Imaging and Interventions for Lymphatic and Lymphatic-related Disorders.

The lymphatic system is critical in fluid balance homeostasis. Yet, until recently, lymphatic imaging has been outside of mainstream medicine due to a lack of robust imaging and interventional options. However, during the last 20 years, both clinical lymphatic imaging and interventions have shown dramatic advancement. The key to imaging advancement has been the interstitial delivery of contrast agents through lymphatic-rich tissues. These techniques include intranodal lymphangiography and dynamic contrast-enhanced MR lymphangiography. These methods provide the ability to image and recognize lymphatic anatomy and pathologic conditions. Percutaneous thoracic duct catheterization and embolization became the first widely accepted interventional technique for the management of chyle leaks. Advances in interstitial lymphatic embolization, as well as liver and mesenteric lymphatic interventions, have broadened the scope of possible lymphatic interventions. Also, recent techniques of lymphatic decompression allow for the treatment of a variety of lymphatic disorders. Finally, immunologic studies of central lymphatic fluid reveal the potential of lymphatic interventions on immunity. These advances herald an exciting new chapter for lymphatic imaging and interventions in the coming years.

Intranodal CT Lymphangiography with Water-soluble Iodinated Contrast Medium for Imaging of the Central Lymphatic System.

Background Dynamic contrast-enhanced MR lymphangiography (DCMRL) is the reference standard used to diagnose various thoracic lymphatic disorders, such as traumatic chylothorax and plastic bronchitis. However, accessibility and logistical challenges have prevented the wide dissemination of this technology. Purpose To evaluate the feasibility of intranodal CT lymphangiography (ICTL) in the diagnosis and planning of subsequent intervention in patients with thoracic lymphatic disorders. Materials and Methods In this retrospective review, five women suspected of having lymphatic abnormalities (ranging from traumatic chylothorax to plastic bronchitis) and with contraindications to MRI underwent ICTL from September 2019 to May 2020. Needles (25 gauge) were placed in the bilateral inguinal lymph nodes with US guidance, and water-soluble iodinated contrast material was injected. CT fluoroscopy was used to monitor the opacification of the cisterna chyli to determine the timing of CT. After ICTL, the thoracic duct was catheterized, and lymphangiography was performed through the thoracic duct catheter. The ICTL and subsequent lymphangiographic findings were then visually compared by using three-dimensional reconstructions. Results Intranodal injection of water-soluble contrast medium was successful in all patients evaluated (five women; mean age, 68 years ± 11 [standard deviation]; range, 53-83 years). The central lymphatics were opacified in four of the five women, demonstrating abnormal pulmonary lymphatic flow from the thoracic duct into the lung parenchyma. In one of the five women, thoracic duct injection showed successful ligation of the thoracic duct. The time elapsed from injection of contrast medium to visualization of the thoracic duct ranged from 2 to 27 minutes. ICTL and lymphangiographic findings matched well. Conclusion Intranodal CT lymphangiography sufficiently depicted central lymphatic anatomy in patients with lymphatic abnormalities, thereby demonstrating its use as a feasible alternative to more technically challenging methods, such as dynamic contrast-enhanced MR lymphangiography. © RSNA, 2021.

Thoracic duct embolization in treating postoperative chylothorax: does bail-out retrograde access improve outcomes?

OBJECTIVES: To evaluate clinical outcomes of thoracic duct embolization (TDE) for the management of postoperative chylothorax with the aid of the bail-out retrograde approach for thoracic duct cannulation (TDC). MATERIALS AND METHODS: Forty-five patients with postoperative chylothorax underwent Lipiodol lymphangiography (LLG) between February 2016 and November 2019. If targetable central lymphatic vessels were identified in LLG, TDC, a prerequisite for TDE, was attempted. While the conventional antegrade transabdominal approach was the standard TDC method, the retrograde approach was applied as a bail-out method. Embolization, the last step of TDE, was performed after confirming leakages in the trans-TDC catheter lymphangiography. Technical and clinical success rates were determined retrospectively. RESULTS: TDC was attempted in 40 among 45 patients based on LLG findings. The technical success rate of TDC with the conventional antegrade approach was 78% (31/40). In addition, six more patients were cannulated using the bail-out retrograde approach, which raised the technical success rate to 93% (37/40). While 35 patients underwent embolization (TDE group), ten patients did not (non-TDE group) for the following reasons: (1) lack of targetable lymphatics for TDC in LLG (n = 5), (2) technical failure of TDC (n = 3), and (3) lack of discernible leakages in the transcatheter lymphangiography (n = 2). The clinical success of the TDE group was 89% (31/35), compared with 50% (5/10) of the non-TDE group. One major procedure-related complication was bile peritonitis caused by the needle passage of the distended gallbladder. CONCLUSIONS: Bail-out retrograde approach for TDC could improve the overall technical success of TDC significantly. KEY POINTS: • Bail-out retrograde thoracic duct access may improve the overall technical success of thoracic duct access, thus improving the clinical success of thoracic duct embolization.

