Purpose: Standard methods for percutaneous transhepatic portal vein embolization have not yet been established. This study aimed to elucidate the effectiveness of balloon occlusion in percutaneous transhepatic portal vein embolization using gelatin sponges on the hypertrophy ratio of the future liver remnant volume.

Material and Methods: This retrospective study included 93 patients who underwent percutaneous transhepatic portal vein embolization for right hepatectomy between January 2018 and September 2022. Based on the embolization procedure, patients were divided into a balloon group (n = 13) and a non-balloon group (n = 80). The clinical factors and future liver remnant volume hypertrophy ratios were compared. Moreover, significant factors associated with the future liver remnant volume hypertrophy ratio between the groups were analyzed.

Results: The future liver remnant volume hypertrophy ratio was significantly higher in the balloon group than in the non-balloon group (1.44 [interquartile range, 1.37-1.89] vs. 1.29 [1.15-1.46], p = 0.011). The initial future liver remnant volume (289 [interquartile range, 259-454] vs. 400 [324-479] mL, p = 0.036) and number of gelatin sponge sheets (5 [interquartile range, 5-6] vs. 4 [3-5], p = 0.008) significantly differed. However, recanalization and severe complications were not different between groups. According to the multivariate linear regression analysis, diabetes mellitus (coefficient, −0.202, p = 0.009), initial future liver remnant volume (coefficient, −0.001, p < 0.001), and balloon occlusion (coefficient, 0.228, p = 0.007) were independent factors affecting the future liver remnant volume hypertrophy ratio.

Conclusions: Balloon occlusion may be effective in future liver remnant volume hypertrophy in percutaneous transhepatic portal vein embolization using gelatin sponges.

Thoracic duct embolization has emerged as an alternative treatment for refractory chylothorax, in addition to thoracic duct ligation. Thoracic duct embolization is typically performed via direct puncture of the cisterna chyli and cannulation of the thoracic duct, or via a retrograde approach to the thoracic duct through the venous angle. The former requires a long puncture through abdominal organs; the latter has anatomical limitations depending on the case. The reported success rates of both approaches are insufficient to provide a complete solution. We report a case of refractory chylothorax successfully treated with thoracic duct embolization using a catheter inserted through a chest tube to cannulate the leaking stump of the thoracic duct. This technique offers a less invasive treatment option that avoids additional punctures or surgical intervention.

Purpose: We retrospectively analyzed the effect of coil type on the number of coils used and the procedure time in pre-Fontan coil embolization of collateral arteries.

Material and Methods: Twelve patients with congenital heart disease underwent coil embolization before Fontan surgery between 2010 and 2021. They were divided into 2 groups. Group A comprised 6 patients who underwent coil embolization before the introduction of longer microcoils (≥30 cm) and group B comprised 6 patients who underwent embolization after the introduction of the microcoils. The primary endpoints (number of coils used, embolized area per patient and the internal thoracic artery, and procedure time) were compared between the 2 groups.

Results: The number of coils used per patient and internal thoracic artery (groups A vs. B: 36.5 vs. 18; p = 0.036, 11.7 vs 7.4; p = 0.047) and the procedure time (247 vs 180 minutes; p = 0.002) were significantly smaller in group B than in group A. The embolized area per internal thoracic artery was significantly larger in group B than in group A (45 vs. 93.5; p < 0.001). All patients underwent Fontan surgery at a mean of 24 days after embolization. Fontan circulation was established in nine of 12 patients. There were no major complications in either group.

Conclusions: In pre-Fontan coil embolization, a combination of longer microcoils (≥30 cm) may help reduce the number of coils used and the procedure time, which may decrease the health care cost and radiation exposure.

An 89-year-old woman presented with altered mental status. Computed tomography revealed multiple shunts between the portal (segment 3) and hepatic veins (left and middle hepatic veins); detailed vascular anatomy of the shunts could not be determined owing to its complexity. Blood tests revealed an elevated ammonia level. The patient was diagnosed with hepatic encephalopathy secondary to an intrahepatic portosystemic venous shunt. Transcatheter embolization was performed after unsuccessful conservative treatment. The peripheral left and middle hepatic veins downstream of the shunt vessels were embolized through an internal jugular vein approach using Amplatzer vascular plugs and coils. Computed tomography conducted 1 week later indicated occlusion of the shunts. The patient's ammonia levels were normalized. Thus, transcatheter embolization can be useful for treating complex intrahepatic portosystemic venous shunts causing hepatic encephalopathy.

Lower extremity artery disease affects more than 230 million people worldwide, leading to significant cardiovascular and limb-related complications. Recent advancements in endovascular treatment, driven by technological innovations and increasing patient prevalence due to aging populations and lifestyle diseases, has contributed to a growing demand for endovascular treatment. In Japan, the number of endovascular treatment procedures has increased specifically among cardiologists, whereas the involvement of interventional radiology physicians remains limited. This review explores the latest trends and clinical outcomes of endovascular treatment, and the importance of multidisciplinary collaboration, including the role of interventional radiology physicians. The findings encourage greater involvement of interventional radiology physicians in endovascular treatment.

