Balloon-Assisted Portal Vein Embolization Using n-Butyl-2-Cyanoacrylate-Lipiodol-Iopamidol Mixture in Swine: A Comparison of 2 Formulations.

PURPOSE: To compare 2 ratios of n-butyl-2-cyanoacrylate (nBCA)-ethiodized oil (Lipiodol)-iopamidol (NLI) in balloon-assisted portal vein embolization (PVE) in swine. MATERIALS AND METHODS: In an in vitro study, NLI prepared at a ratio of 2:3:1 (NLI231) or 1:4:1 (NLI141) was injected into 2.5- or 10-mL syringes filled with swine blood, and the viscosity of NLI was measured to determine an appropriate balloon occlusion time. Two portal vein branches in 8 female swine (n = 16 vein branches) were embolized with NLI231 (n = 8) or NLI141 (n = 8) under balloon occlusion. Portal venography was performed before, immediately after, and 3 days after PVE to evaluate the migration of NLI and the recanalization of embolized portal vein branches. Then, the livers were removed for histopathologic evaluation. RESULTS: The times to peak viscosity of NLI231 in the 2.5- and 10-mL syringes were 55.8 seconds (SD ± 7.0) and 85.2 seconds (SD ± 6.3), and those to peak viscosity of NLI141 were 129.2 seconds (SD ± 11.8) and 254.0 seconds (SD ± 21.8), respectively. No migration of NLI231 was observed in all 8 procedures immediately or 3 days after PVE. Migration of NLI141 was observed in 6 of 8 procedures within 3 days after PVE. The migration frequency of the embolic material was lower in the NI231 group than in the NLI141 group (0/8 vs 6/8; P = .051). Histologically, NLI231 occupied the portal veins without any thrombi, whereas NLI141 was accompanied by thrombi in the portal veins. CONCLUSIONS: NLI231 may be more suitable than NLI141 for balloon-assisted PVE in swine.

Duodenal bleeding outside covered stents identified by selective computed tomography during arteriography that was successfully treated by embolization: A case report.

The patient was a man in his 60s who previously underwent placement of covered stents in the duodenum for a duodenal stricture caused by pancreatic cancer invasion. He experienced multiple episodes of hematemesis and hematochezia during hospitalization. Emergency upper and lower gastrointestinal endoscopies were performed but were unable to reveal the bleeding source. Based on these findings, we suspected small intestinal bleeding and emergency angiography was performed for the purpose of hemostasis. Computed tomography during arteriography was performed from the superior mesenteric artery and revealed extravasation outside the covered stents in the descending portion of the duodenum. Angiography of the inferior pancreaticoduodenal artery revealed extravasation in the descending portion of the duodenum, and the inferior pancreaticoduodenal artery was embolized with n-butyl cyanoacrylate. There were no postoperative symptoms indicative of intestinal ischemia or pancreatitis, and there was no rebleeding after embolization. In patients with bleeding outside the duodenal-covered stents, it can be difficult to identify the bleeding source by upper gastrointestinal endoscopy. In this case, selective computed tomography during arteriography and angiography revealed bleeding outside the duodenal-covered stents that was successfully treated by arterial embolization with n-butyl cyanoacrylate.

Successful coil embolization of a ruptured aneurysm of the arc of Riolan artery.

The arc of Riolan (AOR) is an anastomosis between the middle and left colic arteries. Aneurysms of the AOR are very rare visceral artery aneurysms. A 44-year-old man presented with abdominal pain and loss of consciousness. Computed tomography and angiography showed hemorrhagic ascites around the liver and spleen. An irregularly dilated artery was visible within a hematoma in the upper left region of the abdomen, consistent with a ruptured pseudoaneurysm of the AOR. Transcatheter arterial embolization was performed with microcoils. The patient's abdominal pain disappeared after embolization, and no symptoms of intestinal ischemia were observed. To our knowledge, this is the first case of an AOR aneurysm with AOR dilation due to dissection of the celiac artery that was successfully treated by coil embolization.

Impact of anticancer drugs on the therapeutic efficacy and side effects of hepatic arterial embolization for hepatocellular carcinoma.

