Prophylactic Intraoperative Embolization of Abdominal Aortic Aneurysm Sacs Using N-Butyl Cyanoacrylate/Lipiodol/Ethanol Mixture with Proximal Neck Aortic Balloon Occlusion during Endovascular Abdominal Aortic Repair.

PURPOSE: To determine the feasibility of prophylactic intraoperative abdominal aortic aneurysm (AAA) sac embolization using a mixture of N-butyl cyanoacrylate/Lipiodol/ethanol (NLE) with proximal neck aortic balloon occlusion during endovascular aneurysm repair (EVAR) to prevent the occurrence of endoleak and aneurysm sac expansion. MATERIALS AND METHODS: Prophylactic intraoperative AAA sac embolization was performed in 24 patients with an infrarenal neck angulation > 60° (n = 16) or AAA sac diameter > 60 mm (n = 17). AAA sac pressure was continuously measured with a 3-F catheter inserted into the AAA sac. The systolic sac pressure index (SPI) was calculated as the ratio of systolic AAA sac pressure to the simultaneously measured systolic aortic pressure, and was measured with and without proximal neck aortic balloon occlusion. The aneurysm sac was embolized with NLE during proximal neck aortic balloon occlusion immediately after EVAR. Endoleak and AAA sac diameter were evaluated by enhanced computed tomography and subtraction magnetic resonance imaging at 6 months and yearly after EVAR. RESULTS: Mean SPIs after EVAR with and without proximal neck aortic balloon occlusion were 0.36 and 0.57, respectively. There were no adverse events related to intraoperative sac embolization. Follow-up imaging (mean, 12.1 mo) revealed three minor endoleaks (12.5%) and no aneurysm sac expansion. CONCLUSIONS: Prophylactic intraoperative sac embolization with NLE during proximal neck aortic balloon occlusion was safe and feasible and may reduce endoleaks and prevent sac expansion after EVAR in patients with unfavorable anatomic factors.

Systolic Sac Pressure Index for the Prediction of Persistent Type II Endoleak for 12 Months After Endovascular Abdominal Aortic Aneurysm Repair.

PURPOSE: To assess the relationship between the systolic sac pressure index (SPI) and the presence of endoleaks 12 months after endovascular abdominal aortic aneurysm repair (EVAR). MATERIALS AND METHODS: We performed a single-center prospective trial of consecutively treated patients. SPI (calculated as systolic sac pressure/systolic aortic pressure) was measured by catheterization immediately after EVAR. Contrast-enhanced computed tomography was scheduled 12 months after EVAR to detect possible endoleaks. RESULTS: Data were available for 34 patients who underwent EVAR for an AAA. Persisting type II endoleak was found in 8 patients (endoleak-positive group) but not in the other 26 patients (endoleak-negative group). The mean ± standard deviation SPI was significantly greater in the endoleak-positive group than in the endoleak-negative group (0.692 ± 0.048 vs. 0.505 ± 0.081, respectively; P = .001). Receiver-operating characteristic curve analysis revealed that an SPI of 0.638 was the optimum cutoff value for predicting a persistent endoleak at 12 months with high accuracy (0.971; 33/34), sensitivity (1.00), and specificity (0.962) values. The mean change in AAA diameter was -4.28 ± 5.03 mm and 2.22 ± 4.54 mm in patients with SPI of <0.638 or ≥0.638, respectively (P = .002). CONCLUSION: Patients with an SPI of ≥0.638 immediately after EVAR were more likely to have a persistent type II endoleak at 12 months with an accuracy of 0.971, and showed increases in aneurysm sac diameter compared with patients with an SPI of <0.638.

Synthesis of 24-h soluble gelatin sponge particles and their effect on liver necrosis following hepatic artery embolization: Results of in vitro and in vivo studies.