Purpose: To investigate the risk factors for local maxillary sinus squamous cell carcinoma recurrence/residual tumor after superselective intra-arterial cisplatin infusion and concomitant radiotherapy.

Material and Methods: The protocol of superselective intra-arterial cisplatin infusion and concomitant radiotherapy was as follows: cisplatin was administered once per week for 7 weeks, and the dose of every procedure was 100 mg/m². Radiation was administered during the same period using intensity-modulated radiation therapy, with a total dose of 70 Gy (2 Gy/35 fractions). The risk factors for local recurrence/residual tumor were retrospectively analyzed using the Cox hazard model in 31 advanced primary maxillary sinus squamous cell carcinoma cases treated with superselective intra-arterial cisplatin infusion and concomitant radiotherapy from October 2016 to 2022. The analyzed risk factors were age, sex, T- and N-factors, invasion of the pterygoid muscle, tumor heterogeneity on imaging modality, tumor signal intensity on diffusion-weighted imaging (b = 1000), tumor-brain stem signal ratio on diffusion-weighted imaging (b = 1000), therapeutic response after the fourth infusion, and complete superselective intra-arterial cisplatin infusion and concomitant radiotherapy or not. We also compared overall survival between the recurrence/residual tumor and non-recurrence groups.

Results: This study included 31 patients. Non-complete superselective intra-arterial cisplatin infusion and concomitant radiotherapy was the only risk factor that showed a statistically significant difference among all the analyzed risk factors. Overall survival was favorable in the non-recurrence/residual tumor group; however, there was no statistical difference compared to the recurrence/residual tumor group.

Conclusions: Complete superselective intra-arterial cisplatin infusion and concomitant radiotherapy was the only factor that prevented local recurrence/residual tumor. Therefore, all health careers involved in superselective intra-arterial cisplatin infusion and concomitant radiotherapy should avoid interrupting whenever possible.

A 74-year-old man who had received Bacillus Calmette-Guérin therapy for bladder cancer developed vasovagal syncope. Contrast-enhanced computed tomography showed multiple pseudoaneurysms in the left internal carotid artery, aorta, and right common femoral artery, which were considered to be infected aneurysms. Parent artery occlusion was planned for the left internal carotid artery, but the balloon occlusion test was not possible because of the patient's restlessness; therefore, the patient was treated with a Viabahn stent graft. Approximately 1 month later, another ruptured pseudoaneurysm occurred in the right internal carotid artery, which was also treated with a Viabahn stent graft. The patient did not experience rebleeding or complications such as cerebral infarction. Viabahn may be an effective alternative for the management of carotid artery-infected aneurysms.

This case report describes a 56-year-old woman with autosomal dominant polycystic kidney disease and chronic renal failure who underwent transcatheter arterial embolization with N-butyl-2-cyanoacrylate-Lipiodol before renal transplantation. Both kidneys were significantly enlarged, necessitating transcatheter arterial embolization to reduce renal volume and create space for transplantation. The right kidney volume decreased from 2520 to 1150 mL within 9 months after transcatheter arterial embolization, enabling successful transplantation. Long-term (37 months) follow-up demonstrated continued shrinkage of the transcatheter arterial embolization-treated right kidney and a spontaneous reduction in the non-transcatheter arterial embolization-treated left kidney. The reduction in renal volume achieved with transcatheter arterial embolization exceeded that reported for conventional methods using metal coils or ethanol. This case highlights the potential of as an effective embolizing agent for patients with autosomal dominant polycystic kidney undergoing renal transplantation.

Purpose: N-butyl cyanoacrylate is a liquid embolic material used to treat bleeding. Rebleeding may occur after N-butyl cyanoacrylate embolization due to vasospasm and dilation of the embolized artery. However, the impact of vasospasm on N-butyl cyanoacrylate embolization has not been fully investigated. Therefore, we investigated the impact of vasospasm on the effects of N-butyl cyanoacrylate embolization in swine arteries.

Material and Methods: Using a swine bleeding model, 24 arteries (hepatic/splenic/both renal/cranial mesenteric) in 5 swine were divided into vasoactive and control groups. The recanalization rates after embolization with 20% N-butyl cyanoacrylate and the volume of N-butyl cyanoacrylate used for embolization were compared between the 2 groups. Arteries in the vasoactive group were constricted by constant venous infusion of vasopressin and an arterial injection of noradrenaline just before embolization and then dilated by arterial injection of papaverine and lidocaine immediately after embolization. Angiography was performed to evaluate recanalization of the embolized arteries immediately and at 5, 15, 30, 45, and 60 minutes after embolization. Recanalization was defined as complete recanalization within 60 minutes or partial recanalization at 60 minutes.

Results: Angiography revealed recanalization in a significantly greater proportion of arteries in the vasospasm group (11/12 arteries [91.7%]) than in the control group (2/12 arteries [16.7%]) (p = 0.0006). The median volume of N-butyl cyanoacrylate used during embolization was significantly lower in the vasoactive group (0.32 mL) than in the control group (0.78 mL) (p = 0.0037).

