Publications by authors named "Saebeom Hur"

65 Publications

Novel interventional radiological management for lymphatic leakages after gynecologic surgery: lymphangiography and embolization.

Gland Surg 2021 Mar;10(3):1260-1267

Department of Radiology, Seoul National University Hospital, Seoul, Korea.

Post-operative lymphatic leakage is a common complication of a radical gynecologic surgery involving aggressive lymph node dissection. Its manifestation varies from asymptomatic lymphoceles to life-threatening chylous ascites. In the past, nuclear medicine lymphoscintigraphy was the sole imaging modality for the confirmation of the leakage, of which application is limited due to its poor spatial resolution. While a conservative treatment with percutaneous drainage was the mainstream treatment method, surgical exploration was the last resort for the recalcitrant leakages. Recently, there have been a series of innovations in the field of interventional radiology, including intranodal Lipiodol lymphangiography, dynamic magnetic resonance (MR) lymphangiography, lymphatic embolization, and mesenteric lymph node lymphangiography. Intranodal Lipiodol lymphangiography provides very reliable and secure access to the lymphatic system, while requiring only fundamental skills and equipment available to all interventional radiologists. Besides, Lipiodol is being received a spotlight for its potential therapeutic effects on refractory lymphatic leakage. Dynamic MR lymphangiography plays a vital role in the diagnosis and management of non-traumatic lymphatic diseases, as well as in the post-operative lymphatic leakage with its superior contrast, spatial and temporal resolution. Lymphatic embolization is a technique of using N-BCA glue, a liquid embolic agent, for lymphatic leakages. It can be further described as lymphopseudoaneurysm (LPA) embolization or lymph node embolization, according to which structure is being embolized. Lymphatic embolization opened a new realm of possibilities in the field of interventional lymphology, resulting in the development of treatment approaches for chylous ascites and lymphoceles. Mesenteric lymph node lymphangiography offers the opacification of the upstream mesenteric chylous lymphatic system and can detect lymphatic leakage from the intestinal trunk or the more proximal parts of the mesenteric lymphatic system. With the advent of these latest interventional radiological techniques, more comprehensive approaches to the management of recalcitrant post-operative lymphatic leakages have been enabled.
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http://dx.doi.org/10.21037/gs-2019-ursoc-10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8033090PMC
March 2021

Lymphatic Interventional Treatment for Chyluria via Retrograde Thoracic Duct Access.

J Vasc Interv Radiol 2021 Mar 6. Epub 2021 Mar 6.

Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address:

Chyluria is the leakage of intestinal lymph (chyle) into the urine. Novel lymphatic intervention techniques, such as interstitial lymphatic embolization, proved to be a useful treatment option for chyluria. However, one of the challenges of this approach is the difficulty in identifying connections between the lymphatic system and kidney collecting system. Here, embolization of the abnormal lymphatic connection through retrograde thoracic duct access in 3 chyluria patients is introduced.
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http://dx.doi.org/10.1016/j.jvir.2021.03.410DOI Listing
March 2021

Research Priorities in Lymphatic Interventions: Recommendations from a Multidisciplinary Research Consensus Panel.

J Vasc Interv Radiol 2021 05 18;32(5):762.e1-762.e7. Epub 2021 Feb 18.

Clinical Research and Registries Division, SIR Foundation, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin.

Recognizing the increasing importance of lymphatic interventions, the Society of Interventional Radiology Foundation brought together a multidisciplinary group of key opinion leaders in lymphatic medicine to define the priorities in lymphatic research. On February 21, 2020, SIRF convened a multidisciplinary Research Consensus Panel (RCP) of experts in the lymphatic field. During the meeting, the panel and audience discussed potential future research priorities. The panelists ranked the discussed research priorities based on clinical relevance, overall impact, and technical feasibility. The following research topics were prioritized by RCP: lymphatic decompression in patients with congestive heart failure, detoxification of thoracic duct lymph in acute illness, development of newer agents for lymphatic imaging, characterization of organ-based lymph composition, and development of lymphatic interventions to treat ascites in liver cirrhosis. The RCP priorities underscored that the lymphatic system plays an important role not only in the intrinsic lymphatic diseases but in conditions that traditionally are not considered to be lymphatic such as congestive heart failure, liver cirrhosis, and critical illness. The advancement of the research in these areas will lead the field of lymphatic interventions to the next level.
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http://dx.doi.org/10.1016/j.jvir.2021.01.269DOI Listing
May 2021

