Persistent or recurrent varicocoele after failed varicocoelectomy: outcome in patients treated using percutaneous transcatheter embolization.

AIM: To determine the efficacy of percutaneous transcatheter embolization in the management of patients with spermatic varicocoeles persisting or recurring after surgery. MATERIALS AND METHODS: Over a period of 10 years, 28 patients (age range 13-55 years) were referred for percutaneous transcatheter embolization of postsurgical, recurrent varicocoeles. Medical documents were retrospectively reviewed to evaluate past surgical history, subjective symptoms, and results of scrotal examination, ultrasound, and semen parameters. Pre-embolization venograms were analysed to assess the anatomy of the testicular vein. The technical and clinical outcomes of embolization were then determined. RESULTS: The 28 patients included in the study had undergone laparoscopic varicocoelectomy (39.3%), high retroperitoneal ligation (25%), or inguinal ligation (25%). Subjective symptoms were scrotal pain (60.7%) and a palpable scrotal mass (50%) exclusively on the left side. Venograms revealed abnormalities of the left testicular vein in all cases. Embolization was technically successful in all but two cases, thus yielding an occlusion rate of 93%; a single case of suspected thrombophlebitis was the only complication. After excluding two, technically unsuccessful cases and one patient who was lost to follow-up, 25 patients underwent scrotal examination after embolization, which revealed complete resolution in 20 cases (80%), partial improvement in four cases (16%), and no improvement in a single case (4%). Among the follow-up group of patients, of the 12 who initially presented with scrotal pain, six (50%) were symptom-free and four (33.3%) had partial improvement. CONCLUSION: Percutaneous transcatheter embolization of the testicular vein is technically feasible and effective for managing postsurgical recurrent varicocoeles.

Volumetric analysis of the liver after right portal vein embolization: mid-term follow-up based on embolization score.

AIM: To evaluate liver volume alterations and liver function after right portal vein embolization (PVE) during mid-term follow-up based on embolization score. MATERIALS AND METHODS: Computed tomography (CT) images and liver function profiles were obtained before PVE, and at short-term (7-45 days), and mid-term follow-up (106-380 days) after PVE in all 30 patients. The patients were divided into group A (PVE score >or=3, n=20) and group B (PVE score <3, n=10). High score indicates more complete embolization. RESULTS: Left liver volume (LLV) and percentage future liver remnant (%FLR) increased significantly between pre-PVE and short-term follow-up and between short-term and mid-term follow-up in group A. Increase in FLR volume was significantly higher at the mid-term follow-up than at the short-term follow-up in group A. The ratio of embolized to total liver volume (RETLV) on short-term follow-up was significantly higher in group A than in group B. Aspartate transaminase (AST) and alanine transaminase (ALT) were elevated on short-term follow-up, whereas at mid-term follow-up in group A, they had significantly returned to the baselines. CONCLUSION: PVE resulted in continued compensatory hypertrophy of the unembolized liver during the 6-month follow-up. Compensatory hypertrophy in the unembolized liver was proportional to the ratio of embolization and to the embolized liver volume.

Primary hepatic angiosarcoma: imaging findings and palliative treatment with transcatheter arterial chemoembolization or embolization.

AIM: To describe the image findings and results of transcatheter arterial chemoembolization (TACE) or transcatheter arterial embolization (TAE) for treating primary hepatic angiosarcoma. MATERIALS AND METHODS: A retrospective review of the electronic medical database from 2002 to 2007, revealed six patients with primary hepatic angiosarcoma confirmed by percutaneous liver biopsy. The computed tomography (CT) and angiography imaging findings, the TACE or TAE results, and the post-procedure course were evaluated in all patients. RESULTS: On CT and angiography, each tumour appeared as a solitary mass or as multiple nodules or masses with heterogeneously early and progressive enhancement. One of the two patients with tumour response to TACE died 8 months after initial presentation, and the remaining patient was still alive at the last follow-up 12 months after initial presentation. However, two patients with no response to TACE and two patients who underwent emergent TAE for tumour rupture died 1 week to 5 months (mean 2.1 months) after initial presentation. CONCLUSIONS: Primary hepatic angiosarcoma appears as a solitary or multiple, hypervascular lesions with heterogeneously early and progressive enhancement on CT and angiography. Although TAE may be the primary procedure for achieving emergent bleeding control caused by the rupture of hepatic angiosarcomas, TACE may be effective for treating patients with a dominant hepatic angiosarcoma with or without intrahepatic metastases.

