Three-dimensional angiography using rotational digital subtraction angiography: usefulness in transarterial embolization of hepatic tumors

Purpose: To assess the usefulness of three-dimensional (3D) angiography using rotational digital subtraction angiography (DSA) in transarterial embolization of hepatic tumors.

Material and Methods: Thirty-one 3D angiographies were conducted using rotational DSA during abdominal angiography for transarterial embolization of hepatic tumors. The quality of visualization of the tumor and feeder arteries as imaged by 3D angiography versus DSA anterioposterior (AP) images was compared.

Results: 3D rotational angiography provided excellent 3D visualization of the vascular structures of the hepatic artery, and was especially useful in patients with overlapping tumors on DSA AP images and in patients with complex vascular anatomies. Compared to DSA AP images, however, tumor stains could not be detected on 3D-A, but could be detected on DSA in four patients (13%). In 9 patients, feeding arteries could not be detected on 3D-A, but could be detected on DSA (29%).

Conclusion: 3D rotational angiography alone may not be suitable for pre-procedural mapping in transarterial embolization of hepatic tumors, but may be of value when information supplementary to DSA AP images is needed.     

Three-dimensional digital angiography: new tool for simultaneous three-dimensional rendering of vascular and osseous information during rotational angiography

Three-dimensional (3D) digital subtraction angiography (DSA) is the latest development in the neurovascular imaging armamentarium. 3D-DSA combines the anatomic resolution of DSA with 3D visualization abilities previously offered by only CT or MR angiography. 3D-DSA provides more detailed information than does DSA alone in the evaluation of neurovascular lesions, such as cerebral aneurysms. However, the inability of 3D-DSA to simultaneously image osseous and vascular structures is noted as a weakness of this technique compared with CT angiography. We describe a new 3D digital angiography reconstruction algorithm that allows the concurrent display of the cerebral vasculature and the osseous landmarks.     

Three-dimensional rotational angiography of neurovascular lesions in pediatric patients

OBJECTIVE: In this pictorial essay, we review the 3D rotational angiography (RA) studies of six pediatric patients; in these cases, the information obtained with 3D RA was uniquely beneficial in diagnosis and treatment planning. CONCLUSION: Three-dimensional RA is an excellent tool for the evaluation of a number of intracranial lesions in pediatric patients: There is less total radiation exposure from a single rotational run than from CT or a conventional angiography examination that involves more than one view and the study is quick, with data acquisition requiring less than 8 sec and fully rendered 3D reconstructions generated within 180 sec.     

Three-dimensional rotational angiography for craniotomy planning and postintervention evaluation of intracranial aneurysms

Purpose

The authors evaluated the usefulness of three-dimensional rotational angiography (3DRA) in surgical planning and postoperative evaluation of cerebral aneurysms.

Materials and methods

A total of 111 consecutive aneurysms in 100 patients (32 emergency referrals due to haemorrhage) were evaluated with 3DRA over a period of 3 years. The rotational study was always performed with a single injection of 20 cc of contrast agent in the afferent vessel after diagnostic cerebral angiography in the two orthogonal projections. Three-dimensional reconstructions were obtained for the pre- and postoperative assessment.

Results

Three-dimensional RA provides a virtual view of the surgical field with the same orientation required for the surgical approach and, compared with surgical findings, reliably defined location, orientation, morphology and relationship with parent vessels of the aneurysm in all cases. Postoperatively, it allowed better assessment of any residual lesion and of the relationship between surgical clips and parent vessels, compared with standard 2D angiography.

Conclusions

3DRA is a reliable method for preliminary assessment of cerebral aneurysms undergoing surgery. It provides multiple projections with a preview of the surgical field and study of lesion characteristics, which can help achieve faster and safer surgery. Compared with 2D angiography, the 3D model, with its multiple views, allows better assessment of postoperative outcomes. The method also significantly reduces the number of angiographic projections and therefore radiation and contrast-medium dose to the patient.     

