CT angiography for the management of postpartum hemorrhage refractory to conservative treatment.

INTRODUCTION: Postpartum hemorrhage (PPH) is one of the leading causes of maternal morbidity and mortality. Computerized tomographic (CT) angiography is a useful tool to identify hemorrhage from various conditions. However, the feasibility of CT angiography for the management of PPH has not been well evaluated. OBJECTIVE: To evaluate the clinical usefulness of CT angiography in the management of PPH refractory to the conservative treatment. METHODS: This retrospective cohort study consisted of 528 consecutive patients who were transferred to our institute after delivery at 28 primary maternity hospitals for the management of PPH between 2009 and 2017. Immediate intervention such as arterial embolization and hysterectomy were performed on 278 patients. Of the remaining 250 patients, CT angiography was performed on 61 patients with hemodynamic stability but with sustained hemorrhage refractory to medical treatment. The diagnostic index was assessed using conventional angiography as the reference standard. The clinical outcome was compared between patients with and without contrast extravasation on CT angiography. RESULTS: (1) The prevalence of contrast extravasation was found in 61% of patients (37/61); (2) conventional angiography and arterial embolization were performed in 78% of patients (29/37) with contrast extravasation on CT angiography. Contrast extravasation was confirmed in 83% of patients (24/29) by conventional angiography; (3) among the 24 patients without contrast extravasation on CT angiography, 96% (23/24) were managed conservatively; (4) the patients with contrast extravasation on CT angiography received more packed red blood cell (PRBC) transfusion than those without that condition (7.3 ± 5.2 units vs. 3.8 ± 2.9 units, p = .009). Massive transfusion (defined as transfusion of 10 or more units of PRBC) was more common in patients with contrast extravasation than in those without (27% [10/37] vs. 0% [0/24], p = .004). CONCLUSIONS: Conservative treatment succeeded in 96% of patients without contrast extravasation on CT angiography. CT angiography is useful to identify patients requiring intervention in the management of hemorrhage refractory to medical treatment.

Percutaneous treatment of benign bilioenteric anastomotic strictures: temporary covered stent placement versus balloon dilatation.

OBJECTIVES: To compare percutaneous temporary covered stent placement with balloon dilatation in the treatment of benign stricture of bilioenteric anastomosis. METHODS: From November 2004 to August 2017, 56 patients with benign bilioenteric anastomotic strictures underwent percutaneous transhepatic treatment. A temporary covered stent designed for spontaneous migration was placed in 23 patients (stent group). Balloon dilatation was performed in 33 patients (balloon group). The technical success, percutaneous transhepatic biliary drainage (PTBD) indwelling times, stent indwelling times and patency rates were retrospectively compared between the two groups. RESULTS: Technical success was achieved in all patients in the stent group and in 96.8% (32/33) of patients in the balloon group. All stents spontaneously migrated into the jejunum, and stent indwelling times were 3-9 months (median, 6 months). The PTBD indwelling time was shorter for the stent group than for the balloon group (median, 7 vs. 71 days, p = 0.001). Recurrent strictures occurred more frequently in the balloon group than in the stent group (54.5% vs. 13.0%, p = 0.002; hazard ratio 3.7). The 1- and 3-year primary patency rates were 90.2% and 84.9% for the stent group and 75.1% and 52.8% for the balloon group, respectively (p = 0.04). CONCLUSIONS: Percutaneous temporary covered stenting is an effective treatment in patients with benign bilioenteric anastomotic strictures. It provides longer patency and shorter PTBD indwelling time compared with balloon dilatation. KEY POINTS: • A temporary covered stent designed for spontaneous migration is a feasible and effective treatment for patients with benign bilioenteric anastomotic strictures. • Percutaneous temporary covered stents provide longer patency and shorter drainage catheter indwelling time compared with conventional balloon dilatation. • A covered stent with flared ends spontaneously migrated after 3-9 months.

Comparison of Combined Therapy Using Conventional Chemoembolization and Radiofrequency Ablation Versus Conventional Chemoembolization for Ultrasound-Invisible Early-Stage Hepatocellular Carcinoma (Barcelona Clinic Liver Cancer Stage 0 or A).

