Role of Percutaneous Deep Venous Arterialization for Patients with Chronic Limb-threatening Ischemia.

Efficacy of percutaneous deep venous arterialization (pDVA) has been reported for patients with no-option chronic limb-threatening ischemia (CLTI). In the countries where a manufactured device dedicated for pDVA has not been reimbursed, pDVA using the off-the-shelf technique has alternatively spread. The off-the-shelf techniques for arteriovenous fistula (AVF) creation reported are as follows: AV spear technique, venous arterialization simplified technique (VAST), and a use of penetration guidewire or a reentry device. Technical success rates of the procedures are similar to those using the dedicated device. pDVA could be a last resort for the patients with no-option CLTI, including those suffering from stump ulcer after major limb amputation or those with occluded surgical bypass.

Transarterial Chemoembolization with Irinotecan-loaded Beads Followed by Arterial Infusion of 5-Fluorouracil for Metastatic Liver Tumors Refractory to Standard Systemic Chemotherapy.

We report two cases of liver metastases from colorectal and anal cancers after the failure of systemic chemotherapies that were successfully treated with a combination therapy of transarterial chemoembolization using irinotecan-loaded drug-eluting beads and hepatic arterial infusion chemotherapy. In both cases, hepatic arterial infusion chemotherapy was performed as maintenance therapy after irinotecan-loaded drug-eluting beads. Irinotecan at a dose of 120 mg was loaded on drug delivery beads for irinotecan-loaded drug-eluting bead-transarterial chemoembolization. A weekly high-dose 5-fluorouracil regimen (1000 mg/m2/5 h) was used for hepatic arterial infusion chemotherapy. The liver metastases shrank remarkably in both cases, and progression-free survivals of 13 and 9 months, respectively, were obtained without any severe adverse events.

Clinical significance of spread of lipiodol marking for pulmonary nodules and its influence on surgery.

OBJECTIVE: Computed tomography (CT)-guided lipiodol marking is one of the targeting methods for resecting small pulmonary nodules or ground-glass nodules in video-assisted thoracic surgery (VATS). However, lipiodol spreading during marking has not been assessed, practically. In this study, we examined the clinical significance and the influence of lipiodol spreading on surgery. METHODS: From April 2010 to March 2021, 176 pulmonary nodules in 167 patients were marked with lipiodol under CT guided before VATS. The marking images after lipiodol injection were classified into "Spread" and "non-Spread." Lung resection was sequentially performed on the same day. RESULTS: All target nodules were successfully resected in VATS. In the classification of marking images, Spread was 32 (18%), non-Spread was 144 (82%). There was a significant difference in duration of surgery (mean; 138.7 min vs. 118.3 min, p = 0.0496) and amount of bleeding (mean; 32.7 g vs. 11.2 g, p = 0.0173). Provided that limited to the data of wedge resections without intrathoracic pleural adhesion (n = 117), there was no significant difference in duration of surgery (mean; 104.8 min vs. 99.6 min, p = 0.48), amount of bleeding (mean; 4.9 g vs. 5.3 g, p = 0.58). In the multivariate logistic regression analysis, the risk factor of lipiodol spreading was intrathoracic pleural adhesion (odds ratio: 3.16, 95% confidence interval: 1.12-8.97, p = 0.03). There was no relationship between marking image and complication rate. CONCLUSIONS: Lipiodol spreading did not directly influence surgery and complication. However, it was a sign of intrathoracic pleural adhesion, which could lead to increased duration of surgery and amount of bleeding.

[Case of Central Venous Catheter Laceration of the Pectoralis Minor Muscle].

A 50's underwent gastrectomy for gastric cancer 4 years before. He had received chemotherapy for para-aortic lymph node metastases. A central venous catheter with a subcutaneous port was implanted via the right subclavian vein, under ultrasonographic guidance, 1 year 3 months earlier. The patient complained of swelling in his right chest during intravenous injection of ramucirumab and paclitaxel via the port. A chest radiograph revealed that a catheter fracture. A CT scan showed that the fractured catheter had lacerated the pectoralis minor muscle and the tip was in the right inferior pulmonary artery. The catheter fragment was removed using a pigtail catheter and a snare catheter via a percutaneous transfemoral approach, without any complication. The catheter was cut at 15.5 cm from the tip. This fracture was thought to be caused by a kink in the pectoralis muscle.

