LI-RADS Classification and Outcomes of Hepatocellular Carcinoma Treated With Transcatheter Arterial Chemoembolization Plus Radiofrequency Ablation.

AIM: The aim of this study was to clarify the usefulness of the Liver Imaging Reporting and Data System (LI-RADS) for predicting a patient's prognosis after transcatheter arterial chemoembolization (TACE) combined with radiofrequency ablation (TACE-RFA) for hepatocellular carcinoma (HCC) of Barcelona-Clinic Liver Cancer (BCLC) stage 0 or A. PATIENTS AND METHODS: We retrospectively analyzed cases of patients with HCC who underwent TACE-RFA (Jan 2005 to Dec 2015). Nodules were categorized based on their LI-RADS v2018 core. The LI-RADS category was assigned to each nodule using dynamic contrast-enhanced computed tomography. LR-3, LR-4 and LR-5 nodules were extracted. The overall (OS) and recurrence-free (RFS) survival was assessed among patients with BCLC 0 and BCLC A disease. RESULTS: Of the 64 nodules extracted, 22 were LR-3 or -4 (mean±standard deviation=14.8±6.7 mm) and 42 were LR-5 (17.1±6.9 mm). Regarding OS, there was no significant difference between those with LR-3 or -4 and LR-5 (p=0.278). In terms of RFS, there was a significant difference between those with LR-3 or -4 and those with LR-5 (p=0.03). In particular, patients with BCLC A with LR-5 nodules had significantly poorer RFS than those with LR-3 or -4 (p=0.016) nodules. CONCLUSION: For patients with BCLC A, LR-3 or -4 nodules are associated with a better prognosis than LR-5 nodules.

Adrenal Vein Sampling With Gadolinium Contrast Medium in a Patient With Florid Primary Aldosteronism and Iodine Allergy.

We describe a 35-year-old woman who was allergic to iodine contrast medium and was diagnosed with primary aldosteronism (PA) based on functional confirmatory tests. She was suspected to have unilateral PA because of marked hypertension, spontaneous hypokalemia, high plasma aldosterone, reduced plasma renin activity, and a right hypodense adrenal tumor. She wanted to become pregnant and requested adrenalectomy instead of medical treatment with mineralocorticoid receptor antagonists. Localization of PA by adrenal vein sampling (AVS) was necessary, but angiography with iodine contrast medium was not possible because of her allergy. AVS was performed using gadolinium contrast agent (gadoterate meglumine) instead of iodine, in combination with computed tomography angiography (CTA). In AVS, before and after adrenocorticotropin (ACTH) loading, 12 blood samples were drawn from the right adrenal vein, left adrenal central vein, left adrenal common duct, left and right renal veins, and the lower inferior vena cava with only 5 mL of gadolinium medium. There were no complications during AVS. Examination revealed an elevated aldosterone/cortisol ratio on the right side, lateralized ratio of 7.4, and contralateral ratio of 0.76; the patient was diagnosed with right unilateral PA. She underwent right adrenalectomy and showed improvements in aldosterone level from 312.4 pg/mL to 83.0 pg/mL, potassium from 3.0 mEq/L to 3.9 mEq/L, and systolic blood pressure from 138 mm Hg to 117 mm Hg. In PA patients with iodine allergy, AVS can be performed safely and precisely using gadolinium contrast combined with CTA.

Angiographic features and transarterial embolization of retained placenta with abnormal vaginal bleeding.

OBJECTIVES: To clarify characteristic angiographic features and clinical efficacy of selective transarterial embolization (TAE) of retained placenta with abnormal vaginal bleeding. METHODS: The study cohort comprised 22 patients (mean age, 33.5 years; range, 22-24 years) who underwent selective TAE for retained placenta with abnormal bleeding between January 2018 and December 2020 at our institution. Angiographic images were reviewed by two certified radiologists with consensus. Medical records were reviewed to evaluate the efficacy of TAE. Angiographic features of retained placenta, technical success (disappearance of abnormal findings on angiography), complications, clinical outcomes (hemostatic effects and recurrent bleeding) were evaluated. RESULTS: Pelvic angiography showed a dilated vascular channel mimicking arteriovenous fistulas or an aneurysm contiguous with dilated uterine arteries in the mid-arterial-capillary phase in 20 patients; it showed contrast brush in the remaining two patients. TAE technical success was achieved in all patients. No major complications were observed in any patients. Fifteen patients were followed up with expectant management after TAE; all but one patient showed no re-bleeding during the follow-up period (mean follow-up interval, 3.4 months; range, 1-17 months). One patient showed minor rebleeding, which resolved spontaneously. Seven patients underwent scheduled hysteroscopic resection within 1 week after TAE, and no excessive bleeding was observed during or after the surgical procedure in all seven patients. CONCLUSIONS: The characteristic angiographic feature of retained placenta is "dilated vascular channel that mimic low flow AVM." TAE is a safe and effective treatment to manage retained placenta with abnormal bleeding.

