Association Between Targeted Aortic Segment Tortuosity and Stent-Graft-Induced New Entry After Thoracic Endovascular Aortic Repair for Aortic Dissection or Intramural Hematoma.

OBJECTIVE. The aim of this study was to investigate the association between the tortuosity of the targeted aortic segment (TAS) for stent-graft implantation and distal stent-graft-induced new entry (SINE) after thoracic endovascular aortic repair (TEVAR) for aortic dissection or intramural hematoma. MATERIALS AND METHODS. We retrospectively analyzed data from 70 patients who underwent TEVAR using a single stent-graft between 2006 and 2016, and the tortuosity index of the TAS was measured. The patients were divided into high and low TAS tortuosity groups according to the median value of the tortuosity index. The incidence of distal SINE was compared between the two groups. RESULTS. The cumulative incidence of distal SINE at 2 years after TEVAR was 39% in patients in the high TAS tortuosity group and 7% in patients in the low TAS tortuosity group. The incidence of distal SINE was higher in patients in the high TAS tortuosity group than in those in the low TAS tortuosity group (p < 0.01, log-rank test). Multivariate Cox regression showed a higher risk of distal SINE in the high TAS tortuosity group (adjusted hazard ratio, 4.56 [95% CI, 1.40-14.86]; p = 0.01). CONCLUSION. Patients with high TAS tortuosity have a higher incidence of distal SINE after TEVAR. More caution must be exercised during follow-up of patients with high TAS tortuosity after TEVAR.

Interobserver and intraobserver variability in measuring the tortuosity of the thoracic aorta on computed tomography.

OBJECTIVE: The variability in measuring the tortuosity of the thoracic aorta has not been previously studied. This study evaluated the interobserver and intraobserver variability of major methods used for measuring the tortuosity of the thoracic aorta in patients with aortic arch or descending thoracic aortic aneurysm. METHODS: This retrospective study enrolled 66 patients with aortic arch or descending thoracic aortic aneurysm who had undergone thoracic endovascular aortic repair. Two radiologists used preoperative computed tomography images to measure the tortuosity of the thoracic aorta at multiple segments by using the fitting circle diameter, tortuosity index, and centerline angle methods; these measurements were repeated after an interval of >28 days. The variability of the methods was analyzed for interobserver and intraobserver reliability and agreement. The estimated intraclass correlation coefficient (ICC) was used to analyze the reliability. The Bland-Altman plot was used to analyze the interobserver and intraobserver agreement. The association between aortic characteristics, including calcification, luminal irregularity, shape, and diameter, and the variability of the measurements was also analyzed. RESULTS: The interobserver ICC estimates for the tortuosity index at multiple aortic segments, centerline angle methods at the supra-aortic branch orifices, and fitting circle diameter on the greater and lesser curvature sides were 0.97 to 0.98, 0.39 to 0.75, and 0.82 to 0.84, respectively. The corresponding intraobserver ICC estimates were 0.98 to 1.00, 0.44 to 0.75, and 0.82 to 0.85, respectively. In the agreement analysis, the 95% limits of agreement for the tortuosity index, centerline angle, and fitting circle diameter were -5.5% to 5.6%, -10.9% to 10.9%, and -18.0% to 24.0%, respectively. The tortuosity index had the highest ICC estimate and narrowest 99.5% limits of agreement of the three methods. Aortic characteristics, including calcification, grade of atheroma, aneurysm shape, and diameter, were not associated with the variability of the tortuosity index method in the thoracic aorta. CONCLUSIONS: The tortuosity index method has low interobserver and intraobserver variability in measuring the tortuosity of the thoracic aorta in patients with thoracic aortic aneurysm. The characteristics of the aorta and aneurysm are not associated with the interobserver or intraobserver variability of the tortuosity index.

Rituximab therapy in primary Sjögren's syndrome with interstitial lung disease: a retrospective cohort study.

