Real-Time 3D CT Image Guidance for Transjugular Intrahepatic Portosystemic Shunt Creation Using Preoperative CT: A Prospective Feasibility Study of 20 Patients.

OBJECTIVE: The purpose of this study is to prospectively evaluate the feasibility and efficacy of real-time 3D CT image guidance during transjugular intrahepatic portosystemic shunt (TIPS) creation. SUBJECTS AND METHODS: Between October 2013 and December 2013, a total of 20 patients were prospectively enrolled in the present study. Previously acquired portal venous phase CT datasets and intraoperative CT datasets were registered on a dedicated workstation. We accomplished semiautomatic registration for the datasets of 11 of 20 patients (55%), and we performed manual registration for the datasets of the remaining nine patients. The selected volume of interest of the CT image showing the portal vein vasculature was overlaid onto the fluoroscopic display to provide real-time 3D CT image guidance during the procedure. RESULTS: For all 20 patients, TIPS procedures were successfully performed by the same operator. The mean (± SD) number of needle passes required for portal vein entry was 1.8 ± 1.1 passes (range, 1-5 passes). The mean duration of radiographic fluoroscopy was 3.5 ± 1.1 minutes for portal vein entry and 11.4 ± 2.1 minutes for the whole procedure. The mean radiation dose used for the whole TIPS procedure was 295.5 ± 66.6 Gy · cm2. No major technical complications were observed. CONCLUSION: Real-time 3D guidance with the use of preoperative CT is feasible, safe, and effective for assisting in the creation of TIPS. This approach may result in a shorter procedural time and less radiation exposure. However, future studies are required to compare this method with other mapping techniques.

An evaluation on novel application of cone-beam CT imaging with multi-volume technique in carotid body tumor.

Due to the high risk of vascular and nerve damage during surgery, precise pre-operative evaluation of carotid body tumor (CBT) is important. We aim to apply intra-operative contrast-enhanced cone-beam CT (CBCT) with multi-volume technique in CBT evaluation, where the tumor, patent carotid arteries, and skull are demonstrated in three different colors, and to compare this novel technique with traditional computed tomography angiography (CTA). Seven CBT patients scheduled for traditional surgical removal were enrolled in this study between October 2013 and March 2016. For each patient, two CBCT scans were performed on the carotid region both pre- and post-operatively, with contrast injected into the common carotid artery directly. CT-like cross-sectional slices were then reconstructed with a dedicated workstation, and a novel multi-volume technique was further applied for advanced image post-processing. For all seven patients, the anatomic relationship between tumor and surrounding vessels was clearly demonstrated by reconstructed CBCT images with multiple fused volumes. Carotid was either completely or partially incarcerated by tumors. Interestingly, two sets of draining vein systems of CBT were found feeding into the internal jugular vein and the anterior vertebral venous plexus, respectively, which have not been revealed in pre-operative CTA. Post-operative CBCT confirmed the thorough removal of the tumor with an intact preservation of the internal carotid artery. CBCT with multi-volume technique outperforms CTA in discovering fine structures and revealing tumor-vessel relationship for CBT. This emerging imaging technique would offer more accurate diagnosis of CBT and assist in the decision of surgical plan.

Comparison of diagnostic sensitivity of C-arm CT, DSA and CT in detecting small HCC.

BACKGROUND/AIMS: To compare the detection rate of 64-slice CT, digital subtraction angiography (DSA) and C-arm computed tomography (C-arm CT) in small lesions with a diameter ≤3.0 cm of hepatocellular carcinoma (HCC). METHODOLOGY: Sixty-six patients with HCC underwent 64-slice CT, DSA, and C-arm CT, and were followed up by lipiodol CT two weeks after transcatheter arterial chemoembolization (TACE). Whose result was used as diagnostic reference. The number of detected lesions with diameter ≤3.0 cm in each imaging modality was counted independently by 4 radiologists. RESULTS: A total of 174 lesions out of the 66 patients were confirmed by lipiodol CT, among which 47.7% were detected by 64-slice CT, 82.2% by DSA, and 97.1% by C-arm CT. McNemar test showed the statistical difference in detection rate between each two methods of CT, DSA and C-arm CT (all p<0.0001). All lesions were further classified into 3 groups (group A, B, C) according to the diameter (≤1cm, 1-2cm, 2-3cm), where C-arm CT showed significantly higher diagnostic sensitivity in group A and B. CONCLUSIONS: Compared to 64-slice CT and DSA, C-arm CT has the best sensitivity by detecting small lesions of HCC, and thus may play a guiding role in TACE procedure.

