Large uterine arteriovenous malformation successfully treated with combined endovascular treatment and supracervical hysterectomy: A case report.

Uterine arteriovenous malformations (AVMs) are rare conditions that cause life-threatening bleeding. Endovascular treatment or total hysterectomy is performed to safely treat most AVMs. This case report describes a 54-year-old female patient with a large uterine AVM, uterine bleeding, and cardiac overload that was difficult to manage but successfully treated. Total hysterectomy poses a high risk of hemorrhage due to significant uterine and internal iliac vein dilation; thus, embolization of feeding arteries was performed with N-butyl cyanoacrylate. However, a postembolization computed tomography scan detected paradoxical embolization of the liver, kidneys, and spleen. Therefore, supracervical hysterectomy was performed with preoperative coil embolization and intraoperative balloon occlusion of the feeding arteries. In this case, supracervical, not total, hysterectomy needed to be performed as the shunts were determined to be in the uterine corpus.

Enhancing precision in vascular embolization: evaluating the effectiveness of the intentional early detachment technique with detachable coils in complex cases.

BACKGROUND: This study aimed to assess the effectiveness and versatility of an intentional early detachment technique with detachable coils in addressing challenging vascular embolization scenarios. This novel approach aims to provide an alternative method for achieving precise coil placement when standard methods of detachable coil placement are ineffective owing to vascular anatomy or limited available equipment. MATERIALS AND METHODS: This retrospective study included 11 patients (nine males and two females; median age, 77 years) who underwent embolization procedures between October 2021 and December 2023 using the intentional early detachment technique through 1.6-Fr or 1.3-Fr microcatheters. In this technique, detachable coils were intentionally detached within the microcatheter and placed through saline flushing. The technique's technical success, complications, and clinical success were evaluated. RESULTS: The technique was applied in three distinct scenarios: tortuous vascular anatomy (four cases), inadequate system backup (three cases), and 1.3-Fr microcatheter use (four cases). The technical and clinical success rates were 100%. No complications were observed, and no cases of coil migration or malpositioning. CONCLUSION: The intentional early detachment technique is valuable for interventional radiologists and offers a solution for challenging vascular embolization scenarios. Its application is limited to specific circumstances; however, it can significantly enhance coil placement in complex cases, thereby contributing to improved patient care.

Transcatheter Arterial Embolization for Bleeding Caused by Endoscopic Ultrasound-Guided Fine-Needle Aspiration: A Case Series.

Introduction Bleeding is the most frequent complication of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). In a few cases of massive bleeding caused by EUS-FNA, transcatheter arterial embolization (TAE) has been used to obtain hemostasis. We present a case series of patients who underwent TAE for bleeding due to EUS-FNA. Methods This case series included six patients (five men and one woman) who underwent TAE for bleeding caused by EUS-FNA between January 2018 and December 2022 at the four institutions involved in this study. The median age at TAE was 72.5 years (range, 67-83 years). The target sites for EUS-FNA were the pancreatic tail (n = 3), pancreatic head (n = 2), and hepatic hilar lymph nodes (n = 1). The angiographic findings, embolization procedures, technical and clinical success rates, and TAE complications were retrospectively assessed. Results Angiography revealed contrast-media extravasation or pseudoaneurysms in five patients. In all patients, TAE using a microcatheter was performed via the transfemoral approach. N-butyl cyanoacrylate, coils, and gelatin sponges were used for embolization. The technical and clinical success rates of TAE were 100%. One complication, a duodenal ulcer, developed in one patient and was managed conservatively. Conclusion TAE is an effective and safe treatment for EUS-FNA-induced bleeding.

Association Between Pancreatic Cysts and Diabetes Mellitus in Von Hippel-Lindau Disease.

