Pre-emptive Aortic Side Branch Embolization during Endovascular Aneurysm Repair Using the Excluder Stent-Graft System: A Prospective Multicenter study.

PURPOSE: To evaluate the effectiveness and safety of pre-emptive transcatheter arterial embolization (P-TAE) for aortic side branches (ASBs) to prevent Type 2 endoleaks (EL2) before endovascular aneurysm repair (EVAR) using the Excluder stent-graft system (Excluder). MATERIALS AND METHODS: In this prospective, multicenter study, 80 patients (mean age, 79.1 years [SD ± 6.7]; 85.0% were men; mean aneurysmal sac diameter, 48.4 mm [SD ± 7.4]) meeting the eligibility criteria were prospectively enrolled from 9 hospitals. Before EVAR, P-TAE was performed to embolize the patent ASBs originating from the abdominal aortic aneurysm. Contrast-enhanced computed tomography (CT) was performed at 1 month and 6 months after EVAR. The primary endpoint was EL2 incidence at 6 months, and the secondary endpoints were aneurysmal sac diameter changes at 6 and 12 months, P-TAE outcomes, adverse events related to P-TAE, reintervention, and aneurysm-related mortality. RESULTS: All patients successfully underwent P-TAE without serious. Coil embolization was successful in 81.6% of ASBs. EL2 incidence at 6 months was identified in 18 of 70 (25.7%) patients. Aneurysmal sac diameter shrinkage (≥5 mm) was observed in 30.0% of patients at 6 months and in 40.9% at 12 months. Only 1 patient required reintervention for EL2 within 1 year of EVAR; aneurysm-related deaths were not observed. CONCLUSIONS: P-TAE for ASBs before EVAR using Excluder is a safe and effective strategy. It aids in achieving early aneurysmal sac shrinkage and reduces EL2 reintervention at 1 year after EVAR.

Side branch embolization before endovascular abdominal aortic aneurysm repair to prevent type II endoleak: A prospective multicenter study.

PURPOSE: The purpose of the study was to evaluate the efficacy and safety of pre-emptive transcatheter arterial embolization (P-TAE) of aortic side branches to prevent type II endoleak in patients with abdominal aortic aneurysm after endovascular abdominal aneurysm repair (EVAR). MATERIALS AND METHODS: This multicenter, prospective, single-arm trial enrolled 100 patients with abdominal aortic aneurysm from nine hospitals between 2018 and 2021. There were 85 men and 15 women, with a mean age of 79.6 ± 6.0 (standard deviation) years (range: 65-97 years). P-TAE was attempted for patent aortic side branches, including the inferior mesenteric artery, lumbar arteries, and other branches. The primary endpoint was late type II endoleak incidence at 6 months post-repair. Secondary endpoints included changes in aneurysmal sac diameter at 6- and 12 months, complications, re-intervention, and aneurysm-related mortality. Aneurysm sac changes at 6- and 12 months was compared between the late and no-late type II endoleak groups. RESULTS: Coil embolization was successful in 80.9% (321/397) of patent aortic side branches, including 86.3% of the inferior mesenteric arteries, 80.3% of lumbar arteries, and 55.6% of other branches without severe adverse events. Late type II endoleak incidence at 6 months was 8.9% (8/90; 95% confidence interval: 3.9-16.8%). Aneurysm sac shrinkage > 5 mm was observed in 41.1% (37/90) and 55.3% (47/85) of the patients at 6- and 12-months post-EVAR, respectively. Patients with late type II endoleak had less aneurysm sac shrinkage than those without type II endoleak at 12 months (-0.2 mm vs. -6.0 mm; P = 0.040). No patients required re-intervention for type II endoleak, and no aneurysm-related mortalities occurred. CONCLUSION: P-TAE is safe and effective in preventing type II endoleak, leading to early sac shrinkage at 12 months following EVAR.

Uterine diverticulum mimicking endometriotic cyst of the ovary.

