REPEATED INTRANODAL LYMPHANGIOGRAPHY FOR THE TREATMENT OF LYMPHATIC LEAKAGE.

Treatment of patients with chylous or non-chylous lymphatic leakage can be difficult. An approach using therapeutic lymphangiography can reduce the lymphatic leakage, but it seldom stops the leakage immediately and subsequent conservative treatment is necessary. We report three cases in which intranodal lymphangiography was performed multiple times to inhibit lymphatic leakage. In each case, the lymph node was punctured under ultrasound guidance using a 23-gauge needle and lipiodol was injected manually at a rate of 1 ml/3 min. The procedure was repeated twice in two cases of gastrointestinal carcinoma and four times in one case of lymphoma. In all three cases, the postoperative lymphatic leakage stopped after the repeated intranodal lymphangiography.

CO2 microbubble contrast enhancement in x-ray angiography.

AIM: To demonstrate that carbon dioxide (CO2) microbubble contrast enhancement depicts blood vessels when used for x-ray examinations. MATERIALS AND METHODS: Microbubbles were generated by cavitation of physiological saline to which CO2 gas had been added using an ejector-type microbubble generator. The input pressure values for CO2 gas and physiological saline that produced a large quantity of CO2 microbubbles were obtained in a phantom. In an animal study, angiography was performed in three swine using three types of contrast: CO2 microbubbles, conventional CO2 gas, and iodinated contrast medium. For CO2 microbubble contrast enhancement, physiological saline, and CO2 gas were supplied at the input pressures calculated in the phantom experiment. Regions of interest were set in the abdominal aorta, external iliac arteries, and background. The difference in digital values between each artery and the background was calculated. RESULTS: The input pressures obtained in the phantom experiment were 0.16 MPa for physiological saline and 0.5 MPa for CO2 gas, with physiological saline input volume being 8.1 ml/s. Three interventional radiologists all evaluated the depictions of all arteries as "present" in the CO2 microbubble contrast enhancement, conventional CO2 contrast enhancement, and iodinated contrast enhancement performed in three swine. Digital values for all vessels with microbubble CO2 contrast enhancement were higher than background values. CONCLUSIONS: In x-ray angiography, blood vessels can be depicted by CO2 microbubble contrast enhancement, in which a large quantity of CO2 microbubbles is generated within blood vessels.

Composite material stent comprising metallic wire and polylactic acid fibers, and its mechanical strength and retrievability.

BACKGROUND: Although metallic stents are characterized by strong expanse of force, thin walls, and easy stent deployment, their removal from the body is usually difficult or impossible due to the difficulty of unraveling their mesh structure. A stent built of a composite material comprising a metallic wire and a polylactic acid (PLA) fiber, in which the metallic wire component could be unraveled after PLA fiber degradation in the body, should allow easy stent removal. PURPOSE: To evaluate the mechanical strength and retrievability of a composite material stent comprising a metallic wire and a PLA fiber. MATERIAL AND METHODS: We produced a composite material stent comprising a metallic wire and a biodegradable fiber (hybrid stent). As the metallic wire is not cross-linked with itself, but with the PLA fibers only, the hybrid stent can be easily unraveled after PLA fiber degradation. This stent was built with a 0.2-mm stainless-steel wire and a 0.23-mm PLA fiber knitted in the same textile as an Ultraflex stent. For comparison, an identical stent was built using PLA fiber only (PLA stent). The mechanical strength of these stents was tested by the radial expansive force response against circumferential shrinkage stress load. Change in radial force due to PLA fiber degradation was estimated by adding an artificial PLA degeneration process, by immersing each stent in a water bath at 80 degrees C for 48 hours. Retrievability of the hybrid stent after PLA degeneration was examined by hooking and pulling out the residual stainless-steel wire from a silicon tube. RESULTS: The hybrid stent exhibited a linear response in radial expansive force within the range of 15% diameter reduction. The PLA stent did not exhibit linear response at over 15% diameter reduction. Decrease of radial expansive force after PLA degradation was within 5% of the original force in the hybrid stent, but the PLA stent did not create effective radial expansive force. Hybrid stents, even after PLA degradation, exhibited a linear response in radial expansive force, within the range of 15% diameter reduction. The metallic component of the heat-processed hybrid stent was easily unraveled by pulling out the wire. CONCLUSION: The hybrid stent comprising a stainless-steel wire and a PLA fiber appears to provide effective radial expansive force and retrievability.