INTRODUCTION: Pancreatic cysts are frequently observed in patients with von Hippel-Lindau disease (VHL), and they are considered clinically not important. This study aimed to evaluate the association between pancreatic cysts and diabetes mellitus (DM) in patients with VHL. METHODS: Among patients who were on a patient list at the VHL Center at Kyoto University Hospital as of December 2022, those who had undergone an upper abdominal magnetic resonance imaging study after 2010 were retrospectively evaluated. The presence or absence of DM and high glycated hemoglobin (HbA1c) levels (>6.0%) were assessed. Patients were divided into two groups: those with DM or high HbA1c levels, and those without DM or high HbA1c levels. The area of the whole pancreas, including the pancreatic cysts and tumors, the area of the pancreatic cysts, and the percentage of pancreatic cysts, calculated by dividing the area of pancreatic cysts by the area of the whole pancreas, were measured on T2-weighted magnetic resonance images and compared between the two groups. RESULTS: Thirty-six patients with VHL, comprising 22 men and 14 women, with a mean age of 36.4 years (range, 11-79 years), were identified. Seven patients had DM, and two additional patients had high HbA1c levels. The area of the pancreatic cysts (p = 0.0013) was significantly larger and the percentage of the pancreatic cysts (p = 0.0016) was significantly higher in patients with DM or high HbA1c levels (n = 9) than in patients without DM or high HbA1c levels (n = 27); however, the difference in the area of the whole pancreas was not significant (p = 0.068). CONCLUSION: Our findings suggest that patients with VHL who have a large area covered by pancreatic cysts are more likely to have DM than those without.

Transarterial Embolization of Type 2 Endoleak Post Thoracic Endovascular Aortic Repair (TEVAR) Using a Triaxial System With a 1.3-F Microcatheter: A Case Report.

Although transarterial embolization is recognized as a treatment for type 2 endoleaks, it can occasionally be challenging. We report the case of an 86-year-old man who presented with an enlarging thoracoabdominal aortic aneurysm following thoracic endovascular aortic repair. Using a triaxial system with a 1.3-F microcatheter, transarterial embolization of a type 2 endoleak was successfully performed through a long and tortuous arterial route comprising the thoracodorsal and ninth intercostal arteries. The postoperative clinical course was uneventful, and computed tomography obtained six days later showed no endoleak in the thoracoabdominal aortic aneurysm. This case suggests the usefulness of a triaxial system with a 1.3-F microcatheter for transarterial embolization of type 2 endoleaks.

Pseudoaneurysm of the superficial temporal artery after sagittal split ramus osteotomy: A case report.

Sagittal split ramus osteotomy (SSRO) is a widely performed orthognathic surgery; however, among the various reported complications of SSRO, pseudoaneurysms are rarely reported. Pseudoaneurysms are rare vascular lesions formed by damage to the arterial wall that can occur after trauma or postoperatively, causing uncontrolled bleeding. The present report describes a case of a pseudoaneurysm that occurred after SSRO in a 22-year-old female patient. Le Fort I osteotomy and bilateral SSRO were performed under general anesthesia to improve the gummy smile and mandibular asymmetry of the patient. While osteotomizing the medial side of the left SSRO, major bleeding occurred from the soft tissue of the posterior margin of the mandibular branch. Direct compression with gauze and a local hemostatic agent stopped the bleeding. Immediately after returning to the ward, bleeding was observed from the left wound site and marked swelling of the left buccal area occurred. Contrast-enhanced computed tomography revealed a pseudoaneurysm of the left superficial temporal artery (STA). Subsequently, arterial embolization for the pseudoaneurysm was performed. Overall, the present report describes a rare case of pseudoaneurysm of the STA as a postoperative complication of SSRO.

Dual Lumen Microcatheter in Percutaneous Biliary Drainage for Postoperative Bile Leakage: A Case Report.

Percutaneous biliary intervention is widely accepted as an effective and safe treatment for various types of bile duct diseases. We present the case of a 44-year-old woman who developed bile leakage after a living-donor liver transplantation for locally advanced cholangiocarcinoma. A percutaneous drainage tube was placed in the segment 8 bile duct via the blind end of the jejunum. However, the bile leakage was unchanged. Bile leakage from the right posterior hepatic duct was suspected. Using a dual lumen microcatheter, a percutaneous drainage tube was placed in the segment 7 bile duct via the blind end of the jejunum, which reduced the bile leakage. These results suggest that a dual lumen microcatheter is a valuable tool for navigating the biliary tree during difficult percutaneous biliary interventions.

