N-Butyl-cyanoacrylate-assisted retrograde transvenous obliteration (NARTO) for gastric varices.

We describe the usefulness of n-butyl-cyanoacrylate (nBCA)-assisted retrograde transvenous obliteration (NARTO) for gastric varices in 3 consecutive patients. In all patients, balloon catheters were inserted into the gastrorenal shunt via the left renal vein. After injecting sclerosant into the gastric varix under balloon occlusion, nBCA was injected to the proximal side of the shunt, to completely embolize the shunt. NARTO is a simple technique to achieve stagnation of the injected sclerosant in gastric varices and to occlude a gastrorenal shunt. This procedure is also cost-effective, and may improve procedure time compared with original or modified balloon-occluded retrograde transvenous obliteration.

Metallic Stents for Hepatic Venous Outflow Obstruction After Living-Donor Liver Transplantation and their Therapeutic Effects.

BACKGROUND: Living-donor liver transplantation (LDLT) is established as a standard therapy for end-stage liver disease; however, vessel reconstruction is more demanding due to the short length and small size of the available structures compared with deceased-donor whole liver transplantation. Interventional radiology (IR) has become the first-line treatment for vascular complications after LDLT. Hepatic venous outflow obstruction (HVOO) is a life-threatening complication after LDLT. The aim of this study of 592 adult-to-adult LDLT cases was to investigate the safety and efficacy of stent implantation for HVOO after LDLT. METHODS: Records of patients who developed HVOO requiring any treatment were collected with special reference to the metallic stent implantation. There were 232 left-side grafts and 360 right-side grafts. Sixteen cases developed HVOO after LDLT with an incidence rate of 2.7%, 5 with a left liver graft (2%), and 11 with a right-side graft (3%). The IR was attempted for 14 cases; among those, 8 cases were treated by stent implantation. RESULTS: The technical success rate of the initial stent implantation was 100%. The pressure gradient at the stenotic site significantly improved from 12.2 (range, 10.9-20.4 cm H2O) to 3.9 cm H2O (range, 1.4-8.2 cm H2O; P = .03). The volume of the congested graft liver decreased significantly from 1448 (range, 788-2170 mL) to 1265 mL (range, 748-1665 mL; P = .01), and the serum albumin level improved significantly from 3.3 (range, 1.7-3.7 g/dL) to 3.7 g/dL (range, 2.9-4.1 g/dL; P = .02). No procedure-related complication was noted, and the long-term stent patency was 100%. CONCLUSION: Metallic stent implantation for stenotic venous anastomosis after LDLT is a safe and effective treatment.

A case of intermittent CT imaging for up to 2 hours following asymptomatic air emboli due to a CT-guided lung biopsy.

Air emboli represent rare but severe complications of computed tomography (CT)-guided lung biopsy (CTLB). No reports exist regarding the behavior of air during the early stages of air emboli. We present a case of air emboli following CTLB, evaluated by intermittent CT over a 2-hour period, spanning from onset to resolution. A man in his 60s underwent CTLB for diagnosis of a slowly enlarging pulmonary nodule in the right lower lobe. Immediately post-biopsy, chest CT revealed air emboli in the right coronary artery and apex of the ascending aorta. The patient was in the head-down position on the CT table, and intermittent CT scans were performed over a 2-hour period until the air emboli resolved. Subsequently, the patient was discharged without any complications.

Myeloid sarcoma and pathological fracture: a case report and review of literature.

Myeloid sarcoma is a rare clinical entity that presents as an isolated proliferation of leukemic cells, concurrently with or at relapse of acute myeloid leukemia (AML), myelodysplastic syndromes/neoplasms (MDS), chronic myeloid leukemia (CML), and myeloproliferative neoplasm (MPN). Myeloid sarcoma disrupts the normal architecture of its surrounding tissues. When it forms in long bones, it can cause their pathological fracture. We recently experienced a rare case of MDS presenting with myeloid sarcoma in the femur that eventually resulted in its pathological fracture. Detailed chromosomal analysis of the bone marrow cells suggested emergence of myeloid sarcoma during the fast-paced progression of MDS just after acquiring trisomy 22. A comprehensive review of previous cases of myeloid sarcoma-associated pathological fracture indicated possible involvement of structural rearrangements of chromosomes 9 and 22. Management of myeloid sarcoma should continue to improve, and clinicians should note that myeloid sarcoma with specific chromosomal alterations needs extra medical attention to prevent pathological fracture.

