Clinical impact of fluoropolymer-based drug-eluting stent thrombosis in femoropopliteal artery occlusive lesions.

BACKGROUND: Endovascular treatment (EVT) is recommended for superficial femoral artery (SFA) lesions, and good results have been reported after implantation of drug-eluting stents (DES) for SFA. However, the major concern after implantation is acute thrombosis during the follow-up period, resulting in major amputation and major adverse limb events. In this study, we examined the incidence and outcome of acute thrombosis after DES implantation in the SFA. OBJECTIVES AND METHODS: DES implantation for a femoropopliteal lesion was performed in 288 patients at multiple centers in Japan from 2019 to 2021. A total of 25 patients (8.6%) with DES acute occlusion were analyzed retrospectively. The primary endpoint was amputation-free survival (AFS) after acute occlusion. RESULTS: The median patient age was 77 years, with 48% having diabetes, 40% undergoing maintenance dialysis, and 66% having chronic limb-threatening ischemia (CLTI). The mean time from initial DES implantation to acute occlusion was 153.5 ± 177.6 days, with a median of 104 days. EVT was performed in 18 patients (72%), surgical revascularization in 3 (12%), and conservative treatment in 4 (16%). Two deaths within 30 days were both due to sepsis. No major amputation or major adverse cardiovascular events occurred within 30 days. The 1-year rates of patency and freedom from target lesion revascularization after DES thrombosis were 22.9% and 48.8%, respectively. AFS at 1 year was 55.1%. CONCLUSION: Acute DES occlusion is relatively frequent, and the outcome is poor. Therefore, the indication of DES implantation for a complex SFA lesion may require careful consideration. Further investigation may be needed in DES implantation for a complex SFA lesion.

Protocol for a confirmatory trial of the effectiveness and safety of palliative arterial embolization for painful bone metastases.

BACKGROUND: Transcatheter arterial embolization (TAE) has long been used for hemostasis of traumatic or postoperative hemorrhage and embolization of tumors. Previous retrospective studies of TAE for painful bone metastases showed 60%-80% pain reduction with a median time to response of 1-2 days. Compared with radiotherapy and bisphosphonates, time to response appeared earlier than that of radiotherapy or bone-modifying agents. However, few prospective studies have examined TAE for this indication. Here, we describe the protocol for a confirmatory study designed to clarify the efficacy and safety profile of TAE. METHODS: This study will be a multicenter, single-arm confirmatory study (phase 2-3 design). Patients with painful bone metastases from any primary tumor are eligible for enrollment. TAE will be the main intervention. Following puncture of the femoral artery under local anesthesia and insertion of an angiographic sheath, angiography will confirm that the injected region includes tumor vasculature. Catheter position will be adjusted so that the embolization range does not include non-target tissues. Spherical embolic material will then be slowly injected into the artery to embolize it. The primary endpoint (efficacy) is the proportion of subjects with pain relief at 72 h after TAE and the secondary endpoint (safety) is the incidence of all NCI Common Terminology Criteria for Adverse Events version 5.0 Grade 4 adverse events and Grade ≥ 3 necrosis of the central nervous system. DISCUSSION: If the primary and secondary endpoints are met, TAE can be a treatment choice for painful bone metastases. Trial registry number is UMIN-CTR ID: UMIN000040794. TRIAL REGISTRATION: The study is ongoing, and patients are currently being enrolled. Enrollment started in March 2021. A total of 36 patients have participated as of Aug 2022. PROTOCOL VERSION: Ver1.4, 13/07/2022.

Rapidly Progressive Stenosis of the Left Main Trunk Ostium Starting 21 Months After Stent Implantation.

Rapidly progressive in-stent restenosis (ISR) after stent deployment from the left main trunk (LMT) to the left anterior descending artery (LAD) without plaque at the LMT ostium has not been reported. A 60-year-old Japanese man with a history of scleroderma, pulmonary fibrosis, and type 2 diabetes developed acute myocardial infarction of the right coronary artery (RCA) and was treated by emergency percutaneous coronary intervention (PCI) for RCA. Nine days later he underwent PCI from the LMT to the LAD. Follow-up coronary angiography (CAG) at 9 and 21 months post-PCI did not reveal ISR in any lesion, but the patient experienced cardiac arrest at 25 months post-PCI. Emergency CAG after resuscitation revealed ISR of the LMT ostium; emergency PCI was conducted. The development of ISR at the ostium of the LMT although the patient was free of plaque 4 months before is extremely unusual. This rare ISR of the LMT ostium progressed rapidly after follow-up CAG revealed no ISR at 21 months post-stent implantation.