Prognosis of patients with intermediate-stage hepatocellular carcinomas based on the Child-Pugh score: subclassifying the intermediate stage (Barcelona Clinic Liver Cancer stage B).

PURPOSE: Retrospective evaluation of intermediate-stage hepatocellular carcinoma (HCC) patient survival after undergoing chemoembolization based on the Child-Pugh score. MATERIALS AND METHODS: Data of intermediate-stage HCC patients undergoing chemoembolization were gathered from 43 centers in Japan. Overall survival rates were compared with Child-Pugh scores. RESULTS: Of the 329 patients examined in this study, Child-Pugh scores were 5 (CP-5) in 136 patients (41.3%), 6 (CP-6) in 101 patients (30.7%), 7 (CP-7) in 58 (17.7%), 8 (CP-8) in 22 (6.7%), and 9 (CP-9) in 12 (3.6%). Two-year survival rates were 77.5% in CP-5 patients (p = 0.047 vs. CP-6), 65.1% in CP-6 patients (p = 0.038 vs. CP-7), 51.3% in CP-7 patients (p = 0.30 vs. CP-8, p = 0.034 vs. CP-9), 50.3% in CP-8 patients (p = 0.0065 vs. CP-9), and 16.7% in CP-9 patients. Two-year survival rates were 77.2% in 139 patients meeting the 4 tumors of 7 cm criterion with Child-Pugh class A (B1) (p < 0.0001 vs. B2), 59.5% in 178 patients other than B1 and B3 (B2) (p = 0.0014 vs. B3), and 16.7% in 12 patients with Child-Pugh score 9 (B3). CONCLUSION: The Child-Pugh score is a useful prognostic factor to stratify intermediate-stage HCC patients.

Subgrouping of intermediate-stage (BCLC stage B) hepatocellular carcinoma based on tumor number and size and Child-Pugh grade correlated with prognosis after transarterial chemoembolization.

PURPOSE: To find a subgroup that benefits most from transarterial chemoembolization (TACE) in terms of tumor number and size and liver profile in patients with intermediate-stage hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Data of 325 intermediate-stage HCC patients who received TACE as the initial treatment were gathered. Four tumor numbers (3-6 tumors) and five maximum tumor diameters (3-7 cm) as well as all of their combinations but one (3 tumors and 3 cm) and Child-Pugh grade were used as variables to ascertain prognostic factors. RESULTS: The respective 1-, 3-, and 5-year overall survival rates in all patients were 86.5, 47.0, and 23.7%, respectively. Tumor numbers of 4 (P = 0.00145) and 5 (P = 0.036), and tumor size of 7 cm (P = 0.015), and 12 other combinations of tumor number and size, and Child-Pugh grade (P = 0.0015) were identified as significant prognostic factors in univariate analysis, and 4 tumors of 7 cm (P = 0.0008) and Child-Pugh grade (P = 0.0036) remained significant in the stepwise Cox proportional hazard model. The overall survival was significantly better in a patient subgroup having two factors other than patient subgroups having one or no prognostic factors. CONCLUSION: A patient subgroup having two prognostic factors benefited most from TACE in intermediate-stage HCC patients.

Obstacles encountered during transradial angiography from after Radial Artery puncture to the aortic arch.

OBJECTIVE: To elucidate the key points for safe performance of transradial angiography. CONCLUSIONS: Transradial angiography can be performed safely if attention is paid to the following points from after radial artery puncture to reaching the aortic arch: resistance during guide wire operation for sheath insertion after puncture; confirmation of the superficial brachial artery; guide wire resistance while guiding the catheter to the aortic arch; and aortic arch anomalies.

Hepatic arterial embolization for unresectable hepatocellular carcinomas: do technical factors affect prognosis?