Outcomes of Venoplasty-Assisted, Peripherally Inserted Central Catheter Placement in Patients with Upper-Arm Venous Stenosis: Comparison with Midlines and Contralateral Placement.

PURPOSE: To compare the effectiveness and safety of percutaneous transluminal angioplasty and peripherally inserted central catheter (PTA + PICC), contralateral PICC, and midline catheterization (MC) in patients with venous stenosis. MATERIALS AND METHODS: A total of 7,327 PICC procedures were performed in 5,421 patients at a single institution between 2013 and 2019. Among them, 87 patients had upper-arm venous stenoses and were managed with PTA + PICC, contralateral PICC, or MC. Data on catheter-dwell time, clinical success rate, and adverse events were recorded. The procedure was considered to have clinically succeeded when a PICC was removed from the patient just before discharge or after the completion of therapy. Catheter survival time and the chance of adverse events were compared among the groups using the Kaplan-Meier method and log-rank test. RESULTS: PTA + PICC, contralateral PICC, and MC procedures were performed for 57 (65.5%, 57/87), 10 (11.5%, 10/87), and 20 (23.0%, 23/87) patients, respectively. The mean catheter-dwell time in the PTA + PICC, contralateral PICC, and MC groups was 49.7, 28.7, and 15.1 days, respectively, and the clinical success rate of each group was 86.0% (49/57), 80.0% (8/10), and 50.0% (10/20). The PTA + PICC group had a significantly longer catheter survival time than the MC group (P < .001). The chance of a catheter-related infection (P = .008) was significantly lower in the PTA + PICC group than in the MC group. CONCLUSIONS: PTA + PICC or contralateral PICC should be considered prior to ipsilateral MC when venous stenosis is encountered during PICC procedures.

Dextroplantation of Left Liver Graft in Infants.

The position of the left side liver graft is important, and it could lead to complications of the hepatic vein (HV) and portal vein (PV), especially in a small child using a variant left lateral section (vLLS) graft. The purpose of this study was to evaluate the outcome of a novel technique for the implantation of a vLLS graft to the right side (dextroplantation) in infants. For 3 years, 10 consecutive infants underwent dextroplantation using a vLLS graft (group D). The graft was implanted to the right side of the recipient after 90° counterclockwise rotation; the left HV graft was anastomosed to inferior vena cava using the extended right and middle HV stump, and PV was reconstructed using oblique anastomosis without angulation. Surgical outcomes were compared with the historical control group (n = 17, group C) who underwent conventional liver transplantation using a vLLS during infancy. Group D recipients were smaller than group C (body weight <6 kg: 50.0% versus 11.8%; P = 0.03). The rate of graft-to-recipient weight ratio >4% was higher in group D (60.0%) than C (11.8%; P = 0.01). Surgical drains were removed earlier in group D than in group C (15 versus 18 postoperative days [PODs]; P = 0.048). Each group had 1 PV complication (10.0% versus 5.9%); no HV complication occurred in group D, but 3 HV complications (17.6%) occurred in group C (P > 0.05). Hospital stay was shorter in group D than in group C (20 versus 31 PODs; P = 0.02). Dextroplantation of a vLLS graft, even a large-for-size one, was successful in small infants without compromising venous outcomes, compared with conventional vLLS transplantation. We could remove the surgical drains earlier and reduce hospital stays in cases of dextroplantation.

Lymphatic Interventional Treatment for Chyluria via Retrograde Thoracic Duct Access.