Conclusions: Vasospasm during N-butyl cyanoacrylate embolization increased the recanalization rate of the embolized arteries and reduced the embolization effect in swine.

A 75-year-old man with a history of open surgical repair for a thoracoabdominal aortic aneurysm presented with an aortic pseudoaneurysm at the anastomosis and a celiac artery aneurysm. During endovascular treatment, multiple celiac artery branches were embolized, and an aortic stent graft was placed to cover the aortic anastomosis and celiac artery origin. Four days post-treatment, a computed tomography scan revealed poor enhancement and fluid collection in the pancreatic body and tail, indicating acute ischemic pancreatitis with pancreatic necrosis. Computed tomography 22 days after treatment indicated enlargement of the fluid collection, leading to endoscopic ultrasound-guided drainage of the collection. Despite the low risk of ischemic complications, recognizing the risk of ischemic pancreatitis and splenic infarction when multiple celiac artery branches are embolized to treat celiac artery aneurysms is crucial.

Endoleak is a significant complication of endovascular aortic repair, associated with adverse long-term outcomes. This review discusses the classification, mechanisms, and imaging diagnosis of endoleaks. Five types of endoleaks are described, each with distinct characteristics and management approaches. Imaging modalities for endoleak detection include computed tomography, magnetic resonance imaging, ultrasonography, and angiography, each with unique advantages and limitations. Computed tomography remains the gold standard, but magnetic resonance imaging and contrast-enhanced ultrasound show promise in specific scenarios. The article details imaging findings for each endoleak type, emphasizing the importance of multimodality imaging for accurate diagnosis. While computed tomography is essential for early postoperative evaluation and reintervention planning, a tailored approach using various imaging techniques may optimize long-term surveillance. Future research should focus on establishing cost-effective, radiation-minimizing protocols for lifelong post-endovascular aortic repair monitoring.

Arterial esophageal hemorrhage, a relatively rare condition, necessitates prompt therapeutic intervention. The esophageal arteries, originating directly from the aorta and being extremely narrow, are often difficult to identify through angiography alone. We report two cases of arterial esophageal hemorrhage related to esophageal cancer in which the esophageal arteries were identified by contrast-enhanced computed tomography prior to angiography, enabling successful transcatheter arterial embolization. Arterial esophageal hemorrhage requires rapid treatment intervention due to its complex blood supply. Preoperative evaluation with computed tomography appears to be effective.

Type II endoleak is the most common complication after endovascular abdominal aortic aneurysm repair. Type II endoleak with aneurysm sac growth is not benign for long-term outcomes of endovascular abdominal aortic aneurysm repair and should be treated to prevent secondary stent graft-related complications and aneurysm rupture. The current consensus is to consider treatments for persistent type II endoleak with significant aneurysm sac growth. For complete embolization of type II endoleak to obliterate the endoleak cavity with the elimination of all supplying arteries, it is necessary to select and combine the treatment options. Although the treatment techniques for type II endoleak have advanced, clinical outcomes remain unsatisfactory. To overcome this clinical discrepancy, the optimal patient-tailored treatment strategy is required in clinical practice, with an understanding of the current status and limitations of treatment for type II endoleak.

Preemptive side branch embolization may help prevent type II endoleak, reduce reintervention rates, and promote early aneurysm sac shrinkage after endovascular aneurysm repair. However, evidence of its effectiveness in preventing aneurysm rupture, reducing aneurysm-related mortality, ensuring safety, and maintaining cost-effectiveness is limited. The 2024 European Society for Vascular Surgery guidelines do not recommend routine preemptive embolization due to a lack of high-quality evidence. Concerns about radiation exposure and financial costs remain unresolved. Further research is needed to identify patients who would benefit most from preemptive embolization, as well as to evaluate its long-term impact on clinical outcomes, safety, and cost-effectiveness.

Barcelona Clinic Liver Cancer staging system, which has been identified as the most commonly used staging system in patients with hepatocellular carcinoma, was initially published in 1999, and it was updated in 2022. This new Barcelona Clinic Liver Cancer staging shows more flexible strategies for the treatment of hepatocellular carcinoma based on each stage. Although the roles of trans-arterial chemoembolization were limited in intermediate stage (Barcelona Clinic Liver Cancer-B) patients in the previous version, its roles have been expanded in the new version of Barcelona Clinic Liver Cancer staging system. In this manuscript, we introduce how trans-arterial chemoembolization is incorporated in a new Barcelona Clinic Liver Cancer staging system and explore the new role of trans-arterial chemoembolization and what interventional radiologists seek for in a near future.

Transarterial chemoembolization is still an effective treatment option for hepatocellular carcinoma worldwide and is categorized into conventional transarterial chemoembolization with ethiodized oil transarterial chemoembolization and transarterial chemoembolization with drug-eluting spherical material transarterial chemoembolization. Several randomized controlled trials conducted in Europe have shown the equivalent efficacy of ethiodized oil transarterial chemoembolization and drug-eluting spherical material transarterial chemoembolization. However, a recent randomized controlled trials in Japan established the superiority of ethiodized oil transarterial chemoembolization in terms of complete response rates although higher liver toxicity for ethiodized oil transarterial chemoembolization. Nevertheless, the survival advantage of ethiodized oil transarterial chemoembolization is yet to be substantiated. The adverse effects of drug-eluting spherical material transarterial chemoembolization are milder than those of ethiodized oil transarterial chemoembolization, rendering drug-eluting spherical material transarterial chemoembolization an advantageous option for patients with bilobar tumors and impaired liver function/performance status. This article aims to provide an overview of these embolization techniques and a review of recent literature.