Cell refractive index for cell biology and disease diagnosis: past, present and future.

Cell refractive index is a key biophysical parameter, which has been extensively studied. It is correlated with other cell biophysical properties including mechanical, electrical and optical properties, and not only represents the intracellular mass and concentration of a cell, but also provides important insight for various biological models. Measurement techniques developed earlier only measure the effective refractive index of a cell or a cell suspension, providing only limited information on cell refractive index and hence hindering its in-depth analysis and correlation. Recently, the emergence of microfluidic, photonic and imaging technologies has enabled the manipulation of a single cell and the 3D refractive index of a single cell down to sub-micron resolution, providing powerful tools to study cells based on refractive index. In this review, we provide an overview of cell refractive index models and measurement techniques including microfluidic chip-based techniques for the last 50 years, present the applications and significance of cell refractive index in cell biology, hematology, and pathology, and discuss future research trends in the field, including 3D imaging methods, integration with microfluidics and potential applications in new and breakthrough research areas.

Fiber confocal reflectance microscope (FCRM) for in-vivo imaging.

In-vivo imaging can be achieved with a coherent-fiber-bundle based confocal reflectance microscope. Such a microscope could provide the means to detect pre-cancerous lesions in the cervix by characterizing cells' nuclear-to-cytoplasmic ratio. In this paper we present the design of such a fiber confocal reflectance microscope, with an emphasis on its optical sub-systems. The optical sub-systems consist of a commercially available microscope objective and custom designed telescope, scan lens, and coupling lens systems. The performance of the fiber confocal reflectance microscope was evaluated by imaging a resolution bar target and human cervical biopsy tissues. The results presented in this paper demonstrate a lateral resolution of 2 microm and axial resolution of 6 microm. The sensitivity of the system defined by the smallest refractive-index mismatch that can be detected is approximately Delta n 0.05.

Near real time confocal microscopy of amelanotic tissue: dynamics of aceto-whitening enable nuclear segmentation.

High resolution, in vivo confocal imaging of amelanotic epithelial tissue may offer a clinically useful adjunct to standard histopathologic techniques. Application of acetic acid has been shown to enhance contrast in confocal images of these tissues. In this study, we record the time course of aceto-whitening at the cellular level and determine whether the contrast provided enables quantitative feature analysis. Confocal images and videos of cervical specimens were obtained throughout the epithelium before, during and post-acetic acid after the application of 6% acetic acid. Aceto-whitening occurs within seconds after the application. The confocal imaging system resolved sub-cellular detail throughout the entire epithelial thickness and provided sufficient contrast to enable quantitative feature analysis.

Transluminal angioplasty for middle cerebral artery stenosis in patients with acute ischemic stroke.

BACKGROUND AND PURPOSE: Precutaneous transluminal angioplasty (PTA) is currently performed to treat supraaortic atherosclerotic lesions. Our purpose was to evaluate the safety and efficacy of PTA for middle cerebral artery (MCA) stenosis in patients with acute ischemic stroke. METHODS: We performed PTA with the use of a microballoon (2-2.5 mm in diameter and 10-13 mm in length) in 10 consecutive patients (mean age, 48 years) who met the following criteria: high-grade M1 stenosis (> 70%) and mild neurologic deficits (NIH stroke scale < 4) and/or recurrent transient ischemic attacks (TIAs) resistant to anticoagulation, or a large area of hypoperfusion in the MCA territory on brain perfusion SPECT scans. During follow-up, we administered antiplatelet agents and evaluated the status of restenosis by angiography (n = 2), brain perfusion SPECT (n = 4), and/or transcranial Doppler sonography (TCD) (n = 7). RESULTS: Stenotic arteries were successfully dilated in nine of 10 patients. Angioplasty failed in one patient because the balloon could not pass through the tortuous cavernous internal carotid artery. None of the patients experienced either peri- or postangioplasty complications. Residual stenosis was less than 50%, and clinical improvement, including elimination of TIAs in four patients who had suffered resistant TIAs, was observed in all patients; improvement of the cerebral perfusion was also noted in two patients with a large hypoperfusion area in the MCA territory. The average follow-up period was 11 months (range, 2 to 36 months). None experienced recurrent stroke during the follow-up period. TCD revealed decreased flow velocity of the MCA after angioplasty in seven patients. CONCLUSION: PTA of the proximal portion of the MCA seems to be a safe and effective therapeutic technique for the prevention of secondary ischemic stroke.

