Congenital extrahepatic portocaval shunt (CEPS) is a rare anomaly of the mesenteric vasculature in which the intestinal and splenic venous drainage bypasses the liver and drains directly into the inferior vena cava, the left hepatic vein or the left renal vein. This uncommon disease is frequently associated with other malformations and mainly affects females. Here we report a case of pulmonary arterial hypertension associated with CEPS (Abernethy type 1b shunt) in a 20-yr-old man who was incidentally diagnosed during evaluation of multiple nodules of the liver. The patient was treated by inhalation of iloprost (40 microg/day) with improved condition and walking test. Physicians should note that congenital portocaval shunt may cause pulmonary hypertension.
Echocardiography, Doppler ; Humans ; Hypertension, Pulmonary/*diagnosis/drug therapy ; Iloprost/therapeutic use ; Liver/blood supply/radiography ; Magnetic Resonance Imaging ; Male ; Thoracic Arteries/ultrasonography ; Tomography, X-Ray Computed ; Vasodilator Agents/therapeutic use ; Vena Cava, Inferior/*abnormalities/ultrasonography ; Young Adult

OBJECTIVEDue to its minimal-invasive approach, endovascular procedure had replaced surgery in treating Budd-Chiari syndrome (BCS). The interventional therapy was a safe and effective treatment in adults with BCS and the cure rate was high. However Budd-Chiari syndrome in children and adolescents is rare. Published literature on interventional procedure for Budd-Chiari syndrome in children and adolescents is scarce. The aim of the study was to present results of percutaneous transluminal angioplasty (PTA) and stents placement in children and adolescents with BCS and to evaluate the efficacy and safety in these patients of this approach.

METHODTwenty-five patients [16 boys and 9 girls; average age of (14.5 ± 3.4) years old; age ranged from 5 to 17 years] with Budd-Chiari syndrome who were hospitalized from December 1990 to August 2012 were presented. All of them were diagnosed by color Doppler ultrasound scan while 12 of them had magnetic resonance venography (MRV) scan. All of the patients had undergone angiographic examination. Four cases with membranous obstruction of the inferior vena cava (IVC) were treated with PTA. One case with segmental block of IVC was treated with PTA and stent placement. Five cases with membranous obstruction of IVC and hepatic vein (/and accessory hepatic vein) were treated with PTA. Among 8 cases with membranous obstruction of hepatic veins, 6 cases were treated with PTA and the others with PTA and stent placement. Among 4 cases with blocks of 3 hepatic veins (HVs), one was treated with PTA, one with PTA plus catheter thrombolysis plus PTA, one with PTA and stent placement and the other one was unsuccessful. Three cases with obstruction of HV and accessory HV (AHV) were treated with PTA. Totally, 24 patients were treated with interventional approach and followed up.

RESULTThe procedure was successful in 24 patients. The involved veins (hepatic veins or IVC) were patented after interventional procedure. The pressure of hepatic vein was (42.1 ± 4.2) cm H2O (37-50 cm H2O) (1 cm H2O = 0.098 kPa) before the interventional therapy, while it was (17.3 ± 3.3) cm H2O (14-26 cm H2O) after it. The pressure of IVC was (30.6 ± 2.9) cm H2O (26-36 cm H2O) before the interventional therapy, while it was (18.8 ± 4.2) cm H2O (15-26 cm H2O) after it. The symptoms and signs vanished instantly after interventional procedure. There were no procedure-related complications. The rate of overall initial cure was 96%. The patients were followed up for a mean of 25.8 months (range 6 months to 8 years). Seven cases developed restenosis after first procedure. Five of them were treated with PTA, one with PTA plus catheter thrombolysis plus PTA, one with PTA and stent placement. All of the involved veins were patented again. Clinical symptoms were relieved. There were no procedure-related complications as well.

CONCLUSIONThe interventional procedure in children and adolescents with BCS is the same as in adults. Radiological therapeutic intervention is efficacious and safe in children and adolescents with BCS.