Balloon-Occluded Retrograde Transcatheter Magnetic Resonance Lymphangiography to Detect Leakage in Postoperative Chylous Ascites.

J Vasc Interv Radiol 2021 04 30;32(4):617-619. Epub 2021 Jan 30.

Department of Radiology, Seoul National University Hospital, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.

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http://dx.doi.org/10.1016/j.jvir.2020.12.014DOI Listing
April 2021

Reversed Approach through Lymphocele/Lymphatic Fluid Collection for Glue Embolization of Injured Lymphatic Vessels.

J Vasc Interv Radiol 2021 02 27;32(2):299-304. Epub 2020 Nov 27.

Department of Radiology, Sahmyook Medical Center, Seoul, Korea.

A total of 9 glue embolization procedures of injured lymphatic vessels with a reversed approach from the lymphocele/lymphatic fluid collection in 8 patients were retrospectively reviewed. The approach routes were via the indwelling chest tube for pleural effusion (n = 2), the drainage catheter tract for abdominopelvic lymphocele/lymphatic fluid collection/thigh lymphocele (n = 4), and the direct puncture of the lymphatic fluid collection at the operation bed (n = 2). All the procedures were technically successful without complications. The mean daily leakage rate decreased from 465 mL/d before the procedure to 42 mL/d after the procedure, and the drainage catheters could be removed after 8 procedures, achieving a clinical success rate of 88.9% (8 of 9 procedures).
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http://dx.doi.org/10.1016/j.jvir.2020.10.014DOI Listing
February 2021

Spectral CT-Based Iodized Oil Quantification to Predict Tumor Response Following Chemoembolization of Hepatocellular Carcinoma.

J Vasc Interv Radiol 2021 01 5;32(1):16-22. Epub 2020 Nov 5.

Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul, 03080, Korea. Electronic address:

Purpose: To quantify iodized oil retention in tumors after transarterial chemoembolization using spectral computed tomography (CT) imaging in patients with hepatocellular carcinoma (HCC) and evaluate its performance in predicting 12-month tumor responses.

Materials And Methods: From September 2017 to December 2018, 111 patients with HCC underwent initial conventional transarterial chemoembolization. Immediately after the procedure, unenhanced CT was performed using a spectral CT scanner, and the iodized oil densities in index tumors were measured. In tumor-level analyses, a threshold level of iodized oil density in the tumors was calculated using clustered receiver operating characteristic curve analyses to predict the 12-month tumor responses. In patient-level analyses, significant factors associated with a 12-month complete response, including the presence of tumors below the threshold value (ie, suspected residual tumors), were evaluated by logistic regression.

Results: Forty-eight HCCs in 39 patients were included in the analyses. The lower 10th percentile of the iodine density was identified as the threshold for determining the 12-month nonviable responses. The area under the curve of the iodine density measurements in predicting the 12-month nonviable responses was 0.893 (95% confidence interval, 0.797-0.989). The threshold value of the iodine density of 10.68 mg/mL yielded a sensitivity of 82.76% and specificity of 94.74% (P < .001). In the patient-level analysis, the 12-month complete response was significantly associated with the presence of a suspected residual tumor, with an odds ratio of 72.0 (95% confidence interval, 7.273-712.770).

Conclusions: Spectral CT imaging using quantitative analysis of the iodized oil retention in target HCCs can predict tumor responses after a conventional transarterial chemoembolization procedure.
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http://dx.doi.org/10.1016/j.jvir.2020.09.020DOI Listing
January 2021

The Value of Preprocedural MR Imaging in Genicular Artery Embolization for Patients with Osteoarthritic Knee Pain.

