Transcatheter CT arterial portography and CT hepatic arteriography for liver tumor visualization during percutaneous ablation.

PURPOSE: To evaluate the feasibility of combining transcatheter computed tomography (CT) arterial portography or transcatheter CT hepatic arteriography with percutaneous liver ablation for optimized and repeated tumor exposure. MATERIALS AND METHODS: Study participants were 20 patients (13 men and 7 women; mean age, 59.4 y; range, 40-76 y) with unresectable liver-only malignancies--14 with colorectal liver metastases (29 lesions), 5 with hepatocellular carcinoma (7 lesions), and 1 with intrahepatic cholangiocarcinoma (2 lesions)--that were obscure on nonenhanced CT. A catheter was placed within the superior mesenteric artery (CT arterial portography) or in the hepatic artery (CT hepatic arteriography). CT arterial portography or CT hepatic arteriography was repeatedly performed after injecting 30-60 mL 1:2 diluted contrast material to plan, guide, and evaluate ablation. The operator confidence levels and the liver-to-lesion attenuation differences were assessed as well as needle-to-target mismatch distance, technical success, and technique effectiveness after 3 months. RESULTS: Technical success rate was 100%; there were no major complications. Compared with conventional unenhanced CT, operator confidence increased significantly for CT arterial portography or CT hepatic arteriography cases (P < .001). The liver-to-lesion attenuation differences between unenhanced CT, contrast-enhanced CT, and CT arterial portography or CT hepatic arteriography were statistically significant (mean attenuation difference, 5 HU vs 28 HU vs 70 HU; P < .001). Mean needle-to-target mismatch distance was 2.4 mm ± 1.2 (range, 0-12.0 mm). Primary technique effectiveness at 3 months was 87% (33 of 38 lesions). CONCLUSIONS: In patients with technically unresectable liver-only malignancies, single-session CT arterial portography-guided or CT hepatic arteriography-guided percutaneous tumor ablation enables repeated contrast-enhanced imaging and real-time contrast-enhanced CT fluoroscopy and improves lesion conspicuity.

Diagnostic accuracy of C-arm CT during selective transcatheter angiography for hepatocellular carcinoma: comparison with intravenous contrast-enhanced, biphasic, dynamic MDCT.

PURPOSE: This study was aimed to compare the accuracy, sensitivity, and positive predictive value of C-arm CT (CACT) during selective transcatheter angiography with those of multidetector CT (MDCT) in the detection of hepatocellular carcinoma (HCC). MATERIAL AND METHODS: In this prospective study, 30 patients (mean age, 73 years) with unresectable HCC were examined with CACT before chemoembolisation. Images of a combination of CACT during arterial portography (CACTAP) and dual-phase CACT during hepatic arteriography (CACTHA) was obtained and images of intravenous contrast-enhanced, biphasic, dynamic, MDCT was also obtained beforehand. Three blinded observers independently reviewed CACT and MDCT. Diagnostic accuracy was evaluated by the alternative free-response receiver operating characteristic (AFROC) method. Sensitivities and positive predictive values (PPV) were analyzed with the paired t-test. RESULTS: In the mean area under the AFROC curve (Az), there was no significant difference between MDCT and CACT (MDCT, mean Az value, 0.83; CACT, 0.85, respectively) (P = 0.32). There was also no significant difference between the two techniques in sensitivity (MDCT, mean 0.65; CACT, 0.60) and PPV (MDCT, mean 0.98; CACT, 0.97) (P = 0.40, P = 0.68, respectively). CONCLUSION: The diagnostic accuracy of CACT was equivalent to that of biphasic CT in the diagnosis of HCC. KEY POINTS: C-arm CT helps detection of hepatocellular carcinoma (HCC) during interventional (TACE) treatment. C-arm CT for HCC seemed just as accurate as biphasic CT. TACE can be performed with greater confidence using C-arm CT.

Usefulness of Y-shaped sheaths in CT angiography for examination of liver tumors.