Chyluria is the leakage of intestinal lymph (chyle) into the urine. Novel lymphatic intervention techniques, such as interstitial lymphatic embolization, proved to be a useful treatment option for chyluria. However, one of the challenges of this approach is the difficulty in identifying connections between the lymphatic system and kidney collecting system. Here, embolization of the abnormal lymphatic connection through retrograde thoracic duct access in 3 chyluria patients is introduced.

Reversed Approach through Lymphocele/Lymphatic Fluid Collection for Glue Embolization of Injured Lymphatic Vessels.

A total of 9 glue embolization procedures of injured lymphatic vessels with a reversed approach from the lymphocele/lymphatic fluid collection in 8 patients were retrospectively reviewed. The approach routes were via the indwelling chest tube for pleural effusion (n = 2), the drainage catheter tract for abdominopelvic lymphocele/lymphatic fluid collection/thigh lymphocele (n = 4), and the direct puncture of the lymphatic fluid collection at the operation bed (n = 2). All the procedures were technically successful without complications. The mean daily leakage rate decreased from 465 mL/d before the procedure to 42 mL/d after the procedure, and the drainage catheters could be removed after 8 procedures, achieving a clinical success rate of 88.9% (8 of 9 procedures).

Transcatheter Dynamic Contrast-Enhanced MR Lymphangiography for Nontraumatic Lymphatic Disorders: Technical Feasibility and Imaging Findings.

This study aimed to evaluate the feasibility and added value of transcatheter dynamic contrast-enhanced magnetic resonance (MR) lymphangiography for nontraumatic lymphatic disorders. Five patients (2 males and 3 females; median age, 16.0 years; range, 3-74 years) who underwent both intranodal and transcatheter dynamic contrast-enhanced MR lymphangiography for suspected nontraumatic lymphatic leakages from June 2017 to January 2020 were included in this retrospective study. The imaging findings of both dynamic contrast-enhanced MR lymphangiography techniques were assessed for the presence of chylolymphatic reflux or direct sign of leakage. Intranodal dynamic contrast-enhanced MR lymphangiography demonstrated chylolymphatic reflux into the thoracic area in 2 patients (40%) but no direct evidence of leakage in any of the 5 patients. Transcatheter dynamic contrast-enhanced MR lymphangiography revealed chylolymphatic reflux and extravasation of the contrast agent in all 5 patients (100%). In conclusion, transcatheter dynamic contrast-enhanced MR lymphangiography may reveal additional signs of reflux and extravasation even when the findings of intranodal dynamic contrast-enhanced MR lymphangiography are negative.

Spectral CT-Based Iodized Oil Quantification to Predict Tumor Response Following Chemoembolization of Hepatocellular Carcinoma.

PURPOSE: To quantify iodized oil retention in tumors after transarterial chemoembolization using spectral computed tomography (CT) imaging in patients with hepatocellular carcinoma (HCC) and evaluate its performance in predicting 12-month tumor responses. MATERIALS AND METHODS: From September 2017 to December 2018, 111 patients with HCC underwent initial conventional transarterial chemoembolization. Immediately after the procedure, unenhanced CT was performed using a spectral CT scanner, and the iodized oil densities in index tumors were measured. In tumor-level analyses, a threshold level of iodized oil density in the tumors was calculated using clustered receiver operating characteristic curve analyses to predict the 12-month tumor responses. In patient-level analyses, significant factors associated with a 12-month complete response, including the presence of tumors below the threshold value (ie, suspected residual tumors), were evaluated by logistic regression. RESULTS: Forty-eight HCCs in 39 patients were included in the analyses. The lower 10th percentile of the iodine density was identified as the threshold for determining the 12-month nonviable responses. The area under the curve of the iodine density measurements in predicting the 12-month nonviable responses was 0.893 (95% confidence interval, 0.797-0.989). The threshold value of the iodine density of 10.68 mg/mL yielded a sensitivity of 82.76% and specificity of 94.74% (P < .001). In the patient-level analysis, the 12-month complete response was significantly associated with the presence of a suspected residual tumor, with an odds ratio of 72.0 (95% confidence interval, 7.273-712.770). CONCLUSIONS: Spectral CT imaging using quantitative analysis of the iodized oil retention in target HCCs can predict tumor responses after a conventional transarterial chemoembolization procedure.

Research Priorities in Lymphatic Interventions: Recommendations from a Multidisciplinary Research Consensus Panel.

