Silver-Mixed Port Reduces Venous Access Port Related Infection Rate Compared to Non-Silver-mixed Port: A Single-center Retrospective Analysis.

PURPOSE: Totally implantable venous access ports (TIVAPs) are increasingly used as safe and convenient central venous access devices. However, several TIVAP-related complications occur, with port/catheter infection being most common. Silver-mixed ports have recently been introduced in anticipation of reducing TIVAP infection. This study aimed to investigate the efficacy of this device in reducing port infection by examining groups with and without silver-mixed devices. MATERIALS AND METHODS: From April 2017 to July 2022, silver-mixed ports (S group) and non-silver-mixed port group (NS group) were reviewed at our institution. The incidence of TIVAP-related infections, patient characteristics, and bacteriological data were evaluated. Univariate and multivariate analyses were used to evaluate risk factors for TIVAP-related infection. RESULTS: A total of 607 patients (S group, n = 203; NS group, n = 404) were enrolled. The rates of TIVAP-related infection were 3.0% (n = 6) and 7.7% (n = 31) in the S and NS groups, respectively. The incidence of total infection per 1000 catheter-days were 0.114 and 0.214 the S and NS groups, respectively. In the entire group, the rates of infection were 6.1% (n = 37) and the incidence of total infection per 1000 catheter-days was 0.187. Univariate and multivariate analyses revealed a significantly lower TIVAP-related infection rate in S group than NS group (p = 0.0216, odds ratio = 2.88 confidence interval: 1.17-7.08). No gram-negative rods were detected in the S group as port infection. CONCLUSION: Silver-mixed port may be feasible in preventing port infection. LEVEL OF EVIDENCE: Level 3, Local non-random sample.

Polymerization Properties of n-Butyl Cyanoacrylate Mixed with Ethiodized Oil in the Lymphatic System: In Vivo Investigation in a Rabbit Model.

PURPOSE: To evaluate the polymerization properties of a mixture of n-butyl cyanoacrylate (nBCA) and ethiodized oil in the lymphatic system using an animal model. MATERIALS AND METHODS: Nineteen male Japanese White rabbits underwent 28 lymphatic embolization procedures under fluoroscopic guidance using manually injected mixtures of nBCA and ethiodized oil at ratios of 1:2 (nBCA density of 33%), 1:4 (20%), 1:6 (14%), and 1:8 (11%) via the popliteal lymph node. The time required for polymerization and the distance traveled by the mixture were evaluated and compared among the groups using the Kruskal-Wallis test. Histopathologic intergroup comparisons and time-course changes were also evaluated using embolized lymph nodes. RESULTS: Among 23 successful procedures, the mean polymerization times were 14 ± 3, 88 ± 93, 331 ± 292, and 932 seconds ± 540 and the mean distances traveled were 13 ± 10, 31 ± 44, 85 ± 89, and 108 mm ± 35 in the 33% (n = 5), 20% (n = 6), 14% (n = 6), and 11% (n = 6) groups, respectively. The 11% group demonstrated a significantly longer polymerization time than the 33%, 20%, and 14% groups and distance traveled than the 33% group. Pathologically, the embolized lymph nodes showed inflammatory changes and massive necrosis regardless of the nBCA density. CONCLUSIONS: Polymerization times and distances traveled were increased when nBCA was diluted with increasing quantitites of ethiodized oil in this rabbit model of lymphatic embolization. These relationships should be considered when dilution is prescribed for clinical use.

Inferior vena cava diameter on CT angiography predicts mesenteric angiography positive for extravasation in colonic diverticular bleeding.