Japanese clinical practice guidelines for vascular anomalies 2017.

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Computed tomography-guided percutaneous needle biopsy for middle mediastinal tumors with retroaortic paravertebral approach: A case report.

A 74-year-old man was referred to our hospital for a close examination of a mediastinal mass. Contrast-enhanced CT showed a middle mediastinal tumor. We planned to perform a CT-guided percutaneous needle biopsy of the tumor using a retroaortic paravertebral approach to avoid transpulmonary puncture. A coaxial blunt-tip needle with a side hole was used to create space in the mediastinum and avoid azygos vein injury. After injecting normal saline, a blunt-tip needle was advanced through the space between the aorta and the vertebral body to the anterior surface of the tumor, and tissue was obtained. The patient was discharged the following day with no complications. For percutaneous middle mediastinal tumor biopsy, the retroaortic paravertebral approach may be a safe, effective route.

Patient characteristics and procedural and safety outcomes of percutaneous transesophageal gastro-tubing: A nationwide database study in Japan.

BACKGROUND: Percutaneous transesophageal gastro-tubing (PTEG) is an alternative interventional procedure in cases where gastrostomy is not feasible. However, the safety and complication rates of PTEG have not yet been evaluated. We aimed to describe the characteristics of patients who underwent PTEG and investigate complications using a nationwide Japanese inpatient database. METHODS: In this retrospective cohort study, we used the Diagnosis Procedure Combination database in Japan to identify patients who underwent PTEG from April 2012 to March 2020. The outcomes were the occurrence of complications, invasive treatment within 7 days after PTEG, and tube replacement within 14 days after PTEG. We statistically compared patient background, complication rates, and outcomes using PTEG indications. RESULTS: A total of 3,684 patients underwent PTEG, which was performed in 1,455 patients for decompression and 2,193 patients for feeding. The patients' mean age was 73.1 years, and 62.1% were men. More patients in the decompression group had cancer than those in the feeding group. The overall number of complications was 47 cases (1.3%). The most common treatment administered after PTEG was red blood cell transfusion (3.9%), followed by early tube replacement (3.3%). As invasive treatments for PTEG complications, percutaneous drainage and transcatheter arterial embolization were required in 4 and 1 cases, respectively, and no cases required surgery. CONCLUSION: We performed a descriptive study on PTEG using a nationwide database in Japan. This study also showed a low complication rate after PTEG in the real world. Our findings provide practical information on the safety of PTEG in Japan.

Sedation With Dexmedetomidine During Lymphangiography and Thoracic Duct Embolization in an Elderly Man.

An 83-year-old man underwent cervical esophagectomy and developed a chylothorax as a postoperative complication. We decided to perform lymphangiography and thoracic duct embolization for chylous leakage, but it was expected to be challenging to maintain bed rest. Therefore, dexmedetomidine was administered for procedural sedation. The patient's blood pressure and heart rate were mostly stable during the procedure, and the sedation level was maintained within the desired limits. Due to its specific sedative pattern and mild analgesic effect, Dexmedetomidine is suitable for procedural sedation in various painless interventional radiology procedures, such as lymphangiography and thoracic duct embolization. Therefore, it may be the best sedative for the elderly and should be widely and effectively used in interventional radiology.

Utility of a multidisciplinary team approach with transanal total mesorectal excision for resection of a large pelvic solitary fibrous tumor.

INTRODUCTION: Solitary fibrous tumors require complete surgical resection to avoid recurrence. Large solitary fibrous pelvic tumors are difficult to resect completely with conventional surgical methods. We herein report a case in which a joint surgical approach was required for resection due to the location and size of tumor. CASE PRESENTATION: A 45-year-old man had a large solitary fibrous tumor in the pelvis, which extended into the left obturator foramen. The patient underwent tumor resection with vesico-prostatectomy, transanal total mesorectal excision, and opening of the foramen obturatum. The tumor was grossly resected completely. No recurrence was noted nine months after surgery. CONCLUSION: A multidisciplinary team approach with transanal total mesorectal excision may provide complete resect of large pelvic solitary fibrous tumors.

Successful transcatheter arterial embolization for uretero-inferior epigastric arterial fistula: A rare complication of cutaneous ureterostomy.

