Multidisciplinary approach to hand arteriovenous malformations: treatment strategies and clinical outcomes - insights from a 25-year experience at a single vascular anomalies center.

OBJECTIVE: Hand arteriovenous malformations (AVMs) are extremely difficult to manage for their functional importance and cosmetic disfiguration. A single-center retrospective study was conducted to identify long-term outcomes of multidisciplinary team management of hand AVMs. METHODS: Institutional review board approved this retrospective study. Multidisciplinary vascular anomalies center data was reviewed from 1995 to 2023. Patient demographics, Schobinger's AVM stage, sclerotherapy details, surgical history, and adverse events after sclerotherapy were reviewed. RESULTS: A total of 150 patients with hand AVMs visited our hospital from 1995 to 2023, with a mean age of 33 years (range, 1-75 years), and 91 were females. Forty-four patients were Schobinger stage II, and 106 were stage III. Sclerotherapy was performed on 101 patients (67%) with 320 sessions. Angiographic devascularization rates after sclerotherapy were: 16 with 100%, 30 with over 90%, 34 with 50% to 90%, 15 with 0% to 50%, and six showed aggravation. Sclerotherapy-related adverse events occurred in 123 of 320 sessions (39%), with 112 minor and 11 major events. Fifteen patients (15%) eventually underwent amputation surgery a mean of 1618 days after sclerotherapy for necrosis (n = 3) and delayed complications (n = 12). Thirteen patients (9%) underwent primary surgical amputation for ulcers or bleeding (all Schobinger stage III). Thirty-six patients (24%) were followed without any procedure. CONCLUSIONS: Multidisciplinary management of hand AVMs shows varied long-term outcomes. Although sclerotherapy is effective for many patients, it carries a significant risk of adverse events. The necessity for amputation in some cases highlights the severity of advanced AVMs and the need for individualized treatment approaches.

Arteriovenous Malformation Associated with Intravenous Leiomyomatosis of the Uterus: Characteristic CT Findings and Treatment by Embolization and Surgery.

Seven consecutive female patients with pathologically confirmed arteriovenous malformation (AVM) with intravenous leiomyomatosis (IVL) of the uterus (age range, 32-61 years; mean age, 43 years) treated between 2005 and 2021 from a single institution were reviewed. Computed tomography (CT) findings of congenital pelvic AVM of 10 female patients were compared with those of AVM with IVL. Characteristic CT findings of AVM with IVL revealed a focal soft tissue mass inside a dilated venous structure of the AVM. Multiple sessions of transvenous coil embolization of the AVM with or without the injection of ethanol were performed. After complete (6/7, 86%) or partial (1/7, 14%) embolization of the AVM, complete surgical resection of the IVL and embolized AVM mass was performed in 4 patients. Patients with lung metastasis or residual embolized AVM masses are under follow-up with antiestrogen hormonal therapy.

Risk factors for stent occlusion after catheter-directed thrombolysis and iliac vein stenting in the treatment of May-Thurner syndrome with iliofemoral deep vein thrombosis: a retrospective cohort study.

Background: This study aimed to identify the risk factors for stent occlusion in patients with iliofemoral deep vein thrombosis (DVT) secondary to May-Thurner syndrome (MTS) who underwent catheter-directed thrombolysis (CDT) and iliac vein stenting. Methods: A retrospective analysis was performed on 44 patients who underwent CDT and iliac vein stenting for MTS with iliofemoral DVT between October 2001 and March 2018. MTS was diagnosed based on extrinsic compression of the left common iliac vein (CIV) by the overlying right common iliac artery (CIA) on computed tomography (CT). Clinical records of the study population were reviewed to collect baseline data, procedural characteristics, and outcomes. Final venograms showing diffuse and irregular wall thickening in the iliofemoral vein were considered to indicate a chronic post-thrombotic lesion. The stent position was categorized as follows: confluence coverage without touching the contralateral inferior vena cava (IVC) wall, IVC extension contacting the contralateral IVC wall, or distal to the iliocaval junction. Stent patency was assessed using duplex ultrasonography. Risk factors for stent occlusion were assessed using univariate and multivariate Cox proportional hazard models. Results: The median duplex ultrasound follow-up period was 25 months (range, 1-196 months). The overall cumulative patency rate at 12 months was 70.0%. In the univariate Cox regression, factors significantly associated with stent occlusion included symptom duration >2 weeks before CDT, partial thrombolysis (50-99% of thrombus removal), chronic post-thrombotic lesions, and stent position. Multivariate Cox regression showed that chronic post-thrombotic lesions [hazard ratio (HR) =7.15; 95% confidence interval (CI): 1.32-38.81; P=0.023] and a stent distal to the iliocaval junction (HR =5.59; 95% CI: 1.46-21.38; P=0.012) were significantly associated with stent occlusion. Conclusions: Chronic post-thrombotic lesion and a stent distal to the iliocaval junction were important risk factors for stent occlusion in patients who underwent CDT and iliac vein stenting.