PURPOSE: Transcatheter arterial embolization (TAE) for colonic diverticular bleeding (CDB), an established procedure for hemostasis, is sometimes complicated by spontaneous hemostasis and unclear bleeding site on angiography despite active arterial bleeding on preoperative computed tomography angiography (CTA). Therefore, to investigate and increase the feasibility of TAE, this retrospective study evaluates the clinical and radiological features related to positive extravasation on angiography. MATERIAL AND METHODS: Sixty CDB patients with extravasation on CTA underwent TAE between January 2011 and February 2021 and were divided into extravasation-positive (P-group; n = 25) and -negative groups (N-group; n = 35) based on the superior or inferior mesenteric angiography. Patient characteristics, laboratory findings, the diameter of the inferior vena cava (IVCD), the diameter of superior and inferior mesenteric veins, and technical outcomes were evaluated. RESULTS: TAE was successful in 24 patients in the P-group (96%) and 14 in the N-group (40%) (p < 0.001). Univariate analysis revealed "usage of anticoagulant" (p < 0.05) and "larger IVCD (p < 0.05) on preoperative CTA" to be significant predictors of positive extravasation. In the multivariate analysis, IVCD remained significant with an adjusted odds ratio of 1.17. The IVCD cutoff value was 13.6 mm (area under the curve = 0.72, sensitivity = 84.0%, specificity = 54.3%). There were no significant differences in other parameters. CONCLUSION: Measurement of IVCD in CDB with the cutoff value of 13.6 mm can be a simple and useful indicator to predict the detectability of extravasation following TAE procedures.

Efficacy and safety of endovascular therapy for delayed hepatic artery post-pancreatectomy hemorrhage: development of extrahepatic collateral circulation and complications of post endovascular therapy.

BACKGROUND: Endovascular therapy (ET) for delayed hepatic artery post-pancreatectomy hemorrhage (HA-PPH) may require complete hepatic artery occlusion (HAO). Nonetheless, the development of extrahepatic collateral circulation (EHC) and the relationship between radiological factors (EHC, portal vein stenosis, and HAO) and adverse hepatic events after ET remain unclear. This study aimed to evaluate the efficacy and safety of ET for delayed PPH and examine the development of EHC. METHODS: A total of 19 ET cases for delayed HA-PPH were reviewed. Hepatic adverse events, portal vein stenosis, HAO, and mortality rate after ET were evaluated. Moreover, EHC from the left gastric artery (LGA), right inferior phrenic artery (RIPA), left inferior phrenic artery (LIPA), right internal thoracic artery (RITA), left internal thoracic artery (LITA), renal artery (RA), omental artery (OA), intercostal artery (IA), and branch of superior mesenteric artery (BSMA) was assessed using angiogram and computed tomography angiography (CTA). RESULTS: All cases were successfully treated using transcatheter arterial embolization (n = 17) and stent-graft placement (n = 2) without mortality. EHC from the LGA (8/19), RIPA (10/19), LIPA (4/19), and RITA (3/19) was observed on post-ET CTA. The incidence of hepatic adverse events was significant in the group with both HAO and portal vein stenosis (p < 0.001) and absence of EHC from LIPA and RITA (p < 0.05). CONCLUSION: ET for delayed HA-PPH might be effective and safe. While avoiding both HAO and portal vein stenosis is important, the development of EHCs from LIPA and RITA may prevent hepatic adverse events after ET.

Risk and prognostic factors of post-catheterization pseudoaneurysm.

PURPOSE: To evaluate the risk and prognostic factors of post-catheterization pseudoaneurysm (PPA). MATERIAL AND METHODS: To identify the risk factors for PPA occurrence, clinical findings were compared between 22 consecutive patients with radiologically confirmed PPAs (PPA group) and 300 randomly extracted patients without PPA, who underwent transarterial angiography or intervention (sample group) between 1 January 2015 and 31 March 2020. The PPA group was further divided into those treated successfully with mechanical compression (group A) and those requiring ultrasound-guided thrombin injection after compression failed (group B). Univariate and multivariate analyses were used to compare patient demographics, preoperative laboratory findings, procedure details, PPA diameter, and time interval between the procedure and compression between groups A and B to evaluate the prognostic factors of PPA. RESULTS: The PPA group demonstrated significantly elevated prothrombin time international normalized ratios (PT/INR) (odds ratio [OR]: 6.27, 95% confidence interval [CI]: 2.020-19.5; p = 0.00151) and more frequent popliteal access (OR: 14.2, 95% CI: 1.040-195.0; p = 0.0467) compared to the sample group, and radial access decreased the risk of PPA (OR: 0.382, 95% CI: 0.0148-0.987; p = 0.0468). One of the 22 PPAs resolved spontaneously, and 11 others (52.4%) were successfully treated by mechanical compression. An interval exceeding 24 hours between the procedure and compression was the only significant prognostic factor (p = 0.0281) between groups A and B. CONCLUSIONS: Elevated PT/INR and popliteal access may predispose patients to PPA; close consideration of the site of access may lower the risk of refractory PPA.