Adult-to-adult living donor liver transplantation at the Asan Medical Center, Korea.

Between February 1997 and December 2001, 311 adult-to-adult living donor liver transplants (A-A LDLTs) were performed at the Asan Medical Center for patients above 20 years of age. Indications for A-A LDLT were: chronic hepatitis B (203), chronic hepatitis C (5), hepatocellular carcinoma (64), alcoholic cirrhosis (9), cryptogenic cirrhosis (4), secondary biliary cirrhosis (5), primary biliary cirrhosis (1), Wilson' s disease (2), autoimmune hepatitis (1), hepatic tuberculosis (1), cholangiocarcinoma (1), fulminant hepatic failure (14) and primary non-function of cadaveric liver graft (1). Of 311 A-A LDLTs, 36 were of medical high urgency, 20 were for acute and subacute hepatic failure, 15 were for hepato-renal syndrome and 1 was for primary non-function. Recipient age ranged from 27 to 64 years. Donor age ranged from 16 to 62 years. There was no donor mortality. Implanted liver grafts were categorized into seven types: 175 modified right lobe (MRL), 70 left lobe, 32 right lobe, 20 dual grafts, 10 left lobe plus caudate lobe, three extended right lobe and one posterior segment. In MRL, the tributaries of the middle hepatic vein were reconstructed by interpositioning a vein graft. Indication for dual graft implantation was the same as single graft A-A LDLT, and four of 20 were emergency cases. Of 20 dual grafts, 14 received two left lobes, four received a left lobe and a lateral segment, one received a right lobe and a left lobe and one received a lateral segment and a posterior segment. Graft volume ranged from 28% to 83% of the standard liver volume of the recipients. There were 33 (10.6%) in-hospital mortalities (< 4 months) among the 310 patients after 311 A-A LDLTs. Of the 36 patients receiving emergency transplants, 31 survived. These encouraging results justify the expansion of A-A LDLT in coping with increasing demands, even in urgent situations. We have aimed to introduce the establishment of the efficacy of A-A LDLT in various end-stage chronic and acute liver diseases, as well as new technical advances to overcome small graft-size syndrome by using dual-graft implantation and MRL, both of which were first developed in our department.

Angiographic evaluation of hepatic arterial injury after cisplatin and Gelfoam-based transcatheter arterial chemoembolization for hepatocellular carcinoma in a 205 patient cohort during a 6-year follow-up.

OBJECTIVE: To evaluate the overall and cumulative incidence, degree, interval change and predictors of hepatic arterial injury (HAI) after cisplatin and Gelfoam® (Upjohn, Kalamazoo, MI)-based transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). METHODS: A total of 205 patients with HCC who underwent three or more sessions of TACE without additional surgical or local treatment were included. HAI was evaluated at each segment of the hepatic artery using a three-grade scale: 1 (slight wall irregularity), 2 (overt stenosis) and 3 (occlusion). HAI interval change was categorized into three groups: progression, stable state and improvement. Cumulative incidence of HAI was analysed using Kaplan- Meier method, and predictors of HAI (patient age, sex, portal vein thrombosis and Child-Pugh classification) were analysed by univariate logistic regression. RESULTS: HAI occurred in 50 of the 205 study patients (24.4%). The cumulative incidence of HAI was 16.0% [95% confidence interval (CI), 10.21-21.77] during 5 sessions of TACE, 52.1% (95% CI, 37.83-66.29) during 10 sessions and 68.0% (95% CI, 67.62-88.46) during 15 sessions. Initial HAI was interpreted as grades 1, 2 and 3 in 11 (22.0%), 17 (34.0%) and 22 (44.0%) patients, respectively. When the interval change was assessed in 48 patients with available follow-up TACE, 40 (83.3%) were included in the progression, 2 (4.2%) in the stable state and 6 (12.5%) in the improvement groups. The univariate analysis used to determine the predictors of HAI revealed no significant predictors. CONCLUSION: In three or more sessions of TACE, the incidence of HAI was 24%. Increasing TACE causes increased incidence of HAI. The initial presentation was most commonly grade 3, and 12.5% of the patients with HAI showed improvement of the HAI grade during follow-up TACE. ADVANCES IN KNOWLEDGE: In patients who underwent three or more sessions of cisplatin and Gelfoam-based TACE, the overall incidence of HAI was 24.4%, and increasing TACE causes increased incidence of HAI.