AIM: To synthesize 24-h soluble gelatin sponge particles (SGSP) of 200-500 and 500-1000 µm, and to investigate their ischemic potency following hepatic artery embolization (HAE). METHODS: Low-endotoxin gelatin was freeze-dried and heated at 110, 115, 118, 120, 122 and 125°C to form cross-linked gelatin sponge. We prepared 200-500- and 500-1000-µm SGSP by pulverizing and sieving the gelatin sponge. The dissolution times in saline were measured. Eight healthy pigs underwent HAE of the right and left hepatic arteries with either 200-500- or 500-1000-µm SGSP (n = 4/group). RESULTS: The particles prepared at 110-122°C were soluble whereas particles prepared at 125°C or more were insoluble. The mean dissolution time of the particles increased with increasing temperature. In each pig, sequential arteriography confirmed that recanalization was complete 24 h after embolization. Pathological tests 48 h after HAE revealed coagulation necrosis but least damage to the biliary tract. The liver necrosis rate (mean ± standard deviation) was significantly greater in the 200-500-µm group than in the 500-1000-µm group (9.89 ± 4.04% vs 4.44 ± 0.67%, respectively; P = 0.0027). A significantly greater proportion of arteries with a diameter of 100-200 µm had residual SGSP in the 200-500-µm group than in the 500-1000-µm group (P < 0.002). CONCLUSION: HAE with 200-500-µm SGSP had greater effects on promoting liver necrosis without biliary damage than did HAE with 500-1000-µm SGSP.

Balloon-assisted packing of wide-neck aneurysms with a mixture of n-butyl cyanoacrylate, Lipiodol, and ethanol: an experimental study.

PURPOSE: To evaluate the feasibility of balloon-assisted packing with a mixture of n-butyl cyanoacrylate (NBCA), Lipiodol, and ethanol for wide-neck aneurysms. MATERIALS AND METHODS: Of 10 carotid aneurysms with wide necks created in a swine model, 3 aneurysms (long and short diameters 10.9 × 9.8 mm; neck width 8.3 ± 1.2 mm (mean ± SD)) and 7 aneurysms (11.2 × 9.5 mm; neck width 8.3 ± 1.4 mm) were packed with a mixture of NBCA, Lipiodol, and ethanol in the ratios 1:1:0 (NL11) and 1:1:2 (NLE112), respectively. A microcatheter was advanced into the aneurysm and a balloon catheter was inflated at the aneurysm neck. Ten minutes after injection, the balloon catheter was deflated and its removal was attempted. RESULTS: For all three aneurysms in the NL11 group, the balloon catheter and the microcatheter adhered strongly to the vessel and could not be adjusted. For all seven aneurysms in the NLE112 group, both the balloon catheter and the microcatheter could be easily removed, which enabled successful full packing of the aneurysm by re-advancing the microcatheter and re-injecting NLE112 after re-inflation of the balloon catheter. CONCLUSION: Although at a preliminary stage, balloon-assisted NLE injection is feasible for packing a wide-neck aneurysm.

Reactive lymphoid hyperplasia of the liver: Perinodular enhancement on contrast-enhanced computed tomography and magnetic resonance imaging.

We report the case of a 69-year-old woman with reactive lymphoid hyperplasia (RLH) of the liver. She underwent partial hepatectomy under a preoperative diagnosis of hepatocellular carcinoma; however, histopathological analysis revealed RLH. The liver nodule showed the imaging feature of perinodular enhancement in the arterial dominant phase on contrast-enhanced computed tomography and magnetic resonance imaging, which could be a useful clue for identifying RLH in the liver. Histologically, the perinodular enhancement was compatible with prominent sinusoidal dilatation surrounding the liver nodule.

Effect of transcatheter arterial embolization with a mixture of n-butyl cyanoacrylate, lipiodol, and ethanol on the vascular wall: macroscopic and microscopic studies.