Objective: To compare the therapeutic efficacy between conventional transarterial chemoembolization (cTACE) and combined therapy using cTACE and radiofrequency ablation (RFA) in ultrasound (US)-invisible early stage hepatocellular carcinoma (HCC). Materials and Methods: From January 2008 to June 2016, 167 patients with US-invisible early stage HCCs were treated with cTACE alone (cTACE group; n = 85) or cTACE followed by immediate fluoroscopy-guided RFA targeting intratumoral iodized oil retention (combined group; n = 82). Procedure-related complications, local tumor progression (LTP), time to progression (TTP), and overall survival (OS) were compared between the two groups. Multivariate analyses were performed to identify prognostic factors. Results: There was no major complication in either group. The cTACE group showed higher 1-, 3-, and 5-year LTP rates than the combined group; i.e., 12.5%, 31.7%, and 37.0%, respectively, in the cTACE group; compared to 7.3%, 16.5%, and 16.5%, respectively, in the combined group; p = 0.013. The median TTP was 18 months in the cTACE group and 24 months in the combined group (p = 0.037). Cumulative 1-, 3-, and 5-year OS rates were 100%, 93.2%, and 87.7%, respectively, in the cTACE group and 100%, 96.6%, and 87.4%, respectively, in the combined group (p = 0.686). Tumor diameter > 20 mm and cTACE monotherapy were independent risk factors for LTP and TTP. Conclusion: Combined therapy using cTACE followed by fluoroscopy-guided RFA is a safe and effective treatment in US-invisible early stage HCCs. It provides less LTP and longer TTP than cTACE alone.

Transjejunostomy Stent Placement in Patients With Malignant Small-Bowel Obstructions.

OBJECTIVE: The objective of our study was to evaluate the clinical effectiveness and safety of transjejunostomy stent placement in patients with malignant small-bowel obstructions (SBOs). MATERIALS AND METHODS: Twenty-three patients (age range, 20-81 years) who underwent transjejunostomy stent placement between March 2009 and December 2016 for one (n = 20) or two (n = 3) malignant SBOs from advanced abdominal and pelvic malignancies were included in our study. Percutaneous jejunostomy was created 30-100 cm upstream to malignant SBOs and was immediately followed by stent placement through the jejunostomy stoma during the same session. A retrospective analysis was conducted for technical success, bowel decompression, improvement of obstructive symptoms (3-point scale), improvement of food intake capacity (4-point scale), and procedure-related complications. RESULTS: Stent placement was technically successful in 22 of 23 patients (95.7%). Bowel decompression was confirmed by enterography (n = 21) and CT (n = 16). Obstructive symptoms improved partially (n = 9) or completely (n = 13) within 2 weeks after the procedure. Food intake capacity improved by 3 points in one patient, 2 points in seven patients, and 1 point in 14 patients (p < 0.0001). Major complications (n = 3, 13.0%), including localized peritonitis (n = 2) and bowel perforation (n = 1), were successfully treated conservatively. CONCLUSION: Transjejunostomy stent placement is an effective treatment in patients with malignant SBOs. It is technically feasible in most patients (95.7%) and provides substantial symptomatic improvement. Procedure-related complications are not rare but can be managed conservatively.

Cryptogenic Hemoptysis: Effectiveness of Bronchial Artery Embolization Using N-Butyl Cyanoacrylate.

