Diaphragmatic perforation after transcatheter arterial chemoembolization of hepatocellular carcinoma via inferior phrenic artery: a case report.

BACKGROUND: Transcatheter arterial chemoembolization (TACE) via the inferior phrenic artery has been recognized to have its own therapeutic role without causing serious procedural complications. We report a case of diaphragmatic perforation after repeated TACE sessions conducted via the right inferior phrenic artery. CASE PRESENTATION: A 43-year-old man diagnosed with hepatocellular carcinoma was admitted to the hospital with a chief complaint of cough. The patient underwent TACE via the right inferior phrenic artery 3 months prior and was discharged without specific complications. Physical examination revealed decreased breathing sounds in the right lower lung zone. Chest radiograph demonstrated a small right pleural effusion. Chest CT scan revealed a small diaphragmatic perforation. The patient was unable to undergo surgical exploration, and a follow-up CT scan after 2 months revealed progression of the right diaphragmatic perforation with massive herniation of omental fat into the thoracic cavity. CONCLUSIONS: Although TACE via the inferior phrenic artery is a relatively safe procedure, it can be associated with rare but serious complications after repeated procedures. This is a rare case report of diaphragmatic perforation after TACE via the right inferior phrenic artery. Early recognition and prompt surgical management are essential to prevent catastrophic outcomes.

Ultrasound-Guided Deployment of a Plug-Based Vascular Closure Device in Femoral Arteries with Calcified Plaque or Stenosis.

From January 2019 to January 2020, 106 patients (age, 64.8 ± 14.1 years; male, 63.2%) were included to retrospectively investigate the feasibility and safety of ultrasound-guided deployment of ExoSeal after femoral artery access. Baseline characteristics were not different except for age (P = .022), body mass index (P = .009), and diameter (P < .001) between the calcified plaque or stenosis (CS) group (n = 49) and non-CS group (n = 57). The overall technical and clinical success rates were 96.2% and 100%, respectively. The technical (CS group, 48/49; non-CS group, 54/57) and clinical success rates (100%), time to hemostasis (CS group, 3.21 ± 0.54 min; non-CS group, 3.39 ± 0.71 min), and complication rates (CS group, 1/49; non-CS group, 0/57) were not different between the 2 groups. ExoSeal seems to be safe to use under ultrasound guidance in the femoral arteries with CS.

Subclassification and Treatment Results of Ethanol Embolotherapy of Type II Arteriovenous Malformations of the Extremity and Body.

PURPOSE: To evaluate the safety and efficacy of ethanol and coil embolization of type II arteriovenous malformation (AVM) according to a new subtype classification. MATERIALS AND METHODS: Eighty-four type II AVMs in the body or extremity of 79 patients who underwent AVM treatment from 1996 to 2017 were retrospectively subclassified according to the angiographic morphology of the draining vein as type IIa (arterioles shunt to focal segment of single draining vein), type IIb (arterioles shunt to venous sac with multiple draining veins), and type IIc (arterioles shunt along long segment of draining vein). Coil and ethanol embolization of the focal or long segment of the draining vein or the venous sac was performed with direct puncture or transvenous approach according to subtype. Treatment outcomes, number of treatment sessions, and complications were analyzed. RESULTS: AVM cure (ie, complete embolization) rates were 95%, 76%, and 65% in types IIa, IIb, and IIc AVMs, respectively. The cure rate of type IIa AVMs was significantly better than that of type IIc AVMs (P = .015). Median numbers of treatment sessions were 1 in types IIa and IIb AVMs and 2.5 in type IIc AVMs, with a significant difference between type IIc and the other 2 types (P < .05). Minor complications occurred in 20% of patents and major complications occurred in 7%. CONCLUSIONS: The cure rate of type IIa AVMs was significantly better than that of type IIc AVMs, which also required significantly more treatment sessions than the other 2 types.

Gastrointestinal bleeding after failed endoscopic hemostasis: diagnostic efficacy of angiography compared with computed tomography and treatment outcomes of transcatheter arterial embolization.

PURPOSE: This study compared the detection sensitivity of catheter angiography to that of contrast-enhanced multi-detector computed tomography (MDCT) for detecting acute non-variceal gastrointestinal bleeding (GIB) to elucidate the diagnostic efficacy of catheter angiography. We also determined GIB outcomes of transcatheter arterial embolization after failed endoscopic hemostasis. MATERIALS AND METHODS: Data were collected retrospectively from 63 patients managed at four institutions who met the following criteria during a 3-year period: (1) ongoing non-variceal GIB confirmed during endoscopy; (2) failed endoscopic hemostasis; and (3) endoscopy, MDCT, and catheter angiography performed within 24 h. The diagnostic efficacies of MDCT, selective angiography with a 5-Fr catheter (5Fr-angiography), and super-selective angiography with a microcatheter (micro-angiography) were compared using endoscopic diagnosis as the reference method. The rates of technical success, clinical success, and complications were analyzed when arterial embolization was performed. RESULTS: All transcatheter angiographies were performed after MDCT. Micro-angiography had a significantly higher GIB detection rate (73.0%) than MDCT (57.1%) and 5Fr-angiography (39.7%) (micro-angiography vs. MDCT, P = 0.021; MDCT vs. 5Fr-angiography, P = 0.043). Arterial embolization was attempted in 55 of 63 patients, with technical success achieved in 53 of 55 patients (96.4%) and clinical success in 38 of 42 patients (90.5%). Eleven patients were lost to follow-up. Three patients experienced complications, including bowel infarction (two patients) and common bile duct stricture (one patient). CONCLUSION: In cases of endoscopic hemostasis failure, angiography can be performed even if MDCT yields negative results but should include micro-angiography; moreover, embolization can be performed safely and effectively. TRIAL REGISTRATION: None.

