Hepatic arterial infusion of autologous CD34+ cells for hepatitis C virus-related decompensated cirrhosis: A multicenter, open-label, exploratory randomized controlled trial.

Introduction: In this multicenter clinical study, we aimed to investigate the efficacy and safety of the transhepatic arterial administration of granulocyte-colony stimulating factor (G-CSF)-mobilized autologous peripheral blood (PB)-CD34+ cells compared with standard therapy in patients with decompensated cirrhosis type C. Methods: Patients were randomly assigned (2:1) to the CD34+ cell transplant (CD34+ cell) or standard-of-care (SOC) group and followed up for 52 weeks. The primary endpoints were the non-progression rate of Child-Pugh (CP) scores at 24 weeks post-enrollment and the safety of the protocol treatment. Results: Fourteen patients (CD34+ cell group: 10; SOC group: 4) were enrolled. CP scores at 24 weeks had a non-progression rate of 90% in the CD34+ cell group and 100% in the SOC group, with no significant difference between groups. Importantly, 4 out of 10 patients in the CD34+ cell group exhibited an improvement from decompensated to compensated cirrhosis, whereas all patients in the SOC group remained in decompensated cirrhosis. With regard to secondary endpoints, a trend toward increased serum albumin levels in the CD34+ cell group was noted. Serious adverse events (SAEs) occurred in three patients in the CD34+ cell group and in one patient in the SOC group. No causal relationship was observed between all SAEs and G-CSF, leukapheresis, or cell transplantation in the CD34+ cell group. No patients died and no hepatocellular carcinoma occurred within the study period. Conclusions: PB-CD34+ cell infusion therapy may have the potential to circumvent the decompensated stage of cirrhosis, thus avoiding the need for liver transplantation.

Radiofrequency Ablation Combined with Hepatic Artery Embolization Using a Tris-acryl Gelatin Microsphere for Colorectal Liver Metastases-Initial Experience.

Purpose: We aim to evaluate retrospectively the feasibility, safety, and initial therapeutic outcomes of radiofrequency ablation combined with hepatic artery embolization using a tris-acryl gelatin microsphere for colorectal liver metastases. Material and Methods: Six consecutive patients (4 men and 2 women) with median age of 68 years (range 57-78 years) underwent computed tomography fluoroscopy-guided radiofrequency ablation immediately after hepatic artery embolization using microspheres. This study evaluated tumor visibility on noncontrast-enhanced computed tomography immediately after hepatic artery embolization; analyzed local tumor progression; defined technical success as the coverage of the tumor by the ablative zone; and assessed adverse events based on Common Terminology Criteria for Adverse Events v5.0. Results: Ten tumors with median maximum diameter of 9 mm (range 5-52 mm) were treated in nine sessions. Eight tumors (80%, 8/10 tumors) were detected as high-attenuation nodules. One tumor was treated in two sessions because follow-up computed tomography revealed an insufficient ablative margin. Therefore, the primary and secondary technical success was 90% (9/10 tumors) and 100% (10/10 tumors), respectively. Grade 2 pneumothorax was observed in one session (11%, 1/9 sessions). No grade 3 or higher adverse event was observed. The local tumor progression rate was 20% (2/10 tumors) during the median follow-up of 14 months. Conclusions: Radiofrequency ablation following microsphere embolization may be a feasible, safe, and useful therapeutic option for controlling small colorectal liver metastases.

Efficacy of Percutaneous Direct Puncture Biopsy of Malignant Lung Tumors Contacting to the Pleura.

BACKGROUND/AIM: This is a retrospective evaluation of whether percutaneous direct puncture biopsy of lung lesions contacting to the pleura is justified. PATIENTS AND METHODS: Between August 2016 and July 2021, 163 consecutive patients (100 males, 63 females with a median age of 73 years) who had malignant lung tumors measuring 0.6-12.4 cm (median, 2.9 cm) that contacted to the pleura and underwent percutaneous lung biopsy under computed tomography fluoroscopic guidance using an 18-gauge end-cut needle were examined. The trajectory was direct puncture in 80 patients (49.1%, 80/163), and trans-lung in 83 patients (50.9%, 83/163). Diagnostic yield and major adverse event rates of direct and trans-lung puncture biopsies were compared. RESULTS: No difference was found in diagnostic yield between direct puncture and trans-lung biopsies (93.8% vs. 98.8%, p=0.11). Major adverse events were major pneumothorax (n=13/163, 8.0%), pleural dissemination (n=18/163, 11.0%), and hemothorax requiring arterial embolization (n=1/163, 1.0%). Direct puncture caused major pneumothorax significantly less than trans-lung puncture did (0%, 0/80 vs. 15.7%, 13/83, p<0.001). No significant difference was found between the two biopsy methods regarding the incidence of pleural dissemination (11.0%, 11/80 vs. 8.4%, 7/83, p=0.32). CONCLUSION: Direct puncture biopsy of malignant lung tumors contacting to the pleura is justified.