OBJECTIVES: Interstitial lung disease (ILD) is one of the major systemic manifestations of primary Sjögren's syndrome (pSS). The aim of this study was to evaluate the therapeutic effect of rituximab on pSS patients with ILD. METHODS: Pulmonary function test results, including diffusing capacity for carbon monoxide (DLCO) and DLCO/alveolar volume (Va) ratio, and high-resolution computed tomography (HRCT) findings/scores in ten pSS patients with ILD treated with rituximab were retrospectively investigated. Global disease, fatigue, dryness of eyes and mouth, shortness of breath, and cough were assessed by visual analogue scales (VAS, 0-100 mm). RESULTS: At 6 months after rituximab treatment, improvement in pulmonary function was observed (from 49.3±12.6 to 56.9±11.4% for DLCO, p=0.011; from 74.4±15.8 to 85.6±10.3% for DLCO/Va, p=0.021). Similarly, significant improvement of subjective symptoms were also noted after treatment (VAS global disease, from 62.0±11.4 to 26.0±10.8 mm, p<0.001; VAS fatigue, from 38.0±23.0 to 18.0±7.9 mm, p=0.006; VAS dryness of eyes, from 53.0±24.4 to 29.0±13.7 mm, p=0.004; VAS dryness of mouth, from 45.0±14.3 to 28.0±9.2 mm, p=0.001; VAS shortness of breath, from 64.0±16.5 to 31.0±16.0 mm, p<0.001; VAS cough, from 42.0±23.5 to 18.0±10.3 mm, p=0.011). The mean HRCT score decreased after rituximab therapy although to a lesser extent (from 8.7±4.1 to 7.6±4.6, p=0.419). An adverse event was observed in only one patient who had non-fatal pneumonia 4 months after rituximab infusion. CONCLUSIONS: Rituximab was effective in improving clinical symptoms and gas exchange, and in stabilising HRCT score in pSS patients with ILD.

Percutaneous cryoablation for inoperable malignant lung tumors: midterm results.

OBJECTIVE: To retrospectively analyze the efficacy and short- to mid-term survival rate of cryoablation for malignant lung tumors. METHODS: Percutaneous CT-guided cryoablation for 45 malignant lung tumors in 26 patients during 41 sessions from 2009 to 2013 were performed. Follow up CT-scan were used to determine local tumor progression. Survival rate, local tumor control rate and associated risk factors were analyzed. RESULTS: The immediate during and short-term complications with CTCAE grade 2 or upper include pneumothorax (15%), pleural effusion (20%), pulmonary hemorrhage (24%), pneumonitis (15%), hemothorax (15%), hemoptysis (10%), pain (20%), bronchopleural fistula (n=1), and empyema (n=2). Life-threatening bleeding or hemodynamic instability was not observed. There was no procedural-related mortality. Overall survival rate of 1, 2, 3 years are 96%, 88%, 88%. For curative intent, local tumor control (LTC) rate of 1, 2, 3 years are 75%, 72%, 72%. CONCLUSION: Cryoablation for malignant lung tumors is effective and feasible in local control of tumor growth, with good short- to mid-term survival rate, as an alternative option for inoperable patients.

Glomus tumor in the stomach.

Gastric glomus tumor is rare and most commonly described as a solitary, well-defined, submucosal lesion in the antrum with non-specific clinical manifestations. We report this case with representative image findings, correlate with clinical presentations and pathologic demonstrations that can help to early detect and distinguish it from other malignant tumors such as gastrointestinal stromal tumor.

Elongation of the Aorta after Thoracic Endovascular Aortic Repair: A longitudinal study.

Aortic morphology is associated with age, with the diameter being larger in older people. Thoracic endovascular aortic repair (TEVAR) is a treatment for aortic diseases, such as aortic dissection. When evaluating patients, aortic elongation could interfere with the classification of TEVAR complications. The longitudinal change in aortic length has not been studied in detail. In patients receiving thoracic endovascular aortic repair between 2007 and 2013, we determined the aortic length between the sinotubular junction, left common carotid artery, subclavian artery, and celiac artery on their first five annual follow-up computed tomography (CT) exams. Using the immediate post-TEVAR follow-up CT as the comparison reference and a lengthening of the aortic segment by 10 mm or more as the definition of elongation, 16 of 41 (39%) showed elongation between the innominate artery and celiac artery. When compared with the immediate follow-up CT, a higher proportion of patients showed elongation at the fifth year's follow-up CT than the first year's follow-up CT (p < 0.01), and the average lengthening per year was 1.7 mm. There was progressive lengthening of the aorta after TEVAR.

Utilization and Safety of Percutaneous Lung Biopsy: A 10-Year Nationwide Population-Based Study.

Percutaneous lung biopsy is a technique used for sampling peripherally located lung masses and has been gaining in popularity. However, its exact utilization is unknown, and its safety has not been well studied. The current study aimed to assess the trend of utilization and study the safety of this procedure. Using the National Health Insurance Research Database, we retrospectively determined the total number of procedures that were performed on subjects older than 20 years between 2001 and 2010. We also estimated the rates of major complications, such as pneumothorax, requiring intercostal drainage. A total of 630 percutaneous biopsies were performed in 2001, while 3814 were performed in 2010, representing a 6.1-fold increase. The compound annual growth rate was 22.1%. The number of hospitals that performed the procedure increased from 55 to 99. Pneumothorax requiring drainage occurred in 1.5% of the procedures. The factors associated with a higher complication rate included male gender, chronic obstructive pulmonary disease, rural hospital, and low-volume hospital. Percutaneous lung biopsies are a relatively safe procedure, and their performance has been rapidly increasing. The number of procedures performed by a hospital was associated with the complication rate.

