A Case of a Giant Hemangioma of a Primary Cardiac Tumor.

We report a case of a 71-year-old female with a primary cardiac tumor. The patient had undergone surgery for uterine cancer 10 years ago and presented to a nearby clinic complaining of dyspnea on exertion. Chest X-ray revealed cardiac enlargement, prompting further investigations, which revealed a massive tumor protruding into the left atrium and extending toward the outer wall of the left ventricle. The patient was referred to a cardiac surgery department for myocardial biopsy. The tumor biopsy confirmed a diagnosis of a vascular tumor. Due to the tumor's large size and the difficulty in achieving complete resection, a conservative approach was chosen as the patient expressed a preference for non-surgical treatment. This is an extremely rare case of a large primary cardiac tumor, and we report it accordingly.

Initial Outcomes of Physician-Modified Inner Branched Endovascular Repair in High-Surgical-Risk Patients.

PURPOSE: To report the initial outcomes of physician-modified inner branched endovascular repair (PMiBEVAR) for pararenal aneurysms (PRAs), thoracoabdominal aortic aneurysms (TAAAs), and aortic arch aneurysms in high-surgical-risk patients. MATERIALS AND METHODS: A total of 10 patients (6 men; median age, 83.0 years) treated using PMiBEVAR were enrolled in this retrospective, single-center study. All patients were at high surgical risk because of severe comorbidities (American Society of Anesthesiologists physical status score≥3 or emergency repair). End points were defined as technical success per patient and per vessel (successful deployment), clinical success (no endoleaks postoperatively), in-hospital death, and major adverse events. RESULTS: There were 3 PRAs, 4 TAAAs, and 3 aortic arch aneurysms with 12 renal-mesenteric arteries and 3 left subclavian arteries incorporated by inner branches. The technical success rate was 90.0% (9/10) per patient and 93.3% (14/15) per vessel. The clinical success rate was 90% (9/10). There were 2 in-hospital deaths, unrelated to aneurysms. Paraplegia and shower emboli occurred separately in 2 patients. Three patients experienced prolonged ventilation for 3 days after surgery. Aneurysm sac shrinkage occurred in 4 patients, and aneurysm size stabilized in 1 patient during follow-up, more than 6 months later. None of the patients required intervention. CONCLUSION: PMiBEVAR is a feasible approach for treating complex aneurysms in high-surgical-risk patients. This technology may complement the existing technology in terms of improved anatomical adaptability, no time delay and practicability in many countries. However, long-term durability remains undetermined. Further large-scale and long-term studies are needed. CLINICAL IMPACT: This is the first clinical study to investigate outcomes of physician-modified inner branched endovascular repair (PMiBEVAR). PMiBEVAR for treating pararenal aneurysm, thoracoabdominal aortic aneurysm, or aortic arch aneurysm is a feasible procedure. This technology is likely to complement existing technology in terms of improved anatomical adaptability (compared to off-the-shelf devices), no time delay (compared to custom-made devices), and the potential to be performed in many countries. On the other hand, surgery time varied greatly depending on the case, suggesting a learning curve and the need for technological innovation to perform more consistent surgeries.

A suicide attempt by intramuscular injection of pentobarbital sodium into rectus abdominis suggested by computed tomography.

Suicide attempts in humans due to injections of the veterinary drug pentobarbital sodium have been rarely reported. Herein, we present a case of a suicide attempt by intramuscular injection of pentobarbital sodium into the rectus abdominis muscle, which was suggested by computed tomography (CT). A 73-year-old man was brought to the emergency department with GCS 3 (E1V1M1) and an incised wound on the right side of the neck. A bottle of Somnopentyl® (pentobarbital sodium, 64.8 mg/ml), a 20-ml empty syringe with an 18-mm needle, and no. 10 scalpel were present at the scene. At the emergency department, the patient was intubated and was admitted to the intensive care unit. A urine drug screen test by SIGNIFY® ER was positive for benzodiazepines and barbiturates, and continuous veno-venous hemofiltration (CHF) was initiated. The route of drug administration was initially unknown; however, a CT scan revealed swelling of the left rectus abdominis muscle with a wound suggestive of a needle puncture, and the CT analysis suggested 38.16 ml as the maximum dose of pentobarbital sodium. On day 3, the patient's consciousness improved, and he was weaned off CHF and mechanical ventilation. There have been several reports of postmortem CT yielding information on the site of administration of intoxicants, but there have been none for surviving intoxicated patients. This is the first report of the usefulness of CT to identify the site of administration of the causative agent of intoxication while the patient is still alive.