Untangling a Knotted Angiographic Catheter Using a Balloon Catheter: A Case Report.

When a 66-year-old man with hepatocellular carcinoma underwent an angiographic examination, a 4-Fr catheter was inserted from the right femoral artery. It became tightly knotted in the descending aorta. To untangle the knotted catheter, a noncompliant balloon catheter was delivered into the knotted loop from the contralateral femoral artery. After the balloon catheter was inflated from the inside of the knotted loop, the knot became loose. Finally, the knotted catheter was untangled. Subsequently, the remainder of the examination was performed as initially planned.

Clinical Utility of Bland Embolization Using Microspheres for Painful Malignant Musculoskeletal Tumors.

BACKGROUND/AIM: To evaluate retrospectively whether bland embolization using microspheres is safe and useful for relieving pain in patients with painful malignant musculoskeletal (MSK) tumors. PATIENTS AND METHODS: Bland embolization using microspheres was performed for 20 patients (11 women/9 men) with a median age of 69 years (range=40-89 years) who had 22 painful malignant MSK tumors. The maximum tumor diameters were 2.4-13.8 cm (median, 7.5 cm). Pain was evaluated using the visual analog scale. A decrease of this score by 2 or more after embolization was defined as clinically effective pain relief. Adverse events (AEs) were evaluated using CTCAE v5.0. Objective response, disease control rates, and overall survival were also evaluated. RESULTS: Effective pain relief was achieved in 18 patients (90.0%, 18/20). Grade-3 AEs developed in four patients (20.0%, 4/20): skin ulcer (n=2), skin ulcer and pain (n=1), and muscle weakness with dysesthesia (n=1). No grade-4 or grade-5 AEs developed. Objective response and disease control rates were 26.7% (4/15) and 86.7% (13/15), respectively. The 1-year survival rate was 43.8%, with median survival of 9.2 months (range=0.5-41.0 months). CONCLUSION: Although the survival benefit is equivocal, bland embolization is acceptably safe and useful for relieving pain by controlling tumor growth in patients with painful malignant MSK tumors.

Radioprotective Effects of a Semicircular X-ray Shielding Device for Operators During CT Fluoroscopy-Guided Interventional Procedures: Experimental and Clinical Studies.

PURPOSE: To evaluate, experimentally and clinically, the radioprotective effects of a semicircular X-ray shielding device for operators during CT fluoroscopy-guided IR procedures. MATERIALS AND METHODS: During experimentation, the reduction rates of scattered radiation rates from CT fluoroscopy were evaluated using a humanoid phantom. Two shielding device positions were tested: "shielding close to the CT gantry" and "shielding close to the operator". The scattered radiation rate without shielding was also evaluated. The clinical study retrospectively evaluated the operator's radiation exposure during 314 CT-guided IR procedures. With a semicircular X-ray shielding device (with shielding group, n = 119) or without it (no shielding group, n = 195), CT fluoroscopy-guided IR procedures were performed. Radiation dose measurements were taken using a pocket dosimeter placed near the operator's eye. For shielding and no shielding groups, the procedure time, dose length product (DLP), and the operator's radiation exposures were compared. RESULTS: Experimentation revealed the respective mean reduction rates of "shielding close to the CT gantry" and "shielding close to the operator" as 84.3% and 93.5% compared with the no-shielding setting. Although no significant differences were found in the procedure time and the DLP between "no shielding" and "with shielding" groups in the clinical study, the operators' radiation exposure in the "with shielding" group (0.03 ± 0.04 mSv) was significantly lower than in the "no shielding" group (0.14 ± 0.15 mSv; p < .001). CONCLUSION: The semicircular X-ray shielding device provides valuable radioprotective effects for operators during CT fluoroscopy-guided IR.

Metastasis of Hepatocellular Carcinoma in the Pouch of Douglas Successfully Treated by Radiation Therapy: A Case Report.