Evolutionary magnetic resonance appearance of renal cell carcinoma after percutaneous cryoablation.

OBJECTIVE: To determine the evolutionary MRI appearance of renal cell carcinoma (RCC) following cryoablation. METHODS: For this institution review board-approved study, we recruited patients with biopsy-proven RCC and treated them with percutaneous cryoablation between November 2009 and October 2014. Two radiologists retrospectively reviewed the pre-procedural and follow-up MRI. The findings included tumour sizes, signal intensities on T1 weighted imaging (T1WI), T2 weighted imaging (T2WI), diffusion-weighted imaging, apparent diffusion coefficient (ADC) map and contrast enhancement patterns. The ADC values of the tumours before and after treatment were measured. RESULTS: A total of 26 patients were enrolled. The ablated tumours exhibited predominantly high signals on T1WI at 1-9-month follow-up (47.1% strong hyperintense at 3 months) and subsequently returned to being isointense. In T2WI, the signals of the ablated tumours were highly variable during the first 3 months and became strikingly hypointense after 6 months (58.3% strong hypointense at 6 months). Diffusion restriction was prominent during the first 3 months (lowest ADC: 0.62 ± 0.29 × 10(-3) mm(2) s(-1) at 1 month). Contrast enhancement persisted up to 6 months after the procedure. The residual enhancement gradually increased in the dynamic scan and was most prominent in the delay phase. CONCLUSION: The MRI of the cryoablated renal tumour follows a typical evolutionary pattern. ADVANCES IN KNOWLEDGE: Familiarity of practitioners with the normal post-cryoablation change of RCC on MRI can enable the early detection and prevention of tumour recurrence.

Percutaneous computed tomography-guided cryoablation for renal tumor: Experience in 30 cases.

BACKGROUND: Percutaneous cryoablation is a minimally invasive alternative for surgical resection of a renal tumor. We report our experience with applying computed tomography-guided cryoablation in renal tumors, focusing on the technique, safety, and treatment response. METHODS: We retrospectively reviewed the medical records of patients who received cryoablation from October 2009 to August 2013 for renal tumor diagnosed by imaging studies performed at Taipei Veterans General Hospital, Taipei, Taiwan. Patient comorbidities and tumor morphology, technical success rate, tumor control rate, renal function change, and complications were recorded. RESULTS: A total of 30 patients (32 tumors) were treated, comprising 30 renal cell carcinomas and two angiomyolipomas. The mean age of the patients was 73.7 years (range, 34-89 years). The patients were referred for percutaneous cryoablation arising from old age, medical comorbidities, or preexisting malignancy. The mean follow-up period was 15.2 months (range, from 32 days to 47.4 months). According to the Clavien-Dindo classification, surgical complications included one Grade III, four Grade II, and two Grade I complications. The mean decrease in hemoglobin was 0.77 g/dL (range, from +1.1 g/dL to -3 g/dL). The mean hospital stay after cryoablation was 2.2 days (range, 1-10 days). Incomplete ablation was noted in two patients and local tumor recurrence in two patients. One of them received repeated cryoablation and achieved successful local control. Of the 22 renal cell carcinoma patients with follow-up period > 6 months, 19 patients achieved successful local tumor control (86.4%). The percentage change of glomerular filtration rate before and 3-6 months after the procedure was +1.9%, which was statistically nonsignificant (p = 0.94). CONCLUSION: Computed tomography-guided percutaneous cryoablation is a safe and effective technique for treating renal tumors with excellent renal function preservation.

Outcome comparison between thoracic endovascular and open repair for type B aortic dissection: A population-based longitudinal study.

BACKGROUND: Management of diseases of the descending thoracic aorta is trending from open surgery toward thoracic endovascular aortic repair (TEVAR), because TEVAR is reportedly associated with less perioperative mortality. However, comparisons between TEVAR and open surgery, adjusting for patient comorbidities, have not been well studied. In this nationwide population-based study, we compared the outcomes between TEVAR and open surgery in type B aortic dissection. METHODS: From 2003 to 2009, data on patients with type B aortic dissection who underwent either open surgery or TEVAR were obtained from the National Health Insurance Research Database. Survival, length of stay, and complications were compared between TEVAR and open repair. To minimize possible bias, we performed an additional analysis after matching patients by age, sex, and propensity score. RESULTS: A total of 1661 patients were identified, of whom 1542 underwent open repair and 119 TEVAR. Patients in the TEVAR group were older (63.0 ± 15.4 years vs. 58.1 ± 13.1 years; p = 0.001), included more males, and had more preoperative comorbidities. Thirty-day mortality in the TEVAR group was significantly lower than that in the open repair group (4.2% vs. 17.8%; p < 0.001). The midterm survival rates in the unmatched cohort between the open surgery and TEVAR groups at 1 year, 2 years, 3 years, and 4 years were 76%, 73%, 71%, and 68% vs. 92%, 86%, 82%, and 79%, respectively. The length of stay in the TEVAR group was shorter than that in the open repair group (p = 0.001). The TEVAR group had less respiratory failure (p = 0.022) and fewer wound complications than the open repair group (p = 0.008). The matched cohort showed similar results. CONCLUSION: TEVAR for type B aortic dissection repair has less perioperative mortality, a shorter length of hospitalization, a higher midterm survival rate, less postoperative respiratory failure, and fewer wound complications than open surgery.