PURPOSE: To describe angiographic findings and assess safety and effectiveness of bronchial artery embolization (BAE) with N-butyl cyanoacrylate (NBCA) in patients with cryptogenic hemoptysis (CH). MATERIALS AND METHODS: Between May 2003 and March 2014, 26 patients who underwent BAE for CH were enrolled. A retrospective review was conducted for angiographic findings and clinical outcomes of BAE, including technical and clinical success, complications, and recurrent hemoptysis. RESULTS: Selective arteriograms were abnormal in 22 patients (85%), showing hypertrophied bronchial arteries (n = 19), parenchymal hypervascularity (n = 18), and bronchial-to-pulmonary shunting (n = 8). All abnormal bronchial and nonbronchial collateral arteries (n = 36) were successfully embolized with NBCA. Hemoptysis ceased within 24 hours in all patients. There were no procedure-related complications. During 11-117 months of follow-up (median, 60.2 mo), 1 patient (4%) experienced recurrent hemoptysis at 5 months after initial BAE, which was treated with repeat BAE. The 5-year hemoptysis-free survival rate was 96%. CONCLUSIONS: Bronchial arteries were angiographically abnormal in most patients with CH (85%). BAE is a safe and effective treatment with excellent short- and long-term results in patients with CH. NBCA appears to be a useful embolic material for this application.

Percutaneous transhepatic versus EUS-guided gallbladder drainage for malignant cystic duct obstruction.

BACKGROUND AND AIMS: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) has been proposed as an alternative management strategy for acute cholecystitis caused by malignant cystic duct obstruction in patients for whom surgery is not an option. This study aimed to compare the results of EUS-GBD with those of percutaneous transhepatic gallbladder drainage (PTGBD) for palliative management of malignant cystic duct obstruction with acute cholecystitis or symptomatic gallbladder hydrops. METHODS: Between November 2013 and November 2015, 14 patients with acute cholecystitis or symptomatic gallbladder hydrops as a result of malignant cystic duct obstruction underwent EUS-GBD with covered metal stents. Nineteen patients with acute cholecystitis as a result of malignant cystic duct obstruction who received PTGBD served as a control group. Patients' medical records were reviewed retrospectively. RESULTS: The technical and clinical success rates of EUS-GBD were 85.7% (12/14) and 91.7% (11/12) and of PTGBD were 100% (19/19) and 86.4% (17/19), respectively. The groups had similar adverse event rates (28.5% and 21.1%, respectively). The average duration of stent patency in patients with EUS-GBD was 130.3 ± 35.3 days, and no patient required an additional procedure before death. In 6 of 17 patients (35.3%) with clinically successful PTGBD, the catheter was not removed until the end stage of life. CONCLUSIONS: EUS-GBD is a feasible, safe, and effective modality for the treatment of malignant cystic duct obstruction in patients who are not indicated for surgery. It enables improved long-term quality of life in patients with advanced-stage cancer.

Clinical results of renal artery embolization to control postoperative hemorrhage after partial nephrectomy.

BACKGROUND: With the wider application of nephron-sparing surgery, there has been an increase in the occurrence of postoperative hemorrhage. However, despite such an increase, there are only a limited number of reports regarding renal artery embolization (RAE) for the management of postoperative bleeding after nephron-sparing surgery, especially after robot-assisted laparoscopic partial nephrectomy (RALPN). PURPOSE: To evaluate the safety and clinical efficacy of transcatheter RAE for postoperative hemorrhage after open partial nephrectomy (OPN) and RALPN. MATERIAL AND METHODS: A total of 29 patients (17 men, 12 women; age range, 31-70 years) who were referred to our hospital for postoperative hemorrhage after partial nephrectomy, between December 2003 and December 2014, were selected. We retrospectively reviewed patients' clinical data, angiographic findings, embolization details, and clinical outcomes. RESULTS: Embolization was performed in patients who underwent OPN (25/29) and RALPN (4/29). The angiographic findings were as follows: renal artery pseudoaneurysm (n = 18), contrast extravasation (n = 8), and arteriovenous fistula (n = 3). Fiber-coated microcoil and n-butyl-2-cyanoacrylate (NBCA) was administered to the targeted bleeding renal arteries in 12 and 11 patients, respectively. In six patients, fiber-coated microcoil and NBCA were used concurrently. Technical and clinical successes were achieved in all patients (100%). Bleeding cessation was achieved in all patients, and no further relevant surgeries or interventions were required for hemorrhage control. There were no episodes of hemorrhagic recurrence during the follow-up period (median, 20 days; range, 7-108 days). CONCLUSION: Angiography and RAE identified the origin of bleeding and could successfully preserve the residual renal function.