Metastasis of hepatocellular carcinoma (HCC) in the pouch of Douglas is relatively rare. A 65-year-old man with liver cirrhosis was admitted for detailed examination of a pelvic tumor. He had a previous history of ruptured HCC, and received emergent hemostasis with transcatheter arterial embolization followed by curative ablation. His blood tests showed an increase in des-gamma-carboxy prothrombin (DCP). Contrast-enhanced computed tomography (CE-CT) revealed a heterogeneously enhanced large pelvic tumor, but no additional tumorous lesions were detected in other organs, including the lungs, liver and abdominal lymph nodes. The colonoscopy showed compression by an extra-luminal/submucosal tumor, and computed tomography-guided percutaneous needle biopsy revealed that the pelvic tumor was metastasis of HCC. Because of the poor liver function, the solitary pelvic tumor was treated with three-dimensional conformal radiation therapy (3D-CRT). The tumor size and the DCP value were markedly decreased after radiation therapy. Nine months later, occasional mild bloody stool due to radiation proctitis was observed; however, no serious side effects occurred. Our case suggests that radiation therapy may be a therapeutic option for a solitary metastatic lesion of HCC in the pouch of Douglas.

Clinical Experience of Percutaneous Radiofrequency Ablation Using an arfa RF ABLATION SYSTEMⓇ in Various Organs.

Purpose: To evaluate the feasibility, safety, and efficacy of radiofrequency (RF) ablation using an ablation system (arfa RF ABLATION SYSTEMⓇ; Japan Lifeline Co. Ltd.) for treating solid tumors in various organs. Material and Methods: Between October 2019 and August 2021, 80 patients (29 women, 51 men; median age, 70.0 yr) underwent 107 RF ablation sessions using the ablation system to treat 151 tumors in the liver (n = 86), lung (n = 51), adrenal gland (n = 4), pleura (n = 4), bone (n = 3), lymph node (n = 2), and kidney (n = 1). The maximum tumor diameter was 2-40 mm (median, 11 mm). This study evaluated technical success (defined as the completion of planned RF ablation), technique efficacy (defined as the complete tumor ablation on follow-up images), and adverse events. Local tumor progression in 146 curatively treated malignant tumors was evaluated. Results: The technical success rate was 100% (107/107). Ablation zones in two tumors were insufficient. Therefore, the primary technique efficacy rate was 98.1% (105/107). Grade 3 hepatic infarction (1.6%, 1/64) and grade 4 pleuritis (3.4%, 1/29) occurred respectively after liver and lung RF ablation. During the median follow-up period of 10.2 months (Interquartile range, 4.2 and 16.4 months), local tumor progression developed in two tumors (1.4%, 2/146). Conclusions: The arfa RF ABLATION SYSTEMⓇ is a feasible, safe, and effective RF ablation device for managing solid tumors in various organs.

Lymphangiography as a Treatment for Refractory Congenital Chylothorax Due to RASopathies: A Report of Two Cases.

In this study, we report two cases in which intranodal lymphangiography helped improve congenital chylothorax due to RASopathies. We performed lymphangiography after conservative treatments failed to improve chylothorax in an 8-year-old girl with cardiofaciocutaneous syndrome and a 2-month-old boy with Noonan syndrome. Inguinal lymph nodes were punctured with 25-gauge needles under ultrasonographic guidance, and 4 and 1 mL of iodized oil were injected, respectively, showing a backflow of iodized oil into the lungs. Chylothorax had improved in both patients after nodal lymphangiography. However, the second child experienced worsening of disease-associated extremity edema and died of sepsis 4 months later.

Use of Microballoon Catheter in Transarterial Ethanol Embolization of Renal Angiomyolipoma: A Retrospective Comparative Study with Historical Control?

Purpose: To clarify the utility of microballoon catheter in renal arterial ethanol embolization of renal angiomyolipoma (AML). Material and Methods: A total of 20 patients (15 women, 5 men) with median age of 45 years (39-60 years) underwent embolization to treat 22 AMLs. A mixture of ethanol and iodized oil was injected into the feeding arteries of 13 tumors using balloon occlusion (the balloon embolization group) with a microballoon catheter and 9 tumors without using balloon occlusion (the non-balloon embolization group). Changes in the maximum tumor diameter, tumor volume, and adverse events were evaluated. Result: The median baseline maximum tumor diameters and volumes were 6.3 cm and 61.4 cm3 in the balloon embolization group, and 4.6 cm and 40.1 cm3 in the non-balloon embolization group, respectively. Tumor enhancement disappeared on postembolization angiography in all cases. All tumors shrunk after embolization. There were no statistically significant differences in the percent decrease in the maximum tumor diameter and volume at 10-12 month between balloon occlusion group (31.5% and 67.9%) and control group (34.8% and 62.6%). Fever was significantly more frequent when balloon occlusion was used: 38% vs. 0% (p = 0.03). No major complication was observed in either patient group. Conclusions: Balloon occlusion may not affect tumor shrinkage when embolizing AMLs with a mixture of ethanol and lipiodol.

