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.

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.

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.

Safety of gadobutrol in over 23,000 patients: the GARDIAN study, a global multicentre, prospective, non-interventional study.

OBJECTIVES: To investigate the safety and tolerability of gadobutrol at the recommended dose in patients requiring contrast-enhanced magnetic resonance imaging/angiography (MRI/MRA) in the routine setting. METHODS: GARDIAN prospectively enrolled 23,708 patients undergoing routine gadobutrol-enhanced MRI/MRA for approved indications at 272 study centres in Europe, Asia, North America, and Africa and monitored for adverse events. RESULTS: Median gadobutrol dose was 0.11 mmol/kg body weight. The overall incidence of adverse drug reactions (ADRs) was 0.7 % (n = 170 patients), with similar incidences in patients with renal impairment or cardiac disease, from different geographic regions and in different gadobutrol dose groups. Patients at risk for contrast media reaction had an ADR incidence of 2.5 %. Five patients (0.02 %) experienced serious adverse events, four were drug-related. One patient experienced a fatal anaphylactoid shock, assessed to be related to injection of gadobutrol. The contrast quality of gadobutrol-enhanced images was rated by treating physicians as good or excellent in 97 % cases, with similar ratings in all patient subgroups and indications. CONCLUSIONS: The GARDIAN study shows that gadobutrol at the recommended dose is well tolerated across a large, diverse patient population. KEY POINTS: • Gadobutrol at recommended dose shows low rates of adverse drug reactions • Gadobutrol demonstrates a uniform safety profile across diverse patient groups • Gadobutrol provides excellent contrast quality in routine practice.

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.

USPIO enhanced lymph node MRI using 3D multi-echo GRE in a rabbit model.

Ultrasmallsuperparamagnetic iron oxide (USPIO) has been suggested to be a negative MR contrast agent to detect metastatic lymph nodes. Previously reported studies have evaluated the diagnostic performance of USPIO-enhanced MR lymph node imaging based on signal intensity. In this study, we investigate the specific performance of three different parametric approaches (normalized signal intensity, R2 * and susceptibility) using 3D multi-echo gradient echo to quantify the USPIO particles in lymph nodes. Nine rabbits with VX2 tumor implants were scanned before and after USPIO injection. From 3D multi-echo GRE magnitude and phase data, we generated multi-echo combined T2 *-weighted images, an R2 * map, and a quantitative susceptibility map. Eighteen lymph nodes (nine reactive and nine metastatic) were evaluated and showed remarkable signal drops in the area of USPIO accumulation. On parametric analysis, the R2 * difference before and after USPIO injection was significantly different (p < 0.05) between reactive and metastatic lymph nodes; in contrast, the normalized signal intensity and susceptibility were not significantly different between the nodes. Our study showed the potential utility of USPIO-enhanced MRI using R2* mapping from 3D multi-echo GRE for the detection of lymph node metastasis and parametric analysis of lymph node status in a rabbit model. Copyright © 2016 John Wiley & Sons, Ltd.

Transjugular Intrahepatic Portosystemic Shunt Occlusion Complicated with Biliary Fistula Successfully Treated with a Stent Graft: A Case Report.

A 43-year-old man with liver cirrhosis received transjugular intrahepatic portosystemic shunt (TIPS) for the treatment of recurrent variceal bleeding and F3 esophageal varices. During routine follow up liver ultrasound examination, six months after the implantation, TIPS occlusion was suspected and TIPS revision was performed. During the revision, moderate to severe stenosis at the hepatic venous segment of the tract and a total occlusion at the parenchymal segment of TIPS tract near the portal vein with biliary-TIPS fistula were identified with a clear visualization of the common bile duct. After the successful TIPS revision with the placement of an additional stent-graft, the biliary fistula and common bile duct were no more delineated. We herein report a rare case with an obvious visualization of biliary-TIPS fistula associated with obstruction of TIPS shunt on the tractogram and recanalization with an additional stent-graft.