AIM: To conduct a single-stage, combined computed tomography (CT) arterial portography (CTAP) and CT arteriography (CTA) imaging operation, we used Y-shaped sheaths with 2 valves, which allowed the insertion of 2 catheters simultaneously. METHODS: Of 1254 patients who underwent abdominal angiography for transarterial embolization and/or intraarterial chemotherapy in our department from May 2002 to November 2009, 664 patients in whom Y-shaped sheaths with 2 valves were used underwent CT angiography using a combination of CTA and CTAP. The Seldinger method was used to insert a 10 cm Y-shaped short sheath with 2 valves into the femoral artery. Under radiographic guidance, a 3.2 French (Fr) catheter was placed in the celiac artery or proper hepatic artery, and a second 3.2 Fr catheter was then placed distal to the inferior pancreaticoduodenal artery of the superior mesenteric artery. CTAP was then performed followed by CTA 10 min later. Photographs were taken during the early and late phases of the procedure. RESULTS: Insertion of 3.2 Fr catheters was not possible in 6 of 664 (0.9%) patients with strong curvature of the femoral artery and 4 of 664 (0.6%) patients with strong curvature of the abdominal aorta. In addition, performing CTAP and CTA as a single-stage combined intervention was not possible in 14 of 664 (2.1%) patients whose right hepatic artery originated from the superior mesenteric artery and in 8 of 664 (1.2%) patients whose left hepatic artery branched from the left gastric artery. There were no sheath-related complications such as those related to arterial dissection or hemostasis. CONCLUSION: Although transfers to and from the CT room were necessary for anatomically variant patients, CT angiography using the Y-shaped sheath for combined CTAP and CTA was considered useful.

Pancreatic arteriovenous malformation: a case report of hemodynamic and three-dimensional morphological analysis using multi-detector row computed tomography and post-processing methods.

CONTEXT: Although rare, a pancreatic arteriovenous malformation can have serious consequences. A diagnosis of arteriovenous malformation requires evidence of aberrant communication between the arterial and the venous systems. This report describes a case where the use of multi-detector row CT and specific post-processing methods provided a diagnosis of arteriovenous malformation. This minimally invasive diagnostic approach resulted in a clear, precise and comprehensive visual representation of the pancreatic arteriovenous malformation. CASE REPORT: A 60-year-old man with right hypochondriac pain presented with a mass in the head of the pancreas. The hypochondriac pain resolved spontaneously and physical examination revealed no abnormal findings. A multi-detector row CT study was performed. The data obtained in the arterial phase demonstrated a high-contrast mass in the head of the pancreas and early enhancement of the portal vein. A maximum intensity projection method clarified the aberrant vascular communication. Changes in Hounsfield numbers were observed using a multi-planar reformation method. A volume-rendering method was used to create a 3D model which demonstrated the spatial relationship between the aberrant vascular communication and the surrounding tissue. An annual follow-up study using this technique showed no significant alteration. CONCLUSIONS: Multi-detector row CT with specific post-processing methods is a useful diagnostic tool for pancreatic arteriovenous malformation.

Ultrafine needle CO2 splenoportography: a comparative investigation with transarterial portography and MR portography.

PURPOSE: To evaluate the safety and quality of CO2 splenoportography (CO2-SP) by comparison to 3-dimensional dynamic contrast-enhanced magnetic resonance portography (3D-DCE-MRP) and transarterial portography (TAP). MATERIALS AND METHODS: CO2-SP, 3D-DCE-MRP and TAP were performed within 3 days in 35 patients. CO2-SP was conducted with a 26G needle by puncture of spleen under fluoroscopy and/or ultrasound guidance. A fifty mm3 of CO2 was manually injected within 3s. The safety and the side effects of CO2-SP were assessed with a scoring system based on both the subjective feeling of patients questioned and the objective appearances of vital signs, electrocardiogram (ECG) and saturation of percutaneous blood oxygen (SpO2). The quality of the imaging was compared among the three groups using different methods by a scoring criterion based on visualization of the portal branches. RESULTS: Transient mild discomfortable reaction was present in 18 patients (51.4%). The scores measured for quality of portal vein branch visualization in the groups with CO2-SP, 3D-DCE-MRP and TAP were 226, 196 and 167, respectively (P<0.001, the higher of the scores, the better of the quality). The visibility of collateral veins was not significantly different amongst the three imaging techniques. CONCLUSION: Ultrafine needle CO2-SP is safe and minimally invasive. The quality of CO2-SP is better than that with 3D-DCE-MRP and TAP in terms of the visualizing portal vein branches.