Efficacy of Portal Vein Embolization with a Procedure of Sheath Injection and Balloon Occlusion with Gelatin Sponge.

INTRODUCTION: To evaluate the efficacy, safety, and associated complications of a novel and simple approach to portal vein embolization that utilizes sheath injection and balloon occlusion (PVE-SIBO) with gelatin sponge (GS) for the purpose of increasing future liver remnant (FLR) volume. METHODS: Between 1 January, 2006, and 31 August, 2020, 20 patients (15 men, 5 women, aged 64.6 ± 10.2 years) diagnosed with hepatobiliary malignancy underwent presurgical PVE-SIBO at our institution via a percutaneous transhepatic approach to the right portal vein and embolization of the portal vein with GS. We evaluated the increased ratio of FLR volume, operation duration, recanalization rate, and complications following this procedure. RESULTS: All procedures were successful and without complications such as subcapsular hematoma, intra-abdominal bleeding, and bile leakage. The increased ratio of FLR volume was 34.7 ± 23.7% after a mean of 14.3 ± 2.57 days, and there was a significant difference in the FLR volume before and after PVE (P < 0.01). Procedure time was 52.7 ± 11.4 minutes. CONCLUSION: PVE-SIBO with GS is a simple, effective, and safe procedure to increase the ratio of FLR volume prior to hepatic surgeries.

Hemorrhagic Complication in Surgical Resection for Massive Plexiform Neurofibroma in Body Trunk: The Flow-Void Sign as a Predictor and Preoperative Embolization as Prevention.

BACKGROUND: Plexiform neurofibromas (PNs) are highly vascularized and potentially malignant tumors. Surgical resection of a PN can be complicated by perioperative hemorrhagic events (PHE), including excessive intraoperative blood loss and postoperative hematoma at the surgical site. This study aimed to evaluate the predictive factors of PHE and the usefulness of preoperative embolization for PN. MATERIALS AND METHODS: Consecutive surgical resections of 24 massive PNs in the body trunk with a maximum diameter > 5 cm in 22 patients between January 2015 and December 2020 were reviewed. Patient demographics, laboratory analyses, MRI findings, preoperative transcatheter arterial embolization (TAE), and pathological findings were evaluated between PNs with and without PHE, which consists of intraoperative blood loss over 15% of their estimated total blood volume and/or postoperative hematoma requiring surgical intervention or blood transfusion. RESULTS: PHE was observed in 7 out of 24 PNs (29.2%), with 5 events of excessive intraoperative bleeding and 2 postoperative hematomas. The PHE group (n = 7) showed a significantly higher flow-void effect inside the tumor on preoperative MRI than the non-PHE group (n = 17) (P = 0.0186). Preoperative TAE was not associated with PHE occurrence for the 24 PNs; however, it significantly reduced the PHE risk by 12 PNs with a flow-void sign (P = 0.00126). Other characteristics showed no significant differences between groups. CONCLUSION: The flow-void sign on MRI can be the only predictive factor of PHE in surgical resection for massive PNs in the body trunk. Preoperative TAE can reduce the PHE risk for PNs with a flow-void sign.

