Comparison of the effectiveness of celiac versus common hepatic artery injection for the detection of hepatocellular carcinoma and of the feeding artery on cone-beam computed tomographs obtained during hepatic angiography.

BACKGROUND: Cone-beam computed tomography (CBCT) has been widely used during transcatheter arterial chemoembolization for hepatocellular carcinoma. PURPOSE: To evaluate the sensitivity of CBCT for the detection of hepatocellular carcinomas and the tumor feeders by comparing celiac artery (CA) and common hepatic artery (CHA) injection. MATERIAL AND METHODS: We retrospectively enrolled 30 patients (52 hepatocellular carcinoma lesions) who had undergone CBCT-assisted transcatheter arterial chemoembolization. In 17 procedures (28 hepatocellular carcinomas) we acquired CBCT scans using CA injections (CBCT-CA) and in 18 (24 hepatocellular carcinomas) we used CHA injections (CBCT-CHA). Of the 30 patients, 5 underwent CBCT-CA and CBCT-CHA at different transcatheter arterial chemoembolization procedures. We performed inter-group comparisons of the detectability of hepatocellular carcinoma, the feeding artery, the intrahepatic artery branch order, and the tumor-to-liver contrast. RESULTS: CBCT-CA detected all 28 hepatocellular carcinomas and 27 of their feeders (96.4%); CBCT-CHA identified 22 of 24 hepatocellular carcinomas (91.7%) and 21 of their feeders (95.5%). There was no significant inter-group difference in the detectability of hepatocellular carcinoma lesions (p = 0.21) or feeding arteries (p = 0.69). CBCT-CHA was superior for the assessment of the tumor-to-liver contrast and the intrahepatic artery branch order (both: p < 0.01). CONCLUSION: CBCT-CA and CBCT-CHA were equally useful for the detection of hepatocellular carcinoma and of the feeding artery, although CBCT-CHA yields better visualization of hepatocellular carcinoma and the hepatic artery. Thus CA injection seems sufficient for lesion and vessel detection when the insertion of an angiographic catheter into the CHA is difficult.

Risk factors for severity of pneumothorax after CT-guided percutaneous lung biopsy using the single-needle method.

The purpose of this study is to evaluate the risk factors for the severity of pneumothorax after computed tomography (CT)-guided percutaneous lung biopsy using the single-needle method. We reviewed 91 biopsy procedures for 90 intrapulmonary lesions in 89 patients. Patient factors were age, sex, history of ipsilateral lung surgery and grade of emphysema. Lesion factors were size, location and pleural contact. Procedure factors were position, needle type, needle size, number of pleural punctures, pleural angle, length of needle passes in the aerated lung and number of harvesting samples. The severity of pneumothorax after biopsy was classified into 4 groups: "none", "mild", "moderate" and "severe". The risk factors for the severity of pneumothorax were determined by multivariate analyzing of the factors derived from univariate analysis. Pneumothorax occurred in 39 (43%) of the 91 procedures. Mild, moderate, and severe pneumothorax occurred in 24 (26%), 8 (9%) and 7 (8%) of all procedures, respectively. Multivariate analysis showed that location, pleural contact, number of pleural punctures and number of harvesting samples were significantly associated with the severity of pneumothorax (p < 0.05). In conclusion, lower locations and non-pleural contact lesions, increased number of pleural punctures and increased number of harvesting samples presented a higher severity of pneumothorax.

Decrease of renal function due to warm ischemia after laparoscopic partial nephrectomy: evaluation using 99mTc-DMSA renal scintigraphy.

INTRODUCTION: The purpose of this study is, using technetium-99m-dimercaptosuccinic acid ((99m)Tc-DMSA), to evaluate the decrease of renal function caused by warm ischemia. PATIENTS AND METHODS: The (99m)Tc-DMSA scan was performed before and 1, 3 and 6 months after the operation for 19 consecutive patients. The patients were divided into three groups by warm ischemic time (group A: 40 min intersection 60 min). Renal function of the unresected part was defined as the uptake to unresected part relative to the uptake to the contralateral kidney. The reduction of renal function was expressed as a ratio of the function after the surgery divided by function before the surgery and was compared between the three groups. RESULTS: The reduction in group C after 1 and 3 months tended to be greater than that in group A or B, although not reaching statistical significance (one-way ANOVA test, 1 month: p = 0.15 and 3 months: p = 0.13). There was a significant difference in reduction of renal function between the three groups after 6 months (one-way ANOVA test, p = 0.02). The Scheffé test showed a statistical significance between groups A and C (p < 0.05). CONCLUSION: Renal function calculated by (99m)Tc-DMSA shows that prolonged ischemic time causes significant damage to the kidney.

Accuracy of sonographic elastography in the differential diagnosis of enlarged cervical lymph nodes: comparison with conventional B-mode sonography.

