Transvenous embolization for a huge pelvic arteriovenous malformation associated with prominent outflow veins.

We describe the case of an adult female with a huge pelvic arteriovenous malformation (AVM) measuring approx. 8 × 10 × 13 cm, treated via the transvenous approach alone. Management of huge pelvic AVMs is challenging; there is no consensus on a standardized treatment strategy. In our patient, multiple arterioles shunted to prominently dilated outflow veins. Selective occlusion of prominent outflow veins as close to the nidus as possible achieved significant flow reduction through the nidus. Our treatment may be a safe and acceptable option to control hematuria for huge pelvic AVMs associated with prominent outflow veins, especially when both transarterial embolization and direct puncture are difficult.

Usefulness of dynamic computed tomography for diagnosing and evaluating uterine artery pseudoaneurysms in women with late post-partum hemorrhage not complicated by retained products of conception.

AIM: We examined whether critical conditions, which were defined as having hemoglobin (Hb) less than 7.0 g/dL, shock index ≥1.0, or need for transfusion, were associated with the presence of extravasation (EV) on dynamic computed tomography (CT) in women with late post-partum hemorrhage (PPH). METHODS: Forty post-partum women with late PPH without evident retained products of conception performed dynamic CT. Two radiologists retrospectively evaluated dynamic CT, and determined the presence or absence of EV and a sac-like structure within the uterine cavity with enhancement. RESULTS: Ultrasound images were available in 34/40 patients. Color Doppler flow in uterine cavity was evaluated in 33/34 (97%), and all women showed abnormal flow. Of 40 patients, dynamic CT revealed EV in 8 (20%), and a sac-like structure in 30 (75%). Thus, we diagnosed these 38 (95%) as having uterine artery pseudoaneurysm (UAP). Uterine artery embolization was performed in 36/38 diagnosed as having UAP, and in 2/2 patients with an unknown cause of hemorrhage. The incidence rates of critical conditions were significantly increased in PPH women with than without EV on dynamic CT: Hb <7.0 g/dL (62.5 vs 0%, [P < 0.001]), shock index ≥1.0 (50 vs 9.4% [P = 0.020]), and need for transfusion (37.5 vs 0% [P = 0.006]). Abnormal color Doppler flows were observed in all patients with either EV and sac on dynamic CT. CONCLUSION: Dynamic CT was useful for diagnosing UAP, and for evaluating critical conditions, in women with late PPH not complicated by retained products of conception.

Blood flow of the venous system during resuscitative endovascular balloon occlusion of the aorta: Noninvasive evaluation using phase contrast magnetic resonance imaging.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a viable resuscitation approach for a subdiaphragmatic injury that can regulate arterial blood flow. On the other hand, the evaluation of venous or portal venous blood flow during REBOA remains insufficient because invasive cannulation or exposure of the vessel may affect the blood flow, and Doppler echography is highly operator-dependent. However, phase contrast magnetic resonance imaging has enabled accurate evaluation and noninvasive measurement. This study aimed to investigate the change of venous and portal venous blood flow during REBOA in a porcine model. METHODS: Seven pigs were anesthetized, and a REBOA catheter was placed. The blood flows of the inferior vena cava (IVC), hepatic vein (HV), portal vein (PV), and superior vena cava (SVC) were measured using phase contrast magnetic resonance imaging, in both the balloon deflated (no-REBOA) and fully balloon inflated (REBOA) states. Mean arterial pressure (MAP), central venous pressure, cardiac index, and systemic vascular resistance index were measured. RESULTS: The blood flows of the suprahepatic, infrahepatic, and distal IVC, HV, and PV in the no-REBOA state were 1.40 ± 0.36 L·min, 0.94 ± 0.16 L·min, 0.50 ± 0.19 L·min, 0.060 ± 0.018 L·min, and 0.32 ± 0.091 L·min, respectively. The blood flow of each section in the REBOA condition was significantly decreased at 0.41 ± 0.078 (33% of baseline), 0.15 ± 0.13 (15%), 0.043 ± 0.034 (9%), 0.029 ± 0.017 (37%), and 0.070 ± 0.034 L·min (21%), respectively. The blood flow of the SVC increased significantly in the REBOA condition (1.4 ± 0.63 L·min vs. 0.53 ± 0.14 L·min [257%]). Mean arterial pressure, central venous pressure, cardiac index, and systemic vascular resistance index were significantly increased after REBOA inflation. CONCLUSION: Resuscitative endovascular balloon occlusion of the aorta decreased blood flows of the IVC, HV, and PV and increased blood flow of the SVC. This result could be explained by the collateral flow from the lower body to the SVC. A better understanding of the effect of REBOA on the venous and portal venous systems may help control liver injury.

