Rupture, Breakdown, and Pulmonary Artery Embolism of a Balloon Catheter Tip during Percutaneous Transluminal Angioplasty of Arteriovenous Fistula

Percutaneous transluminal angioplasty is a well-known treatment for arteriovenous fistula stenosis. Balloon rupture during endovascular procedures is a rare but possible complication. The bursting balloon itself does not cause a serious problem, but it can occasionally cause entrapment, especially in case of breakdown of the balloon catheter tip. Here, we present four cases of balloon rupture during angioplasty in the hemodialysis circuit. In three cases, the ruptured balloon catheter was removed by cutdown of access conduit, while in one case, tip of ruptured balloon catheter was migrated into the pulmonary artery and was removed surgically. The operator must attempt to reduce the risk of balloon rupture by gradually expanding the balloons under bursting pressure. If the balloon bursts, it should not be removed excessively and attempt should be made to remove it using endovascular techniques. Surgical removal is considered after careful evaluation of the condition of the balloon and vessel.

Diffusion-Weighted Imaging of Upper Abdominal Organs Acquired with Multiple B-Value Combinations: Value of Normalization Using Spleen as the Reference Organ

OBJECTIVE: To compare apparent diffusion coefficient (ADC) of the upper abdominal organs acquired with multiple b-value combinations and to investigate usefulness of normalization. MATERIALS AND METHODS: We retrospectively analyzed data, including 3T diffusion-weighted images, of 100 patients (56 men, 44 women; mean age, 63.9) that underwent liver magnetic resonance imaging. An ADC map was derived with the following six b-value combinations: b1 = 0, 50, 400, 800; b2 = 0, 800; b3 = 0, 50, 800; b4 = 0, 400, 800; b5 = 50, 800; and b6 = 50, 400, 800 s/mm2. ADC values of the right liver lobe, left liver lobe, spleen, pancreas, right kidney, and left kidney were measured. ADC values of the spleen were used for normalization. Intraclass correlation coefficients (ICCs), comparison of dependent ICCs, and repeated-measures analysis of variance were used for statistical analysis. RESULTS: Intraclass correlation coefficients of the original ADC revealed moderate to substantial agreement (0.5145–0.6509), while normalized ADCs revealed almost perfect agreement (0.8014–0.8569). ICC of normalized ADC for all anatomical regions revealed significantly less variability than that of the original ADC (p < 0.05). Coefficient of variance for normalized ADC was significantly lower than that for the original ADC (3.0.3.8% vs. 4.8.8.8%, p < 0.05). CONCLUSION: Normalization of the ADC values of the upper abdominal organs using the spleen as the reference organ significantly decreased variability in ADC measurement acquired with multiple b-value combinations.

Estimation of Standard Liver Volume Using CT Volume, Body Composition, and Abdominal Geometry Measurements

PURPOSE: The present study developed formulas for estimation of standard liver volume (SLV) with high accuracy for the Korean population. MATERIALS AND METHODS: SLV estimation formulas were established using gender-balanced and gender-unbalanced measurements of anthropometric variables, body composition variables, and abdominal geometry of healthy Koreans (n=790). Total liver volume excluding blood volume, was measured based on CT volumetry. RESULTS: SLV estimation formulas as preferred in various conditions of data availability were suggested in the present study. The suggested SLV estimation formulas in the present study were found superior to existing formulas, with an increased accuracy of 4.0–217.5 mL for absolute error and 0.2–18.7% for percentage of absolute error. CONCLUSION: SLV estimation formulas using gender-balanced measurements showed better performance than those using gender-unbalanced measurements. Inclusion of body composition and abdominal geometry variables contributed to improved performance of SLV estimation.

