New Diagnostic Criteria for the Localization of Insulinomas with the Selective Arterial Calcium Injection Test: Decision Tree Analysis.

PURPOSE: To explore optimal diagnostic criteria for localizing insulinomas with the selective arterial calcium injection (SACI) test using decision tree analysis. MATERIALS AND METHODS: A retrospective study included 86 vessels of 18 patients (5 men, 13 women; mean age 67 y; range, 49-73 y) with insulinomas who underwent SACI test between June 2007 and May 2016. Of 27 insulinomas, 7 were found in the head, 13 in the body, and 7 in the tail of the pancreas. Two patients had multiple tumors. To identify optimal diagnostic criteria, decision tree analysis was performed, and sensitivity, specificity, and accuracy of the conventional and the proposed new diagnostic criteria (plasma insulin concentration after calcium injection [ICpost] > 2.0 × plasma insulin concentration before calcium injection [ICpre]) were compared. RESULTS: The proposed new diagnostic criteria for insulinoma obtained by decision tree analysis were (i) ICpost > 2.7 × ICpre and maximum insulin concentration > 60.3 µIU/mL or (ii) ICpost > 2.7 × ICpre and maximum insulin concentration < 60.3 µIU/mL with ICpre being ≥ 7.5 µIU/mL. Sensitivity, specificity, and accuracy of the new criteria for the SACI test were 100%, 91.4%, and 94.2; sensitivity, specificity, and accuracy of conventional criteria were 100%, 69.0%, and 79.1%. CONCLUSIONS: New diagnostic criteria for localization of insulinomas with the SACI test yielded higher diagnostic performance than conventional criteria.

Portosystemic Encephalopathy without Liver Disease Masquerading as Dementia.

An 84-year-old woman was hospitalized due to consciousness disorder as hyperammonemia. She had no etiology of liver disease. Twelve months before the current admission, she had been diagnosed with dementia based on her low level of daily perception and physical activity. Abdominal computed tomography revealed a large portosystemic shunt between the medial branch of the portal vein and middle hepatic vein. After the improvement of her consciousness disturbance by medical treatment, percutaneous shunt embolization was electively performed. The patient showed a remarkable clinical improvement. Consciousness disturbance caused by hyper-ammonemia might be underlying in dementia patients. Increase of hepatopetal portal blood flow might have contributed to the improvement of her consciousness disturbance. Embolization of the portosystemic shunt might be more effective for patients without liver disease as in the present case.

Preoperative Coil Embolization in Patients With a Replaced Hepatic Artery Scheduled for Pancreatectomy With Splanchnic Artery Resection Helps to Prevent Ischemic Organ Injury.

OBJECTIVE: The aim of this study was to evaluate the prevention of liver ischemic injury by preoperative coil embolization in patients with a replaced hepatic artery scheduled for pancreatectomy with splanchnic artery resection. METHODS: Between July 2009 and May 2012, 4 patients with replaced hepatic artery underwent pancreatectomy plus splanchnic artery resection. The replaced right hepatic artery was preoperatively embolized in 2 patients. In the other 2 patients, the common hepatic artery was embolized preoperatively. We evaluated the complications encountered in the perioperative period. RESULTS: There were no embolization-related complications. Although 2 patients presented with small liver infarcts, the aspartate aminotransferase and alanine aminotransferase levels did not exceed 1000 IU/L in any of the patients, and none experienced severe liver injury. CONCLUSIONS: Coil embolization before pancreatectomy with splanchnic artery resection in patients with a replaced hepatic artery may help to prevent severe ischemic liver injury in the perioperative period.

Embolization therapy for bleeding from jejunal loop varices due to extrahepatic portal vein obstruction.

Four patients underwent embolization therapy for hemorrhage from varices in the jejunal loop after choledochojejunostomy existing in hepatopetal collateral veins due to chronic extrahepatic portal vein obstruction through the afferent veins using microcoils and/or n-butyl cyanoacrylate. In all four patients, all afferent veins were successfully embolized and successful hemostasis was achieved without liver dysfunction. However, recurrence of the varices and rebleeding occurred within a year in two patients. Embolization for hemorrhage from varices in the jejunal loop after choledochojejunostomy through afferent veins is acceptable in terms of safety and is useful to achieve hemostasis in emergency circumstances.

