Usefulness of computed tomography aortography and dye infusion in confirming the feeding arteries for effective treatment of a large squamous cell carcinoma of the lower lip with a single intra-arterial infusion chemotherapy combined with radiotherapy.

A 73-year-old male presented with a lower lip squamous cell carcinoma (SCC) (23 mm in diameter). Systemic imaging, including computed tomography (CT) and positron emission tomography, showed no evidence of distant metastasis. Due to the large size of the tumor, reconstruction after surgical tumor removal was considered to be difficult. Therefore, we decided to initially perform intra-arterial chemotherapy. Under local anesthesia, a catheter was inserted via the femoral artery. CT aortography from the ascending aorta was performed to visualize the precise vascular anatomy. The tumor's feeding arteries were confirmed by injecting indigo carmine dye through the catheter. Then, 87.5 mg of cisplatin was selectively injected through the left and right facial arteries (total dose of 175 mg). The tumor significantly shrank and almost disappeared 1 month after chemotherapy. Although additional intra-arterial chemotherapy was considered, the risks associated with the procedure meant that radiotherapy was performed instead. There were no signs of recurrence at the 2-year follow-up. In this patient, a single intra-arterial infusion chemotherapy combined with radiotherapy achieved complete disappearance of a large SCC of the lower lip. This treatment strategy allowed us to preserve the functional and cosmetic aspects of the patient's lower lip with minimal side effects. CT aortography and dye infusion were important in confirming the tumor's feeding arteries.

An anomalous left adrenal vein draining into both the left renal vein and inferior vena cava: A case report.

A male patient in his forties was diagnosed with primary aldosteronism following blood tests. The patient requested surgical treatment and was transferred to our department for adrenal vein sampling. Preoperative contrast-enhanced computed tomography (CT) revealed that the left adrenal vein (LAV) did not form a common trunk with the left inferior phrenic vein, and instead drained into both the left renal vein (LRV) and inferior vena cava (IVC) after the bifurcation. Angiography from the LAV showed a branch draining into the IVC. Left-sided sampling was performed. Aldosterone levels were elevated at all 3 sites. Because the sampling results were bilaterally positive, the patient was contraindicated for surgery. There are no reports of an anomalous LAV draining into both the LRV and IVC, making this case extremely unique. Regarding the LAV sampling site, it has been reported that aldosterone levels are higher in the common trunk than in the LAV. Therefore, we increased the number of blood sampling sites. In adrenal vein sampling, we often focus on the anatomy of the right adrenal vein because of difficulties in accessing to it. However, anomalies of the LAV may also occur. Therefore, it is important to determine the anatomy of both adrenal veins using preoperative contrast-enhanced CT to plan an appropriate sampling strategy.

Successful coil embolization of post-hepatectomy arterioportal fistula that reduced ascites and improved liver function.

A 71-year-old man had previously undergone S7 + S8 dorsal segmentectomy and S5 partial hepatectomy for hepatocellular carcinomas. Six months later, he experienced abdominal distention. Abdominal computed tomography (CT) showed massive ascites and a significant hepatic arterioportal shunt. The ascites was thought to be caused by portal hypertension due to a high-flow hepatic arterioportal fistula (HAPF). The fistula, located between the right hepatic artery A7 and the right portal vein, was embolized with microcoils under flow control using a balloon catheter. After embolization, the shunt blood flow disappeared and the hepatopetal venous flow was restored. His body weight and abdominal circumference decreased immediately, and his liver function on blood tests improved after the procedure. CT performed 11 days after embolization showed decreased ascites. A HAPF after hepatectomy is extremely rare. Balloon-assisted embolization using microcoils is a useful endovascular procedure for treating a high-flow HAPF.

Balloon-Assisted Portal Vein Embolization Using n-Butyl-2-Cyanoacrylate-Lipiodol-Iopamidol Mixture in Swine: A Comparison of 2 Formulations.