Incidence and management of postoperative abdominal bleeding after liver transplantation.

PURPOSE: To assess the incidence and management of postoperative abdominal bleeding after orthotopic liver transplantation (OLT) and to identify risk factors for abdominal bleeding. METHODS: We retrospectively reviewed the medical records of 1039 patients who underwent OLT at our institution from January 2008 to December 2010 seeking to identify subjects with posttransplantation abdominal bleeding, defined as any hemorrhage requiring radiologic intervention or laparotomy within the first month. RESULTS: Among the 1039 patients, 94 (9%) showed abdominal bleeding, occurring at a mean of 6.1 days (range, day 1 to 21 days). Active bleeding was controlled by endovascular interventional techniques (n = 37; 39%), by surgical ligation or vascular reconstruction (n = 43; 46%), or by sequential combinations of endovascular intervention and surgery (n = 14; 15%). The most frequent bleeding sites for radiologic intervention were the right inferior phrenic artery (n = 14), right and left epigastric arteries (n = 7), intercostal artery (n = 5) and right renal capsular artery (n = 4). The most frequent bleeding sites requiring laparotomy were the hepatic artery (n = 9), diaphragm (n = 8), inferior vena cava (n = 5), abdominal drain insertion site (n = 4), portal vein anastomosis site (n = 4), abdominal wall (n = 3), liver graft cut surface (n = 3), hilar plate (n = 3), and greater omentum (n = 3). Bleeding episodes were associated with greater patient age and increased intraoperative blood loss. CONCLUSIONS: The risk of bleeding from coagulopathy and iatrogenic injury is high during the early posttransplantation period. This risk of bleeding can be minimized by meticulous surgical dissection and bleeding control.

Effect of splenic artery embolization for splenic artery steal syndrome in liver transplant recipients: estimation at computed tomography based on changes in caliber of related arteries.

PURPOSE: To estimate the effect of splenic artery embolization (SAE) on blood flow in orthotopic liver transplantation (OLT) recipients with splenic artery steal syndrome (SASS) based on changes in caliber of related arteries upon serial computed tomography (CT) scans. METHODS: Between 2004 and 2007, nine OLT recipients with SASS underwent SAE. They had CT scans before and after SAE: short-, mid-, and long-term, ie, approximately 1 week, 1 month, and 1 year, respectively. The diameters of the celiac axis (CA), common hepatic artery (CHA), and splenic artery (SA) were measured with arterial phase of each CT scan and the ratios of SA to CHA diameter (SA/CHA) calculated to analyze their changes during the follow-up period. RESULTS: The diameters of celiac axis, CHA, and SA and SA/CHA changed most rapidly during the short-term period. The CHA diameter significantly increased short-term post-SAE by CT and slightly decreased thereafter. However, the mid-term and long-term post-SAE CT values were still significantly greater than those on the pre-SAE CT. The SA diameter steadily decreased throughout the follow-up. The SA/CHA decreased until the mid-term. The SA diameter and SA/CHA were significantly smaller upon mid-term and long-term post-SAE CT compared with those at pre-SAE CT. CONCLUSIONS: The effect of SAE to improve hepatic arterial flow in OLT recipients with SASS might be expected for at least approximately one year. The effect maximally occurred during the short-term after SAE on the basis of changes in the caliber of related arteries upon CT.

Percutaneous transluminal angioplasty of suture-mediated closure device-related femoral artery stenosis or occlusive disease.