Vessel Occlusion using Hydrogel-Coated versus Nonhydrogel Embolization Coils in Peripheral Arterial Applications: A Prospective, Multicenter, Randomized Trial.

PURPOSE: To evaluate the safety and effectiveness of hydrogel-coated coils for vessel occlusion in the body trunk. MATERIALS AND METHODS: A total of 77 patients with various peripheral vascular lesions, treatable by embolization with coils, were randomized (hydrogel group, n = 38; nonhydrogel group, n = 39). In the hydrogel group, embolization of the target vessel was conducted using 0.018-inch hydrogel-coated coils (AZUR 18; Terumo Medical Corporation, Tokyo, Japan) with or without bare platinum coils. The nonhydrogel group received both bare platinum coils and fibered coils without the use of hydrogel-coated coils. RESULTS: Complete target vessel occlusion was accomplished in 36 patients in the hydrogel group and 37 patients in the nonhydrogel group. No major adverse events were observed in either group. The median number of coils/vessel diameter and the median total coil length/vessel diameter were significantly larger in the nonhydrogel group than in the hydrogel group (P = .005 and P = .004, respectively). The median embolization length was significantly longer in the nonhydrogel group (31.95 mm) than in the hydrogel group (23.43 mm) (P = .002). If no expansion was assumed, the median packing density in the hydrogel group was 44.9%, which was similar to that in the nonhydrogel group (46.5%) (P = .79). With full expansion assumed, the median packing density in the hydrogel group was 125.7%. CONCLUSIONS: Hydrogel-coated coils can be safely used for peripheral vascular coil embolization, and hydrogel-coated and conventional coils in combination allow for a shorter embolization segment and shorter coil length.

Location of embolization affects patency after coil embolization for pulmonary arteriovenous malformations: importance of time-resolved magnetic resonance angiography for diagnosis of patency.

OBJECTIVES: This study aimed to assess the diagnostic accuracy of computed tomography (CT) and time-resolved magnetic resonance angiography (TR-MRA) for patency after coil embolization of pulmonary arteriovenous malformations (PAVMs) and identify factors affecting patency. METHODS: Data from the records of 205 patients with 378 untreated PAVMs were retrospectively analyzed. Differences in proportional reduction of the sac or draining vein on CT between occluded and patent PAVMs were examined, and receiver operating characteristic analysis was performed to assess the accuracy of CT using digital subtraction angiography (DSA) as the definitive diagnostic modality. The accuracy of TR-MRA was also assessed in comparison to DSA. Potential factors affecting patency, including sex, age, number of PAVMs, location of PAVMs, type of PAVM, and location of embolization, were evaluated. RESULTS: The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of CT were 82%, 81%, 77%, 85%, and 82%, respectively, when the reduction rate threshold was set to 55%, which led to the highest diagnostic accuracy. The sensitivity, specificity, PPV, NPV, and accuracy of TR-MRA were 89%, 95%, 89%, 95%, and 93%, respectively. On both univariable and multivariable analyses, embolization of the distal position to the last normal branch of the pulmonary artery was a factor that significantly affected the prevention of patency. CONCLUSIONS: TR-MRA appears to be an appropriate method for follow-up examinations due to its high accuracy for the diagnosis of patency after coil embolization of PAVMs. The location of embolization is a factor affecting patency. KEY POINTS: • Diagnosis of patency after coil embolization for pulmonary arteriovenous malformations (PAVMs) is important because a patent PAVM can lead to neurologic complications. • The diagnostic accuracies of CT with a cutoff value of 55% and TR-MRA were 82% and 93%, respectively. • The positioning of the coils relative to the sac and the last normal branch of the artery was significant for preventing PAVM patency.

Correction To: Where is the Origin of the Last Normal Branch from Feeding Artery of Pulmonary Arteriovenous Malformations?