PURPOSE: To compare 2 ratios of n-butyl-2-cyanoacrylate (nBCA)-ethiodized oil (Lipiodol)-iopamidol (NLI) in balloon-assisted portal vein embolization (PVE) in swine. MATERIALS AND METHODS: In an in vitro study, NLI prepared at a ratio of 2:3:1 (NLI231) or 1:4:1 (NLI141) was injected into 2.5- or 10-mL syringes filled with swine blood, and the viscosity of NLI was measured to determine an appropriate balloon occlusion time. Two portal vein branches in 8 female swine (n = 16 vein branches) were embolized with NLI231 (n = 8) or NLI141 (n = 8) under balloon occlusion. Portal venography was performed before, immediately after, and 3 days after PVE to evaluate the migration of NLI and the recanalization of embolized portal vein branches. Then, the livers were removed for histopathologic evaluation. RESULTS: The times to peak viscosity of NLI231 in the 2.5- and 10-mL syringes were 55.8 seconds (SD ± 7.0) and 85.2 seconds (SD ± 6.3), and those to peak viscosity of NLI141 were 129.2 seconds (SD ± 11.8) and 254.0 seconds (SD ± 21.8), respectively. No migration of NLI231 was observed in all 8 procedures immediately or 3 days after PVE. Migration of NLI141 was observed in 6 of 8 procedures within 3 days after PVE. The migration frequency of the embolic material was lower in the NI231 group than in the NLI141 group (0/8 vs 6/8; P = .051). Histologically, NLI231 occupied the portal veins without any thrombi, whereas NLI141 was accompanied by thrombi in the portal veins. CONCLUSIONS: NLI231 may be more suitable than NLI141 for balloon-assisted PVE in swine.

Comparison of Renal Damage Following Renal Artery Embolization with Three Different Embolic Mixtures in Swine.

Purpose: Renal artery embolization is a minimally invasive and effective procedure for renal ablation, a complete necrosis of the renal parenchyma. This study aims to compare the extent of renal damage in swine following renal artery embolization with ethanol and N-butyl-2-cyanoacrylate, commonly used as embolic materials in renal ablation. Material and Methods: Three different embolic mixtures were prepared for renal artery embolization in swine: 33% ethanol-Lipiodol mixture (ethanol:Lipiodol = 1:2; Group A), 67% ethanol-Lipiodol mixture (ethanol:Lipiodol = 2:1; Group B), and 10% N-butyl-2-cyanoacrylate-Lipiodol mixture (N-butyl-2-cyanoacrylate:Lipiodol = 1:9; Group C). Three swine were assigned to each group and underwent embolization of the unilateral renal artery. Renal arteriography was performed before, immediately after, and two days after renal artery embolization. After two days, the kidneys were removed to determine the macroscopic necrosis rate and for histologic examination. Dark tissue regions were considered necrotic. Results: The macroscopic necrosis rate of the kidneys was 50.3%±7.4%, 100%±0%, and 100%±0% in Groups A, B, and C, respectively. The necrosis rates were higher in Groups B and C than in Group A. Histologically, the renal tubules were damaged in the necrotic areas. In addition, the glomeruli were damaged in Groups A and B but were preserved in Group C. Conclusions: Sixty-seven percent ethanol-Lipiodol mixture and 10% N-butyl-2-cyanoacrylate-Lipiodol mixture are effective embolic materials in renal artery embolization for renal ablation in swine. Also, ethanol caused partial glomerular necrosis, whereas N-butyl-2-cyanoacrylate preserved the glomeruli. Therefore, ethanol should be used for renal ablation.

Feasibility of the Glue-in-Plug Technique Using a Novel Liquid Embolic Material in a Swine Model.

PURPOSE: To evaluate the feasibility of the glue-in-plug (GIP) technique using n-butyl-2-cyanoacrylate‒Lipiodol (NL)-iopamidol (NLI) for short-segment embolization in swine. MATERIALS AND METHODS: The renal arteries, left external iliac artery, subclavian arteries, and common carotid arteries were each embolized in 4 swine using the GIP technique under general anesthesia. First, a type I Amplatzer vascular plug (AVP) (1-2 times the target vessel diameter) was deployed in the target artery. Next, the AVP was filled with NL mixture prepared at a ratio of 1:2 (NL12) (n = 11) or with NLI mixture prepared at a ratio of 2:3:1 (NLI231) (n = 11). Angiography was performed before, immediately after, and 1 hour after embolization to assess embolization and migration of the embolic materials. The embolized arteries were also evaluated histopathologically. RESULTS: The migration distance of the embolic material beyond the plug tip was significantly shorter in the NLI231 group than in the NL12 group immediately after embolization (6.5 mm ± 4.5 vs 1.0 mm ± 1.8, P = .0024) and 1 hour after embolization (8.4 mm ± 5.6 vs 1.0 mm ± 1.8, P = .0013). Angiography revealed no sign of recanalization of the target vessels in any artery in either group. Mild inflammatory cell infiltration was observed around the arterial wall at the embolization site in all arteries in both groups. CONCLUSIONS: The GIP technique using NLI231 may be a feasible procedure for short-segment embolization based on these short-term results.