Transcatheter arterial embolization of a type 2 endoleak through the dorsal pancreatic artery after the hybrid repair of a thoracoabdominal aortic aneurysm: A case report.

An 83-year-old woman with a history of hybrid repair of thoracoabdominal aortic aneurysm presented with enlargement of the aneurysm due to a type 2 endoleak from the celiac artery. The endoleak cavity was accessed via the dorsal pancreatic artery, and embolization using N-butyl cyanoacrylate and coils was successfully performed. When celiac artery branches are embolized during hybrid repair of a thoracoabdominal aortic aneurysm, attention should be paid to the dorsal pancreatic artery to appropriately determine which branches are to be embolized, because a nonembolized dorsal pancreatic artery may lead to type 2 endoleaks.

Percutaneous Image-Guided Transesophageal Long Intestinal Tube Placement for Palliative Decompression in Advanced Cancer Patients with Unresectable Malignant Small Bowel Obstruction.

PURPOSE: To assess the safety and efficacy of long intestinal tube placement following percutaneous image-guided esophagostomy for palliative decompression of incurable malignant small bowel obstruction. MATERIALS AND METHODS: Between January 2013 and June 2022, a single-institution retrospective study was conducted to examine patients undergoing percutaneous transesophageal intestinal intubation for an occluded intestinal segment. Patients' baseline characteristics, procedural details, and clinical courses were reviewed. Severe complications were defined as those with ≥ 4 grade according to the CIRSE classification. RESULTS: This study included 73 patients (mean age, 57.7 years) who underwent 75 procedures. All bowel obstructions were caused by peritoneal carcinomatosis or similar disease, which precluded transgastric access in almost 50% of the patients due to massive cancerous ascites (n = 28), diffuse gastric involvement (n = 5), or omental dissemination in front of the stomach (n = 3). Technical success (appropriate tube positioning) was achieved in 98.7% (74/75) of procedures. The cumulative 1-month overall survival and sustained clinical success (adequate bowel decompression) rates were estimated at 86.8% and 88%, respectively, using Kaplan-Meier analysis. At the median survival of 70 days, the disease progression required other gastrointestinal interventions, including additional tube insertion, repositioning, or venting enterostomy in 16 patients (21.9%). The severe complication rate was 4% (3/75); one patient aspirated to death due to tube clogging and two encountered fatal perforation of isolated intestinal loops developing far beyond the tip of the indwelling tube. CONCLUSION: Percutaneous image-guided transesophageal intestinal intubation achieves feasible bowel decompression as palliative care in advanced cancer patients. LEVEL OF EVIDENCE: Level 4, Case Series.

Transcatheter arterial embolization of the subclavian and axillary artery branches for hemorrhage control.

OBJECTIVE: To evaluate the effectiveness and safety of transcatheter arterial embolization (TAE) of the branches of the subclavian and axillary arteries for hemorrhage control. METHODS: Between January 2015 and June 2022, 35 TAE procedures were performed for hemorrhage from the branches of the subclavian and axillary arteries in 34 patients (22 men, 12 women; 1 male underwent TAE twice; mean age = 76 years). Pre-TAE CT showed hematomas in the chest (n = 25) and abdominal walls (n = 3), shoulder (n = 2), and lower neck (n = 2). CT showed hemothorax in eight cases. Angiographic findings, embolization technique, and technical and clinical success of TAE were retrospectively assessed in all cases. RESULTS: TAE was performed by transfemoral (n = 16), transradial (n = 12), and transbrachial (n = 7) approaches. Angiography revealed contrast media extravasation or pseudoaneurysms in 32 cases (91.4%). The most commonly embolized arteries were the internal thoracic (n = 12), lateral thoracic (n = 6), and thoracoacromial (n = 6) arteries. Technical and clinical success rates were 100 and 85.7%, respectively. A complication (skin necrosis after injection of the liquid embolic agent) developed in only one patient (2.9%) and was conservatively managed. CONCLUSION: TAE is an effective and safe treatment for hemorrhage from the branches of the subclavian and axillary arteries. ADVANCES IN KNOWLEDGE: Transfemoral approach has been used for TAE of the branches of the subclavian and axillary artery. Transradial and transbrachial approaches can also be considered.

