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Plexiform neurofibromas (PNs) are highly vascularized and potentially malignant tumors. Surgical resection of a PN can be complicated by perioperative hemorrhagic events (PHE), including excessive intraoperative blood loss and postoperative hematoma at the surgical site. This study aimed to evaluate the predictive factors of PHE and the usefulness of preoperative embolization for PN. Consecutive surgical resections of 24 massive PNs in the body trunk with a maximum diameter > 5 cm in 22 patients between January 2015 and December 2020 were reviewed. Patient demographics, laboratory analyses, MRI findings, preoperative transcatheter arterial embolization (TAE), and pathological findings were evaluated between PNs with and without PHE, which consists of intraoperative blood loss over 15% of their estimated total blood volume and/or postoperative hematoma requiring surgical intervention or blood transfusion. PHE was observed in 7 out of 24 PNs (29.2%), with 5 events of excessive intraoperative bleeding and 2 postoperative hematomas. The PHE group (n = 7) showed a significantly higher flow-void effect inside the tumor on preoperative MRI than the non-PHE group (n = 17) (P = 0.0186). Preoperative TAE was not associated with PHE occurrence for the 24 PNs; however, it significantly reduced the PHE risk by 12 PNs with a flow-void sign (P = 0.00126). Other characteristics showed no significant differences between groups. The flow-void sign on MRI can be the only predictive factor of PHE in surgical resection for massive PNs in the body trunk. Preoperative TAE can reduce the PHE risk for PNs with a flow-void sign.

The purpose of this study is to evaluate whether anatomical variations of the cystic duct and accessory bile duct can be grasped by cystic duct three-dimensional (3D)-computed tomography (CT) using non-contrast CT and to examine the possibility of omitting magnetic resonance cholangiopancreatography (MRCP).Of patients who underwent non-contrast abdominal CT between May and October 2019, those who underwent MRCP within 1 month before and afterwards were targeted. Seven assessors visually evaluated the cystic duct 3D-CT images on a 5-point scale. Average scores of ≥3 and3 points were assigned as the good and poor groups, respectively. Regions of interest (ROIs) were placed inside the cystic duct and four places around it, and the CT values in those ROIs were measured. The CT value difference was calculated by subtracting the surrounding CT values from the CT value in the cystic duct and converting the result to an absolute value. The CT value difference was classified into good and poor groups, and statistical analysis was performed. Seven assessors evaluated anatomical variations of the cystic duct and the presence of the accessory bile duct. The results were compared with the MRCP interpretation results to calculate sensitivity, specificity, positive predictive value, and negative predictive value.The average visual evaluation score was 3.8. The good and poor groups were comprised by 53 (85.5%) and 9 (14.5%) patients, respectively. The CT difference value averages were 54.7 and 15.9 for the good and poor groups, respectively, and the value was significantly higher in the good group (p = 0.001). The comparison results with MRCP were sensitivity=83.3%, specificity=78.0%, positive predictive value=47.6%, and negative predictive value=95.1%.Cystic duct 3D-CT using non-contrast CT is a useful technique for understanding anatomical variations of the cystic duct and accessory bile duct. Our method may reduce the number of MRCP sessions performed.

Percutaneous transabdominal lymphangiography and embolization have been reported as useful approaches for intractable chylothorax or chylous ascites. However, they are often difficult to perform after extensive lymph node dissection because disruption of the antegrade lymphatic flow makes leaks identification difficult. When the leakage point cannot be identified or percutaneous transabdominal lymphangiography and embolization fail, a retrograde transvenous approach to the thoracic duct can be used instead. We report 3 cases of refractory chylous ascites after retroperitoneal operation or extensive lymph node dissection that was addressed by retrograde transvenous lymphatic embolization. In one case, a combination of retrograde transvenous lymphatic embolization, transcatheter sclerotherapy, and transcatheter embolization was used. These findings suggest that retrograde transvenous lymphatic embolization appears to be feasible and efficient for postoperative chylous ascites.

To evaluate the influence of ectopic origin of bronchial arteries (BAs) on bronchial artery embolization (BAE) for hemoptysis. CT and angiography images of 50 consecutive sessions in 39 patients (aged 26–93 years; mean, 70.6 years) who underwent BAE for hemoptysis from April 2010 to December 2019 were reviewed. We defined ectopic BA as a systemic artery originating from other than the T5–T6 vertebral level of the descending aorta with course along the major bronchi. The background of patients, number of BAs, culprit arteries, and treatment outcomes were compared between the cases with and without ectopic BAs. Seventeen patients (43.6%) demonstrated 19 ectopic BAs, originating from the subclavian artery (n = 7), aortic arch above the T5–T6 level (n = 6), internal mammary artery (n = 3), brachiocephalic trunk (n = 2) or lower descending thoracic aorta (n = 1). Total number of BAs in the cases with ectopic BA was significantly greater than those in cases without ectopic BA (p = 0.0062). Required sessions of embolization were similar in the two groups. No procedure-related significant complications were noted; however, four ectopic BAs caused unexpected filling of contrast media or migration of the embolic material from the orthotopic BA to ectopic BA originating from the arch vessels via tiny communication. Although BAE under the presence of ectopic BA is feasible and safe, detection of BAs with ectopic origin, even of small diameter, is needed to avoid risk of non-target coursing of embolic materials.