宫颈癌术前动脉化疗栓塞疗效

目的 研究局部进展期宫颈癌术前子宫动脉化疗栓塞的疗效及病理改变.方法 经阴道镜活检证实宫颈癌患者43例,其中鳞癌38例,腺癌5例;FIGO临床分期Ⅰ B2期14例,ⅡA期5例,ⅡB期23例,ⅢB期1例.所有患者均进行1次子宫动脉化疗栓塞,化疗药物为博莱霉素+顺铂+异环磷酰胺,栓塞剂为明胶海绵颗粒.其后择期行子宫广泛切除加盆腔淋巴结清扫术,分析手术及病理所见.结果①介入治疗后CR 4例,PR 29例,总有效率为76.7%.②介入治疗与外科手术间隔时间为肿瘤治疗无效的风险因素,即随着间隔时间延长介入疗效下降.③术后病理显示,镜下表现为肿瘤细胞退行性变,凋亡,肿瘤组织结构松散,周边及肿瘤内大量炎细胞浸润,纤维组织增生,部分病例镜下未见肿瘤细胞.宫旁浸润率减低,部分肿瘤分期逆转,术后病理与术前病理比较10例分化程度降低,5例术后未见肿瘤或残余个别肿瘤细胞而不能判定分化,9例分化程度增高,19例无变化.结论 子宫动脉化疗栓塞用于宫颈癌根治新辅助化疗安全有效,可在短期内有效控制肿瘤生长,并可能降低临床分期,有利于肿瘤根治切除.介入治疗后应尽早择期进行手术而不宜过于延长间隔时间.     

Three-dimensional rotational angiography of transplanted renal arteries: influence of an extended angle of rotation on beam-hardening artifacts

PURPOSE: To investigate whether three-dimensional rotational angiography (3D-RA) of the transplant renal artery performed with an extended angle of rotation can reduce beam-hardening artifacts in 3D reconstructed images without image quality being lost or side effects to the transplanted kidney being increased. MATERIAL AND METHODS: 3D-RA with a C-arm rotation of 180 degrees was performed consecutively in 12 renal transplanted patients with suspicion of renal artery stenosis. A 1.7-mm balloon occlusion catheter was placed using the crossover technique and this was compared to a protocol with 160 degrees rotation and a traditional 1.4-mm catheter in 10 patients. The occurrence of beam-hardening artifacts was registered and the effects of the reduced contrast load on image quality and of arterial occlusion on renal function were assessed. RESULTS: The extended angle of rotation, from 160 degrees to 180 degrees, reduced the beam-hardening artifacts. Artifacts were observed in 4/11 patients (36%) in the study group and in all 10 (100%) of the controls. There was no statistical difference regarding image quality between the two protocols. Renal function was equally affected in both protocols. CONCLUSION: 3D-RA with an extended C-arm rotation reduced the beam-hardening artifacts. Image quality was not reduced despite the reduced contrast medium load. The different protocols had no effect on patient outcome.     

Sequential transarterial chemoembolization for unresectable advanced hepatocellular carcinoma

Purpose The aim of this prospective study was to evaluate the feasibility, safety, and efficacy of sequential transarterial chemoembolization (TACE) for patients with unresectable advanced hepatocellular carcinoma (HCC). Methods Twenty-one consecutive patients with unresectable T3 and T4 HCC were treated by sequential TACE (median time interval between treatments 7 weeks) up to six times with an emulsion of lipiodol, epirubicin, and cisplatin. All TACE procedures were performed as unilobar or whole-liver chemoembolization. Results An average of 3.9 TACE procedures were performed per patient. One primary and two secondary technical failures occurred. No procedural death was observed. After exclusion of the patient with the primary technical failure and 3 patients with extrahepatic disease, the survival rates for the remaining 17 patients at 6, 12, 18, and 24 months were 70.6%, 52.9%, 44.1%, and 33.1%, respectively. Conclusion Sequential TACE is a safe procedure in patients with unresectable advanced HCC and feasible in most cases. It seems to prolong the survival time compared with historical series of untreated patients.     