Pulmonary vessels and bronchus anatomy of the left upper lobe.

PURPOSES: The bronchopulmonary vascular bifurcation patterns in the upper lobe of the left lung are diverse. Therefore, it is important for general thoracic surgeons to understand the detailed anatomy of the pulmonary segments when performing thoracoscopic anatomical pulmonary resection. This study aimed to analyze the bronchovascular patterns of the left upper lobe and summarize the anatomical information associated with pulmonary anatomical pulmonary resection. METHODS: We reviewed the anatomical patterns of pulmonary vessels and the left lung bronchus of 539 patients using computed tomography imaging data including those obtained using three-dimensional computed tomography. We herein report the anatomic structure in the left upper lobe. RESULTS: Regarding the superior division bronchi, a pattern of trifurcation into B1+2, B3, lingular division bronchus was observed in nine patients (1.7%). A pattern of proximal bifurcation of B4 was found in eight patients (1.5%). Regarding the lingular veins (LV), patterns of LV drainage into the left lower pulmonary vein were observed in 22 patients (4.1%). Regarding the pulmonary artery, mediastinal lingular arteries (MLA) were found in 161 patients (29.9%). CONCLUSION: The bifurcation patterns of the bronchovascular region in the upper lobe of the left lung were clarified. These results should be carefully noted when performing anatomical pulmonary resection.

Anatomy of the left subsuperior segment for segmentectomy.

PURPOSE: The subsuperior segmental bronchi (B*) forms the subsuperior segment (S*) between the superior (S6) and basal segment (S7, S8, S9, S10) of the lung. However, the anatomical planes of S* remains undefined. The present study clarified the anatomical features of S*. METHODS: We reviewed the anatomical patterns of pulmonary vessels and the left lung bronchus in 539 patients using three-dimensional computed tomography. We report the anatomic structure in S*. RESULTS: A total of 537 patients were analyzed. B* was observed in 129 (24.0%) patients. The intersegmental vein between S6 and S* was complete in all cases. The absence of intersegmental veins of S* was observed in 77 (14.3%) patients, reaching 59.7% of B* cases. Twenty-two (4.1%) cases of B* diverged from the trunk of the basal bronchus, and about half of the B* branched to the dorsolateral (n = 77, 14.3%) or dorsal (n = 2, 0.37%) direction. CONCLUSION: Our study revealed the branching patterns of B* and anatomical intersegmental veins of S*. Our results provide useful information regarding anatomical segmentectomy including or adjusting to the left S*.

Atrial flutter after surgeries of congenitally corrected transposition of great arteries in total visceral inversion.

A 51-year-old man, who had a history of open heart surgery for corrected transposition of great arteries, presented with palpitation due to atrial tachycardia. A propagation map using three-dimensional electroanatomical mapping (CARTO3) showed atrial flutter and underwent linear ablation successfully. This case highlights the difficulty of diagnosis before mapping following a complicated cardiac operation and the usefulness of three-dimensional mapping.

CT reconstruction with thick slices not only underestimates lymph node size but also reduces data reproducibility in colorectal cancer.

