Prediction of common hepatic artery catheter insertion based on celiac trunk morphology

PURPOSE: This study aimed to predict the ability to insert a 4-5 French (Fr) catheter insertion with a guidewire into the common hepatic artery (CHA) based on celiac trunk morphology. METHODS: This retrospective study included 64 patients who underwent balloon-occluded transcatheter arterial chemoembolization (n = 56), transcatheter arterial chemotherapy (n = 2), or were fitted with an implantable port system (n = 6) between June 2019 and December 2019 in our institution. The morphology of the celiac trunk was classified into three types (upward, horizontal, and downward) based on celiac angiography. The aortic-celiac trunk angle was measured on sagittal images of preprocedural contrast-enhanced computed tomography (CT). We reviewed whether a 4-5-Fr shepherd's hook catheter could advance beyond the CHA using a 0.035-inch guidewire (Radifocus® Guidewire M; Terumo). Three patients were diagnosed with median arcuate ligament syndrome (MALS) based on the characteristic hook shape of the celiac artery on sagittal images of contrast-enhanced CT. The predictive ability of celiac angiography and preprocedural CT for CHA insertion success was evaluated. In unsuccessful cases, the balloon anchor technique (BAT) was attempted as follows: (1) a 2.7/2.8-Fr microballoon catheter (Attendant Delta; Terumo) was placed beyond the proper hepatic artery, and (2) the balloon was inflated as an anchor for parent catheter advancement. RESULTS: Upward, horizontal, and downward celiac trunk types were noted in 42, 9, and 13 patients, respectively. The median CT angle was 122.83° (first quartile-third quartile, 102.88°-136.55°). Insertion in the CHA using the guidewire was successful in 56 of 64 patients (87.50%), and the success rate in the downward type was significantly lower than that in the upward type [42/42 (100%) vs. 7/13 (53.85%), P < 0.001]. The CT angle was significantly larger downward in the unsuccessful group than in the successful group (121.03° vs. 140.70°, P = 0.043). Celiac angiography had a significantly higher area under the curve (AUC) than preprocedural CT (AUC = 0.91 vs. AUC = 0.72, P = 0.040). All three cases of MALS showed unsuccessful CHA insertion. In all eight patients with unsuccessful insertion, the catheter could be advanced using the BAT [8/8 (100%)]. CONCLUSION: Celiac angiography and preprocedural CT could predict CHA catheter insertion using a guidewire, and celiac angiography had high predictability. CT could detect MALS, a risk factor for unsuccessful CHA insertion.

Prophylactic Steroids for Preventing Postembolization Syndrome after Transcatheter Arterial Embolization of Renal Angiomyolipoma: A Comparative Study.

Purpose: Postembolization syndrome (PES) after renal arterial embolization (RAE) can reduce the patient's tolerance of the procedure and extend the length of hospital stay. We aimed to assess the efficacy of steroid administration in preventing PES in patients undergoing RAE for angiomyolipoma (AML). Material and Methods: Between May 2004 and March 2020, 29 RAE procedures in 26 patients with AML were performed. Patient information, including age, sex, tumor size, tuberous sclerosis complex-associated/sporadic AML, hemorrhagic/nonhemorrhagic AML, embolic material, steroid use, medication type, some blood laboratory parameters, hospital stay, and PES occurrence were retrospectively obtained. The prophylactic steroid protocol used in the study was as follows: 250 mg of intravenous methylprednisolone (Solu-Medrol) 2 h before the RAE procedure, followed by 2 days of intravenous prednisolone (Predonine; 2 mg/kg/day), which was tapered by halving the dose every 2 days within the course of 2 weeks. After the discharge, intravenous prednisolone was changed to oral prednisolone (Predonine). PES was defined as the presence of fever, pain, nausea, or vomiting. Data were compared between the steroid and non-steroid groups and between PES and non-PES groups. Results: The PES incidence rate was 76%, and a comparison between the steroid and non-steroid groups revealed that steroid use significantly decreased the incidence of PES (P < 0.001), including fever (P < 0.001), pain (P = 0.005), and nausea (P = 0.028). The use of anti-inflammatory drugs during the hospital stay was significantly lower in the steroid group (P = 0.019). Moreover, in the steroid group, C-reactive protein level was significantly lower (P = 0.006), whereas white blood cell count was significantly higher (P = 0.004). Conversely, the median length of hospital stay was not significantly shorter in the steroid group (P = 0.292). Conclusions: The prophylactic use of steroids before and after embolization of renal AML may be effective in preventing PES in this small retrospective study.

Celiac Artery Dissection and Retroperitoneal Hemorrhage in Median Arcuate Ligament Syndrome Treated With a Stent and Transcatheter Arterial Embolization: Preprocedural 4-Dimensional Computed Tomography Angiography Assessment.

A 61-year-old man presented with retroperitoneal hemorrhage caused by an aneurysm rupture of the pancreaticoduodenal arcade (PDA), and acute celiac artery dissection distal to celiac axis stenosis. Owing to the gradual growth of the false lumen, we planned to deploy a stent to the celiac artery dissection and embolize the PDA aneurysm. Prior to stent placement, we assessed the acute celiac artery dissection distal to the stenosis using four-dimensional computed tomography (CT) angiography through expiration/inspiration/expiration cycle. We diagnosed median arcuate ligament syndrome considering that the celiac axis showed a hooked narrowing at end-expiration, and the compression decreased at end-inspiration. Additionally, the true lumen distal to the stretched axis dilated in the inspiration phase. Therefore, we could advance a catheter into the true lumen during inspiration and successfully deploy a stent. Subsequently, laparoscopic median arcuate ligament release was performed after the stent deployment. A postoperative CT scan showed good patency in the stent, with disappearance of the blood filling the false lumen and with reduced celiac axis stenosis.

Late Nonanastomotic Pseudoaneurysm From the Prosthetic Graft: A Successful Transcatheter Arterial Embolization Using Coils.

A 71-year-old man who received a total arch replacement with a knitted Dacron® graft presented aneurysmal sac re-expansion due to leakage at the distal anastomotic site of the graft. He did not tolerate the stress of general anesthesia due to severe pulmonary function impairment. Therefore, thoracic endovascular aortic repair (TEVAR) in zone 3 was performed under epidural anesthesia. Contrast-enhanced computed tomography (CT) revealed another leakage into the aneurysmal sac in zone 1 after performing TEVAR. Because open surgical repair and debranching TEVAR were contraindicated, transcatheter arterial embolization was performed with careful consideration of his comorbidities. Follow-up contrast-enhanced CT performed 2 weeks after embolization indicated no opacification of the aneurysmal sac, and noncontrast-enhanced CT a year after embolization showed no dilatation of the aneurysmal sac.

Bowstring Phenomenon in Renal Artery Aneurysm Exclusion Using a Viabahn Stent Graft.

A 77-year-old man presented with an incidental finding of right renal artery aneurysm without symptoms. Computed tomography revealed a 22 mm saccular aneurysm with a wide neck at the main renal artery trunk. An 8 × 100 mm Viabahn stent graft (W. L. Gore, Flagstaff, AZ) was deployed by fully pulling back the guiding sheath. However, the deployment knob was not able to be pulled. We returned the guiding sheath to the original position and confirmed the cause was the bowstring phenomenon. Because avoidance of this phenomenon required straightening of the tortuous vessel, the stent graft was deployed by short pull-back of the guiding sheath. Computed tomography after a year revealed no opacification of the aneurysm and the patency of the stent graft.