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We herein report a successfully treated case of huge ruptured hepatocellular carcinoma (HCC) by conversion hepatectomy after transarterial embolization (TAE) and lenvatinib therapy. A 33-year-old male patient with right hypochondralgia and liver tumor was referred to our hospital. He had a history of surgery for heart malformation. The tumor at the right lobe was 15 cm in diameter with bloody ascites. Right atrial thrombus 4.5 cm in diameter and marked cardiac dilatation were observed. TAE with ethanol suspended in lipiodol and gelatin sponge achieved hemostasis of the ruptured HCC. Although viable HCC remained after TAE, surgical treatment was abandoned because of abdominal wall invasion and his heart function. Lenvatinib and rivaroxaban were then initiated for HCC and atrial thrombus, respectively. Lenvatinib treatment resulted in a reduction in tumor marker levels and the tumor size. First, we planned conversion hepatectomy after 5 months of lenvatinib. However, recurrence of atrial thrombus prompted us to put off the surgery, and lenvatinib was re-administered. After improvement of atrial thrombus, we finally performed conversion hepatectomy 10 months after starting lenvatinib administration. The tumor was completely removed by combined resection of the diaphragm, and the patient has been doing well without any signs of recurrence., (© 2021. Japanese Society of Gastroenterology.)

Diffuse pulmonary arteriovenous malformations (PAVMs) are defined as arteriovenous malformations (AVMs) involving subsegmental, segmental, or both types of arteries in at least 1 lung lobe and are more extensive than multiple PAVMs. Diffuse PAVMs involving systemic arterial shunts are very rare. We describe a rare case, in which diffuse PAVMs involving systemic arterial shunts were successfully treated with coil embolization.

The purpose of this article is to describe the indications for use of n-butyl cyanoacrylate (NBCA) in abdominal and pelvic embolotherapy, appropriate techniques for NBCA embolotherapy, and NBCA-related complications and their management. NBCA embolotherapy is a feasible and effective method for treating a variety of abdominal and pelvic vascular lesions or tumors; however, the techniques suitable for each case and knowledge of NBCA-related complications are essential to achieve favorable outcomes.

Background/aims: To identify clinical significances of portal vein embolization (PVE) prior to major hepatectomy, we examined clinical parameters and outcome after right hepatectomy in patients who underwent PVE., Methodology: The subjects were 30 patients who underwent PVE (PVE group), and 52 patients (non-PVE), in whom PVE was considered unnecessary, followed by right hepatectomy for hepatobiliary cancer., Results: Total hepatic volume after PVE (1068+/-268 ml) tended to increase compared with before PVE (p=0.059). After PVE, the change in hemi-liver volume was 8.9+/-6.0%. Increases in hepatic volume of non-embolized left liver before and at 4 weeks after hepatectomy between the PVE and non-PVE groups were similar. Changes in hepatic volumes before and after PVE were not significantly influenced by background liver disease. After PVE, the functional liver volume (419+/-185 cm3) was significantly lower than morphological volume (564+/-165 cm3) in the embolized liver (p<0.05). Although preoperative liver function was worse in the PVE group compared with non-PVE, serious hepatic complications were rarely observed in the PVE group., Conclusions: Marked changes in hepatic volume were noted after PVE in patients with impaired liver function and those who need large-volume right hepatectomy, especially in functional volume, suggesting that PVE is a useful procedure to prevent postoperative liver failure.