PURPOSE: To compare the pathologic effect of a mixture of n-butyl cyanoacrylate (NBCA), lipiodol, and ethanol (NLE) with a mixture of NBCA and lipiodol (NL) on the embolized vascular wall. MATERIALS AND METHODS: Embolization was performed using four swine with NBCA and lipiodol in a volume ratio of 1:1 (NL11 group) in the common hepatic artery (n = 1) and the internal iliac artery (n = 2); and with NBCA, lipiodol, and ethanol in a volume ratio of 1:1:2 (NLE112 group) in the common hepatic artery (n = 3) and the internal iliac artery (n = 6). RESULTS: NL11 casts had an intricate appearance in reticular configuration with red thrombus, while NLE112 casts presented in a single round configuration with surrounding ring-like red thrombus. Desquamation of endothelial cells and infiltration of neutrophils into the adventitial layer were found in all embolized vessels in both groups. Infiltration of neutrophils into the intermediate layer was found in the NL11 group but not in the NLE112 group. CONCLUSION: The damage to the vascular wall caused by NLE112 was milder than that by NL11, implying the adverse effects of NLE112 are within tolerable limits.

Risk factors associated with late aneurysmal sac expansion after endovascular abdominal aortic aneurysm repair.

PURPOSE: We aimed to identify the risk factors associated with late aneurysmal sac expansion after endovascular abdominal aortic aneurysm repair (EVAR). METHODS: We retrospectively reviewed contrast-enhanced computed tomography (CT) images of 143 patients who were followed for ≥6 months after EVAR. Sac expansion was defined as an increase in sac diameter of 5 mm relative to the preoperative diameter. Univariate and multivariate analyses were performed to identify associated risk factors for late sac expansion after EVAR from the following variables: age, gender, device, endoleak, antiplatelet therapy, internal iliac artery embolization, and preprocedural variables (aneurysm diameter, proximal neck diameter, proximal neck length, suprarenal neck angulation, and infrarenal neck angulation). RESULTS: Univariate analysis revealed female gender, endoleak, aneurysm diameter ≥60 mm, suprarenal neck angulation >45°, and infrarenal neck angulation >60° as factors associated with sac expansion. Multivariate analysis revealed endoleak, aneurysm diameter ≥60 mm, and infrarenal neck angulation >60° as independent predictors of sac expansion (P < 0.05, for all). CONCLUSION: Our results suggest that patients with small abdominal aortic aneurysms (<60 mm) and infrarenal neck angulation ≤60° are more favorable candidates for EVAR. Intraprocedural treatments, such as prophylactic embolization of aortic branches or intrasac embolization, may reduce the risk of sac expansion in patients with larger abdominal aortic aneurysms or greater infrarenal neck angulation.

Change in portal vein hemodynamics after chemoembolization for hepatocellular carcinoma: evaluation through multilevel dynamic multidetector computed tomography during arterial portography.

OBJECTIVE: This study aimed to clarify the effect of embolization with lipiodol on portal vein hemodynamics. METHODS: Time-density curves of the main portal vein on multilevel dynamic multidetector computed tomography during arterial portography were used to analyze peak computed tomography value (PV), time to PV (TPV), arrival time of contrast medium at the main portal vein (ATMPV), slope [(PV - 150) / (TPV - ATMPV)], and slope ratio (slope after embolization / slope before embolization). RESULTS: In 20 patients with hepatoma, ATMPV and TPV were significantly prolonged and the time-density curve slope was significantly less after embolization. The difference in TPV increased (P = 0.02) and the slope ratio decreased with increasing embolized volume rate (P < 0.001). Strong correlation (R = -0.86) was found between the slope ratio and the embolized volume rate. CONCLUSIONS: Time-density curves revealed significant portal vein flow delay after embolization; the degree of which was correlated with the extent of the embolized volume.

Utility of 99mTc-human serum albumin diethylenetriamine pentaacetic acid SPECT for evaluating endoleak after endovascular abdominal aortic aneurysm repair.