This study evaluates the efficacy of percutaneous transluminal balloon angioplasty (PTA) to treat stenosis or occlusion following haemostasis using a suture-mediated closure (SMC) device. Steno-occlusion occurred in 7 (0.4%) patients, some with claudication, others without. Steno-occlusion was diagnosed immediately after haemostasis in the four patients without claudication, but diagnosis was delayed in all three patients with claudication. Six of the patients subsequently underwent PTA using a contralateral femoral arterial approach. Technical success, clinical response and vessel patency were evaluated retrospectively. Follow-up angiography revealed focal segmental steno-occlusion (<1 cm) in the common femoral or proximal superficial femoral artery in four patients and long segmental occlusion (>1 cm) in the external iliac and common femoral arteries in three patients. PTA was technically successful in all patients (6/6, 100%). Among the three patients who developed delayed onset of claudication, one declined treatment and the claudication improved in two. Doppler ultrasound obtained 28-129 days (mean; 75 days) after PTA revealed patent arterial flow in six patients. One patient with delayed-onset occlusion refused the procedure because the symptoms were mild. This study has shown that PTA is a useful treatment for steno-occlusion following haemostasis using the SMC device. Careful angiography and review of the femoral bifurcation prior to use of an SMC device is important.

Transcatheter arterial chemoembolization vs. chemoinfusion for unresectable hepatocellular carcinoma in patients with major portal vein thrombosis.

BACKGROUND: Transcatheter arterial chemoembolization (TACE) has been limited in palliative treatment of unresectable hepatocellular carcinoma (HCC) with major portal vein (PV) invasion due to the possibility of liver failure following embolization. Transcatheter arterial chemoinfusion (TACI) has been an option in such cases. AIM: To compare clinical outcomes after TACE vs. TACI in HCC patients with major PV occlusion. METHODS: We compared clinical outcomes after TACE vs. TACI in HCC patients with major PV occlusion. From 2005 to 2007, 110 HCC patients with major PV thrombosis were treated with TACE (n = 49) or TACI (n = 61). RESULTS: The morbidity rate was similar for both TACE (6.1%) and TACI (6.5%) patients, and complications were adequately managed using medical treatment. The Kaplan-Meier survival analysis showed that the survival period was significantly longer for the TACE group (median: 14.9 months) than for the TACI (median: 4.4 months) group (P < 0.001). There was a higher probability of death in the TACI group than in the TACE group in both our multivariate Cox-proportional hazards (OR 3.09, P < 0.001) and the propensity score-matched (27 pairs) cohort analyses (OR 2.27, P = 0.024). CONCLUSIONS: Transcatheter arterial chemoembolization can be safely performed in HCC patients with main PV occlusion. Compared with TACI, TACE may result in longer survival of HCC patients with major PV occlusion.

A case of successful embolotherapy for gastric ulcer bleeding from the intercostal artery after oesophagectomy and gastric reconstruction.

We report a successful treatment with coil embolisation of an intercostal artery for ulcer bleeding in a gastric tube in a 70-year-old man who underwent a total oesophagectomy and gastric tube reconstruction for oesophageal cancer. This case teaches us to search aberrant feeding vessels when active bleeding is suspected in reconstructed gastric tube in the patient with oesophagectomy and oesophagogastrostomy.

Percutaneous removal of residual intrahepatic stones.

In the Orient there is a high frequency of residual intrahepatic stones after biliary tract surgery. Percutaneous removal of residual intrahepatic stones was attempted in a group of 74 patients. Stones were exclusively intrahepatic in 57 patients, whereas 17 patients also had stones in the common bile duct. Biliary strictures were present in 60 cases (81%). A combination of techniques was used, including preshaped angulated catheters, irrigation-suction, balloon dilation of strictures, and crushing of large stones. In 36 cases all stones were removed and in 14 cases most stones were removed, for a success rate of 67.6%. Biliary stricture was the factor most often responsible for failure.

Herpes zoster ophthalmicus and delayed contralateral hemiparesis.

Central nervous system is often involved by herpes zoster but it is very rarely seen that contralateral hemiparesis or hemiplegia developed after herpes zoster ophthalmicus. We report a case of herpes zoster ophthalmicus followed by the delayed contralateral hemiparesis. A 33-year-old man developed acute cerebral infarction and resultant right hemiparesis 44 days after herpes zoster ophthalmicus in the left side. Brain CT disclosed hypodense area in the left basal ganglia. Cerebral angiography revealed segmental narrowing of M1 portion of the right middle cerebral artery.

