Renal arteriovenous malformation treated using glue embolization under inflow and outflow control by balloon occlusion.

A 45-year-old female presented with gross hematuria. Right renal arteriovenous malformation on abdominal contrast-enhanced computed tomography necessitated urgent transcatheter arterial embolization. Right renal digital subtraction angiography revealed a single tortuous and dilated vessel converging to an aneurysmal dilated vein. To selectively embolize the malformation, we closed the arterial side with a microballoon and attempted glue embolization; filling occurred unexpectedly early, and another balloon on the vein side helped control the renal vein blood flow. Glue embolization was performed without adverse events. Glue embolization for high-flow arteriovenous malformation under balloon occlusion-mediated inflow and outflow control can effectively and safely embolize complete target vessels.

New technique for false lumen coiling of spontaneous isolated superior mesenteric artery dissection.

BACKGROUND: Spontaneous isolated visceral artery dissection is rarely encountered. Endovascular intervention with good outcomes has become popular for patients with persistent symptoms or developing ischemia. We could perform life-saving treatment for a spontaneous isolated superior mesenteric artery dissection with a unique endovascular intervention. CASE PRESENTATION: We describe the case of an 80-year-old man who presented with acute abdominal pain and a spontaneous isolated superior mesenteric artery dissection measuring 35 mm in major diameter and 6.6 mm in minor diameter on abdominal contrast-enhanced computed tomography. After admission, abdominal pain was progressive, and a repeated scan revealed progression of the dissection. As an endovascular intervention, via the bilateral femoral approach, detachable coils were placed in the false lumen of the superior mesenteric artery dissection through the false lumen under the micro-balloon occlusion at the point of re-entry and entry through the true lumen to prevent coil migration. Technical and clinical success was achieved without serious adverse events. CONCLUSION: Coil embolization using micro-balloon assistance combined with the double-catheter technique for a large entry and re-entry false lumen of a spontaneous isolated superior mesenteric artery dissection was useful and feasible.

The effects of silicone-based resilient denture liners on pain: A randomized controlled trial.

PURPOSE: This randomized controlled trial aimed to study the effects of lining mandibular complete dentures with silicone-based resilient denture liners, especially with respect to sensation. METHODS: The trial included completely edentulous patients who were willing to fabricate new set of complete denture. A random permuted block method (block size: 4) was used to assign participants to one of the following groups: mandibular conventional denture (CD) group or mandibular denture with resilient denture liner (RD) group. The outcomes were evaluated using both, objective measures (current perception threshold (CPT) and pain threshold (PT)) for external stimuli measured using the Neurometer CPT® and subjective measures (physical pain and psychological discomfort measured using the Japanese version of Oral Health Impact Profile for Edentulous patients-OHIP-EDENT-J). The outcomes were measured twice, at immediately after completion of denture adjustments (first measurement), and 3 months after the completion of denture adjustments (second measurement). All outcomes were analyzed using the Student t-test. A p-value of <0.05 was considered statistically significant. RESULTS: CPT was significantly higher with RD than CD only at second measurement with frequency level of 2000 Hz and 5 Hz. The pain thresholds were significantly higher in the RD group than the CD group. The physical pain and psychological discomfort scores were significantly lower in the RD group than in the CD group. CONCLUSION: This study concludes that edentulous patients wearing mandibular complete dentures with silicone-based resilient denture liners dull perception mandibular ridge mucosa and felt less pain than those without the liners.

Receptivity of the mandible versus the maxilla to external stimuli in patients with complete dentures.