Uterine diverticulum is a rare congenital malformation caused by abnormal fusion of the Müllerian ducts. The diagnosis of uterine diverticulum is difficult, and it is often misdiagnosed as a Müllerian duct anomaly, degenerated uterine fibroid, or ovarian cyst. We herein report a case of uterine diverticulum mimicking an ovarian endometriotic cyst. A multiparous woman with a history of normal vaginal delivery underwent magnetic resonance imaging for investigation of lower abdominal pain and fever. A 155-mm cystic lesion was observed on the ventral side of the uterus. The content of the cyst showed high signal intensity on T1- and T2-weighted images with precipitates of low signal intensity on the dorsal side, suggesting an endometriotic cyst of the ovary. Surgical and pathological findings revealed that the cyst was pedunculated from the anterior uterine body and composed of 3 layers: CD10-positive endometrium, a smooth muscle layer, and serosa. A uterine diverticulum was definitively diagnosed.

Endovascular Aneurysm Repair with Balloon Thrombectomy for Acute Thrombosis of Abdominal Aortic Aneurysm.

Acute occlusion of abdominal aortic aneurysm (AAA) is a rare complication and is usually treated with surgical reconstruction. We present a case of acute AAA occlusion that was successfully treated by endovascular aneurysm repair (EVAR) with Fogarty balloon thrombectomy. A 77-year-old man with a history of acute myocardial ischemia presented with limb weakness and coldness. Contrast-enhanced computed tomography showed a 42-mm-diameter infrarenal AAA that was completely thrombosed in the distal portion. The proximal neck of the aneurysm was patent, and its shape was suitable for EVAR. Therefore, we performed balloon thrombectomy of the aortoiliac thrombus that was followed by EVAR. EVAR can be a less invasive alternative than traditional treatment for acute occlusion of AAA.

Radiologic-Pathologic Correlation of Primary and Secondary Cardiomyopathies: MR Imaging and Histopathologic Findings in Hearts from Autopsy and Transplantation.

Cardiac magnetic resonance (MR) imaging with late gadolinium enhancement (LGE) is used to detect and assess the myocardial damage seen with a variety of cardiomyopathies. Gadolinium-based contrast material accumulates in the expanded interstitial space of the myocardium. Areas with LGE correspond to replacement fibrosis, fibrofatty change, epithelioid granuloma, inflammatory cell infiltration, cardiomyocyte necrosis, and amyloid deposition-conditions that represent a focal increase in interstitial space. Areas without LGE correspond to interstitial or plexiform fibrosis, mildly degenerated cardiomyocytes, inflammatory cell infiltration, and diffuse amyloid deposition-conditions that represent diffuse increases in interstitial space. LGE MR imaging cannot depict these diffuse changes and does not enable quantitative evaluation of this increased interstitial space because on inversion-recovery MR images, the inversion time is adjusted to null the signal from normal-appearing or the least enhancing regions of the myocardium. Thus, the absence of LGE does not always indicate normal myocardial tissue. The use of current T1 mapping techniques enables one to overcome these drawbacks of LGE imaging, detect diffuse myocardial abnormalities, and perform quantitative analysis of the interstitial space. The authors describe the histopathologic and corresponding cardiac MR imaging findings of hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, cardiac sarcoidosis, giant cell myocarditis, and cardiac amyloidosis-mainly those seen on LGE MR images-as assessed by using whole-heart specimens obtained from autopsy or transplantation. ©RSNA, 2017.

The feasibility of a 64-slice MDCT for detection of the Adamkiewicz artery: comparison of the detection rate of intravenous injection CT angiography using a 64-slice MDCT versus intra-arterial and intravenous injection CT angiography using a 16-slice MDCT.