Kidney Transplant Patient with a Facial Redness / 대한이식학회지

Posttransplant erythrocytosis (PTE) is a common complication of renal transplantation, which can occur in approximately 10% to 15% of renal transplant patients and usually affects males with relatively good renal function. It is also associated with an increased incidence of thromboembolic events. Clinical manifestations of PTE include malaise, headache, plethora, lethargy, and dizziness. It is correlated with use of cyclosporin, gender, posttransplant renal function, and type of antihypertensive medication. The angiotensin receptor blocker (ARB) or angiotensin-converting enzyme inhibitor is preferred as an initial treatment for PTE because these agents are effective and reasonably safe in the majority of patients with PTE, and can also provide a necessary antihypertensive effect for kidney transplant patients. We report here on a 35-year-old male who had erythrocytosis after renal transplantation. After renal transplantation, his level of hemoglobin was 21 g/dL. We treated this patient with ARB and his symptoms and signs have been completely relieved.

Usefulness of Artificial Jump Graft to Portal Vein Thrombosis in Deceased Donor Liver Transplantation

Severe portal vein thrombosis (PVT) is often considered a relative contraindication for living donor liver transplantation due to high associated risks and morbidity. Meanwhile, improvement in operative techniques, resulting in higher success rates has removed PVT from the list of contraindications in deceased donor liver transplantation (DDLT). In this report, we describe a surgical technique for DDLT using polytetrafluoroethylene graft from the inferior mesenteric vein for portal inflow in patient with portomesenteric thrombosis.

The Results of Self-Expandable Kissing Stents in Aortic Bifurcation

PURPOSE: Kissing stent reconstruction is a widely used technique for the management of aortoiliac occlusive disease involving the aortic bifurcation or proximal common iliac arteries. The purpose of this study was to evaluate the results of self-expandable kissing stents in the aortic bifurcation. METHODS: We reviewed medical records of the patients treated with a kissing stent retrospectively from January 2007 to December 2012. The primary and secondary patencies were determined with Kaplan-Meier analysis, and Cox regression was used to determine the factors associated with patency. RESULTS: A total of 21 patients were included, and all were male (median age 53+/-15 years, range 48-78 years). Major symptoms were claudication (n=16, 61.9%), rest pain (n=5, 23.8%) and gangrene (n=5, 23.8%). Tans-Atlantic Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) II classification was A 2 (9.5%), B 5 (23.8%), C 7 (33.3%) and D 8 (38%). The mean follow-up was 40.7 months. Major complication occurred in only one case which consisted of distal limb ischemia by emboli. Six patients developed symptomatic restenosis or occlusion. There was no major amputation, but minor amputation occurred in 3 patients. There were 2 mortalities not associated with the procedure (lung cancer and intracranial hemorrhage). Primary patency was 89.6% at 1 year, 74.7% at 3 years and 64.0% at 5 years. Secondary patency was 94.1% at 1 year, 88.2% at 3 years and 68.6% at 5 years. No risk factors for restenosis or occlusion were identified. CONCLUSION: Self-expandable kissing stents can be used successfully with comparable patency for endovascular treatment of symptomatic atherosclerotic occlusive lesions in the aortic bifurcation area.

Distribution of CD10-positive epithelial and mesenchymal cells in human mid-term fetuses: a comparison with CD34 expression / 대한해부학회지

CD10, a marker of immature B lymphocytes, is expressed in the developing epithelium of mammary glands, hair follicles, and renal tubules of human fetuses. To assess mesenchymal and stromal expression of CD10, we performed immunohistochemical assays in whole body sections from eight fetuses of gestational ages 15-20 weeks. In addition to expression in urinary tract and intestinal epithelium, CD10 was strongly expressed at both gestational ages in fibrous tissues surrounding the airways from the larynx to lung alveoli, in the periosteum and ossification center, and in the glans of external genitalia. CD10 was not expressed, however, in other cavernous tissues. These findings suggest that mesenchymal, in addition to epithelial cells at specific sites, are likely to express CD10. The glomeruli, alveoli, and glans are all end products of budding or outgrowth processes in the epithelium or skin. However, in contrast to the CD34 marker of stromal stem cells, CD10 was not expressed in vascular progenitor cells and in differentiated vascular endothelium. The alternating pattern of CD10 and CD34 expression suggests that these factors play different roles in cellular differentiation and proliferation of the kidneys, airway and external genitalia.