Duodenal bleeding outside covered stents identified by selective computed tomography during arteriography that was successfully treated by embolization: A case report.

The patient was a man in his 60s who previously underwent placement of covered stents in the duodenum for a duodenal stricture caused by pancreatic cancer invasion. He experienced multiple episodes of hematemesis and hematochezia during hospitalization. Emergency upper and lower gastrointestinal endoscopies were performed but were unable to reveal the bleeding source. Based on these findings, we suspected small intestinal bleeding and emergency angiography was performed for the purpose of hemostasis. Computed tomography during arteriography was performed from the superior mesenteric artery and revealed extravasation outside the covered stents in the descending portion of the duodenum. Angiography of the inferior pancreaticoduodenal artery revealed extravasation in the descending portion of the duodenum, and the inferior pancreaticoduodenal artery was embolized with n-butyl cyanoacrylate. There were no postoperative symptoms indicative of intestinal ischemia or pancreatitis, and there was no rebleeding after embolization. In patients with bleeding outside the duodenal-covered stents, it can be difficult to identify the bleeding source by upper gastrointestinal endoscopy. In this case, selective computed tomography during arteriography and angiography revealed bleeding outside the duodenal-covered stents that was successfully treated by arterial embolization with n-butyl cyanoacrylate.

Permissive untreated pseudoaneurysm concept in damage control interventional radiology for traumatic pancreaticoduodenal artery injury.

Background: Angioembolization for traumatic pancreaticoduodenal artery injury with unstable circulation, which characteristically requires a prolonged procedure time, does not yet have a standardized strategy for damage control interventional radiology. Case Presentation: We encountered two cases of rare traumatic pancreaticoduodenal artery injury wherein the patients were saved by a multidisciplinary team with a shared goal of clinical success, rather than the procedural success of angioembolization. Both patients treated with angioembolization had residual pseudoaneurysm or faint extravasation in the pancreaticoduodenal artery arcade. We prioritized critical care with preemptive plasma transfusion and aggressive blood pressure control, and planned repeat angiography. The patients showed no clinical signs of rebleeding or pseudoaneurysm based on computed tomography during follow-up. Conclusion: Our findings suggest that the permissive untreated pseudoaneurysm concept can be useful in developing damage control interventional radiology strategies for trauma cases with challenging time limitations, such as traumatic pancreaticoduodenal artery injury with circulatory collapse.

Successful coil embolization of a ruptured aneurysm of the arc of Riolan artery.

The arc of Riolan (AOR) is an anastomosis between the middle and left colic arteries. Aneurysms of the AOR are very rare visceral artery aneurysms. A 44-year-old man presented with abdominal pain and loss of consciousness. Computed tomography and angiography showed hemorrhagic ascites around the liver and spleen. An irregularly dilated artery was visible within a hematoma in the upper left region of the abdomen, consistent with a ruptured pseudoaneurysm of the AOR. Transcatheter arterial embolization was performed with microcoils. The patient's abdominal pain disappeared after embolization, and no symptoms of intestinal ischemia were observed. To our knowledge, this is the first case of an AOR aneurysm with AOR dilation due to dissection of the celiac artery that was successfully treated by coil embolization.

Percutaneous transsplenic venous embolization of elevated jejunal varices after pancreaticoduodenectomy: A case report.

Recent advances in chemotherapy and radiotherapy have led to an increase in the number of long-term survivors of pancreatic cancer. However, this has also increased the number of patients suffering from ectopic varices and bleeding owing to left-sided portal hypertension and thrombocytopenia caused by splenomegaly after pancreaticoduodenectomy combined with resection of the splenic vein. A 65-year-old woman with varices of the elevated jejunum due to left sided portal hypertension after pancreaticoduodenectomy had repeated melena, which started about 1 year before admission. We describe the first reported case of percutaneous transsplenic venous embolization using metallic coils, which successfully achieved hemostasis of refractory bleeding from the elevated jejunal varices after pancreaticoduodenectomy.

Impact of anticancer drugs on the therapeutic efficacy and side effects of hepatic arterial embolization for hepatocellular carcinoma.