PURPOSE: This study aimed to investigate whether the mandible is more receptive to external stimuli than the maxilla in patients with complete dentures by comparing regional current perception thresholds (CPTs) and pain threshold (PTs). METHODS: A single operator obtained measurements from maxillae at the incisor foramen and the left side of the greater palatine foramen region and the mandible at the left side of the mental foramen region, using the Neurometer CPT/C device, CPT and PT values from the oral mucosa of 20 edentulous individuals wearing complete dentures were analyzed. Participant characteristics such as mucosal thickness, occlusal force, age, and sex. Mucosal thickness over target regions and occlusal force were measured by the same operator using Krupp SDM and Occlusal Force-Meter GM10s devices. Differences in CPT and PT among the three measurement regions were tested with an analysis of covariance, and post hoc t-tests with the Bonferroni correction. RESULTS: There were no significant differences between the mental foramen, incisor papilla, and greater palatine regions CPT values. PTs obtained at all current frequencies (2000Hz, 250Hz, and 5Hz) were lowest in the mental foramen region and highest in the greater palatine region. Covariates including sex, mucosal thickness, and occlusal force had no significant influence on CPT or PT values at all frequencies. CONCLUSIONS: The mandible exhibits higher receptivity to external pain stimuli than the maxilla.

Verification of the reliability of current perception threshold and pain threshold testing by application of an electrical current stimulus to mandibular mucosa in young adults.

BACKGROUND: There is little evidence regarding the reliability of CPT and PT measurements to gauge mandibular perception. Thus, this study aimed to evaluate the test-retest reliability of CPT and PT values obtained from the mandibular oral mucosa and to test the bilateral differences in CPT and PT values obtained from the mental foramen region and buccal shelf region by a single operator. METHODS: CPT and PT values were obtained from the mental foramen and buccal shelf regions of 20 volunteers (10 males and 10 females; average age: 26.4 ± 2.6 years) by using the Neurometer CPT/C® device to deliver electrical stimulation. RESULTS: Relative and absolute reliabilities were confirmed over two measurements of CPT and PT over a 7- to 10-day measurement interval. Intra-class correlation coefficients (ICCs) for CPT and PT table obtained from the mental foramen region were >0.8, while most ICC for the buccal shelf region were <0.8. Standard error of measurement, minimal detectable change and Bland-Altman analyses showed that the CPT and PT measurements had no systematic error and could serve as useful methods. At all frequencies, the bilateral difference in CPT and PT values at the mental foramen and buccal shelf region was not significant. CONCLUSION: CPT and PT measurements using a custom-made device that applied an electrical current to the mental foramen region have appropriate reliability to assess intra-oral sensitivity to electrical stimulation in young adults.

Strategy for the treatment of spontaneous isolated visceral artery dissection.

OBJECTIVES: To determine the incidence of rare spontaneous isolated visceral artery dissection (SIVAD), characterize its pathogenesis, and suggest treatment strategies. MATERIALS AND METHODS: We reviewed abdominal contrast-enhanced computed-tomography (CE-CT) scans from January 2005 to December 2016 retrospectively in our institution, identified 47 SIVAD patients and classified them into a symptomatic (n = 22) or asymptomatic group (n = 25). Further, we classified the five types based on the CE-CT images. Patient characteristics, incidence, vascular risk factors, complications, symptoms, treatments outcomes, and morphology features on CE-CT images were analyzed. RESULTS: SIVAD was seen on 0.09% of all abdominal CE-CT scans, and 0.68% of all abdominal CT-CT scans obtained for the evaluation of acute abdominal symptoms. The asymptomatic group had significantly fewer patients with periarterial fat stranding or branch vessel involvement on CE-CT images (p < 0.01). The mean length of the dissection was longer in the symptomatic group (p < 0.05). In the asymptomatic group, dissection-related abdominal symptoms and complications did not develop; followed-up CE-CT scans showed improvement in the dissection lesions in 1 (4.0%) patient, no changes in 22 (88.0%), and complete remodeling in 2 (8.0%). In the symptomatic group, one patient presented with organ ischemia at diagnosis and five patients developed organ ischemia underwent endovascular intervention. In the remaining 16 patients received nonoperative intervention only, followed-up CE-CT scans showed improvement in 13 (86.7%), and complete remodeling in 2 (13.3%). CONCLUSIONS: Symptomatic SIVAD patients should be hospitalized because some of those may experience organ ischemia or aneurysm formation. Endovascular intervention is a feasible treatment for complications of SIVAD.

