Hepatic falciform artery. Angiographic findings in 25 patients.

PURPOSE: To determine the frequency of hepatic falciform artery (HFA) occurrence on celiac or hepatic angiograms and elucidate the anatomy and clinical importance. MATERIAL AND METHODS: Among 1,250 patients who underwent celiac or hepatic arteriography, we encountered 25 patients (2%) with a HFA. Prospectively, CT hepatic falciform arteriography (CTHA) was performed in 4 patients. Indigocarmine dye was injected into the HFA in 6 patients to evaluate whether the abdominal skin was stained. Embolization of the HFA before chemoembolization for hepatocellular carcinoma was performed in 4 patients to prevent abdominal wall injury. RESULTS: Among 25 patients, the HFA arose as a terminal branch of the middle hepatic artery in 14 patients (56%) and of the left hepatic artery in 11 patients (44%). The vessel was single in 18 patients (72%) and double in 7 patients (28%). Two vessels ran side by side along the hepatic falciform ligament. On CTHA, the HFA ran within the hepatic falciform ligament and the branches were connected with the liver around the hepatic falciform ligament. After indigocarmine dye injection, the stain of abdominal skin was recognized in all 6 patients. No abdominal wall injury occurred in any of the 4 patients who were subjected to hepatic chemoembolization. CONCLUSION: HFA is an extrahepatic pathway which runs to the abdominal wall. Before chemoembolization of the middle or left hepatic artery for hepatic malignancy, the HFA should be recognized.

Transcatheter arterial chemoembolization therapy using iodized oil for patients with unresectable hepatocellular carcinoma: evaluation of three kinds of regimens and analysis of prognostic factors.

BACKGROUND: The current study was conducted to evaluate retrospectively the effects of three kinds of regimens used in transcatheter arterial chemoembolization (TACE) in patients with unresectable hepatocellular carcinoma (HCC) and patients' prognosis, and to analyze their prognostic factors. METHODS: The study population was comprised of 152 patients who were treated by TACE alone. Three kinds of regimens were used successively: doxorubicin hydrochloride (ADM) and mitomycin C mixed with iodized oil in 26 patients (ADMOS group), a combination of cisplatin (CDDP) solution and ADMOS in 70 patients (CDDP-ADMOS group), and CDDP powder and pirarubicin hydrochloride mixed with iodized oil in 56 patients (CTLS group). The CTLS group was comprised of patients with significantly worse background factors than the other two groups. RESULTS: The initial tumor response rate with a > 50% reduction was 12%, 23%, and 30%, respectively, in the ADMOS, CDDP-ADMOS, and CTLS groups. CTLS was significantly more effective than ADMOS (P < 0.05), and slightly but not significantly better than CDDP-ADMOS (P <0.1). The cumulative survival rates for the ADMOS, CDDP-ADMOS, and CTLS groups were 59.0%, 70.1%, and 72.0%, respectively, at 1 year; 0%, 16. 3%, and 29.8%, respectively, at 3 years; and 0%, 4.1%, and 16.8%, respectively, at 5 years, with median survival times of 448 days, 574 days, and 758 days, respectively. The CTLS group showed a slightly but not significantly better survival than the ADMOS and CDDP-ADMOS groups (P <0.1). Multivariate analysis indicated that the significantly important prognostic factors (in order) were extrahepatic metastasis followed by the TACE regimen, serum alpha-fetoprotein levels, and portal vein involvement and that CTLS was the best of the three regimens. CONCLUSIONS: Although TACE, using an effective regimen, improves clinical results, tumor factors appear to be more important when determining prognosis.

Localization of insulinomas. Comparison of conventional arterial stimulation with venous sampling (ASVS) and superselective ASVS.

PURPOSE: To examine the value of superselective arterial stimulation venous sampling (ASVS) to localize insulinomas. MATERIAL AND METHODS: Superselective ASVS (SS-ASVS) was performed in 9 patients with insulinoma. Injection of secretagogue (calcium gluconate: 0.01 mEq Ca++/kg) was performed into the gastroduodenal, splenic (proximal and distal), and superior mesenteric arteries in 9 patients and additionally into the dorsal pancreatic artery in 6 patients. Sampling from the hepatic vein was performed to measure serum insulin concentrations at 30, 60 and 120 s after each injection of secretagogue into these arteries. SS-ASVS results were correlated with surgical findings, compared to those of conventional ASVS. RESULTS: Insulinomas were correctly localized to the head, body or tail of the pancreas by SS-ASVS in 8 patients (89%). Conventional ASVS detected insulinomas in 7 patients (78%), although it could not distinguish whether the insulinoma was located in the pancreatic body or tail in 4 of the 7 patients. There were eight-fold or more increases in serum insulin levels in hepatic venous samples related to the artery supplying the tumor in 8 patients. Localization of the insulinomas was verified at surgery in all patients. CONCLUSION: SS-ASVS is a useful method for detailed evaluation of overproduction of insulin from pancreatic insulinomas and their localization. When the pancreatic insulinoma is situated in the pancreatic body or tail, the localization is more accurately made by SS-ASVS than by conventional ASVS.