Successful treatment of posttraumatic arteriovenous malformation of the lower lip.

Arteriovenous malformations (AVMs) are most commonly reported in the brain. Head and neck AVMs are reported to occur in 0.1% of the general population. On the other hand, posttraumatic AVMs are quite rare. Traumatic AVMs are extremely rare in the head and neck and are mostly seen in the extremities. The management of such lesions may include selective embolization or surgical exploration with ligation. A 13-year-old male adolescent visited our hospital for lower lip swelling, which developed 5 years ago after a lower lip laceration. The AVM was expanded and was graded as stage II. It was fed by the mandibular branch of both facial arteries and drained to the posterior facial vein. The radiologic intervention department performed an embolization before the operation. The main operation was performed 12 days after the embolization. A well-demarcated AVM lesion was found in the oral mucosa and was totally excised under general anesthesia. The authors easily performed the operation owing to the embolization making the AVM definitely demarcated and firmly palpable. The lip closure was done carefully considering the lip contour. No sign of recurrence was seen during 6 months of follow-up. The excellent treatment result of the posttraumatic facial AVMs occurs largely because of a collaboration with the radiologic intervention department using the selective embolization.

CT and MRI evaluation of cardiac complications in patients with hematologic diseases: a pictorial review.

Cardiac complications with hematologic diseases are not uncommon but it is difficult to diagnose, due to non-specific clinical symptoms. Prompt recognition of these potentially fatal complications by cardiac computed tomography (CT) or cardiac magnetic resonance imaging (MRI) may help to direct clinicians to specific treatments according to causes. Thrombosis is often related to central venous catheter use and is usually located at the catheter tip near the atrial wall. Differentiation of thrombosis from normal structure is possible with CT and, distinction of a thrombus from a tumor is possible on a delayed enhancement MRI with a long inversion time (500-600 ms). Granulocytic sarcoma of the heart is indicated by an infiltrative nature with involvement of whole layers of myocardium on CT and MRI. MRI with T2* mapping is useful in evaluating myocardial iron content in patients with hemochromatosis. Diffuse subendocardial enhancement is typically observed on delayed MRIs in patients with cardiac amyloidosis. T1 mapping is an emerging tool to diagnose amyloidosis. Myocardial abscess can occur due to an immunocompromised status. CT and MRI show loculated lesions with fluid density and concomitant rim-like contrast enhancement. Awareness of CT and MRI findings of cardiac complications of hematologic diseases can be helpful to physicians for clinical decision making and treatment.

Evaluation of arterial impairment after experimental gelatin sponge embolization in a rabbit renal model.

OBJECTIVE: Arterial stenosis is a major obstacle for subsequent interventional procedures. We hypothesized that the stenosis is caused by gelatin sponge embolization and performed an experimental study in a rabbit renal model. MATERIALS AND METHODS: A total of 24 rabbits were embolized with porcine gelatin sponge particles injected into the renal arteries. Four rabbits were sacrificed on 1 day, 4 days, 1 week, 2 weeks, 3 weeks, and 4 weeks after embolization. Microscopic evaluations were performed on hematoxylin-eosin and smooth muscle actin immunohistochemical stained sections. RESULTS: Gelatin sponge particles were mainly observed in the segmental and interlobar arteries. Transmural inflammation of the embolized arterial wall and mild thickening of the media were observed 1 week after embolization. Resorption of the gelatin sponge and organization of thrombus accompanied by foreign body reactions, were observed from 2 to 4 weeks after embolization. Microscopic images of the 3 weeks group showed vessel lumens filled mostly with organized thrombi, resulting in severe stenosis. Additionally, vessels showed a thickened intima that contained migrating smooth muscle cells and accompanying interruption of the internal elastic lamina. The migrating smooth muscle cells were distributed around the recanalized arterial lumen. CONCLUSION: Gelatin sponge embolization may induce arterial stenosis by causing organized thrombus and intimal hyperplasia, which consists of migrating smooth muscle cells and intimal collagen deposits.