Adolescent ; Angioplasty ; Budd-Chiari Syndrome ; diagnostic imaging ; surgery ; therapy ; Catheterization, Peripheral ; Child ; Child, Preschool ; Female ; Follow-Up Studies ; Hepatic Veins ; diagnostic imaging ; surgery ; Humans ; Liver ; blood supply ; diagnostic imaging ; Male ; Phlebography ; methods ; Radiography, Interventional ; Retrospective Studies ; Stents ; Thrombolytic Therapy ; Treatment Outcome ; Vena Cava, Inferior ; diagnostic imaging ; surgery ; Venous Thrombosis ; therapy

OBJECTIVE: To investigate whether the low-tube-voltage (80-kVp), intermediate-tube-current (340-mAs) MDCT using the Iterative Reconstruction in Image Space (IRIS) algorithm improves lesion-to-liver contrast at reduced radiation dosage while maintaining acceptable image noise in the detection of hepatocellular carcinomas (HCC) in thin (mean body mass index, 24 +/- 0.4 kg/m2) adults. SUBJECTS AND METHODS: A phantom simulating the liver with HCC was scanned at 50-400 mAs for 80, 100, 120 and 140-kVp. In addition, fifty patients with HCC who underwent multiphasic liver CT using dual-energy (80-kVp and 140-kVp) arterial scans were enrolled. Virtual 120-kVP scans (protocol A) and 80-kVp scans (protocol B) of the late arterial phase were reconstructed with filtered back-projection (FBP), while corresponding 80-kVp scans were reconstructed with IRIS (protocol C). Contrast-to-noise ratio (CNR) of HCCs and abdominal organs were assessed quantitatively, whereas lesion conspicuity, image noise, and overall image quality were assessed qualitatively. RESULTS: IRIS effectively reduced image noise, and yielded 29% higher CNR than the FBP at equivalent tube voltage and current in the phantom study. In the quantitative patient study, protocol C helped improve CNR by 51% and 172% than protocols A and B (p < 0.001), respectively, at equivalent radiation dosage. In the qualitative study, protocol C acquired the highest score for lesion conspicuity albeit with an inferior score to protocol A for overall image quality (p < 0.001). Mean effective dose was 2.63-mSv with protocol A and 1.12-mSv with protocols B and C. CONCLUSION: CT using the low-tube-voltage, intermediate-tube-current and IRIS help improve lesion-to-liver CNR of HCC in thin adults during the arterial phase at a lower radiation dose when compared with the standard technique using 120-kVp and FBP.
*Algorithms ; Analysis of Variance ; Carcinoma, Hepatocellular/*blood supply/*radiography ; Contrast Media/diagnostic use ; Female ; Humans ; Iohexol/analogs & derivatives/diagnostic use ; Liver Neoplasms/*blood supply/*radiography ; Male ; Middle Aged ; Phantoms, Imaging ; Radiographic Image Interpretation, Computer-Assisted/*methods ; Regression Analysis ; Retrospective Studies ; Tomography, X-Ray Computed/*methods

OBJECTIVE: To predict which intercostal artery supplies a tumor by examining the spatial relationship between hepatocellular carcinoma (HCC) and the intercostal artery feeding the tumor on transverse computed tomography (CT) images. MATERIALS AND METHODS: Between January 2000 and September 2009, 46 intercostal arteries supplying HCCs smaller than 4 cm were noted in 44 patients, and CT scans and angiograms of these patients were retrospectively reviewed. The intercostal artery feeding the tumor was marked on the CT scan showing the center of the tumor. In addition, its spatial relationship with the tumor center was examined. The angle of the tumor location was measured on the transverse CT scan in the clockwise direction from the sagittal line on the virtual circle centered in the right hemithorax. Correlations between the angle of the tumor location and the level of the tumor-feeding intercostal artery were assessed with the Spearman rank coefficient. RESULTS: Of 46 intercostal arteries feeding HCC, 39 (85%) were the first ones observed from the tumor center in a counterclockwise direction on the transverse CT image containing the tumor center. The level of the tumor-feeding intercostal artery was significantly correlated with the angle of the tumor, as the posteriorly located tumor tends to be supplied by lower intercostal arteries, while the laterally located tumor by upper intercostal arteries (Spearman coefficient = -0.537; p < 0.001). CONCLUSION: We can predict the tumor feeder with an accuracy of 85% as the first intercostal artery encountered from the tumor center in a counterclockwise direction on a transverse CT image.
Adult ; Aged ; Aged, 80 and over ; Carcinoma, Hepatocellular/*blood supply/radiography/therapy ; Chemoembolization, Therapeutic ; Female ; Humans ; Liver Neoplasms/*blood supply/radiography/therapy ; Male ; Middle Aged ; *Multidetector Computed Tomography

