection was evaluated. During the last 8 years, TACE was performed in 68 patients with r-HCC for an aggregate total of 150 times. Of the 68 patients, 4 had a massive type r-HCC with tumor thrombus in the main portal vein (PVTT) at the time of the first TACE. Among the remaining 64 patients without PVTT, multiple r-HCCs were revealed in 46, and a single r-HCC in 18 by angiography and/or follow-up CT scans after the initial TACE. In 26 of the 68 patients (38.2%), at least one or more r-HCCs were fed not only by the hepatic arteries, but also by the extrahepatic collateral arteries, such as branches of the right inferior phrenic artery. The cumulative survival rates of these patients after hepatectomy and after the initial TACE for r-HCC were 98.6% and 87.1% for one year, 89.7% and 62.9% for 2 years, 74.0% and 34.3% for 3 years, 53.1% and 20.0% for 4 years and 40.3% and 0% for 5 years (mean survival duration: 1,647 days and 947 days), respectively. These results indicate that repeat TACE against r-HCC can help obtain long-term survival in patients with r-HCC. However, during TACE, we must give consideration to the newly developed collateral feeding artery to the r-HCC.

Chemoembolization for hepatocellular carcinoma via the inferior pancreaticoduodenal artery in patients with celiac artery stenosis.

Twenty-one patients with hepatocellular carcinoma (HCC) accompanied by extensive celiac artery stenosis or obstruction were treated by chemoembolization via the inferior pancreaticoduodenal artery (IPDA). The tip of the catheter was placed in the arteries in front of the confluence with the proper hepatic artery in 12 patients (group A: the proximal portion of the IPDA in 10, and common hepatic artery in 2), and in the proper hepatic artery or branches of it (group B) in 9 using a coaxial catheter system. Transient hyperamylasemia was observed in 10 of the 12 patients in group A and in 3 of the 9 patients in group B after chemoembolization. Splenic infarction developed in 8 patients in group A and in none in group B. Intrapancreatic fluid collection was present in 2 patients in group A following chemoembolization. No fatal complications were encountered. The 1-, 2-, and 3-year survival rates of the 10 patients in group A treated by only chemoembolization were 90, 57, and 23%, respectively (mean survival 780 days). The 1- and 2-year survival rates of 9 patients in group B were 85.8 and 85.8% (mean 879 days), respectively. Considering the severity of complications and the survival rates in groups A and B, chemoembolization by superselective catheterization into the hepatic artery via the IPDA is the treatment of choice. However, chemoembolization from the arteries in front of the confluence with the proper hepatic artery seems to be acceptable in cases of hypervascular HCC which fail to be superselectively catheterized.

Angiographic findings of Meckel's diverticulum: the characteristic appearance of the vitelline artery.

Angiographic findings of the vitelline artery in five patients with surgically proven Meckel's diverticulum were reviewed retrospectively. Superselective vitelline arteriography was performed in two patients and superior mesenteric arteriography in three. Arteriography showed the elongated artery without branching originating from the distal ileal artery and a group of tortuous vessels at the distal portion of this artery in all patients. A dense capillary staining of the vitelline artery was exclusively shown in patients with ectopic gastric mucosa. In one patient, injection of methylene blue intraoperatively through a previously placed angiographic catheter into the vitelline artery stained only the vitelline artery and Meckel's diverticulum in blue but neither the mesentery nor the ileum. Demonstration of a nonbranching artery from the ileal artery and a group of dilated tortuous vessels at the distal portion of this artery should suggest the possibility of Meckel's diverticulum and can be confirmed by selective injection of the artery. It should be emphasized that angiography can detect Meckel's diverticulum even in the absence of acute bleeding.

Hepatocellular carcinoma: a multivariate analysis of prognostic features in patients treated with hepatic arterial embolization.

The prognosis after hepatic arterial chemoembolization was retrospectively analyzed in relation to therapeutic modalities, stage of tumor, and degree of liver cirrhosis in 150 patients with solitary tumors of hepatocellular carcinoma. The analyses of life-table methods revealed that adjunct hepatectomy, tumor size, bilirubin, albumin, globulin, and the 15-min retention rate of indocyanine green are statistically significant prognostic factors for hepatic arterial chemoembolization. Results of Cox's proportional hazard analyses disclosed that adjunct hepatectomy (p = 0.0001), serum albumin level (p = 0.0032), and stage of tumor (p = 0.0194) are statistically significant and independent prognostic factors. These findings suggest that the prognosis after hepatic arterial chemoembolization depends on the hepatic functional reserve and stage of tumor in patients with hepatocellular carcinoma, and adjunct hepatectomy improves the prognosis in these patients.

Embolotherapy of massive duodenal hemorrhage.