J Vasc Interv Radiol 2020 12 31;31(12):2043-2050. Epub 2020 Oct 31.

Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea.

Purpose: To determine the value of preprocedural MR imaging in genicular artery embolization (GAE) for patients with osteoarthritic knee pain.

Materials And Methods: This single-center study retrospectively analyzed 28 knees in 18 patients who underwent GAE for intractable knee pain < 1 month after MR imaging. The pain experienced in each knee was evaluated on a 100-mm visual analog scale (VAS) at baseline and 1- and 3-month after GAE. "GAE responders" were defined as knees that exhibited greater than 30% reduction of VAS pain scores from baseline at both follow-up visits. Musculoskeletal radiologists evaluated MR images of the affected knee compartment regarding cartilage defects, osteophytes, subchondral cysts, bone marrow lesions (BMLs), meniscal injury, and joint effusion. The performances of Kellgren-Lawrence (KL) grading and MR findings in predicting GAE responders was estimated based on receiver operating characteristic curves.

Results: The mean VAS pain score was 84.3 mm. BML (area under the curve [AUC], 0.860; P < .001), meniscal injury (AUC, 0.811; P = .003), and KL grading (AUC, 0.898; P < .001) were significantly associated with GAE outcome. To predict GAE responders, KL grade ≤ 2 yielded a sensitivity of 87.5% and a specificity of 60.9%, BML grade ≤ 1 yielded a sensitivity of 75.0% and a specificity of 69.6%, and meniscal injury grade ≤ 2 yielded a sensitivity of 83.3% and a specificity of 72.7%.

Conclusions: Large BMLs and severe meniscal injuries on MR imaging, as well as high KL grades, indicated poor responses to GAE.
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http://dx.doi.org/10.1016/j.jvir.2020.08.012DOI Listing
December 2020

Guidelines for Nonvariceal Upper Gastrointestinal Bleeding.

Gut Liver 2020 09;14(5):560-570

Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.

Nonvariceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB requires hospitalization and is associated with significant morbidity and mortality. Although European and Asian-Pacific guidelines have been published, there have been no previous guidelines regarding management of NVUGIB in Korea. Korea has a high prevalence of Helicobacter pylori infections, and patients have easy accessibility to endoscopy. Therefore, we believe that guidelines regarding management of NVUGIB in Korea are essential. The Korean Society of Gastroenterology reviewed the recent evidence and recommends practical management guidelines on NVUGIB in Korea.
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http://dx.doi.org/10.5009/gnl20154DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7492499PMC
September 2020

Glue Embolization of Lymphopseudoaneurysm for Chylous Ascites after Retroperitoneal Surgery.

Korean J Radiol 2021 03 28;22(3):376-383. Epub 2020 Aug 28.

Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.

Objective: To assess the safety and efficacy of lymphopseudoaneurysm (LPA) glue (n-butyl cyanoacrylate [NBCA]) embolization in the management of chylous ascites after retroperitoneal surgery.

Materials And Methods: A retrospective analysis from January 2014 to October 2018 was performed in six patients (4 females and 2 males; mean age, 45.3 ± 14.2 years; range, 26-61 years) who underwent LPA embolization for chylous ascites developing after retroperitoneal surgery involving the perirenal space (four donor nephrectomies, one partial nephrectomy, and one retroperitoneal lymphadenectomy). After placing a percutaneous drainage catheter into the LPA or adjacent lymphocele, embolization was performed by filling the LPA itself with a mixture of glue and Lipiodol (Guerbet).

