Safety and Effectiveness of Endovascular Treatment of Complications Associated with Persistent Sciatic Artery: A Qualitative Systematic Review.

PURPOSE: To conduct a systematic review to evaluate the safety and efficacy of endovascular treatment with stent grafts (SGs) for complications associated with persistent sciatic artery (PSA). MATERIALS AND METHODS: The MEDLINE, Web of Science, Scopus, and Ichushi Web databases were searched to identify articles focusing on endovascular treatment with SGs for complications associated with PSA published from inception to 15 September 2023. The review included 31 case reports, 2 case series, and 7 conference proceedings. Forty patients (median age: 67 years, range: 22-88 years; 25 women) with 41 limbs underwent endovascular treatment with 65 SGs for ischemia (n=26), aneurysm (n=13), and trauma (n=2). Prior treatments were systemic anticoagulation (n=7), thrombolysis (n=5), thrombectomy in (n=3), and amputation (n=1), while concurrent treatments were thrombolysis (n=6) and thrombectomy (n=2). The median number of SGs implanted was 2 (range: 1-4). Early outcomes were technical success and complications. Late outcomes were primary patency, secondary patency, freedom from re-intervention, and clinical success. RESULTS: The technical success rate was 100%. Intervention-specific complications were reported in 4 cases, but there were no major adverse events. The clinical success rates at 1 and 2 years were 100% and 95.7%, respectively. The primary patency rates at 1 and 2 years were 81.5% and 67.6%, respectively, and the secondary patency rates at 1 and 2 years were 94.5% and 81.6%, respectively. CONCLUSION: Endovascular treatment with SGs for complications associated with PSA is safe and effective, with acceptable mid-term patency and durability, and is recommended as the first-choice treatment.

Chronological Course and Clinical Features after Denver Peritoneovenous Shunt Placement in Decompensated Liver Cirrhosis.

BACKGROUND: Refractory ascites affects the prognosis and quality of life in patients with liver cirrhosis. Peritoneovenous shunt (PVS) is a treatment procedure of palliative interventional radiology for refractory ascites. Although it is reportedly associated with serious complications (e.g., heart failure, thrombotic disease), the clinical course of PVS has not been thoroughly evaluated. OBJECTIVES: To evaluate the relationship between chronological course and complications after PVS for refractory ascites in liver cirrhosis patients. MATERIALS AND METHODS: This was a retrospective study of 14 patients with refractory ascites associated with decompensated cirrhosis who underwent PVS placement between June 2011 and June 2023. The clinical characteristics, changes in cardiothoracic ratio (CTR), and laboratory data (i.e., brain natriuretic peptide (BNP), D-dimer, platelet) were evaluated. Follow-up CT images in eight patients were also evaluated for ascites and complications. RESULTS: No serious complication associated with the procedure occurred in any case. Transient increases in BNP and D-dimer levels, decreased platelet counts, and the worsening of CTR were observed in the 2 days after PVS; however, they were improved in 7 days in all cases except one. In the follow-up CT, the amount of ascites decreased in all patients, but one patient with a continuous increase in D-dimer 2 and 7 days after PVS had thrombotic disease (renal and splenic infarction). The mean PVS patency was 345.4 days, and the median survival after PVS placement was 474.4 days. CONCLUSIONS: PVS placement for refractory ascites is a technically feasible palliative therapy. The combined evaluation of chronological changes in BNP, D-dimer, platelet count and CTR, and follow-up CT images may be useful for the early prediction of the efficacy and complications of PVS.

Characteristics of Suspicious Breast Lesions Visible Only on MR Imaging: Is It Possible to Classify into Immediate Biopsy and Careful Observation Groups?