Introduction: To evaluate the efficacy, safety, and associated complications of a novel and simple approach to portal vein embolization that utilizes sheath injection and balloon occlusion (PVE-SIBO) with gelatin sponge (GS) for the purpose of increasing future liver remnant (FLR) volume. Methods: Between 1 January, 2006, and 31 August, 2020, 20 patients (15 men, 5 women, aged 64.6 ± 10.2 years) diagnosed with hepatobiliary malignancy underwent presurgical PVE-SIBO at our institution via a percutaneous transhepatic approach to the right portal vein and embolization of the portal vein with GS. We evaluated the increased ratio of FLR volume, operation duration, recanalization rate, and complications following this procedure. Results: All procedures were successful and without complications such as subcapsular hematoma, intra-abdominal bleeding, and bile leakage. The increased ratio of FLR volume was 34.7 ± 23.7% after a mean of 14.3 ± 2.57 days, and there was a significant difference in the FLR volume before and after PVE (P < 0.01). Procedure time was 52.7 ± 11.4 minutes. Conclusion: PVE-SIBO with GS is a simple, effective, and safe procedure to increase the ratio of FLR volume prior to hepatic surgeries.

Purpose: To evaluate the risk and prognostic factors of post-catheterization pseudoaneurysm (PPA). Material and methods: To identify the risk factors for PPA occurrence, clinical findings were compared between 22 consecutive patients with radiologically confirmed PPAs (PPA group) and 300 randomly extracted patients without PPA, who underwent transarterial angiography or intervention (sample group) between 1 January 2015 and 31 March 2020. The PPA group was further divided into those treated successfully with mechanical compression (group A) and those requiring ultrasound-guided thrombin injection after compression failed (group B). Univariate and multivariate analyses were used to compare patient demographics, preoperative laboratory findings, procedure details, PPA diameter, and time interval between the procedure and compression between groups A and B to evaluate the prognostic factors of PPA. Results: The PPA group demonstrated significantly elevated prothrombin time international normalized ratios (PT/INR) (odds ratio [OR]: 6.27, 95% confidence interval [CI]: 2.020-19.5; p = 0.00151) and more frequent popliteal access (OR: 14.2, 95% CI: 1.040-195.0; p = 0.0467) compared to the sample group, and radial access decreased the risk of PPA (OR: 0.382, 95% CI: 0.0148-0.987; p = 0.0468). One of the 22 PPAs resolved spontaneously, and 11 others (52.4%) were successfully treated by mechanical compression. An interval exceeding 24 hours between the procedure and compression was the only significant prognostic factor (p = 0.0281) between groups A and B. Conclusions: Elevated PT/INR and popliteal access may predispose patients to PPA; close consideration of the site of access may lower the risk of refractory PPA.

Purpose: Pancreatitis-related pseudoaneurysm, a potentially life-threatening condition, is treated utilising endovascular management as a first choice and alternatively by percutaneous direct puncture of the aneurysm and embolisation. Case report: A 50-year-old man with alcohol-induced necrotic pancreatitis underwent transcatheter arterial embolisation (TAE) for multiple pancreatic pseudoaneurysms. TAE failed in one enlarged aneurysm in the pancreatic body, and percutaneous direct needle puncture and coagulation using thrombin was planned. Precise puncture of the aneurysmal sac under fluoroscopy and computed tomographic (CT) guidance failed, but we could inject about 500 units of thrombin through the outer cannula into the collection of fluid surrounding the aneurysm. Compared to preoperative images, contrast-enhanced CT (CECT) showed shrinkage of the pseudoaneurysm without complications just after the procedure and its disappearance five days after the procedure. Conclusions: Percutaneous direct puncture and embolisation is a feasible choice to treat pancreatic pseudoaneurysms, and injection of thrombin even into the collection of fluid surrounding the pseudoaneurysm can be a viable alternative, especially in cases in which precise puncture of the aneurysmal sac is difficult because of its size and location.