A novel arthroscopically assisted reduction technique for three patterns of posterolateral tibial plateau fractures.

BACKGROUND: Posterolateral tibial plateau fractures (PTPF) remain a challenge for orthopedics surgeons because the special anatomical structures of the posterolateral corner of knee joint including the fibular head, the lateral collateral ligament, and the peroneal nerve, which impedes the exposure of the fracture fragments and need irregular implants to get a stable fixation. The purpose of present study was to introduce a new articular fracture fragments restoration technique for three patterns of PTPF and investigate the relationship between associated soft injuries and fracture patterns. METHODS: From May 2016 to April 2018, 31 patients with PTPF who had undertaken arthroscopically assisted reduction and fixation (AARF) were enrolled in present study. Demographic data, pre-operation, and post-operation X plan films, three-dimensional computed tomography (CT) scans and magnetic resonance imaging (MRI) were reviewed. Present samples were divided into three patterns with lateral inclination (LI), posterior inclination (PI), and parallel compression (PC) according to the orientation of the articular fragment inclination. Rasmussen anatomical score was used to assess the radiological results. Rasmussen functional score, Hospital for Special Surgery knee-rating Score (HSS), and range of motion (ROM) of the knee joint at the final follow-up were measured to evaluate the clinical outcomes. RESULTS: In this series, the post-operation tibial plateau angle (TPA) was 9.7° ± 3.5°(range 4.0°-15.8°) and the Rasmussen anatomical score was 17.7 ± 0.7(range 16-18); clinical outcomes showed that the HSS score was 92.7 ± 21.8 (range 90-96) and the Rasmussen functional score was 27.9 ± 1.0 (range 26-30). Of all the patients, the anterior cruciate ligament (ACL) injuries including the ACL tibial attachment ruptures occurred in 16 patients (51.6%), meniscus lesions happened in 19 patients (61.3%), medial collateral ligament (MCL) injuries were founded in 13 patients (41.9%). The number of ACL injuries including the ACL tibial attachment ruptures in the PI fracture pattern (12 cases) is significantly higher than LI (2 cases) and PC (2 cases) fracture pattern (p < 0.05). CONCLUSION: Profound understanding the different patterns of PTPF and using our reduction technique will facilitate to restore the main articular fracture fragments. The PI fracture patterns have a significant high incidence of the ACL ruptures. LEVEL OF EVIDENCE: Therapeutic study, Level IV.

Three-dimensional path planning software-assisted transjugular intrahepatic portosystemic shunt: a technical modification.

PURPOSE: This study was designed to report our results with a modified technique of three-dimensional (3D) path planning software assisted transjugular intrahepatic portosystemic shunt (TIPS). METHODS: 3D path planning software was recently developed to facilitate TIPS creation by using two carbon dioxide portograms acquired at least 20° apart to generate a 3D path for overlay needle guidance. However, one shortcoming is that puncturing along the overlay would be technically impossible if the angle of the liver access set and the angle of the 3D path are not the same. To solve this problem, a prototype 3D path planning software was fitted with a utility to calculate the angle of the 3D path. Using this, we modified the angle of the liver access set accordingly during the procedure in ten patients. RESULTS: Failure for technical reasons occurred in three patients (unsuccessful wedged hepatic venography in two cases, software technical failure in one case). The procedure was successful in the remaining seven patients, and only one needle pass was required to obtain portal vein access in each case. The course of puncture was comparable to the 3D path in all patients. No procedure-related complication occurred following the procedures. CONCLUSIONS: Adjusting the angle of the liver access set to match the angle of the 3D path determined by the software appears to be a favorable modification to the technique of 3D path planning software assisted TIPS.