Guidewire-catheter induced hydrodissection to assist radiofrequency ablation for subcapsular hepatocellular carcinoma with iodized oil retention in patients with failed artificial ascites due to perihepatic adhesion.

PURPOSE: We aimed to evaluate the usefulness of guidewire-catheter induced hydrodissection (GIH) to assist radiofrequency ablation (RFA) for subcapsular hepatocellular carcinoma (HCC) with iodized oil retention in patients with failed artificial ascites due to perihepatic adhesion. METHODS: This retrospective study included 17 patients with small subcapsular HCC ineligible for ultrasonography-guided RFA who received RFA under guidance of fluoroscopy and cone-beam computed tomography immediately after iodized oil transarterial chemoembolization (TACE) between April 2011 and January 2016. In the study patients, creation of artificial ascites to protect the perihepatic structures failed due to perihepatic adhesion and GIH was attempted to separate the perihepatic structures from the ablation zone. The technical success rate of GIH, technique efficacy of RFA with GIH, local tumor progression (LTP), peritoneal seeding, and complications were evaluated. RESULTS: The technical success rate of GIH was 88.24% (15 of 17 patients). Technique efficacy was achieved in all 15 patients receiving RFA with GIH. During an average follow-up period of 48.1 months, LTP developed in three patients. Cumulative LTP rates at 1, 2, 3, and 5 years were 13.3%, 20.6%, 20.6%, and 20.6%, respectively. No patient had peritoneal seeding. Two of the 15 patients receiving RFA with GIH had a CIRSE grade 3 liver abscess, but none had complications associated with thermal injury to the diaphragm or abdominal wall near the ablation zone. CONCLUSION: GIH can be a useful method to assist RFA for subcapsular HCC with iodized oil retention in patients with failed artificial ascites due to perihepatic adhesion.

Combined transarterial chemoembolization and radiofrequency ablation for subphrenic versus nonsubphrenic hepatocellular carcinoma: a propensity score matched study.

PURPOSE: To compare therapeutic outcomes of combined transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) treatment for small hepatocellular carcinoma (HCC) in subphrenic versus nonsubphrenic locations by propensity score matching. METHODS: This retrospective study included 293 patients with single HCC (≤ 3 cm) ineligible for ultrasound-guided RFA who received iodized oil TACE and subsequent RFA between June 2010 and January 2017. The patients were divided into two groups according to the tumor location: subphrenic (n = 99) and nonsubphrenic (n = 194). Subphrenic HCC was defined as a tumor abutting the diaphragm. Local tumor progression (LTP) and overall survival (OS) rates were compared by propensity score matching. Procedure-related complications were also assessed. RESULTS: Matching yielded 93 matched pairs of patients. In the matched cohorts, cumulative 1-, 3-, and 5-year LTP rates were 5.4%, 12.1%, and 12.1% in the subphrenic group and 1.1%, 7.5%, and 8.6% in the nonsubphrenic group, respectively, with no significant differences (p = 0.278). Corresponding OS rates were 100%, 80.2%, and 71.3% in the subphrenic group and 97.9%, 88.1%, and 75.6% in the nonsubphrenic group, respectively, with no significant differences (p = 0.308). The subphrenic location was not a significant risk factor for LTP and OS in multivariate analysis. There were no significant differences in complication rates between the two groups (p > 0.05). CONCLUSION: The therapeutic outcomes of combined TACE and RFA for small subphrenic HCC were similar to those for nonsubphrenic HCC. The combination therapy seems to be an effective and safe method in treating small subphrenic HCC.