Altered flow dynamics of intravascular contrast material to the liver in superior vena cava syndrome: CT findings.

BACKGROUND: To evaluate the findings of altered flow dynamics in the livers of patients with obstruction of superior vena cava (SVC) on helical computed tomography (CT). METHODS: In six patients (age range = 28-80 years) with SVC obstruction, CT findings were retrospectively reviewed to identify the abnormal enhancement patterns of the liver and the relation with the extrahepatic collateral vessels and hepatic vessels. RESULTS: Abnormal hepatic enhancement was observed in the following four (A-D) portions: (A) anterior portion of segment IV (n = 5), (B) subdiaphragmatic portion of the liver (n = 4), (C) posterior portion of the right lobe (bare area; n = 1), and (D) lateral segment of the left lobe (n = 2). Two major collateral pathways to the liver were demonstrated as follows: A and D --> from the umbilical vein to the left portal vein, and B and C --> from the subcapsular vein to the bare area of the liver or to the hepatic veins. On helical CT, these collateral pathways were also clearly visualized. CONCLUSION: When these abnormal enhancements of the liver on CT are recognized within the liver, these findings indicate diversion of contrast material into collateral pathways to the liver with SVC obstruction.

Small hepatocellular carcinoma supplied by the right renal capsular artery. A case report.

We present a case of hepatocellular carcinoma (HCC), which was fed only by the right renal capsular artery. Ten years earlier, this patient underwent surgery for a solitary HCC in segment IV. However, the hepatic artery was patent and did not participate in feeding the HCC. We consider the renal capsular artery as an essential extrahepatic parasitic feeding artery to HCC.

Left lobe recurrent hepatocellular carcinoma treated with lipiodol-TAE via the left internal mammary artery.

A multinodular hepatocellular carcinoma (HCC) was treated with seven transarterial interventions via the hepatic artery over a 2-year, 5-month period before the eighth angiography showed a recurrent HCC in the anterior portion of the left hepatic lobe. The left internal mammary artery (IMA) was feeding the tumor. This was successfully treated with Lipiodol-transcatheter arterial embolization using a coaxial system via a branch of the left IMA. No complications resulted from the procedure. The left IMA should be considered as a possible feeding artery to an HCC occurring in the anterior portion of the left hepatic lobe.

[Evaluation of anastomosis between intrahepatic or extrahepatic vessels by intra-arterial digital subtraction angiography using carbon dioxide].

Carbon dioxide (CO2) intraarterial subtraction angiography (IADSA) was performed in 31 patients with various hepatobiliary diseases. The injection sites of CO2 were proper hepatic artery (10/31; group A), segmental hepatic artery (18/31; group B), and peripheral inferior phrenic artery (3/31; group C), respectively. In group A, only the third order branches of the portal venous system were visualized anterogradely in 8 of 10 patients. In group B, the microcatheter was placed coaxially through a 5 French guiding catheter at the main arterial supply of the tumor in 7 patients and at the peripheral segmental branch of the hepatic artery in 11 patients. The portal venous system was visualized retrogradely in all of the patients regardless of the injection site. The injected CO2 may flow back into the portal vein through the anastomosis known as the peribiliary or periportal plexus. In group C, not only the portal vein but also the pulmonary artery or pericardial vein were visualized by this method. CO2-IADSA was useful to image the minute communications between the various vessels, which have been not hitherto visualized by iodinated contrast medium.

Retrograde visualization of the portal venous system using CO2 intraarterial digital subtraction angiography.

Carbon dioxide (CO2) intraarterial digital subtraction angiography (IADSA) provides retrograde visualization of the portal vein via a peripheral segmental hepatic artery. IADSA was performed in 12 patients with known hepatic diseases by injecting a peripheral hepatic artery with both CO2 gas and an iodinated contrast medium. The portal vein was constantly visualized only with CO2 IADSA in all patients. The injected CO2 may flow back into the portal vein through an anastomotic system known as the peribiliary or periportal plexus. This new method is safe and useful to image the portal venous system in patients with hepatic malignancy.