Coil embolization using microballoon assistance combined with the double-catheter technique for a large superior mesenteric arterial pseudoaneurysm and fistula secondary to acute pancreatitis.

Pseudoaneurysm of the superior mesenteric artery (SMA) is rare and associated with the risk of massive fatal hemorrhage and acute mesenteric ischemia. We describe a 43-year-old man with acute pancreatitis who presented with an SMA pseudoaneurysm measuring 13 × 12 cm in diameter. The pseudoaneurysm originated between the first and second jejunal arteries and drained into the mesenteric vein. The SMA trunk between the first and second jejunal arteries was embolized with detachable coils using microballoon assistance. After coil placement, arteriography showed the collateral circulation and no perfusion delay of the distal SMA. This technique was useful for isolation of the SMA pseudoaneurysm.

Evaluation of the relationship between hepatocellular carcinoma location and transarterial chemoembolization efficacy.

AIM: To evaluate the relationship between the location of hepatocellular carcinoma (HCC) and the efficacy of transarterial chemoembolization (TACE). METHODS: We evaluated 115 patients (127 nodules), excluding recurrent nodules, treated with TACE between January 2011 and June 2014. TACE efficacy was evaluated according to mRECIST. The HCC location coefficient was calculated as the distance from the central portal portion to the HCC center (mm)/liver diameter (mm) on multiplanar reconstruction images rendered (MPR) to visualize bifurcation of the right and left branches of the portal vein and HCC center. The HCC location coefficient was compared between complete response (CR) and non-CR groups in Child-Pugh grade A and B patients. RESULTS: The median location coefficient of HCC among all nodules, the right lobe, and the medial segment was significantly higher in the CR group than in the non-CR group in the Child-Pugh grade A patients (0.82 vs 0.62, P < 0.001; 0.71 vs 0.59, P < 0.01; 0.81 vs 0.49, P < 0.05, respectively). However, there was no significant difference in the median location coefficient of the HCC in the lateral segment between in the CR and in the non-CR groups (0.67 vs 0.65, P > 0.05). On the other hand, in the Child-Pugh grade B patients, the HCC median location coefficient in each lobe and segment was not significantly different between in the CR and in the non-CR groups. CONCLUSION: Improved TACE efficacy may be obtained for HCC in the peripheral zone of the right lobe and the medial segment in Child-Pugh grade A patients.

Haemodynamic changes in hepatocellular carcinoma and liver parenchyma under balloon occlusion of the hepatic artery.

OBJECTIVES: To investigate haemodynamic changes in hepatocellular carcinoma (HCC) and liver under hepatic artery occlusion. METHODS: Thirty-eight HCC nodules in 25 patients were included. Computed tomography (CT) during hepatic arteriography (CTHA) with and without balloon occlusion of the hepatic artery was performed. CT attenuation and enhancement volume of HCC and liver with and without balloon occlusion were measured on CTHA. Influence of balloon position (segmental or subsegmental branch) was evaluated based on differences in HCC-to-liver attenuation ratio (H/L ratio) and enhancement volume of HCC and liver. RESULTS: In the segmental group (n = 20), H/L ratio and enhancement volume of HCC and liver were significantly lower with balloon occlusion than without balloon occlusion. However, in the subsegmental group (n = 18), H/L ratio was significantly higher and liver enhancement volume was significantly lower with balloon occlusion; HCC enhancement volume was similar with and without balloon occlusion. Rate of change in H/L ratio and enhancement volume of HCC and liver were lower in the segmental group than in the subsegmental group. There were significantly more perfusion defects in HCC in the segmental group. CONCLUSIONS: Hepatic artery occlusion causes haemodynamic changes in HCC and liver, especially with segmental occlusion. KEY POINTS: • Hepatic artery occlusion causes haemodynamic changes in hepatocellular carcinoma and liver. • Segmental occlusion decreased rate of change in hepatocellular carcinoma-to-liver attenuation ratio. • Subsegmental occlusion increased rate of change in hepatocellular carcinoma-to-liver attenuation ratio. • Hepatic artery occlusion decreased enhancement volume of hepatocellular carcinoma and liver. • Hepatic artery occlusion causes perfusion defects in hepatocellular carcinoma.