Eleven patients with massive duodenal hemorrhage were treated by emergent embolization. Bleeding originated from duodenal ulcer in three patients, from duodenal tumor in one, from ruptured pancreaticoduodenal artery pseudoaneurysm in three, and from ruptured gastroduodenal artery pseudoaneurysm in four. Complete hemostasis was obtained immediately after embolotherapy in all cases. Three of these patients died during the hospitalization period, one of whom from duodenal infarction and pancreas necrosis induced by embolization. In three patients with duodenal ulcer, complete hemostasis was obtained only by the gastroduodenal artery embolization with Gelfoam particles. Seven patients with pseudoaneurysms of the gastroduodenal artery or its branches required not only blockage of blood flow from the celiac artery but also the superior mesenteric artery for complete hemostasis. Therefore, in patients presenting with duodenal hemorrhage, the possibility of dual blood supply to the duodenum should be considered. Emergent embolization represents a useful alternative to surgery for massive duodenal hemorrhage, but it carries a risk of complications in patients with previous gastroduodenal surgery or significant visceral atherosclerosis.

Emergent embolization for control of massive hemorrhage from a splanchnic artery with a new coaxial catheter system.

Emergent superselective embolization with a 3.0 F (1 mm) coaxial catheter and a steerable guidewire was performed in 27 patients with massive hemorrhage from a small-caliber splanchnic artery. Eight patients had intraperitoneal hemorrhage, 3 had hemobilia, 9 had gastric hemorrhage, and 7 had intestinal hemorrhage. Out of 27 patients, 7 had hemorrhage from a splanchnic artery pseudoaneurysm. Complete cessation of bleeding was obtained in all patients initially, but in 3 patients gastric hemorrhage recurred later. Otherwise, there was no rebleeding nor any major complication such as marked infarction of tissue or misplacement of embolic materials. This coaxial catheter system was highly reliable for achieving superselective catheterization in small-caliber arteries, minimizing the volume of infarcted tissue and allowing maximal preservation of splanchnic organic function. We conclude that this system represents a major advance in interventional radiology.

Emergent embolotherapy of small intestine hemorrhage.

The efficacy of emergent embolotherapy was evaluated in six patients suffering hemorrhage from the small intestine. Hemorrhage was from the jejunum in four patients, from the ileum in one, and from Meckel's diverticulum in one. Superselective embolization of the arcade of the small intestine artery branch was performed in all patients with a coaxial catheter. Embolic materials used were Gelfoam particles alone or Gelfoam particles plus coils in earlier cases and microcoils in recent cases. Complete hemostasis was immediately achieved in all patients, but one patient died of disseminated intravascular coagulation. After stabilization of the patient's condition by hemostasis, elective surgery was performed on three patients suffering small intestine ulcer. Histopathologically, no bowel infarction was noted but mild mucosal inflammation with submucosal edema was found in the jejunum of two patients. We recommend embolization for life-threatening small intestine hemorrhage, preferentially in situations where the blood vessel involved can be super-selectively occluded at the nearest level of the arcade of the vasa recta, lest the vasa recta should be occluded.

Percutaneous embolization of ruptured splanchnic artery pseudoaneurysms.

The usefulness of emergent embolotherapy was evaluated in 17 patients with life-threatening hemorrhage from 18 ruptured splanchnic artery pseudoaneurysms. Complete hemostasis was obtained in 16 out of 17 patients by embolotherapy. Of the 12 initial embolization procedures with permanent embolic materials including stainless steel coils, microcoils, and Ivalon, complete cessation of bleeding was obtained in 11. On the other hand, 6 out of 9 initial embolization procedures with Gelfoam particles failed to halt bleeding, and additional embolization with permanent embolic materials was required. Emergent embolization with permanent embolic materials using superselective catheterization should be considered the initial treatment of choice for ruptured splanchnic artery pseudoaneurysms.

Intraperitoneal hemorrhage from hepatocellular carcinoma: emergency chemoembolization or embolization.

From 1982 to 1990, 38 patients with intraperitoneal hemorrhage from hepatocellular carcinoma (HCC) underwent treatment with emergency embolization with or without anticancer drug and iodized oil. Before emergency embolization, 24 patients had a serum total bilirubin value of 3.0 mg/dL or less (group A) and 14 patients had hyperbilirubinemia, with a serum bilirubin level greater than 3.0 mg/dL (group B). Successful hemostasis was achieved in all patients. The mean length of survival was 165 days in group A and 13 days in group B. A significant correlation (P less than .00003) between serum bilirubin level and prognosis was obtained. While tumor thrombus in the portal vein made the prognosis poor, there was no significant difference in prognosis between groups with and without tumor thrombus (P = .145). Emergency embolization is an effective treatment in patients with intraperitoneal hemorrhage from HCC. The prognosis for patients with HCC depends on the serum bilirubin level before embolization.

Angiographic management of massive hemobilia due to iatrogenic trauma.

Ten patients with massive hemobilia in shock or preshock status were treated with angiography. The hemobilia had been induced by iatrogenic trauma: biliary drainage in seven patients, and surgery, liver biopsy, and angiography in one patient each. Angiography was performed on all patients. Embolization was performed in nine, and in the one remaining patient, spasm of the right anterior hepatic artery and catheter manipulation injured the intima and obliterated the artery. In seven patients with hepatic artery pseudoaneurysm, gelfoam particles were injected in five, however, extravasation could not be prevented in four of these patients. Permanent embolic materials were added and complete hemostatis was obtained. Hemobilia never recurred in any patient. Emergency embolization should be considered as the initial treatment of choice for hemobilia and when pseudoaneurysms are discovered, they should be obliterated by permanent embolic materials. Moreover, tumor thrombus in the portal vein is not a contraindication for this procedure.