PURPOSE: To investigate the characteristics of suspicious MRI-only visible lesions and to explore the validity of subcategorizing these lesions into the following two groups: lesions that would require immediate biopsy (4Bi) and lesions for which careful clinical follow-up could be recommended (4Fo). METHODS: A retrospective review of 108 MRI-only visible lesions in 106 patients who were diagnosed as Breast Imaging Reporting and Data System (BI-RADS) category 4 between June 2018 and June 2022 at our institution was performed by two radiologists. The breast MR images were evaluated according to BI-RADS and additional MRI descriptors (linear ductal, branching, and apparent diffusion coefficient values). The lesions were categorized by previously reported classification systems, and the positive predictive values (PPVs) for the different categories were determined and compared. Subsequently, a new classification system was developed in this study. RESULTS: The total malignancy rate was 31% (34/108). No significant differences between benign and malignant lesions were identified for focus and mass lesions. For non-mass lesions, linear ductal and heterogeneous internal enhancement suggested a benign lesion (P = 0.0013 and P = 0.023, respectively), and branching internal enhancement suggested malignancy (P = 0.0066). Segmental distribution suggested malignancy (P = 0.0097). However, the PPV of segmental distribution with heterogeneous enhancement was significantly lower than that of category 4 segmental lesions with other enhancement patterns (11% vs. 59%; P = 0.0198).As a new classification, the distribution of focal, linear, and segmental was given a score of 0, 1, or 2, and the internal enhancement of heterogeneous, linear-ductal, clumped, branching, and clustered-ring enhancement was given a score of 0, 1, 2, 3, and 4, respectively. When categorized using a scoring system, a statistically significant difference in PPV was observed between 4Fo (n = 27) and 4Bi (n = 33) (7% vs. 61%, P = 0.000029). CONCLUSION: The new classification system was found to be highly capable of subcategorizing BI-RADS category 4 MRI-only visible non-mass lesions into 4Fo and 4Bi.

Node-by-node diagnosis for multiple ipsilateral nodules by segmental adrenal venous sampling in primary aldosteronism.

OBJECTIVES: In patients with primary aldosteronism (PA), multiple adrenocortical nodules may be present on the surgical side. The aim of this study was to clarify the pathological diagnosis and the node-by-node diagnostic capability of segmental adrenal venous sampling (sAVS). DESIGN: Retrospective study. PATIENTS: A total of 162 patients who underwent adrenalectomy following sAVS were studied. MEASUREMENTS: Multiple nodules on the surgical side were extracted while referring to contrast-enhanced computed tomography images. We also performed a detailed histopathological analysis of the resected specimens from patients undergoing sAVS, which included immunohistochemistry for CYP11B2. RESULTS: In 11 (6.8%) patients, two to three nodules were detected on the surgical side. All patients were diagnosed by sAVS with at least one aldosterone-producing adenoma (APA) for localized aldosterone elevation in tributaries. Seven patients showed a lateralization index value of ≥4 after ACTH stimulation. Histopathologically and clinically, two patients had two or three CYP11B2-positive APAs, and the other nine patients both APAs and non-APAs. The positive predictive value of the most suspected APA, that is, the drainer that showed the highest aldosterone level by sAVS, was 11/11 (100%, 95% confidence interval [CI]: 71.5%-100%), while that for the second and third suspected APA was 3/7 (42.9%, 95% CI: 9.9%-81.6%), and they were significantly different (p = .01). Further, the positive predictive value of non-APA was 4/4 (100%, 95% CI: 39.8%-100%). CONCLUSIONS: The sAVS could correctly diagnose the aldosterone production in multiple ipsilateral adrenal nodules.

Radiological characteristics and diagnostic impact of duplicated right adrenal veins on adrenal venous sampling in primary aldosteronism.

PURPOSE: We aimed to analyze the prevalence and radiological characteristics of duplicated right adrenal veins (DRAVs) and evaluate the diagnostic impact of adrenal venous sampling (AVS) in primary aldosteronism. METHODS: DRAVs were retrospectively identified among patients who underwent segmental AVS between April 2017 and March 2020. DRAVs were defined as main or accessory according to the drainage area. The diameter, position, hormone levels, and treatment plan based on AVS were compared between main and accessory RAVs, using the Wilcoxon rank-sum test. RESULTS: Fourteen of 432 patients (3.2%) were diagnosed with DRAVs. On venography, the mean diameters of the main and accessory side were 3±0.63 mm and 2.1±0.41 mm, respectively, and were significantly different (p < 0.001). The mean relative position in craniocaudal direction of main and accessory veins from the adrenal caudal edge on computed tomography was 65.5%±16.0%, and 48.1%±16.8%, respectively, which was significantly different (p = 0.007). The left-right positions and hormone levels were not significantly different. Based on conventional AVS, the treatment plan between DRAVs was not changed in six of eight patients, but changed from surgery to medication in two patients with right aldosterone-producing adenoma (APA)/microadenoma based on segmental AVS findings. CONCLUSION: DRAVs, in which the main RAV was thicker and more cranially located than the accessory RAV were rare. Depending on blood sampled from either of DRAVs, the diagnosis made through conventional AVS might change treatment approach from surgery to medication, especially with right APA. Hence, their identification is important to make an accurate subtyping by AVS.