OBJECTIVE: The purpose of our study was to evaluate the diagnostic performance of sonographic elastography and B-mode sonography individually and combined in the differentiation of reactively and metastatically enlarged cervical lymph nodes. SUBJECTS AND METHODS: Eighty-five lymph nodes (metastatic, n = 53; reactive, n = 32) from 37 patients were examined by both elastography and B-mode sonography in this prospective study. Elastographic patterns were determined on the distribution and percentage of the lymph node area with high elasticity (hard), with pattern 1 being an absent or very small hard area to pattern 5, a hard area occupying the entire lymph node. The cutoff line for reactive versus metastatic was set between patterns 2 and 3; patterns 3-5 were considered metastatic. B-mode sonographic diagnosis was based on the sum of scores for five criteria: short-axis diameter, shape, border (regular or irregular), echogenicity (homogeneous or inhomogeneous), and hilum (present or absent). The cutoff line for reactive versus metastatic was set between scores 6 and 7; scores 5 and 6 were considered reactive, and scores 7-10, metastatic. RESULTS: Sensitivity, specificity, and accuracy of B-mode sonography were 98%, 59%, and 84%, respectively; 83%, 100%, and 89% for elastography; and 92%, 94%, and 93% for the combined evaluation. CONCLUSION: The combination of highly specific elastography with highly sensitive conventional B-mode sonography has the potential to further improve the diagnosis of metastatic enlarged cervical lymph nodes.

Evaluation of hepatocellular carcinoma supplied by the right inferior phrenic artery at initial treatment.

OBJECTIVES: Recurrent hepatocellular carcinoma (HCC) often occurs with extrahepatic supply because of various factors. The right inferior phrenic artery (RIPA) is the most frequent extrahepatic feeding artery, however, it is rarely found that the RIPA supplies the tumor in patients with HCC at initial treatment. The purpose of this study is to evaluate the radiological findings of untreated cases of HCC fed by the RIPA. MATERIALS AND METHODS: Medical records, computed tomography scans, and angiograms in 14 patients with HCC fed by the RIPA at initial therapy were reviewed. We evaluated growth pattern, size, location of tumors, and patency of the hepatic artery. RESULTS: In all cases, tumors showed exophytic growth. Eleven cases (79%) were massive type. Tumor size ranged from 4.5 cm to 16.8 cm (mean, 11.1 cm). In 11 cases (79%), tumors were mainly located in liver segment 7. The patency of the hepatic arteries was intact in all cases. CONCLUSIONS: Regardless of initial therapy, HCC with exophytic growth pattern, especially located in the hepatic areas directly beneath the diaphragm and of massive type, can be supplied by the RIPA.

Traumatic mesenteric bleeding managed solely with transcatheter embolization.

We report a rare case of mesenteric bleeding following blunt abdominal trauma successfully treated solely with transcatheter arterial embolization (TAE) of the right colic marginal artery. A 56-year-old woman presented with mesenteric bleeding after being involved in a car accident. Computed tomography (CT) showed a large mesenteric hematoma and hemoperitoneum with no associated major injuries to other organs. There was a pseudoaneurysm with extravasation inside the hematoma. TAE was attempted to control bleeding during the preparation for surgical laparotomy. A superior mesenteric angiogram revealed a right colic marginal artery pseudoaneurysm. After successful TAE with microcoils, the affected colon perfusion was preserved via collateral circulation from the ileocolic artery. No ischemic gastrointestinal complications have occurred, and laparotomy has not been necessary during the 6 months after TAE. In isolated mesenteric injury cases, TAE may be a reasonable alternative to emergency laparotomy.

A feasibility study: evaluation of radiofrequency ablation therapy to hepatocellular carcinoma using image registration of preoperative and postoperative CT.

RATIONALE AND OBJECTIVES: The therapeutic response to radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) often is evaluated by comparing pre- and post-RFA computed tomography (CT). However, judgment about whether an ablative margin, ie, 5-10 mm of normal hepatic tissue, is ensured sometimes is difficult. The aim of this study is to assess the feasibility of fusion images of pre- and post-RFA CT. MATERIALS AND METHODS: HCCs (n = 20) sized 13 +/- 5 mm (range, 4-23 mm) were included. For pre-RFA CT, the arterial phase of intravenous dynamic CT (n = 17), CT arterioportography (n = 2), and CT hepatic arteriography (n = 1) was used. Using automatic image registration software (n = 20) and a manual segmentation technique (n = 4), fusion images were created in combination with post-RFA CT (equilibrium phase of intravenous CT). RESULTS: Automatic image registration and manual segmentation technique took approximately 2-3 and 5 minutes, respectively. Total time required for the creation of fusion images was less than 10 minutes in all cases. Fusion images enabled easier understanding of the relationship between the tumor and ablation zone, helping judge whether an ablative margin was ensured. CONCLUSION: Fusion of pre- and post-RFA CT images is considered a feasible tool in the evaluation of RFA therapy for HCC.