OBJECTIVETo investigate the ideal approach in creating rabbit model of hepatic fibrosis and to evaluate the feasibility and value of dynamic whole-liver 3D magnetic resonance (MR) perfusion-weighted imaging (PWI) in the quantitative study on the staging of hepatic fibrosis.

METHODSRabbit model of hepatic fibrosis was created by intraperitoneal injection of 5% and 100% carbon tetrachloride (0.1 ml/kg, once a week) respectively. MR perfusion weighted imaging was performed at the 6th, 8th, 10th and 12th week since injection. The time of peak (TOP), the time to peak (TTP), the maximum slope of increase(MSI) and the maximal relative signal increase (MRSI) of portal vein and hepatic parenchyma were analyzed quantitatively, and were compared with pathological results. Comparison of different concentrations of CCl4 was analyzed using chi-square test. Inter-group comparison of perfusion parameters was analyzed using one-way ANOVA P less than 0.05 was regarded as statistically significant.

RESULTS40% of the rabbits treated with 5% carbon tetrachloride developed hepatic fibrosis, while 75% of the rabbits treated with 100% carbon tetrachloride developed hepatic fibrosis; the mortality rate is significantly different between these two groups (X2=5.013, P less than 0.05). PWI examination was successfully achieved in 31 rabbits, liver perfusion baseline was stable, and good TIC curve was obtained. With the progress of hepatic fibrosis, TOP and TTP of portal vein and hepatic parenchyma were increased, and MSI and MRSI were decreased. There were significant differences among stage of S0-S2, S3 and S4.

CONCLUSIONSThe method (100% carbon tetrachloride intraperitoneal injection, 0.1 ml/kg, once a week) has high success rate of creating rabbit model of hepatic fibrosis. The stage of hepatic fibrosis could be evaluated quantitatively with dynamic whole-liver 3D MR perfusion-weighted imaging.

Animals ; Carbon Tetrachloride ; administration & dosage ; Disease Models, Animal ; Image Interpretation, Computer-Assisted ; methods ; Imaging, Three-Dimensional ; Liver ; blood supply ; diagnostic imaging ; pathology ; Liver Circulation ; Liver Cirrhosis, Experimental ; diagnosis ; diagnostic imaging ; Magnetic Resonance Angiography ; methods ; Male ; ROC Curve ; Rabbits ; Radiography ; Sensitivity and Specificity

An infarction of regenerative nodules in liver cirrhosis is a rare abnormality characterized by their coagulative necrosis. We presume that ischemic necrosis is induced by a sudden reduction in the portal and arterial blood flows after blood loss or shock. Most patients with infarcted regenerative nodules have experienced previous episodes of gastrointestinal hemorrhage. Awareness of the entity of infarcted regenerative nodules and its inclusion in the differential diagnosis of multiple hepatic nodules in liver cirrhosis is important, particularly in patients with an episode of gastrointestinal bleeding. The possible difficulty of differentiating infarcted regenerative nodules in liver cirrhosis from hypovascular hepatocellular carcinoma by initial imaging findings alone means that a liver biopsy and serial imaging might be helpful in the differential diagnosis. We report three cases of multiple infarcted regenerative nodules in liver cirrhosis after gastrointestinal hemorrhage.
Adult ; Diagnosis, Differential ; Esophageal and Gastric Varices/*complications/diagnosis ; Gastrointestinal Hemorrhage/*complications/diagnosis/etiology ; Hepatic Artery ; Humans ; Infarction/*diagnosis/etiology ; Liver/*blood supply/pathology ; Liver Cirrhosis/etiology/*radiography ; Liver Regeneration/physiology ; Male ; Middle Aged ; Tomography, X-Ray Computed

OBJECTIVETo explore the feasibility and outcome of radiofrequency ablation (RFA) in blocking feeding vessels of hypervascular hepatocellular carcinoma (HCC).