Identification of the Adamkiewicz artery (AKA) using CT angiography (CTA) is crucial in patients with thoracic aortic aneurysm (TAA) or aortic dissection (AD). The purpose of this study was to compare the AKA detection rate of intravenous injection with a 64-slice MDCT (IV64) versus a 16-slice MDCT (IV16) as well as by CTA using intra-arterial injection with a 16-slice MDCT (IA16). A retrospective review of 160 consecutive patients who underwent CTA was performed. There were 108 TAA and 52 AD cases, 105 of whom were examined with IV64, 15 with IV16, and 40 with IA16. The AKA detectability for each imaging method was assessed, and the factors influencing the detectability were analyzed by multivariate analysis. The detection rates for IV64, IV16, and IA16 were 85.7, 60.0, and 80.0 %, respectively, with IV64 being more sensitive than IV16 (P = 0.025). The detection rate for AD patients was 66.7 % with IV64, which was similar to IV16 (57.1 %) and IA16 (66.8 %). On the other hand, the detection rate for TAA patients was 93.3 % with IV64, which was higher than IV16 (62.5 %, P = 0.021) and similar to IA16 (88.0 %). Multivariate analysis demonstrated the independent factors for AKA detectability were TAA versus AD (P = 0.005, Odds ratio = 3.98) and IV64 versus IV16 (P = 0.037, Odds ratio = 4.03). The detection rate was higher for IV64 than for IV16, especially for TAA patients, while the rate was similar between IV64 and invasive IA16. A 64-slice MDCT thus provides a less invasive visualization of the AKA.

Long-term results of endovascular stent graft placement of ureteroarterial fistula.

PURPOSE: To evaluate the safety, efficacy, and long-term results of endovascular stent graft placement for ureteroarterial fistula (UAF). METHODS: We retrospectively analyzed stent graft placement for UAF performed at our institution from 2004 to 2012. Fistula location was assessed by contrast-enhanced computed tomography (CT) and angiography, and freedom from hematuria recurrence and mortality rates were estimated. RESULTS: Stent graft placement for 11 UAFs was performed (4 men, mean age 72.8 ± 11.6 years). Some risk factors were present, including long-term ureteral stenting in 10 (91%), pelvic surgery in 8 (73%), and pelvic radiation in 5 (45%). Contrast-enhanced CT and/or angiography revealed fistula or encasement of the artery in 6 cases (55%). In the remaining 5 (45%), angiography revealed no abnormality, and the suspected fistula site was at the crossing area between urinary tract and artery. All procedures were successful. However, one patient died of urosepsis 37 days after the procedure. At a mean follow-up of 548 (range 35-1,386) days, 4 patients (36%) had recurrent hematuria, and two of them underwent additional treatment with secondary stent graft placement and surgical reconstruction. The hematuria recurrence-free rates at 1 and 2 years were 76.2 and 40.6%, respectively. The freedom from UAF-related and overall mortality rates at 2 years were 85.7 and 54.9%, respectively. CONCLUSION: Endovascular stent graft placement for UAF is a safe and effective method to manage acute events. However, the hematuria recurrence rate remains high. A further study of long-term results in larger number of patients is necessary.

Is embolization of the pancreas safe? Pancreatic histological changes after selective transcatheter arterial embolization with N-butyl cyanoacrylate in a swine model.

PURPOSE: This study was designed to evaluate the safety of selective transcatheter arterial embolization (TAE) with N-butyl cyanoacrylate (NBCA) in a swine model in terms of histological changes in the pancreas. METHODS: Three groups of two female swine (58-64 kg) per group underwent TAE of the dorsal pancreatic artery, under anesthesia, with 1:1, 1:4, and 1:9 mixtures of NBCA and iodized oil. Blood parameters were evaluated at days 1, 4, and 10 after TAE, after which the animals were sacrificed and pancreatic tissues were examined under light microscopy. RESULTS: All of the animals were asymptomatic and survived for 10 days. Cone beam computed tomographic angiography revealed occlusion of the dorsal pancreatic artery and no enhancement in the embolized area. The white blood cell count and C-reactive protein level were elevated slightly on day 1 after TAE (mean ± SD: 252.7 ± 27.8 × 10(2)/µl and 0.15 ± 0.07 mg/l, respectively), but they normalized or remained near the upper normal limit thereafter. The serum amylase and lipase levels also were elevated on day 1 (8831.7 ± 2169.2 U/l and 130 ± 53.4 U/l, respectively) but normalized thereafter. Histologically, necrosis and fibrosis were noted only in the embolized segment, and necrosis and acute inflammatory reactions were absent in the nonembolized segment. The border between both segments was well defined. Lymphocytic infiltration and foreign body reaction were noted around the embolized vessels. CONCLUSIONS: Selective TAE with NBCA in the pancreas caused localized ischemic necrosis without clinically significant pancreatitis; therefore, this procedure is tolerable in swine.