Evaluation of therapeutic effectiveness of transarterial chemoembolization for hepatocellular carcinoma: correlation of dynamic susceptibility contrast-enhanced echoplanar imaging and hepatic angiography

The objective of this study was to evaluate the therapeutic effectiveness of transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) with dynamic susceptibility contrast-enhanced magnetic resonance imaging (DSC-MRI). Seventeen patients with histopathologically proven HCC were included in this study. All patients underwent MR examinations with conventional T1- and T2-weighted images, gadolinium-enhanced images, and DSC-MRI before TACE treatment. Hepatic blood volume (HBV) maps were reconstructed from the time-intensity curves. The same MRI sequences and techniques were repeated 24 h and 6 weeks after TACE. Serial changes in tumor perfusion on HBV maps were correlated with vascularity in hepatic angiography. All tumors were hypointense on T1-weighted images and hyperintense on T2-weighted images. Heterogeneous enhancement was observed in all tumors before and immediately after TACE. Hyperperfusion was noted in most of the tumors on HBV map before TACE and moderate to marked hypoperfusion following TACE. The degree of tumor perfusion on HBV map correlated well with the vascularity in angiography. In conclusion, the noninvasive nature of DSC-MRI is useful to evaluate the effectiveness of TACE. Invasive procedures, such as angiography, are seldom necessary.     

Conventional versus doxorubicin-eluting bead transarterial chemoembolization for hepatocellular carcinoma

Purpose

To compare short- and long-term clinical outcomes after conventional transarterial chemoembolization and drug-eluting bead (DEB) transarterial chemoembolization in hepatocellular carcinoma (HCC).

Materials and Methods

Patients with unresectable HCC unsuitable for ablative therapies were randomly assigned to undergo conventional or DEB chemoembolization. The primary endpoints of the study were safety, toxicity, and tumor response at 1 month. Secondary endpoints were number of repeated chemoembolization cycles, time to recurrence and local recurrence, time to radiologic progression, and survival.

Results

In total, 67 patients (mean age, 70 y ± 7.7) were evaluated. Mean follow-up was 816 days ± 361. Two periprocedural major complications occurred (2.9%) that were treated by medical therapy without the need for other interventions. A significant increase in alanine aminotransferase levels 24 hours after treatment was reported, which was significantly greater after conventional chemoembolization (n = 34) than after DEB chemoembolization (n = 33; preprocedure, 60 IU ± 44 vs 74 IU ± 62, respectively; at 24 h, 216 IU ± 201 vs 101 IU ± 89, respectively; P = 0.007). No other differences were observed in liver toxicity between groups. At 1 month, complete and partial tumor response rates were 70.6% and 29.4%, respectively, in the conventional chemoembolization group and 51.5% and 48.5%, respectively, in the DEB chemoembolization group. No differences were observed between groups in time to recurrence and local recurrence, radiologic progression, and survival.

Conclusions

Conventional chemoembolization and DEB chemoembolization have a limited impact on liver function on short- and long-term follow-up and are associated with favorable clinical outcomes.     

Three-dimensional rotational spinal angiography in the evaluation and treatment of vascular malformations