Mortality after Use of Paclitaxel-Coated Balloons Correlates with Total Cumulative Dosage of Paclitaxel in Real-World Analysis.

This study used independent, real-world, patient-level data to examine whether the dosage or frequency of paclitaxel exposure correlated with mortality during follow up. We conducted a retrospective analysis of patients treated with a drug-coated balloon (DCB) for an atherosclerotic femoropopliteal lesion from February 2013 to December 2018, excluding patients with non-atherosclerotic lesions or restenosis after DCB treatment in another hospital. We investigated the causes of death, comorbidities (including cancer status), and the initial and total cumulative dosages and frequency of paclitaxel use. To determine whether the dosage or frequency of paclitaxel exposure affected mortality during follow up, we analyzed the risk factors for all-cause death by conducting a time-dependent Cox regression analysis that considered demographics, comorbidities, lesion and procedural characteristics, and paclitaxel exposure data (dosage and frequency). Our analysis examined 225 patients (mean age 71 ± 9 years, range 38-93 years, male 81%). During a mean follow-up duration of 35 months (range 1-89 months), 56 patients (24.9%) died from cardiac disorders (16%, including acute myocardial infarction, heart failure, or sudden cardiac arrest), malignancy (14.3%), respiratory failure with pneumonia (12.5%), septic shock (12.5%), or another cause. Univariable and multivariable Cox regression analyses identified age (hazard ratio, HR, 1.057; 95% confidence interval, CI, 1019-1096; p = 0.0032), critical limb ischemia (CLI) (HR, 4135; 95% CI, 2171-7876; p < 0.0001), and the total dosage of paclitaxel (mg) (HR, 1.040; 95% CI, 1006-1074; p = 0.0210) as predictors of mortality during follow up. The subgroup analysis found that the total dosage of paclitaxel (mg) was also a predictor of mortality during follow up in the CLI group (HR, 1.046; 95% CI, 1007-1087, p = 0.0198). The estimated cut-off value of total cumulative paclitaxel dosage for predicting mortality was 12 mg as evaluated by minimum p value approach. This patient-level analysis identified the total cumulative dosage of paclitaxel as a predictor of mortality after the use of paclitaxel-coated balloons. Our results provide limited information about the potential dose-response relationship underlying paclitaxel-associated mortality concerns.

Radiologic and clinical results of transarterial ethanol embolization for renal angiomyolipoma.

OBJECTIVE: We sought to determine the efficacy and safety of selective arterial embolization for renal angiomyolipoma (AML) using ethanol alone or ethanol with additional embolic materials and to analyze the factors influencing safety and efficacy. METHODS: One hundred nineteen AMLs treated with embolization were included retrospectively during a 15-year period. Technical, radiologic, and clinical success were recorded and risk factor analysis was performed. Complications on follow-up images, post-embolization syndrome (PES), major complications, and changes in renal function were also evaluated. RESULTS: Technical success was achieved in 106 of 119 tumors. Tumor size significantly decreased after treatment (reduction rate: 55%). Significant risk factors for tumor reduction included tumor enhancement on preprocedural CT and residual tumor staining. Radiologic success was achieved in 114 of 119 tumors (risk factor: residual tumor staining), and clinical success was achieved in 22 of 23 patients. Complications on follow-up images occurred in 40 of 119 tumors, and PES occurred in 53 of 104 patients. No major complications occurred. There were no cases of renal function impairment. CONCLUSION: Selective transarterial embolization using ethanol alone or ethanol with additional embolic materials reduced AML size, alleviated symptoms, and can be performed safely without permanent impairment. KEY POINTS: • Percutaneous transarterial ethanol embolization reduces AML size and alleviates symptoms. • Embolization can be performed safely without permanent impairment of renal function.

How to Treat Peripheral Arteriovenous Malformations.