Results: Daily drainage from percutaneously placed drains exceeded 300 mL/day despite medical and surgical treatment (volume: mean, 1173 ± 1098 mL; range, 305-2800 mL). Intranodal lymphangiography was performed in four of the six patients and revealed leakage in 2 patients. Percutaneous embolization of the LPA was successful in all patients using an NBCA and Lipiodol mixture in a ratio of 1:1-1:2 (volume: mean, 4.3 ± 1.1 mL; range, 3-6 mL). Chylous ascites was resolved and the drainage catheter was removed in all patients within 4 days after the procedure (mean, 2.0 ± 1.8 days; range, 0-4 days). No procedure-related complications or recurrence of chylous ascites occurred during a mean follow-up period of 37.3 months (range, 21.1-48.4 months).

Conclusion: Glue embolization of LPA has the potential to be a feasible and effective treatment method for the management of chylous ascites after retroperitoneal surgery.
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http://dx.doi.org/10.3348/kjr.2020.0056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7909856PMC
March 2021

Dextroplantation of Left Liver Graft in Infants.

Liver Transpl 2021 02 20;27(2):222-230. Epub 2020 Oct 20.

Division of HBP Surgery, Departments of Surgery, Seoul National University College of Medicine, Seoul, South Korea.

The position of the left side liver graft is important, and it could lead to complications of the hepatic vein (HV) and portal vein (PV), especially in a small child using a variant left lateral section (vLLS) graft. The purpose of this study was to evaluate the outcome of a novel technique for the implantation of a vLLS graft to the right side (dextroplantation) in infants. For 3 years, 10 consecutive infants underwent dextroplantation using a vLLS graft (group D). The graft was implanted to the right side of the recipient after 90° counterclockwise rotation; the left HV graft was anastomosed to inferior vena cava using the extended right and middle HV stump, and PV was reconstructed using oblique anastomosis without angulation. Surgical outcomes were compared with the historical control group (n = 17, group C) who underwent conventional liver transplantation using a vLLS during infancy. Group D recipients were smaller than group C (body weight <6 kg: 50.0% versus 11.8%; P = 0.03). The rate of graft-to-recipient weight ratio >4% was higher in group D (60.0%) than C (11.8%; P = 0.01). Surgical drains were removed earlier in group D than in group C (15 versus 18 postoperative days [PODs]; P = 0.048). Each group had 1 PV complication (10.0% versus 5.9%); no HV complication occurred in group D, but 3 HV complications (17.6%) occurred in group C (P > 0.05). Hospital stay was shorter in group D than in group C (20 versus 31 PODs; P = 0.02). Dextroplantation of a vLLS graft, even a large-for-size one, was successful in small infants without compromising venous outcomes, compared with conventional vLLS transplantation. We could remove the surgical drains earlier and reduce hospital stays in cases of dextroplantation.
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http://dx.doi.org/10.1002/lt.25883DOI Listing
February 2021

Liver Lymphatic Imaging and Interventions: Resurrection of the Forgotten Knowledge.

Semin Intervent Radiol 2020 Aug 31;37(3):318-323. Epub 2020 Jul 31.

Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea.

Lymphatic imaging and interventions are gaining wider acceptance as the treatment of various lymphatic diseases. Meanwhile, the liver lymphatic system remains relatively unknown despite its physiological importance. Liver lymph has been at the center of the lymphatic research since the 19th century; however, the acquired knowledge has not been used in clinical research and treatment due to the lack of robust imaging methods. Recently introduced liver lymphangiography and interstitial embolization allow for the diagnosis and treatment of several diseases associated with the lymphatic system of the congested liver, providing additional treatment options for conditions that were considered incurable until now.
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http://dx.doi.org/10.1055/s-0040-1713638DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7424986PMC
August 2020

Interventional Radiology Treatment for Postoperative Chylothorax.

Korean J Thorac Cardiovasc Surg 2020 Aug;53(4):200-204

Department of Radiology, Seoul National University Hospital, Seoul, Korea.

Postoperative chylothorax is a rare occurrence after various thoracic surgical procedures, but it poses a substantial risk of morbidity and mortality. Thoracic duct embolization (TDE) is currently deemed the optimal treatment due to its safety and efficacy. This review offers an introduction to interventional options in this setting, detailing the steps of TDE for the edification of those engaged in postoperative care.
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http://dx.doi.org/10.5090/kjtcs.2020.53.4.200DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7409884PMC
August 2020

Shaping the tip of microcatheters for superselective catheterization: steam vs. manual methods.