Usefulness of Gd-EOB-DTPA-enhanced MRI for evaluating the potential for early development of hepatocellular carcinoma after HCV eradication by direct-acting antiviral treatment.

Objective: The development of hepatocellular carcinoma (HCC) is not uncommon in patients who achieve eradication of the hepatitis C virus through direct-acting antiviral (DAA) treatment. The aim of this study was to identify the patients at high risk for novel HCC development after a sustained virologic response (SVR) by DAA treatment. Patients and Methods: A total of 518 patients with no history of HCC treatment and who achieved SVR by DAA treatment were evaluated retrospectively. The correlations between HCC development and the patients' characteristics were evaluated. For patients who underwent gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) or dynamic contrast-enhanced computed tomography, the relationship between the imaging findings and subsequent HCC development was also assessed. Results: HCC developed newly in 22 patients, and the 1-year and 3-year cumulative HCC rates were 2.0% and 8.5%, respectively. In multivariate analysis, a FIB-4 index >4.0 and a post-treatment α-fetoprotein >4.0 ng/ml were significant risk factors for HCC. In 26 of 118 patients who underwent an MRI before DAA treatment, a non-hypervascular hypo-intense nodule was seen in the hepatobiliary phase, and in 6 of 182 patients who underwent a CT, a non-hypervascular hypo-enhanced nodule was seen in the delayed phase. The sensitivity and specificity of the MRI-positive findings for the subsequent development of HCC were 0.92 and 0.87, respectively, and those of the CT were 0.40 and 0.99, respectively. In multivariate analysis of patients who underwent an MRI, a non-hypervascular hypo-intense nodule was the only factor that was significantly related to HCC development (HR 32.4, p = 0.001). Conclusion: Gd-EOB-DTPA-enhanced MRI was found to be reliable for risk evaluation of subsequent HCC development in patients after SVR by DAA treatment. Patients with a non-hypervascular hypo-intense nodule need more careful observation for incident HCC.

Transcatheter Proximal Coil Blocking with n-Butyl-2-Cyanoacrylate Injection via the Pulmonary Artery Alone for Rasmussen's Aneurysm.

Rasmussen's aneurysm is a peripheral pulmonary artery pseudoaneurysm (PAP) within a tuberculosis cavity. Because it can be perfused from the bronchial and pulmonary arterial circulations, combined embolization via the bronchial and pulmonary arteries is sometimes required. Herein, we present case of a 51-year-old man with Rasmussen's aneurysm that was successfully treated by proximal coil blocking with n-butyl-2-cyanoacrylate (NBCA) injection via the pulmonary artery alone. With proximal coil blocking, a sufficient amount of NBCA could be injected without unintended reflux of the NBCA cast to the proximal pulmonary artery. To our knowledge, there has been no report that attempted NBCA injection under proximal coil blocking for Rasmussen's aneurysm. Our treatment approach may be safe and effective for infectious lung disease-related PAP, which has to be treated from the pulmonary artery side.

Uterine artery pseudoaneurysm: its occurrence after non-traumatic events, and possibility of "without embolization" strategy.

OBJECTIVES: Uterine artery pseudoaneurysm (UAP) has been considered to occur very rarely after traumatic delivery/abortion, and is usually detected after its rupture, yielding massive bleeding. Our hypothesis is: some UAP may be undetected without massive bleeding and may spontaneously resolve, and, thus, may not require transarterial embolization (TAE). We attempted: (1) to detect both ruptured and non-ruptured UAP, thereby characterizing candidates of spontaneously resolving UAP, and (2) to confirm that UAP is not rare and not always associated with traumatic events. STUDY DESIGN: This was a retrospective observational study of 50 women with angiographically confirmed UAP and treated by TAE. Angiograms and medical charts were retrieved to examine the associations among symptoms, ultrasound findings, and extravasation. Gray-scale ultrasound was performed for all women after delivery or abortion as our routine practice. RESULTS: UAP occurred in 3-6/1000 deliveries and 40% occurred after non-traumatic deliveries/abortion. While 36% had active vaginal bleeding at admission, 64% did not. While 100% of patients with current active bleeding showed extravasation from the pseudoaneurysmal sac, patients without it showed a varied incidence of extravasation depending on the bleeding pattern/history and ultrasound findings. Interestingly, all patients with current bleeding (-), bleeding history (+), and ultrasound-discernable-intrauterine low echoic mass (-) were devoid of extravasation, suggesting that UAP may show progression to thrombosis and, thus, resolve spontaneously. CONCLUSIONS: UAP may not be so rare and not associated with traumatic delivery/abortion. Some UAP may resolve, and, thus, may not require TAE, at least immediately.