Can an enhanced thin-slice computed tomography delineate the right adrenal vein and improve the success rate?

PURPOSE: To evaluate the usefulness of enhanced thin-slice computed tomography (TSCT) for delineating the right adrenal vein (RAV) anatomy before adrenal vein sampling (AVS). MATERIALS AND METHODS: A total of 151 consecutive AVSs with CT during angiography (interventional CT) were included. Of them, TSCT was performed before AVS for 72 patients. Successful RAV cannulation was confirmed using cortisol measurement. The RAV on TSCT was classified as certain, probable, or unidentified, and cases with certain or probable RAV identification were classified as useful. In the cases where AVS was successful, the anatomical features of the presumed RAV from the useful TSCT, including the position along the inferior vena cava, vertebral level, and distance from the upper pole of the right kidney, were compared with the RAV features identified on interventional CT. Estimated successful cannulation rates before interventional CT were compared between patients with and without useful TSCT. RESULTS: In total, 66 TSCTs were classified as useful. The anatomical features identified on TSCT were significantly correlated with those on interventional CT. The estimated successful cannulation rates for cases with and without useful TSCT were 92.4 and 82.4 %, respectively. CONCLUSIONS: TSCT clearly shows the anatomical features of the RAV, facilitating accurate sampling and increasing the success rate.

Detection of an interaction between prion protein and neuregulin I-ß1 by fluorescence resonance energy transfer analysis.

Cellular prion protein (PrP) copurifies with neuregulin type I-ß1 (NRG I-ß1), but no interaction has been detected by a general immunoprecipitation study. We speculate that PrP interacts with NRG I-ß1. Here, the interaction of PrP with NRG I-ß1 was detected by measuring fluorescence resonance energy transfer (FRET) between enhanced blue (EBFP) and enhanced green (EGFP) fluorescent protein-fusion proteins. Full-length PrP interacted with EGFP in addition to NRG I-ß1. From this result, we deduced that PrP interacts with EGFP through its unstructured N-terminal domain. We therefore detected FRET between PrP deleting the N-terminal domain and NRG I-ß1. In contrast, the C-terminal domain of PrP interacted with NRG I-ß1 and the proteins dissociated completely in the presence of sodium chloride. This interaction occurs at the nanomolar level, which is important for the reaction to be functional in organisms. We concluded that PrP interacted with NRG I-ß1 through its C-terminal domain.

Evaluation of monitor unit calculation based on measurement and calculation with a simplified Monte Carlo method for passive beam delivery system in proton beam therapy.

Calibrating the dose per monitor unit (DMU) for individual patients is important to deliver the prescribed dose in radiation therapy. We have developed a DMU calculation method combining measurement data and calculation with a simplified Monte Carlo method for the double scattering system in proton beam therapy at the National Cancer Center Hospital East in Japan. The DMU calculation method determines the clinical DMU by the multiplication of three factors: a beam spreading device factor FBSD, a patient-specific device factor FPSD, and a field-size correction factor FFS(A). We compared the calculated and the measured DMU for 75 dose fields in clinical cases. The calculated DMUs were in agreement with measurements in ± 1.5% for all of 25 fields in prostate cancer cases, and in ± 3% for 94% of 50 fields in head and neck (H&N) and lung cancer cases, including irregular shape fields and small fields. Although the FBSD in the DMU calculations is dominant as expected, we found that the patient-specific device factor and field-size correction also contribute significantly to the calculated DMU. This DMU calculation method will be able to substitute the conventional DMU measurement for the majority of clinical cases with a reasonable calculation time required for clinical use.