Arteriovenous malformations (AVMs) are direct communications between primitive reticular networks of dysplastic vessels that have failed to mature into capillary vessels. Based on angiographic findings, peripheral AVMs can be classified into six types: type I, type IIa, type IIb, type IIc, type IIIa, and type IIIb. Treatment strategies vary with the types. Type I is treated by embolizing the fistula between the artery and the vein with coils. Type II (IIa, IIb, and IIc) AVM is treated as follows: first, reduce the blood flow velocity in the venous segment of the AVM with coils; second, perform ethanol embolotherapy of the residual shunts. Type IIIa is treated by transarterial catheterization of the feeding arteries and injection of diluted ethanol. Type IIIb is treated by transarterial or direct puncture approaches. A high concentration of ethanol is injected through the transarterial catheter or direct puncture needle. When the fistula is large, coil insertion is required to reduce the amount of ethanol. Type I and type II AVMs showed the best clinical results; type IIIb showed a satisfactory response rate. However, type IIIa showed the poorest response rate, either alone or in combination with other types. Clinical success can be achieved by using different treatment strategies for different angiographic AVM types.

CT findings after left renal vein division during abdominal aortic surgery.

BACKGROUND: The rationale behind left renal vein division (LRVD) is the assumption that adequate collateral draining channels will develop. PURPOSE: To describe computed tomography (CT) findings after LRVD during aortic surgery. MATERIAL AND METHODS: Among 61 consecutive patients who underwent LRVD during aneurysm repair or revascularization for aortic occlusive disease between January 2003 and December 2017, 51 patients (40 men, mean age 71.4 ± 8.4 years) were enrolled. Contrast-enhanced CT images were analyzed to evaluate collateral drainage, patency, left renal vein diameter, and left renal parenchymal thickness. A total of 115 radiologic reports were reviewed to check whether these findings were accurately mentioned. RESULTS: The median time period of the first postoperative follow-up CT was 36 days (range 7-1351 days). The gonadal vein (n = 47) was the most common collateral draining channel, followed by the retroperitoneal veins (n = 42) and adrenal vein (n = 33). Thrombosis occurred in five patients between postoperative days 7 and 17 in the remnant renal vein (n = 3), remnant renal vein plus gonadal and adrenal veins (n = 1), and gonadal vein (n = 1). There was a significant decrease in renal vein diameter (-0.48 ± 2.12 mm, P = 0.006). There was no significant difference in parenchymal thickness (-0.25 ± 1.27 mm, P = 0.193). Neither LRVD nor any associated findings were correctly stated on radiologic reports. CONCLUSION: Postoperative contrast-enhanced CT can delineate collateral draining channels and complications following LRVD. However, these findings tend to be either missed or misinterpreted.

Therapeutic outcomes of embolotherapy of extremity bone intraosseous arteriovenous malformation with ethanol, coils, and n-butyl cyanoacrylate.

OBJECTIVE: We evaluated the therapeutic outcomes of embolotherapy for bone arteriovenous malformations (AVMs) affecting the extremities using ethanol, coils, and n-butyl cyanoacrylate (NBCA). METHODS: We reviewed the data from 36 patients (18 males, 18 females; mean age 25 years; age range, 1-64 years) with bone AVMs affecting their extremities who had undergone embolotherapy using ethanol, coils, and NBCA from December 1996 to July 2019. Of the 36 patients, 19 had had pure bone AVMs and 17 mixed bone and soft tissue (MBS) AVMs. Embolotherapy was performed using direct puncture or a transvenous or an intra-arterial approach (range, 1-18 procedures; mean, 5 procedures). During the 178 embolotherapy procedures, ethanol was used in all 36 patients, except for 1. Coils were used in 14 patients, and NBCA and a lipiodol mixture in 9 patients. The therapeutic outcomes were evaluated by the clinical symptom response and the degree of devascularization on follow-up angiography or computed tomography. The major and minor complications were also evaluated. RESULTS: The clinical success (cure or markedly improvement) rate of embolotherapy for pure bone AVMs was significantly better than that for the MBS AVMs (88% vs 18%; P < .001). The complete devascularization rate of the bone AVM component of the MBS AVMs was 71%; however, the cure rate of the MBS AVMs was 0% owing to the remaining soft tissue AVMs. Of the 36 patients, 12 experienced complications, including 11 minor (2 skin bullae formation and 10 transient peripheral nerve injury) and 1 major (longstanding nerve palsy). CONCLUSIONS: Embolotherapy for bone AVMs affecting the extremities using ethanol, coils, and an NBCA mixture is effective and safe for the resolution or improvement of symptoms, especially in those with pure bone AVMs.