Background and Aim: Transcatheter arterial chemoembolization (TACE) using various anticancer drugs is often performed to treat hepatocellular carcinoma (HCC). We aimed to compare the therapeutic efficacy and side effects of TACE with anticancer drugs versus transcatheter arterial embolization (TAE) without anticancer drugs for HCC. Methods: Patients with HCC were randomized to either the TACE or TAE group. Up to five target nodules were treated in each patient. Lipiodol (Lp; 10 mL), contrast media (CM; 10 mL), epirubicin (40 mg), mitomycin C (10 mg), miliplatin (70 mg), and 1-2-mm 2-day soluble gelatin sponge particles (2D-SGS) were injected into the TACE group, whereas Lp (10 mL), CM (10 mL), and 2D-SGS were injected into the TAE group. Treatment effect (TE) of the target nodules was graded (TE1-TE4) and patient responses were assessed. Three months after treatment, blood tests were performed to compare tumor markers and adverse events. Results: Fifty-four patients and 161 target nodules were included; 75 nodules in 28 patients were treated by TACE, and 86 nodules in 26 patients were treated by TAE. The number of nodules graded TE1, TE2, TE3, and TE4 was 1, 28, 7, and 39, respectively, in the TACE group and 2, 25, 7, and 52, respectively, in the TAE group. The response rates were 89% (25/28) and 73% (19/26) in the TACE and TAE groups, respectively. There were no significant differences in TE, response rates, or blood test results between the two groups. Conclusion: In hepatic arterial embolization for HCC, anticancer drugs did not have any impact on the therapeutic efficacy or side effects at 3 months after embolization.

Usefulness of ethiodized oil and gelatin sponge particles for delaying the washout of indocyanine green from the liver in swine.

PURPOSE: To assess the effect of ethiodized oil (EO) and gelatin sponge particles (GS) on delaying the washout of indocyanine green (ICG) from the liver in swine. METHODS: Fifteen swine were divided into 3 groups: injection of a mixture of ICG and water-soluble contrast medium (CM) followed by embolization with GS (group A), injection of a mixture of ICG and EO (group B) and injection of a mixture of ICG and EO followed by embolization with GS (group C). The liver surface was observed using an infrared camera system during and at 1, 2, 3, and 6 h after the procedure to measure ICG contrast. Livers were removed at 6 h for histopathological examination. RESULTS: The contrast ratio between injected and non-injected regions at 6 h was 1.45 ± 0.44 in group A, 1.89 ± 0.37 in group B, and 3.62 ± 0.76 in group C. The contrast ratio in group C was significantly greater than that in groups A and B (P = 0.032 and 0.033, respectively). CONCLUSIONS: EO and GS delayed the washout of ICG from the liver in swine and may extend intraoperative navigation in clinical use. Indocyanine green (ICG) mixed with ethiodized oil (EO) was injected into the left hepatic artery in swine, and the artery was embolized with gelatin sponge particles (GS). We confirmed that ICG remained in the liver parenchyma up to 6 h after the procedure. EO and GS delayed the washout of ICG from the liver in swine.

Transcatheter arterial embolization of abnormal neovessels in a swine model of knee arthritis.

BACKGROUND: In recent years, transcatheter arterial embolization (TAE) using imipenem/cilastatin (IPM/CS) has attracted attention as a treatment for relieving osteoarthritis (OA) pain. However, IPM/CS is not approved by Japanese medical insurance for use as an embolic material. Therefore, it is necessary to develop new embolic materials for TAE to relieve OA pain. The purpose of this study was to develop a swine model of knee arthritis and embolize abnormal neovessels (ANs) using two different embolic materials. We compared the embolic effects and tissue damage in knees. METHODS: Knee arthritis was induced by intra-articular injection of papain into 12 knees in six female swine. The swine were divided into two groups of three swine each (six knees per group) for embolization of ANs in the knees with either IPM/CS or soluble gelatin sponge particles (SGSs). Three days after embolization, we compared the embolic effects using angiography and the tissue damage histopathologically. RESULTS: ANs were observed in all 12 knees at 42 days after papain injection. The ANs disappeared and the patent arteries were recanalized 3 days after TAE in all 12 knees. Histopathological evaluation revealed synovitis changes, such as synovial thickening and inflammatory cell infiltration, in all 12 knees. There was no evidence of skin or muscle necrosis in either group. The appearance of ANs, recanalization of the parent arteries, and histopathological outcomes were not significantly different between the two groups. CONCLUSION: SGSs were as safe as IPM/CS for TAE of ANs in this swine model of knee arthritis.

Efficacy and safety of CT-guided cryoablation after lipiodol marking and embolization for RCC.