Transcatheter arterial embolization for subcapsular hematoma of the liver.

PURPOSE: This study aimed to evaluate the technical and clinical success rates of transcatheter arterial embolization (TAE) for subcapsular hematoma of the liver. METHODS: Between January 2010 and March 2022, 34 patients underwent TAE for subcapsular hematomas of the liver. The causes of subcapsular hematoma were liver tumor rupture (n = 12), trauma (n = 12), iatrogenic complications (n = 9), and spontaneous bleeding (n = 1). The technical and clinical success rates of TAE, blood test results after TAE and additional treatments were evaluated. The patients were divided into either with or without retrograde segmental or lobar portal venous flow on angiography. Technical and clinical success rates and blood test results after TAE were compared between the two groups. RESULTS: Technical and clinical success rates were 94.1% and 73.5%, respectively. Six patients died within one month of TAE. A repeat TAE was performed in three patients. Surgical removal and hemostasis for subcapsular hematoma were done in four patients. One patient had liver failure. The retrograde portal venous flow was observed in 18 patients. The difference in technical and clinical success rates and blood test results after TAE between the two groups was statistically insignificant. CONCLUSION: TAE is an effective and safe treatment for subcapsular hematomas of the liver. The success rates of TAE and liver damage due to TAE did not differ between patients with and without retrograde portal venous flow.

Natural History of Hepatic Hemangiomas Larger Than 10 cm: Imaging Findings and Clinical Course of 22 Cases.

INTRODUCTION: The natural history of a large hepatic hemangioma is important in determining the treatment strategy. Although several studies have assessed the natural history of hepatic hemangiomas, no study has focused on hepatic hemangiomas measuring >10 cm. The aim of this study was to assess the natural history of hepatic hemangiomas measuring >10 cm by evaluating imaging findings and clinical course. METHODS: Computed tomography (CT) and magnetic resonance imaging (MRI) reports at Kyoto University Hospital, Kyoto, Japan, between January 2001 and March 2023 were retrospectively searched to find adult patients with hepatic hemangiomas >10 cm. Patients who were followed up without treatment for over six months were included. The maximum diameter of the hepatic hemangioma was compared between the baseline and the final CT or MRI. The clinical course of the patients was evaluated. RESULTS: Twenty-two patients (17 women, five men; median age, 51 years) were identified. The median diameter of hepatic hemangiomas in the baseline study was 114 mm. Two patients had abdominal distention at the time of the baseline imaging, whereas the others were asymptomatic. After follow-up without treatment (the median; 95.5 months), enlargement, no change, shrinkage of hepatic hemangioma was observed in six, 11, and five patients, respectively. The median growth rate of hepatic hemangiomas was 2.5 mm/year. Two patients underwent liver resection for hepatic hemangioma, while the others were followed up without treatment. In four patients, symptoms appeared or worsened. Two patients died: one patient died from prostate cancer progression; the cause of death for the other was not confirmed. CONCLUSION: Hepatic hemangiomas show a slow growth rate during follow-up, and shrinkage is occasionally observed. Some patients experience new symptoms or aggravation of symptoms; however, deaths associated with hepatic hemangiomas are uncommon.

Transcatheter arterial embolization for bleeding from the pancreaticoduodenal artery in patients with celiac artery stenosis: A technical report.