N-butyl-2-cyanoacrylate Packing of a Gastroduodenal Artery Pseudoaneurysm due to Distal Pancreatectomy After Subtotal Esophagectomy.

We describe the successful n-butyl cyanoacrylate (NBCA) packing of a large gastroduodenal artery pseudoaneurysm after distal pancreatectomy in a patient with a history of subtotal esophagectomy and gastric tube reconstruction. The pseudoaneurysm was considered to be caused by direct injury to the gastroduodenal artery (GDA). However, embolization of the GDA was not possible in this case because due to prior esophageal surgery, the main blood vessel supplying the gastric tube was the right epigastric artery from the GDA. Packing a pseudoaneurysm with NBCA is a treatment option when preservation of the parent artery is required.

Effects of deep learning on radiologists' and radiology residents' performance in identifying esophageal cancer on CT.

OBJECTIVE: To investigate the effectiveness of a deep learning model in helping radiologists or radiology residents detect esophageal cancer on contrast-enhanced CT images. METHODS: This retrospective study included 250 and 25 patients with and without esophageal cancer, respectively, who underwent contrast-enhanced CT between December 2014 and May 2021 (mean age, 67.9 ± 10.3 years; 233 men). A deep learning model was developed using data from 200 and 25 patients with esophageal cancer as training and validation data sets, respectively. The model was then applied to the test data set, consisting of additional 25 and 25 patients with and without esophageal cancer, respectively. Four readers (one radiologist and three radiology residents) independently registered the likelihood of malignant lesions using a 3-point scale in the test data set. After the scorings were completed, the readers were allowed to reference to the deep learning model results and modify their scores, when necessary. RESULTS: The area under the curve (AUC) of the deep learning model was 0.95 and 0.98 in the image- and patient-based analyses, respectively. By referencing to the deep learning model results, the AUCs for the readers were improved from 0.96/0.93/0.96/0.93 to 0.97/0.95/0.99/0.96 (p = 0.100/0.006/<0.001/<0.001, DeLong's test) in the image-based analysis, with statistically significant differences noted for the three less-experienced readers. Furthermore, the AUCs for the readers tended to improve from 0.98/0.96/0.98/0.94 to 1.00/1.00/1.00/1.00 (p = 0.317/0.149/0.317/0.073, DeLong's test) in the patient-based analysis. CONCLUSION: The deep learning model mainly helped less-experienced readers improve their performance in detecting esophageal cancer on contrast-enhanced CT. ADVANCES IN KNOWLEDGE: A deep learning model could mainly help less-experienced readers to detect esophageal cancer by improving their diagnostic confidence and diagnostic performance.

Interventional treatment for portal vein complications utilizing a hybrid operating room after liver transplantation.

BACKGROUND: Vascular complications after liver transplantation (LT) can be lethal and require immediate treatment to prevent graft failure. Nowadays, with interventional radiology (IR), approaches such as the percutaneous transhepatic (PTH) and transileocolic venous (TIC), have become major treatment options. We reviewed the safety and efficacy of a hybrid operating room (OR) for portal vein complications after LT. METHODS: Patients who underwent IR for post-LT vascular complications in the hybrid OR from May 2014 to May 2022 were enrolled. Patients who underwent post-LT IR in conventional angiography rooms were excluded. RESULTS: Nine patients developed portal vein complications; eight after living donor LT and one after deceased donor LT. Six patients had portal vein stenosis, two had portal vein thrombosis, and one had both. In the hybrid OR, PTH and TIC were used in five and three cases, respectively. The Rendezvous technique was used in one case. Angioplasty was performed in all patients. A stent was placed in four patients. The portal venous pressure gradient across the stenotic site significantly decreased after IR (P &= 0.031). The IR success rate in the hybrid OR was 100%. CONCLUSION: The hybrid OR enables us to accomplish IR for post-LT vascular complications safely and effectively.

Pull-through technique for hepatic vein angioplasty after liver transplantation.

Hepatic venous outflow complication is one of the crucial vascular complications after liver transplantation. We describe successful use of the pull-through technique for hepatic vein angioplasty in a patient with stenosis of the middle and left hepatic veins (MHV and LHV) after living-donor liver transplantation. It was difficult to select the stenotic MHV with a femoral approach. However, the guidewire was unexpectedly inserted into a small collateral vein and selective angiography showed the MHV through the collaterals. Because the guidewire proceeded to the MHV via the collateral and finally into the inferior vena cava, we advanced a catheter from the inferior vena cava to the MHV using the pull-through technique and performed balloon angioplasty.