BACKGROUND AND PURPOSE: Conventional spinal angiography, although useful in providing angioarchitectural details of spinal vascular disease, has limitations. The advent of 3D angiography has provided a better comprehension of angioarchitectural detail when evaluating the intracranial circulation. The purpose of this study was to evaluate the usefulness of 3D angiography in the diagnosis and treatment of vascular malformations of the spine. METHODS: This retrospective analysis included 17 3D spinal angiograms acquired in 14 consecutive patients examined at our institution for a spinal vascular lesion, which included nine spinal cord arteriovenous malformations (AVMs), one perimedullary arteriovenous fistula (AVF), three spinal dural AVFs, and one nerve root AVM. 3D angiography was obtained with apnea under general anesthesia by using a 14-second acquisition and 200 degrees rotation of the gantry during injection of 300 mg I/mL nonionic contrast material at a rate of 0.5-3.5 mL/s. Multiple reconstructed images were obtained with or without opacification of the surrounding structures. These images were then evaluated by the interventionalists at the time of the procedure and compared with findings obtained by conventional subtraction angiography. RESULTS: 3D angiography was useful in differentiating intramedullary lesions from perimedullary surface lesions; detecting arterial, nidal, or venous aneurysms; and evaluating the 3D structure of the lesion as well as the relationship between the malformation and its draining veins or surrounding bony structures. In specific situations, it obviated the need for contrast-enhanced conventional or 3D CT, as well as for lateral or oblique angiographic views, which are sometimes difficult to obtain with good quality. No 3D angiography-related complications were experienced. Some limitations in the definition of small vessel anatomy in the reconstructed images were noted. CONCLUSION: In this small series of patients, 3D angiography was safe and useful for evaluation of the 3D vascular anatomy of spinal vascular malformations.     

Three-dimensional reconstructed rotational digital subtraction angiography in planning treatment of intracranial aneurysms

We evaluated three-dimensional (3D) reconstructions of 200 ° rotational digital subtraction angiography (DSA) images for their contributions to improving the safety of endovascular embolization of intracranial aneurysms. Standard DSA and 200 ° rotational DSA were performed in 40 adult patients (aged 21–77 years) with 45 intracranial aneurysms. Information obtainable from standard DSA and 3D-DSA images about aneurysm shape and size was compared. In 40 (89 %) of the 45 aneurysms 3D-DSA gave additional information about the anatomy of the aneurysm. In 17 (43 %) of these cases aneurysm anatomy could be visualized better on 3D-DSA than on standard DSA images. In three cases only 3D-DSA images showed blood vessels originating from the aneurysm. Reconstructed 3D images were also helpful in visualizing partially clipped aneurysms. On maximum-intensity projection images it was even possible to depict previously embolized aneurysms. Blood vessels originating from the aneurysm are visible on 3D-DSA images, and even previously clipped aneurysms can be visualized well. Rotational DSA with 3D reconstruction is a helpful tool in the assessment of intracranial aneurysms. Received: 7 September 1999; Revised: 26 November 1999; Accepted: 26 November 1999     

Three-dimensional fusion digital subtraction angiography: new reconstruction algorithm for simultaneous three-dimensional rendering of osseous and vascular information obtained during rotational angiography

This report describes three-dimensional (3D) fusion digital subtraction angiography (FDSA), a new algorithm for rotational angiography that combines reconstructions of the blood vessels and the osseous frame in a single 3D representation. 3D-FDSA is based on separate reconstructions of the mask and contrast sequences of the rotational acquisition. The two independent 3D data sets (3D-bone and 3D-digital subtraction angiography [DSA]) are fused in a single 3D representation. The algorithm uses a modification of the Feldkamp method that compensates for signal intensity inhomogeneity inherent to the reconstruction of nonsubtracted rotational acquisitions. By separately reconstructing the osseous and vascular information obtained from the rotational angiogram, 3D-FDSA provides optimal angiographic resolution and precise topographic analysis even when the studied vascular tree is in the immediate vicinity of bone.     

Artifacts in 3D rotational angiography: an experimental study

PURPOSE: To investigate artifacts in three-dimensional rotational angiography (3D-RA) in an experimental model and to evaluate which parameters influence their distribution. MATERIAL AND METHODS: 3D-RA was carried out in a circular vessel phantom filled with contrast medium. Two different rotational angulations were used: 160 degrees causing 64 images and 180 degrees causing 90 or 120 images. The images were transferred to one workstation for reconstruction of axial slices and then to another workstation for 3D reconstructions. The 3D reconstructions were compared with standardized threshold settings. RESULTS: The artifacts occurred where the vessel had a longer path parallel to the rotation plane and became increasingly pronounced when the threshold level was raised. The artifacts decreased in size when rotation angle and number of projections were increased. CONCLUSION: The quality of the 3D reconstructions from RA was degraded by beam-hardening and sampling artifacts. The sampling artifacts were diminished by increasing both the rotation angle and the number of projections. The distortions in the 3D reconstructions caused by beam-hardening remain to be resolved. The threshold values also had a considerable influence on the 3D reconstructions.     