Off-site smartphone reading of CT images for patients with inconclusive diagnoses of appendicitis from on-call radiologists.

OBJECTIVE: The purpose of this study was to simulate a mobile consultation in patients with inconclusive diagnosis of appendicitis made by on-call radiologists, as well as to measure the diagnostic confidence and performance of the mobile consultation. MATERIALS AND METHODS: Two off-site abdominal radiologists interpreted the CT images from 68 patients (including 29 patients with confirmed appendicitis) on a smart-phone for whom the preliminary CT reports by 25 in-house on-call radiologists were inconclusive. The smartphone readings were compared with the preliminary reports by on-call radiologists and with the original final reports by in-house abdominal radiologists. Heat maps, kappa statistics, Wilcoxon signed-rank tests, and ROC curves were used for data analysis. RESULTS: The heat maps and kappa statistics showed that the smartphone readings were more similar to the final reports than to the preliminary reports. In diagnosing or ruling out appendicitis, the smartphone readings were more confident than the preliminary reports (p ≤ 0.01) and did not significantly differ in diagnostic confidence from the final reports (p ≥ 0.19). The AUCs of the smartphone readings (0.91 and 0.92) did not differ significantly from those of the preliminary (0.85) or final (0.97) reports (p ≥ 0.09). CONCLUSION: With the given study sample, the diagnostic performance of the off-site smartphone readings did not differ significantly from that of the in-house preliminary reports. However, the smartphone readings provided higher diagnostic confidence than the preliminary reports.

Post-operative hemorrhage after myomectomy: safety and efficacy of transcatheter uterine artery embolization.

OBJECTIVE: To evaluate the safety and clinical efficacy of transcatheter uterine artery embolization (UAE) for post-myomectomy hemorrhage. MATERIALS AND METHODS: We identified eight female patients (age ranged from 29 to 51 years and with a median age of 37) in two regional hospitals who suffered from post-myomectomy hemorrhage requiring UAE during the time period from 2004 to 2012. A retrospective review of the patients' clinical data, uterine artery angiographic findings, embolization details, and clinical outcomes was conducted. RESULTS: The pelvic angiography findings were as follows: hypervascular staining without bleeding focus (n = 5); active contrast extravasation from the uterine artery (n = 2); and pseudoaneurysm in the uterus (n = 1). Gelatin sponge particle was used in bilateral uterine arteries of all eight patients, acting as an empirical or therapeutic embolization agent for the various angiographic findings. N-butyl-2-cyanoacrylate was administered to the target bleeding uterine arteries in the two patients with active contrast extravasation. Technical and clinical success were achieved in all patients (100%) with bleeding cessation and no further related surgical intervention or embolization procedure was required for hemorrhage control. Uterine artery dissection occurred in one patient as a minor complication. Normal menstrual cycles were restored in all patients. CONCLUSION: Uterine artery embolization is a safe, minimally invasive, and effective management option for controlling post-myomectomy hemorrhage without the need for hysterectomy.

Treatment outcomes of transcatheter arterial chemoembolization for hepatocellular carcinoma that invades hepatic vein or inferior vena cava.