Successful transcatheter embolization of an unruptured idiopathic peripheral pulmonary artery aneurysm.

Pulmonary artery aneurysms (PAAs) occurring in the distal branch of the pulmonary artery are rare, and there are only a few reports of transcatheter embolization of unruptured idiopathic peripheral PAAs. We report a case of a 66-year-old woman with a history of surgery for pulmonary arteriovenous malformations who presented with an idiopathic peripheral PAA of A10 confirmed by contrast-enhanced computed tomography and pulmonary artery angiography. Transcatheter embolization was performed to prevent rupture, and the aneurysm was successfully embolized. Although there is no consensus on the indications and treatment for unruptured idiopathic peripheral PAAs, transcatheter embolization may be a favorable treatment option.

Marked Cognitive and Activities of Daily Living Improvement by Shunt Embolization in a Very Old Man with Portosystemic Encephalopathy Mimicking Alzheimer Disease: A Case Report.

A 91-year-old man with chronic cognitive impairment underwent shunt embolization for portosystemic encephalopathy (PSE). He experienced intermittent episodes of impaired consciousness and decreased cognitive function and activities of daily living (ADL), for which Alzheimer disease was suspected. On admission, he was in a coma and PSE was diagnosed based on his high ammonia level and the computed tomography findings. After shunt embolization, the patient fully recovered from the impaired consciousness and experienced no recurrence. The patient's Revised Hasegawa Dementia Scale and Mini-Mental State Examination scores improved significantly from 12 and 17 to 30 and 29 points, respectively. The Barthel Index score also improved from 55/100 to 85/100, suggesting a marked improvement in ADL. PSE progresses slowly in very old patients and may mimic the clinical course of Alzheimer disease but without liver enzyme abnormalities. Therefore, it should be distinguished in every dementia case.

A Case of Preeclampsia with Uterine Necrosis after Uterine Artery Embolization for Postpartum Hemorrhage.

Uterine necrosis is a rare complication in uterine artery embolization (UAE) for postpartum hemorrhage (PPH). Preeclampsia (PE) is a condition characterized with systemic endothelial damage and intravascular volume depletion. Whether a patient with PE is at high risk for uterine necrosis after UAE for PPH has been unknown. A 30-year-old primipara woman was diagnosed with PE based on hypertension and proteinuria during delivery. UAE was performed for PPH after forceps delivery. After UAE, the patient presented with pleural effusion and massive ascites as well as persistent fever unresponsive to antibiotics. Ultrasonography and contrast-enhanced magnetic resonance imaging (MRI) led to the diagnosis of uterine necrosis, for which we performed total laparoscopic hysterectomy. It should be kept in mind that patients with PE associated with massive ascites may be at high risk for uterine necrosis after UAE due to decreased uterine perfusion. Therefore, it is important to pay attention to persistent symptoms such as fever and abdominal pain after UAE to diagnose uterine necrosis.

Preoperative portal vein embolization: a comparison of ethanol and coils versus ethanol alone.

PURPOSE: To compare the efficacy and safety of preoperative portal vein embolization (PVE) with ethanol and coils versus ethanol alone. MATERIAL AND METHODS: Between April 2014 and May 2019, 45 patients underwent right preoperative PVE with ethanol and coils (n = 19; EthCo group) or ethanol alone (n = 26; Eth group). RESULTS: The change in % future liver remnant (FLR) was not significantly different between the EthCo and Eth groups (11.2 ± 4.3% versus 11.3 ± 4.1%, p = .98). Less ethanol was used in the EthCo group (9.7 ± 3.5 mL versus 11.9 ± 4.4 mL, p = .02). Recanalization was observed in eight patients only in the Eth group (p < .01). There were no differences in the pre-/post-PVE laboratory data between the two groups, except for post-PVE albumin. The volume of ethanol used was positively correlated with the post-PVE total bilirubin (p = .01), aspartate aminotransferase (AST) (p < .01) and alanine aminotransferase (ALT) (p < .01) levels. CONCLUSION: The efficacy of PVE did not differ between the EthCo and Eth groups. The use of ethanol and coils was associated with less recanalization and liver damage compared with ethanol alone.

Atypical Neurofibromatous Neoplasm with Uncertain Biologic Potential in the Posterior Mediastinum of a Young Patient with Neurofibromatosis Type 1: A Case Report.

