Arterial Administration of DNA Crosslinking Agents with Restraint of Homologous Recombination Repair by Intravenous Low-Dose Gemcitabine Is Effective for Locally Advanced Pancreatic Cancer.

(1) Background: Pretreatment by Rad51-inhibitory substances such as gemcitabine followed by arterial chemotherapy using antineoplastic agents causing DNA crosslink might be more beneficial for patients with locally advanced pancreatic cancers than conventional treatments. The efficacy of arterial administration of DNA crosslinking agents with pretreatment of intravenous low-dose gemcitabine for patients with unresectable locally advanced or metastatic pancreatic cancer (LAPC or MPC) is evaluated. (2) Methods: A single-arm, single-center, institutional review board-approved prospective study was conducted between 2005 and 2015. Forty-five patients (23 LAPC, 22 MPC) were included. Patients received a weekly low dose of gemcitabine intravenously for three weeks followed by arterial administration of mitomycin C and epirubicin hydrochloride at tumor-supplying arteries on the fifth or sixth week. This treatment course was repeated at 1.5-to-2-month intervals. Overall survival (OS), local progression-free survival (LPFS), and therapeutic response were evaluated. LAPC or MPC were divided according to treatment compliance, excellent or poor (1 or 2), to subgroups L1, L2, M1, and M2. (3) Results: OS of LAPC and MPC were 23 months and 13 months, respectively. The OS of LAPC with excellent treatment compliance (subgroup L1, 10 patients) was 33 months with 31 months of LPFS, and four patients (40%) had a complete response (CR). The OS of the L1 subgroup was significantly longer than those of other subgroups L2, M1, and M2, which were 17 months, 17 months, and 8 months, respectively. As Grade 3 adverse effects, severe bone marrow suppression, interstitial pneumonitis, and hemolytic uremic syndrome were observed in six (13.0%), three (6.5%), and three (6.5%) patients, respectively. (4) Conclusions: Arterial DNA crosslinking with the systemic restraint of homologous recombination repair can be a new treatment option for LAPC.

Anatomic features and retrograde transvenous obliteration of duodenal varices associated with mesocaval collateral pathway.

PURPOSE: To evaluate techniques and efficacy of retrograde transvenous obliteration for the treatment of duodenal varices associated with mesocaval collateral pathway. MATERIALS AND METHODS: Six consecutive cases of large/growing or ruptured duodenal varices treated by retrograde transvenous obliteration were retrospectively reviewed. Selective balloon-occluded retrograde transvenous obliteration (B-RTO) with 5% ethanolamine oleate (EO) was performed in all cases. When EO could not be sufficiently stagnated in the varices, additional/alternative techniques were performed, including coil embolization of afferent vein or intravariceal injection of n-butyl-2-cyanoacrylate (NBCA). Clinical findings, anatomic features of duodenal varices, obliteration techniques, complications, posttherapeutic computed tomography (CT) findings, and follow-up endoscopic findings were investigated. RESULTS: All duodenal varices were located at the second/third junction of the duodenum and were fed by single (n = 1) or multiple (n = 5) pancreaticoduodenal veins. One varix fed by a single afferent vein was successfully treated by simple selective B-RTO technique alone. The other five cases required coil embolization of afferent vein (n = 1) or intravariceal injection of NBCA (n = 4) because sclerosant was not sufficiently stagnated in the varices. CT 1 week after the procedure showed complete occlusion of the varices in all cases. A duodenal ulcer at the variceal site developed in one patient and was successfully treated by medication. Follow-up endoscopy showed disappearance of varices in all cases, and no recurrence was observed during follow-up. CONCLUSIONS: Retrograde transvenous obliteration is an effective technique for the treatment of duodenal varices. However, additional/alternative techniques are required for successful treatment because of the complex anatomic features of duodenal varices.

Partial thrombosis of gastric varices after balloon-occluded retrograde transvenous obliteration: CT findings and endoscopic correlation.