A 70-year-old man presented with pulsatile bleeding upon changing his catheter for cutaneous ureterostomy. He was suspected to have a uretero-arterial fistula. Computed tomography showed an abnormally dilated right inferior epigastric artery, the suspected bleeding source. Angiography revealed a tortuous dilated branch from the inferior epigastric artery. Transcatheter arterial embolization was performed with a gelatin sponge and coil. He was discharged 15 days after the procedure. Uretero-arterial fistula is a rare but fatal complication among patients with long-term indwelling ureter catheters. An abnormal inferior epigastric artery surrounding the cutaneous ureterostomy should be considered a rare cause of uretero-arterial fistula.

Japanese clinical practice guidelines for vascular anomalies 2017.

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety, and systematizing treatment, employing evidence-based medicine (EBM) techniques and aimed at improvement of the outcomes. Clinical questions (CQs) were decided based on the important clinical issues. For document retrieval, key words for literature searches were set for each CQ and literature published from 1980 to the end of September 2014 was searched in Pubmed, Cochrane Library, and Japana Centra Revuo Medicina (JCRM). The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System (MINDS) technique. A total of 33 CQs were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy, and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

Japanese Clinical Practice Guidelines for Vascular Anomalies 2017.

The objective was to prepare guidelines to perform the current optimum treatment by organizing effective and efficient treatments of hemangiomas and vascular malformations, confirming the safety and systematizing treatment, employing evidence-based medicine techniques and aimed at improvement of the outcomes. Clinical questions (CQ) were decided based on the important clinical issues. For document retrieval, key words for published work searches were set for each CQ, and work published from 1980 to the end of September 2014 was searched in PubMed, Cochrane Library and Japana Centra Revuo Medicina databases. The strengths of evidence and recommendations acquired by systematic reviews were determined following the Medical Information Network Distribution System technique. A total of 33 CQ were used to compile recommendations and the subjects included efficacy of resection, sclerotherapy/embolization, drug therapy, laser therapy, radiotherapy and other conservative treatment, differences in appropriate treatment due to the location of lesions and among symptoms, appropriate timing of treatment and tests, and pathological diagnosis deciding the diagnosis. Thus, the Japanese Clinical Practice Guidelines for Vascular Anomalies 2017 have been prepared as the evidence-based guidelines for the management of vascular anomalies.

A Case of Common Peroneal Nerve Palsy Associated with Internal Iliac Artery Embolization by Using N-butyl-2-cyanoacrylate (NBCA).

A 64-year-old man was scheduled to undergo endovascular aneurysm repair for an abdominal aortic aneurysm (AAA). Since preoperative computed tomography showed an AAA with common iliac artery and internal iliac artery (IIA) aneurysms, IIA embolization was scheduled. Embolization using a coil was supposed to be performed; however, the lateral sacral artery could not be selected. For this reason, IIA embolization using N-butyl-2-cyanoacrylate (NBCA) was undertaken. During embolization, the median sacral artery was unexpectedly embolized through the lateral sacral artery. The patient complained of drop foot just after embolization; he was diagnosed with iatrogenic common peroneal nerve palsy. We have learned that sciatic nerve palsy can occur in cases of embolization with a liquid NBCA-Lipiodol mixture to the lateral or sacral median artery.

Successful Preoperative Chemoembolization in the Treatment of a Giant Malignant Phyllodes Tumor.

The malignant phyllodes tumor is a relatively rare neoplasm and has not previously been a therapeutic target of interventional radiology. Herein, we report a successful case of preoperative chemoembolization of a giant malignant phyllodes tumor. The objective was to achieve sufficient tumor shrinkage before surgery to avoid the requirement for skin grafting after resection. Intra-arterial epirubicin infusion and subsequent embolization with Embosphere Microspheres (BioSphere Medical, Rockland, MA, USA) was undertaken three times over the course of 6 weeks and was well tolerated. The patient underwent surgery without skin grafting. Neither local recurrence nor distant metastasis was observed at 6 months after surgery.

Preliminary findings of arterial embolization with balloon-occluded and flow-dependent histoacryl glue embolization in a swine model.