A 50-year-old man with von Hippel-Lindau syndrome who had undergone repeated tumor enucleation and transcatheter arterial embolization for multiple renal cell carcinomas (RCC) was referred to our hospital for percutaneous cryoablation (PCA) of an RCC of 42 mm in the midpole region of the right kidney. Transcatheter arterial embolization was planned prior to devascularize the RCC and selective angiography revealed parasitic arterial supply to the tumor by the ileocecal artery. Parasitic arterial supply to RCCs, particularly in patients with history of nephron-sparing treatment, can originate even from an intraperitoneal source and may lead to unexpected embolization. Keywords: Parasitic circulation, Renal cell carcinoma

We report the first case of percutaneous cryoablation (PCA) for stage T1b renal cell carcinoma (RCC) in a horseshoe kidney (HK). A 76-year-old man with an HK underwent computed tomography-guided PCA for RCC measuring 42 mm (stage T1b) in diameter. Although transcatheter embolization before the PCA and hydrodissection were required to avoid complication and incomplete ablation, PCA was successfully performed without complication. The complete ablation was confirmed on computed tomography images 1 month after the procedure. There was no recurrence or metastasis during 2 years of follow-up. We believe this is the first report of PCA for stage T1b RCC in a patient with HK. This technique can be performed without regard to tumor size and location and may be considered as a treatment option to avoid complex surgery. Keywords: Cryoablation, Renal cell carcinoma, Horseshoe kidney

To retrospectively evaluate the feasibility of transcatheter arterial embolization (TAE) using a mixture of absolute ethanol and iodized oil to improve localization of endophytic renal masses on unenhanced computed tomography (CT) prior to CT-guided percutaneous cryoablation (PCA). Our institutional review board approved this retrospective study. From September 2011 to June 2015, 17 patients (mean age, 66.8 years) with stage T1a endophytic renal masses (mean diameter, 26.5 mm) underwent TAE using a mixture of absolute ethanol and iodized oil to improve visualization of small and endophytic renal masses on unenhanced CT prior to CT-guided PCA. TAE was considered successful that accumulated iodized oil depicted whole of the tumor edge on CT. PCA was considered successful when the iceball covered the entire tumor with over a 5 mm margin. Oncological and renal functional outcomes and complications were also evaluated. TAE was successfully performed in 16 of 17 endophytic tumors. The 16 tumors were performed under CT-guided PCA with their distinct visualization of localization and safe ablated margin. During the mean follow-up period of 15.4 ± 5.1 months, one patient developed local recurrence. Estimated glomerular filtration rate declined by 8 % with statistical significance (P = 0.01). There was no procedure-related significant complication. TAE using a mixture of absolute ethanol and iodized oil to improve visualization of endophytic renal masses facilitated tumor localization on unenhanced CT, permitting depiction of the tumor edge as well as a safe margin for ablation during CT-guided PCA, with an acceptable decline in renal function.

Background Scimitar syndrome can present with a wide clinical spectrum of symptoms either early in the neonatal period or later in life. Case description We report a case of a 62-year-old woman with anomalous systemic arterial supply to the basal lung with scimitar syndrome presenting as recurrent hemoptysis. Bronchoscopy revealed normal major bronchial branches without bronchial atresia, indicating that sequestration of the lung was not confirmed. The anomalous drainage of the scimitar vein was to the inferior vena cava, and an anomalous artery from the aorta supplied the right basal lung. There were no findings of pulmonary hypertension and arteriovenous malformation such as an anomalous artery to the scimitar vein. The distal portions of anomalous arteries were embolized using gelatin sponge particles and the proximal portion was embolized using fibered detachable coils. Although a small pulmonary infarction was observed as a complication, the patie nt has not experienced any subsequence recurrence of the hemoptysis during a follow-up period of 6 months. Discussion and evaluation Deformities of the blood vessels and the lungs are frequently complex in scimitar syndrome. Although patients treated with surgical repair of this disorder may be at higher risk than those treated less invasively, we believe that transcatheter embolization was a useful strategy for the treatment of the anomalous systemic arterial supply to the basal lung, particularly in this patient with scimitar syndrome. Conclusion Hemoptysis in a patient with scimitar syndrome associated with anomalous systemic arterial supply to the basal lung was successfully treated with transcatheter arterial embolization. However, it might be better to avoid the use of gelatin sponge particles in patients with a similar anomaly without pulmonary artery distribution because of the possibility of causing severe pulmonary infarction.

We report a case each of duodenorenal and colorenal fistula that arose after computed tomography-guided percutaneous cryoablation (PCA) for renal cell carcinoma and use imaging and endoscopic findings to analyze their causes and mechanisms. Both complications occurred though the edge of the iceball did not touch the intestinal wall, and patients’ symptoms and fistula formation occurred several days after the PCA procedure. Based on imaging and endoscopy findings, we suspected the colorenal fistula resulted from bowel injury caused by ischemia from the occlusion of small vessels at the procedure’s low temperature. Both cases were resolved conservatively without surgical intervention.