Evaluation of the usefulness of cystic duct three-dimensional computed tomography with non-contrast for before laparoscopic cholecystectomy and endoscopic transpapillary gallbladder drainage in comparison to magnetic resonance cholangiopancreatography.

INTRODUCTION: The purpose of this study is to evaluate whether anatomical variations of the cystic duct and accessory bile duct can be grasped by cystic duct three-dimensional (3D)-computed tomography (CT) using non-contrast CT and to examine the possibility of omitting magnetic resonance cholangiopancreatography (MRCP). METHODS: Of patients who underwent non-contrast abdominal CT between May and October 2019, those who underwent MRCP within 1 month before and afterwards were targeted. Seven assessors visually evaluated the cystic duct 3D-CT images on a 5-point scale. Average scores of ≥3 and <3 points were assigned as the good and poor groups, respectively. Regions of interest (ROIs) were placed inside the cystic duct and four places around it, and the CT values in those ROIs were measured. The CT value difference was calculated by subtracting the surrounding CT values from the CT value in the cystic duct and converting the result to an absolute value. The CT value difference was classified into good and poor groups, and statistical analysis was performed. Seven assessors evaluated anatomical variations of the cystic duct and the presence of the accessory bile duct. The results were compared with the MRCP interpretation results to calculate sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS: The average visual evaluation score was 3.8. The good and poor groups were comprised by 53 (85.5%) and 9 (14.5%) patients, respectively. The CT difference value averages were 54.7 and 15.9 for the good and poor groups, respectively, and the value was significantly higher in the good group (p = 0.001). The comparison results with MRCP were sensitivity=83.3%, specificity=78.0%, positive predictive value=47.6%, and negative predictive value=95.1%. CONCLUSION: Cystic duct 3D-CT using non-contrast CT is a useful technique for understanding anatomical variations of the cystic duct and accessory bile duct. Our method may reduce the number of MRCP sessions performed.

Retrograde transvenous lymphatic embolization for postoperative chylous ascites: A report of three cases and literature review.

Percutaneous transabdominal lymphangiography and embolization have been reported as useful approaches for intractable chylothorax or chylous ascites. However, they are often difficult to perform after extensive lymph node dissection because disruption of the antegrade lymphatic flow makes leaks identification difficult. When the leakage point cannot be identified or percutaneous transabdominal lymphangiography and embolization fail, a retrograde transvenous approach to the thoracic duct can be used instead. We report 3 cases of refractory chylous ascites after retroperitoneal operation or extensive lymph node dissection that was addressed by retrograde transvenous lymphatic embolization. In one case, a combination of retrograde transvenous lymphatic embolization, transcatheter sclerotherapy, and transcatheter embolization was used. These findings suggest that retrograde transvenous lymphatic embolization appears to be feasible and efficient for postoperative chylous ascites.

Ectopic origin of bronchial arteries: still a potential pitfall in embolization.

PURPOSE: To evaluate the influence of ectopic origin of bronchial arteries (BAs) on bronchial artery embolization (BAE) for hemoptysis. METHODS: CT and angiography images of 50 consecutive sessions in 39 patients (aged 26-93 years; mean, 70.6 years) who underwent BAE for hemoptysis from April 2010 to December 2019 were reviewed. We defined ectopic BA as a systemic artery originating from other than the T5-T6 vertebral level of the descending aorta with course along the major bronchi. The background of patients, number of BAs, culprit arteries, and treatment outcomes were compared between the cases with and without ectopic BAs. RESULTS: Seventeen patients (43.6%) demonstrated 19 ectopic BAs, originating from the subclavian artery (n = 7), aortic arch above the T5-T6 level (n = 6), internal mammary artery (n = 3), brachiocephalic trunk (n = 2) or lower descending thoracic aorta (n = 1). Total number of BAs in the cases with ectopic BA was significantly greater than those in cases without ectopic BA (p = 0.0062). Required sessions of embolization were similar in the two groups. No procedure-related significant complications were noted; however, four ectopic BAs caused unexpected filling of contrast media or migration of the embolic material from the orthotopic BA to ectopic BA originating from the arch vessels via tiny communication. CONCLUSION: Although BAE under the presence of ectopic BA is feasible and safe, detection of BAs with ectopic origin, even of small diameter, is needed to avoid risk of non-target coursing of embolic materials.