PURPOSE: We aimed to elucidate the treatment outcomes of transcatheter arterial chemoembolization (TACE) and survival-associated factors in hepatocellular carcinoma (HCC) patients with hepatic vein (HV) and/or inferior vena cava (IVC) invasion. METHODS: The subjects were consecutively enrolled, newly diagnosed HCC patients with HV/IVC invasion who underwent TACE (n = 62) at the Seoul National University Bundang Hospital from May 2003 to October 2012. Clinical characteristics, treatment responses, overall survival, and survival-related factors were analyzed. RESULTS: The mean subject age was 56.6 years, 82.3% were hepatitis B surface antigen-positive, and 76.2% were classified as Child-Pugh class A. The tumor volume was ≥50% of the liver in 64.5% of patients, and 79, 41.9, and 9.7% of patients had accompanying portal vein, IVC, and right atrial invasion, respectively. TACE response rates for primary tumors and tumor thrombi in HV or IVC were 55.6 and 13%, respectively. Median overall survival was 10.9 months (range 0.1-23.0 months). Multivariate analysis showed that Child-Pugh class A (hazard ratio [HR] = 0.31; 95% confidence interval [CI] 0.14-0.72; p = 0.007), tumor volume <50% of liver (HR = 0.31; 95% CI 0.11-0.83; p = 0.019), alpha-fetoprotein (AFP) response (HR = 0.28; 95% CI 0.11-0.69; p = 0.006), and tumor thrombi treatment response (HR = 0.09; 95% CI 0.01-0.77; p = 0.027) were independent survival-related factors. CONCLUSIONS: TACE seems effective for HCC with HV/IVC invasion, especially in patients with preserved hepatic function, a treatment response for tumor thrombi, and an AFP response.

Bronchial artery embolization to control hemoptysis: comparison of N-butyl-2-cyanoacrylate and polyvinyl alcohol particles.

PURPOSE: To retrospectively compare safety and effectiveness of embolic agents polyvinyl alcohol (PVA) particles versus n-butyl-2-cyanoacrylate (NBCA) for bronchial artery embolization (BAE) for control of hemoptysis. MATERIALS AND METHODS: Institutional review board approved this retrospective study; informed consent was waived. From January 2005 to December 2008, 406 patients (242 men, 164 women; age range, 6-92 years) with major hemoptysis underwent BAE by using PVA particles (n = 293) or NBCA (n = 113). Technical and clinical success, complications, hemoptysis-free survival rates, and causes of recurrent hemoptysis were compared between PVA and NBCA groups. The differences in hemoptysis-free survival rates were assessed between subgroups stratified to underlying diseases. The predictive factor for recurrent hemoptysis was identified with Cox proportional hazard regression model. RESULTS: Technical success was achieved in 93.9% (275 of 293) and 96.5% (109 of 113) of patients for PVA and NBCA, respectively (P = .463); clinical success was achieved in 92.2% (270 of 293) and 96.5% (109 of 113) of patients for PVA and NBCA, respectively (P = .180). Overall and major complication rates were not statistically different (overall complication rates: 34.1% for PVA, 31.0% for NBCA; P = .56; major complication rates: 0.3% for PVA, 0% for NBCA; P > .999). The 1-, 3-, and 5-year hemoptysis-free survival rates were, respectively, 77%, 68%, and 66% for PVA and 88%, 85%, and 83% for NBCA (P = .01). Recanalization of previously embolized vessels was more frequent in PVA group (21.5%) than in NBCA group (1.8%; P < .001). NBCA group showed hemoptysis-free survival rates superior to PVA group in patients with bronchiectasis (P = .016). PVA (P = .050) and aspergilloma (P < .001) were predictive factors for recurrent hemoptysis. CONCLUSION: BAE with NBCA provided higher hemoptysis-free survival rates compared with PVA particles without increasing complication rates. This improvement was evident in patients with bronchiectasis and was caused by more durable embolic effect than PVA particles. SUPPLEMENTAL MATERIAL: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.13130046/-/DC1.

Safety and efficacy of radiological percutaneous jejunostomy for decompression of malignant small bowel obstruction.