Atypical neurofibromatous neoplasm with unknown biological potential (ANNUBP), proposed in a recent NIH consensus overview, is a rare precursor entity of malignant peripheral nerve sheath tumor (MPNST) in neurofibromatosis type 1 (NF1) patients. Only one report on imaging findings of ANNUBP is available. Herein, we present the case of a 19-year-old female, diagnosed with a mediastinal tumor by chance, who visited to our hospital. She had café-au-lait spots on her trunk and a past history of resected neurofibroma. Her family also had café-au-lait spots; therefore, an NF1-induced tumor was strongly suspected. MRI revealed a paravertebral mass of 7.5 cm in size consisting of an inner rim with low T2 signal intensity and an outer rim with high T2 intensity, which was similar to a target sign, adjacent to the pulmonary veins; the center of the tumor was well enhanced by gadolinium, and the peripheral region was myxoid and slightly enhanced. FDG-PET showed high FDG uptake, SUVmax of 8.5, although the peripheral region represented low FDG accumulation. CT-guided needle biopsy was repeated because of the suspicion of an MPNST, which resulted in the histopathological diagnosis of ANNUBP. Marginal tumor resection was performed, and the final post-resection histopathological diagnosis was ANNUBP transformed from neurofibroma; the region of ANNUBP lost p16 immunostaining, although it was retained in the peripheral region of the neurofibroma. There has been no recurrence or metastasis 1 year after treatment. In conclusion, ANNUBP could be represented as a well-enhanced homogeneous mass on MRI and a high FDG accumulated region on FDG PET/CT, as seen in MPNST, in NF1 patients.

Tumor-associated macrophage-derived inflammatory cytokine enhances malignant potential of malignant pleural mesothelioma.

Malignant pleural mesothelioma (MPM) is an asbestos-related aggressive malignant neoplasm. Due to the difficulty of achieving curative surgical resection in most patients with MPM, a combination chemotherapy of cisplatin and pemetrexed has been the only approved regimen proven to improve the prognosis of MPM. However, the median overall survival time is at most 12 mo even with this regimen. There has been therefore a pressing need to develop a novel chemotherapeutic strategy to bring about a better outcome for MPM. We found that expression of interleukin-1 receptor (IL-1R) was upregulated in MPM cells compared with normal mesothelial cells. We also investigated the biological significance of the interaction between pro-inflammatory cytokine IL-1ß and the IL-1R in MPM cells. Stimulation by IL-1ß promoted MPM cells to form spheroids along with upregulating a cancer stem cell marker CD26. We also identified tumor-associated macrophages (TAMs) as the major source of IL-1ß in the MPM microenvironment. Both high mobility group box 1 derived from MPM cells and the asbestos-activated inflammasome in TAMs induced the production of IL-1ß, which resulted in enhancement of the malignant potential of MPM. We further performed immunohistochemical analysis using clinical MPM samples obtained from patients who were treated with the combination of platinum plus pemetrexed, and found that the overexpression of IL-1R tended to correlate with poor overall survival. In conclusion, the interaction between MPM cells and TAMs through a IL-1ß/IL-1R signal could be a promising candidate as the target for novel treatment of MPM (Hyogo College of Medicine clinical trial registration number: 2973).

Embolization of visceral arterial aneurysms: Simulation with 3D-printed models.

OBJECTIVES: The present technical article aimed to describe the efficacy of three-dimensional (3D)-printed hollow vascular models as a tool in the preoperative simulation of endovascular embolization of visceral artery aneurysms. METHODS: From November 2015 to November 2016, four consecutive endovascular treatments of true visceral artery aneurysms were preoperatively simulated with 3D-printed hollow models. The mean age of the patients (one male and three females) was 54 (range: 40-71) years. Three patients presented with splenic artery aneurysm and one with anterior pancreaticoduodenal artery aneurysm. The average diameter of the aneurysms was 16.5 (range: 10-25) mm. The 3D-printed hollow models of the visceral artery aneurysms and involved arteries were created using computed tomography angiography data of the patients. After establishing treatment plans by simulations with the 3D-printed models, all patients received endovascular treatment. RESULTS: All four hollow aneurysm models were successfully fabricated and used in the preoperative simulation of endovascular treatment. In the preoperative simulations with 3D-printed hollow models, splenic aneurysms were embolized with coils and/or n-butyl-2-cyanoacrylate to establish the actual treatment plans, and a small arterial branch originating from an anterior pancreaticoduodenal artery aneurysm was selected to obtain feedback regarding the behavior of catheters and guidewires. After establishing treatment plans by simulations, the visceral artery aneurysms of all patients were successfully embolized without major complications and recanalization. CONCLUSIONS: Simulation with 3D-printed hollow models can help establish an optimal treatment plan and may improve the safety and efficacy of endovascular treatment for visceral artery aneurysms.