Multiple hepatic aneurysms and dry gangrene of fingertips in eosinophilic granulomatosis with polyangiitis: a case report.

BACKGROUND: Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic necrotizing vasculitis mainly affecting small-sized arteries. Involvement of medium-sized vessels is very rare in EGPA. Here we present the case of a patient with EGPA who showed multiple hepatic aneurysms and distal gangrene. CASE PRESENTATION: A known EGPA patient visited to the emergency room (ER) with abrupt squeezing abdominal pain. She had suffered from gangrene in the fingertips of both hands for 1 year because of arterial thrombosis associated with hypereosinophilia. However, her absolute eosinophil count in the ER was 1120 cells/µL. An abdomen-pelvis CT demonstrated subcapsular hematoma in the right hepatic lobe. A celiac angiogram demonstrated multiple sized aneurysms in both hepatic lobes and some aneurysms in S7 and S8 were huge, more than 1 cm in size. The shape of the small aneurysms resembled a string of beads, as in polyarteritis nodosa. Given the clinical situation, emergency embolization was performed. Before this patient visited to the ER, she had been treated with a high dose of systemic corticosteroid, azathioprine, and cyclophosphamide. After addition of mepolizumab, the eosinophil count remained stable state with a near zero percentage of total white blood cell count. CONCLUSIONS: Aneurysm and gangrene resulting from the involvement of medium-sized vessels can occur in EGPA. Destruction of vessels might occur even if eosinophil count is below 1500 cells/µL. If involvement of medium-sized arteries is suspected, thorough investigation to identify the involved organs and prompt management are needed to prevent fatal complications.

Selective Versus Non-selective Transarterial Chemoembolization via the Intercostal Artery for the Treatment of Hepatocellular Carcinoma.

PURPOSE: To report the 1-month tumor response and safety of selective transarterial chemoembolization (TACE) via the intercostal artery (ICA) for the treatment of hepatocellular carcinoma (HCC) in comparison with those of non-selective TACE. METHODS: This retrospective study included 79 HCC patients who underwent TACE via the ICA selectively (selective TACE group; n = 26) or non-selectively (non-selective TACE group; n = 53) between January 2001 and December 2016. Selective TACE was defined when TACE was performed with selective catheterization of the tumor feeding branch of the ICA. TACE performed without selective catheterization of the tumor feeding branch was defined as non-selective TACE. One-month target and overall tumor responses and complications of the two groups were compared. Univariate and multivariate analyses were performed to identify prognostic factors. RESULTS: Selective TACE group showed better 1-month target and overall tumor responses and lower frequency of complications than non-selective TACE group (P = .007, P = .018, and P < .001, respectively). Performing selective TACE was the only significant favorable factor for better target and overall tumor responses (P = .001 and P = .028, respectively). In univariate analysis for complications, serum α-fetoprotein > 200 ng/mL and non-selective TACE were statistically significant. However, multivariate analysis showed that performing non-selective TACE was the only significant risk factor (odds ratio 13.56; 95% confidence interval 3.51-52.5; P < .001). CONCLUSION: Compared to non-selective TACE via the ICA, selective TACE via the ICA for the treatment of HCC can achieve better tumor response and safety.

Endovascular treatment results and risk factors for complications of body and extremity arteriovenous malformations.

OBJECTIVE: The objective of this study was to investigate the factors associated with the complication rate and treatment outcomes of arteriovenous malformations (AVMs) during a 20-year period. METHODS: This was a retrospective study of 306 patients (135 men, 171 women; mean age, 30.8 years) with body and extremity AVMs who were treated between 1996 and 2017. A total of 913 sessions of endovascular treatment were performed. Patients were divided into two decades of the study period to compare complications and clinical results. Group 1 comprised 107 patients treated in the first decade of the study period, and group 2 comprised 199 patients treated in the last decade. AVMs were classified according to the angiographic findings. Complication rates, number of treatment sessions, and treatment results were compared between the two groups. RESULTS: Minor complication (group 1, 20.1%; group 2, 18.5%) and major complication (group 1, 3.1%; group 2, 4.1%) rates were similar between groups (P = .79). The mean number of treatment sessions in group 1 and group 2 was 4.2 and 2.3, respectively, indicating a 45% reduction in treatment sessions (P < .0001). The treatment failure rate decreased from 9.3% in group 1 to 1.5% in group 2 (P = .04). The clinical success rate was 54.2% in group 1 and 64.3% in group 2 (P = .10). CONCLUSIONS: With an accumulation of AVM treatment experience, the number of treatment sessions and the rate of treatment failures were significantly reduced.

