Bronchial bleeding caused by recurrent pneumonia after radical esophagectomy for esophageal cancer.

We herein report a case of bronchial bleeding after radical esophagectomy that was treated with lobectomy. A 65-year-old male who underwent subtotal esophagectomy with three-field lymph node dissection for esophageal carcinoma was referred to our hospital because of sudden hemoptysis. After the esophagectomy, bilateral vocal cord paralysis was observed, and the patient suffered from repeated episodes of aspiration pneumonia. Bronchoscopy revealed hemosputum in the right middle lobe bronchus, and contrast-enhanced computed tomography showed tortuous arteries arising from the right inferior phrenic artery and left subclavian artery toward the right middle lobe bronchus. Although bronchial arterial embolization was performed twice to control the recurrent hemoptysis, the procedures were unsuccessful. Right middle lobectomy was therefore performed via video-assisted thoracic surgery. Engorged bronchial arterys with medial hypertrophy and overgrowth of the small branches were noted near the bronchus in the resected specimen. The patient recovered uneventfully and was discharged on postoperative day 14.

Survival after arterial embolization therapy in patients with polycystic kidney and liver disease.

BACKGROUND: Transcatheter arterial embolization (TAE) has become a therapeutic option for symptomatic polycystic kidney disease (PKD) and polycystic liver disease (PLD). However, factors affecting survival with renal TAE remain unknown. METHODS: All symptomatic patients with severe PKD and/or PLD who received renal and/or hepatic TAE at our center from October 1996 through March 2013 (n = 1,028) were followed until death. Their survival was compared with that of the general PKD population on dialysis in Japan. Factors affecting survival were analyzed using the Cox hazard model. RESULTS: After renal TAE, 5- and 10-year survival was, respectively, 0.78 (95% confidence interval, 0.74-0.82) and 0.56 (0.49-0.63); with hepatic TAE, 0.69 (0.58-0.77) and 0.41 (0.22-0.60); and with dual TAE (renal and hepatic), 0.82 (0.72-0.88) and 0.45 (0.31-0.59). Survival after dialysis initiation was better among patients with renal TAE than among general PKD patients. Factors affecting survival after renal TAE were age [hazard ratio (HR) 3.02 (1.44-6.33) for every 10 years] and albumin [HR 0.70 (0.55-0.89) per 0.1 g/dl]. Kidney volume was not associated with patient death after TAE. The main causes of death among patients after renal TAE were similar to those of the general PKD population on dialysis whereas, after hepatic TAE, the main cause was cyst infection with liver failure (12.5% with PLD and 5.9% with PKD, p < 0.01). CONCLUSION: Survival after renal TAE with severe PKD was better than for the general PKD population on dialysis, suggesting that renal TAE could overcome the disadvantage due to huge organ size.

Intravascular embolization therapy in patients with enlarged polycystic liver.

BACKGROUND: Hepatic transcatheter arterial embolization (TAE) has become an accepted treatment option for patients with symptomatic autosomal dominant polycystic kidney disease (ADPKD) who also have polycystic liver disease and who are not good candidates for surgery. However, indications for TAE and long-term outcome with it are still unclear. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Symptomatic patients with ADPKD with polycystic liver disease who underwent hepatic TAE, June 2001 to December 2012, at Toranomon Hospital and whose liver volume data were available were studied (N=244; 56% on dialysis therapy, none with kidney transplants). Mean age was 55 ± 9 (SD) years, and mean liver volumes were 8,353 ± 2,807 and 6,626 ± 2,485 cm(3) in men and women, respectively. Target arteries were embolized from the periphery using platinum microcoils. PREDICTORS: Sex-specific quartiles (6,433, 8,142, and 9,574 cm(3) in men and 4,638, 6,078, and 8,181 cm(3) in women) of total liver volume pretreatment. OUTCOMES: All causes of mortality were obtained from medical records, followed up until July 31, 2013. MEASUREMENTS: Laboratory values were measured before TAE and 1, 3, 6, and 12 months after. Organ volumes were measured pretreatment, then 6 and 12 months after, by summing the products of the organ areas traced in each computed tomographic image. RESULTS: Liver/cyst volume decreased to 94.7% (95% CI, 93.5%-95.8%) at 6 months and 90.8% (95% CI, 88.7%-92.9%) at 12 months of pretreatment volumes. Serum protein and hematocrit values improved significantly without liver damage. Survival was significantly better for patients with liver volume ≤ 9,574 cm(3) (men) and ≤ 8,181 cm(3) (women) than for those with larger livers (5-year survival, 69% and 48%; P=0.02). Infection and liver failure caused most deaths, especially in patients with larger livers. LIMITATIONS: Referral bias and lack of control group. CONCLUSIONS: Hepatic TAE appears to be a safe and less invasive option for patients with symptomatic polycystic liver, especially those contraindicated for surgical treatment (eg, with malnutrition or on dialysis therapy), improving both hepatic volume and nutrition.