OBJECTIVES: This study aimed to evaluate the safety and efficacy of percutaneous radiological jejunostomy (PRJ) and stent placement in patients with malignant small bowel obstructions (MSBO). METHODS: A total of 21 patients (mean age 60 years) with single (n = 4) or multiple (n = 17) MSBO underwent PRJ following jejunopexy. The medical records and imaging studies were retrospectively reviewed to evaluate the technical/clinical success and complications. Clinical success was determined by symptomatic relief and radiologic bowel decompression. RESULTS: PRJ using a 12- or 14-F drainage catheter was technically successful in all patients. Eleven patients required placement of an 18-F nasogastric tube across one (n = 3), two (n = 6) and three (n = 2) obstructions to achieve clinical success. Subsequently, self-expandable stents were placed through the PRJ tracts to recanalise MSBO in four patients. Clinical success was achieved in 18 patients (85.7 %). The median food intake capacity score improved from 4.0 to 2.0 (P = 0.001). There were one major (peritonitis, 4.8 %) and six minor complications (28.6 %) CONCLUSIONS: PRJ using a nasogastric tube across the obstructions is an effective palliative treatment for MSBO. The PRJ tract can be used as an approach route for stent placement to recanalise MSBO. However, dedicated devices should be developed to reduce frequent procedure-related complications. KEY POINTS: • Bowel decompression provides palliative treatment in malignant small bowel obstruction • Percutaneous radiological jejunostomy (PRJ) is a safe and effective palliative treatment. • Long tube placement across obstructions facilitates adequate drainage of multiple bowel obstructions. • PRJ tract can be used for stent placement to approach MSBO recanalisation.

Postpartum haemorrhage from ruptured pseudoaneurysm: efficacy of transcatheter arterial embolisation using N-butyl-2-cyanoacrylate.

OBJECTIVES: To evaluate the efficacy of transcatheter arterial embolisation (TAE) using N-butyl-2-cyanoacrylate (NBCA) in the treatment of postpartum haemorrhage (PPH) due to ruptured pseudoaneurysm. METHODS: From March 2004 to December 2010, 33 patients underwent TAE using NBCA for massive PPH. Twenty-one patients (63.6 %) were in coagulopathic condition. Angiograms and medical records were retrospectively reviewed to determine technical/clinical success, complications and recurrent haemorrhage after TAE. Telephone interviews were conducted to obtain fertility-related data. RESULTS: Emergent angiograms revealed ruptured pseudoaneurysms at the uterine (n = 17), vaginal (n = 14), internal pudendal (n = 3) and obturator (n = 1) arteries, which were successfully embolised with NBCA. Four patients required additional embolisation of the uterine (n = 3) or ovarian artery (n = 1) with an absorbable gelatine sponge. Adequate haemostasis was achieved in 31 patients (93.9 %) after TAE. Two patients experienced persistent (n = 1) or recurrent (n = 1) haemorrhage, which required hysterectomy. There were no major embolisation-related complications. All 29 patients who were interviewed reported regaining of their regular menstruation. Nine patients had normal pregnancies and delivered healthy babies at full term. CONCLUSIONS: TAE using NBCA is an effective treatment of PPH from ruptured pseudoaneurysms. In particular, NBCA is a potent embolic material in patients with coagulopathy. It does not seem to adversely affect future fertility. KEY POINTS: • Transcatheter arterial embolisation is a safe and effective treatment for postpartum haemorrhage. • NBCA is potent embolic material to treat bleeding patients with severe coagulopathy. • NBCA does not seem to adversely affect future fertility.

Failed pelvic arterial embolization for postpartum hemorrhage: clinical outcomes and predictive factors.

PURPOSE: To evaluate clinical outcomes of failed pelvic arterial embolization (PAE) and determine predictive factors associated with this failure in the treatment of postpartum hemorrhage (PPH). MATERIALS AND METHODS: This retrospective study included all consecutive patients who underwent PAE for life-threatening PPH between March 2004 and January 2011 at a tertiary-care center. Medical records and imaging studies were reviewed to identify cases of failed PAE and their clinical outcomes. Multiple parameters were compared between the failed and successful PAE groups, and multivariate analysis was performed to determine the predictive factors associated with failed PAE. RESULTS: PAE was performed in 257 patients (mean age, 32 y; range, 20-40 y). A total of 24 cases of PAE involved a failure to achieve hemostasis (9.3%). Patients in the failed PAE group experienced more major complications than those in the successful PAE group (37.5% [nine of 24] vs 9.4% [22 of 233]). Factors more frequently found in failed PAE included hemodynamic instability, hemoglobin level lower than 8g/dL, disseminated intravascular coagulation (DIC), and extravasation detected on angiography. After multivariate analysis, DIC emerged as the only significant predictive factor (odds ratio, 6.569; 95% confidence interval, 1.602-26.932; P = .009). CONCLUSIONS: PAE is an effective treatment for medically intractable PPH. However, PAE failed in a high percentage of patients and was commonly associated with major complications. DIC was the only significant predictor of failed PAE.