Background: Transcatheter arterial embolization (TAE) is widely accepted as a treatment for bleeding from the pancreaticodoudenal artery (PDA) in patients with celiac artery stenosis. However, the technical aspect of TAE has not received much attention. Purpose: To report the technical details and success rate of TAE for bleeding from the PDA in patients with CA stenosis. Material and Methods: Between 2015 and 2021, nine TAE procedures were performed in eight patients (five women, three men; one woman underwent TAE twice). The cause of CA stenosis was compression by the median arcuate ligament in eight cases and CA dissection in one case. The cause of bleeding was flow-related aneurysm rupture in six cases. Pre-TAE CT showed a pseudoaneurysm in all cases. The technical details of TAE were recorded, and the success rate was evaluated. Results: The technical and clinical success rates were 100%. In six cases, both the CA and superior mesenteric artery (SMA) were cannulated using two parent catheters: a microcatheter advancing to the pseudoaneurysm from the CA (the CA approach) to achieve embolization and another catheter for angiography advancing from the SMA to map the vascular anatomy. In five cases, the CA approach was successfully performed after failed attempts of advancing a microcatheter from the SMA. Conclusion: TAE is an effective treatment for bleeding from the PDA in patients with CA stenosis. Using two parent catheters, one for CA cannulation and microcatheter advancement and another for SMA cannulation and vascular mapping, may be a useful technique.

Selection of the right inferior phrenic artery using a dual-lumen microcatheter in transarterial chemoembolization for hepatocellular carcinoma.

An 88-year-old woman with a history of multiple hepatocellular carcinomas (HCCs) presented with a new HCC in segment seven of the liver. We decided to perform transarterial chemoembolization for HCC. During treatment, the HCC was supplied by the right inferior phrenic artery (IPA), which originated from the proximal part of the left gastric artery with a steep bifurcation angle. Due to the very short distance between the origins of the left gastric artery and right IPA, the microguidewire and microcatheter were unstable in the left gastric artery and easily prolapsed into the celiac artery. Although different types of microcatheters were used, the right IPA could not be selected. Therefore, we used a dual-lumen microcatheter (DLM) to select the right IPA. The DLM stabilized the microguidewire in the left gastric artery, and the right IPA was successfully selected. Subsequently, transarterial chemoembolization was administered using a branch of the right IPA. Given this experience, we will consider using a DLM as an alternative method for selecting an abdominal artery when other techniques are unsuccessful.

Chest wall systemic artery-to-pulmonary artery vascular malformation treated by embolization of feeders and drainers: A case report.

A 74-year-old woman presented with progressive dyspnea. Computed tomography revealed a large systemic artery-to-pulmonary artery vascular malformation (VM) on the right chest wall. Embolization of the VM was performed. First, the main drainers of the VM were retrogradely selected from the segmental pulmonary arteries and embolized using microcoils. Second, 2 main feeders of the VM were selected and embolized with N-butyl cyanoacrylate. Thus, marked flow reduction in the VM was achieved, and the patient's symptom improved dramatically. We believe that embolization of both feeders and drainers is an effective technique for treatment of a chest wall systemic artery-to-pulmonary artery VM.

Percutaneous Radiologic Gastrostomy in Patients After Partial Gastrectomy: A Retrospective Study to Assess the Technical Feasibility of Postsurgical Remnant Stomach Access.

PURPOSE: To evaluate the technical feasibility of percutaneous radiologic gastrostomy in patients after partial gastrectomy. MATERIALS AND METHODS: This retrospective study included 15 consecutive gastrectomized patients with attempted percutaneous radiologic gastrostomy at our institution between April 2014 and March 2021. When the stomach was sufficiently insufflated to distend below the left anterior subcostal margin, percutaneous radiologic gastrostomy with gastropexy was conventionally performed by the Seldinger technique. When the stomach was still highly positioned and/or overlaid by the other organs, some adjunctive maneuvers, such as hydro-displacement, intragastric balloon support, or cephalad oblique puncture or left intercostal puncture, were employed as modified gastrostomy. Ultrasonography or x-ray or computed tomography fluoroscopy was used for imaging guidance during the gastric puncture. Adequate tube placement was defined as technical success. Technical details, clinical outcomes, and complications were reviewed. RESULTS: One patient underwent percutaneous radiologic jejunostomy instead of gastrostomy because safe gastric access could not be ensured. Seven patients underwent conventional gastrostomy; the other seven underwent modified gastrostomy with no gastropexy. The technical success rate was 100% (7/7) in the conventional group and 85.7% (6/7) in the modified group. The stomach was punctured under x-ray or computed tomography fluoroscopy for conventional gastrostomy. In contrast, the combination of various modalities was used for modified gastrostomy except for one failed case with unintentional transhepatic access. During a median follow-up of 108 days, no major complications occurred. CONCLUSION: The adequate combination of multimodal imaging guidance and technical modifications could secure radiological creation of gastrostomy for the postsurgical stomach. LEVEL OF EVIDENCE: Level 4, Case Series.