Acute portal vein thrombosis is characterized by nonspecific abdominal pain, causing severe morbidity and mortality. Prompt diagnosis is crucial to avoid short-term complications such as intestinal infarction, sepsis, and death. The therapeutic goal is to prevent thrombus extension into the mesenteric veins and intestinal ischemia complications. Systemic anticoagulation is the standard treatment. However, endovascular treatments such as thrombolysis, thrombectomy, balloon angioplasty, stent placement, and transjugular intrahepatic portosystemic shunt placement have been performed in patients who are refractory to anticoagulation therapy or at a high risk of intestinal ischemia. This review discusses the clinical and diagnostic considerations in acute portal vein thrombosis, focusing on current endovascular treatments that are effective and safe. However, prospective data are required to compare endovascular treatment techniques and assess their outcomes.

Nonocclusive mesenteric ischemia (NOMI) is a condition characterized by segmental or discontinuous mesenteric ischemia and intestinal necrosis without an organic obstruction in the mesenteric vessels. Diagnosis is challenging, and early intervention is crucial for improving patient outcomes. Various factors such as background factors, symptoms, biomarkers, and imaging techniques contribute to the diagnosis. Ensuring an early diagnosis and prompt treatment is of paramount importance. Although studies reported on the effectiveness of intra-arterial vasodilator infusion therapy as an endovascular treatment, its future role remains uncertain. Therefore, this review primarily aimed to provide a comprehensive summary of the advancements in the current state of NOMI management, with a specific emphasis on the implementation of endovascular therapy.

A woman in her 40s was found to have a sewing needle within the right lumbar erector spinae muscle on imaging. The needle tip nearly reached the first lumbar vertebra and was close to the intervertebral foramen. An 8-gauge bone marrow biopsy needle was advanced under local anesthesia and biplane fluoroscopic guidance. The inner needle was withdrawn, while the outer needle was gently advanced to capture the proximal end of the sewing needle. The sewing needle was successfully grasped and removed using the endoscopic biopsy forceps. She was discharged without symptoms. Under biplane fluoroscopy guidance, percutaneous coaxial removal of the intramuscular sewing needle was successfully performed minimally invasively and at a low cost using an 8-gauge bone marrow biopsy needle and endoscopic forceps.

We report a case of lumbar spinal hematoma caused by balloon-occluded retrograde transvenous obliteration for gastric varices in a woman in her 60 s with liver cirrhosis due to non-alcoholic steatohepatitis. The patient presented to the emergency department with a chief complaint of sudden nausea and hematemesis. Endoscopic sclerotherapy was performed, followed by balloon-occluded retrograde transvenous obliteration for residual varices. During balloon-occluded retrograde transvenous obliteration, she complained of back pain and subsequently developed thigh pain. CT and MR scans revealed subdural hematoma and subarachnoid hemorrhage within the spinal canal at the thoracolumbar level. It is presumed that balloon-occluded retrograde transvenous obliteration altered blood flow in the paravertebral plexus, causing an intraspinal canal hemorrhage. To our knowledge, this study is the first to report a case of an iatrogenic spinal hematoma caused by balloon-occluded retrograde transvenous obliteration.

Postoperative hepatic lymphorrhea is a rare complication that can lead to refractory ascites. During surgery with lymph node dissection of the hepatoduodenal ligament, leakage of liver lymph into the abdominal cavity can occur. Due to the development of interventional radiology for various lymphatic leaks in recent years, the pathogenesis of hepatic lymphatic leakage has become more evident. Percutaneous transhepatic lymphangiography is important for the diagnosis of hepatic lymphorrhea. Although there have been case reports of percutaneous embolization and sclerotherapy treatments for hepatic lymphorrhea in recent years, there have been no case studies. However, the standard treatment for this condition remains unknown. This study discusses the anatomy of hepatic lymphatics and the pathogenesis, diagnosis, and treatment of hepatic lymphorrhea, including the latest literature on interventional radiology.

In the current systemic therapy era, such as immunotherapy and molecular targeted therapy, treatment strategy of hepatocellular carcinoma is changing. Transarterial chemoembolization is more expected as a curative treatment option than before. Therefore, it is important to learn key techniques of transarterial chemoembolization procedures to achieve complete response. This article delineates the current indications for transarterial chemoembolization and several techniques used for its implementation.