Background and Aim: Transcatheter arterial chemoembolization (TACE) using various anticancer drugs is often performed to treat hepatocellular carcinoma (HCC). We aimed to compare the therapeutic efficacy and side effects of TACE with anticancer drugs versus transcatheter arterial embolization (TAE) without anticancer drugs for HCC. Methods: Patients with HCC were randomized to either the TACE or TAE group. Up to five target nodules were treated in each patient. Lipiodol (Lp; 10 mL), contrast media (CM; 10 mL), epirubicin (40 mg), mitomycin C (10 mg), miliplatin (70 mg), and 1-2-mm 2-day soluble gelatin sponge particles (2D-SGS) were injected into the TACE group, whereas Lp (10 mL), CM (10 mL), and 2D-SGS were injected into the TAE group. Treatment effect (TE) of the target nodules was graded (TE1-TE4) and patient responses were assessed. Three months after treatment, blood tests were performed to compare tumor markers and adverse events. Results: Fifty-four patients and 161 target nodules were included; 75 nodules in 28 patients were treated by TACE, and 86 nodules in 26 patients were treated by TAE. The number of nodules graded TE1, TE2, TE3, and TE4 was 1, 28, 7, and 39, respectively, in the TACE group and 2, 25, 7, and 52, respectively, in the TAE group. The response rates were 89% (25/28) and 73% (19/26) in the TACE and TAE groups, respectively. There were no significant differences in TE, response rates, or blood test results between the two groups. Conclusion: In hepatic arterial embolization for HCC, anticancer drugs did not have any impact on the therapeutic efficacy or side effects at 3 months after embolization.

Recent volcanic activity at the Asama volcano and long-period seismic signals.

Modern observation systems composed of seismic, geodetic, other geophysical, and geochemical networks developed in and around volcanic areas provide a mass of knowledge about volcanic activities. This paper summarizes the magma pathway and recent volcanic activity of the Asama volcano. The seismic velocity structure beneath the Asama volcano was investigated via seismic ambient noise tomography and active source seismic tomography. The magma pathway in the upper crust beneath the Asama volcano was synthesized by combining the velocity structure with a hypocenter distribution of volcanic earthquakes and ground deformations before and after eruptions. Temporal evolutions of multidiscipline data regarding the volcanic activity from October 2003 to January 2018 revealed that the supplied amount of magma from the magma chamber and the internal condition in the shallow regions of the conduit controlled the recent eruptions.

Comparison of Uterine Necrosis After Uterine Artery Embolization with Soluble Gelatin Sponge Particles or Tris-acryl Gelatin Microspheres in Swine.

PURPOSE: To compare the recanalization of the uterine arteries and uterine necrosis after uterine artery embolization (UAE) using either soluble gelatin sponge particles (SGS), which dissolve in saline, or tris-acryl gelatin microspheres (MS), which are permanent embolic materials, in swine. METHODS: Fourteen uteri in seven swine were divided into two groups for embolization with either 500-1000 µm SGS (SGS group) or 500-700 µm MS (MS group) (seven uteri per group). The uterine arteries were embolized using SGS or MS, and angiography was performed to evaluate recanalization of the uterine arteries immediately, 1, 2, 3, 4, 5, and 6 h, and 3 days after embolization. On day 3, the uteri were removed to determine the macroscopic necrosis rate and for histopathologic examination. RESULTS: In the SGS group, four uterine arteries were completely recanalized, two were partially recanalized, and one was still occluded 5 h after embolization. In contrast, all seven uterine arteries in the MS group were still occluded 6 h after embolization. The complete recanalization rate at 3 days was significantly greater in the SGS group than in the MS group (100.0% vs. 14.3%, respectively; P = .0047). The mean uterine necrosis rate was not significantly different between the SGS and MS groups (15.0 ± 15.7% vs. 26.8 ± 13.3%, respectively; P = .096). The mean smallest arterial diameter containing embolic materials was 48.2 ± 22.0 µm (range 21-109 µm) for SGS and 446.7 ± 107.0 µm (range 352-742 µm) for MS (P < .0001). CONCLUSION: The uterine arteries recanalized earlier in the SGS group than in the MS group and the uterine necrosis rates were similar in both groups. SGS have the potential for a more distal penetration in comparison with MS.