Stereotactic body radiotherapy for patients with small hepatocellular carcinoma ineligible for resection or ablation therapies.

AIM: To evaluate the efficacy and safety of stereotactic body radiotherapy (SBRT) in patients with small hepatocellular carcinoma (HCC) who were ineligible for resection or ablation therapies. METHODS: Overall, 65 patients with 74 HCC (median tumor size, 16 mm) were enrolled. They were treated at the prescribed dose of 48 Gy in four fractions at the isocenter. Child-Turcotte-Pugh (CTP) scoring was used to classify 56 and nine patients into classes A and B, respectively. Local progression was defined as irradiated tumor growth on a dynamic computed tomography follow up. The median follow-up period was 26 months. Tumor responses were assessed according to the modified Response Evaluation Criteria in Solid Tumors. Treatment-related toxicities were evaluated according to the Common Terminology Criteria for Adverse Events version 4.0. RESULTS: The 2-year overall survival, progression-free survival and local control rates were 76.0% (95% confidence interval [CI], 65.4-86.7%), 40.0% (95% CI, 27.6-52.3%) and 100% (95% CI, 100%), respectively. At 6-12 months after SBRT, grade 3 or higher toxicities was observed in 15 (23.1%) patients. The incidence of grade 3 or higher toxicities was higher in CTP class B than in class A (P = 0.0127). CONCLUSION: SBRT was effective and relatively safe for patients with small HCC who were ineligible for resection or ablation therapies.

Hepatic arterial infusion chemotherapy with fine-powder cisplatin and iodized-oil suspension in patients with intermediate-stage and advanced-stage (Barcelona Clinic Liver Cancer stage-B or stage-C) hepatocellular carcinoma: multicenter phase-II clinical study.

PURPOSE: This single-arm, multicenter, phase-II trial evaluated the efficacy and safety of hepatic arterial infusion chemotherapy (HAIC) using fine-powder cisplatin and iodized-oil suspension in patients with intermediate- and advanced-stage [Barcelona Clinic Liver Cancer (BCLC) stage-B and stage-C] hepatocellular carcinomas (HCCs). METHODS: The Institutional Review Board approved this study and patients provided written informed consent. Thirty-five patients (24 men and 11 women, mean 74 ± 6 years [range 60-87 years]) with BCLC stage-B (57 %, 20/35) or stage-C (43 %, 15/35) HCCs who were not candidates for other locoregional treatments were enrolled. HAIC was performed using a suspension of fine-powder cisplatin with a maximum dose of 65 mg/m(2) and iodized oil on demand. The primary endpoint was the response rate evaluated based on Response Evaluation Criteria in Solid Tumor (RECIST) and modified RECIST (mRECIST). Secondary endpoints were overall survival, progression-free survival, and safety. RESULTS: The initial and best overall response rates at 4 weeks and 3 months, respectively, were 14 and 17 % based on RECIST, and 57 and 23 % based on mRECIST. The median overall and progression-free survival times were 18 and 4 months, respectively. The most frequent grade-3 or grade-4 adverse events were elevation of serum alanine (23 %) and aspartate aminotransferase (20 %), and thrombocytopenia (17 %). CONCLUSION: This HAIC provides promising therapeutic effects with acceptable safety to patients with intermediate-stage and advanced-stage HCCs.

Effectiveness of combined use of imprint cytological and histological examination in CT-guided tissue-core biopsy.