Small arterial-portal venous shunts: a cause of pseudolesions at hepatic imaging.

PURPOSE: To compare hepatic angiographic findings of small arterial-portal venous shunts with those of other imaging modalities, and to determine whether these shunts are related to hepatocellular carcinoma. MATERIALS AND METHODS: At hepatic angiography in 223 patients, small arterial-portal venous shunts not directly related to hepatocellular carcinoma and focal areas of parenchymal contrast material enhancement more than 1 cm in diameter were found in 28 patients. These 28 patients were prospectively evaluated with computed tomography (CT) during arterial portography (CTAP) (n = 12), CT after iodized oil administration (n = 23), intraoperative ultrasonography (n = 5), or follow-up hepatic angiography (n = 13). Magnetic resonance (MR) images (n = 10) and dynamic CT scans (n = 4) in these patients were retrospectively reviewed. RESULTS: Arterial-portal venous shunts noted at angiography manifested as perfusion defects at CTAP in 10 patients and as an area of arterial contrast enhancement at dynamic CT in three patients. No lesion was seen at MR imaging, and no persistent iodized oil uptake was seen at CT. There was no evidence of hepatocellular carcinoma tumor growth around the shunts at follow-up angiography, and no tumor was present at surgery. CONCLUSION: Understanding of the hemodynamic changes caused by these small shunts can aid in the interpretation of vascular imaging findings.

Self-expandable metallic stents in high-risk patients with benign prostatic hyperplasia: long-term follow-up.

PURPOSE: To evaluate the long-term clinical utility of self-expandable metallic Z stents in benign prostatic hyperplasia (BPH). MATERIALS AND METHODS: Under fluoroscopic guidance, 14 multiple-connected Z stents (10 mm in diameter fully expanded, 30-60 mm in length) were placed in 13 patients with bladder obstruction from BPH and high operative risks. The stents were placed in the prostatic urethra with 2-20-mm protrusion into the urinary bladder in six patients (group A) and entirely within the prostatic urethra in seven patients (group B). RESULTS: Eleven of 13 patients could void immediately, and the other two patients with atonic bladder voided within 8 weeks. Maximum urine flow rates just after stent placement were 8-27 mL/sec. Two patients died of unrelated causes within 2 months. During the follow-up period (mean, 37 months) in the other 11 patients, all patients in group A but none in group B underwent surgery owing to stone formation where the stent protruded into the bladder. CONCLUSION: Expandable Z stents are effective in patients with BPH but should not protrude into the urinary bladder because of stone formation.

Nasolacrimal duct obstruction treated nonsurgically with use of plastic stents.

PURPOSE: To evaluate the clinical utility of plastic stents in treatment of complete obstruction of the nasolacrimal duct. MATERIALS AND METHODS: Nineteen plastic stents were successfully placed under fluoroscopic guidance in 16 consecutive patients with epiphora due to complete obstruction of the nasolacrimal duct. After balloon dilation of the obstructed area, the stents were placed in the lacrimal system with the head portion lying in the dilated lacrimal sac and the body in the nasolacrimal duct and projecting into the inferior meatus of the nasal cavity. RESULTS: Complete resolution of epiphora was accomplished in 15 (79%) of 19 eyes and partial resolution in the remaining four (21%) eyes. CONCLUSION: These preliminary results with use of plastic nasolacrimal stents are encouraging.

A case of aneurysm of the vein of Galen.

Aneurysm of the vein of Galen is a very rare disease. The authors present a case of secondary aneurysm of the vein of Galen which was confirmed by characteristic clinical symptoms, brain CT and angiographic findings. The patient was a 14-year-old right handed girl with intermittent headache, nausea, vomiting, dysphasia and gait disturbance. Neurologic examination revealed dysarthria, nasal voice, blurring of both margins of optic discs, truncal ataxia and dysdiadochokinesia. Sensory function was normal but right hemiparesis was seen. Roentgenogram of the skull revealed diffuse thinning of the calvarium, widening of sella turcica and erosion of clinoid processes. Computed tomogram of the brain showed dilatation of all ventricles and round hyperdense mass behind the third ventricle in the midline. The lesion was enhanced markedly and homogeneously. Left and right internal carotid angiograms showed arteriovenousmal-formation with drainage to the aneurysm of the vein of Galen.