Combined transarterial chemoembolization of the right inferior phrenic artery and radiofrequency ablation for small hepatocellular carcinoma near the diaphragm: its efficacy and safety.

PURPOSE: The purpose of the study is to report the efficacy and safety of combined transarterial chemoembolization (TACE) of the right inferior phrenic artery (IPA) and radiofrequency ablation (RFA) for small hepatocellular carcinoma (HCC) near the diaphragm supplied by the right IPA. METHODS: From July 2009 through April 2015, 11 patients with small (≤ 3 cm) HCC near the diaphragm, which was infeasible for ultrasound-guided RFA and supplied by the right IPA, received TACE of the right IPA and subsequent RFA in one session. The safety and therapeutic efficacy, including technique effectiveness and local tumor progression (LTP), were evaluated. RESULTS: Technique effectiveness was achieved in all the 11 patients (100%). During average follow-up period of 39.2 months (range 13-89 months), LTP occurred in none of the 11 patients. There were twelve minor complications in eight patients, including right shoulder pain (n = 4), right pleural effusion (n = 2), diaphragmatic thickening (n = 2), transient lung change (n = 2), subsegmental intrahepatic bile duct stricture (n = 1), and subsegmental hepatic infarction (n = 1). No major complications were encountered CONCLUSION: Combined TACE of the right IPA and RFA can be a safe and effective treatment for small HCC near the diaphragm that is supplied by the right IPA.

Combined transarterial chemoembolization and radiofrequency ablation for small treatment-naïve hepatocellular carcinoma infeasible for ultrasound-guided radiofrequency ablation: long-term outcomes.

Background Ultrasound (US)-guided radiofrequency ablation (RFA) for small hepatocellular carcinoma (HCC) is often infeasible due to unfavorable location and poor conspicuity. Those small HCCs can be treated with combined transarterial chemoembolization (TACE) and RFA. Purpose To evaluate long-term outcomes of combined TACE and RFA for small treatment-naïve HCC infeasible for US-guided RFA. Material and Methods Between February 2009 and January 2014, 69 patients with small (≤3 cm) HCC infeasible for US-guided RFA received TACE and subsequent RFA in one session as a first-line treatment. Local tumor progression (LTP), overall survival (OS), and event-free survival rates were evaluated. Univariate and multivariate analyses were conducted to identify prognostic factors. Results Cumulative rates of LTP were 4.4%, 6.8%, 8.2%, 9.5%, and 9.5% at one, two, three, five, and seven years, respectively. Cumulative one-, two-, three-, five-, and seven-year OS rates were 100%, 95%, 89%, 80%, and 80%, respectively. Cumulative one-, two-, three-, five-, and seven-year event-free survival rates were 81%, 63%, 54%, 31%, and 20%, respectively. No significant prognostic factors for LTP, OS, and event-free survival were identified in univariate analysis. Conclusion Combined TACE and RFA appears to be an effective treatment for small treatment-naïve HCC infeasible for US-guided RFA in terms of LTP and OS.

Portal Vein Stenting for Delayed Jejunal Varix Bleeding Associated with Portal Venous Occlusion after Hepatobiliary and Pancreatic Surgery.