[Interventional radiology techniques in the treatment of Budd-Chiari syndrome]. / Zastosowanie metod radiologii interwencyjnej w zespole Budd-Chiari.

Budd-Chiari syndrome (BCS) is rare clinical state characterized by the stenosis or complete obstruction of hepatic veins. Currently interventional radiology techniques are more frequently used as a single method of treatment or as a bridge to liver transplantation. This paper presents current interventional radiology techniques used in BCS treatment. Depending on etiology of BCS two major techniques are used: transjugular intrahepatic portocaval shunts (TIPS) or percutaneous angioplasties of stenosed hepatic veins. We also present selected cases of BCS diagnosed and treated in our Department in years 1999-2003.

CO2 digital subtraction splenoportography with the "skinny" needle: experimental study in a swine model.

PURPOSE: To evaluate the safety and the effectiveness of CO2 splenoportography with the "skinny" needle. METHODS: A flexible, 22 gauge needle ("skinny" needle) was introduced into the exteriorized spleens of five pigs. After checking the intrasplenic positioning with CO2 injection, increasing doses of CO2 (10-60 cm3) were injected using a dedicated CO2 injector with digital imaging. The puncture sites were observed during and after CO2 injections, and after removal of the needle. The spleens were then removed for gross and microscopic examination. RESULTS: In all animals digital subtraction CO2 splenoportograms showed the splenic, extra- and intrahepatic portal veins, and the most distal portion of the superior mesenteric vein. No CO2 extravasation occurred in the spleen. There was no significant bleeding from the puncture site after removal of the needle. Gross and microscopic examination revealed no evidence of splenic rupture or intrasplenic hematoma. CONCLUSION: CO2 splenoportography with the "skinny" needle is a safe and simple method of visualizing the portal vein and its branches. Careful appraisals of the clinical usefulness of the method will be needed in various clinical settings.

Intravenous three-dimensional CT portography using multi-detector row CT in patients with hepatic cirrhosis: evaluation of scan timing and image quality.

PURPOSE: To evaluate the scan timing and image quality of intravenous three-dimensional (3D) CT portography using multi-detector row CT (MDCT) and to assess the influence of patients' body weight on enhancement of the portal vein (PV). METHODS: One hundred nine patients with hepatic cirrhosis underwent triple-phase contrast enhanced CT using MDCT. The early, portal, and late phases were started at 30 sec, 60 sec, and 90 sec, respectively, after the beginning of intravenous injection of contrast medium (300 mgI/mL, 100 mL total). The CT value of the PV was assessed in the three phases: precontrast, portal phase, and late phase. 3D-portography of the MIP image was evaluated by three-point scale based on vessel visualization. The relationship between these data and body weight was investigated. RESULTS: The mean CT value of PV at 60 sec was 172.01+/-25.94 HU, which was significantly higher than that at 90 sec. Good or excellent 3D-CT portography was obtained in 97/109 patients (89%). Heavy patients tended to show less opacification of PV. CONCLUSIONS: Intravenous 3D-CT portography using MDCT at a 60 sec delay provided adequate PV images for patients with hepatic cirrhosis. Enhancement of PV was affected by patients' body weight.

MR-guided intravascular catheter manipulation: feasibility of both active and passive tracking in experimental study and initial clinical applications.