Recognizing the increasing importance of lymphatic interventions, the Society of Interventional Radiology Foundation brought together a multidisciplinary group of key opinion leaders in lymphatic medicine to define the priorities in lymphatic research. On February 21, 2020, SIRF convened a multidisciplinary Research Consensus Panel (RCP) of experts in the lymphatic field. During the meeting, the panel and audience discussed potential future research priorities. The panelists ranked the discussed research priorities based on clinical relevance, overall impact, and technical feasibility. The following research topics were prioritized by RCP: lymphatic decompression in patients with congestive heart failure, detoxification of thoracic duct lymph in acute illness, development of newer agents for lymphatic imaging, characterization of organ-based lymph composition, and development of lymphatic interventions to treat ascites in liver cirrhosis. The RCP priorities underscored that the lymphatic system plays an important role not only in the intrinsic lymphatic diseases but in conditions that traditionally are not considered to be lymphatic such as congestive heart failure, liver cirrhosis, and critical illness. The advancement of the research in these areas will lead the field of lymphatic interventions to the next level.

Iatrogenic Arterioportal Fistula Caused by Radiofrequency Ablation of Hepatocellular Carcinoma: Clinical Course and Treatment Outcomes.

PURPOSE: To analyze the clinical course and treatment outcomes of patients with iatrogenic arterioportal fistula (APF) caused by radiofrequency (RF) ablation of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Among the 1,620 hepatocellular carcinoma patients treated by RF ablation between January 2012 and August 2017, 99 who developed APF after RF ablation were included in this retrospective study. Depending on the extent of portal vein enhancement on arterial phase images, APF was classified as massive or nonmassive. The patients' clinical course was investigated and statistically evaluated by univariable and multivariable analyses. RESULTS: Thrombocytopenia (odds ratio [OR] = 3.939; 95% confidence interval [CI], 1.141-13.598) was the only risk factor for developing massive APF. Eleven patients underwent embolotherapy (technical success rate, 90.9%) and no patients experienced serious adverse events within 30 days of the procedure. Patients with massive APF (66.7%) had a significantly higher chance of a Child-Pugh score increase than did the patients with nonmassive APF (13.6%) (P < .001). Massive APF had a significantly lower chance of natural regression than did nonmassive APF (P < .001). Child-Pugh B (OR = 17.739; 95% confidence interval, 2.361-133.279) and massive APF without treatment (OR = 11.061; 95% confidence interval, 1.257-97.341) were independent risk factors for liver failure that led to death of liver transplant within 1 year after RF ablation. CONCLUSIONS: Massive APF caused by RF ablation is mostly irreversible and significantly worsens patients' outcomes, but may be effectively treated with embolotherapy.

The Value of Preprocedural MR Imaging in Genicular Artery Embolization for Patients with Osteoarthritic Knee Pain.

PURPOSE: To determine the value of preprocedural MR imaging in genicular artery embolization (GAE) for patients with osteoarthritic knee pain. MATERIALS AND METHODS: This single-center study retrospectively analyzed 28 knees in 18 patients who underwent GAE for intractable knee pain < 1 month after MR imaging. The pain experienced in each knee was evaluated on a 100-mm visual analog scale (VAS) at baseline and 1- and 3-month after GAE. "GAE responders" were defined as knees that exhibited greater than 30% reduction of VAS pain scores from baseline at both follow-up visits. Musculoskeletal radiologists evaluated MR images of the affected knee compartment regarding cartilage defects, osteophytes, subchondral cysts, bone marrow lesions (BMLs), meniscal injury, and joint effusion. The performances of Kellgren-Lawrence (KL) grading and MR findings in predicting GAE responders was estimated based on receiver operating characteristic curves. RESULTS: The mean VAS pain score was 84.3 mm. BML (area under the curve [AUC], 0.860; P < .001), meniscal injury (AUC, 0.811; P = .003), and KL grading (AUC, 0.898; P < .001) were significantly associated with GAE outcome. To predict GAE responders, KL grade ≤ 2 yielded a sensitivity of 87.5% and a specificity of 60.9%, BML grade ≤ 1 yielded a sensitivity of 75.0% and a specificity of 69.6%, and meniscal injury grade ≤ 2 yielded a sensitivity of 83.3% and a specificity of 72.7%. CONCLUSIONS: Large BMLs and severe meniscal injuries on MR imaging, as well as high KL grades, indicated poor responses to GAE.