Endovascular treatment, such as catheter-directed thrombolysis, thrombectomy, balloon angioplasty, and metallic stent placement, is performed for symptomatic upper body central venous obstruction caused by both malignant and benign etiologies. In particular, metallic stent placement should be performed in emergent situations for malignant superior vena cava syndrome presenting with cerebral or laryngeal edema. In malignant cases, the obstruction is usually traversed via the femoral vein. When it fails, an additional trial via the brachial or internal jugular vein is performed, and if necessary, through-and-through access is established. In benign chronic obstructions that cannot be crossed by conventional techniques, sharp recanalization techniques are salvage options. The procedures are relatively safe; however, major complications such as acute pulmonary edema, cardiac tamponade, pulmonary embolism, and stent migration should be warned.

Purpose: This study aimed to examine the effectiveness of preoperative image guided botulinum toxin A injection in achieving fascial closure and reducing recurrence rates after repair of complex incisional abdominal wall hernias.

Material and Methods: A total of 32 patients, consisting of 14 males and 18 females, with complex incisional hernias who underwent image guided botulinum toxin A injection at a median 33 [28-38.3] days before surgery were included in this retrospective study. Their mean age was 59.4 ± 11.2 years. Abdominal computed tomography imaging was obtained prior to botulinum toxin A administration to characterize the hernia defects of 26 patients (81.3%, 26/32). The transverse and vertical abdominal wall defects were measured and recorded. Three-dimensional objects of the hernia sac and peritoneal cavity were created based on the delineated borders, and volumes were calculated. The loss of domain was determined using the following formula:

where x represents the hernia sac volume and y represents the peritoneal volume. Under ultrasound guidance, the abdominal wall musculature was injected with 300 units of botulinum toxin A across six sites. The fascial closure rate and rate of hernia recurrence were the principal outcomes investigated.

Results: Fascial closure was achieved in 29 patients (90.6%, 29/32). Recurrence was observed in two patients (6.3%, 2/32) over an average followup of 2.5 ± 1.5 years (maximum 6.5). Fascial closure was obtained in 12 out of 14 patients with previous hernia repairs (85.7%, 12/14). One botulinum toxin A related complication was observed―a weakened cough that resolved without further treatment.

Conclusions: Botulinum toxin A is safe and effective in improving rates of fascial closure and reducing instances of reoccurrence in patients with complex incisional hernias.

A 54-year-old man presented with epigastric pain and underwent contrast-enhanced computed tomography. A ruptured anterior superior pancreaticoduodenal artery aneurysm was diagnosed. Transcatheter arterial embolization was successfully accomplished using coils; however, the patient started vomiting 18 days later. Contrast-enhanced computed tomography showed hepatic portal venous gas with gastric emphysema and duodenal stenosis. The patient was conservatively treated after being diagnosed with duodenal stenosis caused by hematoma, causing hepatic portal venous gas with gastric emphysema because of increased gastric pressure during vomiting. Consequently, the patient was doing well and was discharged.

A 78-year-old man who had been treated for perihilar cholangiocarcinoma presented with hematemesis 1.5 years later. Computed tomography revealed a pseudoaneurysm of the proper hepatic artery protruding into the lumen of the duodenum. Esophagogastroduodenoscopy revealed a duodenal ulcer with massive hemorrhage at the duodenal bulb. Endoscopic hemostasis therapy was not possible due to the exposure of the proper hepatic artery pseudoaneurysm to the duodenal lumen. Endovascular stent-graft placement was chosen; the proper hepatic artery pseudoaneurysm disappeared and hematemesis was no longer observed. However, 2.5 years later, he presented with hematemesis, and esophagogastroduodenoscopy showed migration of the stent-graft into the duodenum due to duodenal ulcer recurrence.

Recent advances in systemic therapy for hepatocellular carcinoma are remarkable. The treatment goal for advanced hepatocellular carcinoma is to prolong survival, while for intermediate-stage hepatocellular carcinoma, it is to achieve a cancer-free and drug-free status. Patients unsuitable for transarterial chemoembolization may benefit from prior systemic therapy with lenvatinib or atezolizumab plus bevacizumab. The TACTICS-L trial, a prospective phase II trial, demonstrated favorable progression-free and overall survival by lenvatinib-transarterial chemoembolization sequential therapy. The REPLACEMENT trial, a multicenter, prospective, single-arm phase II trial, confirmed combination immunotherapy efficacy with atezolizumab plus bevacizumabin a population exceeding up-to-seven criteria. In a proof-of-concept study, atezolizumab plus bevacizumab plus curative therapy showed a 35% complete response rate and 23% drug-free status in intermediate-stage hepatocellular carcinoma patients with a tumor burden exceeding up-to-seven criteria.

Acute mesenteric ischemia is a life-threatening condition. A comprehensive approach involving a multidisciplinary team to review patient background, clinical history, physical examination, laboratory data, and imaging examination for respective diagnosis of superior mesenteric arterial occlusion, nonocclusive mesenteric ischemia, and superior mesenteric venous occlusion is essential. The most important imaging modality is computed tomography, which is used for diagnosis and for directing therapeutic strategy (e.g., endovascular revascularization, surgical bowel resection, or conservative management). Computed tomography image findings can support triaging of irreversible transmural bowel necrosis compared with reversible ischemic change with reperfusion. In this review article, the computed tomography imaging findings specifically associated with the pathophysiology of superior mesenteric arterial occlusion, nonocclusive mesenteric ischemia, and superior mesenteric venous occlusion are reviewed.