Combination with portosystemic shunt occlusion and antiviral therapy improves prognosis of decompensated cirrhosis.

BACKGROUND AND AIM: Portosystemic shunt occlusion using endovascular treatment can transiently improve liver function in patients with decompensated cirrhosis. In recent years, viral hepatitis can be easily controlled. The present study aimed to clarify the safety and efficacy of endovascular treatment in decompensated cirrhotic patients, and to elucidate whether viral treatment improves the prognosis after shunt occlusion. METHODS: Among 98 cirrhotic patients who received portosystemic shunt occlusion from January 2007 to June 2016, we retrospectively analyzed 61 decompensated cirrhotic patients. RESULTS: Forty-five patients had viral hepatitis. Recovery rates of liver function to Child A within 6 months in viral hepatitis, non-viral hepatitis, and overall were 78% (35/45), 81% (13/16), and 79% (48/61), respectively. Recovery rates according to baseline Child-Pugh score were as follows: score 7, 88% (15/17); score 8, 89% (24/27); score 9, 69% (9/13); and score ≥ 10, 0% (0/4). Three-year reprogression rates to decompensated cirrhosis for non-virus, non-sustained viral negativity (SVN), and SVN groups were 23 100, and 0%, respectively (P < 0.01). Three-year survival rates for those were 63, 62, and 91%, respectively (P < 0.01). Eight-year survival rate for SVN group was also 91%. Multivariate analysis revealed age, baseline ammonia level, baseline Child class, and SVN as independent contributors to survival. CONCLUSIONS: SVN in patients with viral hepatitis appears prerequisite to maintaining recovered liver function by shunt occlusion and to improving prognosis. Combination therapy with shunt occlusion and antiviral treatment should be considered as a first-line treatment for decompensated cirrhotic patients with viral hepatitis and large portosystemic shunt growth.

Balloon-Assisted Embolization of Wide-Neck Aneurysms Using a Mixture of n-Butyl Cyanoacrylate, Lipiodol, and Ethanol in Swine: A Comparison of Four n-Butyl Cyanoacrylate Concentrations.

PURPOSE: To determine the optimal ratio of n-butyl cyanoacrylate (NBCA)-Lipiodol-ethanol (NLE) mixture for balloon-assisted embolization of wide-neck aneurysms. MATERIALS AND METHODS: We created 32 wide-neck aneurysms on both the common carotid arteries and external iliac arteries in eight female swine. Eight aneurysms were randomly assigned to four groups. Under balloon occlusion, the aneurysms were packed using NLE at one of four ratios of NLE: 2:2:1 (NLE221; 40%NBCA); 3:6:1 (NLE361; 30%NBCA); 2:7:1 (NLE271; 20%NBCA); and 1:5:1 (NLE151; 14.3%NBCA). We performed angiography before and after embolization to assess the aneurysms, and we compared adhesion between NLE and the balloon and assessed NLE migration. Three days after embolization, the aneurysms were removed for histopathologic evaluation. RESULTS: Embolization was performed in 27 aneurysms. Adhesion between NLE and the balloon was not observed in any group. NLE migration was found in 0/7 aneurysms in the NLE221 group, 0/6 in the NLE361 group, 5/6 in the NLE271 group, and 7/8 in the NLE151 group. NLE migration was significantly lower in the NLE221 group than in the NLE271 and NLE151 groups (P = 0.0047 and 0.0014, respectively) and was significantly lower in the NLE361 group than in the NLE271 and NLE151 groups (P = 0.0152 and 0.0047, respectively). Media necrosis of the arterial wall close to the aneurysms was observed in all groups. CONCLUSION: NLE with an NBCA concentration of ≥ 30% is a safe and feasible embolic material for balloon-assisted embolization of wide-neck aneurysms in swine in the short term up to 3 days after embolization.

Hepatic Arterial Embolization with an Indocyanine Green-LipiodolⓇ Mixture before Laparoscopic Anatomical Liver Resection.

