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.