Estimation of the kinetics of iodized oil injected into the feeding artery of hepatocellular carcinoma using dynamic computed tomography.

The distribution of iodized oil (Lipiodol) after its injection in hepatocellular carcinoma (HCC) was evaluated by dynamic computed tomography (CT) in 10 patients. Following the injection of Lipiodol into the hepatic artery, two patterns were observed. In type I (4/10 tumors) Lipiodol retention began at the tumor periphery and then spread contiguously towards the central portion. In type II (6/10 tumors), the accumulation began at the periphery, but then skipped directly to the central portion of the tumor. Hypervascular tumors were predominantly type I, and avascular or hypovascular tumors were all type II. This difference in Lipiodol kinetics suggests that lipid-based intra-arterial (i.a.) chemoembolization should precede the i.a. infusion of water-soluble chemotherapeutic agents or injection of solid embolic materials in hypervascular tumors.

Visualization of left bronchial-to-coronary artery communication after distal bronchial artery embolization for bronchiectasis.

We present a 44-year-old woman in whom a bronchial-to-coronary artery communication via the conus branch was discovered after distal bronchial artery embolization with gelatin sponge for hemoptysis. If this bronchial-to-coronary artery anastomosis, not visible prior to embolization, had been inadvertently embolized, the patient could have developed a myocardial infarction. To reduce the likelihood of a serious complication, the possibility of this anastomosis should be kept in mind and angiography should be repeated before attempting proximal bronchial artery embolization.

A case with Cushing's syndrome treated with arterial ablation of adrenal gland by absolute ethanol.

Adrenal arterial embolization with absolute ethanol was performed for the treatment of Cushing's syndrome. A 55-year-old woman was admitted to our hospital with complaints of obesity, hypertension, and back pain caused by left adrenal hyperplasia after surgical resection of the right adrenal gland. Therapeutic adrenal arterial embolization was performed by the coaxial technique using absolute ethanol (AE) as an embolic material. No severe complications were encountered during the procedure, and the patient was discharged without symptoms or abnormalities on laboratory tests.

Successful therapeutic embolization of aldosteronoma using absolute ethanol.

Adrenal arterial infusion of absolute ethanol (AE) was successfully performed to treat a hyperfunctioning aldosteronoma. One milliliter of AE was infused into the branches of the inferior adrenal artery using a microcatheter with coaxial technique. No severe complications occurred during the procedure. The patient has experienced no recurrence of symptoms, and laboratory values have remained normal for eight months after therapy.

[Anticancer and side effect of arterial subsegmental chemoembolization using cisplatinum/pirarubicin lipiodol suspension (CTLS) for hepatocellular carcinoma].

Twenty patients with unresectable hepatocellular carcinoma were treated by intra-arterial subsegmental injection of Cisplatin/4-0-Tetrahydro-Pyranyl-adriamycin Lipiodol suspension (CTLS). The mean single doses of Lipiodol, cisplatin and THP were 2.3 ml, 85 mg and 8.9 mg, respectively. The therapy was given once in 10 patients, twice in 8 and 3 times in two. Over 25% reduction in tumor size was recognized in 12 patients (60%). Fifty or more % decrease of alfa-feto-protein (AFP) was observed in all of 7 patients (100%) with the initial serum AFP level of more than 200 ng/ml. Although transitional and mild symptoms, such as fever, abdominal pain and vomiting were recognized in some cases, no severe complications were encountered. This method is promising as an excellent procedure for unresectable hepatocellular carcinoma.

Treatment of hepatocellular carcinoma by intraarterial injection of adriamycin/mitomycin C oil suspension (ADMOS) alone or combined with cis-diaminodichloroplatinum (CDDP).