Isolated persistent left superior vena cava is a rare congenital venous anomaly. It imposes technical challenges and increased risks in patients requiring a transjugular intrahepatic portosystemic shunt. The patient was a 67-year-old man with cirrhosis, recurrent large-volume ascites, hepatic hydrothorax, and portal vein thrombosis. The patient had a history of failed transjugular intrahepatic portosystemic shunt creation using a conventional CO₂ portal venography technique via a left jugular vein access. The patient underwent successful transjugular intrahepatic portosystemic shunt creation under fluoroscopy and intravascular ultrasound guidance. The patient required transjugular intrahepatic portosystemic shunt revision with mechanical thrombectomy in 2 months. Intravascular ultrasound can provide additional live information to assist transjugular intrahepatic portosystemic shunt creation in patients with complex congenital venous anatomy, including those with isolated persistent left superior vena cava.

Acute mesenteric arterial occlusion, resulting from impaired blood flow in the superior mesenteric artery, is classified into embolism and thrombosis; both conditions lead to rapid intestinal ischemia, with a high mortality rate of >30% within 30 days. A multidisciplinary treatment approach, including prompt revascularization, necrotic intestinal tract resection, intensive postoperative care, and recurrence prevention, is crucial for managing acute mesenteric arterial occlusion. Recent meta-analyses have indicated that endovascular treatments result in lower bowel resection and mortality rates than open revascularization. As a minimally invasive treatment option, endovascular therapy can become prevalent in the aging population. Interventional radiologists who provide diagnostic imaging and endovascular procedures must understand the disease and play a central role in the treatment team.

We performed transportal coil-assisted balloon-occluded retrograde transvenous obliteration II, a modification of balloon-occluded retrograde transvenous obliteration, for gastric varices due to left-sided portal hypertension. Significant scale-down of varices was confirmed on upper gastrointestinal endoscopy and contrast-enhanced computed tomography at 6 months after intervention. In the meantime, there were no complications related to treatment. We present transportal coil-assisted balloon-occluded retrograde transvenous obliteration II as a new alternative in addition to splenectomy and partial splenic embolization for gastric varices induced by left-sided portal hypertension.

Purpose: To evaluate the feasibility and preliminary evidence of the efficacy of combined cutting balloon and drug-coated balloon angioplasty for the treatment of arteriovenous fistula stenoses resistant to conventional balloon angioplasty.

Material and Methods: From August 2018 to January 2019, 19 patients (mean age = 64.9 ± 8.6 years; males = 63%) with resistant arteriovenous fistula stenosis, defined as >30% residual stenosis after conventional balloon angioplasty, were enrolled into this single-center prospective pilot study. The resistant arteriovenous fistula stenoses were treated with a cutting balloon followed by a drug-coated balloon. The primary outcome measure was 6-month target lesion patency.

Results: The degree of residual stenosis after conventional balloon angioplasty was 48.8 ± 11.3%, decreasing to 18.7 ± 10.4% after combined cutting and drug-coated balloon angioplasty. Technical success, defined as < 30% residual stenosis, was achieved in 94.7% (18 of 19 stenoses). The 6-month target lesion patency was 100%, while the 6-month access circuit primary patency was 94.7% (n = 18/19) due to recurrent non-target lesion stenosis. No venous rupture or major complication was encountered.

Conclusions: This pilot study provides evidence to support the conduct of a phase 3 randomized clinical trial to prove the superiority of a cutting balloon and drug-coated balloon combination for resistant arteriovenous fistula stenoses.

Intranodal lymphangiography has replaced conventional pedal lymphangiography and has advanced lymphatic intervention. In this method, a lymph node is punctured and Lipiodol is injected to visualize the subsequent lymphatic vessels. This has facilitated the widespread adoption of lymphatic interventional radiology due to the simplicity of the technique and the shortened examination time of the procedure, which allows easy mapping of lymphatic vessels and lymphatic fluid dynamics. With this technique, lymphatic embolization was achieved by injecting an embolic substance into the lymph nodes upstream of the lymphatic leak. Although complications associated with lymphangiography are rare, caution should be exercised due to potential complications associated with the use of Lipiodol. This study summarizes intranodal lymphangiography techniques, complications, and lymphatic embolization.

Purpose: Transarterial embolization of the internal iliac artery-associated type II endoleaks necessitates adequate support to approach the abdominal aortic aneurysm sac. Herein, we report initial experience with transarterial embolization of the internal iliac artery-associated type II endoleaks using the quintet-coaxial catheter system.

Techniques: The quintet-coaxial catheter system consisted of the following five coaxial devices: a 5-F thin-walled flexible guiding sheath, a 5-F guiding catheter, a 3.4-F large-bore distal access catheter, a 2.7-F high-flow microcatheter, and a 1.9-F microcatheter. From the ipsilateral femoral artery, the system was advanced into the abdominal aortic aneurysm sac via a long, thin, and tortuous access route arising from the lumbar and iliolumbar arteries. Embolization using a 20% mixture of n-butyl 2-cyanoacrylate with iodized oil was successfully performed in three cases with sac expansion caused by a persistent internal iliac artery-associated type II endoleaks. The inflow artery was embolized using metallic coils through the 2.7-F microcatheter. The 3.4-F large-bore distal access catheter improved the stability of the double coaxial microcatheter system and facilitated the access of the 1.9-F microcatheter to the abdominal aortic aneurysm sac.