Leukoaraiosis and hippocampal atrophy predict neurologic outcome in patients who undergo total aortic arch replacement.

BACKGROUND: This retrospective study determined whether leukoaraiosis and hippocampal atrophy seen in preoperative magnetic resonance imaging (MRI) predict neurologic outcome after total aortic arch replacement. METHODS: From August 2001 to November 2007, 131 consecutive patients (22% women) who underwent elective total arch replacement with selective cerebral perfusion were enrolled. Mean patient age was 71 +/- 17 years (range, 27 to 88 years). On preoperative MRI, mean leukoaraiosis score and hippocampal atrophy score, rated according to the Scheltens scale, were 11.0 +/- 9.2 and 1.5 +/- 1.9, respectively. Forty-three patients (32.8%) had carotid or basilica arterial stenosis, 18 (12.6%) had a stroke, and 6 (4.2%) had a transient ischemic attack. RESULTS: One hospital death (0.8%) occurred. Adverse perioperative neurologic events included intraoperative stroke in 8 (6.1%), postoperative stroke in 2 (1.5%), and temporary neurologic dysfunction (TND) in 11 (8.4%). On multivariate logistic regression, significant predictors of postoperative intraoperative stroke were leukoaraiosis (odds ratio [OR], 1.1, p = 0.02) and aortic arch atheroma (OR, 2.4; p = 0.001). TND was significantly associated with leukoaraiosis (OR, 1.1, p = 0.03) and hippocampal atrophy (OR, 1.6, p = 0.01). The best cutoff value for predicting intraoperative stroke was a leukoaraiosis score exceeding 16 (sensitivity, 70%; specificity, 70%); that for predicting TND was a leukoaraiosis score exceeding 18 (sensitivity, 82%; specificity, 77%) and a hippocampal atrophy score exceeding 2 (sensitivity, 82%; specificity, 76%). CONCLUSIONS: Leukoaraiosis and hippocampal atrophy are significant independent factors for adverse neurologic outcome after total arch replacement.

Dual-energy CT head bone and hard plaque removal for quantification of calcified carotid stenosis: utility and comparison with digital subtraction angiography.

We evaluated quantification of calcified carotid stenosis by dual-energy (DE) CTA and dual-energy head bone and hard plaque removal (DE hard plaque removal) and compared the results to those of digital subtraction angiography (DSA). Eighteen vessels (13 patients) with densely calcified carotid stenosis were examined by dual-source CT in the dual-energy mode (tube voltages 140 kV and 80 kV). Head bone and hard plaques were removed from the dual-energy images by using commercial software. Carotid stenosis was quantified according to NASCET criteria on MIP images and DSA images at the same plane. Correlation between DE CTA and DSA was determined by cross tabulation. Accuracies for stenosis detection and grading were calculated. Stenosis could be evaluated in all vessels by DE CTA after applying DE hard plaque removal. In contrast, conventional CTA failed to show stenosis in 13 out of 18 vessels due to overlapping hard plaque. Good correlation between DE plaque removal images and DSA images was observed (r (2) = 0.9504) for stenosis grading. Sensitivity and specificity to detect hemodynamically relevant (>70%) stenosis was 100% and 92%, respectively. Dual-energy head bone and hard plaque removal is a promising tool for the evaluation of densely calcified carotid stenosis.

Dual-energy direct bone removal CT angiography for evaluation of intracranial aneurysm or stenosis: comparison with conventional digital subtraction angiography.

Dual-energy CT can be applied for bone elimination in cerebral CT angiography (CTA). The aim of this study was to compare the results of dual-energy direct bone removal CTA (DE-BR-CTA) with those of digital subtraction angiography (DSA). Twelve patients with intracranial aneurysms and/or ICA stenosis underwent a dual-source CT in dual-energy mode. Post-processing software selectively removed bone structures using the two energy data sets. Three-dimensional images with and without bone removal were reviewed and compared to DSA. Dual-energy bone removal was successful in all patients. For 10 patients, bone removal was good and CTA maximum-intensity projection (MIP) images could be used for vessel evaluation. For two patients, bone removal was moderate with some bone remnants, but this did not inhibit the three-dimensional visualization. Three aneurysms adjacent to the skull base were only partially visible in conventional CTA but were fully visible in DE-BR-CTA. In five patients with ICA stenosis, DE-BR-CTA revealed the stenotic lesions on the MIP images. The correlation between DSA and DE-BR-CTA was good (R (2)=0.822), but DE-BR-CTA led to an overestimation of stenosis. DE-BR-CTA was able to eliminate bone structure using only a single CT data acquisition and is useful to evaluate intracranial aneurysms and stenosis.