On page 1852, the first sentence of the second paragraph "In all PAVMs, the mean diameter of the feeding artery was 7.24 ± 0.015 mm, and the mean maximum diameter of the sac was 19.10 ± 0.585 mm" should be corrected to read as follows.

Coexistence of "extra-gastric afferent-efferent direct connection" with gastric varices: CT evaluation and clinical significance.

PURPOSE: To evaluate the prevalence of extra-gastric direct connection between afferent and efferent veins of gastric varices (GVs) (i.e., EAEDC) and its clinical significance during balloon-occluded retrograde transvenous obliteration (BRTO). MATERIALS AND METHODS: 57 patients who underwent BRTO for GVs obliteration were retrospectively enrolled in this study. Pre-procedural CT images were reviewed for the presence of EAEDC. Patients were categorized into group A (patients with EAEDC) and group B (Patients with no detectable EAEDC). Intraprocedural images were reviewed to see if EAEDCs could be seen and if additional techniques were used to preserve or occlude them. Post-procedural CT images were reviewed for GVs obliteration, portal/splenic vein thrombosis, EAEDC patency, and ascites exacerbation. Post-procedural esophageal varices aggravation was evaluated by upper endoscopy. RESULTS: 39 EAEDCs were identified in CT images of 35 patients (i.e., group A = 61.4%). Among them, only 20 EAEDCs were visualized during BRTO. In the remaining 22 patients, EAEDC was not identified in CT images or during BRTO (i.e., group B = 38.6%). There was no statistically significant difference between group A and B regarding post-BRTO GVs obliteration and portal/splenic vein thrombosis. Use of additional techniques to preserve EAEDC patency had significantly reduced the incidence of ascites and esophageal varices exacerbation (p = 0.036 and 0.028, respectively). In patients with EAEDC diameter ≥ 5 mm, EAEDC preservation or obliteration by coils or balloon had significantly reduced the injected sclerosant volume (p = 0.003). CONCLUSION: CT is very useful for EAEDC detection. EAEDC preservation may decrease the incidence of post-BRTO ascites and esophageal varices exacerbation.

Where is the Origin of the Last Normal Branch from Feeding Artery of Pulmonary Arteriovenous Malformations?

PURPOSE: Reperfusion via pulmonary-to-pulmonary arterial anastomoses is known as one type of recurrence of pulmonary arteriovenous malformations (PAVMs) after embolization. It is important to occlude the fistulous portion beyond the origin of the last normal branch from feeding artery of PAVMs to prevent recurrence. In this study, we evaluate the origin of the last normal branch by CT as well as its visibility on pulmonary arteriography (PAG). MATERIALS AND METHODS: We reviewed forty patients with 77 PAVMs who underwent coil embolization between October 2007 and December 2017. All patients underwent MDCT before embolization. Axial and MPR CT lung images were reviewed with special interests in the origin of the last normal branch from feeding artery of PAVMs. The origin was classified into three portions, including sac, junction (portion just proximal to the sac) and proximal feeder (more than 5 mm proximal to the sac). We also evaluated whether PAG can depict the normal branches detected by MDCT. RESULTS: MDCT showed that the last normal branch originated from sac in 30 PAVMs (39.0%), junction in 39 (50.6%), and proximal feeder in 8 (10.4%).On selective PAG, the last normal branch could be visualized in 30 PAVMs (39.0%), although it could not be visualized due to high-flow shunt in the other 47 PAVMs. CONCLUSIONS: Selective PAG frequently fails to demonstrate the last normal branch from feeding artery of PAVMs, which often originates from the sac. Pretherapeutic evaluation of CT images of the last normal branch is important to prevent reperfusion of PAVMs. LEVEL OF EVIDENCE: Level 3, local non-random sample.

Renal Arteriovenous Shunts: Clinical Features, Imaging Appearance, and Transcatheter Embolization Based on Angioarchitecture.