OBJECTIVES: This study evaluated the efficacy of the combination of imprint cytology and histology in tissue-core percutaneous biopsy under real-time computed tomography (CT) fluoroscopic guidance. METHODS: Between October 2009 and June 2013, 156 percutaneous needle biopsies were performed in our institution. Those obtained by tissue-core biopsy underwent both imprint cytological and histological examinations routinely after touch imprint cytology was performed on site to evaluate the samples' sufficiency for cytological and pathological examination. Final diagnosis was confirmed by independent surgical pathology, independent culture results or clinical follow-up. RESULTS: Rates of adequate specimens and precise diagnosis, by combined cytological and histological examination were 100 % (156/156) and 96.2 % (150/156), by cytology 94.4 % (152/156) and 83.3 % (130/156) and by histology 99.3 % (155/156) and 92.3 % (144/156). Precise diagnosis was achieved by combined examinations in 94.7 % (89/94) of thoracic lesions, 97.6 % (40/41) of musculoskeletal lesions, and 100 % (21/21) of abdominal, pelvic and retroperitoneal lesions. In all 104 lesions diagnosed as malignant by CT-guided biopsy and in 30 of 52 diagnosed as benign, specific cell types could be proved by combined examinations. CONCLUSIONS: Combined imprint cytology and histology performed after on-site touch imprint cytological evaluation improved the diagnostic ability of CT fluoroscopically guided biopsy. KEY POINTS: • CT-guided needle biopsy is a well-established diagnostic technique. • Touch imprint cytological evaluation on site is helpful in improving quality of CT-guided biopsy. • The rate of diagnosing malignant lymphoma specifically with cytological examination is relatively low. • The rate of specific diagnosis of benign lesion in musculoskeletal regions is low.

Transarterial therapy of hepatocellular carcinoma fed by the right renal capsular artery.

PURPOSE: To evaluate the characteristics of hepatocellular carcinomas (HCCs) fed by the right renal capsular artery and to assess the tumor response and complications in patients treated with transarterial therapy via the renal capsular arteries with or without other extrahepatic arteries and/or intrahepatic arteries. MATERIALS AND METHODS: Between March 2006 and May 2012, 24 lesions in 19 patients were treated by transcatheter arterial chemoembolization (23 sessions), transcatheter arterial embolization (two sessions), or transcatheter arterial infusion (one session), with HCCs fed by the right renal capsular artery with or without intrahepatic arteries and/or other collateral arteries. Other intrahepatic lesions were concurrently treated if needed. RESULTS: Tumor size ranged from 10 mm to 107 mm (mean, 30.5 mm). Of the 24 tumors, 12 were located in segment VI, 10 in segment VII, one in the posterior segment, and one in the anterior segment after posterior segment resection. Severe complication occurred in four patients: liver abscess (n = 2), pleural effusion (n = 1), and duodenal ulcer (n = 1). Pleural effusion might be related to chemoembolization via the right renal capsular artery. A complete response was obtained in six sessions and a partial response in eight; 10 sessions were associated with stable disease and two with progressive disease. CONCLUSIONS: Precise renal capsular artery knowledge would facilitate successful and safe transarterial therapy for HCCs fed by the renal capsular arteries.

Percutaneous transvenous embolization for portosystemic shunts associated with encephalopathy: Long-term outcomes in 14 patients.

AIM: To evaluate the clinical outcomes of percutaneous transvenous embolization (PTE) for portosystemic shunt (PSS) associated with encephalopathy METHODS: Fourteen patients with portosystemic encephalopathy (PSE) were enrolled in this retrospective cohort study. We evaluated technical success, clinical success, complication and outcomes. RESULTS: In cases in which PSS was one of main causes of PSE, three also had splenorenal shunts, four gastrorenal shunts, four superior mesenteric vein systemic shunts, one inferior mesenteric vein systemic shunt and two main trunk of portal vein inferior vena cava shunts. We used only ethanolamine oleate (EO) in five; EO and coils in five; EO, coils and n-butyl 2-cyanoacrylate (NBCA) in two; and coils and NBCA in two patients as embolic materials. The rate of primary and secondary technical success was 93% (13/14 patients) and 100%, respectively. No major complications were encountered related to PTE. Follow-up period was a median of 27 months (range, 12-79). All patients had sustained disappearance of PSE. PSE recurred in one patient because of another PSS development. Thus, clinical success was achieved in 93% (13/14 patients). The ammonia levels 1 year after PTE were significantly improved compared with pre-PTE (median, 102 vs 41 µmol/L) and maintained lower levels 2 and 3 years later. Child-Pugh scores did not change significantly. Esophageal varices were aggravated in 29% (4/14 patients). Five patients died, but no death of hepatic failure related to PTE was encountered. CONCLUSION: PTE could be one of the useful treatment options for PSE.