Transcatheter coil embolization for steal syndrome in patients with hemodialysis access.

BACKGROUND: Drainage of large amounts of shunt blood into deep veins via collaterals reduces resistance to venous outflow and decreases blood flow to the artery distal to the arterial anastomotic site, potentially resulting in steal syndrome. PURPOSE: To evaluate the effectiveness of transcatheter coil embolization for collateral veins of hemodialysis access in the treatment of steal syndrome. MATERIALS AND METHODS: Five hemodialysis patients (four male, one female; mean age 58.8 years, range 40-71 years) with symptomatic steal syndrome were treated. Steal syndrome was diagnosed based on decreased or absent distal pulse, coolness, pain, abnormal skin color, ischemic ulceration of digits, numbness, sensory impairment, or motor impairment. Coil embolization was performed to block collaterals communicating with deep veins, with conscious sedation and local anesthesia. Fistulography was performed before, immediately after, and 1 month after embolization. Ultrasonography was performed 2 days after embolization. Symptoms and signs were assessed 2 days after embolization. Clinical findings related to steal syndrome and access failure were observed at each hemodialysis. RESULTS: Blood flow in the collaterals was successfully blocked by coil embolization in all patients. Distal pulse, coolness, pain, and skin color improved in all patients. Numbness, sensory impairment, and motor impairment were unimproved in two patients. In all patients, hemodialysis following embolization was performed normally. The mean observation period after embolization was 33 months (range 9-75 months). CONCLUSION: Coil embolization of collaterals that drain shunt blood into deep veins is effective for steal syndrome for hemodialysis access originating in the brachial artery.

Cerebral microembolisation during radiofrequency ablation of lung tumours: detection by carotid duplex ultrasound.

The aim of this study was to investigate the appearance of microbubbles during radiofrequency ablation (RFA) of lung tumours. Eight consecutive patients (mean age, 73.1 years; 3 men and 5 women; 10 malignant lesions; mean lesion size, 24.8 mm) who underwent RFA of lung tumours using internally cooled single electrodes were enrolled. During the RFA procedure, the right internal carotid artery was continuously monitored by duplex ultrasound. High-intensity transient signals (HITS) that occurred in the Doppler blood flow waveform were taken to indicate microbubbles. 21 RFA applications were performed for the 10 lesions. HITS were observed in 19 of 21 RFA applications; the mean frequency in a single application was 10+/-13.3. A statistical correlation was seen between the duration of energy deposition and the number of HITS, and between tumour size and the number of HITS. Microbubbles were detected in all patients in the late phase of the first session of RFA.

Improvement in respiratory function by percutaneous vertebroplasty.

BACKGROUND: Percutaneous vertebroplasty (PVP) improves back pain and corrects spinal misalignment to some extent, and thus may improve respiratory function. PURPOSE: To retrospectively investigate changes in respiratory function after PVP. MATERIAL AND METHODS: 41 patients (mean age 72.0 years, range 59-86 years; 39 women, two men) who had undergone PVP for vertebral compression fractures (37 thoracic vertebral bodies [Th6-Th12] and 50 lumbar vertebral bodies [L1-L5]) caused by osteoporosis visited our hospital for follow-up consultation between January and June 2005. At this follow-up consultation, respiratory function testing, including percent forced vital capacity (FVC%) and percent forced expiratory volume in 1 s (FEV(1)%), was performed. We retrospectively compared these values with those taken before PVP using a Wilcoxon signed-rank test. RESULTS: FVC% was 85.2+/-30.3% before PVP and 91.5+/-16.8% at follow-up (mean 10 months after PVP), which represented a significant difference (P<0.003). No significant difference in FEV(1)% was detected. Regarding the number of treatment levels, that is, single vertebroplasty versus multiple vertebroplasty, no significant difference in improvement of FVC% was confirmed (P=0.1). FVC% was abnormally low (

Diffusion-weighted imaging for predicting new compression fractures following percutaneous vertebroplasty.