Long-term survival following radiofrequency ablation of lung metastases in an elderly patient with calcaneal osteosarcoma: A case report and review of the literature.

RATIONALE: Recently, the number of osteosarcomas has been increasing in elderly patients due to human longevity. Lung metastases are the primary cause of death from osteosarcomas. Complete resection of lung metastases can prolong the survival. However, complete resection in elderly patients is often difficult due to high risk of operative complications. Computed tomography (CT) guided radiofrequency ablation (RFA) is a minimally invasive technique to destroy tumor nodules using heat. In this report, we present the first case older than 65 years applying RFA for lung metastases due to osteosarcoma. PATIENT CONCERNS: A 74-year-old male presented with 1-year history of heel pain. A conventional high-grade osteosarcoma in his calcaneus was diagnosed. Below-knee amputation was performed. However, lung metastases were found in both lungs 1 year after amputation. CT-guided lung RFA was chosen since surgical intervention for lung metastases was abandoned because of tumor multiplicity and medical comorbidities. A total of 18 lung metastases were treated by CT-guided RFA. The most frequent complication was pneumothoraxes in 4 of 8 (50%) procedures and chest tube drainage was required in 2 of these (2 of 8 (25%) procedures). DIAGNOSES: Six lung metastases of osteosaroma were found in both lungs at 1 year after surgery. INTERVENTIONS: CT-guided lung RFA was performed. A total of 18 lung metastases were treated in 8 lung RF procedures. OUTCOMES: The patient has been alive with disease for 5.5 years after the initial surgery. LESSONS: CT-guided lung RFA is effective for elderly patients with osteosarcoma lung metastases in spite of discouragement of lung metastasectomy due to multiplicity of metastases and medical-comorbidities.

Adrenal pheochromocytoma treated by combination of adrenal arterial embolization and radiofrequency ablation.

Combined therapy with adrenal arterial embolization and RF ablation may represent a useful therapeutic option with curative properties in select patients with pheochromocytoma.

Successful Embolization of Collaterals from the Round Ligament Artery during Uterine Artery Embolization for Traumatic Uterine Leiomyoma Rupture: A Case Report.

We describe the case of a 48-year-old woman who presented with traumatic rupture of a giant leiomyoma and massive hemoperitoneum caused by slipping and falling in the bathroom. She was in shock on arrival, and resuscitation was performed. Contrast-enhanced computed tomography showed massive intra-abdominal hematoma and extravasation from the subserous leiomyoma. Uterine artery embolization was performed, but she went into shock again after 6 h. The second contrast-enhanced computed tomography revealed persistence of extravasation. During 2nd UAE, an angiogram revealed extravasation originating from left round ligament artery. After the embolization of the left round ligament and bilateral uterine arteries, the patient recovered from shock. Total abdominal hysterectomy was performed on day 2 of admission to prevent re-bleeding and infection, then she discharged on day 19 of admission.

[Measurement of Head and Neck Exposure in CT Guided IVR].

In April 2011, the International Radiological Protection Committee recommended that "The equivalent dose of the crystalline lens should not exceed 20 mSv/year, averaged over defined periods of 5 years, with no single year exceeding 50 mSv". Based on this recommendation, it is predicted that the equivalent dose limit of our crystalline lens can be lowered in the near future. Therefore, it is important to grasp the current situation of radiation exposure. The purpose of this study is to measure the crystalline lens of surgeons by focusing on the CT-fluoroscopy guided interventional radiology's (IVRs). We also examined whether the exposure dose of the crystalline lens can be correctly evaluated by measuring the unequal exposure dose of the neck, which is usually used for the unequal exposure measurement. Results of the analysis of 200 CT-fluoroscopy guided IVR procedures showed that the unequal exposure dose of the neck was significantly correlated with the exposure dose of the crystalline lens which was measured near the left eye ball (R=0.83). However, the exposure dose of the crystalline was 33% lower than those of the neck. Therefore, although the individual dosimeter worn on the neck can be used as the useful index of the exposure dose of the crystalline lens, the results can be overestimated.

Balloon-occluded retrograde transvenous obliteration of varices: focusing on the portal hemodynamics and the recent techniques.