射频消融联合肝动脉化疗栓塞治疗肝转移癌

目的 评价射频消融术(RFA)联合肝动脉化疗栓塞术(TACE)对于肝转移癌的治疗效果.方法 搜集2005年3月至2010年10月36例肝转移癌患者的临床资料进行分析,其中男22例,女14例;年龄42～82岁,平均(63±12)岁;肿瘤最大径1.5～12.0 cm,平均(4.5±2.4) cm.其中单发转移灶29例,多发转移7例,共47个病灶.患者均为全身化疗失败或无法耐受,且无其他脏器转移证据者.术前CT扫描,对于富血供者先行TACE,术后3周内行RFA;对于乏血供者,先行RFA,术后3周内行TACE.对于多个病灶,采取分次逐一治疗.术后每个月行B超复查及肝功能、血象、肿瘤标记物检查,每3个月行腹部CT增强扫描1次.对于随访过程中肿瘤的局部残存及复发,在可能的前提下仍行RFA+TACE治疗.根据治疗后的影像表现分为病灶完全消融组和病灶部分消融组2个亚组,完全消融组不再进行任何治疗,定期随访观察;部分消融组如无法行进一步RFA治疗,则根据患者情况定期行TACE治疗.随访终点事件为患者死亡.对所有患者的整体生存期及两个亚组的生存期采用SPSS 18.0统计分析软件,Kaplan-Meier方法进行统计分析.结果 RFA全部采用经皮途径在局部麻醉结合静脉基础麻醉下完成,无严重并发症发生.16例患者经过1次或多次联合治疗后达到局部病灶完全消除(病灶完全消融组);20例患者病灶部分消除(病灶部分消融组).随访时间10～40个月,平均(25±10)个月.死亡23例,至今存活13例.中位生存期27个月(95%可信区间:24～32个月).至观察终点1、2、3年生存率分别为91.7%(33/36例)、55.5%(20/36例)、36.1%(13/36例).病灶完全消融组和部分消融组的3年生存率分别为75.0%(12/16例)和5.0%(1/20例),差异有统计学意义(P<0.01).结论 RFA+TACE可以有效控制肝转移癌患者肝内病变的进展,延长患者生存期.争取病灶的完全消融是提高疗效的关键.

Abstract：

Objective To investigate the efficacy and safety of radiofrequency ablation (RFA) combined with transarterial chemoembolization (TACE) for treating of hepatic metastasis. Methods From Mar. 2005 to Oct. 2010, 22 males and 14 females with hepatic metastasis were enrolled in this study. Mean age of the patients was 63±12 (42-82) years. Tumor size was (4.5±2.4) cm (min.1.5 cm, max. 12.0 cm). Totally 47 lesions were treated with single metastasis in 29 cases and multiple ones in 7 cases. All cases were failed to chemotherapy or could not stand for the side effect of chemotherapy. Contrast enhanced CT scan was given to all patients before RFA+TACE. For lesions with rich blood supply, TACE was given and then RFA. For those with poor blood supply, RFA was given first and then TACE. For multiple lesions, RFA+TACE was given one by one for each lesion. As for follow up, ultrasound and blood check was given monthly. Enhanced CT scan was given every 3 month. For residual lesions or recurrent lesions, RFA+TACE were given repeatedly. The whole patients was divided into two groups according to the image follow up including complete ablation group and partial ablation group. For complete ablation group, no further treatment was given. For partial ablation group, if it was not suitable for further RFA, repeated TACE was given there after. The end point of follow up was death event. Survival of the whole group and the two subgroups was analyzed statistically by Kaplan-Meier method. Results All RFA procedures was given under intravenous anesthesia and local anesthesia, no severe complication was noted. Lesions in 16 patients were completely ablated after single or multiple sections of RFA+TACE. Twenty patients were in the partially ablated group. Follow up time was 25±10 (10-40) months. Twenty-three patients died and 13 kept alive during the follow up time. The estimated median survival time was 27 month (95%CI: 24-32 months). Survival ration at 1, 2, 3 years for the whole group was 91.7%(33/36),55.5%(20/36),36.1%(13/36) for the whole group. The 3 years survival for complete and partial ablation group was 75.0%(12/16),5.0%(1/20),there was a significant difference between the two groups(P<0.01). Conclusion For patients with hepatic metastasis, RFA+TACE can effectively control the local lesion. Complete ablation is the key point for a better survival.     