A Rare Independent Left Inferior Phrenic Vein Sampling in a Left Adrenal Aldosterone-Producing Adenoma.

This report presents a case of left adrenal aldosterone-producing adenoma (APA) diagnosed by segmental adrenal venous sampling in a patient with primary aldosteronism and a rare venous anomaly in which the left inferior phrenic vein (LIPV) and adrenal central vein entered the left renal vein separately. The outflow of tumor blood into the LIPV and the specimen from the LIPV that showed much higher aldosterone level than that from the adrenal central vein and tributaries were useful for proving the aldosterone hypersecretion from the APA. Sampling from the LIPV could be of diagnostic value for left APA.

CT-Guided Percutaneous Needle Biopsy in Patients with Suspected Retroperitoneal Fibrosis: A Retrospective Cohort Study.

PURPOSE: The outcome of CT-guided biopsy in patients with suspected retroperitoneal fibrosis (RF), regarded as technically challenging, remains unclear. This study aimed to evaluate the results of CT-guided biopsy in patients with lesions considered in the differential diagnosis of RF and compare them with results from patients with other retroperitoneal lesions. MATERIALS AND METHODS: Patients who underwent CT-guided biopsy of retroperitoneal lesions between January 2010 and September 2018 were retrospectively reviewed. The study cohort with retroperitoneal lesions surrounding the infra-abdominal aorta, iliac vessels, and/or ureters was divided into two groups: Group F included patients with lesions for which RF was considered in the differential diagnosis, and Group C comprised patients with a retroperitoneal mass or lymphadenopathy. Lesion size and depth, and biopsy details including technical success, position, procedure time, diagnostic yield, and complications between the two groups were compared. RESULTS: Group F included 27 patients (mean age 68.5 years ± 11.6, 17 male) and Group C 30 patients (mean age 65.0 years ± 11.8, 16 male). The short axis was significantly smaller in Group F than in Group C (19 mm vs 26 mm, P = 0.041), and procedure time was significantly longer in Group F than in Group C (31.5 min ± 13.2 vs 20.3 min ± 8.4, P = 0.001). Technical success rate (93% vs 100%), accuracy (93% vs 93%), and complications (3.7% vs 10%) between Groups F and C were not significantly different. CONCLUSIONS: CT-guided biopsy of patients with suspected RF is considered safe and effective.

Dynamic volumetric CT angiography for the detection and classification of endoleaks: application of cine imaging using a 320-row CT scanner with 16-cm detectors.

PURPOSE: To assess the feasibility and diagnostic performance of dynamic volumetric computed tomography (CT) angiography with large-area detectors in the detection and classification of endoleaks after endovascular aneurysm repair (EVAR). MATERIALS AND METHODS: Low-dose dynamic volumetric CT angiography performed with the patient in Fowler position was used to scan the entire stent graft with a 16-cm-area detector during the first follow-up examination after EVAR. There were 39 consecutive patients (36 men and 3 women; mean age, 74 y ± 8.7) examined with approximately 14-20 intermittent scans (temporal resolution, 2 s; scan range, 160 mm). The effective radiation dose, image quality, interobserver and intraobserver agreement for endoleak detection, and time delay between peak enhancement of the aorta and endoleaks were evaluated. RESULTS: All examinations with the patient in Fowler position enabled the entire stent graft to be scanned and were rated as diagnostic. The mean effective radiation dose was 13.1 mSv. Endoleaks were detected in eight patients (type Ia, n = 1; type II, n = 6; type III, n = 1). Interobserver agreement (κ = 0.794) and intraobserver agreement (κ = 1.00) for detection of endoleaks were excellent. The mean time delay between peak enhancement of the aorta and the endoleaks was significantly less for type I/III endoleaks (2.0 s ± 0) compared with type II endoleaks (5.3 s ± 1.0; P < .001). CONCLUSIONS: Low-dose dynamic volumetric CT angiography performed with the patient in Fowler position is feasible after EVAR. Dynamic information, including cine imaging, the timing of peak enhancement, and the Hounsfield units index, is useful in detecting and classifying endoleaks.