Timing on 16-slice scanner and implications for 64-slice cardiac CT: do you start scanning immediately after breath hold?

RATIONALE AND OBJECTIVES: Slow heart rate and small changes in heart rate are factors for improving image quality on spiral cardiac computed tomography (CT). The purpose of this study is to investigate whether it is possible to improve non-enhanced cardiac CT quality by delaying the data-acquisition window after breath hold. MATERIALS AND METHODS: Electrocardiograph files (n = 240) for 16-slice non-enhanced cardiac CT scans were analyzed. Mean heart rates and maximal changes in heart rates between adjacent cardiac cycles were compared between phase 1 (defined as cardiac cycles 1-5), phase 2 (cardiac cycles 2-6), ... , and phase 6 (cardiac cycles 6-10). RESULTS: Heart rates gradually increased by phases, but were limited to a range of 66.8-68.0 beats/min. Maximal changes in heart rates were 2.5 beats/min (phase 1) at the highest and 1.3 beats/min (phases 5 and 6) at the lowest (t-test; P < .01). Maximal changes in heart rates for more than five beats/min occurred in 24, eight, and eight patients on phases 1, 5, and 6, respectively (chi-square test; P < .01). CONCLUSION: The delayed scan (four or five cardiac cycles after breath hold) has the potential to improve the quality of non-enhanced cardiac CT.

Pseudoaneurysm embolization and vasopressin infusion for lower gastrointestinal bleeding due to recurrence of urinary bladder carcinoma.

We report a case that was successfully treated for massive lower gastrointestinal (LGI) bleeding due to a recurrent urinary bladder carcinoma. Treatment consisted of combination therapy including embolization of an inferior gluteal artery (IGA) pseudoaneurysm and low-dose arterial vasopressin infusion via a sigmoid artery (SA). A 57-year-old man presented with life-threatening sudden, massive LGI bleeding due to an obturator lymph node (LN) metastasis from a urinary bladder carcinoma. Computed tomography showed that the LN recurrence had invaded all the way to the sigmoid colon, and there was a pseudoaneurysm with extravasation inside the recurrence. An angiogram revealed a left IGA pseudoaneurysm. We therefore excluded the pseudoaneurysm by embolization with microcoils. Following this treatment the bleeding decreased, but intermittent LGI bleeding continued. Endoscopic examination showed the tumor with a huge ulcer inside the colonic lumen, and continuous oozing was confirmed. A second angiogram showed no recurrence of the IGA pseudoaneurysm and no apparent findings of bleeding. Then a 3F microcatheter was placed in the SA selectively using a coaxial catheter system, and vasopressin was infused at a rate 0.05 U/min for 12 h. Bleeding completely ceased 2 days later. There were no signs of ischemic gastrointestinal complications. Massive LGI bleeding has not recurred in 5 months.

Gynecologic abscess: CT-guided percutaneous drainage.

A 42-year-old woman with recurrent bilateral endometrial ovarian cystoma presented with fever and pelvic pain caused by a tubo-ovarian abscess (TOA), which was resistant to several varieties of intravenous and oral antibiotics for 2 weeks (Case 1). Computed tomography (CT)-guided diagnostic aspiration for a rapid enlarged right ovarian cystoma through a transabdominal route confirmed that it had developed into a TOA. Subsequent percutaneous abscess drainage (PAD) and irrigation for 3 days were successful. One-year follow-up revealed no recurrence of TOA. A 58-year-old woman with recurrent cervical cancer after external radiation therapy (RT) presented with fever, confusion and tremor caused by pyometra (Case 2). Since transvaginal drainage was impossible due to cervical os obstruction, the patient had undergone CT-guided transabdominal PAD and irrigation for a month. Thereafter, the clinical findings improved and a tracheloplasty was performed to prevent recurrence. CT-guided PAD may be a useful treatment option for gynecologic abscess as a diagnostic aspiration, a temporizing procedure until surgery, or an alternative surgery.

The impact of motion artifacts on the reproducibility of repeated coronary artery calcium measurements.