Aim: To evaluate the effects of extrahepatic collaterals to the liver on liver damage and patient outcome after embolotherapy for the ruptured hepatic artery pseudoaneurysm following hepatobiliary pancreatic surgery., Methods: We reviewed 9 patients who underwent transcatheter arterial embolization (TAE) for the ruptured hepatic artery pseudoaneurysm following major hepatobiliary pancreatic surgery between June 1992 and April 2006. We paid special attention to the extrahepatic arterial collaterals to the liver which may affect post-TAE liver damage and patient outcome., Results: The underlying diseases were all malignancies, and the surgical procedures included hepatopancreatoduodenectomy in 2 patients, hepatic resection with removal of the bile duct in 5, and pancreaticoduodenectomy in 2. A total of 11 pseudoaneurysm developed: 4 in the common hepatic artery, 4 in the proper hepatic artery, and 3 in the right hepatic artery. Successful hemostasis was accomplished with the initial TAE in all patients, except for 1. Extrahepatic arterial pathways to the liver, including the right inferior phrenic artery, the jejunal branches, and the aberrant left hepatic artery, were identified in 8 of the 9 patients after the completion of TAE. The development of collaterals depended on the extent of liver mobilization during the hepatic resection, the postoperative period, the presence or absence of an aberrant left hepatic artery, and the concomitant arterial stenosis adjacent to the pseudoaneurysm. The liver tolerated TAE without significant consequences when at least one of the collaterals from the inferior phrenic artery or the aberrant left hepatic artery was present. One patient, however, with no extrahepatic collaterals died of liver failure due to total liver necrosis 9 d after TAE., Conclusion: When TAE is performed on ruptured hepatic artery pseudoaneurysm, reduced collateral pathways to the liver created by the primary surgical procedure and a short postoperative interval may lead to an unfavorable outcome.

Background: To identify predictors of changes in hepatic volumes after portal vein embolization (PVE) before hepatectomy, we examined the relationship between clinicopathological parameters and changes in volume of embolized and nonembolized liver and regeneration of remnant liver after hepatectomy., Materials and Methods: The subjects were 25 patients who underwent laparotomy. PVE was performed through transileocolic vein (n = 15) and percutaneous transhepatic puncture (n = 10)., Results: Significant atrophy and hypertrophy of the embolized and nonembolized liver were observed after PVE, respectively, and further increase of remnant liver volume was observed after hepatectomy. Background liver disease did not seem to influence the results. Alkaline phosphatase (ALP) level correlated negatively with atrophy of embolized lobe (r = -0.433). Platelet count correlated positively with hypertrophy of nonembolized lobe (r = 0.412, P < 0.05) and percent increase between lobes and (r = 0.515, P < 0.05). Seven (32%) patients developed postoperative complications, such as long-term ascites or cholestasis. Changes in embolized liver and percent increase between lobes in patients with postoperative cholestasis (-94 +/- 97 cm(3) and 9.6 +/- 5.1% gain) were significantly lower than those in patients without cholestasis (17 +/- 54 cm(3) and 6.6 +/- 1.3% gain, P < 0.05)., Conclusion: ALP and platelet counts might be able to predict PVE effect and were related to postoperative course. Identification of more specific predictors is desirable.

Purpose: To evaluate the efficacy of embolizing iliac artery aneurysms (IAAs) developing after abdominal aortic aneurysm (AAA) repair., Methods: The records of 6 patients (5 men; mean age 79 years, range 61-87) with unilateral (n=3) or bilateral (n=3) IAAs that had developed after AAA repair were reviewed. In all patients, the limbs of the bifurcated graft were anastomosed end-to-end or end-to-side with the external iliac arteries during AAA repair. Before embolization, superior mesenteric artery (SMA) arteriography was done in all patients to evaluate collateral pathways to the inferior mesenteric artery (IMA)., Results: The unilateral IAAs were treated by proximal and distal embolization. In 2 patients with bilateral IAAs, SMA angiography showed sufficient collateral flow to the IMA, so the aneurysms were treated by proximal embolization and packing. In the other bilateral IAA case, the left 6-cm IAA was treated by proximal and distal embolization, while the contralateral 3-cm IAA was not embolized because angiography demonstrated inadequate collateral flow to the IMA, indicating a possible risk of colon ischemia if both IAAs were embolized. Immediate postprocedural angiography in all patients showed complete exclusion of the IAAs. Mild buttock claudication occurred in 1 patient. There were no episodes of rupture over a mean 46-month follow-up., Conclusions: Embolization is a safe and effective alternative to open surgery for the treatment of IAAs that develop after AAA repair. However, before embolization, angiographic evaluation of collateral pathways to the IMA is essential to reduce the risk of colon ischemia.

