New methods for the management of esophageal varices

Bleeding from esophageal varices (EVs) is a catastrophic complication of chronic liver disease. Many years ago, surgical procedures such as esophageal transection or distal splenorenal shunting were the only treatments for EVs. In the 1970s, interventional radiology procedures such as transportal obliteration, left gastric artery embolization, and partial splenic artery embolization were introduced, improving the survival of patients with bleeding EVs. In the 1980s, endoscopic treatment, endoscopic injection sclerotherapy (EIS), and endoscopic variceal ligation (EVL), further contributed to improved survival. We combined IVR with endoscopic treatment or EIS with EVL. Most patients with EVs treated endoscopically required follow- up treatment for recurrent varices. Proper management of recurrent EVs can significantly improve patients’ quality of life. Recently, we have performed EVL at 2-mo (bimonthly) intervals for the management of EVs. Longer intervals between treatment sessions resulted in a higher rate of total eradication and lower rates of recurrence and additional treatment.     

Radiofrequency ablation in a porcine liver model： Effects of transcatheter arterial embolization with iodized oil on ablation time, maximum output, and coagulation diameter as well as angiographic characteristics

AIM:To evaluate the effects of combined radiofrequen-cy ablation and transcatheter arterial embolization with iodized oil on ablation time,maximum output,coagula-tion diameter,and portal angiography in a porcine liver model. METHODS: Radiofrequency ablation (RFA) was applied to in vivo livers of 10 normal pigs using a 17-gauge 3.0 cm expandable LeVeen RF needle electrode with or with-out transcatheter arterial embolization (TAE) with iodized oil (n = 5). In each animal,2 areas in the liver were ab-lated. Direct portography was performed before and af-ter RFA. Ablation was initiated at an output of 30 W,and continued with an increase of 10 W per minute until roll-off occurred. Ablation time and maximum output until roll-off,and coagulated tissue diameter were compared between the 2 groups. Angiographic changes on portog-raphy before and after ablation were also reviewed. RESULTS: For groups with and without TAE with iodized oil,the ablation times until roll-off were 320.6 ± 30.9 seconds and 445.1 ± 35.9 seconds,respectively,maxi-mum outputs were 69.0 ± 7.38 W and 87.0 ± 4.83 W and maximal diameters of coagulation were 41.7 ± 3.85 mm and 33.2 ± 2.28 mm. Significant reductions of abla-tion time and maximum output,and significantly larger coagulation diameter were obtained with RFA following TAE with iodized oil compared to RFA alone. Portography after RFA following TAE with iodized oil revealed more occlusion of the larger portal branches than with RFA alone. CONCLUSION: RFA following TAE with iodized oil can increase the volume of coagulation necrosis with lower output and shorter ablation time than RFA alone in nor-mal pig liver tissue.     

支气管动脉栓塞术治疗大咯血17例分析

目的探讨支气管动脉栓塞术治疗大咯血的方法和疗效。方法对17例大咯血患者行病灶供血支气管动脉栓塞术,栓塞材料为明胶海绵颗粒、聚乙烯醇（PVA）颗粒、海藻酸钠微球（KMG）,观察疗效。结果即刻止血14例（82．4％）,出血明显减少3例（17．6％）,总有效率100％,无特殊并发症发生。结论支气管动脉栓塞术是治疗大咯血的安全、有效、确切的治疗方法。     

急性肠系膜静脉血栓形成的有效治疗方法

目的探讨不同程度的急性肠系膜静脉血栓形成采用不同治疗方法的治疗效果。方法通过CT检查,探明28例急性肠系膜静脉血栓形成患者的发病情况,根据临床体征与CT影像显示的病情分别采用手术、非手术、介入治疗。结果非手术组12例患者全部治愈。手术组8例治愈,2例死亡,1例复发。介入治疗组3例均治疗成功,血栓清除满意。结论急性肠系膜静脉血栓形成患者根据其临床体征、CT检查结果综合考虑分别采用手术、非手术及介入治疗的治疗措施,临床取得比较好的效果。     

Successful coil embolization of a ruptured hepatic aneurysm in a patient with polyarteritis nodosa accompanied by angioimmunoblastic T cell lymphoma

Polyarteritis nodosa (PN) occasionally develops in association with malignant disorders. A 71-year-old man suddenly suffered from bleeding due to the rupture of a hepatic artery aneurysm. The ruptured lesion was embolized endovascularly by coiling, and the bleeding was stopped. A biopsy of the right inguinal lymph node demonstrated angioimmunoblastic T cell lymphoma (AITL). He received immunosuppressive treatment with transient response, although he relapsed 4 months later. To our knowledge, this is the first case of which PN was associated with AITL.     