Renal arteriovenous (AV) shunt, a rare pathologic condition, is divided into two categories, traumatic and nontraumatic, and can cause massive hematuria, retroperitoneal hemorrhage, pain, and high-output heart failure. Although transcatheter embolization is a less-invasive and effective treatment option, it has a potential risk of complications, including renal infarction and pulmonary embolism, and a potential risk of recanalization. The successful embolization of renal AV shunt requires a complete occlusion of the shunted vessel while preventing the migration of embolic materials and preserving normal renal arterial branches, which depends on the selection of adequate techniques and embolic materials for individual cases, based on the etiology and imaging angioarchitecture of the renal AV shunts. A classification of AV malformations in the extremities and body trunk could precisely correspond with the angioarchitecture of the nontraumatic renal AV shunts. The selection of techniques and choice of adequate embolic materials such as coils, vascular plugs, and liquid materials are determined on the basis of cause (eg, traumatic vs nontraumatic), the classification, and some other aspects of the angioarchitecture of renal AV shunts, including the flow and size of the fistulas, multiplicity of the feeders, and endovascular accessibility to the target lesions. Computed tomographic angiography and selective digital subtraction angiography can provide precise information about the angioarchitecture of renal AV shunts before treatment. Color Doppler ultrasonography and time-resolved three-dimensional contrast-enhanced magnetic resonance angiography represent useful tools for screening and follow-up examinations of renal AV shunts after embolization. In this article, the classifications, imaging features, and an endovascular treatment strategy based on the angioarchitecture of renal AV shunts are described.

Balloon-Occluded Retrograde Transvenous Obliteration for Isolated Gastric Varices Draining through Pericardiophrenic Vein without Gastrorenal or Gastrocaval Shunts.

Balloon-occluded retrograde transvenous obliteration (BRTO) is an effective and minimally invasive treatment for isolated gastric varices (GVs) that is usually performed through a gastrorenal shunt (GRS) or gastrocaval shunt (GCS). However, there are some cases in which GVs drain mainly into the left pericardiophrenic vein without an accessible GRS or GCS. This brief report presents four cases of GVs without a GRS/GCS treated by BRTO through the pericardiophrenic vein. BRTO was successfully performed with the use of flexible balloon catheters without any complications in all four patients, and the GVs were completely obliterated.

Unenhanced magnetic resonance angiography with time-spatial labeling inversion pulse for evaluating visceral artery aneurysms after endosaccular packing with detachable coils: preliminary results.

The aim of this brief report is to compare unenhanced magnetic resonance (MR) angiography with time-spatial labeling inversion pulse (Time-SLIP) with conventional digital subtraction angiography (DSA) in assessing degree of saccular visceral artery aneurysm (VAA) occlusion after endosaccular packing with detachable coils. Eight patients with VAAs (five renal and three splenic artery aneurysms) were enrolled in this study. VAA occlusion rates based on Time-SLIP MR angiography were complete occlusion in four patients, neck remnants in three patients, and body filling in one patient. These findings corresponded with the DSA findings.

Multidetector CT anatomy of drainage routes of gastric varices: a pictorial review.

Most gastric varices arise at hepatofugal collateral pathways and drain into the systemic vein through one or both of two different types of portosystemic collateral drainage systems: the gastroesophageal (azygous) venous system and the gastrophrenic venous system. The gastroesophageal venous system consists of gastric varices contiguous with esophageal varices, paraesophageal varices, and the azygos vein, which terminates into the superior vena cava. Gastric varices draining through the gastroesophageal venous system can be treated with endoscopic techniques or creation of a transjugular intrahepatic portosystemic shunt. The gastrophrenic venous system consists of the gastric varices and the left inferior phrenic vein (IPV), which terminates into the left renal vein or the inferior vena cava. The left IPV has abundant anastomoses with peridiaphragmatic and retroperitoneal veins, and these anastomoses can function as drainage pathways from gastric varices. Balloon-occluded retrograde transvenous obliteration is a preferred treatment option for this type of gastric varix. Occasionally, gastric varices can form at the hepatopetal collateral pathway that develops secondary to localized portal hypertension caused by splenic vein occlusion. Splenectomy is often required for the treatment of this type of gastric varix. Multidetector computed tomography permits comprehensive evaluation of these venous drainage systems. Familiarity with and assessment of these draining routes of gastric varices are important for selecting treatment options and interventional techniques.

Balloon-occluded retrograde transvenous obliteration of complex gastric varices assisted by temporary balloon occlusion of the splenic artery.

Six cases of gastric varices with multiple afferent veins, in which balloon-occluded venography of the draining vein showed insufficient filling of gastric varices with contrast medium, were treated by balloon-occluded retrograde transvenous obliteration (BRTO) and temporary balloon occlusion of the splenic artery. The gastric varices were completely filled with sclerosant in all but one patient. No procedure-related complications were encountered. Computed tomography (CT) after the procedure showed complete thrombosis of the varices in five patients and partial thrombosis in one patient. Temporary balloon occlusion of the splenic artery is a useful additional technique for complete obliteration of gastric varices in selected cases.