OBJECTIVE: The purpose of this study was to assess the utility of (99m)Tc-human serum albumin diethylenetriamine pentaacetic acid ((99m)Tc-HSAD) SPECT in the detection of endoleaks after endovascular abdominal aortic aneurysm repair. SUBJECTS AND METHODS: Fifteen patients (11 men, four women) with aneurysm sac expansion of 5 mm or greater after endovascular abdominal aortic aneurysm repair underwent three-phase CT, (99m)Tc-HSAD SPECT, and CT during aortography. Sensitivity calculations for three-phase CT and (99m)Tc-HSAD SPECT were performed with CT during aortography as the reference standard. The volume of each endoleak was measured with CT during aortography. Seven subjects underwent embolization with N-butyl cyanoacrylate (NBCA)-Lipiodol (ethiodized oil, Guerbet and metallic coils. Three-phase CT and (99m)Tc-HSAD SPECT were repeated after embolization to assess their efficacy. RESULTS: Endoleaks were interpreted as perigraft radioisotope accumulation in 12 patients (80.0%) on (99m)Tc-HSAD SPECT images, in 13 patients (86.7%) on three-phase CT images, and in 15 patients (100%) on CT during aortography. The mean endoleak volume visualized with (99m)Tc-HSAD SPECT was 8.37 cm(3) (range, 5.2-15.1 cm(3)), and the volume not visualized was 3.47 cm(3) (2.5-4.6 cm(3)), a statistically significant difference (p = 0.019). In two patients, (99m)Tc-HSAD SPECT depicted endoleaks evident at delayed phase CT during aortography but not at three-phase CT, suggesting they were slow-filling endoleaks. Accumulation of (99m)Tc-HSAD corresponding to endoleaks disappeared after embolization, but CT evaluation of embolization was impeded by artifacts of NBCA-Lipiodol and metallic coils. CONCLUSION: Technetium-99m-labeled HSAD SPECT proved less sensitive than three-phase CT but depicted endoleaks with volumes 5.2 cm(3) or greater as perigraft radioisotope accumulation. Slow-filling endoleaks can be visualized with (99m)Tc-HSAD SPECT, which can be used to evaluate the efficacy of embolization.

Radiation dose to rectum in high-dose-rate brachytherapy with a single implant and two fractions for prostate cancer, and its prediction by prostate volume.

We aimed to clarify the differences between the estimated rectal dose (ERD) and the first measured dose (FMD) and second measured dose (SMD) to the rectum during high-dose-rate (HDR) brachytherapy, and to predict FMD from the prostate volume (PV) or the rectal dose-volume parameters (RDVPs). ERD, FMD, and SMD were assessed with a rectal dosimeter during HDR brachytherapy of 18 Gy given in two fractions to 110 patients (48 hormone recipients, 62 hormone-naïve patients) with prostate cancer. The correlations between FMD and PV, and between FMD and RDVP (D 2ml-D 5ml) were investigated. ERD (mean ± SD) was 219 ± 44 cGy, FMD was 255 ± 52 cGy, and SMD was 298 ± 63 cGy, which differed significantly (p < 0.001). The correlation coefficients between ERD and FMD, and between FMD and SMD, were 0.82 and 0.78, respectively. SMD was equivalent to 118 ± 16 % FMD. The measured doses were significantly greater in the hormone recipients than in the hormone-naïve patients (p < 0.001). The increase in FMD correlated with the increases in PV and in RDVPs. The correlation coefficients between PV and FMD in all of the patients, in the hormone recipients, and in the hormone-naïve patients were 0.61, 0.64, and 0.64, respectively, whereas that between RDVPs and FMD was <0.53. In conclusion, the dose to the rectum increased with time and was correlated with the increases in PV and RDVPs. The correlation coefficient between FMD and PV was greater than that between FMD and RDVPs.

Incorporating GSA-SPECT into CT-based dose-volume histograms for advanced hepatocellular carcinoma radiotherapy.