Successful thoracic duct embolisation in a child with recurrent massive pericardial effusion diagnosed as a lymphatic anomaly.

A 29-month-old girl had idiopathic massive pericardial effusion for over 6 months. Lymphangiography was performed for chronic and recurrent pericardial effusion and pulmonary lymphangiectasia, suspected based on CT findings. Magnetic resonance lymphangiography revealed chylolymphatic reflux from a tortuously dilated thoracic duct in the mediastinum to the pericardial space, suggesting primary chylopericardium with lymphangiectasia. Pericardial effusion resolved immediately after thoracic duct embolisation at the lower thoracic level. However, pericardial effusion recurred after 5 months, which resolved after additional embolisation of the abnormal lymphatic collateral vessels from the remnant upper thoracic duct. Here, we report an unusual case with chylous massive pericardial effusion diagnosed by magnetic resonance lymphangiography and treated with percutaneous embolisation.

Cone-Beam CT-Guided Chemoembolization in Patients with Complete Response after Previous Chemoembolization but Subsequent Elevated α-Fetoprotein without Overt Hepatocellular Carcinoma.

PURPOSE: To evaluate the performance of C-arm computed tomography (CT)-guided chemoembolization in patients with hepatocellular carcinoma (HCC) with serum α-fetoprotein (AFP) level > 20 ng/mL but with no overt tumor on CT and/or magnetic resonance imaging. MATERIALS AND METHODS: From May 2010 to May 2017, 34 patients with HCC (25 men and 9 women; mean age, 59.7 y) who had elevated serum AFP levels (> 20 ng/mL) but no overt tumor on 6-mo imaging studies and had shown complete response (CR) after previous chemoembolization underwent C-arm CT-guided conventional chemoembolization. Three radiologists retrospectively reviewed the imaging studies (preprocedural images, C-arm CT scans, and follow-up images) in consensus, and clinical data including AFP levels were retrospectively obtained. Tumor detection by C-arm CT and treatment response after chemoembolization were assessed. RESULTS: HCC was imaged at the time of chemoembolization in 24 of 34 patients (70.6%). C-arm CT detected tumors in 25 patients (73.5%); 23 detections were true positives, 2 were false positives, and 1 was a false negative (diaphragm metastasis). Among the 23 patients with true-positive results, the first follow-up enhanced imaging studies showed CR (n = 17), partial response (n = 1), progressive disease (n = 4), and indeterminate status (n = 1; treated by percutaneous ethanol injection). CONCLUSIONS: C-arm CT-guided chemoembolization may help to detect and treat recurrent tumors in patients who have shown CR after previous chemoembolization but subsequently, during follow-up surveillance, had serum AFP levels > 20 ng/mL without an overt tumor evident on imaging studies.

The Efficacy of Lymph Node Embolization Using N-Butyl Cyanoacrylate Compared to Ethanol Sclerotherapy in the Management of Symptomatic Lymphorrhea after Pelvic Surgery.

PURPOSE: To compare the efficacy of lymph node (LN) embolization using N-butyl cyanoacrylate versus ethanol sclerotherapy in the management of symptomatic postoperative pelvic lymphorrhea. MATERIALS AND METHODS: Thirty-three patients with 40 instances of symptomatic postoperative lymphorrhea were treated with either LN embolization or sclerotherapy at Seoul National University Hospital from January 2009 to July 2017 and were retrospectively included (LN embolization group: 24 lymphoceles of 19 patients, mean age of 59.29 years; sclerotherapy group: 16 lymphoceles of 14 patients, mean age of 60.95 years). The types of operations were hysterectomy and bilateral oophorectomy with pelvic lymph node dissection (n = 9), radical prostatectomy (n = 3), and renal transplantation (n = 2) for the sclerotherapy group and radical prostatectomy (n = 10) and hysterectomy and bilateral oophorectomy with pelvic lymph node dissection (n = 9) for the LN embolization group. The 3 most common indications of treatment were lower extremity edema (n = 11), pain (n = 11), and fever (n = 8). The amount of leak before treatment (initial daily drainage) and clinical outcomes, including the clinical success rate in 3 weeks, treatment period, and complication rate were compared between both groups. RESULTS: LN embolization showed a higher 3-week clinical success rate than sclerotherapy in a univariate analysis (83.3% and 43.8%, P = .026). There was no statistically significant difference in the treatment period and the complication rate (7.1 days and 12.3 days, P = .098; 8.3% and 25.0%, P = .184). CONCLUSIONS: LN embolization is more effective for treating postoperative pelvic lymphorrhea than sclerotherapy with similar safety.