Rupture of hepatic aneurysm complicating hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) for which hepatic arterial coil embolization was effective

A 74-year-old woman was transferred to our hospital for further examinations because of abdominal fullness and abnormal levels of serum liver/biliary enzyme persisting for 3 weeks. She had anemia and dilatation of many capillary vessels in her fingers, palms, and tongue in addition to reporting frequent incidences of nasal bleeding in herself and her family. Abdominal ultrasonography detected a cystic lesion in the right hepatic lobe, connected to a dilated tortuous hepatic artery. A low-echoic hepatic phyma was also detected in the back of the cystic lesion. Abdominal computed tomography and magnetic resonance imaging indicated that the cystic lesion was an aneurysm and the low-echoic phyma was a hematoma. Hepatic arteriography confirmed a hepatic aneurysm, tortuous dilatation of the hepatic artery, and the complication of an arteriovenous shunt in the liver. Taking all of these findings into consideration, this case was diagnosed as hereditary hemorrhagic telangiectasia (HTT) complicated by a hepatic aneurysm causing intrahepatic hematoma. To prevent re-rupture of the aneurysm, we performed a hepatic arterial coil embolization. After therapy, no blood flow to the aneurysm was detected by ultrasonic color Doppler method and the hematoma gradually diminished. There have been no reports of a case in which hepatic arterial embolization was effective for HHT-associated hepatic aneurysm causing intrahepatic hematoma. This very rare case provides important clinical information regarding abdominal vascular complications of HTT and a less invasive treatment for them.     

Safety of endovascular treatment of intracranial aneurysms with a new,complex shaped Guglielmi detachable coil

Introduction The Guglielmi detachable coil (GDC) 360°, a new complex shaped bare platinum coil, became available in Europe for aneurysm treatment in September 2005. The purpose of this study was to assess the feasibility and safety of selective embolization of intracranial aneurysms with the GDC 360° in 52 consecutive patients. Methods All patients included in this study were registered in a prospectively maintained database. We assessed the patient clinical history, aneurysm shape and dimensions, technical details and complications of the procedures, degree of aneurysm occlusion, and clinical findings upon discharge. In all patients, the first coil deployed was a GDC 360°. Results Over a 6-month period, we intended to treat 52 aneurysms with the GDC 360° in 52 patients. Of these 52 patients, 42 (81%) were treated in the context of subarachnoid haemorrhage. In 51 of 52 patients, the underlying aneurysm was successfully treated by coil embolization. Six procedures (11.5%) were complicated by the formation of thrombus in the parent artery during the intervention. One patient suffered a stroke related to the procedure. Angiograms obtained immediately after the procedure showed complete occlusion of the aneurysmal sac in 38 of 51 procedures (74.5%), a neck remnant in 11 (21.6%), and a residual aneurysm in 2 (3.9%). In 43 of 51 patients (84.3%), clinical assessment demonstrated independent clinical status, whereas 7 patients (13.7%) required assistance in the activities of daily living upon hospital discharge. One patient (2.0%) died after development of a severe vasospasm 10 days after the endovascular procedure. Conclusion The GDC 360° can be safely used for the endovascular occlusion of intracranial aneurysms.     

Palliative Airway Stenting Performed Under Radiological Guidance and Local Anesthesia

Purpose To assess the effectiveness of airway stenting performed exclusively under radiological guidance for the palliation of malignant tracheobronchial strictures. Methods We report our experience in 16 patients with malignant tracheobronchial stricture treated by insertion of 20 Ultraflex self-expandable metal stents performed under fluoroscopic guidance only. Three patients presented dysphagia grade IV due to esophageal malignant infiltration; they therefore underwent combined airway and esophageal stenting. All the procedures were performed under conscious sedation in the radiological room; average procedure time was around 10 min, but the airway impediment never lasted more than 40 sec. Results We obtained an overall technical success in 16 cases (100%) and clinical success in 14 patients (88%). All prostheses were successfully placed without procedural complications. Rapid clinical improvement with symptom relief and normalization of respiratory function was obtained in 14 cases. Two patients died within 48 hr from causes unrelated to stent placement. Two cases (13%) of migration were observed; they were successfully treated with another stent. Tumor overgrowth developed in other 2 patients (13%); however, no further treatment was possible because of extensive laryngeal infiltration. Conclusions Tracheobronchial recanalization with self-expandable metal stents is a safe and effective palliative treatment for malignant strictures. Airway stenting performed exclusively under fluoroscopic view was rapid and well tolerated.     

Treatment of Secondary Stent-Graft Collapse After Endovascular Stent-Grafting for Iliac Artery Pseudoaneurysms

We report the case of a patient who developed an asymptomatic pseudoaneurysm in the left external iliac artery after transplant nephrectomy. The pseudoaneurysm most probably arose as a suture aneurysm from the external iliac artery after removal of the graft renal artery. Obviously we can not exclude the possibility it was a true aneurysm, although this seems much less likely. The pseudoaneurysm was detected during a routine CT scan and was treated interventionally with a stent-graft. One month later the asymptomatic patient underwent a vascular ultrasound examination including color Doppler, power Doppler, and B-flow as a routine control. An endoleak with collapse of the stent-graft was diagnosed. There was no evidence of stent infection. At a reintervention, the pseudoaneurysm was successfully treated using two uncovered Palmaz stents at the proximal and distal edge of the stent graft. Peri- and post-interventional ultrasound and CT angiography confirmed the exclusion of the aneurysm without an endoleak.