In single photon emission computed tomography-based three-dimensional radiotherapy (SPECT-B-3DCRT), images of Tc-99m galactosyl human serum albumin (GSA), which bind to receptors on functional liver cells, are merged with the computed tomography simulation images. Functional liver is defined as the area of normal liver where GSA accumulation exceeds that of hepatocellular carcinoma (HCC). In cirrhotic patients with a gigantic, proton-beam-untreatable HCC of ≥ 14 cm in diameter, the use of SPECT-B-3DCRT in combination with transcatheter arterial chemoembolization achieved a 2-year local tumor control rate of 78.6% and a 2-year survival rate of 33.3%. SPECT-B-3DCRT was applied to HCC to preserve as much functional liver as possible. Sixty-four patients with HCC, including 30 with Child B liver cirrhosis, received SPECT-B-3DCRT and none experienced fatal radiation-induced liver disease (RILD). The Child-Pugh score deteriorated by 1 or 2 in > 20% of functional liver volume that was irradiated with ≥ 20 Gy. The deterioration in the Child-Pugh score decreased when the radiation plan was designed to irradiate ≤ 20% of the functional liver volume in patients given doses of ≥ 20 Gy (FLV20Gy). Therefore, FLV20Gy ≤ 20% may represent a safety index to prevent RILD during 3DCRT for HCC. To supplement FLV20Gy as a qualitative index, we propose a quantitative indicator, F 20Gy, which was calculated as F 20Gy = 100% × (the GSA count in the area irradiated with ≥ 20 Gy)/(the GSA count in the whole liver).

Acute appendicitis with intestinal malrotation: the usefulness of coronal computed tomography.

We herein present a rare case of acute appendicitis with intestinal malrotation. Coronal images of contrast-enhanced computed tomography (CT) revealed the small intestine on the right side and the large intestine on the left side, thus indicating intestinal malrotation (non-rotation type). In addition, an enhanced, tubular, fluid-filled structure was detected attached to the cecum, which was located superior to the urinary bladder, suggesting acute appendicitis. The present study shows that coronal CT images provide important information for the diagnosis and treatment of acute appendicitis in patients with intestinal malrotation.

Guidelines for the use of NBCA in vascular embolization devised by the Committee of Practice Guidelines of the Japanese Society of Interventional Radiology (CGJSIR), 2012 edition.

Cyanoacrylates are a group of fast-acting adhesives. They form low viscosity liquids in the monomer state and instantly polymerize to become adhesive upon contact with ionic substances. Since the 1950s, they have been used around the world for industrial and household purposes. N-butyl cyanoacrylate (NBCA) is a cyanoacrylate that is commonly used for medical care, and the closure of skin wounds with NBCA has been found to promote hemostasis. However, in Japan, the intravascular injection of NBCA is considered to be off-label use, except during the treatment of gastric varices under endoscopy. The use of NBCA in embolotherapy is considered when the target vessels cannot be cannulated superselectively, for vascular diseases that require long segments of the target vessel to be embolized, or for patients in a hypocoagulable state. NBCA-based embolotherapy can be used to treat vascular malformations, acute hemorrhaging, tumors, and venous disease. The complications associated with NBCA-based embolotherapy include tissue ischemia, hemorrhaging, systemic or local reactions, and catheter adhesion to blood vessels. NBCA is mixed with Lipiodol to make it radiopaque and to adjust its polymerization time. Since there are various technical aspects to performing NBCA-based embolotherapy safely, it should be carried out by, or with the assistance of, proficient interventional radiologists.

Creation of cisplatin-adsorbing regenerative-medicine gelatin sponge and its Cisplatin release pattern.