PURPOSE: To evaluate the safety and efficacy of CT fluoroscopy-guided percutaneous cryoablation (PCA) after lipiodol marking and embolization (LME) in patients with renal cell carcinoma (RCC). MATERIAL AND METHODS: This study included 29 patients (18 men, 11 women; mean age 69 years, range 22-89 years) with 42 RCCs. They underwent CT fluoroscopy-guided PCA after LME between March 2016 and March 2020. The mean tumor diameter was 21 mm (range 7-50 mm). LME was performed with lipiodol and gelatin particles. PCA was considered successful when the ice ball encapsulated the entire tumor and the margin was sufficient on post-ablation CT scans. RESULTS: LME was successfully performed in 39 of 40 tumors (97.5%). PCA after LME was successful in all 39 of 39 tumors (100%). During the follow-up period (mean 13.9 ± 12.1 months), one of the 39 tumors (2.6%) developed local tumor progression. A significant complication (reversible hypertensive crisis) was encountered in only one of 37 (2.7%) procedures. The mean eGFR was 64.2 ± 26.8 before and 63.3 ± 26.4 after PCA (p = .44). CONCLUSION: LME using iodized oil and gelatin particles to improve visualization of the RCC facilitated tumor localization on unenhanced CT images. PCA after LME might be a safe and effective for treatment in patients with RCC.

Determination of the Optimal Ratio and the Relationship Between Viscosity and Adhesion of n-Butyl Cyanoacrylate-Lipiodol-Iopamidol for Balloon-Assisted Embolization of Wide-Neck Aneurysms in Swine.

PURPOSE: To determine the optimal ratio of n-butyl cyanoacrylate-Lipiodol-iopamidol (NLI) for balloon-assisted embolization of wide-neck aneurysms in swine. MATERIALS AND METHODS: Sixteen NLI mixtures were prepared for in vitro studies. The viscosity of each mixture was measured for 30 min. We evaluated whether the mixtures could be injected through a microcatheter and whether they adhered to the microcatheter. In vivo, 15 wide-neck aneurysms were created on the arteries in 4 female swine. Under balloon occlusion, 7 aneurysms were embolized with NLI141 (NBCA:Lipidol:iopamidol = 1:4:1) and 8 were embolized with NLI231. We performed angiography to evaluate adhesion of NLI to the balloons or microcatheters and NLI migration. RESULTS: In vitro, the iopamidol content needed to comprise at least 1/6 of the mixture in order for NLI to be non-adhesive with increased viscosity. NLI could not be injected through a microcatheter if the iopamidol content exceeded 1/6 of the mixture. Only NLI141 and NLI231 did not adhere to the microcatheter with increased viscosity, and could be injected through a microcatheter. In vivo, neither NLI mixture adhered to the balloons or microcatheters. The migration of NLI was observed in 6 of 7 aneurysms embolized with NLI141 and in none of 8 aneurysms embolized with NLI231. CONCLUSION: Our in vitro study revealed that the ratios of NLI that were non-adhesive and could be injected through a microcatheter were 1:4:1 and 2:3:1. The optimal ratio of NLI for balloon-assisted embolization of wide-neck aneurysms in swine was considered to be 2:3:1.

A case of maxillary cancer treated by intra-arterial therapy using a steerable microcatheter.

We report on a 69-year-old man with locally-advanced left maxillary sinus cancer who underwent treatment with intra-arterial chemoradiotherapy. Angiography showed that the main feeding arteries were the left maxillary artery and the ophthalmic artery, arising from the internal carotid artery. Due to acute branching of the ophthalmic artery, conventional microcatheters could not be inserted. Using a steerable microcatheter, we were able to repeatedly administer chemoradiotherapy via the ophthalmic artery. The tumor has mostly disappeared after intra-arterial chemoradiotherapy, and the patient is still alive two years after treatment. A steerable microcatheter is very useful for acute-angled vascular branches.

Artificially induced pneumothorax with a Veress needle for cryoablation of renal cell carcinoma.

Thermal ablative techniques are used increasingly to treat renal cell carcinoma (RCC). Percutaneous cryoablation of tumors at the upper pole of the kidney may result in pulmonary damage due to the intervening lung parenchyma. We treated two patients with RCC in the upper pole of the kidney by inducing pneumothorax with a pneumoperitoneum needle before proceeding to percutaneous cryoablation. The procedures, performed under computed tomography (CT) fluoroscopy guidance, resulted in complete tumor necrosis. There was no pulmonary damage.