Efficacy of Preemptive Embolization of Sac Branches During Endovascular Aneurysm Repair Using N-butyl-2-cyanoacrylate.

OBJECTIVE: A type 2 endoleak (T2EL) is the most frequently occurring endoleak type after endovascular aneurysm repair (EVAR). Residual T2ELs may cause aneurysm rupture; however, the management of a T2EL remains controversial. This study evaluated sac branch preemptive embolization using N-butyl-2-cyanoacrylate, aiming to prevent T2ELs and sac shrinkage. METHODS: Twelve consecutive patients underwent elective preemptive embolization during EVAR at our hospital between August 2018 to March 2019. Their demographic information, operative details, and sac diameters were examined at 6 months after EVAR. RESULTS: No procedural complications were observed. There were no in-hospital deaths among the 12 patients. Sac shrinkage was observed in this cohort (53.8-52.1 mm, p = 0.01). A total of 33 lumbar arteries were occluded with this procedure, and 2 patients had residual T2ELs at 6 months. CONCLUSIONS: A T2EL in preemptive sac branch embolization during EVAR has advantages in terms of safety and reduction. Although no clear evidence is available for the management of T2ELs, this study proposes a new standard to prevent it and improve the long-term outcomes after EVAR. However, embolization remains imperfect and further research is necessary.

Multiple asynchronous recurrence as a predictive factor for refractoriness against locoregional and surgical therapy in patients with intermediate-stage hepatocellular carcinoma.

Development of subclassification of intermediate-stage hepatocellular carcinoma (HCC) by treatment suitability is in demand. We aimed to identify predictors that define treatment refractoriness against locoregional(transarterial chemoembolization(TACE) or thermal ablation) and surgical therapy. This multicenter retrospective study enrolled 1167 HCC patients between 2015 and 2021. Of those, 209 patients were initially diagnosed with intermediate-stage HCC. Treatment refractoriness was defined as clinical settings that meets the following untreatable progressive conditions by TACE (1) 25% increase of intrahepatic tumor, (2) transient deterioration to Child-Pugh class C, (3) macrovascular invasion or extrahepatic spread, within one year. We then analyzed factors contributing to treatment refractoriness. The Child-Pugh score/class, number of tumors, infiltrative radiological type, and recurrence were significant factors. Focusing on recurrence as a predictor, median time to untreatable progression (TTUP) was 17.2 months in the recurrence subgroup whereas 35.5 months in the initial occurrence subgroup (HR, 2.06; 95% CI, 1.44-2.96; P = 0.001). Median TTUP decreased in cases with more later times of recurrence (3-5 recurrences, 17.3 months; ≥ 6 recurrences, 7.7 months). Recurrence, even more at later times, leads to increased treatment refractoriness. Early introduction of multidisciplinary treatment should be considered against HCC patients after multiple recurrent episodes.

First Experience With the Utility of ReMAP (Repeatable Microcatheter Access Port) in Portal Vein Stenting.

Portal vein stenting is a treatment option for portal hypertension caused by extrahepatic portal vein obstruction or stenosis. However, limited pathways to approach the portal vein are available, hindering re-intervention in the portal vein. Portal vein puncture through the transjugular intrahepatic portosystemic shunt route is less invasive and considered suitable for portal vein stenting. Furthermore, transjugular intrahepatic portosystemic shunting facilitates repeat approaches to the portal vein. However, a transjugular intrahepatic portosystemic shunt stent is not recommended unless necessary because of adverse events, and cannot be retrieved, once placed. Herein, we report on a novel approach using the repeatable microcatheter access port: ReMAP™ (Toray, Tokyo, Japan), a central vein port into which a 2.9 Fr catheter can be inserted. We used it for a repeat approach to the portal vein with only one puncture and without placing a transjugular intrahepatic portosystemic shunt stent.

Reduced Muscle Mass and Muscle Quality in Patients with Intermittent Claudication due to Peripheral Artery Disease.