PURPOSE: To evaluate clinically the feasibility and usefulness of MR-guided intravascular procedures with either active or passive tracking. METHODS: With an active MR tacking system and a 0.2 Tesla open MR imager, real-time and biplane displays of positions of a receive-only coil at the tip of catheters were obtained. For passive tracking, 4 Fr catheters with suitable susceptibility for passive tracking were used. Passive tracking with a 1.5 Tesla MR imager could be performed with parameters of TR 15-50 msec, TE 2.2-2.7 msec, and FA 30 degrees. The temperature of each tracking catheter was monitored in vitro. Clinical trials were performed on six patients (three each). The catheter was introduced to the superior mesenteric artery (SMA) under MR guidance by active or passive tracking to perform MR imaging during arterial portography. RESULTS: The temperature increased minimally. In humans, the SMA and celiac artery could be easily introduced on active tracking. MR-guided manipulation of catheters by active or passive tracking in the model and in dogs' vessels was very successful. Introduction of the catheter into the SMA was successful in two cases of active tracking and in all cases of passive tracking. CONCLUSION: The MR-guided intravascular manipulation of catheters by active or passive tracking may be a clinically feasible method.

CT arterial portography and CT arteriography with a triple-lumen balloon catheter.

PURPOSE: To evaluate the usefulness of the triple-lumen balloon catheter in the serial performance of CT arterial portography (CT-AP) and CT arteriography (CT-A). MATERIAL AND METHODS: A combined CT-AP and CT-A examination of 58 patients was carried out in which a cobra-type triple-lumen balloon catheter was used. CT-AP was performed by injecting contrast medium either into the splenic artery through a side-hole in the catheter proximal to the balloon inflated in the common hepatic artery, or into the superior mesenteric artery through an end-hole in the catheter. Then CT-A was serially performed by delivering contrast medium either to the common hepatic artery or the proper hepatic artery from the end-hole, or to the accessory right hepatic artery through a side-hole proximal to the inflated balloon. RESULTS: Sufficient CT-APs were obtained in 53 of the 58 patients (91%), CT-A in 42 (72%), and both in 42 (72%). Incomplete CT-AP was due to technical failure or anatomical anomaly, as was incomplete CT-A. No complications were seen. CONCLUSION: The triple-lumen balloon catheter technique is useful and convenient in the serial performance of CT-AP and CT-A.

[Trial of a detachable Y-shaped tube with two valves for serial examinations of CT arterial portography and CT hepatic arteriography].

In five patients with hepatocellular carcinoma, CT arterial portography (CTAP) and CT hepatic arteriography (CTHA) were performed serially by using a newly developed detachable Y-shaped tube with two valves that could be attached to a conventional angiographic sheath. Two catheters could be inserted into the conventional angiographic sheath without blood backflow by using the Y-shaped tube. One catheter could be easily and safety placed on the common or proper hepatic artery, and the other on the superior mesenteric artery. This detachable Y-shaped tube with two valves could make it easy to perform serial CTAP and CTHA examinations.

[Digital subtraction arterioportography in the examination of patients with the portal hypertension syndrome]. / Digital'naia subtraktsionnaia arterioportografiia v obsledovanii bol'nykh s sindromom portal'noi gipertenzii.

Based upon data of 107 angiographic examinations in the regimen of digital subtraction the authors propose a regional program of angiographic examinations of patients with the syndrome of portal hypertension including the digital subtraction recurrent celiac and mesenteric portography, terminal occlusive flebohepatography. The given complex of investigations allows the determination with a minimum traumatic action of the form of portal hypertension and selection of the best for each patient kind of operative intervention. The article describes the methods of angiographic examinations improved and adapted by the authors for diagnosing the syndrome of portal hypertension. Criteria for the assessment of the results obtained are proposed. The use of digital subtraction arterioportography in complex with digital occlusive flebohepatography allows the main problems facing the surgeons when choosing the kind of operative interventions for patients with portal hypertension to be solved.

CT during arterial portography: comparison of injection into the splenic versus superior mesenteric artery.