Prospective comparison of high- and low-spatial-resolution dynamic MR imaging with sensitivity encoding (SENSE) for hypervascular hepatocellular carcinoma.

The purpose of this study was to prospectively evaluate the efficacy of high-spatial-resolution dynamic MRI using sensitivity encoding (SENSE) in detection of hypervascular hepatocellular carcinoma (HCC). Thirty-five patients were included in this prospectively planned study, and 25 patients with 31 HCCs were assigned into three groups and underwent the following sequences: group A (n=11): three-dimensional fast-gradient-echo (3D-FGE) high-spatial-resolution dynamic MRI (HR-MRI) with SENSE; group B (n=10): 3D-FGE low-spatial-resolution dynamic MRI (LR-MRI) with SENSE; and group C (n=14): 3D-FGE/LR-MRI without SENSE. For the quantitative analysis, the lesion-to-liver contrast-to-noise ratio (CNR) between the liver and HCCs was measured. For the qualitative analysis, overall image quality for each group was evaluated with a five-point scale analysis. The sensitivities for detection of HCCs were evaluated. The overall image quality in group A was significantly greater than both groups B and C (P<0.01). The sensitivity of lesion detection on HAP was not significantly higher in group A (100%) than group C (69.2%; P>0.05). In our pilot study on a small number of patients, image quality in HR-MRI with SENSE was superior to LR-MRI. A high detection rate was seen with HR-MRI with SENSE in the patients with hypervascular HCCs.

Hypointensity on postcontrast MR imaging from compression of the sacral promontory in enlarged uterus with huge leiomyoma and adenomyosis.

PURPOSE: In patients with huge leiomyoma and with adenomyosis of the uterus, a peculiar area of hypointensity was occasionally observed on postcontrast magnetic resonance (MR) imaging in the dorsal portion of the enlarged uterus near the sacral promontory. We describe the imaging characteristics of these MR findings and correlate them with histopathological findings to examine whether the areas represent specific pathological changes. METHODS: Ten patients with huge leiomyomas and two with huge adenomyotic lesions whose imaging revealed the hypointensity were enrolled. All had enlarged uteri that extended beyond the sacral promontory. MR findings of the hypointense areas were evaluated and correlated with histopathological findings in 5 patients with leiomyoma and two with adenomyosis who had hysterectomy. RESULTS: The ten patients with leiomyoma showed flare-shaped hypointensity arising from the dorsal surface of the uterine body that extended deep into the tumor. The base of the hypointense areas was narrow in 5 patients with intramural leiomyoma and broad in five with subserosal leiomyoma. Two patients with adenomyosis showed nodular-shaped areas of hypointensity in front of the sacral promontory. Precontrast T(1)- and T(2)-weighted MR images showed no signal abnormalities in the portions corresponding to the hypointensity in any of the 12 patients. Pathological examinations showed no specific findings in the portions corresponding to the hypointensity in the 7 patients who had hysterectomy. CONCLUSION: The areas of hypointensity may represent functional changes, such as decreased localized blood flow caused by compression of the sacral promontory.

[Diagnostic imaging--recent progress].

Current advances in the diagnostic imaging for lung cancer includes multidetector-row CT (MDCT), lung cancer screening using low-dose MDCT and fluorodeoxyglucose positron emission tomography (FDG-PET) imaging. There is no question about the clinical usefulness of MDCT, and the further development of the hardware and the software of MDCT will open new horizons for CT diagnosis. PET is not an alternative modality to CT but a supplementary one, which adds metabolic information to the morphology. Recently, experimental research on the refraction imaging of human lung specimens has been performed with synchrotron radiation. With progressive refinement, this technique may come to have some practical purpose in diagnosing lung cancer in vivo.