C-Arm Cone-Beam Volume CT in Transjugular Intrahepatic Portosystemic Shunt: Initial Clinical Experience.

PURPOSE: The purpose of this study was to compare two-dimensional digital subtraction angiography (2D-DSA) with C-arm cone-beam volume computed tomography (CACT) in the evaluation of portal vein entry and shunt course during transjugular intrahepatic portosystemic shunt (TIPS) procedure. MATERIALS AND METHODS: Between May 2010 and November 2011, 21 patients who underwent direct portography in anteroposterior and lateral projections and subsequent CACT before stent placement during TIPS creation were reviewed retrospectively. CACT images were examined for evaluation of the portal vein entry and shunt course in comparison to 2D-DSA images by two experienced interventional radiologists. RESULTS: CACT was proven to be better than 2D-DSA in identification of the portal vein entry (P < 0.001) and intra- or extrahepatic puncture (P < 0.001). No significant difference was observed in evaluating the shunt course (P = 0.086). The portal vein entry was considered inappropriate in seven (33%) out of 21 patients; among them, four cases were due to extrahepatic puncture, and three cases were due to peripheral puncture of the portal vein which may result in stent kinking. CONCLUSION: While 2D-DSA remains the standard imaging method to evaluate portal vein entry, shunt course, and portal vein anatomy during TIPS procedure, CACT can effectively identify the portal vein entry and assess shunt course in difficult cases intra-procedurally, hence may reduce the risk of potential life-threatening intra-abdominal hemorrhage and shunt dysfunction.

C-arm Lipiodol CT in transcatheter arterial chemoembolization for small hepatocellular carcinoma.

AIM: To investigate the value of C-arm Lipiodol computed tomography (CT) for intra-procedural hepatocellular carcinoma (HCC) lesion detection during transcatheter arterial chemoembolization (TACE). METHODS: Forty patients (37 male, 3 female; mean age, 52.6 ± 12.5 years, age range: 25-82 years) diagnosed with HCC were enrolled in this study. All patients underwent 64-slice CT 1-2 wk before TACE. During the procedure, hepatic angiography was performed first. Following diagnostic embolization with Lipiodol injected into the hepatic artery, a C-arm CT scan was immediately conducted (C-arm Lipiodol CT). If new HCC lesions were confirmed, gelfoam particles were super-selectively injected into the tumor-nourishing blood vessel. A Lipiodol CT scan was performed 7-14 d after TACE. All images acquired from 64-slice CT, digital subtraction angiography (DSA), C-arm Lipiodol CT and Lipiodol CT were retrospectively reviewed by four radiologists and the number of detected lesions in each examination was counted, respectively. The results of Lipiodol CT were taken as the diagnostic reference. Alpha-fetoprotein values were examined both before and after TACE. This study only takes into account the lesions that were not found or were considered suspicious on 64-slice CT before TACE. RESULTS: Preprocedural 64-slice CT detected a total of 13 suspicious lesions in the 40 patients. DSA detected ten definite and four suspicious lesions. C-arm Lipiodol CT detected 71 lesions in total and Lipiodol CT confirmed 67 lesions with a diameter range of 3-12 mm. Four false-positive lesions, which were detected by C-arm Lipiodol CT, were considered to be hepatic artery-portal vein fistulas. The average alpha-fetoprotein values before and after TACE were significantly different (452.3 ± 192.6 ng/mL vs 223.8 ± 93.2 ng/mL; P = 0.039). CONCLUSION: C-arm Lipiodol CT has a higher diagnostic sensitivity for small HCC lesions. This technique may help physicians make intraprocedural decisions to provide patients with earlier treatment.