We present a 65-year-old woman who was found to have a spontaneous rupture of an aneurysmal intrarenal arteriovenous fistula. To our knowledge, the present case is only the 3rd reported in the literature. The preferred method of treatment of ruptures of arteriovenous fistulae is embolization. However, the process of choosing among embolization, surgery, or a combination of both procedures must be individualized for each patient based on vital signs and symptoms., (Copyright 2003 S. Karger AG, Basel)

We present a case of pancreatic pseudoaneurysm converted from a pseudocyst. Contrast-enhanced CT disclosed a round enhancing lesion at the previously identified pseudocyst, and angiography confirmed the diagnosis of a pseudoaneurysm. The pseudoaneurysm was successfully treated by arterial embolization. We believe arterial embolization to be the treatment of choice for pseudoaneurysm as a complication of pancreatitis.

Transcatheter arterial embolization (TAE) is widely used in the treatment of hepatic tumors. A total of 2,300 TAE procedures were performed with a 2-15-mL injection of a mixture or suspension of anticancer drugs and iodized oil, followed by administration of gelatin sponge particles. One or two chemotherapeutic drugs, including doxorubicin hydrochloride (10-30 mg), epirubicin hydrochloride (10-30 mg), mitomycin C (10-20 mg), and cisplatin (25-100 mg), were used for each procedure. Complications were encountered in 4.4% of cases (n = 102) and were related to the use of chemoembolic agents or the manipulation of a catheter or guide wire. These complications included acute hepatic failure (n = 6), liver infarction (n = 4) or abscess (n = 5), intrahepatic biloma (n = 20), multiple intrahepatic aneurysms (n = 6), cholecystitis (n = 7), splenic infarction (n = 2), gastrointestinal mucosal lesions (n = 5), pulmonary embolism or infarction (n = 4), tumor rupture (n = 1), variceal bleeding (n = 3), and iatrogenic dissection (n = 35) or perforation (n = 4) of the celiac artery and its branches. Knowledge of these complications is important for correct diagnosis and appropriate management.

Preoperative transcatheter arterial chemo-embolization (TAC-E) was used for 19 patients with locally advanced breast cancer, to eradicate the extensive loco-regional areas prior to surgery and hopefully to reduce the postoperative recurrence rate. The results were as follows: (1) Each primary tumor showed marked regression within 2 weeks after TAC-E. (2) Surgicopathology confirmed the excellent efficacy of TAC-E against both primary tumors and metastatic lymph node tumors. (3) Side effects due to this treatment were few, compared with other forms of cancer chemotherapy. (4) The prognosis of each patient was good. We conclude that preoperative TAC-E has a great potential for the treatment of locally advanced breast cancer.

The anticancer drugs, Adriamycin and Mitomycin were individually immobilized on absorbable gelatin materials, together with a blood clotting factor, Factor XIII and thrombin, using a special technique. The materials were applied as thrombotic agents in preoperative therapeutic transcatheter arterial embolization for patients with locally advanced breast cancer. This approach to preoperative management proved to be superior to intra-arterial infusion therapy currently applied in various clinics.

Anticancer agents, Mitomycin C and Adriamycin, were immobilized on absorbable gelatin materials, respectively with a blood clotting factor, Factor XIII and thrombin with a special technique we have developed. The materials were clinically applied as thrombotic agent in pre-operative therapeutic transcatheter arterial embolization (TAE) to 5 patients with locally advanced breast cancer. About 1 week after TAE, the regression of the primary tumor was found in 4 out of 5 patients; all patients received currative operation without any trouble. The histological examinations of the excised specimens showed remarkable degenerative changes (IIA and IIB: Shimosato's classification) of cancer cells not only in the primary tumor, but also in the metastatic regional lymph node. No complications due to the TAE were observed. These findings strongly suggest that this newly deviced materials are quite effective in pre-operative treatment for the locally advanced breast cancers.