BACKGROUND: Reliable size measurement of lymph node (LN) metastases is important for the evaluation of cancer treatment. However, image analyses without proper settings may result in inappropriate diagnoses and staging. PURPOSE: To investigate whether reconstruction slice thickness in computed tomography (CT) affects measurements of LN size and reproducibility. MATERIAL AND METHODS: We analyzed 48 patients with histological diagnoses of sigmoid colon and rectal cancer who underwent contrast-enhanced CT colonography as part of a surgical treatment preparation. A board-certified radiologist selected 106 LNs whose short-axis diameter was ≥5 mm on 1-mm-thick images; the short-axis diameters were measured on 1- and 5-mm-thick images by the radiologist and residents and compared using Wilcoxon matched-pairs signed rank test. Data variation and reproducibility were evaluated using the F test and Bland-Altman analysis. P<0.05 was considered significant. RESULTS: Short-axis diameters measured on 5-mm-thick images were significantly lower than those measured on 1-mm-thick images (P<0.01), even in the LNs whose short-axis diameters were over twice the slice thickness (P<0.05). Of the 106 LNs, 57 showed short-axis diameter <5 mm on 5-mm-thick images; the maximum short-axis diameter was 6.7 mm on a 1-mm thick image. Data variation was significantly larger on 5-mm thick images than 1-mm-thick images in small LNs (P<0.05) and reproducibility on 5-mm-thick images was inferior to that on 1-mm-thick images. CONCLUSION: Thick reconstruction slices in CT can result in an underestimation of LN size and reduce data reproducibility. When measuring LN size, a thin reconstruction slice would be recommended based on targeted LN size.

Pulmonary vessels and bronchial anatomy of the left lower lobe.

PURPOSE: To identify and clarify the comprehensive anatomic patterns in the left lower lobe (LLL). METHODS: Using computed tomography (CT) imaging data, including that obtained using three-dimensional CT, we reviewed the anatomic patterns of the pulmonary vessels and bronchi in the left lungs of 539 patients, focusing on the LLL. RESULTS: The two-stem type in A6 was observed in 131 (24.7%) patients and the three-stem type in A6 was observed in 11 (2.1%) patients. The independent two-stem type in B6 was observed in four (0.75%) patients. The B7 with independent branching from the basal bronchi was observed in 42 (7.9%) patients. B* was observed in 129 (24.0%) patients and B* was accompanied by A* in all patients. An extrapericardial common trunk of the left pulmonary veins was identified in five patients (0.93%). CONCLUSION: We identified various bronchovascular patterns in the LLL of a large number of patients. Our results provide useful information for anatomic pulmonary resection, especially segmentectomy.

Total thoracoscopic lung segmentectomy of anterior basal segment of the right lower lobe (RS8) for NSCLC stage IA (case report).

A 69-year-old woman with a pulmonary nodule in anterior basal segment of the right lower lobe (RS8) was referred to our department. The diameter of the tumor was 12 mm, and it had increased over a few months. First, video-assisted thoracoscopic lung surgery (VATS) biopsy of the pulmonary nodule was carried out. Frozen section examination of this nodule confirmed the diagnosis of bronchioloalveolar carcinoma (BAC). Segmentectomy of RS8 with lower mediastinal node dissection (ND2a-1) was performed. The intersegmental plane was identified using the intersegmental veins as landmarks and the demarcation between the resected (inflated) and preserved (collapsed) lungs. Electrocautery at 70 watts was used to divide the intersegmental plane. A vessel sealing system was used to seal and cut the pulmonary arteries. Postoperative histopathological examination revealed that the tumor was T1aN0M0 BAC, and the minimal distance between the surgical margin and the tumor edge was 15 mm. The patient was discharged from hospital on postoperative day 5 without any complications.

[Evaluation of three-dimensional enhanced brain surface imaging using CT (3D surface CT angiography) and magnetic resonance imaging (3D surface MR angiography)].

The optimal imaging conditions for 3D brain surface imaging by magnetic resonance imaging (MRI) and multi-slice CT were investigated. Visualization of the sulci, gyri, and veins on the brain's surface was also compared between 3D surface images acquired using multi-slice CT and conventional single-slice CT and MRI. Various imaging parameters, including slice thickness, dose, and matrix size, were evaluated using our original brain surface phantom and longitudinal direction evaluation phantom as well as images obtained from healthy volunteers. Subjects of the clinical study were patients with arteriovenous malformations and brain tumors who underwent CT-angiography at the same time as MR-angiography. The quality of 3D images of the brain surface is most strongly influenced by partial volume effects related to slice thickness. In multi-slice CT, a slice thickness of 0.5 mm can be employed to minimize the partial volume effect, providing results that are far superior to those that can be achieved by conventional single-slice 3D-CT. In addition, the excellent S/N of multi-slice CT permits the veins on the brain's surface to be clearly visualized without the use of contrast medium. With regard to visualization of the sulci and gyri, although some problems remain to be overcome, multi-slice CT was found to be equivalent to 3D surface imaging using MRI.