BACKGROUND: Percutaneous vertebroplasty (PVP) is a technique that structurally stabilizes a fractured vertebral body. However, some patients return to the hospital due to recurrent back pain following PVP, and such pain is sometimes caused by new compression fractures. PURPOSE: To investigate whether the apparent diffusion coefficient (ADC) of adjacent vertebral bodies as assessed by diffusion-weighted imaging before PVP could predict the onset of new compression fractures following PVP. MATERIAL AND METHODS: 25 patients with osteoporotic compression fractures who underwent PVP were enrolled in this study. ADC was measured for 49 vertebral bodies immediately above and below each vertebral body injected with bone cement before and after PVP. By measuring ADC for each adjacent vertebral body, ADC was compared between vertebral bodies with a new compression fracture within 1 month and those without new compression fractures. In addition, the mean ADC of adjacent vertebral bodies per patient was calculated. RESULTS: Mean preoperative ADC for the six adjacent vertebral bodies with new compression fractures was 0.55 x 10(-3) mm(2)/s (range 0.36-1.01 x 10(-3) mm(2)/s), and for the 43 adjacent vertebral bodies without new compression fractures 0.20 x 10(-3) mm(2)/s (range 0-0.98 x 10(-3) mm(2)/s) (P < 0.001). Mean preoperative ADC for the six patients with new compression fractures was 0.55 x 10(-3) mm(2)/s (range 0.21-1.01 x 10(-3) mm(2)/s), and that for the 19 patients without new compression fractures 0.17 x 10(-3) mm(2)/s (range 0.01-0.43 x 10(-3) mm(2)/s) (P < 0.001). CONCLUSION: The ADC of adjacent vertebral bodies as assessed by diffusion-weighted imaging before PVP might be one of the predictors for new compression fractures following PVP.

Lower limb ischaemia caused by fractured osteochondroma of the femur.

Osteochondroma is the most common benign bone tumour and can arise in any bone. They frequently develop around the knee in the distal femur and the proximal tibia. These are usually asymptomatic, but can occasionally impinge on the surrounding vessels and cause various clinical manifestations. We have encountered a patient with multiple hereditary exostoses, in whom the osteochondroma located in the distal portion of the femur fractured as a result of an injury from a traffic accident. The migrated osteochondroma compressed the femoral artery and led to an acute onset of lower extremity ischaemia. Although trauma or vigorous exercise can cause vascular complications caused by osteochondroma, vascular insufficiency due to fracture of osteochondroma after a traumatic injury is extremely rare.

Percutaneous transluminal cutting-balloon angioplasty for hemodialysis access stenoses resistant to conventional balloon angioplasty.

PURPOSE: To examine the value of cutting-balloon percutaneous transluminal angioplasty (PTA) for hemodialysis access with residual stenosis after conventional balloon PTA. MATERIAL AND METHODS: Angioplasty with conventional balloons was performed on 48 hemodialysis access stenoses in 28 patients. If the balloon waist still remained at the rated burst pressure, the balloon was reinflated up to three times. Fifteen of 48 stenoses had residual stenoses of more than 30% after conventional balloon PTA. In these 15 stenoses, additional cutting-balloon PTA was performed. RESULTS: The mean residual percent diameter stenoses before and after conventional balloon PTA were 77.6+/-3.4% and 48.6+/-8.5%, respectively. Additional cutting-balloon PTA decreased the mean residual percent diameter to 27.9+/-10.0%, and the cutting balloon was completely inflated without complication. In 12 patients, the 6-month primary patency rate (+/-SE) was 90.0% (9.5), and the 1-year primary patency rate (+/-SE) was 25.0% (14.8). CONCLUSION: Additional cutting-balloon PTA was found useful for reducing residual stenosis.

Gadolinium-enhanced magnetic resonance imaging after percutaneous vertebroplasty does not improve the short-term prediction of new compression fractures.