The upside down Endurant iliac limb stent graft for treatment of a common iliac artery aneurysm.

Endovascular repair of the coverage from the common iliac artery to the external iliac artery after the internal iliac artery embolization has been proven to be a safe and effective treatment in isolated iliac artery aneurysms. But in cases in which the diameter of the proximal sealing zone is larger than that of the distal sealing zone, a reverse-tapered device is needed. We described the off-label use of the Endurant iliac limb stent graft in an upside down configuration to accommodate this diameter mismatch.

Bilateral approach of redistributed subclavian arterial infusion chemotherapy for locally advanced breast cancer spreading to the contralateral chest wall.

A catheter port system technique called redistributed subclavian arterial infusion chemotherapy (RESAIC) for locally advanced breast cancer was reported and seemed to be effective for local control and as a palliative treatment. However, when the cancer spreads beyond the medial line to the contralateral chest wall, ipsilateral RESAIC would not achieve a favorable drug distribution. We report on two patients with advanced breast cancer spreading to the contralateral chest wall in whom bilateral RESAIC was attempted. In summary, when advanced breast cancer spreads to the contralateral chest wall, bilateral RESAIC may be useful for local control or palliation.

[Oncology IVR--application to palliative medicine].

Oncology IVR is a minimum invasive and locoregional treatment by newly developed interventional techniques consisting of transarterial chemoembolization (TACE), radiofrequency ablation, cryoablation and percutaneous bone plasty (PBP), etc. These treatment methods are considered to be effective to rapid tumor reduction and palliation. The redistributed subclavian arterial infusion chemotherapy via an implanted catheter-port system which was newly developed by authors would be effective for local recurrence of breast cancer. The combination therapy of these interventional techniques can offer new treatment strategies for an improvement of patient's quality of life and more effective palliative medicine.

Transcatheter arterial chemoembolization (TACE) or embolization (TAE) for symptomatic bone metastases as a palliative treatment.

PURPOSE: This study was designed to evaluate the effect of transcatheter arterial chemoembolization (TACE)/embolization (TAE) for symptomatic bone metastases especially in palliation. METHODS: Between April 2006 and December 2009, 24 bone metastatic lesions of 18 patients (8 women and 10 men; mean age, 64 years) underwent palliative TACE or TAE. A total of 40 sessions were performed, with 1-4 sessions per lesion. The primary lesions included hepatocellular carcinoma, colorectal cancer, renal cell cancer, ovarian cancer, thyroid cancer, uterine cervical cancer, and esophageal cancer. Symptomatic lesions involved thoracic spine, lumbar spine, pelvis, rib, and femur. The procedures were performed with a coaxial catheter technique to catheterize selectively target arteries. If not possible due to small branches, blood flow alteration by coil was achieved. Gelatin sponge was the initial embolic materials. As anti-cancer agents, epirubicin, fluorouracil, and mitomycin were mainly used in consideration for primary lesion and past treatment. RESULTS: Sufficient devascularization of targeted lesions was obtained in 18 of 24 (75%) lesions without any serious complication. Pain relief was obtained in 20 lesions (83%), with significantly decrease in the visual analogue scale score (P < 0.001). A relationship was found between the devascularization grade and pain relief (r = 0.49, P < 0.05). Follow-up CT images at 1 month of nine lesions (50%) revealed necrotic change in the tumors. CONCLUSIONS: Palliative TACE/TAE for symptomatic bone metastases could be a suitable treatment method because it is minimally invasive, repeatable, effective, and rapid-acting.