Long-term outcome of patients with gastric varices treated by balloon-occluded retrograde transvenous obliteration.

BACKGROUND AND AIM: To assess the short- and long-term outcome of patients with gastric varices (GV) after balloon-occluded retrograde transvenous obliteration (B-RTO) by comparing bleeding cases with prophylactic cases. METHODS: Consecutive 100 patients with GV treated by B-RTO were enrolled in this retrospective cohort study. We compared the technical success, complications, and survival rates between bleeding and prophylactic cases. RESULTS: Of 100 patients, 61 patients were bleeding cases and 39 patients were prophylactic cases. Technical success was achieved in 95% of bleeding case and in 100% of prophylactic case, with no significant difference between these groups (overall technical success rate, 97%). The survival rates at 5 and 10 years were 50% and 22% in bleeding case, and 49% and 36% in prophylactic case, respectively. There was also no significant difference (P = 0.420). By multivariate analysis, survival rates correlated significantly with liver function (hazard ratio 2.371, 95% CI 1.457-3.860, P = 0.001) and hepatocellular carcinoma development (HR 4.782, 95% CI 2.331-9.810, P < 0.001). The aggravating rates of esophageal varices (EV) were 21%, 50%, and 54% at 12, 60, and 120 months after B-RTO. By multivariate analysis, aggravating rates significantly correlated with EV existing before B-RTO (HR 18.114, 95% CI 2.463-133.219, P = 0.004). CONCLUSION: B-RTO for GV could provide the high rate of complete obliteration and favorable long-term prognosis even in bleeding cases as well as prophylactic cases. Management of EV after B-RTO, especially in coexisting case of GV and EV, would be warranted.

Venous sac embolization of pulmonary arteriovenous malformation: safety and effectiveness at mid-term follow-up.

BACKGROUND: The standard technique for the transcatheter treatment of pulmonary arteriovenous malformations (PAVMs) involves deploying coils into the feeding arteries. We investigated whether venous sac embolization would also be a safe and useful treatment method. PURPOSE: To evaluate the safety and outcomes of venous sac embolization for PAVMs. MATERIAL AND METHODS: This study included 15 consecutive patients (1 man, 14 women; mean age, 54 years; range, 22-76 years) with 50 PAVMs who underwent 26 procedures; four had a history of earlier cerebral infarction or exertional dyspnea. We first placed 0.018-inch interlocking detachable and/or 0.018-inch or 0.010-inch Guglielmi detachable coils to prevent systemic migration from the venous sac. We then packed the sac as tightly as possible and embolized the orifice at the proximal feeding artery. We used angiographic, clinical, and computed tomography (CT) studies to evaluate the treatment outcomes and safety of these procedures. The mean follow-up was 16 months (range, 3-63 months) in 12 patients with 43 PAVMs; three patients (7 PAVMs) were lost to follow-up. RESULTS: Immediate post-embolization angiography confirmed complete primary occlusion in 47 of 50 lesions (94%). Minor complications arose in two of 26 procedures (7.7%); they were abnormal electrocardiograms without symptoms during and pleurisy immediately after the procedure. During follow-up, 40 PAVMs were free of CT evidence of reperfusion. The mean partial arterial oxygen pressure increased from 75.3% ± 13.6 before embolization to 85.4% ± 16.3 after embolization (P < 0.01, t-test). Of the 12 patients who were available for follow-up, none experienced new-onset paradoxical embolization; pre-treatment exertional dyspnea was alleviated in one patient. There were no major complications. CONCLUSION: Venous sac embolization for PAVMs might be safe and more effective with no reperfusion than the standard pulmonary arterial embolization.

Transcatheter arterial chemoembolization with an interventional-CT system for recurrent hepatocellular carcinoma after living donor liver transplantation.