PURPOSE: To investigate the relationships between contrast-enhanced magnetic resonance imaging (MRI) findings and new compression fractures occurring after percutaneous vertebroplasty (PVP) in order to determine the necessity of contrast-enhanced MRI. MATERIAL AND METHODS: The material comprised 13 consecutive patients (27 vertebrae) with compression fractures who underwent vertebroplasty. Twenty-nine adjacent vertebrae were monitored for new compression fractures. We performed contrast-enhanced MRI within the 5 days following PVP. RESULTS: The 29 adjacent vertebrae displayed 10 enhanced lesions and 19 vertebral bodies without enhancement-unenhanced lesions on MRI within the 5 days after PVP. In 4 out of 10 vertebrae, enhanced lesions were seen within the 5 days after PVP, but no abnormalities were seen on preoperative MRI. In these 4 vertebrae, new compression fractures were seen within the 1 month following PVP. In the other 6 vertebrae, enhanced lesions were seen within the 5 days after PVP, and these signal changes were detected by preoperative MRI in the same area. In 3 of these 6 vertebrae, new compression fractures occurred at 4, 8, and 9 months after PVP, respectively. However, all of the enhanced lesions were detectable on unenhanced MRI, which was conducted at the same time as enhanced MRI. CONCLUSION: New compression fractures after PVP may be predicted with early postoperative MRI. Contrast-enhanced MRI does not improve detection of the new lesions.

Percutaneous vertebroplasty for compression fracture: analysis of vertebral body volume by CT volumetry.

PURPOSE: To evaluate the relationships between volume of vertebral bodies with compression fracture (measured by CT volumetry) before percutaneous vertebroplasty, the amount of bone cement injected, and the effect of treatment. MATERIAL AND METHODS: We examined 49 consecutive patients, with 104 vertebral body compression fractures, who underwent percutaneous injection of bone cement. Vertebral body volume was measured by CT volumetry. The patient's pain level was assessed using a visual analog scale (VAS) before and after the procedure. Improvement in VAS was defined as the decrease in VAS after the procedure. Relationships between vertebral body volume, the amount of bone cement, and the effect of treatment were evaluated using Pearson's correlation coefficient test. RESULTS: Average vertebral body volume was 26.3 +/- 8.1 cm3; average amount of bone cement was 3.2 +/- 1.1 ml; and average improvement in VAS was 4.9 +/- 2.7. The vertebral body volume was greater if a larger amount of bone cement was injected. There was a significant positive correlation between vertebral body volume and amount of bone cement (r = 0.44; P < 0.0001). However, there was no correlation between vertebral body volume and improvement in VAS, or between amount of bone cement and improvement in VAS. CONCLUSION: In percutaneous vertebroplasty for vertebral body compression fracture, there is a positive correlation between vertebral body volume and amount of bone cement, but improvement in VAS does not correlate with vertebral body volume or amount of bone cement.

Three-dimensional angiography using rotational digital subtraction angiography: usefulness in transarterial embolization of hepatic tumors.

PURPOSE: To assess the usefulness of three-dimensional (3D) angiography using rotational digital subtraction angiography (DSA) in transarterial embolization of hepatic tumors. MATERIAL AND METHODS: Thirty-one 3D angiographies were conducted using rotational DSA during abdominal angiography for transarterial embolization of hepatic tumors. The quality of visualization of the tumor and feeder arteries as imaged by 3D angiography versus DSA anterioposterior (AP) images was compared. RESULTS: 3D rotational angiography provided excellent 3D visualization of the vascular structures of the hepatic artery, and was especially useful in patients with overlapping tumors on DSA AP images and in patients with complex vascular anatomies. Compared to DSA AP images, however, tumor stains could not be detected on 3D-A, but could be detected on DSA in four patients (13%). In 9 patients, feeding arteries could not be detected on 3D-A, but could be detected on DSA (29%). CONCLUSION: 3D rotational angiography alone may not be suitable for pre-procedural mapping in transarterial embolization of hepatic tumors, but may be of value when information supplementary to DSA AP images is needed.

Computed tomography perfusion of the liver: assessment of pure portal blood flow studied with CT perfusion during superior mesenteric arterial portography.