Clinicopathological characteristics and prognostic factors in combined hepatocellular carcinoma and cholangiocarcinoma

BACKGROUNDS/AIMS: Combined hepatocellular carcinoma and cholangiocarcinoma (cHCC-CC) is an uncommon subtype of primary liver cancer that has rarely been reported in detail. This study was performed in order to evaluate the clinicopathological characteristics and prognostic factors of cHCC-CC in single center. METHODS: The clinicopathological features of patients diagnosed and operated with cHCC-CC at Chonbuk National Hospital between July 1998 and July 2007 were retrospectively studied by comparing them with patients with only hepatocellular carcinoma (HCC) who had undergone a hepatic resection during the same period. RESULTS: Ten out of 152 patients who had undergone a hepatic resection were diagnosed with cHCC-CC and thus included in this study (M : F=8 : 2, median age: 52+/-11.1 years). According to the parameters of the 7th American Joint Committee on Cancer T staging, there were 76 (50.0%), 44 (28.9%), 9 (5.9%), 18 (11.8%) and 5 (3.3%) patients with T stages 1, 2, 3a, 3b and 4, respectively. The overall survival period was longer in the HCC only group (68+/-40.4 months) than in the combined cHCC-CC group (23+/-40.1 months) (p<0.0001). The 5-year survival rate was 10% in the cHCC-CC group and 60% in the HCC group (p<0.0001). The disease free survival for patients with cHCC-HCC and HCC were 16+/-37.4 and 51+/-44.3 months, respectively (p<0.0001). Univariate analysis revealed that age, gender, transarterial chemoembolization (TACE), and T stage were statistically significant in terms of patient's overall survival. However, there were no significant clinicopathological factors identified by the multivariate analysis. CONCLUSIONS: Even after the hepatic resection in the HCC, the prognosis is poorer if the patient has cholangiocellular components compared to the usual HCC.

Analyze the Patency Rates according to Risk Factors and Comorbidities in Patients with Chronic Arterial Occlusive Disease in Lower Extremity / 대한혈관외과학회지

PURPOSE: The aim of this study is to analyze the patency rates according to the risk factors and comorbidities in patients treated with endovascular treatments or arterial bypass surgery due to chronic arterial occlusive disease in the lower extremity. METHODS: Two hundred fifty-seven patients were treated for chronic arterial occlusive disease in lower extremity from January 2000 to December 2010 at Chonbuk National University Hospital; of the 257 patients, we retrospectively reviewed medical records of 142 patients who could be followed-up. We analyzed the patency rates according to the Trans-Atlantic Inter-Society Consensus (TASC) II classification, risk factors and comorbidities. RESULTS: One year, three year, and five year patency rates according to TASC classification had no statistical significance (P=0.301), and those risk factors and comorbidities associated with each other also had no statistical significance. However, the patency rates according to the number of risk factors and comorbidities demonstrated statistical significance (P=0.004), respectively. In addition, when sum of the total number was above 6, the patency rates were the poorest with statistical significance (P<0.001). Also, these analyses had statistical significance in the groups regarding TASC C, D (P<0.001), aorto-iliac lesions (P<0.001) and femoro-popliteal lesions (P<0.001). CONCLUSION: Analysis of risk factors and comorbidities in patients with chronic arterial occlusive disease in the lower extremity can be useful in predicting the patency rates prior to endovascular treatments or arterial bypass surgeries.

Development of the Rectus Abdominis and Its Sheath in the Human Fetus

PURPOSE: Although the rectus abdominis and its sheath are well known structures, their development in the human fetus is poorly understood. MATERIALS AND METHODS: We examined rectus abdominis and sheath development in semiserial horizontal sections of 18 fetuses at 5-9 weeks of gestation. RESULTS: Rectus muscle differentiation was found to commence above the umbilicus at 6 weeks and extend inferiorly. Until closure of the anterior chest wall via fusion of the bilateral sternal anlagen (at 7 weeks), the anterior rectal sheath originated from the external oblique and developed towards the medial margin of the rectus abdominis at all levels, including the supracostal part. After formation of the anterior sheath, fascial laminae from the internal oblique and transversus abdominis contributed to formation of the posterior rectus sheath. However, the posterior sheath was absent along the supracostal part of the rectus abdominis, as the transversus muscle fibers reached the sternum or the midline area. Therefore, it appeared that resolution of the physiological umbilical hernia (8-9 weeks) as well as chest wall closure was not required for development of the rectus abdominis and its sheath. Conversely, in the inferior part of the two largest fetal specimens, after resolution of the hernia, the posterior sheath underwent secondary disappearance, possibly due to changes in mechanical stress. CONCLUSION: Upward extension of the rectus abdominis suddenly stopped at the margin of the inferiorly developing pectoralis major without facing the external intercostalis. The rectus thoracis, if present, might correspond to the pectoralis.