PURPOSE: To evaluate the recent topics of Ballloon-occluded retrograde trasnvenous obliteration(B-RTO). METHOD: We overviewed the recent scientific papers regarding B-RTO. RESULT: B-RTO is a treatment method for occluding varices retrogradely using a sclerosing agent under balloon occlusion of a major draining vein. It has been recognized as an effective treatment method for gastric varices. Hepatic function reserve is improved and liver volume is increased after B-RTO. In recent years, various technical options, such as plug-assisted retrograde transvenous obliteration, coil-assisted retrograde transvenous obliteration, or foam B-RTO, have also been reported. In performing B-RTO, portal hemodynamics must be thoroughly examined radiologically. Judging the classification of the grade of collateral venous hemodynamics is important to select the appropriate embolization technique of B-RTO and to successfully occlude varices. Finally, the word "portosystemic shunt syndrome" has been proposed and the condition should be considered while selecting a treatment for gastric varices. CONCLUSION: B-RTO is effective for gastrointestinal varices and portosystemic shunts.

Changes in liver perfusion and function before and after percutaneous occlusion of spontaneous portosystemic shunt.

PURPOSE: To evaluate changes in liver perfusion after occlusion of spontaneous portosystemic shunt and to analyze mechanisms of liver profile improvement. MATERIALS AND METHODS: Liver function changes and portal venous and hepatic arterial blood flow were evaluated using perfusion CT before and after shunt occlusion in 23 patients who underwent percutaneous occlusion of spontaneous portosystemic shunt because of gastric varices (n = 15) or hepatic encephalopathy (n = 8). RESULTS: Portal venous blood flow was significantly higher at 1 week (278.7 ml/min, 92.7-636.7, p = 0.012), 1 month (290.0 ml/min, 110.1-560.1, p < 0.001) and 3 months (299.6 ml/min, 156.7-618.5, p = 0.033) after shunt occlusion than the baseline (220.9 ml/min, 49.5-566.7). Hepatic arterial liver blood flow became lower than the baseline (132.3 ml/min, 47.9-622.3) after shunt occlusion, but a significant decrease was observed only at 1 month later (107.9 ml/min, 45.8-263.6 p = 0.027). Serum albumin concentration became significantly higher than the baseline (3.4 mg/dl, 1.9-4.5) at 1 month (3.8 mg/dl, 2.3-4.3, p = 0.018) and 3 months (3.9 mg/dl, 2.6-4.3, p = 0.024) after shunt occlusion. CONCLUSION: Shunt occlusion increases portal venous blood flow and decreases hepatic arterial blood flow, thereby improving the liver profile.

Radiological anatomy of spontaneous splenorenal shunts in patients with chronic liver disease.

PURPOSE: We evaluated anatomical variations of spontaneous splenorenal shunt (SSRS) and the prevalence of portosystemic shunts in patients with chronic liver disease by CT. MATERIALS AND METHODS: A total of 451 patients with chronic liver disease underwent contrast-enhanced computed tomography between October 2010 and April 2011. The prevalence of portosystemic shunts including SSRS and gastrorenal shunt, and the frequency of hepatic encephalopathy were examined. The course of the shunt and the point of confluence with the renal vein of the SSRS were analyzed. RESULTS: SSRSs or gastrorenal shunts were found in 11.1 and 5.0% of the patients, respectively. Anatomical variations were classified into three types according to the point of confluence as follows: type 1 = the SSRS joined the inferior phrenic vein (n = 33), type 2 = the SSRS joined the gonadal vein (n = 7), and type 3 = the SSRS joined the left renal vein (n = 14). The course of the SSRS from the splenic hilum was classified as medial (n = 46), posterior (n = 2), or anterolateral (n = 2). CONCLUSIONS: SSRSs were classified into three types depending on the confluence point with the renal vein, and into three types of course. These findings are useful for preoperative information.

Hemorrhagic shock due to ruptured left and right gastric artery aneurysm.

Case: We report a case of hemorrhagic shock due to a ruptured gastric artery aneurysm successfully treated with transarterial embolization. A 72-year-old woman with cholangitis presented with hemoperitoneum following a ruptured aneurysm of the gastric artery. Outcome: Emergent computed tomography and angiography were carried out and the patient was found to have spontaneous bleeding from both branches of the left and right gastric arteries. Transcatheter embolization was carried out at the distal branch of both gastric arteries with a coil. The patient recovered well with no recurrent bleeding. Conclusions: Although rare, visceral artery rupture should be considered in the differential diagnosis of unexplained hemorrhagic shock with abrupt onset of hemoperitoneum. Computed tomography and angiography are useful tools for obtaining prompt and accurate localization of the bleeding points.