OBJECTIVE: The purpose of our study was to investigate the frequency and outcomes of partial thrombosis of gastric varices after balloon-occluded retrograde transvenous obliteration (BRTO). MATERIALS AND METHODS: We reviewed retrospectively 69 consecutive patients with gastric varices who were followed-up for > 6 months after treatment with BRTO. All patients underwent contrast-enhanced CT and gastroscopy before and after BRTO. Imaging findings of gastric varices with particular attention to afferent veins, degree of thrombosis, and variceal changes were investigated. RESULTS: On the basis of pretherapeutic CT images, gastric varices were classified into two types: simple (< 3 afferent veins) and complex (≥ 3 afferent veins). Initial follow-up CT showed complete thrombosis in 58 patients (84%) and partial thrombosis in 11 (16%). Partial thrombosis was observed more frequently in complex-type varices (25% vs 9%). No regrowth or recurrent varices were observed in completely thrombosed varices. Follow-up endoscopy showed regrowth of gastric varices at 6-24 months after BRTO in five patients; all of these were complex-type and partially thrombosed varices. All five recurrent varices were treated successfully with repeated BRTO. CONCLUSION: Partial thrombosis after BRTO can occur in complex-type gastric varices, which have a higher risk of regrowth. Additional techniques that achieve complete thrombosis are required for long-term efficacy for complex-type gastric varices.

Arterial supply to the pancreas; variations and cross-sectional anatomy.

The pancreas has complex arterial supplies. Therefore, special attention should be paid in pancreatic arterial intervention for patients with acute pancreatitis and pancreatic carcinomas. Knowledge of pancreatic arterial anatomy and arterial territory is important not only to perform pancreatic arterial intervention, but to read the pancreatic angiography and cross-sectional image. We reviewed 226 selective abdominal angiography and CT scans during selective arteriography (CTA) of common hepatic artery, superior mesenteric artery, splenic artery, or peripancreatic arteries including posterior superior pancreaticoduodenal artery, anterior superior pancreaticoduodenal artery, inferior pancreaticoduodenal artery, and dorsal pancreatic artery. CTA images were evaluated to clarify the cross-sectional anatomy of the pancreatic arterial territory. Variations of the peripancreatic arteries were also investigated. In this exhibit, schemes and illustrative cases demonstrate pancreatic arterial territory and variations.

Treatment of intracranial dural arteriovenous fistulas: current strategies based on location and hemodynamics, and alternative techniques of transcatheter embolization.

Intracranial dural arteriovenous fistulas (AVFs) can occur anywhere within the dura mater. Patients may be clinically asymptomatic or may experience symptoms ranging from mild symptoms to fatal hemorrhage, depending on the location (eg, cavernous sinus, transverse-sigmoid sinus, tentorium, superior sagittal sinus, anterior fossa) and venous drainage pattern of the AVF. In the past, dural AVFs have been treated with a variety of approaches, including surgical resection, venous clipping, transcatheter embolization, radiation therapy, or a combination of these treatments. Recent developments in catheter intervention now allow most patients to be cured with transcatheter embolization, although stereotactic radiation therapy is demonstrating good results in an increasing number of cases and surgery is still the preferred option in some cases. Familiarity with drainage patterns, the risk of aggressive symptoms, recent technical advances, and current treatment strategies is essential for the treatment of intracranial dural AVFs.

Turn-back technique with use of a shaped microcatheter for superselective catheterization of arteries originating at acute angles.

The authors have developed a novel "turn-back" technique with use of a shaped microcatheter for superselective catheterization of arteries originating at acute angles. Herein this technique is described in clinical use for superselective catheterization of several arteries including the middle hepatic artery, right gastric artery, right inferior phrenic artery, and tracheal artery in six patients after failed catheterization by conventional techniques as a result of difficult geometry of the arteries. Superselective catheterization and intervention were successfully performed without complication in all cases. This turn-back technique is useful for superselective catheterization of arteries originating at acute angles.