Conclusions: The quintet-coaxial catheter system enables the embolization of type II endoleaks through long, thin, and tortuous access routes.

A 60-year-old male presented with jaundice. He had a history of extended left hepatectomy, cholecystectomy, hepaticojejunostomy for moderately to poorly differentiated hepatocellular carcinoma, and transverse colectomy for transverse colon cancer. Computed tomography showed hepatocellular carcinoma recurrence in the liver, extending from the hepaticojejunostomy site to the elevated jejunum, resulting in obstructive jaundice. Internal biliary drainage using a percutaneous transhepatic approach was planned. However, the guidewire could not pass through the obstruction caused by the tumor at the hepaticojejunostomy site. After performing hepatic arterial infusion chemotherapy, to reduce the tumor volume, transcatheter arterial chemoembolization was performed for hepatocellular carcinoma recurrence. After transcatheter arterial chemoembolization, the catheter was successfully advanced beyond the tumor at the elevated jejunum owing to tumor shrinkage, thus completing internal biliary drainage.

Kimura's disease is a lymphoproliferative disorder characterized by eosinophilic infiltration. Although it rarely causes peripheral arterial occlusive disease, its mechanism remains unclear. A 43-year-old man with a seven-year history of Kimura's disease, initially presenting with a cervical mass and treated with prednisolone, developed an ulcerative lesion from the right thumb to the middle finger. Ultrasonography revealed bilateral radial artery dilation and thrombosis. After he was diagnosed with Kimura's disease-associated vasculitis, he was treated with prostaglandin E1, warfarin, and cilostazol. Because of persistent symptoms, angioplasty was performed on the occluded radial artery. The patient's symptoms improved on the first postoperative day, with no re-occlusion observed after 2 years. Percutaneous transluminal angioplasty has been demonstrated as effective for early symptomatic relief in Kimura's disease.

Postoperative chylous ascites is a rare condition that can be caused by abdominal and pelvic surgery. The mortality rate associated with untreated postoperative lymphorrhea is as high as 50%. Conservative management is the primary treatment, and most patients improve. However, some patients continue to exhibit high-volume chylous ascites and need invasive intervention. Many surgical series have shown that the outcomes of patients with chylous ascites were unfavorable. Therefore, the need for minimally invasive interventional radiology procedures, such as intranodal lymphangiography, thoracic duct, lymphatic pseudoaneurysm, lymph node, hepatic lymphatic embolization, and peritoneovenous shunting, is increasing. This review describes the anatomy, physics, and diagnosis related to interventional radiology for postoperative chylous ascites as well as interventional radiology treatment options and strategies for this condition referring to recent literature.

Purpose: To retrospectively assess the clinical outcomes of repeated radiofrequency ablation for lung metastases of head and neck adenoid cystic carcinoma.

Material and Methods: Consecutive 16 patients (mean age, 55.3 years) who were treated with radiofrequency ablation for 289 lung metastases were included. A 17-gauge electrode was used in all radiofrequency ablation procedures and placed under computed tomography fluoroscopic guidance. Evaluated were safety, technical success, local tumor control, and survival.

Results: In total, 143 radiofrequency ablation sessions were performed for 289 lung metastases. One session of radiofrequency ablation was not completed due to pleural hemorrhage during the procedure, resulting in a technical success rate of 99.3% (142/143). Major complications (pneumothorax and hemorrhage) occurred in 40 sessions (27.9%, 40/143). During the mean follow-up period of 5.5 ± 3.6 years (range, 0.4-13.4 years), local tumor progression was observed in 16 tumors (5.5%, 16/289) and repeated radiofrequency ablation (93.8%, 15/16) or metastasectomy (6.2%, 1/16) was performed for all locally progressed lung metastases. The local tumor control rates were 97.1% (95% confidence interval, 95.1%-99.2%) and 89.5% (95% confidence interval, 84.0%-95.0%) at 1- and 5-year. Median survival time after initial lung radiofrequency ablation was 9.8 years and 1-, 3-, 5-, and 10-year overall survival rates were 100% (95% confidence interval, 100%), 91.7% (95% confidence interval, 76.0%-100%), 64.3% (95% confidence interval, 35.7%-92.9%), and 35.7% (95% confidence interval, 0%-70.8%), respectively.

Conclusions: Repeated radiofrequency ablation for multiple lung metastases of adenoid cystic carcinoma was feasible and safe and may allow survival with good local control of lung metastases.