BACKGROUND/AIMS: The aim of this retrospective study was to evaluate the feasibility and treatment effects of transcatheter arterial chemoembolization (TACE) for recurrent intrahepatic hepatocellular carcinoma (HCC) after liver transplantation. METHODOLOGY: Between March 2007 and December 2012, we treated 8 patients (6 men and 2 women; mean age, 54 years) with recurrent HCC after living donor liver transplantation by TACE using an interventional-CT system. We retrospectively investigated treatment outcomes, complications, and the prognosis in these patients. RESULTS: Overall, 17 sessions of TACE were performed. A single TACE session was performed in 4 patients while multiple TACE sessions were performed in 4 patients. Anticancer drugs and embolic agents were selectively infused from the right hepatic artery (n=7), left hepatic artery (n=1), A3 (n=1), A5 (n=1), A6 (n=1), A7 (n=2), anterior branch (n=1), posterior branch (n=3), intercostal artery (n=1), and right inferior phrenic artery (n=5). There were no procedure-related complications. Response rate was 50%. The median overall survival from the initial TACE for recurrence of HCC was 12.9 months (95% confidence interval, 5 to 21). The 1-year survival rate was 42.9%. CONCLUSION: TACE with an interventional-CT system could play an important role in the treatment of recurrent HCC after liver transplantation.

Pilot study of stereotactic body radiation therapy combined with transcatheter arterial chemoembolization for small hepatocellular carcinoma.

BACKGROUND/AIMS: We retrospectively evaluated the local tumor control and safety of transcatheter arterial chemoembolization (TACE) followed by stereotactic body radiation therapy (SBRT) for small hepatocellular carcinoma (HCC) in this pilot study. METHODOLOGY: Twenty-eight patients not for the indication of hepatectomy or ablation procedures were enrolled in this study. Eligible criteria was as followed: i) less than 3 hypervascular HCC nodules, each up to 30 mm in diameter; ii) not suitable for the hepatic resection or ablative therapy; iii) Child-Turcotte-Pugh (CTP) score < or = 7. SBRT was performed within 1-2 months after TACE. Treatment efficacy was evaluated, according to the Response Evaluation Criteria in Cancer of the Liver (RECICL). RESULTS: The median local tumor control time was not reached. The 1-year cumulative local tumor control rate was 96.3%. The median disease-free survival time was 18 months. The 1- year cumulative overall survival rate was 92.6%. One patient (3.6%) died due to intrahepatic ectopic multiple recurrence and systemic metastasis and one (3.6%) due to cerebral hemorrhage. No patients experienced severe acute hematologic or physical toxicity or radiation induced liver damage. CONCLUSIONS: Our study demonstrated SBRT combined with TACE is a safe and effective modality of the locoregional therapy for small primary HCC.

Detectability of hepatocellular carcinoma by gadoxetate disodium-enhanced hepatic MRI: tumor-by-tumor analysis in explant livers.

PURPOSE: To investigate the detectability of hepatocellular carcinoma (HCC) on Gd-EOB-enhanced MR images (Gd-EOB-MRI), we performed tumor-by-tumor analysis of pathologically confirmed tumors using explants from cirrhotic patients who had undergone liver transplantation. MATERIALS AND METHODS: We studied 11 explanted livers and classified the tumor intensity during the arterial phase (AP) and the hepatobiliary phase (HBP) as low in HBP with early enhancement (EE) in AP (A), as high in HBP with EE in AP (B), as low in HBP without EE in AP (C), as high in HBP without EE in AP (D), and as iso-intense in HBP with EE in AP (E). The diagnostic criteria for HCC were (i) pattern A and C, (ii) pattern A and E, (iii) pattern C and E, and (iv) patterns A, C, and E. RESULTS: Of the 71 HCCs, 22 were not detected at MRI; of these, 9 were moderately differentiated and 13 were well-differentiated HCCs. The sensitivity of Gd-EOB-MRI for diagnostic criteria 1, 2, 3, and 4 was 63.4%, 52.1%, 22.5%, and 69.0%. CONCLUSION: The maximum sensitivity of Gd-EOB-MRI for HCC was only 69.0% even when diagnostic criteria that included all previously reported HCC patterns were adopted.