Diagn Interv Radiol 2020 Sep;26(5):456-463

Department of Radiology, Seoul National University Hospital, Seoul, South Korea.

Purpose: We aimed to evaluate and compare the shapeability and stability of five microcatheters commonly used in interventional radiology after steam shaping and manual shaping.

Methods: Steam shaping was performed using three mandrels of different angles: L(S) shape (90°), U(S) shape (180°), and O(S) shape (360°). Three manual shapes-L(M), U(M), and O(M)-were made to have a similar angle to their steam-shaped counterparts. The stability of the microcatheters was evaluated by passing them through a 5 F catheter and inserting microguidewires. The tip angles of the microcatheters and the angle change rates were compared between groups.

Results: The mean angle of the microcatheters after steam shaping was 42.4°-54.1° for L(S) shape, 80.2°-96.7° for U(S) shape, and 130.7°-150.8° for O(S) shape. Five microcatheters showed significantly different mean angle reductions after passing through the 5 F catheter (17.4%-30.3%) and inserting microguidewires (24.1%-61.2%). Different microguidewires also caused significantly different mean angle reductions (34.6%-50.8%). The reduced angle caused by the guidewire was almost completely recovered after withdrawing it (93.2%-101.6%). Although manual-shaped microcatheters showed a 4.2%-6.3% greater angle reduction than steam-shaped microcatheters after passing through the 5 F catheter, the final tip angle was not significantly different between the two groups and was within 10%.

Conclusion: The tip angle of the microcatheters after steam shaping using mandrels may differ depending on the shape of the mandrel and the type of microcatheter used, and the stability varies depending on the type of microcatheter. The manual shaping of microcatheters can be a good alternative to steam shaping.
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http://dx.doi.org/10.5152/dir.2020.19314DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490016PMC
September 2020

Recanalization of an Occluded Vena Cava Filter and Iliac Veins with Kissing Stents to Treat Postthrombotic Syndrome with a Venous Stasis Ulcer.

Vasc Specialist Int 2020 Jun;36(2):116-121

Departments of Surgery, Seoul National University College of Medicine, Seoul, Korea.

Inferior vena cava filters (IVCFs) are effective in preventing pulmonary embolism and their usage has rapidly increased over the past decades. However, complications have also significantly increased, as IVCF occlusion causes serious chronic venous insufficiency. Herein, we report a case of infrarenal IVCF occlusion that was successfully treated with the introduction of kissing stents through the IVCF into both iliac veins. A 54-year-old male presented with non-healing ulcers on his left leg. He had undergone IVCF implantation and warfarin medication due to deep vein thrombosis 4 years earlier in another hospital. Computed tomography (CT) revealed the filter-bearing IVC occlusion. Endovascular IVCF removal was attempted but failed. Kissing stents were deployed across the IVCF and extended into both iliac veins. Cone beam CT showed well-deployed stents just behind the occluded IVCF. Venous flow was restored without complications, and the recurrent ulcer healed immediately.
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http://dx.doi.org/10.5758/vsi.200010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7333087PMC
June 2020

[Guidelines for Non-variceal Upper Gastrointestinal Bleeding].

Korean J Gastroenterol 2020 06;75(6):322-332

Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.

Non-variceal upper gastrointestinal bleeding (NVUGIB) refers to bleeding that develops in the gastrointestinal tract proximal to the ligament of Treitz. NVUGIB is an important cause for visiting the hospital and is associated with significant morbidity and mortality. Although European and Asian-Pacific guidelines have been published, there has been no previous guidelines regarding management of NVUGIB in Korea. Korea is a country with a high prevalence of pylori infection and patients have easy accessibility to receive endoscopy. Therefore, we believe that guidelines regarding management of NVUGIB are mandatory. The Korean Society of Gastroenterology reviewed recent evidence and recommends practical management guidelines on NVUGIB in Korea.
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http://dx.doi.org/10.4166/kjg.2020.75.6.322DOI Listing
June 2020

Aberrant gastric venous drainage and associated atrophy of hepatic segment II: computed tomography analysis of 2021 patients.