Inaccessible postoperative abdominal abscess: percutaneous drainage technique with puncture of a sinus tract.

The present report describes percutaneous drainage involving puncture of a sinus tract in 14 patients with inaccessible postoperative abdominal abscesses. In eight patients, a sinus tract formed by a previously placed surgical drain was percutaneously punctured under ultrasound guidance. In six patients, a sinus tract was accessed under fluoroscopic guidance, aiming at an indwelling surgical drain. A drainage catheter was successfully placed into the abscesses in 13 patients (92.9%). Complete resolution of abscesses was documented on follow-up computed tomography. Percutaneous drainage with puncture of a sinus tract may be a feasible and effective treatment for inaccessible postoperative abdominal abscesses.

Effects of arsenic trioxide on radiofrequency ablation of VX2 liver tumor: intraarterial versus intravenous administration.

OBJECTIVE: Arsenic trioxide (As(2)O(3)) can be used as a possible pharmaceutical alternative that augments radiofrequency (RF) ablation by reducing tumor blood flow. The aim of this study was to assess the effect of intraarterial and intravenous administration of As(2)O(3) on RF-induced ablation in an experimentally induced liver tumor. MATERIALS AND METHODS: VX2 carcinoma was grown in the livers of 30 rabbits. As(2)O(3) (1 mg/kg) was administered through the hepatic artery (n = 10, group A) or ear vein (n = 10, group B), 30 minutes before RF ablation (125 mA ± 35; 90 ± 5℃). As a control group, 10 rabbits were treated with RF ablation alone (group C). RF was intentionally applied to the peripheral margin of the tumor so that ablation can cover the tumor and adjacent hepatic parenchyma. Ablation areas of the tumor and adjacent parenchymal changes among three groups were compared by the Kruskal-Wallis and Mann-Whitney U test. RESULTS: The overall ablation areas were 156 ± 28.9 mm(2) (group A), 119 ± 31.7 (group B), and 92 ± 17.4 (group C, p < 0.04). The ablation area of the tumor was significantly larger in group A (73 ± 19.7 mm(2)) than both group B (50 ± 19.4, p = 0.02) and group C (28 ± 2.2, p < 0.01). The ratios of the tumoral ablation area to the overall ablation area were larger in group A (47 ± 10.5%) than that of the other groups (42 ± 7.3% in group B and 32 ± 5.6% in group C) (p < 0.03). CONCLUSION: Radiofrequency-induced ablation area can be increased with intraarterial or intravenous administration of As(2)O(3). The intraarterial administration of As(2)O(3) seems to be helpful for the selective ablation of the tumor.

Right gastric venous drainage: angiographic analysis in 100 patients.

OBJECTIVE: To evaluate the pattern of right gastric venous drainage by use of digital subtraction angiography. MATERIALS AND METHODS: A series of 100 consecutive patients who underwent right gastric arteriography during transcatheter arterial chemoembolization for hepatocellular carcinoma were included in this study. Angiographic findings were retrospectively analyzed with respect to the presence or absence of the right and aberrant gastric veins, multiplicity of draining veins, aberrant right gastric venous drainage sites, and the termination pattern of aberrant right gastric veins (ARGVs). We also compared the relative size of the right and left gastric veins. RESULTS: A total of 49 patients collectively had 66 ARGVs. The common drainage sites for the ARGVs included the hepatic segment IV (n = 35) and segment I (n = 15). The termination pattern of ARGV could be classified into 4 different types. The most common type was termination as a superficial parenchymal blush formation in small areas without demonstrable portal branches. A statistically significant difference was found for the dominancy of the right gastric vein in gastric venous drainage between the two groups with or without ARGV (p < 0.05, Fisher's exact test). In the group of patients without ARGV (n = 51), the right gastric vein was equal to (n = 9) or larger than (n = 17) the left gastric vein in 26 patients (26 of 51, 51%). CONCLUSION: The incidence of ARGV is higher than expected with four distinct types in its termination pattern. The right gastric vein may play a dominant role in gastric venous drainage.