Surgical outcomes and prognostic factors influencing long-term survival in patients with gallbladder cancer

BACKGROUNDS/AIMS: The aim of this study is to analyze surgical outcomes and prognostic factors affecting survival after surgical resection in patients with gallbladder cancer. METHODS: We retrospectively reviewed 86 patients treated surgically for gallbladder cancer from January 2000 to December 2009 at Chonbuk National University Hospital. Clinicopathologic factors, surgical treatment and outcome data were analyzed. RESULTS: Among the 86 patients (44 male, 42 female) with gallbladder cancer, the mean age was 62.9 years (range: 32-80) and the median survival was 42.4+/-3.5 month. The overall cumulative survival rates of 86 patients were for 1 year, 83.7%; 3 year, 67.4%; 5 year survival, 61.7%. Univariate analysis revealed that preoperative serum alanine aminotransferase, alkaline phosphatase, total bilirubin, carcinoembryonic antigen (CEA), T staging, N staging were statistically significantly associated with survival. CEA (p=0.004) and T staging (p=0.005) were associated with survival in multivariate analysis. Two-year survival rates were analyzed according to the methods of surgical resection, with simple cholecystectomy showing 100%, whereas extended cholecystectomy showed about 83% in T1b. We could not find out any adverse effect of the simple cholecystectomy for survival. CONCLUSIONS: CEA and T stage are independent significant prognostic factor associated with patient survival in our study. Simple cholecystectomy can be regarded as curative resection in stage T1b. Longer observation periods and more cases will be needed to confirm these conclusions.

Endovascular Treatment of an Internal Iliac Artery Aneurysm Using Amplatzer Vascular Plug: 2 Case Reports / 대한혈관외과학회지

To report endovascular occlusion of an internal iliac artery aneurysm (IIAA) of two patients using Amplatzer vascular plug (AVP; AGA Medical Corporation, USA). A 69-year-old asymptomatic man had aneurysms of both internal iliac arteries. The size of the right (Rt) IIAA was 23 mm and that of the left (Lt) IIAA was 45 mm. We decided to induce vascular occlusion of the Lt internal iliac artery (IIA). We deployed an AVP in the proximal and distal Lt IIA. The patient was discharged after four days and showed no recurrence of aneurysm for one year. A 78-year-old women had lower abdominal pain for three days. Computed tomography scan showed a 43 mm Rt common iliac artery (CIA) aneurysm and a 38 mm Rt IIAA. We decided to insert a stent graft in the Rt CIA and to occlude the Rt IIA using AVP. We deployed the stent graft in the Rt CIA and the AVP in the distal Rt IIA. The patient was discharged after seven days and demonstrated no recurrence of aneurysm for four months. AVP is a feasible vascular occlusive device for internal iliac artery aneurysm.

Scoring of prognostic factors that influence long-term survival in patients with hepatic metastasis of colorectal cancer

BACKGROUNDS/AIMS: To find independent predictors that affect the survival in patients with hepatic metastasis of colorectal cancer after surgery and to devise a risk scoring system. METHODS: Among 150 patients who underwent hepatic resection after diagnosis of colorectal cancer with hepatic metastasis between March 1994 and February 2009, we analyzed clinical, pathologic and outcome data retrospectively. RESULTS: The 1-year survival rate was 83%, and the 5-year survival rate was 35%. Nine factors were found to be independent predictors of adverse outcome by univariate analysis: stage of primary tumor, CA19-9 >36 U/ml, extrahepatic disease, distribution of the hepatic tumor, number of hepatic tumors >3, largest hepatic tumor >5 cm, total size >10 cm, CEA >10 ng/ml, and metachronous cancer. The last two of these criteria were also significant risk factors on multivariate analysis. When these criteria were used as a risk scoring system, assigning one point for each criterion and dividing the cases into A, B and C groups, the total score was highly predictive of outcomes (p<0.001). No patients in group C (6 to 9 points) were long-term survivors. CONCLUSIONS: Long-term outcome can be predicted from nine criteria that are readily available for all patients. Patients meeting up to two criteria (group A) are more likely to have a favorable outcome compared to the three or over (groups B and C). This scoring system may offer an easy, rapid, and reliable prognostic indicator of survival outcome after hepatic resection in patients with hepatic metastasis from colorectal cancer.