Comparison of image quality between synthetic and patients' electrocardiogram-gated 320-row pediatric cardiac computed tomography.

BACKGROUND: Pediatric cardiac computed tomography (CT) can be acquired without electrode placement by using synthetic electrocardiogram (ECG). OBJECTIVE: To determine whether the depiction of gross cardiac structures and coronary arteries in 320-row pediatric CT is not inferior when CT is gated with synthetic ECG at 150 beats per minute (bpm), compared to the patients' own ECG. MATERIALS AND METHODS: Sixty 320-row CT examinations performed in children younger than 3 years old with congenital cardiac anomaly were enrolled in this retrospective study. Thirty examinations were scanned using the children's own ECG for gating and 30 examinations were scanned using synthetic ECG at 150 bpm. The image quality was compared between the two gating modes using a 3-point scale to delineate the following anatomical structures: atrial septum, ventricular septum, right atrium, right ventricle, left atrium, left ventricle, main pulmonary artery, ascending aorta, aortic arch including the patent ductus arteriosus, descending aorta, right coronary artery and left main trunk. Beam-hardening artifacts from contrast enhancement material were evaluated using a 3-point scale, and the overall image quality was evaluated using a 5-point scale. RESULTS: Synthetic ECG was not inferior to the patients' ECG in depicting each structure, beam-hardening artifact and overall image quality. Average indices were clinically acceptable imaging quality, except for subjective image quality of mid and distal coronary arteries. CONCLUSION: Pediatric cardiac CT in patients younger than 3 years old can be acquired using synthetic ECG gating, with image quality not inferior to the patients' ECG.

Right Lower Lobectomy for an Aberrant Mediastinal Inferior Lobar Artery.

A 74-year-old woman was referred for a right lower lobe consolidation (maximum diameter, 73 mm) pathologically diagnosed as invasive mucinous adenocarcinoma (c-T4 N0 M0, c-stage IIIA). Computed tomography revealed an aberrant mediastinal inferior lobar branch (A6 and common basal artery [A7 to A10]) from the right main pulmonary artery (PA). Right lower lobectomy and lymph node dissection were performed. A mediastinal inferior lobar branch is extremely rare, and this patient with lung cancer underwent right lower lobectomy for all inferior PA branches (A6 and A7 to A10) arising from the main PA into the lower lobe.

EphA2 inhibition suppresses proliferation of small-cell lung cancer cells through inducing cell cycle arrest.

Small-cell lung cancer (SCLC) is characterized by one of neuroendocrine tumors, and is a clinically aggressive cancer due to its rapid growth, early dissemination, and rapid acquisition of multidrug resistance to chemotherapy. Moreover, the standard chemotherapeutic regimen in SCLC has not changed for three decades despite of the dramatic therapeutic improvement in non-SCLC. The development of a novel therapeutic strategy for SCLC has become a pressing issue. We found that expression of Eph receptor A2 (EphA2) is upregulated in three of 13 SCLC cell lines and five of 76 SCLC tumor samples. Genetic inhibition using siRNA of EphA2 significantly suppressed the cellular proliferation via induction of cell cycle arrest in SBC-5 cells. Furthermore, small molecule inhibitors of EphA2 (ALW-II-41-27 and dasatinib) also exclusively inhibited proliferation of EphA2-positive SCLC cells by the same mechanism. Collectively, EphA2 could be a promising candidate as a therapeutic target for SCLC.

Double-Balloon-Assisted N-Butyl-2-Cyanoacrylate Embolization of Nontumorous Intrahepatic Arterioportal Shunts.

This report describes the safety and efficacy of double-balloon-assisted N-butyl-2-cyanoacrylate embolization of nontumorous intrahepatic arterioportal shunts in 5 consecutive, previously untreated patients. A proximal balloon was used for flow control and a coaxial microballoon was used to control the delivery of N-butyl-2-cyanoacrylate. Complete occlusion was achieved in 3 patients and shunt flow decreased in 2 patients, without complications. In the latter 2 patients, pre-embolization shunt flow was lower than that in patients with complete occlusion. Our results suggest that this coaxial double-balloon-assisted technique may be safe and effective for the embolization of nontumorous intrahepatic arterioportal shunts, especially in high-flow shunts.