The purpose of this study is, using a 16-section multidetector-row helical computed tomography (MDCT) scanner with retrospective reconstruction, to compare variability in repeated coronary calcium scoring and qualitative scores of the motion artifacts. One hundred forty-four patients underwent two subsequent scans using MDCT. According to Agatston and volume algorithms, the coronary calcium scores during mid-diastole (the center corresponding to 70% of the R-R cycle) were calculated and the inter-scan variability was obtained. Motion artifacts from coronary artery calcium were subjectively evaluated and classified using a 5-point scale: 1, excellent; no motion artifacts; 2, fine, minor motion artifacts; 3, moderate, mild motion artifacts; 4, bad, severe motion artifacts; 5, poor, doubling or discontinuity. Each reading was done by vessels (left main, left descending, left circumflex and right coronary arteries) and the motion artifact score (mean of the scales) was determined per patient. The variability in the low (1.2+/-0.2) and high (2.4+/-0.6) motion artifact score groups was 7+/-6 (median, 6)% and 19+/-15 (16)% on the Agatston score (P<0.01) and 7+/-7 (6)% and 16+/-13 (14)% on the volume score (P<0.01), respectively. In conclusion, motion has a significant impact on the reproducibility of coronary calcium scoring.

Endovascular therapy of pulmonary arteriovenous malformations: Utility of 16-detector-row computed tomography pulmonary angiography as a pre-embolization survey.

The utility of computed tomography pulmonary angiography (CTPA) for coil embolization therapy of pulmonary arteriovenous malformations (PAVMs) was considered. Three consecutive patients (group A) with PAVMs underwent CTPA and coil embolization. The CTPA was performed using a 16-detector-row computed tomography scanner. After careful selection of pulmonary vessel trees, each feeding artery, nidus, and drainage vein was colored using different codes. By using the colored images, a 5-French catheter was shaped to fit to each feeding artery, the best fluoroscopic angle to select each feeding artery was chosen, and interlocking detachable coils (IDCs) were used in embolization. The procedure time and contrast material dose of group A were compared with those of the previous 3 patients (group B) who were treated by the conventional method. All PAVMs of both groups were completely embolized without coil migration. The average procedure time per lesion was 48.4 minutes for group A and 124.0 minutes for group B (P < 0.05). The average contrast material dose per lesion was 37.5 mL in group A and 76.0 mL in group B (P < 0.05). Using CTPA and IDCs, procedure time and contrast material dose were statistically significantly reduced. This combination therapy is useful in treating PAVMs less invasively.

Massive hemorrhage from internal carotid artery pseudoaneurysm successfully treated by transcatheter arterial embolization with assessment of regional cerebral oxygenation.

A 54-year-old male presented with intermittent massive hemorrhage from recurrent oropharyngeal cancer. The angiogram showed the encasements at the main trunk of the left internal carotid artery (ICA) and external carotid artery (ECA). Transcatheter arterial embolization (TAE) of the ECA with gelatin sponge particles and microcoils was performed. However, hemorrhage recurred several hours after the initial TAE. The second angiogram showed a large pseudoaneurysm of the ICA developing at the encasement on the initial angiogram. As a simple neurologic test, regional cerebral oxygenation (rSO2) was assessed with and without manual compression of the common carotid artery (CCA). With compression of the left CCA, the rSO2 did not change. We therefore performed isolation of the pseudoaneurysm. We embolized proximally and distally to the ICA pseudoaneurysm with microcoils and the pseudoaneurysm disappeared. No major complications occurred and no massive hemorrhage recurred until death from the cancer. TAE was an effective treatment for massive hemorrhage caused by tumor invasion to ICA. Assessment of rSO2 was a simple and useful neurologic test predicting the cerebral blood flow to prevent complications of TAE.

Radiofrequency ablation therapy combined with cementoplasty for painful bone metastases: initial experience.

The purpose of this study was to assess the efficacy and safety of percutaneous radiofrequency (RF) ablation therapy combined with cementoplasty under computed tomography and fluoroscopic guidance for painful bone metastases. Seventeen adult patients with 23 painful bone metastases underwent RF ablation therapy combined with cementoplasty during a 2-year period. The mean tumor size was 52 x 40 x 59 mm. Initial pain relief, reduction of analgesics, duration of pain relief, recurrence rate of pain, survival rate, and complications were analyzed. The technical success rate was 100%. Initial pain relief was achieved in 100% of patients (n=17). The mean VAS scores dropped from 63 to 24 (p<0.001) (n=8). Analgesic reduction was achieved in 41% (7 out of 17 patients). The mean duration of pain relief was 7.3 months (median: 6 months). Pain recurred in three patients (17.6%) from 2 weeks to 3 months. Eight patients died and 8 patients are still alive (a patient was lost to follow-up). The one-year survival rate was 40% (observation period: 1--30 months). No major complications occurred, but one patient treated with this combined therapy broke his right femur 2 days later. There was transient local pain in most cases, and a hematoma in the psoas muscle (n=1) and a hematoma at the puncture site (n=1) occurred as minor complications. Percutaneous RF ablation therapy combined with cementoplasty for painful bone metastases is effective and safe, in particular, for bulky tumors extending to extraosseous regions. A comparison with cementoplasty or RF ablation alone and their long-term efficacies is needed.