Portal hypertension is associated with poor outcome of transarterial chemoembolization in patients with hepatocellular carcinoma.

OBJECTIVES: To determine whether clinically relevant portal hypertension (CRPH) influences outcome and whether it may serve as a prognostic marker in patients treated with transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). METHODS: One hundred and forty-seven patients underwent conventional TACE as a first-line treatment for a single HCC. CRPH was graded as 0, 1, or 2. The influence of CRPH, together with other factors, on local tumour progression (LTP) and overall survival (OS) were analysed using Cox proportional hazards regression. RESULTS: A higher CRPH grade (grade 1, p = 0.005, hazard ratio [HR] = 3.282; grade 2, p < 0.001, HR = 7.144) and less selective catheterization (p = 0.009, HR = 1.951) were significantly associated with early LTP. Regarding OS, older age, (p < 0.001, HR = 1.050), CRPH grade 2 (p = 0.024, HR = 2.058), and a larger tumour (p < 0.001, HR = 1.454) were significantly associated with early death. CONCLUSIONS: Portal hypertension was significantly associated with poor outcome after TACE, and non-invasive CRPH grading may be a useful prognostic marker of TACE. KEY POINTS: • Portal hypertension was significantly associated with poor outcome after TACE. • Grading portal hypertension non-invasively can help predict TACE outcome in HCC patients. • CRPH grading can aid in selecting optimal candidates for TACE.

Chemoembolisation for hepatocellular carcinoma with bile duct invasion: is preprocedural biliary drainage mandatory?

PURPOSE: To determine the necessity of preprocedural biliary drainage prior to chemoembolisation for hepatocellular carcinoma (HCC) with bile duct invasion. MATERIALS AND METHODS: The study included 52 patients who received chemoembolisation for unresectable HCC invading bile duct and causing hyperbilirubinemia (>3 mg/dL). Patients were divided into three groups according to biliary drainage and its effect: effective drainage (n=21), ineffective drainage (n=17), and non-drainage (n=14). Thirty-day mortality, length of hospitalisation, adverse events recorded using Common Terminology Criteria for Adverse Events (CTCAE), survival, and tumour response was compared among three groups. RESULTS: Thirty-day mortality rates were 14.3% (n=3), 17.6% (n=3), and 7.1% (n=1) for effective, ineffective, and non-drainage groups, respectively, and did not differ significantly among groups (p=0.780). The mean length of hospitalisation was shorter in non-drainage group compared to ineffective drainage group (12.1±11.4 vs 34.1±29.6 days, p=0.012). Mean differences in CTCAE grade for laboratory parameters before and after chemoembolisation were not significantly different among three groups. Survival among three groups was not significantly different (p=0.239-0.825). The tumour response was also not significantly different among three groups (p=0.679). CONCLUSION: Biliary drainage may not be mandatory prior to chemoembolisation in patients with HCC invading the bile duct. KEY POINTS: • Chemoembolisation without biliary drainage can be performed for icteric HCC. • Chemoembolisation without biliary drainage is not accompanied by increased adverse events. • Preprocedural biliary drainage may not be mandatory for chemoembolisation for icteric HCC.

Arteries of the falciform ligament on C-arm CT hepatic arteriography: The hepatic falciform artery and the Sappey's superior artery.