Feasibility and Safety of Negative-Balance Isolated Pelvic Perfusion in Patients with Pretreated Recurrent or Persistent Uterine Cervical Cancer.

BACKGROUND: Second-line therapy has limited activity in patients with recurrent or persistent uterine cervical cancer that has progressed after chemoradiation and palliative chemotherapy. The purpose of this study was to evaluate the efficacy of negative-balance isolated pelvic perfusion (NIPP) in patients with pretreated recurrent/persistent uterine cervical cancer. METHODS: Between April 2004 and May 2013, a total of 26 patients with recurrent or persistent uterine cervical cancer previously treated with platinum-based systemic chemotherapy and/or chemoradiotherapy received NIPP therapy at our institution, consisting of a 30-min isolated pelvic perfusion with cisplatin and fluorouracil, followed by isolated pelvic dialysis. Primary endpoints were response rate (RR) and progression-free survival (PFS), while secondary endpoints were overall survival (OS) and safety. Platinum pharmacokinetics were also evaluated. RESULTS: The RR was 57.7 % (complete response, five patients; partial response, ten patients). The median PFS and OS after NIPP therapy were 11.0 (95 % confidence interval [CI] 6.6-15.4) and 25.1 (95 % CI 17.1-33.1) months, respectively. PFS was significantly better in patients without intestinal involvement (p = 0.016) or dissemination (p < 0.001). Survival rates at 1, 2, and 3 years after initial NIPP therapy were 65.2, 50.4, and 13.4 %, respectively. The plasma pelvic-to-systemic exposure ratios were 15.4 and 15.8, based on the maximum concentration and the concentration-time curve, respectively. Most adverse events were mild (grade 1-2) (Common Terminology Criteria for Adverse Events, version 3.0). Severe neutropenia (grade 3 or higher) occurred in only 7.7 % of patients. CONCLUSIONS: NIPP appears to be an effective and feasible method for patients with pretreated recurrent or persistent cervical cancer.

Interventional treatment for unresectable hepatocellular carcinoma.

Hepatocellular carcinoma (HCC) is the sixth most common cancer and third leading cause of cancer-related death in the world. The Barcelona clinic liver cancer classification is the current standard classification system for the clinical management of patients with HCC and suggests that patients with intermediate-stage HCC benefit from transcatheter arterial chemoembolization (TACE). Interventional treatments such as TACE, balloon-occluded TACE, drug-eluting bead embolization, radioembolization, and combined therapies including TACE and radiofrequency ablation, continue to evolve, resulting in improved patient prognosis. However, patients with advanced-stage HCC typically receive only chemotherapy with sorafenib, a multi-kinase inhibitor, or palliative and conservative therapy. Most patients receive palliative or conservative therapy only, and approximately 50% of patients with HCC are candidates for systemic therapy. However, these patients require therapy that is more effective than sorafenib or conservative treatment. Several researchers try to perform more effective therapies, such as combined therapies (TACE with radiotherapy and sorafenib with TACE), modified TACE for HCC with arterioportal or arteriohepatic vein shunts, TACE based on hepatic hemodynamics, and isolated hepatic perfusion. This review summarizes the published data and data on important ongoing studies concerning interventional treatments for unresectable HCC and discusses the technical improvements in these interventions, particularly for advanced-stage HCC.

Contribution of extrahepatic collaterals to liver parenchymal circulation after proper hepatic artery embolization.