Computed tomography perfusion imaging for monitoring transarterial chemoembolization of hepatocellular carcinoma

PurposeTo prospectively monitor changes in tumor perfusion of hepatocellular carcinoma (HCC) in response to doxorubicin-eluted bead based transarterial chemoembolization (DEB-TACE) using perfusion-CT (P-CT).Methods and materials24 patients (54–79 years) undergoing P-CT before and shortly after DEB-TACE of HCC were prospectively included in this dual-center study. Two readers determined arterial-liver-perfusion (ALP, mL/min/100 mL), portal-venous-perfusion (PLP, mL/min/100 mL) and the hepatic-perfusion-index (HPI, %) by placing matched regions-of-interests within each HCC before and after DEB-TACE. Imaging follow-up was used to determine treatment response and to distinguish complete from incomplete responders. Performance of P-CT for prediction and early response assessment was determined using receiver-operating-characteristics curve analysis.ResultsInterreader agreement was fair to excellent (ICC, 0.716–0.942). PLP before DEB-TACE was significantly higher in pre-treated vs non-treated lesions (P < 0.05). Mean changes of ALP, PLP and HPI from before to after DEB-TACE were −55%, +24% and −27%. ALP and HPI after DEB-TACE were correlating with response-grades (r = 0.45/0.48; both, p < 0.04), showing an area-under-the-curve (AUC) of 0.74 and 0.80 respectively for identification of complete response.ConclusionHigh arterial and low portal-venous perfusion of HCC early after DEB-TACE indicates incomplete response with good diagnostic accuracy.     

Three-dimensional noninvasive contrast-enhanced electron beam tomography angiography of the kidneys: adjunctive use in medical and surgical management

OBJECTIVE: To indicate the use of 3D electron beam computerized tomography angiography (EBCTA) for renal artery lesions, vascular variants that are crucial to detect before surgery, especially partial nephrectomy and extension of the intravascular tumor. METHODS: Forty patients (30 men, 10 women, age range 13-82, mean age 54.2) underwent EBCT (GE-Imatron, C 150 ultrafast CT scanner) of the renal arteries. It is essential to review the axial images for all necessary information before the 3D technique is performed. RESULTS: Maximum intensity projection (MIP) and volume rendering (VR) images were excellent in demonstrating stenosis of the renal arteries. Accessory and main renal arteries were easily depicted, and stenosis has been shown. In our study, among 40 renal angiography patients, 21 had stenosis of the renal arteries with different percentages. A total of 12 accessory renal arteries (five left, seven right) were detected. EBCT, with its 3D techniques, was found to be accurate and useful for renal vascular anatomy as a noninvasive test to delineate renal tumors and renal anatomy prior to nephron sparing surgery because it is known to conserve normal renal parenchyma adjacent to tumor. CONCLUSION: EBCT, with its noninvasive VR and MIP techniques, is easy to apply and is functional and accurate for neoplasms, renal vascular anatomy and renal artery stenosis.