PURPOSE: To quantitatively assess the portal component of hepatic blood flow using computed tomography (CT) perfusion studies during superior mesenteric arterial portography. MATERIAL AND METHODS: Thirty-four patients with hepatocellular carcinoma and liver cirrhosis (LC) and 13 patients with liver metastasis without chronic liver disease were enrolled in this study. Ten milliliters of a non-ionic contrast medium (150 mg I) was injected at a rate of 5 ml/s via a catheter placed in the superior mesenteric artery. Single-slice cine CT images at the level of the main trunk or the right/left main trunk of the portal vein were acquired over 40 s. The deconvolution method was then used on these CT images to measure blood flow (BF), blood volume (BV), and mean transit time (MTT) in (a) liver parenchyma in patients with HCC and liver cirrhosis; (b) liver parenchyma in patients with liver metastasis without cirrhosis; (c) directly in the HCC; and (d) directly in one of the metastases. RESULTS: In 34 LC patients (a), BF, BV, and MTT in the liver parenchyma were 44.7+/-24.5 ml/min/100 g, 3.9+/-2.4 ml/100 g, and 10.9+/-5.5 s, respectively. In 13 patients without cirrhosis (b), BF, BV, and MTT in the liver parenchyma were 89.6+/-52.0 ml/min/100 g, 6.3+/-3.2 ml/100 g, and 8.7+/-3.6 sec, respectively. A significant difference in BF and BV was seen in patients with liver cirrhosis compared to those without cirrhosis. BF, BV, and MTT measured directly in HCC (c) were 6.5+/-4.5 ml/min/100 g, 0.4+/-0.4 ml/100 g, and 3.0+/-3.1 sec respectively, and BF, BV, and MTT in liver metastases (d) were 19.3+/-21.7 ml/min/100 g, 0.6+/-0.8 ml/100 g, and 1.8+/-1.6 s, respectively. CONCLUSION: CT perfusion studies during superior mesenteric arterial portography allow quantitative assessment of pure portal blood flow in the liver.

A new liquid embolic material for liver tumors.

PURPOSE: To evaluate the feasibility of a new liquid embolic material, Onyx, for treating liver tumors. MATERIAL AND METHODS: Onyx is a mixture of 6% (w/v) ethylene-vinyl-alcohol copolymer dissolved in anhydrous dimethyl sulfoxide (DMSO) with 28% (w/v) tantalum powder. In addition to 6% Onyx, we also tried 4%, 2% and 1% solutions, prepared by adjusting the amount of DMSO. We used 15 white rabbits with liver tumors created by percutaneous injection of VX2 tumor cells. In 4 groups with 3 rabbits in each, the liver arteries were embolized with 6%, 4%, 2% and 1% Onyx, respectively, and in 3 rabbits DMSO alone was injected. The injections were performed just proximal to the bifurcation of the proper hepatic artery, followed by celiac arteriography. Post mortem, the livers were examined by soft-tissue radiography, and liver-tissue section microscopy. RESULTS: The maximum number of arterial branching points passed by embolic material in either the right or left hepatic arteries was 11, 15 and 16, for 6%, 4% and 2% Onyx, respectively, but was non-measurable for 1% Onyx. Minimum diameters of arteries reached by 6%, 4%, 2% and 1% Onyx in tumorous areas were 40 microm, 35 microm, 20 microm and 10 microm, respectively, and in non-tumorous areas 35 microm, 5 microm, 5 microm and 5 microm, respectively. CONCLUSION: This study suggests that Onyx may be feasible for treatment of hepatic tumors.

Creation of aortic dissection model in swine.

The use of mongrel dogs for experimental purposes was recently restricted and this report presents the experience of creating an aortic dissection model in swine. All the swine in group 1 were anesthetized without pentobarbital and the descending aorta was side-clamped during the creation of the aortic dissection. The false lumen of the completed dissection was patent in the long term despite not having the anchoring suture that the previous canine model required to stabilize the opening of the entry tear. All the swine anesthetized with pentobarbital (ie, group 2) died of heart failure either during cross-clamping of the descending aorta or postoperative aortography. In conclusion, creation of a thoracic aortic dissection is possible in swine, but cross-clamping of the thoracic descending aorta and pentobarbital anesthesia should be avoided.