BACKGROUND: Peripheral arterial disease (PAD) is associated with reduced muscle mass and quality, but the effects of leg ischemia caused by PAD on muscle quality remain poorly understood. The purpose of this study was to evaluate leg muscle mass and muscle quality in patients with intermittent claudication due to PAD using bioelectrical impedance analysis (BIA). METHODS: One hundred forty-one patients with intermittent claudication due to PAD who visited Tokyo Medical University Hospital from April 2019 to April 2020 were retrospectively analyzed. Leg ischemia was assessed using ankle-brachial pressure index (ABI). The skeletal muscle mass (SMM) assessed leg muscle mass, while the phase angle (PhA) assessed leg muscle quality using BIA. RESULTS: A total of 282 legs in 141 patients were included in the analysis. Leg PhA and SMM showed a decreasing trend according to the severity of leg ischemia (borderline/no ischemia: 2.80 ± 0.50 kg/m2, 4.38 ± 0.94°; mild ischemia: 2.83 ± 0.49 kg/m2, 4.33 ± 1.03°; moderate/severe ischemia: 2.50 ± 0.40 kg/m2, 3.89 ± 0. 88°; P < 0.001 and P = 0.020, respectively). The ABI was moderately correlated with leg SMM (B = 0.347, ß = 0.134, P < 0.001) and leg PhA (B = 0.577, ß = 0.111, P = 0.013) after adjustment for all significant covariates. Leg PhA was moderately correlated with leg SMM (r = 0.318, P < 0.001). CONCLUSIONS: Leg ischemia, especially when moderate or severe, has an adverse effect on both muscle mass and quality in the lower extremities and is associated with skeletal muscle myopathy.

Clinical risk factors for portal hypertension-related complications in systemic therapy for hepatocellular carcinoma.

BACKGROUND: During systemic therapy, the management of portal hypertension (PH)-related complications is vital. This study aimed to clarify factors associated with the incidence and exacerbation of PH-related complications, including the usefulness of contrast-enhanced computed tomography (CECT) in the management of PH-related complications during systemic therapy. METHODS: A total of 669 patients who received systemic therapy as first-line treatment (443 patients for sorafenib, 131 for lenvatinib, and 90 for atezolizumab/bevacizumab [ATZ/BEV]) were enrolled in this retrospective study. Additionally, the lower esophageal intramural vessel diameters (EIV) on CECT and endoscopic findings in 358 patients were compared. RESULTS: The cutoff values of the EIV diameter on CECT were 3.1 mm for small, 5.1 mm for medium, and 7.6 mm for large varices, demonstrating high concordance with the endoscopic findings. esophageal varices (EV) bleeding predictors include EIV ≥ 3.1 mm and portal vein tumor thrombosis (PVTT). In patients without EV before systemic therapy, factors associated with EV exacerbation after 3 months were EIV ≥ 1.9 mm and ATZ/BEV use. Predictors of hepatic encephalopathy (HE) include the ammonia level or portosystemic shunt diameter ≥ 6.8 mm. The incidence of HE within 2 weeks was significantly higher (18%) in patients with an ammonia level ≥ 73 µmol/L and a portosystemic shunt ≥ 6.8 mm. The exacerbating factors for ascites after 3 months were PVTT and low albumin levels. CONCLUSIONS: Careful management is warranted for patients with risk factors for exacerbation of PH-related complications; moreover, the effective use of CECT is clinically important.

Effects of High-Intensity Inspiratory Muscle Warm-Up on High-Intensity Exercise Performance and Muscle Oxygenation.

PURPOSE: An inspiratory muscle warm-up (IMW) improves inspiratory muscle function, but the effects of high-intensity exercise are inconsistent. We aimed to determine the effects of high-intensity IMW on high-intensity exercise performance and muscle oxygenation. METHODS: Ten healthy men (maximal oxygen uptake [V˙O2max] 52.2 [5.0] mL·kg-1·min-1) performed constant-load exercise to exhaustion on a cycle ergometer at V˙O2max under 2 IMW conditions: a placebo condition (PLA) and a high-intensity IMW condition (HIGH). The inspiratory loads were set at 15% and 80% of maximal inspiratory pressure, respectively. Maximal inspiratory pressure was measured before and after IMW. Oxyhemoglobin was measured in the vastus lateralis by near-infrared spectroscopy during exercise. Rating of perceived exertion (RPE) for a leg was measured after 1 and 2 minutes of exercise. RESULTS: Exercise tolerance was significantly higher under HIGH than PLA (228 [49] s vs 218 [49] s, P = .003). Maximal inspiratory pressure was significantly increased by IMW under HIGH (from 125 [20] to 136 [25] cm H2O, P = .031). Oxyhemoglobin was significantly higher under HIGH than PLA at 80% of the total duration of exercise (P = .048). RPE for the leg was significantly lower under HIGH than PLA after 2 minutes of exercise (P = .019). CONCLUSIONS: Given that oxyhemoglobin is an index of local oxygen supply, the results of this study suggest that high-intensity IMW increases the oxygen supply to active limbs. It may also reflect a reduction in RPE in the leg. In addition, high-intensity IMW may improve exercise performance.