Here, we report a case of hepatocellular carcinoma detected on computed tomography and treated with laparoscopic anatomical liver resection in a 69-year-old woman who was being followed-up for hepatitis C. Intraoperative liver segmentation is necessary to accomplish laparoscopic anatomical liver resection. Therefore, the day before surgery, hepatic artery embolization was performed with an indocyanine green-LipiodolⓇ mixture and GelpartⓇ containing indocyanine green to mark the region for hepatectomy. The next day, surgeons visually confirmed the resection segments on indocyanine green fluorescence imaging and performed laparoscopic anatomical liver resection. No major complications resulted from this method. In conclusion, hepatic artery embolization with an indocyanine green-LipiodolⓇ mixture is effective and safe for liver segment identification during laparoscopic anatomical liver resection.

Successful endovascular treatment of endoscopically unmanageable hemorrhage from a duodenal ulcer fed by a renal artery: A case report.

A 52-year-old woman was admitted with hypovolemic shock. Emergency endoscopy revealed three hemorrhagic duodenal ulcers (all stage A1) with exposed vessels. Two ulcers were successfully treated by endoscopic clipping; however, the remaining ulcer on the posterior wall of the horizontal portion of the duodenum could not be clipped. Because her vital signs were rapidly worsening, we performed transcatheter arterial embolization (TAE) as it is less invasive than surgery. Computed tomography aortography showed that the duodenal hemorrhage was sourced from the lower branch of the right renal artery. In general, the duodenum is fed by branches from the gastroduodenal artery or superior mesenteric artery. However, this patient had three right renal arteries. The lower branch of the right renal artery at the L3 vertebral level was at the same level as the horizontal portion of the duodenum. Complete hemostasis was achieved by TAE using metallic coils and n-butyl-2-cyanoacrylate. After TAE, she recovered from the hypovolemic shock and was discharged from hospital. She has had no recurrence of the hemorrhagic duodenal ulcer for over 1 yr, and follow-up endoscopy showed no necrosis or stricture of the duodenum. Although she developed a small infarct of her right kidney, her renal function was satisfactory. In summary, the present case is the first reported case of hemorrhagic duodenal ulcer in which the culprit vessel was a renal artery that was successfully treated by TAE. Computed tomography aortography before TAE provides valuable information regarding the source of a duodenal hemorrhage.

Acute appendicitis with intestinal malrotation: the usefulness of coronal computed tomography.

We herein present a rare case of acute appendicitis with intestinal malrotation. Coronal images of contrast-enhanced computed tomography (CT) revealed the small intestine on the right side and the large intestine on the left side, thus indicating intestinal malrotation (non-rotation type). In addition, an enhanced, tubular, fluid-filled structure was detected attached to the cecum, which was located superior to the urinary bladder, suggesting acute appendicitis. The present study shows that coronal CT images provide important information for the diagnosis and treatment of acute appendicitis in patients with intestinal malrotation.

Ribosomal DNA haplotype distribution of Bursaphelenchus xylophilus in Kyushu and Okinawa islands, Japan.

Ribosomal DNA region sequences (partial 18S, 28S and complete ITS1, 5.8S, and ITS2) of the pinewood nematode (Bursaphelenchus xylophilus) were obtained from DNA extracted directly from wood pieces collected from wilted pine trees throughout the Kyushu and Okinawa islands, Japan. Either a 2569bp or 2573bp sequence was obtained from 88 of 143 samples. Together with the 45 rDNA sequences of pinewood nematode isolates previously reported, there were eight single nucleotide polymorphisms and two indels of two bases. Based on these mutations, nine haplotypes were estimated. The haplotype frequencies differed among regions in Kyushu island (northwest, northeast and center, southeast, and southwest), and the distribution was consistent with the invasion and spreading routes of the pinewood nematode previously estimated from past records of pine wilt and wood importation. There was no significant difference in haplotype frequencies among the collection sites on Okinawa island.

[The influence of wearing a diaper on static and dynamic postural control in the elderly].