BACKGROUND AND AIM: To retrospectively evaluate proper hepatic artery embolization, with respect to the development of extrahepatic collaterals. METHODS: Proper hepatic artery embolization was performed in 18 patients with hemorrhagic arterial lesions in the hepatic hilum. Post-procedural development of extrahepatic collaterals was evaluated by computed tomography or angiography. Embolization data and liver function tests were assessed. The correlation of outcomes with portal venous stenosis, hepatic failure prior to embolization, elevation of prothrombin time, and insufficient collateral development were analyzed. RESULTS: Postoperative bleeding occurred in 17/18 patients, and one was treated for an idiopathic aneurysm of the proper hepatic artery; all treatments achieved technical success. Extrahepatic collaterals were confirmed in 13 patients. Elevations of liver function test values were transient and returned to baseline within 14 days in patients with collateral development (n = 13), but were unimproved in patients without collaterals (n = 5) (P < 0.001). Portal venous stenosis; prior hepatic failure; unrecovered, elevation of prothrombin time; and insufficient collateral development were significantly correlated with poor outcomes (P < 0.05, respectively). CONCLUSIONS: Proper hepatic artery embolization is effective for hemostasis, and extrahepatic collateral development is expected. Therefore, this is a safe treatment without prolonged hepatic ischemic damage, especially in patients without severe portal venous stenosis or prior hepatic failure.

Evaluation of right adrenal vein cannulation by computed tomography angiography in 140 consecutive patients undergoing adrenal venous sampling.

OBJECTIVE: As it is now known that primary aldosteronism (PA) is more prevalent than was previously recognized, and is a potentially curable cause of hypertension and related cardiovascular diseases, the search for a safe and effective means of its diagnosis has reemerged as a topic of interest. Adrenal venous sampling is the gold standard for diagnosis of PA, but the technique is challenging and the small right adrenal vein can be particularly difficult to cannulate. Our objective was to evaluate the usefulness of computed tomography during angiography (angio-CT) in increasing the success of adrenal venous sampling and to identify factors associated with cannulation failure. DESIGN: Retrospective review. METHODS: A total of 140 consecutive patients with suspected PA except Cushing's syndrome treated at a single hospital from June 2008 to May 2013 were included. Catheter misplacement and correct cannulation rates before angio-CT and success rate of sampling after angio-CT were calculated. Univariate analysis for factors related to incorrect cannulation included gender, age, height, weight, BMI, and adrenal nodules. Successful sampling was biochemically defined according to cortisol concentrations in the venous blood samples. RESULTS: Angio-CT detected misplaced catheters in 13 patients (9.3%). The calculated correct cannulation rate of adrenal vein sampling increased from 86.4% before angio-CT to 95.7% after CT (P<0.001, McNemar's test). Univariate analysis showed a tendency for a higher rate of failure of right adrenal venous sampling in taller patients (P=0.052, Mann-Whitney's U test). CONCLUSION: Angio-CT improved success of adrenal venous sampling.

Anatomical relationship between the common carotid artery and the internal jugular vein during head rotation.

This study investigated the anatomical relationship between the common carotid artery and internal jugular vein during head rotation for the effective performance of percutaneous transjugular procedures. The subjects included 30 volunteers who had never undergone internal jugular vein cannulation. In the supine position, two-dimensional ultrasonographic images of the right internal jugular vein and common carotid artery were obtained, 2 and 4 cm above the clavicle, along the lateral border of the sternal head of the sternocleidomastoid muscle. Ultrasonographic images were examined for head rotation at 0°, 15°, 30°, 45°, 60°, and 75° from the midline to the left. The percentage of overlap of the common carotid artery by the internal jugular vein and the flattening of the internal jugular vein at each head rotation position were measured and evaluated. The overlap of the common carotid artery by the internal jugular vein significantly increased at ≥45° of head rotation 2 cm above the clavicle (P < 0.01) and at ≥30° of head rotation 4 cm above the clavicle (P < 0.01), compared with that observed in the neutral position. The flattening of the internal jugular vein significantly decreased at ≥45° of head rotation 2 cm above the clavicle (P < 0.01) and at ≥30° of head rotation 4 cm above the clavicle (P < 0.01). Head rotation should be kept to <45° at 2 cm above the clavicle and <30° at 4 cm above the clavicle to decrease the risk of accidental puncture of the common carotid artery during internal jugular vein puncture. Moreover, flattening of the internal jugular vein gradually decreases during head rotation to the side.