Endovascular treatment for patients with lower extremity artery disease is conducted worldwide due to its efficacy. Many studies have shown durability for patients with intermittent claudication, and various guidelines have shifted to the use of endovascular treatment. However, clinical outcomes in patients with chronic limb-threatening ischemia who undergo endovascular treatment have not been fully investigated. Generally, chronic limb-threatening ischemia cases have complex lesions such as small vessels, severe calcification, poor runoff vessels, chronic total occlusion, and long lesions, which result in poor outcomes. Thus, endovascular treatment for chronic limb-threatening ischemia cases remains challenging, despite the many technical and device advances. In 2019, the Global Vascular Guidelines were proposed for the treatment of patients with chronic limb-threatening ischemia. Here, we review previous guidelines and reports of patients with lower extremity artery disease who underwent endovascular treatment.

Purpose: This study aimed to evaluate type II endoleak incidence and its outcome in patients who underwent endovascular aneurysm repair using the EXCLUDER device for abdominal aortic aneurysm.

Material and Methods: One hundred sixty-seven patients who underwent endovascular aneurysm repair for abdominal aortic aneurysm (96 with patent and 71 with occluded inferior mesenteric artery) between 2008 and 2017 were retrospectively evaluated. Type II endoleak incidence and aneurysm enlargement of >5 mm after endovascular aneurysm repair were evaluated. The predictive factors for late type II endoleak identified >6 months after endovascular aneurysm repair and aneurysm enlargement were assessed based on the preoperative patient and anatomical characteristics.

Results: Late type II endoleak incidence was higher in the patent inferior mesenteric artery at 42.7% (41/96; 95% confidence interval, 33.3-52.7), compared with 22.5% (16/71; 95% confidence interval, 13.5-34.0) in the occluded inferior mesenteric artery group (p = 0.01). Freedom from aneurysm sac enlargement at 1, 3, and 5 years was 100%, 85.0%, and 68.1% in the patent inferior mesenteric artery and 98.9%, 86.7%, and 73.9% in the occluded inferior mesenteric artery group, respectively (p = 0.22). Freedom from aneurysm sac enlargement at 1, 3, 5 years was 100%, 76.9%, 43.5%, and 99.1%, 90.6% and 87.8% in the patients with and without late type II endoleak (p < 0.01). Patent inferior mesenteric artery (odds ratio, 3.43; 95% confidence interval, 1.43-8.21) and an increasing number of patent lumbar arteries (odds ratio, 2.14; 95% confidence interval, 1.48-3.08) were risk factors for late type II endoleak.

Conclusions: Patent inferior mesenteric artery was a risk for late type II endoleak without contributing to aneurysm enlargement after endovascular aneurysm repair using the EXCLUDER. Late type II endoleak was associated with aneurysm enlargement. Patent inferior mesenteric artery and an increasing number of patent lumbar arteries were risk factors for late type II endoleak.

Although transcatheter arterial embolization is the first choice treatment for renal arteriovenous malformation. Renal arteriovenous malformation with dilated venous sac can cause venous pulmonary thromboembolism after transcatheter arterial embolization. A woman in her 60s was diagnosed with a left renal arteriovenous malformation and an 8 cm venous sac with renal dysfunction after right renal arteriovenous malformation treatment. We performed a hybrid treatment of transcatheter arterial embolization and sequential vein ligation to reduce the risk of lethal thrombotic complications. After treatment, the left renal arteriovenous malformation disappeared without fatal complications, and the venous sac shrunk with the preservation of renal function as it was before the hybrid treatment. When performing embolization of renal arteriovenous malformation with a huge venous sac, hybrid treatment of arterial embolization and surgical vein ligation may be safe and useful for preventing fatal post-operative thrombotic complications.

Purpose: To evaluate the ability of automated supply artery tracking software to detect feeding vessels for renal tumors using preoperative dynamic contrast-enhanced computed tomography.

Material and Methods: For 10 sessions in 10 patients in which transarterial embolization was performed before percutaneous ablation therapy for a single renal cell carcinoma, data that had been obtained from dynamic contrast-enhanced computed tomography in the arterial phase were examined. Automated supply artery tracking software was retrospectively applied with arterial phase images of preoperative contrast-enhanced computed tomography, and the extracted feeding vessels were identified by two observers: a radiologist and a radiological technologist. Real supply arteries were determined by arteriography during transarterial embolization. Extracted feeding vessel and real supply arteries were compared. The concordance rate of extracted feeding vessel between observers was examined. Sensitivity and positive predictive value of automated supply artery tracking software and changes in sensitivity and positive predictive value under conversion of the distance recognized as extracted feeding vessel between the tumor and vessels from the preset distance (20 mm) to the cut-off value using receiver operating characteristic curve analysis were investigated.

Results: Twenty real supply arteries were identified among 10 cases. Number of extracted feeding vessel was 32 and 34 by the observers. The concordance rate of extracted feeding vessel was 80% (8/10 cases). Sensitivity of automated supply artery tracking software was 70% (14/20) by both observers and positive predictive value was 43.8% (14/32) and 41.2% (14/34) by each observer. When the cut-off value (12.1 mm) replaced distance, positive predictive value was elevated from 43.8% to 73.7% and from 41.2% to 68.4%.

Conclusions: Ability of automated supply artery tracking software based on transvenous contrast-enhanced computed tomography was acceptable for identifying feeding vessels of a renal tumor preoperatively.