AIM: To clarify characteristics of static and dynamic postural control in elderly people, postural sway during static standing, during an activity, and static standing after the activity were compared between young and elderly subjects. In this study, the action of raising pants-type diapers was selected as the model activity for the measurement of dynamic postural control ability. METHODS: To make differences in the ease of putting on the diapers, their contraction strength around the abdomen was adjusted at 5 levels from loose to tight. Postural sway was measured first during static standing with open and closed eyes and, then, during activity and static standing after activity. The subjects' perceived difficulty in putting on the diapers was also evaluated. RESULTS: Postural sway tended to be larger in elderly than younger subjects during static standing, but the differences were not significant. Also, postural sway was markedly increased in elderly subjects during the raising of diapers requiring greater effort. In static standing after an action, postural sway also remained increased after putting on diapers requiring greater effort only in the elderly group. CONCLUSIONS: Postural sway increased, indicating a decline in the dynamic postural control ability, during an action in association with its level of difficulty even in elderly people showing no decline in static postural control ability. In addition, dynamic postural control responses appeared to affect subsequent static postural control responses, inducing a decline in ability.

A controlled trial of the effect of milk basic protein (MBP) supplementation on bone metabolism in healthy menopausal women.

Milk has more beneficial effects on bone health than other food sources. Recent in vitro and in vivo studies have shown that milk whey protein, especially its basic protein fraction (milk basic protein, MBP), contains several components capable of promoting bone formation and inhibiting bone resorption. The object of this study was to examine the effect of MBP on the bone metabolism of healthy menopausal women. Thirty-two healthy menopausal women were randomly assigned to treatment with either placebo or MBP (40 mg per day) for 6 months. The bone mineral density (BMD) of the lumbar vertebrae L2-L4 of each subject was measured by dual-energy X-ray absorptiometry (DXA) at 0 and 6 months of treatment. Serum and urine indices of bone metabolism were measured at 0, 3 and 6 months. Twenty-seven subjects who completed the study in accordance with the protocol were included in the analysis. The mean rate of gain of lumbar BMD in the MBP group (1.21%) was significantly higher than in the placebo group (-0.66%, P=0.046). When compared with the placebo group, urinary cross-linked N-telopeptides of type-I collagen (NTx) were significantly decreased in the MBP group at 6 months, but no significant difference in serum osteocalcin was observed between the two groups. The urinary NTx excretion was found to be related to serum osteocalcin in the MBP group at 3 and 6 months, indicating that MBP maintained the balance of bone remodeling. These results suggested that MBP supplementation was effective in preventing bone loss in menopausal women and that this improvement in BMD may be primarily mediated through the inhibition of bone resorption while maintaining the balance of bone remodeling by MBP supplementation.

Solution structure of marinostatin, a natural ester-linked protein protease inhibitor.

Marinostatin is a unique protein protease inhibitor containing two ester linkages. We have purified a 12-residue marinostatin [MST(1-12), (1)FATMRYPSDSDE(12)] and determined the residues involved in the formation of the ester linkages and the solution structure by (1)H NMR spectroscopy and restrained molecular dynamics calculation. The two ester linkages of MST(1-12) are formed between hydroxyl and carboxyl groups, Thr(3)-Asp(9) and Ser(8)-Asp(11), indicating that MST(1-12) has two cyclic regions which are fused at the residues of Ser(8) and Asp(9). A strong NOE cross-peak between Tyr(6) H(alpha) and Pro(7) H(alpha) was observed, indicating that the Pro(7) residue takes a cis-conformation. Well-converged structures and hydrogen-deuterium experiments of MST(1-12) showed that the backbone NH proton of the P1'residue, Arg(5), is hydrogen-bonded to the carbonyl oxygen of the ester linkage between Thr(3) and Asp(9). To reveal the significance of the ester linkages, a marinostatin analogue, MST-2SS ((1)FACMRYPCCSCE(12)) with two disulfide bridges of Cys(3)-Cys(9) and Cys(8)-Cys(11), was also synthesized. The inhibitory activity of MST-2SS was as strong as that of MST(1-12), and the Pro(7) residue of MST-2SS also takes a cis-conformation. However, the exchange rate of the Arg(5) NH proton of MST-2SS was about 100 times faster than that of MST(1-12), and the structure calculation of MST-2SS was not converged on account of the small number of NOEs, indicating that MST-2SS takes a more flexible structure. The hydrogen acceptability of the ester linkage formed by the P2 position residue, Thr(3), is crucial for suppressing the fluctuation of the reactive site and sustaining the inhibitory activity, which enables marinostatin to be one of the smallest protease inhibitors in nature.