The purpose of this study was to clarify the adsorption of cisplatin on regenerative-medicine (RM) gelatin sponge, and to verify the relationship between the cisplatin release pattern of cisplatin-adsorbed RM gelatin sponge and the dissolving time of RM gelatin sponge. We tested various RM gelatin sponges, one with a molecular weight of 50000 Daltons (RM-50 gelatin sponge) that is 100% saline soluble at 24 h, RM-50-120 (heated at 120°C) that is 54.3% saline soluble at 24 h, and RM-50-140 (heated at 140°C) that is 15.8% saline soluble at 24 h. We investigated the production of cisplatin-adsorbed RM gelatin sponge and measured free cisplatin released from cisplatin-adsorbed RM gelatin sponge. There was no significant difference in the weight of adsorbed cisplatin among the RM-50, RM-50-120, and RM-50-140. The results mean that cisplatin adsorbs onto RM gelatin sponge irrespective of heating temperature. The average adsorbed weight of cisplatin per gram of RM gelatin sponge was 29.3 mg, which was approximately five times more than that per g previously reported for Gelpart (non-soluble gelatin sponge, clinically available). Cisplatin release in the RM-50 gelatin was the most rapid at only 1 h after incubation; it was released gradually and increasingly in the RM-50-120 gelatin, and released slowly in the RM-50-140 gelatin for 24 h incubation. Cisplatin-adsorbed RM gelatin sponge released cisplatin proportional to the dissolving time of RM gelatin sponge, indicating that the cisplatin release time can be controlled by heating for sterilization of RM gelatin sponge.

Inflammatory myofibroblastic tumor of the lung indistinguishable from adenocarcinoma on imaging studies.

We present the case of a right lung nodule discovered on routine chest x-ray in an asymptomatic 62-year-old man. CT revealed a spiculated nodule in segment 1 of the right upper lobe, 2.2 cm in diameter and without calcification. The nodule showed high focal FDG uptake (SUVmax, 17.8) on PET. Right upper lobectomy was performed under the diagnosis of adenocarcinoma; however, the histopathologic findings were of inflammatory myofibroblastic tumor.

Prostate-supplying arteriogram created by multidetector-row CT during pelvic arteriography: contribution to the treatment strategy of prostatic artery embolization for prostatic hyperplasia.

We describe an 85-year-old man suffering lower urinary tract symptoms, who underwent prostatic artery embolization (PAE) based on a prostate-supplying arteriogram created with multidetector-row computed tomography during pelvic arteriography. This arteriogram was synthesized from a background bone volume-rendered (VR) image, an aorta-pelvic artery VR image, and a prostate-supplying artery VR image. Because the bone background VR image is combined with the aorta-pelvic artery VR image, the prostate-supplying arteriogram can simultaneously show the pelvic branch arteries present on the ventral side, inside, and the dorsal side of the pelvic bone. It showed that the left prostatic artery supplied the urethra at the outlet of the urinary bladder. PAE of the left prostatic artery was performed with catheter navigation based on the prostate-supplying arteriogram. There was marked relief of the lower urinary tract symptoms at the 12-month follow-up.

Changes in inflammatory, coagulopathic, and fibrinolytic responses after endovascular repair of an abdominal aortic aneurysm: relationship between fibrinogen degradation product levels and endoleaks.

PURPOSE: To compare the inflammatory, coagulopathic, and fibrinolytic responses after endovascular aneurysm repair (EVAR) of an abdominal aortic aneurysm between two stent grafts. Fibrinogen degradation product (FDP) levels were compared between patients with or without an endoleak. MATERIALS AND METHODS: EVAR was performed in 88 patients using an Excluder (37 patients) or a Zenith (51 patients). White blood cell count (WBC), C-reactive protein (CRP) levels, platelet count, and FDP levels were measured before and after EVAR. RESULTS: WBC and CRP increased and the platelet count decreased significantly on days 1 and 3 after EVAR in the Zenith group compared with the Excluder group. The change in FDP from baseline to 7 days after EVAR was -1.99 ± 7.46 vs. 8.59 ± 9.38 µg/mL in patients with (n = 24) vs. without (n = 64) an endoleak (p < 0.001). A change in FDP of 3.1 µg/mL was the optimal cutoff point for predicting the presence of an endoleak (accuracy 0.762; sensitivity 0.875; specificity 0.717). CONCLUSION: Inflammatory, coagulopathic, and fibrinolytic responses were greater in the Zenith group than in the Excluder group. A change in FDP of ≤3.1 µg/mL was predictive of an endoleak after EVAR.