Congenital Absence of the Horizontal Segment of the Left Portal Vein

As living-donor liver transplant techniques develop, variations in the portal vein are seen in approximately 20% of the population. However, congenital absence of the horizontal segment of the left portal vein is very rare and has not been reported in Korea. We present a case with a congenital absence of the horizontal segment of the left portal vein that was detected during an evaluation for a living donor liver transplantation, with a review of the relevant literature.

Pelvic Actinomycosis: Is It Possible to Diagnose Preoperatively?

PURPOSE: Pelvic actinomycosis is a rare infection which presents difficulty in establishing a correct preoperative diagnosis. The aim of this study is to find diagnostic clues for pelvic actinomycosis preoperatively. METHODS: A retrospective analysis performed at Chonbuk National University Hospital identified 9 patients with a diagnosis of pelvic actinomycosis from 1998 to 2006. RESULTS: All patients were women with a history of intrauterine device (IUD) use. Abdominal pain (7 cases), palpable mass (3 cases), defecation difficulty (3 cases) and leucorrhea (2 cases) were the main presenting complaints. The median duration of presenting symptoms was 78 days (range: 10~365 days). The median duration of using an IUD unchanged was 11 years (range: 4~30 years). A correct diagnosis was made in 3 patients (33%) without exploration. All patients were treated with antibiotics after pathologic diagnosis. There was no recurrence. CONCLUSIONS: It is very difficult to diagnose pelvic actinomycosis preoperatively. Howere, if a mass or a pelvic abscess is found in women with an IUD that has been unchanged for a long time, pelvic actinomycosis should be suspected to avoid unnecessary exploration.

Up-regulation of P13K/Akt Signaling by 17 beta-estradiol through Activation of Estrogen Receptor-alpha in Breast Cancer Cells / 한국유방암학회지

PURPOSE: Estrogen stimulates cell proliferation in breast cancer, the biological effects of which are mediated through two intracellular receptors: estrogen receptor-alpha (ERalpha) and estrogen receptor-beta (ERbeta). However, the actual role of ERs in the proliferative action of estrogen remains to be established. It was recently found that ER activates phosphatidylinositol-3-OH kinase (PI3K), via its binding with the p85 regulatory subunit of PI3K. Therefore, possible mechanisms may include ER-mediated phosphoinositide metabolism, with the subsequent formation of phosphatidylinositol-3, 4, 5-trisphosphate (PIP(3)), which is generated from phosphatidylinositol 4, 5-bisphosphate (PIP(2)) via PI3K activation. The present study has demonstrated that 17b-estradiol (E2) up-regulates PI3K in an ERalpha, but not an ERbeta dependent manner, and also stimulates cell growth in breast cancer cells. METHODS: To study this phenomenon, we treated ER-positive MCF-7 cells and ER-negative MDA-MB-231 cells with 10 nM E2. RESULTS: The treatment of MCF-7 cells with E2 resulted in a marked increase in the expression of PI3K (p85), which was paralleled by increases in the levels of phospho-Akt (Ser-473) and PIP3. These observations were also correlated with increased E2-induced cell proliferation activity. However, no effects of E2 on breast cancer cells were observed in the MDA-MB-231 cell line, indicating the pathway of E2-mediated up-regulation of PI3K/Akt is ERalpha-dependent. CONCLUSION: These results suggest that estrogen activates PI3K/Akt signaling via an ERalpha-dependent mechanism in MCF-7 cells.