METHODSTotally 101 patients pathologically confirmed hypervascular HCC were included in the study. In percutaneous arterial ablation (PAA) + RFA group, 71 patients with 74 HCC underwent PAA before classical RFA of the other regions of the tumors, while in the RFA group, another 83 patients with 102 HCC were treated with RFA directly. For another 30 patients who responded poorly to transcatheter arterial chemoembolization were treated with percutaneous arterial embolization (PAE), followed by RFA; another 23 patients were treated with RFA alone were regarded as the control group. Contrast-enhanced CT and magnetic resonance imaging were used as post-RFA imaging follow-up at 1, 3, and 6 month.

RESULTSIn PAA + RFA group, post-PAA imaging showed blocked blood flow in 65 (87.8%) HCC. There were average 2.76 +/- 1.12 ablated foci per HCC in PAA + RFA group and 3.36 +/- 1.60 ablated foci per HCC in control group (P = 0.01). The tumor necrosis rate at 1 month after RFA was 90. 5% (67/74) in PAA + RFA group and 90.2% (92/102) in control group. HCC recurrence rate at 6 month after RFA was 17.6% (13/74) in PAA + RFA group and 31.4% (32/102) in control group (P = 0.038). In PAE + RFA group, 88.6% of the main feeding vessels were blocked. The tumor necrosis rate at 1 and 6 month after FRA was 92.6% (25/27) and 85.2% (23/27) in PAA + RFA group and 65.2% (15/ 23) (P = 0.030) and 56.5% (13/23) (P = 0.024) in control group.

CONCLUSIONPAA and PAE can block the feeding vessels of HCC, enhance the ablated necrosis in the tumor, decrease post-RFA recurrence, and therefore provides a safe and feasible method for treating hypervascular HCC.

Aged ; Carcinoma, Hepatocellular ; blood supply ; diagnostic imaging ; drug therapy ; therapy ; Catheter Ablation ; Chemoembolization, Therapeutic ; Female ; Humans ; Liver Neoplasms ; blood supply ; diagnostic imaging ; drug therapy ; therapy ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Radiography

OBJECTIVE: The conventional method of dividing hepatic segment 2 (S2) and 3 (S3) is subjective and CT interpretation is unclear. The purpose of our study was to test the validity of our hypothesis that the actual plane dividing S2 and S3 is a vertical plane of equal distance from the S2 and S3 portal veins in clinical situations. MATERIALS AND METHODS: We prospectively performed thin-section iodized-oil CT immediately after segmental chemoembolization of S2 or S3 in 27 consecutive patients and measured the angle of intersegmental plane on sagittal multiplanar reformation (MPR) images to verify its vertical nature. Our hypothetical plane dividing S2 and S3 is vertical and equidistant from the S2 and S3 portal veins (vertical method). To clinically validate this, we retrospectively collected 102 patients with small solitary hepatocellular carcinomas (HCC) on S2 or S3 the segmental location of which was confirmed angiographically. Two reviewers predicted the segmental location of each tumor at CT using the vertical method independently in blind trials. The agreement between CT interpretation and angiographic results was analyzed with Kappa values. We also compared the vertical method with the horizontal one. RESULTS: In MPR images, the average angle of the intersegmental plane was slanted 15 degrees anteriorly from the vertical plane. In predicting the segmental location of small HCC with the vertical method, the Kappa value between CT interpretation and angiographic result was 0.838 for reviewer 1 and 0.756 for reviewer 2. Inter-observer agreement was 0.918. The vertical method was superior to the horizontal method for localization of HCC in the left lobe (p < 0.0001 for reviewers 1 and 2). CONCLUSION: The proposed vertical plane equidistant from S2 and S3 portal vein is simple to use and useful for dividing S2 and S3 of the liver.
Adult ; Aged ; Aged, 80 and over ; Angiography, Digital Subtraction ; Antibiotics, Antineoplastic/administration & dosage ; Carcinoma, Hepatocellular/blood supply/radiography/therapy ; Chemoembolization, Therapeutic ; Contrast Media ; Doxorubicin/administration & dosage ; Female ; Humans ; Iodized Oil/diagnostic use ; Liver/*blood supply/*radiography ; Liver Neoplasms/blood supply/radiography/therapy ; Male ; Middle Aged ; Prospective Studies ; Registries ; Retrospective Studies ; *Tomography, Spiral Computed