PURPOSE: To evaluate retrospectively whether technical factors of hepatic arterial embolization affect the prognosis of patients with hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Inclusion criteria of this study were the following: (1) patients received embolization as the initial treatment during 2003-2004, (2) Child A or B liver profile, (3) five or fewer HCCs with maximum diameter of 7 cm or smaller, and (4) no extrahepatic metastasis. Patient data were gathered from 43 centers. Prognostic factors were evaluated using univariate and multivariate analyses. RESULTS: Eight hundred fifteen patients were enrolled. The 1-, 3-, 5-, and 7-year overall survival rates were 92.0 % (95 % CI 90.1-93.9), 62.9 % (95 % CI 59.3-66.6), 39.0 % (95 % CI 35.1-43.0), and 26.7 % (95 % CI 22.6-30.8) in all patients. Univariate analysis showed a Child-Pugh class-A, alpha-fetoprotein level lower than 100 ng/ml, tumor size of 3 cm or smaller, tumor number of 3 or fewer, one-lobe tumor distribution, nodular tumor type, within the Milan criteria, stage I or II, no portal venous invasion, use of iodized oil, and selective embolization were significantly better prognostic factors. In the multivariate Cox model, the benefit to survival of selective embolization remained significant (hazard ratio 0.68; 95 % CI 0.48-0.97; p = 0.033). CONCLUSION: Selective embolization contributes to survival in patients with HCCs.

Experimental study of poly-L-lactic acid biodegradable stents in normal canine bile ducts.

PURPOSE: This study was designed to clarify the advantages of biodegradable stents in terms of mucosal reaction and biodegradation after placement. We designed a biodegradable stent and assessed stent degradation and changes in the normal bile ducts of dogs. METHODS: The biodegradable stent is a balloon-expandable Z stent consisting of poly-L-lactic acid (PLLA) with a diameter of 6 mm and a length of 15 mm. We assessed four groups of three beagle dogs each at 1, 3, 6, and 9 months of follow-up. After evaluating stent migration by radiography and stent and bile duct patency by cholangiography, the dogs were sacrificed to remove the bile duct together with the stent. The bile duct lumen was examined macroscopically and histologically, and the stent degradation was examined macroscopically and by scanning electron microscopy (SEM). RESULTS: Bile duct obstruction was absent and none of the stents migrated. Macroscopic evaluation showed moderate endothelial proliferation in the bile ducts at the implant sites at 3 and 6 months and a slight change at 9 months. Slight mononuclear cell infiltration was histologically identified at all time points and epithelial hyperplasia that was moderate at 3 months was reduced to slight at 6 and 9 months. Stent degradation was macroscopically evident in all animals at 9 months and was proven by SEM in two dogs at 6 months and in all of them at 9 months. CONCLUSIONS: Our results suggest that PLLA bioabsorbable stents seems to be useful for implantation in the biliary system with further investigation.

[Mechanical properties of biliary metallic stents: an experimental comparison].

PURPOSE: To assess the physical properties of biliary self-expandable metallic stents. MATERIALS AND METHODS: Six different types of biliary self-expandable metallic stents (Wallstent, ZA stent, Accuflex, S.M.A.R.T. stent, Spiral Z stent, and NT stent) were evaluated for the flexibility, trackability, and resistance of stent release for the introducer, and for repulsion force, flexibility, radial force, radio-opacity, and kink resistance for the stent. RESULTS: The Wallstent showed the best repulsion force, radio-opacity, and kink- resistance, while the ZA stent showed the best flexibility and trackability of the introducer and better radial force and radio-opacity. Accuflex showed the least resistance during stent release and better flexibility and radial force. The S.M.A.R.T. stent showed the largest radial force, and the Spiral Z stent showed better trackability of the introducer and better radio-opacity. The NT stent seemed to require overall improvement. CONCLUSION: The Wallstent appears preferable for placement in the extrahepatic bile ducts. The ZA stent can be applied for various approaches, but placement in comparatively straight bile ducts is preferable. With the Accuflex, insertion through routes where an acute angle exists should be avoided. In addition, balloon expansion before or after stent placement is preferable. The S.M.A.R.T. stent is placed in straighter intrahepatic bile ducts, while the Spiral Z stent should be placed through a straight approach. Balloon expansion before or after stent placement is preferable for the NT stent. No stent exhibited all of the ideal properties required. These results may contribute to the selection of biliary metallic stents.