Endovascular Embolization of an Aberrant Bronchial Artery Originating from the Internal Mammary Artery in a Patient with Hemoptysis.

Massive hemoptysis is a life threatening respiratory emergency with high mortality and the bronchial artery (BA) is its most frequent source. Herein, we report a case of a 76-year-old man with recurrent hemoptysis due to an aberrant right BA arising from the right internal mammary artery (IMA), an extremely rare origin, that was clearly depicted on pretreatment computed tomography angiography (CTA). The patient was treated successfully by transcatheter bronchial artery embolization (BAE) of the aberrant BA and the hemoptysis has since been controlled for 9 months. Knowledge of the detailed BA anatomy is essential for performing BAE, especially in cases of aberrant BA. CTA is a promising tool for pretreatment planning of emergency BAE in patients with hemoptysis.

Subclinical growth of an arteriovenous fistula associated with renal biopsy: a case report.

BACKGROUND: Renal biopsy is not free from complications and patients who undergo this procedure are usually hospitalized to receive intensive care for several days after biopsy. In contrast, after this period, routine follow-up to detect biopsy-associated complications is rarely scheduled, unless the patient develops a clinical manifestation. We describe a case of marked enlargement of arteriovenous fistula in the kidney that occurred many years after renal biopsy. In contrast to the previous cases requiring interventional radiology, our patient showed subclinical growth of fistula over about nine years. CASE PRESENTATION: A 24-year-old man with a history of percutaneous renal biopsy was hospitalized for interventional radiology. Gross hematuria emerged shortly after biopsy, but completely disappeared with administration of hemostatic agents and bed rest. Subsequently, the patient had few symptoms for many years. A giant fistula (a gourd-shaped mass, size 26 × 22 and 12 × 11 mm) was unexpectedly detected by ultrasonography performed for examination of an unrelated disorder (slight elevation of serum transaminase) at 9 years after the original biopsy. The fistula was successfully treated with radiological intervention. Thus, subclinical development of complications associated with renal biopsy should be considered, even in an uneventful course. CONCLUSIONS: This case provides a platform to discuss the importance of long-term follow-up of patients after renal biopsy despite of its difficulty.

Uterine artery pseudoaneurysm hidden behind septic abortion: pseudoaneurysm without preceding procedure.

Uterine artery pseudoaneurysm (UAP) can occur after cesarean section or traumatic delivery, usually manifesting as postpartum hemorrhage. Here we report a patient with UAP possibly caused by septic abortion. She had high fever and bleeding with positive urine pregnancy test. We diagnosed this condition as septic abortion. Ultrasound revealed an intrauterine echogenic mass and color Doppler revealed swirling blood flow within the mass. Contrast-enhanced computed tomography showed a heterogeneously enhanced intrauterine mass. Selective internal iliac artery angiography revealed contrast medium within the mass immediately after medium injection. Bilateral uterine artery embolization was performed, after which medium no longer accumulated in the uterus, and hemostasis was achieved, confirming the diagnosis as UAP. Antibiotic treatment ameliorated the infection and the uterine content was expelled and absorbed. UAP can occur even without preceding procedures and may manifest abortive, and not postpartum, hemorrhage. UAP may be hidden behind septic abortion.

Flank pain, nausea, vomiting and hypotension in a chronic hemodialysis patient with a spontaneous perirenal hemorrhage.

Decreases in blood pressure develop in response to a wide range of clinical disorders. Various factors have been implicated in the development of hemodialysis-associated hypotension, including an impairment of the compensatory processes, an autonomic dysfunction or cardiac failure. The additional presence of concomitant acute abdomen may result in a diagnostically challenging situation. We herein report our experience with a chronic hemodialysis patient who developed severe hypotension with acute flank pain due to spontaneous bleeding around the kidney. Concerns regarding the management of the disease are also discussed.

Bioavailability of orally administered water-dispersible hesperetin and its effect on peripheral vasodilatation in human subjects: implication of endothelial functions of plasma conjugated metabolites.