OBJECTIVE: The study aimed to describe portal stenting for postoperative portal occlusion with delayed (≥ 3 months) variceal bleeding in the afferent jejunal loop. MATERIALS AND METHODS: Eleven consecutive patients (age range, 2-79 years; eight men and three women) who underwent portal stenting between April 2009 and December 2015 were included in the study. Preoperative medical history and the postoperative clinical course were reviewed. Characteristics of portal occlusion and details of procedures were also investigated. Technical success, treatment efficacy (defined as disappearance of jejunal varix on follow-up CT), and clinical success were analyzed. Primary stent patency rate was plotted using the Kaplan-Meier method. RESULTS: All patients underwent hepatobiliary-pancreatic cancer surgery except two children with liver transplantation for biliary atresia. Portal occlusion was caused by benign postoperative change (n = 6) and local tumor recurrence (n = 5). Variceal bleeding occurred at 27 months (4 to 72 months) and portal stenting was performed at 37 months (4 to 121 months), on average, postoperatively. Technical success, treatment efficacy, and clinical success rates were 90.9, 100, and 81.8%, respectively. The primary patency rate of portal stent was 88.9% during the mean follow-up period of 9 months. Neither procedure-related complication nor mortality occurred. CONCLUSION: Interventional portal stenting is an effective treatment for delayed jejunal variceal bleeding due to portal occlusion after hepatobiliary-pancreatic surgery.

Long Term Outcomes of Femorofemoral Crossover Bypass Grafts.

PURPOSE: Femorofemoral crossover bypass (FCB) is a good procedure for patients with unilateral iliac artery disease. There are many articles about the results of FCB, but most of them were limited to 5 years follow-up. The purpose of our study was to analysis the results of FCB with a 10-year follow-up period. MATERIALS AND METHODS: Between January 1995 and December 2010, 133 patients were operated in Samsung Medical Center (median follow-up: 58.8 months). We retrospectively analysed patient characteristics, the preoperative treatment, the operative procedure, and material used. RESULTS: The indications for FCB were claudication in 110 and critical limb ischemia in 23 patients. Three patients were died due to myocardiac infarction, intracranial hemorrhage, and acute respiratory failure within 30 days after surgery. The one-year primary and secondary patency rates were 89% and 97%, the 5-year primary and secondary patency rates were 70% and 85%, and the 10-year primary and secondary patency rates were 31% and 67%. The 5-year and 10-year limb salvage rates were 97% and 95%, respectively. CONCLUSION: Our long term analysis suggests that FCB might be a valuable alternative treatment modality in patients with unilateral iliac artery disease.

Renal artery stenosis presenting with nephrotic-range proteinuria: a case report.

Renal artery stenosis (RAS) is commonly presented with hypertension and chronic kidney disease. We report a rare case of RAS occurring in a 78-year-old man who presented with nephrotic-range proteinuria. Renal biopsy on the left side was performed, and results showed mesangiopathic glomerulonephritis, which was not compatible with the cause of nephrotic-range proteinuria. Proteinuria was decreased by angiotensin receptor blocker, but azotemia was aggravated. Therefore, angiotensin receptor blocker was discontinued inevitably and thorough evaluation for the possibility of RAS was performed. Computed tomography angiography revealed significant RAS on the left side and a renal artery stent was inserted. After stenting, aortic dissection developed and progressed despite tight control of blood pressure. After inserting another stent graft through the true lumen of the left renal artery, the patient's renal function and proteinuria improved markedly.

Early Results of Clinical Application of Autologous Whole Bone Marrow Stem Cell Transplantation for Critical Limb Ischemia with Buerger's Disease.

Our goal was to evaluate early results of the clinical application of autologous whole bone marrow stem cell transplantation (AWBMSCT) for critical limb ischemia (CLI) in patients with Buerger's disease. We retrospectively analyzed the data of 58 limbs of 37 patients (mean age, 43.0 years; range, 28-63 years; male, 91.9%) with Buerger's disease with CLI who were treated with AWBMSCT from March 2013 to December 2014. We analyzed Rutherford category, pain score, pain-free walking time (PFWT), total walking time (TWT), ankle brachial pressure index (ABPI), and toe brachial pressure index (TBPI), and investigated wound healing and occurrence of unplanned amputations. The mean follow-up duration was 11.9 ± 7.2 months (range, 0.9-23.9 months) and 100%, 72.4%, and 74.1% of patients were available to follow-up 1, 3 and 6 months after AWBMST, respectively. At 6 months, patients demonstrated significant improvements in Rutherford category (P < 0.0001), pain score (P < 0.0001), PFWT (P < 0.0001) and TBPI (P < 0.0001). ABPI was increased compared to baseline, but the difference was not significant. A total of 76.5% ischemic wounds achieved complete or improved healing. AWBMSCT is a safe and effective alternative or adjunctive treatment modality to achieve clinical improvement in patients with CLI.