Clinical outcome of sorafenib treatment in patients with advanced hepatocellular carcinoma refractory to hepatic arterial infusion chemotherapy.

BACKGROUND AND AIM: It has been reported about poor prognosis in patients with advanced hepatocellular carcinoma (HCC) refractory to hepatic arterial infusion chemotherapy (HAIC). We assessed the survival benefits of sorafenib therapy for advanced HCC in HAIC refractory patients. METHODS: The study subjects were 191 patients with advanced HCC who had been treated with HAIC. Sorafenib was used in 27 patients who finally failed to respond to HAIC (HAIC/sorafenib group). Clinical outcome was compared between HAIC/sorafenib and HAIC alone groups. RESULTS: There were no significant differences in clinical characteristics and response rate of HAIC between the two groups (response rate: 25.9%, HAIC/sorafenib group; 30.4%, HAIC alone group). The median survival time (MST) for all patients was 11.0 months. The survival rate was significantly higher in the HAIC/sorafenib group than HAIC alone group (MST 22.2 vs 8.7 months, P = 0.017). From administration sorafenib, the disease control rate was 51.8% with MST of 10.4 months. Among HAIC non-responders, the survival rate was significantly higher in the HAIC/sorafenib group than HAIC alone group. Multivariate analysis identified additional therapy with sorafenib as significant and independent determinant of overall survival in all patients and HAIC non-responders. CONCLUSION: Additional therapy with sorafenib could probably improve the prognosis of HAIC refractory patients.

Stereotactic body radiation therapy combined with transcatheter arterial chemoembolization for small hepatocellular carcinoma.

BACKGROUND AND AIMS: To compare the tumor control and safety of stereotactic body radiation therapy (SBRT) combined with transcatheter arterial chemoembolization (TACE) for small, solitary, and hypervascular hepatocellular carcinoma (HCC) with TACE alone. METHODS: Three hundred and sixty-five HCC patients who had solitary, ≤ 3 cm, and hypervascular nodule were treated with TACE. Among them, 30 patients followed by SBRT (SBRT group) and 38 patients without additional therapy and previous HCC treatment (control group) were enrolled in this retrospective cohort study. Local tumor progression, complication, and disease-free survival were compared between these groups. RESULTS: There was no difference in clinical background between these groups. Complete response to therapy was noted in 29 (96.3%) patients of the SBRT group, and in only one (3.3%) patient of the TACE group (P < 0.001). None of the patients developed acute hematologic toxicity of more than Common Terminology Criteria for Adverse Events Grade 3 during and after the treatment. Furthermore, none of the SBRT group developed radiation-induced liver damage. Disease-free survival of the 12 patients without previous HCC treatments in SBRT group was significantly superior to that in control group (15.7 months vs 4.2 months; P = 0.029). CONCLUSION: The results indicated that SBRT combined with TACE is a safe and effective modality for locoregional treatment of small solitary primary HCC, and could be potentially a suitable option.

Controlling the bleeding of jejunal varices formed at the site of choledochojejunostomy: report of 2 cases and a review of the literature.

INTRODUCTION: Hemorrhage from jejunal varices formed at the site of Roux-en-Y choledochojejunostomy is rather rare, and no guidelines have so far been established for its treatment. This report presents the cases of 2 patients with jejunal varices formed at the site of choledochojejunostomy that were treated using different methods. An obstruction of the extrahepatic portal vein resulted in massive gastrointestinal bleeding in both cases CASE 1: A 59-year-old male developed jejunal varices at the site of choledochojejunostomy. Multidetector computed tomography showed that the source of bleeding was located in the small intestine near portojejunal varices. The jejunal vein supplying the afferent loop was embolized using interventional radiology. There was no evidence of liver dysfunction or rebleeding after the embolization CASE 2: A 79-year-old female developed jejunal varices at the site of choledochojejunostomy. Abdominal angiography could not detect the source of bleeding, and hence, a mesocaval shunt operation was performed.

Hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma according to Child-Pugh classification.

BACKGROUND AND AIM: We compared the treatment response, survival, and safety to hepatic arterial infusion chemotherapy (HAIC) in patients with advanced hepatocellular carcinoma (HCC) according to Child-Pugh (CP) score. METHODS: The study subjects were 249 patients with advanced HCC and CP class A and B who had been treated with HAIC. Patients were grouped according to CP score (5/6, 7 and 8/9) and their tumor response, tolerance, and survival were assessed. RESULTS: The median survival time (MST) was 8.2, 9.7, 6.3, and 3.9 months for the whole group, patients with CP 5/6, 7 and 8/9, respectively (P < 0.0001). Complete response (CR) and partial response (PR) were seen in 11 and 57 patients, respectively, with an overall response rate of 27.3%. The response rate was higher in patients with CP score 5/6 and 7, than CP 8/9 (30.5%, 28.2%, 13.8%). The dropout rate was significantly higher in patients with CP score 8/9 than the other two (8.0%, 12.8%, 33.3%, respectively). The survival rate was significantly better in patients who achieved CR/PR than the others with CP score 5/6, 7. CP score 8/9 was an independent negative factor for response and survival. CONCLUSION: Advanced HCC patients with CP score of 5/6 and 7 showed a better response to HAIC and better prognosis than those with CP score 8/9.

Long-term outcomes of hepatic arterial port implantation using a coaxial microcatheter system in 176 patients with hepatocellular carcinoma.

The purpose of this study is to evaluate the feasibility of hepatic arterial port implantation using a 2.9-Fr coaxial microcatheter for hepatic arterial infusion chemotherapy (HAIC) in patients with unresectable hepatocellular carcinoma (HCC) in the long-term follow-up period. Our study subjects were 176 patients with unresectable HCC who underwent hepatic arterial port implantation using a 2.9-Fr coaxial microcatheter via the femoral approach. A 2.9-Fr microcatheter with a side hole was introduced into the hepatic artery through a 5-Fr catheter. We determined the possible length of HAIC, starting with hepatic arterial port implantation and ending with the manifestation of technical difficulties or patient death. We also recorded the technical success rate, the time required for the procedure, and the complications encountered. The median duration of HAIC was 4.3 months (range 0.4-51.6 months) and the predictable cumulative rate of hepatic arterial port functioning at 6-, 12-, and 24 months was 75.1%, 60.9%, and 44.6%, respectively. Our technical success rate was 99.4% (175/176), and the mean time required for the procedure was 121 min. Complications were migration of the infusion hole (8.6%, 15/175), hepatic artery damage (5.7%, 10/175), port-catheter system occlusion (5.7%, 10/175), and problems involving the port or the puncture site (8.0%, 14/175). Our study demonstrates that the technical success rate of hepatic arterial port implantation using a coaxial microcatheter was high but that the incidence of port-catheter system occlusion and catheter dislocation was higher than in conventional methods. Our technique is another option to treat patients with HCC for whom conventional techniques cannot be used.

Recanalization after successful occlusion by transcatheter arterial embolization with N-butyl cyanoacrylate for traumatic splenic artery injury.

A 70-year-old male with advanced pancreatic cancer went into shock after sustaining a traumatic abdominal injury. Computed tomography (CT) showed a hematoma with extravasation around the pancreas and hemorrhagic ascites. After direct catheterization failed due to angiospasm, the ruptured splenic artery was successfully occluded by transcatheter arterial embolization (TAE) using an N-butyl cyanoacrylate (NBCA)-lipiodol mixture and the patient recovered from shock without complications. A follow-up CT obtained 20 days later showed a recurrent splenic artery pseudoaneurysm without extravasation. A repeat angiogram demonstrated recanalization of the splenic artery and pseudoaneurysm via antegrade. We embolized the recanalized pseudoaneurysm using metallic coils for isolation. Our experience indicates that adequate concentration and volume of the NBCA-lipiodol mixture should be considered depending on the vascular spasm in a patient with hypovolemic shock.