Persistent Trigeminal Artery Variant Terminating in the Ipsilateral Superior Cerebellar Artery.

Persistent trigeminal artery (PTA) represent an unusual remnant of the fetal carotid-basilar anastomosis. Persistent trigeminal artery variant (PTAV) is a rare anastomosis between the internal carotid artery and cerebellar artery, without an interposing basilar artery segment. We report the case of 49-year-old female with an incidentally discovered, rare variation of PTA that directly terminated in the ipsilateral superior cerebellar artery. The variation was observed on CT angiography, digital subtraction angiography, and MR angiography. Additionally, we reviewed the embryogenesis of PTA and PTAV and discussed the clinical implications of this variation.

Immunoglobulin G4-Related Lung Disease Mimicking Lung Cancer: Two Case Reports.

Immunoglobulin G4 (IgG4)-related disease is a rare systemic fibroinflammatory condition characterized by elevated serum IgG4 levels and infiltration of IgG4-positive plasma cells in various organs. IgG4-related lung disease shows varied radiologic features on chest CT. Patients usually present with a solid nodule or mass mimicking lung cancer; therefore, distinguishing between IgG4-related disease and other conditions is often challenging. Additionally, co-existing radiologic findings of IgG4-related lung disease may mimic metastasis or lymphangitic carcinomatosis of the lung. We report two cases of histopathologically confirmed IgG4-related lung disease mimicking lung cancer. Chest CT revealed a solid nodule or mass with ancillary radiologic findings, which suggested lung cancer; therefore, IgG4-related lung disease was radiologically indistinguishable from lung cancer in both cases. Measurement of serum IgG4 levels and clinical evaluation to confirm involvement of various organs may be useful to establish the differential diagnosis. However, surgical biopsy evaluation is needed for confirmation.

Transvaginal Direct Puncture and Ethanol Sclerotherapy for Cervicovaginal Venous Malformations: A Case Report and Literature Review.

Cervicovaginal venous malformations are extremely rare. Sclerotherapy is proven to be effective for superficial venous malformations but not for venous malformations in the lower genital tract of women. A 52-year-old female presented with intermittent vaginal bleeding. The amount of vaginal bleeding gradually increased over 3 months. Contrast-enhanced pelvis CT showed several phleboliths and dilated vessels, but pelvic angiography showed no early draining veins, nidus, or feeding artery. We performed transvaginal direct puncture and ethanol sclerotherapy rather than surgical treatment because she wanted to preserve the uterus. After four sessions of sclerotherapy, she had significantly decreased vaginal bleeding without complications. Here, we report the first case of cervicovaginal venous malformations successfully treated with transvaginal direct puncture and ethanol sclerotherapy.

Transcatheter embolization of the esophagomediastinal fistula with N-butyl cyanoacrylate glue: A case report.

INTRODUCTION: Acute mediastinitis with esophageal perforation is a very fatal condition and must be treated promptly. Esophagomediastinal fistula is a rare complication of acute mediastinitis with esophageal perforation. There are many treatment options such as surgery or endoscopic treatment, but it is most important to start treatment immediately. PRESENTATION OF CASE: A 69-year-old female presented with chest pain and fever. Contrast enhanced chest computed tomography was compatible with acute mediastinitis and esophageal perforation. Esophagography revealed esophagomediastinal fistula in the upper esophagus. Endoscopic clipping with fibrin was failed and endoscopic vacuum therapy (EVT) was not effective for esophagomediastinal fistula. We performed the successful transcatheter embolization of the esophagomediastinal fistula with N-butyl cyanoacrylate (NBCA) glue. DISCUSSION: There are many considerations in the treatment of acute mediastinitis with esophageal perforation, but surgery is the mainstay of treatment. Recently non operative management is appropriate in certain well-defined situations. Like our case patients, non-operative management may be considered if the diagnosis is delayed and the surgical treatment period is missed. Currently, endoscopic treatment such as covered stenting, clipping and application of fibrin glue are useful and a less invasive rather than surgical treatment. However, if endoscopic or surgical procedure are not possible, we considered transcatheter NBCA glue embolization. CONCLUSION: Transcatheter embolization with NBCA glue was proven to its effectiveness as an alternative therapeutic option in the treatment of esophagomediastinal fistula which endoscopic or surgical treatment are impossible or fails.

Imaging Features of Breast Dermatofibrosarcoma Protuberans in Various Modalities Including FDG-PET CT.

Dermatofibrosarcoma protuberans is an uncommon malignant mesenchymal tumor of the dermis, which most commonly appears on the body and extremities. A preoperative diagnosis of dermatofibrosarcoma protuberans is extremely difficult, because it is a very rare entity and its appearance is often similar to that of benign breast lesion. Here, we presented a case of breast dermatofibrosarcoma protuberans with associated radiological mammography, ultrasound, magnetic resonance imaging and fludeoxyglucose-positron emission tomography computerized tomography (FDG-PET CT) features. To our knowledge, our case is the first report of PET-CT findings of breast dermatofibrosarcoma protuberans. Furthermore, we reviewed characteristic radiologic features of this rare entity, which are helpful for differentiating it from other primary benign breast lesions.