Carbon dioxide digital subtraction angiography as an option for detection of endoleaks in endovascular abdominal aortic aneurysm repair procedure

ObjectiveThe purpose of this study was to evaluate carbon dioxide digital subtraction angiography (CO2-DSA) as an option for the detection of endoleaks (ELs) in the endovascular abdominal aortic aneurysm repair (EVAR) procedure.MethodsForty patients with abdominal aortic aneurysm who were scheduled to undergo EVAR were enrolled in the study. There were 35 men and five women (mean age, 77.9 years). All patients had both iodinated contrast conventional DSA (C-DSA) and CO2-DSA immediately after EVAR. The sensitivity and specificity were calculated for the ability of CO2-DSA to detect ELs. We also correlated with computed tomography findings 6 months after EVAR.ResultsC-DSA showed that 27 of the 40 patients (68%) had 28 ELs (type I, four; type II, 20; type III, three; type IV, one). CO2-DSA showed that 16 of the 40 patients (40%) had 17 ELs (type I, four; type II, 10; type III, three; type IV, none). For the prediction of direct ELs (type I and type III) with use of C-DSA as the criterion standard, CO2-DSA has a sensitivity of 1.0 and a specificity of 1.0. For the detection of persistent type II ELs (n = 11) with use of computed tomography findings 6 months from EVAR as the criterion standard, CO2-DSA has a sensitivity of 0.87 and a specificity of 0.97. C-DSA has a sensitivity of 0.82 and a specificity of 0.64.ConclusionsCO2-DSA is reliable for the detection of direct ELs and persistent type II ELs in EVAR. CO2-DSA can be an option to detect ELs in the EVAR procedure

Contraction Function of the Left Ventricle in Patients with Dilated Cardiomyopathy: Comparison of Delayed Enhanced MR imaging and indine -123- metaiodobenzylguanidine (123I-MIBG) scintigram

Objective: The purpose of this study was to compare delayed enhancement (DE) cardiac magnetic resonance (MR) imaging with the indine-123-metaiodobenzylguanidine(123I-MIBG) scintigram for measurement of left ventricular (LV) contraction function in patients with dilated cardiomyopathy (DCM). Materials and methods: DCM patients (n=29: mean age,51.9years; seven women) were evaluated by both DE cardiac MR imaging and 123I-MIBG scintigram. In all patients biopsy specimen showed disarray of the myocardium that was consistent with DCM. DE cardiac MR images were acquired using a two-dimensional segmented inversion-recovery prepared gradient-echo sequence (TI=250msec) 15minutes after intravenous administration of 0.1 mmol/kg gadolinium.The average CNR per slice (aCNR) for the LV myocardium was calculated.123I-MIBG scintigram was acquired at 15minutes and 3 hours (delayed imaging) after intravenous administration of 123I-MIBG (111MBq). The heart-to-mediastinum radioactivity ratio (H/M ratio) and washout rate (WR) was calculated. We evaluated the relationships between aCNR, WR, delayed H/M ratio, and the contraction function of the LV. Results: In MR imaging, mean aCNR was significantly higher in the low LV ejection fraction (LVEF<25%) group (n=11, 6.6±3.6) than in the high LVEF (?25%) group (n=18, 2.4±2.9). However, with the 123I-MIBG scintigram, delayed H/M and WR were not significantly different between high (delayed H/M ratio ; 1.7±0.3, WR; 37.6±14.5) and low (delayed H/M ratio; 1.7±0.2, WR; 38.2±14.2) LVEF groups. Conclusions: DE MR imaging reflects the contraction function of the LV in patients with DCM, which may be related with myocardial fibrosis. DE MR imaging may be more useful to evaluate the contraction function of LV than 123I-MIBG scintigram

CT findings of type A acute aortic dissection that did and did not result in prehospital death

The differences between the pathologies of cases of type A acute aortic dissection (AAD) that did and did not result in prehospital death (PHD) have not been fully elucidated. This study aimed to compare the CT findings and clarify the differences between the pathologies of such cases. Ninety four consecutive type A AAD patients between 2010 and 2020 were enrolled in this study. There were 47 males and 47 females (mean age: 69.0 ± 14.4 years). The patients were divided into those that did (n = 25, 27%) and did not (n = 69, 73%) suffer PHD. We retrospectively evaluated the CT or postmortem CT findings of each case and analyzed the relationships between clinical factors (CT findings and clinical characteristics) and PHD using logistic regression analysis.Bloody pericardial effusion (96% vs 35%, P < .0001), bloody pleural effusion (40% vs 1%, P < .0001), and mediastinal hematomas (88% vs 14%, P < .0001) were significantly more common in the PHD group than in the no PHD group. In the multivariate logistic regression analysis, bloody pericardial effusion and lung consolidation were found to be significant risk factors for PHD (odds ratio: 21.29 [95% confidence intervals {CI}: 1.19–248.29] and 13.72 [95% CI: 1.79–105.06], respectively; P = .014 and P = .012, respectively). AD affecting the abdominal aorta was identified as a significant negative risk factor for PHD (odds ratio: 0.02 [95% CI: 0.01–0.65]; P = .0042). Most PHD due to type A AAD are associated with hemorrhaging. Bleeding into the pericardium and type A AAD confined to the thoracic aorta are significant risk factors for PHD. Secondary respiratory failure might contribute to PHD in such cases