Hesperetin is an aglycone of citrus flavonoids and is expected to exert a vasodilatation effect in vivo. We developed water-dispersible hesperetin by the process of micronization to enhance the bioavailability of hesperetin. This study aimed to assess the effect of this process on the bioavailability of hesperetin and to estimate its efficiency on vasodilatation-related functions using endothelial cells in vitro and a human volunteer study at a single dose in vivo. We found that water-dispersible hesperetin was absorbed rapidly, with its maximum plasma concentration (C(max)) being 10.2 ± 1.2 µM, and that the time to reach C(max), which is within 1 h if 150 mg of this preparation was orally administered in humans. LC-MS analyses of the plasma at C(max) demonstrated that hesperetin accumulated in the plasma as hesperetin 7-O-ß-D-glucuronide (Hp7GA), hesperetin 3'-O-ß-D-glucuronide (Hp3'GA) and hesperetin sulfate exclusively. Similar to hesperetin, Hp7GA enhanced nitric oxide (NO) release by inhibiting nicotinamide adenine dinucleotide phosphate-oxidase (NADPH oxidase) activity in a human umbilical vein endothelial cell culture system, indicating that plasma hesperetin metabolites can improve vasodilatation in the vascular system. A volunteer study using women with cold sensitivity showed that a single dose of water-dispersible hesperetin was effective on peripheral vasodilatation.These results strongly suggest that rapid accumulation with higher plasma concentration enables hesperetin to exert a potential vasodilatation effect by the endothelial action of its plasma metabolites. Water-dispersible hesperetin may be useful to improve the health effect of dietary hesperetin.

Novel human papillomavirus type 18 replicon and its application in screening the antiviral effects of cytokines.

Human papillomaviruses (HPVs) infect the stratified epithelial organ. The infection induces benign tumors, which occasionally progress into malignant tumors. To elucidate the virus-induced tumorigenesis, an understanding of the lifecycle of HPV is crucial. In this report, we developed a new system for the analysis of the HPV lifecycle. The new system consists of a novel HPV replicon and an organotypic "raft" culture, by which the HPV-DNA is maintained stably in normal human keratinocytes for a long period and the viral vegetative replication is reproduced. This system will benefit biochemical and genetic studies on the lifecycle of HPV and tumorigenesis. This system is also valuable in screening for antiviral compounds. We confirmed its usefulness by evaluating the antivirus effect of cytokines.

Effect of 4G-alpha-glucopyranosyl hesperidin on brown fat adipose tissue- and cutaneous-sympathetic nerve activity and peripheral body temperature.

Changes in the activity of the autonomic nervous system are good indicators of alterations in physiological phenomena such as the body temperature, blood glucose, blood pressure. Hesperidin, a flavanone known as vitamin P, has been shown to reduce the levels of serum lipids, cholesterol, and blood pressure. However, hesperidin is not water-soluble and is not well absorbed from the intestine. G-hesperidin (4G-alpha-glucopyranosyl hesperidin) is more water-soluble and more rapidly absorbed than hesperidin. In order to clarify the functions of G-hesperidin, we examined the effects of oral administration of G-hesperidin on interscapular brown adipose tissue-sympathetic nerve activity (BAT-SNA) and cutaneous sympathetic nerve activity (CASNA) in rats weighing about 300 g. In this study, we found that oral administration of 60 mg of G-hesperidin increased the BAT-SNA but decreased the CASNA in urethane-anesthetized rats. Since an elevation in BAT-SNA increases heat production (i.e. body temperature (BT)) and a decrease in CASNA increases cutaneous perfusion, we examined whether oral administration of G-hesperidin had an effect on the peripheral BT in rats. Consequently, we observed that the subcutaneous BT at the caudal end of the back after oral administration of 60 mg of G-hesperidin was significantly higher than the subcutaneous BT after oral administration of water in conscious rats. These findings suggest that G-hesperidin enhances the BAT-SNA and suppresses the CASNA resulting in an increase in the peripheral BT, probably by an increase in the thermogenesis in the BAT and an elevation in the cutaneous blood flow.

Ras modifies proliferation and invasiveness of cells expressing human papillomavirus oncoproteins.

Infection by human papillomavirus (HPV) is a major risk factor for human cervical carcinoma. However, the HPV infection alone is not sufficient for cancer formation. Cervical carcinogenesis is considered a multistep process accompanied by genetic alterations of the cell. Ras is activated in approximately 20% of human cancers, and it is related to the metastatic conversion of tumor cells. We investigated how Ras activation was involved in the malignant conversion of HPV-infected lesions. The active form of H-ras was introduced into human primary keratinocytes expressing the HPV type 18 (HPV18) oncoproteins E6 and/or E7. We analyzed the keratinocytes' growth potentials and found that the activation of the Ras pathway induced senescence-like growth arrest. Senescence could be eliminated by high-risk E7 expression, suggesting that the pRb pathway was important for Ras-induced senescence. Then we analyzed the effect of Ras activation on epidermis development by using an organotypic "raft" culture and found that the E7 and H-ras coexpressions conferred invasive potential on the epidermis. This invasiveness resulted from the upregulation of MT1-MMP and MMP9 by H-ras and E7, respectively, in which the activation of the MEK/extracellular signal-regulated kinase pathway was involved. These results indicated that the activation of Ras or the related signal pathways promoted the malignant conversion of HPV-infected cells.