PURPOSE: To determine whether the diagnostic quality of computed tomography (CT) during arterial portography (CTAP) performed via the splenic artery (SA) is better than that performed via the superior mesenteric artery (SMA). MATERIALS AND METHODS: The authors evaluated CTAP images obtained in 98 patients from 1991 to 1994; 47 examinations were performed via the SA and 51 were performed via the SMA. Images were reviewed, by consensus, by three radiologists blinded to catheter location. Hepatic enhancement was quantitatively assessed in 53 patients (31 in the SA group, 22 in the SMA group). RESULTS: The numbers of low-attenuation non-tumor-related perfusion defects (19 in the SA group, 17 in the SMA group), high-attenuation non-tumor-related perfusion defects (six in the SA group, six in the SMA group), diffuse mottled perfusion abnormalities (six in the SA group, five in the SMA group), and portal venous flow defects (20 in the SA group, 20 in the SMA group) were similar in both groups (P > .05). Peak hepatic enhancement was similar in both groups (SMA group = 111 HU; SA group = 112 HU) (P > .05). CONCLUSION: There is no difference in quality between CTAP performed via the SA versus CTAP performed via the SMA.

[The role of portography with computed tomography in the diagnosis of liver metastases from colorectal neoplasms]. / Il ruolo della portografia con Tomografia Computerizzata nella diagnosi di metastasi epatiche da neoplasie del colon-retto.

This study was performed to confirm the high sensitivity of CT during arterial portography (CTAP) versus US and dynamic CT in the diagnosis of liver metastases from colorectal cancer. Ninety patients with 108 colorectal cancers underwent US, dynamic CT and CTAP to investigate the presence of liver metastases. US depicted 39 metastases in 26 patients, dynamic CT 46 metastases in 29 patients and CTAP 54 lesions in 34 patients. CTAP detected 8 metastases missed at dynamic CT; 4 of them were < 1 cm in diameter, 3 ranged 1-2 cm and one metastasis > 2 cm in diameter. After preoperative investigations only 7 patients were considered for hepatic resection. At surgery, palpation and intraoperative US of the liver detected two more metastases in the same patients. Our experience, in agreement with recent studies, confirms CTAP as the most sensitive preoperative method in detecting liver metastases and its superiority to be most apparent in lesions < 1 cm in diameter. Therefore, we consider CTAP an essential imaging technique for planning the correct treatment of liver metastases.

Hipertensao porta esquistossomótica na criança: medidas diretas do diâmetro externo da veia esplênica e dos valores tensionais do sistema porta. Estudo das correlações entre si e com algumas variáveis biométricas / Schistosomotic portal hypertension in child: direct measures of the splenic vein external diameter and the portal pressure values. Study of the correlation between itself and with some biometric variables

A operação de desconexão ázigos-porta e esplenectomia foi realizada, eletivamente, em 48 crianças com hipertensão porta esquistossomótica diagnosticada pelas avaliações clínica, laboratorial, radiológica, endoscópica, histopatológica e pelos valores tensionais do sistema porta. Realizaram-se medição direta do diâmetro externo da veia esplênica no per-operatório e medições dos valores tensionais do sistema porta, no pré-operatório pela medida da pressão porta transparietoesplênica, e no per-operatório pelas medidas das pressões portas inicial, pós-esplenectomia e pós-desconexão ázigos-porta completa. O diâmetro externo da veia esplênica foi medido a cerca de 5 cm de sua ligadura no hilo do baço, com régua de plástico e com o paciente em apnéia expiratória. A pressão porta pré-operatória transparietoesplênica foi medida durante a realização da esplenoportografia, com o paciente em decúbito dorsal e sob anestesia geral ou sedação diazepínica. As pressões portas per-operatórias, determinadas nos diferentes tempos da operação de desconexão ázigos-porta com o paciente em apnéia expiratória, foram medidas através de cateterização de veia tributária da veia mesentérica superior. O nível zero, adotado para medições das pressões portas pré e per-operatórias, situava-se no ponto localizado na metade da distância entre a parte externa da superfície anterior do esterno, à altura do terceiro espaço intercostal, e o ponto mais externo da superfície posterior do tórax. O diâmetro externo da veia esplênica variou de 5mm a 12mm (8,8 ñ 1,7mm), observando-se a relação direta dos valores desse diâmetro com a idade, o peso corporal e a estatura, mas não com o sexo e a cor. O diâmetro externo da veia esplênica não apresentou correlação com os níveis pressóricos do sistema porta...