PURPOSE: To evaluate the potential usefulness of the balloon-occluded histoacryl glue embolization (B-glue) technique. MATERIALS AND METHODS: Both flow-dependent (no balloon occlusion) and B-glue techniques were used for 24 intercostal arteries of two female swine. N-butyl 2-cyanoacrylate (NBCA) was diluted with lipiodol to a 50 % solution, which was infused after occluding the arteries with microballoon catheters. The embolization range, fragmentation, reflux, adhesion, and glue particle attachment were compared between flow-dependent and B-glue techniques. RESULTS: The B-glue technique was performed in a controlled fashion resulting in successful arterial occlusion without fragmented migration of the injected glue cast. Reflux occurred less frequently with the B-glue technique and was significantly different (p = 0.039) [Corrected] from that for the flow-dependent technique. Catheters were safely removed from the arterial walls, although in one instance (8.3 %), large glue particles were found to be attached to the catheter tip on removal. Conversely, the flow-dependent technique was more difficult to control and resulted in several instances of higher rates of fragmentation. CONCLUSION: The B-glue technique can efficiently control NBCA delivery with lower rates of reflux.

A Single Oral Administration of Theaflavins Increases Energy Expenditure and the Expression of Metabolic Genes.

Theaflavins are polyphenols found in black tea, whose physiological activities are not well understood. This study on mice evaluated the influence of a single oral administration of theaflavins on energy metabolism by monitoring the initial metabolic changess in skeletal muscle and brown adipose tissue (BAT). Oxygen consumption (VO2) and energy expenditure (EE) were increased significantly in mice treated with theaflavin rich fraction (TF) compared with the group administered vehicle alone. There was no difference in locomotor activity. Fasting mice were euthanized under anesthesia before and 2 and 5, 20-hr after treatment with TF or vehicle. The mRNA levels of uncoupling protein-1 (UCP-1) and peroxisome proliferator-activated receptor gamma coactivator-1α (PGC-1α) in BAT were increased significantly 2-hr after administration ofTF. The levels of UCP-3 and PGC-1α in the gastrocnemius muscle were increased significantly 2 and 5-hr after administration of TF. The concentration of phosphorylated AMP-activated protein kinase (AMPK) 1α was also increased significantly in the gastrocnemius 2 and 5-hr after treatment with TF. These results indicate that TF significantly enhances systemic energy expenditure, as evidenced by an increase in expression of metabolic genes.

Embolization by Direct Puncture with a Transpedicular Approach Using an Isocenter Puncture (ISOP) Method in a Patient with a Type II Endoleak After Endovascular Aortic Repair (EVAR).

BACKGROUND: Endovascular aortic repair (EVAR) requires further intervention in 20-30 % of cases, often due to type II endoleak (T2EL). Management options for T2EL include transarterial embolization, direct puncture (DP), or transcaval embolization. We report the case of an 80-year-old man with T2EL who successfully underwent DP embolization. METHODS: Embolization by DP was performed with a transpedicular approach using an isocenter puncture (ISOP) method. An isocenter marker (ICM) was placed at a site corresponding to the aneurysm sac on fluoroscopy in two directions (frontal and lateral views). A vertebroplasty needle was inserted tangentially to the ICM under fluoroscopy and advanced to the anterior wall of the vertebral body. A 20 cm-length, 20-G-PTCD needle was inserted through the outer needle of the 13-G needle and advanced to the ICM. Sac embolization using 25 % N-buty-2-cyanoacrylate diluted with Lipiodol was performed. After complete embolization, rotational DA confirmed good filling of the sac with Lipiodol. The outer cannula and 13-G needle were removed and the procedure was completed. RESULTS: The patient was discharged the next day. Contrast-enhanced computed tomography 1 and 8 months later showed no Lipiodol washout in the aneurysm sac, no endoleak recurrence, and no expansion of the excluded aneurysm. CONCLUSION: DP with a transpedicular approach using ISOP may be useful when translumbar and transabdominal approaches prove difficult.

A case of pseudoaneurysm of the deep femoral artery successfully treated by NBCA embolization under occlusion.

Transcatheter embolization of bleeding from distal branches of small arteries can be difficult. N-butyl cyanoacrylate (NBCA) was originally used as a tissue adhesive material, and recent evidence suggests that it can also be used as an embolic material. This report describes a case in which a pseudoaneurysm arising from the distal portion of a small branch of the deep femoral artery was successfully embolized with NBCA using a new technique with a microballoon catheter. Advantages of this technique include its safely, short treatment time, good control of the embolization range, absence of fragmentation, favorable polymerization dynamics, and absence of glue reflux or excessive distal spread of the glue.