Dispersion of coils after parent-artery occlusion of radiation-induced internal carotid artery pseudoaneurysm.

We report a rare complication following parent-artery occlusion in a patient with radiation-induced carotid pseudoaneurysms. Both the right internal carotid artery pseudoaneurysm and the recurrent external carotid artery pseudoaneurysm were treated by parent-artery occlusion with coils. Although rebleeding was not observed after the second embolization, angiography and endoscopy at the 12-month follow-up showed dispersion and migration of coils into the pharynx and the external auditory canal due to progressive radiation necrosis.

Endovascular stenting for restenosis of the intracranial vertebrobasilar artery after balloon angioplasty: two case reports and review of the literature.

Percutaneous transluminal balloon angioplasty (PTA) has been used in the treatment of critical stenosis of the intracranial vertebrobasilar artery (VBA). PTA of the intracranial VBA carries the risk of fatal complications such as arterial dissection or acute occlusion as well as postoperative restenosis. The estimated risk of periprocedural complications and restenosis were approximately 20% and 27%. The use of recently developed stents could prevent these problems of PTA. We present two cases of restenosis of the intracranial VBA after PTA which stenoses were successfully retreated with endovascular stenting using flexible coronary stents without any complications. Neither restenosis nor other recurrent symptoms were observed during the 4- and 6-month follow-up period. Reviewing the literature of 33 cases and our 2 cases, the overall complication rates related to stenting and restenosis were 5.6% and 7.8%. Endovascular stenting for the treatment of intracranial VBA can reduce the risk of arterial dissection and restenosis.

Parotid tumors: MR imaging with pathological correlation.

Most parotid tumors grow slowly, whether benign or malignant; thus, it is difficult to predict the malignant or benign nature of a tumor clinically. Magnetic resonance imaging may have a place in the diagnostic work-up of parotid tumors. The purpose of this article is to illustrate the MR imaging findings of parotid tumors and to correlate them to pathologic findings. The MR imaging may be helpful in differentiation of benign and malignant tumors of the parotid gland, and can provide important clues in the diagnosis of their histologies.

Anatomic variations of the cerebral arteries and their embryology: a pictorial review.

In the embryonic period, several developmental anomalies of the cerebral arteries occur. The knowledge of these anatomic variations of the cerebral artery is important to avoid the unnecessary surgery and to undergo surgery or interventional radiology with safety. We reviewed 3000 MR angiographies and 700 cerebral angiographies of the previous 5 years to assess cerebral arterial system, and to illustrate the embryological development, imaging findings, occurrence, and clinical significance of the anatomic variation of the cerebral arteries. The normal development and variations of the cerebral arteries are depicted. Knowledge of the anatomic variations is important since it can influence surgical and interventional procedure.

[A case of multiple mycotic intracranial aneurysms presenting with subdural hematoma].

A patient with subdural hematoma associated with multiple mycotic intracranial aneurysms is reported. A 22-year-old woman presented with headache and disturbance of consciousness. A CT showed subdural hematoma at the tentrium and the left cerebral convexity. Conservative treatment and was used and she was discharged 10 days later. However, follow-up CT demonstrated a parenchymal hematoma in the right posterior temporal lobe. Cerebral angiography demonstrated a large right posterior cerebral aneurysm and multiple right middle cerebral aneurysms. A cardiac ultrasonography showed a verruca at the mitral valve. The posterior cerebral aneurysms increased in size and one new middle cerebral aneurysm appeared at follow-up angiography one week later. Endovascular treatment with coils was applied for the right posterior cerebral aneurysm, and others were treated with antibiotic therapy under serial observation, using MR angiography. She was discharged without any symptoms two months after embolization. Follow-up angiography at one year after embolization showed disappearance of the aneurysms. The possibility of mycotic aneurysm should be considered in the differential diagnosis of non-traumatic acute subdural hematoma.