Direct percutaneous access to an omental vein for embolization of Roux-en-Y limb varices in a child.

An 11-year-old boy with a history of hepatoblastoma treated with chemotherapy, radiation therapy, and liver transplantation presented with bleeding from Roux-en-Y limb varices. The transhepatic approach for portal intervention posed a risk of liver graft injury. An omental vein that was dilated as a collateral vein due to portal hypertension was found and compressible under ultrasound. The omental vein was percutaneously punctured, and the varices were embolized through a jejunal vein. No complication occurred. Direct percutaneous access to the portal venous system is a useful technique for portal embolization.

Future liver remnant hypertrophy rate in portal vein embolization before left trisectionectomy: a retrospective cohort study.

PURPOSE: Reports on the future liver remnant (FLR) hypertrophy rate in patients undergoing portal vein embolization (PVE) before left trisectionectomy are sparse. This study aimed to assess the FLR hypertrophy rate in patients undergoing PVE before left trisectionectomy. METHODS: Between January 2010 and June 2021, 30 patients (22 men and eight women; mean age, 65.7 years) underwent PVE, mainly using gelatin sponge, before left trisectionectomy. The preoperative diagnosis was cholangiocarcinoma in 28 patients and colorectal liver metastases in two patients. The FLR hypertrophy rate, increase in the FLR volume (FLRV) ratio (the ratio of the FLRV to the total liver volume), and complications were evaluated. The patients were further divided into two groups: one group of patients with left portal vein stenosis or occlusion before PVE (n = 12) and another without left portal vein stenosis or occlusion before PVE (n = 18). The FLR hypertrophy rate and increase in the FLRV ratio were compared between the two groups. RESULTS: The FLR hypertrophy rate and increase in the FLRV ratio were 31.3% and 6.9%, respectively. One major complication, cholangitis, developed; however, its association with PVE was unclear. The difference in the FLR hypertrophy rate and the increase in the FLRV ratio between the two groups of patients was statistically insignificant. CONCLUSION: PVE before left trisectionectomy is effective in achieving FLR hypertrophy. PVE before left trisectionectomy was equally effective in patients with left portal vein stenosis or occlusion as compared to those without. The complication rates were acceptable.

Percutaneous Transhepatic Biliary Intervention in Adult Biliary Atresia Patients After Kasai Portoenterostomy.

Kasai portoenterostomy (KP) is a standard treatment for patients with biliary atresia (BA). After KP, patients with BA occasionally develop biliary complications, such as recurrent cholangitis, biliary stricture, and cystic dilatation of the intrahepatic bile duct. Percutaneous transhepatic biliary drainage is one of the treatment options for these biliary complications. However, limited information is available on percutaneous transhepatic biliary drainage performed after KP in adult BA patients with native livers. Herein, we describe 8 cases of percutaneous transhepatic biliary interventions performed after KP in 7 adult BA patients with native livers. Cholangiography showed multiple cystic dilatation of the intrahepatic bile ducts. Advancing a guidewire and catheter was difficult due to the multiple dilatations and strictures of the bile duct. Successful biliary drainage tube placement and clinical improvement was achieved in 5 and 3 cases, respectively. Because of its technical difficulty and limited clinical effectiveness, it is not recommended that it be performed easily.

Pediatric abdominal arterial intervention using a steerable microcatheter through an introducer with 4-F outer diameter: report of two cases.

In pediatric arteriography, vascular complications are more common than in adults; thus, the use of the smallest catheter to accomplish the objective of the procedure is recommended. We describe two pediatric cases in which abdominal arterial embolization and arteriography were performed with steerable microcatheters without conventional diagnostic catheters. Additionally, we used an introducer with an outer diameter of 4-F in a Mini Access Kit (Merit Medical, South Jordan, UT) as a vascular sheath to reduce sheath size. We believe that this technique may be feasible and safe for abdominal arterial interventions in children.