Precision and accuracy in CT attenuation measurement of vascular wall using region-of-interest supported by differentiation curve.

OBJECTIVES: To evaluate the precision and accuracy in CT attenuation measurement of vascular wall using region-of-interest (ROI) supported by differentiation curves. STUDY DESIGN: We used vascular models (actual attenuation value of the wall: 87HU) with wall thicknesses of 1.5, 1.0, or 0.5mm, filled with contrast material of 250, 348, or 436HU. The nine vascular models were scanned with a 64-detector CT. The wall attenuation values were measured using three sizes (diameter: 0.5, 1.0, and 1.5mm) of ROIs without differentiation curves. Sixteen measurements were repeated for each vascular model by each of two operators. Measurements supported by differentiation curves were also performed. We used analyses of variance with repeated measures for the measured attenuations for each size of the ROI. RESULTS: Without differentiation curves, there were significant differences in the attenuation values of the wall among the three densities of contrast material, and the attenuation values tended to be overestimated more as the contrast material density increased. Operator dependencies were also found in measurements for 0.5- and 1.5-mm thickness models. With differentiation curves, measurements were not possible for 0.5- and 1.0-mm thickness models. Using differentiation curves for 1.5-mm thickness models with a ROI of 1.0- or 1.5-mm diameter, the wall attenuations were not affected by the contrast material densities and were operator independent, measuring between 75 and 103HU. CONCLUSIONS: The use of differentiation curves can improve the precision and accuracy in wall attenuation measurement using a ROI technique, while measurements for walls of ≤1.0mm thickness are difficult.

Evaluation of skin exposure during cerebral CT perfusion studies on a phantom.

OBJECTIVES: To evaluate the skin dose during cerebral CT perfusion on a phantom, and estimate the weighted CT dose index (CTDIw) to maximum skin dose conversion factors for four types of CT scanners. STUDY DESIGN: We evaluated the relationship between surface dose during cerebral CT perfusion and distance from the scan center in the x-y plane using a 64-multidetector row CT scanner. Skin doses were also assessed with 4 different 64-multidetector CT scanners. RESULTS: The surface doses decreased with the distance from the scan center in the x-y plane. The surface doses at the points 6 cm and 10 cm from the scan center in the x-y plane were different from the dose at the point 8 cm by about 15%. CTDIw and skin doses differed among the CT scanners (CTDIw, 143-590 mGy; averaged temporal skin dose, 126-590 mGy). For all the four types of CT scanner, the doses increased in the following order: occipital point

Detection of in-stent restenosis of coronary stents using 40-detector row computed tomography in vitro.

OBJECTIVE: To evaluate the performance of 40-detector row computed tomography (CT) in the detection of in-stent stenosis of coronary stents. METHODS: Seven patent vascular models, 7 stenotic models, and 7 obstructed models were scanned with a 40-detector CT. We made the vascular models using 3 types of stent (Bx-Velocity, Express2, Driver) with an inner diameter of about 2.5, 3.0, or 3.5 mm. We measured the stent lumen diameter and evaluated the in-stent stenosis visually for the 21 vascular models. We evaluated attenuation values of the stent lumen of the 9 patent models of 2.5-mm diameter. RESULTS: The inner diameters of the vascular models were underestimated by CT with mean measurement errors of -1.19 to -1.49 mm. The absolute mean overall measurement error decreased as the inner diameter increased. The direct visualization of in-stent stenosis was possible for the 3.0- and 3.5-mm diameter models, but impossible for the 2.5-mm diameter models. For patent vascular models of 2.5-mm diameter, the CT attenuation inside the stent was significantly higher than that of the unstented portion (P < 0.0001). For obstructed vascular models of 2.5-mm diameter, the CT attenuation inside the stent was significantly lower than that of the unstented portion (P < 0.0001). Also for stenotic vascular models of 2.5-mm diameter, the CT attenuation inside the stent was lower than that of the unstented portion. CONCLUSIONS: Visualization of stent lumen on CT is affected by the stent diameter. Measurement of stent lumen is useful for detection of in-stent stenosis, when the direct visualization of in-stent stenosis is impossible.