A rare manifestation of clinical T1 renal tumor with parasitic arterial supply from the superior mesenteric artery.

A 50-year-old man with von Hippel-Lindau syndrome who had undergone repeated tumor enucleation and transcatheter arterial embolization for multiple renal cell carcinomas (RCC) was referred to our hospital for percutaneous cryoablation (PCA) of an RCC of 42 mm in the midpole region of the right kidney. Transcatheter arterial embolization was planned prior to devascularize the RCC and selective angiography revealed parasitic arterial supply to the tumor by the ileocecal artery. Parasitic arterial supply to RCCs, particularly in patients with history of nephron-sparing treatment, can originate even from an intraperitoneal source and may lead to unexpected embolization.

Percutaneous cryoablation for stage T1b renal cell carcinoma in a patient with horseshoe kidney.

We report the first case of percutaneous cryoablation (PCA) for stage T1b renal cell carcinoma (RCC) in a horseshoe kidney (HK). A 76-year-old man with an HK underwent computed tomography-guided PCA for RCC measuring 42 mm (stage T1b) in diameter. Although transcatheter embolization before the PCA and hydrodissection were required to avoid complication and incomplete ablation, PCA was successfully performed without complication. The complete ablation was confirmed on computed tomography images 1 month after the procedure. There was no recurrence or metastasis during 2 years of follow-up. We believe this is the first report of PCA for stage T1b RCC in a patient with HK. This technique can be performed without regard to tumor size and location and may be considered as a treatment option to avoid complex surgery.

Percutaneous puncture and embolisation for pancreatitis-related pseudoaneurysm: the feasibility of thrombin injection even in collection of fluid surrounding the pseudoaneurysm.

PURPOSE: Pancreatitis-related pseudoaneurysm, a potentially life-threatening condition, is treated utilising endovascular management as a first choice and alternatively by percutaneous direct puncture of the aneurysm and embolisation. CASE REPORT: A 50-year-old man with alcohol-induced necrotic pancreatitis underwent transcatheter arterial embolisation (TAE) for multiple pancreatic pseudoaneurysms. TAE failed in one enlarged aneurysm in the pancreatic body, and percutaneous direct needle puncture and coagulation using thrombin was planned. Precise puncture of the aneurysmal sac under fluoroscopy and computed tomographic (CT) guidance failed, but we could inject about 500 units of thrombin through the outer cannula into the collection of fluid surrounding the aneurysm. Compared to preoperative images, contrast-enhanced CT (CECT) showed shrinkage of the pseudoaneurysm without complications just after the procedure and its disappearance five days after the procedure. CONCLUSIONS: Percutaneous direct puncture and embolisation is a feasible choice to treat pancreatic pseudoaneurysms, and injection of thrombin even into the collection of fluid surrounding the pseudoaneurysm can be a viable alternative, especially in cases in which precise puncture of the aneurysmal sac is difficult because of its size and location.

Transcatheter Arterial Embolization with a Mixture of Absolute Ethanol and Iodized Oil for Poorly Visualized Endophytic Renal Masses Prior to CT-Guided Percutaneous Cryoablation.