Hepatic tumors: role of computed tomographic arterial portography in surgical planning.

Various imaging modalities currently used to evaluate liver tumors include magnetic resonance imaging, ultrasonography, contrast-enhanced computed tomography, and computed tomographic arterial portography. In our review of 28 cases, we found CT arterial portography to be very sensitive, and in 5 of these 28 cases CT arterial portography was a key factor in altering the course of therapy.

Computed tomographic percutaneous transsplenic portography.

The diagnosis of liver tumors should be utilized for determination of not only the number of lesions, but also their size, segmental location and extent, and the relationship of the mass or masses to the hepatic vasculature. CT during arterial portography (CTAP) is the most sensitive imaging modality for precise diagnosis of hepatocellular carcinoma. CTAP is thus widely used as a diagnostic imaging technique, particularly for the detection of small hepatocellular carcinomas. Conventional splenic portography has been carried out for many years using a wide diameter needle, a large amount of contrast medium and a film-screen system. Since the development of arterial portography, fewer splenoportograms have been performed due to the high incidence of bleeding and other complications. In this study a 0.6-mm (23 gauge) thin needle was used for splenic puncture and CT was used as a detector instead of a film-screen system. With this technique CT during percutaneous transsplenic portography may be performed on an outpatient basis.

[CT arterioportography in the spiral technic for the demonstration of liver metastases]. / CT-Arterioportographie in Spiraltechnik zum Nachweis von Lebermetastasen.

CT arterioportography using indirect portal venous application of contrast media is the most sensitive preoperative diagnostic technique for detection of liver metastases. Spiral CT allows continuous examination of the liver (no gap) during a single breathhold. Due to short measurement times an optimized vessel and tissue contrast can be achieved during the portal venous phase. Compared with intraoperative ultrasonography CTAP using spiral CT offers similar sensitivity (96%) in the detection of liver metastases and thus emerges as an important technique for diagnosis and follow-up of liver metastases.

Accuracy of CT arterial portography of the liver compared with findings at laparotomy.

To evaluate the accuracy of CT arterial portography (CTAP) of the liver, CTAP examinations from 111 patients were retrospectively reviewed and compared with the findings at laparotomy. Laparotomy had been performed within 3 weeks after the CTAP examination. In cases of resectable liver tumor, the result from the pathologic examination report was used to calculate the accuracy of CTAP. In cases of nonresectable liver tumor or liver without tumor, CTAP findings were compared with the result of a thorough inspection and palpation of the liver. The right liver lobe and the medial and lateral segments of the left lobe were separately evaluated. Thus, a total of 333 lobes/segments were evaluated. Tumor was found at laparotomy in 80 of 333 lobes or segments. At CTAP a total of 94 lobes were evaluated as positive for tumor growth, 23 of these were falsely interpreted as positive and 9 were falsely interpreted as negative when compared with the findings at laparotomy. However, 3 patients called false-positives later turned out to be true-positives since the lesions were overlooked at operation. A sensitivity of 89%, a specificity of 91%, and an accuracy of 90% was calculated for CTAP. It is concluded that CTAP has a higher accuracy than other radiologic methods and should be considered suitable for preoperative evaluation of potentially resectable liver tumor.

Balloon-occluded arterial portography using prostaglandin E1: improved visualization of the intrahepatic portal vein.

For improved visualization of the intrahepatic portal vein, balloon-occluded superior mesenteric arteriography was performed using a torque-controlled balloon catheter after injection of 20 micrograms prostaglandin E1. In patients who underwent arterial portography twice, i.e., by the method using prostaglandin E1 alone and the prostaglandin E1 plus the balloon method, the latter method provided better visualization, particularly in cases in which an aberrant right hepatic artery arose from the superior mesenteric artery.