Successful percutaneous tracheostomy via puncture through the thyroid isthmus.

Tracheostomy is one of the most frequently performed procedures in intensive care units. Bedside percutaneous tracheostomy has become an increasingly popular option to standard open tracheostomy. Several contraindications for percutaneous tracheostomy, including an enlarged thyroid isthmus, have been described. However, as experience with this technique has increased, most of the described contraindications appear to be relative rather than absolute, provided the procedure is performed by an experienced practitioner. Herein we present a case of an unavoidable direct puncture of the thyroid isthmus during a percutaneous tracheostomy. The procedure was performed smoothly, and no complications occurred.

Lung involvement in primary Sjögren's syndrome: Correlation between high-resolution computed tomography score and mortality.

BACKGROUND: Lung involvement is one of the major systemic manifestations of primary Sjögren's syndrome (pSS). This study aims to demonstrate the correlation between high-resolution computed tomography (HRCT), pulmonary function test (PFT) results, and outcome in these patients. METHODS: Forty-four pSS patients were enrolled and their PFT results and HRCT findings/scores were retrospectively investigated. RESULTS: All patients had reduced carbon monoxide-diffusing capacity (DLCO; <75% of the predicted value); <60% of the predicted value of peak expiratory flow (PEF), of forced vital capacity (FVC), and of forced expiratory volume in the 1st second (FEV1) were noted in 15 (34.1%) patients, 13 (29.5%) patients, and 12 (27.3%) patients, respectively. HRCT scores had a negative correlation with DLCO (r = -0.376, p = 0.012), but not with other PFT results. Twelve patients (27.3%) expired during a mean follow-up of 3.7 years; 11 (91.7%) patients died of respiratory failure in the lung-involved patients, of which three were present with pneumonia. The expired patients had lower predicted values of FEV1 (63.1 ± 19.4% vs. 79.0 ± 22.7%, p = 0.017), FVC (58.7 ± 20.4% vs. 77.1 ± 17.5%, p = 0.005), and PEF (54.3 ± 20.5% vs. 72.0 ± 24.8%, p = 0.035), and higher HRCT scores (9.2 ± 5.7 vs. 5.2 ± 3.5, p = 0.033) than those patients who survived. Patients with FEV1, FVC, PEF < 60% of the predicted value, or high HRCT score (13-18) presented shorter median overall survival (p = 0.005, p < 0.001, p = 0.021, p < 0.001, respectively). Multivariate analysis adjusted for PFT results showed that HRCT ≥13 was an independent risk factor for mortality (p = 0.007). CONCLUSION: The clinical outcome of pSS patients with lung involvement in Taiwan is not very favorable. Although HRCT score was poorly correlated with PFT, high HRCT score was significantly associated with higher mortality.

Image-guided lung tumor ablation: principle, technique, and current status.

Image-guided tumor ablation for lung malignancies has emerged as a treatment modality for medically inoperable patients. Overall, image-guided lung tumor ablation is a minimally invasive procedure that has an acceptable safety profile and less impact on lung function. This is important for patients with poor pulmonary and/or cardiac functions or with multiple comorbidities, which prevent them from undergoing surgery, chemotherapy, and radiation therapy. Herein, we review the principle, techniques, clinical application, and patient outcomes of image-guided lung tumor ablation.

Dynamic computed tomography of angioedema of the small bowel induced by iodinated contrast medium: prompted by coughing-related motion artifact.

Small bowel angioedema is a rare adverse effect of iodinated contrast medium. Here, we report the first case of contrast medium-induced small bowel angioedema with concurrent respiratory tract symptoms. A patient with colon cancer underwent CT scanning for preoperative staging. After injection of the contrast medium, a persistent cough developed and CT images showed that the small bowel wall was abnormally thickened. It returned to normal by the follow-up. The persistent coughing that developed right after the CT and small bowel wall thickening on the contrast-enhanced CT suggested the diagnosis of small bowel angioedema induced by the contrast medium.