Hepatocellular carcinoma: prediction of blood supply from an intercostal artery with multidetector row computed tomography.

PURPOSE: To evaluate the ability of multidetector row computed tomography (CT) to detect blood supply from the intercostal artery in patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Between January 2003 and December 2007, angiography of the intercostal artery was performed in 93 patients (76 men and 17 women, mean age 58 years) with HCC who had also undergone multidetector row CT. CT scans and digital subtraction angiograms of these patients were retrospectively reviewed by two investigators in consensus to evaluate tumor feeding vessels. Multiple logistic regression analysis was used to identify factors that predict the presence of an HCC blood supply from an intercostal artery. RESULTS: Tumor staining fed by an intercostal artery was noted in 65 patients (70%; 112 tumor feeding vessels) by intercostal angiography. Readers interpreted that tumor feeding vessels were evident by CT in 35 (54%) of these 65 patients with tumor staining supplied by an intercostal artery by angiography. Multiple logistic regression analysis showed that a visible tumor feeding vessel by CT (P = .003) and hepatic artery attenuation by angiography (P = .014) were significantly related to the presence of a blood supply from an intercostal artery. CONCLUSIONS: Visualization of a tumor feeding vessel from the intercostal artery by multidetector row CT is an important sign of parasitic supply to an HCC.

Transarterial chemoembolization of a colic branch of the superior mesenteric artery in patients with unresectable hepatocellular carcinoma.

PURPOSE: To evaluate the technical feasibility, safety, and imaging response of transarterial chemoembolization performed through a colic branch of the superior mesenteric artery (SMA) in patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Between July 2000 and June 2009, we observed tumor staining supplied by a colic branch of the SMA in 61 of 5,095 patients (1.2%) with HCC. Computed tomography (CT) scans and digital subtraction angiograms of these patients were retrospectively reviewed by two investigators in consensus to evaluate the tumor location, the technical success of chemoembolization, complications, and imaging response on a follow-up CT scan according to European Association for the Study of the Liver criteria. RESULTS: Tumors supplied by a colic branch of the SMA were located in segment VI (n = 58) or were extrahepatic metastases caused by peritoneal seeding (n = 3). Vessels supplying the tumor arose from the right colic artery (n = 23), middle colic artery (n = 22), or ileocolic artery (n = 26). Selective chemoembolization via a colic branch of the SMA was performed in 24 patients (39%). No patient developed symptoms related to colon ischemia. Complete response or partial response of the tumor fed by a colic branch of the SMA as depicted on follow-up CT was achieved in eight patients (33%). CONCLUSIONS: Chemoembolization via a colic branch of the SMA can be safely performed if the microcatheter can be advanced beyond the antimesenteric border of the colon.

Intercostal artery supplying hepatocellular carcinoma: demonstration of a tumor feeder by C-arm CT and multidetector row CT.

This study was designed to describe tumor feeders from the intercostal artery supplying hepatocellular carcinoma (HCC) on C-arm CT and multidetector row CT. From March 2008 to May 2009, C-arm CT of the intercostal artery was prospectively performed in 24 HCC patients. Two interventional radiologists, who performed C-arm CT, evaluated tumor feeders on C-arm CT and multidetector row CT scans by consensus. In total, 35 intercostal arteries were examined by C-arm CT. All tumor feeders except one showed a sharp upward turn at or near the costochondral junction. On axial C-arm CT images, all tumor feeders were observed as an enhancing dot in the upper intercostal space along the diaphragm. On multidetector CT scans, 17 tumor feeders were observed and 18 were not. Tumor feeders from the intercostal artery are observed as an enhancing dot along the diaphragm on C-arm CT and can be seen on multidetector row CT in approximately half of patients.