合併症を有するB型大動脈解離に対するステントグラフト内挿術における腎動脈に対する治療戦略 : 多施設共同研究

Background: Management of abdominal branches associated with Stanford type B aortic dissection is controversial without definite criteria for therapy after thoracic endovascular aortic repair (TEVAR). This is in part due to lack of data on natural history related to branch vessels and their relationship with the dissection flap, true lumen, and false lumen. Purpose: To investigate the natural history of abdominal branches after TEVAR for type B aortic dissection and the relationship between renal artery anatomy and renal volume as a surrogate measure of perfusion. Materials and Methods: This study included patients who underwent TEVAR for complicated type B dissection from January 2012 to March 2017 at 20 centers. Abdominal aortic branches were classified with following features: patency, branch vessel origin, and presence of extension of the aortic dissection into a branch (pattern 1, supplied by the true lumen without branch dissection; pattern 2, supplied by the true lumen with branch dissection, etc). The branch artery patterns before TEVAR were compared with those of the last follow-up CT (mean interval, 19.7 months) for spontaneous healing. Patients with one kidney supplied by pattern 1 and the other kidney by a different pattern were identified, and kidney volumes over the course were compared by using a simple linear regression model. Results: Two hundred nine patients (mean age ± standard deviation, 66 years ± 13; 165 men and 44 women; median follow-up, 18 months) were included. Four hundred fifty-nine abdominal branches at the last follow-up were evaluable. Spontaneous healing of the dissected branch occurred in 63% (64 of 102) of pattern 2 branches. Regarding the other patterns, 6.5% (six of 93) of branches achieved spontaneous healing. In 79 patients, renal volumes decreased in kidneys with pattern 2 branches with more than 50% stenosis and branches supplied by the aortic false lumen (patterns 3 and 4) compared with contralateral kidneys supplied by pattern 1 (pattern 2 vs pattern 1: −16% ± 16 vs 0.10% ± 11, P = .002; patterns 3 and 4 vs pattern 1: −13% ± 14 vs 8.5% ± 14, P = .004). Conclusion: Spontaneous healing occurs more frequently in dissected branches arising from the true lumen than in other branch patterns. Renal artery branches supplied by the aortic false lumen or a persistently dissected artery with greater than 50% stenosis are associated with significantly greater kidney volume loss.博士（医学）・乙第1461号・令和2年6月30日Copyright © 2019 by authors and RSNA. This work is licensed under the Creative Commons Attribution International License (CC BY-NC-ND 4.0). https://creativecommons.org/licenses/by-nc-nd/4.0/

Use of n-butyl cyanoacrylate in abdominal and pelvic embolotherapy: indications and techniques, complications, and their management

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

Diagnosis of Chronic Thromboembolic Pulmonary Hypertension Using Quantitative Lung Perfusion Parameters Extracted From Dual-energy Computed Tomography Images

Purpose: To evaluate quantified iodine mapping parameters in dual-energy computed tomography in normal patients versus those with chronic thromboembolic pulmonary hypertension (CTEPH) with and without pulmonary thromboembolism. Materials and Methods: Using automatically quantified iodine mapping in dual-energy computed tomography, we evaluated lung relative average enhancement, standard deviation (SD), and the SD/lung relative average enhancement ratio. We compared the values for these parameters in normal patients versus those with CTEPH. We also performed a receiver operating characteristic curve analysis to determine the diagnostic cutoffs for the parameters. Results: Patients constituted 41 patients (10 male [24.4%] and 31 female [75.6%]; mean age [SD]: 70.0 y [13.3]) with CTEPH and 237 (92 male [38.8%] and 145 female [61.2%]; mean age [SD]: 65.9 y [15.9]) normal patients. We found significant differences in lung relative average enhancement (34.9±6.3 vs. 26.9±6.3; P<0.0001), SD (11.6±1.9 vs. 14.7±3.3; P<0.001), and the SD/lung relative average enhancement ratio (33.7±5.0 vs. 55.7±10.4; P<0.001) between the normal and CTEPH groups, respectively. The ROC analyses demonstrated high discriminatory power (area under the curve=0.99) for using the SD/lung relative average enhancement ratio to differentiate between patients in the normal group and CTEPH group. At a threshold for the area under the curve of 44.2, diagnostic sensitivity, specificity, positive predictive value, and negative predictive value for the ratio were 92.7%, 97.5%, 86.5%, and 98.7%, respectively. Conclusions: Patients with CTEPH were well-discriminated from normal patients using the SD/lung relative average enhancement ratio

Embolization for massive bleeding due to spontaneous left external iliac vein rupture: report of a successful case

Background: Spontaneous rupture of the iliac vein has rarely been reported. Its associated hypovolemic shock-related symptoms and signs, including syncope and hypotension, have been observed in most of these cases. Successful transcatheter venous embolization for massive bleeding due to spontaneous rupture of the external iliac vein was herein reported.Case presentation: An 82-year-old female patient developed sudden left lower abdominal and back pain. Immediately, she lost consciousness and went into shock. CT images of her abdomen revealed a huge retroperitoneal hematoma, with leakage of contrast medium in the hematoma in the left flank. These findings suggested left external iliac vein rupture.Open surgery was considered; however, since the patient’s condition may have deteriorated further due to the time needed to prepare for surgery, including general anesthesia, transcatheter venous embolization of the left iliac vein was selected. A 5.2-Fr compliant balloon catheter (nominal diameter of 10 mm) was inflated at the distal site of the external iliac vein to reduce extravasation. N-butyl-2-cyanoacrylate (NBCA) was mixed with Lipiodol at a ratio of 1:2. The left Iliac vein was filled and completely embolized with the NBCA/Lipiodol mixture (total injected volume, 5 mL) using a 1.8-Fr microcatheter. After embolization, the patient quickly. An inferior vena cava filter was placed 1 day after embolization.Conclusion: Spontaneous rupture of the iliac vein is a very rare and lethal condition. Transcatheter venous embolization may control potentially life-threatening bleeding. Rapid bleeding control in a critical condition is facilitated by this minimally invasive approach