Assessment of coronary stents using 40-detector row CT: comparison with 16-detector row CT in vitro.

OBJECTIVE: To evaluate the performance of 40-detector row computed tomography (CT) in the assessment of coronary stents in comparison with 16-detector row CT. METHODS: A total of 6 vascular models (3 models without stenosis and 3 with stenosis) using 3 types of stent (Bx-Velocity, Express2, and Driver) with an approximately 3.5-mm inner diameter filled with contrast material (450 Hounsfield units) were scanned with 2 computed tomographic scanners (collimation, 16 x 0.75 and 40 x 0.625 mm). We evaluated the in-stent stenosis visually for the 6 vascular models in 4 orientations (0, 30, 60, and 90 degrees) to the z-axis of the scanner. We evaluated attenuation values of the stent lumen of the 3 patent models in the 4 orientations. The average and standard deviation of the luminal attenuation values were assessed to evaluate the degree of blooming and streak artifacts. RESULTS: The visualization of the stent lumen of the vascular models at 90 degrees was improved using 40-detector row CT. For all the 3 stents, the average luminal attenuations values using 40-detector row CT were significantly lower than those using 16-detector row CT in all orientations. For all the 3 stents, the standard deviations of the luminal computed tomographic attenuation using 40-detector row CT were significantly smaller than those using 16-detector row CT in the 4 orientations to the z-axis except for Express 2 at 0 degrees. CONCLUSIONS: The visualization of coronary stents is improved by the use of 40-detector row CT with reduced blooming and streak artifacts.

Percutaneous transcatheter hepatic artery embolization for liver cysts in autosomal dominant polycystic kidney disease.

BACKGROUND: We have achieved renal contraction therapy in patients with autosomal dominant polycystic kidney disease (ADPKD) by means of renal transcatheter arterial embolization (TAE) using intravascular coils, decreasing renal size and improving quality of life in almost all patients. We presently perform hepatic TAE in patients with intractable symptomatic polycystic liver. STUDY DESIGN: Uncontrolled trial. SETTING & PARTICIPANTS: 30 patients with ADPKD referred for arteriography to an academic medical center. 22 patients had kidney failure treated by means of dialysis. INTERVENTION: We embolized arteries supplying hepatic segments replaced by cysts that were associated with well-developed hepatic arteries, but obstructed intrahepatic portal veins. OUTCOMES & MEASUREMENTS: Various volumes before and after TAE were compared by using computed tomography and National Institutes of Health Image software in 30 patients with follow-up computed tomography 18 to 37 months after therapy. RESULTS: Total liver volume and total intrahepatic cyst volume decreased from 7,882 +/- 2,916 and 6,677 +/- 2,978 to 6,041 +/- 2,282 and 4,625 +/- 2,299 cm(3), respectively (P < 0.0001 for both). Fractions of remaining (FR) total liver volume and FR of intrahepatic cyst volume were 78.8% +/- 17.6% and 70.4% +/- 20.9%, respectively. Hepatic parenchyma increased from 1,205 +/- 250 to 1,406 +/- 277 cm(3) (P = 0.0004). In 29 of 30 patients, both total liver volume and intrahepatic cyst volume decreased; in 1 patient, total liver volume increased from 5,755 to 7,069 cm(3), whereas cysts enlarged from 4,500 to 5,531 cm(3). No serious complications were experienced. In 24 patients, the post-TAE course was favorable. TAE failed to benefit 6 patients because of unrelated hepatic infection, peritonitis, hepatic failure, acute leukemia, or pelvic fracture. LIMITATIONS: Absence of a control group. CONCLUSIONS: TAE may be an option for patients with ADPKD with symptomatic polycystic liver who are not candidates for surgical treatment.