BACKGROUND AND AIM: To investigate the prevalence, anatomy and distribution of the hepatic falciform artery (HFA) and Sappey's superior artery (SSA) using C-arm CT hepatic arteriography (C-arm CTHA). MATERIALS AND METHODS: From January 2011 to December 2012, 220 patients who underwent C-arm CTHA during initial transarterial treatment for hepatocellular carcinoma were included in this retrospective study. The HFAs and SSAs prevalence and origin were evaluated using axial images of C-arm CTHA. A 5-point scale for HFAs and a 4-point scale for SSAs were used to designate the radiologically conspicuous arteries. RESULTS: The prevalences of the total HFAs and SSAs were 95 % (n=209) and 22 % (n=49), while those of radiologically conspicuous HFAs and SSAs were 62 % (n=137) and 10 % (n=22), respectively. Thirty HFAs (22 % of radiologically conspicuous HFAs and 14 % of the total study population) were distributed in the subcutaneous layer of the anterior abdominal wall, while the majority of SSAs ran through the superior part of the falciform ligament in the left-anterior direction and anastomosed with left inferior phrenic artery. CONCLUSION: Our study using C-arm CTHA revealed that the prevalence of the HFA is higher than the existing knowledge and proved the existence of the SSA radiologically for the first time. KEY POINTS: • Prevalence of hepatic falciform artery is 95 %, higher than previously known. • 22 % of conspicious hepatic falciform arteries distributed in subcutaneous tissue around umbilicus. • The existence of Sappey's superior artery was proved with a radiological method.

Transarterial chemoembolization of hepatocellular carcinoma with segmental portal vein tumour thrombus.

OBJECTIVES: To evaluate the clinical outcome and safety of transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) with segmental or subsegmental portal vein tumour thrombus (sPVTT) in patients with preserved hepatic function, and to address the efficacy of additional chemoinfusion after TACE (TACE+CI). METHODS: From January 2003 to December 2012, TACE was conducted on 81 patients with Child-Pugh score ≤7 who had HCC with sPVTT. Thirty-one of them underwent TACE+CI. The overall survival (OS) and serious adverse events (SAEs) were evaluated. The efficacy of TACE+CI was appraised after adjustment with inverse probability of treatment weighting (IPTW). RESULTS: The OS after TACE (median, 15.5 months) was significantly related with aspartate aminotransferase (hazard ratio [HR], 1.011), modified Barcelona Clinic Liver Cancer (BCLC) stage D (HR, 2.841), extrahepatic spread (HR, 4.862), and TACE+CI (HR, .367). The SAE incidence was significantly associated with modified BCLC stages (HR, 10.174 [proper-C] and 24.000 [D]). After IPTW adjustment, TACE+CI significantly improved OS (p = .028; HR, .511), but the SAE incidence was not significantly altered (p = .737; HR, .819). CONCLUSIONS: TACE can be an effective and safe treatment option for HCC with sPVTT in patients with preserved hepatic function. Furthermore, additional chemoinfusion can enhance the therapeutic efficacy while maintaining the safety. KEY POINTS: • TACE is effective and safe for treating HCC with sPVTT. • Modified BCLC stages can stratify the risk and benefit of TACE. • Additional chemoinfusion can enhance the therapeutic efficacy while maintaining the safety.

Superselective Embolization for Arterial Upper Gastrointestinal Bleeding Using N-Butyl Cyanoacrylate: A Single-Center Experience in 152 Patients.

PURPOSE: To evaluate 30-day safety and efficacy of superselective embolization for arterial upper gastrointestinal bleeding (UGIB) using N-butyl cyanoacrylate (NBCA). MATERIALS AND METHODS: This single-center retrospective 10-year study included 152 consecutive patients with UGIB (gastric, n = 74; duodenal, n = 78) who underwent embolization with NBCA for angiographically positive arterial bleeding. The primary endpoint was clinical success rate defined as achievement of hemostasis without rebleeding or UGIB-related mortality within 30 days after embolization. Mean systolic blood pressure and heart rate were 121.2 mm Hg ± 27.4 and 97.9 beats/minute ± 22.5; 31.1% of patients needed intravenous inotropes, and 36.6% had coagulopathy. The etiology of bleeding was ulcer (80.3%) or iatrogenic injury (19.7%). Statistical analysis was performed to identify predictive factors for outcomes. RESULTS: Technical success rate was 100%. Clinical success, 1-month mortality, and major complication rates were 70.4%, 22.4%, and 0.7%. There were significant differences in the clinical success rates between gastric and duodenal bleeding (79.4% vs 62.2%; P = .025). The need for intravenous inotropes at the time of embolization was a significant negative predictive factor in both gastric (odds ratio [OR] = 0.091, P = .004) and duodenal (OR = 0.156, P = .002) bleeding. The use of a microcatheter with a smaller tip (2 F) was associated with better outcomes in duodenal bleeding (OR = 7.389, P = .005). CONCLUSIONS: Superselective embolization using NBCA is safe and effective for angiographically positive arterial UGIB.