PURPOSE: To retrospectively evaluate the feasibility of transcatheter arterial embolization (TAE) using a mixture of absolute ethanol and iodized oil to improve localization of endophytic renal masses on unenhanced computed tomography (CT) prior to CT-guided percutaneous cryoablation (PCA). MATERIALS AND METHODS: Our institutional review board approved this retrospective study. From September 2011 to June 2015, 17 patients (mean age, 66.8 years) with stage T1a endophytic renal masses (mean diameter, 26.5 mm) underwent TAE using a mixture of absolute ethanol and iodized oil to improve visualization of small and endophytic renal masses on unenhanced CT prior to CT-guided PCA. TAE was considered successful that accumulated iodized oil depicted whole of the tumor edge on CT. PCA was considered successful when the iceball covered the entire tumor with over a 5 mm margin. Oncological and renal functional outcomes and complications were also evaluated. RESULTS: TAE was successfully performed in 16 of 17 endophytic tumors. The 16 tumors were performed under CT-guided PCA with their distinct visualization of localization and safe ablated margin. During the mean follow-up period of 15.4 ± 5.1 months, one patient developed local recurrence. Estimated glomerular filtration rate declined by 8 % with statistical significance (P = 0.01). There was no procedure-related significant complication. CONCLUSION: TAE using a mixture of absolute ethanol and iodized oil to improve visualization of endophytic renal masses facilitated tumor localization on unenhanced CT, permitting depiction of the tumor edge as well as a safe margin for ablation during CT-guided PCA, with an acceptable decline in renal function.

Digestive Tract Complications of Renal Cryoablation.

We report a case each of duodenorenal and colorenal fistula that arose after computed tomography-guided percutaneous cryoablation (PCA) for renal cell carcinoma and use imaging and endoscopic findings to analyze their causes and mechanisms. Both complications occurred though the edge of the iceball did not touch the intestinal wall, and patients' symptoms and fistula formation occurred several days after the PCA procedure. Based on imaging and endoscopy findings, we suspected the colorenal fistula resulted from bowel injury caused by ischemia from the occlusion of small vessels at the procedure's low temperature. Both cases were resolved conservatively without surgical intervention.

Transcatheter embolization for hemoptysis associated with anomalous systemic artery in a patient with scimitar syndrome.

BACKGROUND: Scimitar syndrome can present with a wide clinical spectrum of symptoms either early in the neonatal period or later in life. CASE DESCRIPTION: We report a case of a 62-year-old woman with anomalous systemic arterial supply to the basal lung with scimitar syndrome presenting as recurrent hemoptysis. Bronchoscopy revealed normal major bronchial branches without bronchial atresia, indicating that sequestration of the lung was not confirmed. The anomalous drainage of the scimitar vein was to the inferior vena cava, and an anomalous artery from the aorta supplied the right basal lung. There were no findings of pulmonary hypertension and arteriovenous malformation such as an anomalous artery to the scimitar vein. The distal portions of anomalous arteries were embolized using gelatin sponge particles and the proximal portion was embolized using fibered detachable coils. Although a small pulmonary infarction was observed as a complication, the patie nt has not experienced any subsequence recurrence of the hemoptysis during a follow-up period of 6 months. DISCUSSION AND EVALUATION: Deformities of the blood vessels and the lungs are frequently complex in scimitar syndrome. Although patients treated with surgical repair of this disorder may be at higher risk than those treated less invasively, we believe that transcatheter embolization was a useful strategy for the treatment of the anomalous systemic arterial supply to the basal lung, particularly in this patient with scimitar syndrome. CONCLUSION: Hemoptysis in a patient with scimitar syndrome associated with anomalous systemic arterial supply to the basal lung was successfully treated with transcatheter arterial embolization. However, it might be better to avoid the use of gelatin sponge particles in patients with a similar anomaly without pulmonary artery distribution because of the possibility of causing severe pulmonary infarction.

A successful case of liver biopsy via the right femoral vein using the Quick-Core biopsy needle.

A 35-year-old male with ascites and coagulopathy underwent transjugular liver biopsy (TJLB) for severe hepatic dysfunction. However, the acute angle of the inferior vena cava and hepatic veins (HVs) prevented insertion of a 14-gauge inner stiffening metallic cannula into the HV. He then underwent successful liver biopsy by right femoral vein access (transfemoral liver biopsy) using a TJLB device without complications and was pathologically diagnosed with nonalcoholic steatohepatitis.