BACKGROUND/AIMS: Hepatocellular carcinoma (HCC) is becoming one of the common malignant tumors worldwide, and it is characterized by its high vascularity. Caveolin is the major structural protein in caveolae, which are small omega-shaped invaginations within the plasma membrane. Caveolin has been implicated in mitogenic signaling, oncogenesis and angiogenesis. The expression of caveolin-1 and -2 in HCC and its potential relationship with angiogenesis has not been examined. METHODS: Paraffin sections of 35 HCC specimens were immunostained with caveolin-1, caveolin-2, alpha-smooth muscle actin, and CD34 antibodies. In addition, the expression of caveolin-1 and -2 mRNA in HCC was examined. The relationship between the radiological findings and the number of unpaired arteries and microvessel density (MVD) was also investigated. RESULTS: Caveolin-1 and -2 were expressed in the sinusoidal endothelial cells in 20 out of 35, and 18 out of 35 HCC specimens, respectively. Caveolin-1 and -2 were also expressed in the smooth muscle cells of the unpaired arteries in 26 out of 35, and 18 out of 35 HCC specimens, respectively. Increased expression of caveolin-1 and -2 mRNA was detected in 26.7% and 33.3% of the tumor specimens, respectively, compared with the corresponding non-tumorous adjacent liver tissues. There was a significant correlation between expression of caveolin-1, -2 in the smooth muscle cells of unpaired arteries and the number of unpaired arteries. The number of unpaired arteries in HCCs was found to be associated with the degree of contrast enhancement in the arterial phase imaging. However, it did not correlate with the degree of MVD. CONCLUSIONS: These findings suggest that the expression of caveolin-1, -2 is associated with the formation of unpaired arteries in HCC. In addition, there is a correlation between the degree of contrast enhancement of the HCC in the arterial phase image and the number of unpaired arteries.
Adult ; Aged ; Carcinoma, Hepatocellular/*blood supply/metabolism/radiography ; Caveolin 1/genetics/*metabolism ; Caveolin 2/genetics/*metabolism ; Female ; Hepatic Artery/pathology/radiography ; Humans ; Liver Neoplasms/*blood supply/metabolism/radiography ; Male ; Middle Aged ; Neoplasm Staging ; Neovascularization, Pathologic/etiology/*metabolism/radiography ; Retrospective Studies

In pediatric living-related liver transplantation, preoperative evaluation of the recipient is important for surgical planning, while the accurate diagnosis of postoperative complications is essential for graft salvage. Multiplanar and three-dimensional imaging using multi-slice spiral CT can be used for preoperative vascular imaging, as well as for evaluating postoperative complications. In this essay, we describe the usefulness of multi-slice CT, combined with a variety of different reconstruction techniques, for the preoperative evaluation of transplant recipients. In addition, we demonstrate the multi-slice CT findings of postoperative complications, including vascular stenosis or thrombosis, bile duct leak or stricture, and extrahepatic fluid collection.
Child ; Humans ; Liver/*blood supply/*radiography ; *Liver Transplantation ; *Living Donors ; Postoperative Complications/radiography ; Preoperative Care ; Tomography, Spiral Computed/*methods