We evaluated the effects of intraarterial injection of Adriamycin/Mitomycin C oil (Lipiodol) suspension (ADMOS) alone and ADMOS+cis-diaminodichloroplatinum (CDDP) in 135 patients with hepatocellular carcinoma (HCC). A total of 59 patients received ADMOS alone and 76 patients received ADMOS+CDDP (ADMOS/CDDP). Tumor size was reduced by over 25% in 13 (34%) of the evaluable 38 patients in the ADMOS-alone group and in 39 (51%) of the 76 evaluable patients in the ADMOS/CDDP group. Serum alpha-fetoprotein (AFP) levels decreased by more than 50% in 10 (59%) of 17 ADMOS-alone patients and in 23 (70%) of 33 ADMOS/CDDP patients whose pretreatment AFP levels were above 0.2 mg/l. The overall one- and 2-year survival rates were 68% and 41%, respectively. No severe complications and no significant changes in laboratory values were observed, except for one patient in the ADMOS/CDDP group who developed a liver abscess. Although the tumor response was significantly better in patients treated by ADMOS/CDDP than in those treated by ADMOS-alone (p < 0.05), there was no significant difference in the survival rates between the 2 groups. The intraarterial injection of ADMOS and CDDP was concluded to be effective in treating HCC judging by tumor response.

[Hepatocellular carcinoma treated by intraarterial injection of adriamycin/mitomycin C oil suspension alone or combined with cis-diaminodichloroplatinum].

One hundred thirty-five patients with hepatocellular carcinoma (HCC) were treated by intraarterial injection of adriamycin/mitomycin C oil suspension (ADMOS) alone (59 cases) and ADMOS plus cis-diaminodichloroplatinum (CDDP) (76 cases). Tumor size was reduced by over 25% in 13 of 38 patients (35%) in the ADMOS alone group and in 39 of 76 patients (50%) in the ADMOS plus CDDP group. Serum alpha-fetoprotein (AFP) levels decreased by more than 50% in 7/17 (59%) in the ADMOS alone group and in 23/32 (70%) in the ADMOS plus CDDP group. The overall 1- and 2-year survival rates were 68% and 41% by the Kaplan-Meier method. However, no significant difference in the survival rates was observed between the two groups.

[MR imaging during arterio-portography (MR-AP) in the detection of hepatic cancer].

Magnetic resonance imaging during arterio-portography (MR-AP) was performed in 2 patients of hepatic cancer. Low dose of meglumine gadopentetate (4 ml of a 0.5 mmol/L solution) was injected into a superior mesenteric artery during acquisition of a Turbo-FLASH sequence. An increase in liver to lesion contrast was obtained with MR-AP and it is also useful in the late phase to distinguish a flow defect lesion due to portal obstruction from the tumor.

[Anticancer effect and side effect of arterial chemoembolization using cis-diamine-dichloroplatinum (II)/4-0-tetrahydropyranyl-adriamycin-lipiodol (CTL) suspension on hepatocellular carcinoma].

Seventeen patients with hepatocellular carcinoma were treated by intraarterial injection of CTL suspension. The doses of CTL suspension, CDDP and THP(mean +/- SD)/injection were 4.1 +/- 1.6 ml, 81.9 +/- 31.6 mg and 13.5 +/- 5.2 mg, respectively. The therapy was given once in 10 patients, twice in 6 and 4 times in one. Over 50 per cent reduction in tumor size was obtained in 5 patients (30%). Fifty or more % decrease in serum alpha-feto-protein (AFP) levels was observed in 3 of 7 patients (43%) with the initial serum AFP level of more than 200 ng/ml, Fever, abdominal pain, nausea and vomiting were noted in most cases. However, they disappeared within 2 weeks after therapy was completed. No severe complications were encountered except one case of a liver abscess which healed by administration of antibiotics. No severe changes in laboratory data were observed. This study suggests that a new method of intraarterial injection must be developed to enhance the therapeutic effect even more, in addition to an increased injection dose of CDDP/THP-LPD and higher concentration of CDDP and THP in LPD.

[Combined treatment of invasive bladder cancer by intra-arterial infusion chemotherapy of cisplatin with or without other anticancer agents and concurrent radiotherapy--initial response and side effects].

Fourteen patients with invasive bladder cancer were treated by bilateral internal iliac artery infusion of cisplatin, with or without other anticancer agents, and concurrent radiotherapy. Angiotensin II was simultaneously infused in 10 cases. Of the 14 patients, complete response and partial response were achieved in 9 (64%) and 3, respectively. Hematuria was controlled in all 8 patients, and pain was relieved in 3 of 4 patients. Side effects were observed in 8 patients: appetite loss in 8, nausea and/or vomiting in 7, and leukocytopenia in 6 patients, in 3 of whom radiotherapy had to be intermittent because of severe leukocytopenia (less than 2000/mm3). However, restoration of leukocytopenia occurred one week later. Thus, intra-arterial anticancer agents including cisplatin together with concurrent radiation may be one of the most effective therapies for invasive bladder cancer.