Abdom Radiol (NY) 2020 09;45(9):2764-2771

Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea.

Purpose: To investigate the prevalence and patterns of aberrant gastric venous drainage and associated atrophy of the hepatic segment on contrast-enhanced computed tomography (CT).

Methods: Two radiologists retrospectively reviewed contrast-enhanced CT images from 2021 patients who underwent cone-beam CT-guided chemoembolization between January 2013 and December 2018. They determined the presence or absence of an aberrant gastric vein(s) and its drainage site by consensus, and qualitatively analyzed the presence or absence of atrophy of segments II or III. In cases of disagreement between the two reviewers regarding the presence of atrophy, quantitative analysis was performed using dedicated software.

Results: A total of 31 aberrant right gastric veins were revealed on CT (1.5%), most of which drained into P2 (n = 8), the S2/3 border zone (n = 8), S2 (n = 6), or S4 (n = 5). An aberrant left gastric vein was observed in 21 (1.0%) patients, and P2 was the most common drainage site (n = 13) in these patients. Atrophy of segment II was more frequently observed among patients with aberrant gastric veins than among those without (26.9% versus 4.1%; p < 0.001). In addition, an aberrant gastric vein draining into P2 was most frequently accompanied by segment II atrophy (47.6%).

Conclusion: Aberrant right and left gastric veins were observed in 1.5% and 1.0% of patients, respectively. Atrophy of segment II was frequently observed in patients with aberrant gastric veins, especially those that drained into P2.
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http://dx.doi.org/10.1007/s00261-020-02563-xDOI Listing
September 2020

Transcatheter arterial embolization for advanced gastric cancer bleeding: A single-center experience with 58 patients.

Medicine (Baltimore) 2020 Apr;99(15):e19630

Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul.

To investigate computed tomography and angiography findings and clinical outcomes after transcatheter arterial embolization for acute upper gastrointestinal bleeding from advanced gastric cancers.From January 2005 to December 2014, 58 patients with pathologically proven gastric cancer were treated at our institution with transcatheter arterial embolization due to acute upper gastrointestinal bleeding recalcitrant to endoscopic treatment. The electronic medical records for each patient were reviewed for clinical presentation, endoscopy history, computed tomography and angiographic findings, blood transfusion requirements, and follow-up results.Angiography findings were positive in 13 patients (22.4%): contrast extravasation was found in 9 patients and pseudoaneurysm in 4 patients. All patients with positive angiograms underwent selective embolization treatment. Those with negative angiography findings underwent empirical embolization. Gelfoam, n-butyl cyanoacrylate, coils, or a combination of these were used as embolic agents. The overall clinical success rate was 72.4% (42/58), and the success rate for patients with positive angiography was 53.8% (7/13). The median survival was 97.5 days (range, 7-1415 days), and the 1-month survival rate was 89.6% (52/58). The 1-month survival rate of the clinical success group was 95.2% (40/42), which was significantly higher than that of the clinical failure group (P = .04). The clinical success group also required significantly fewer transfusions (2.43 units, range 0-24 units) (P = .02).Transcatheter arterial embolization is a highly effective treatment for advanced gastric cancer with active bleeding. It should be considered as an additional treatment, especially when endoscopic or surgical treatment fails or when these approaches are difficult.
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http://dx.doi.org/10.1097/MD.0000000000019630DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7220502PMC
April 2020

Iatrogenic Arterioportal Fistula Caused by Radiofrequency Ablation of Hepatocellular Carcinoma: Clinical Course and Treatment Outcomes.

J Vasc Interv Radiol 2020 May 27;31(5):728-736. Epub 2020 Mar 27.

Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, #101 Daehak-ro, Jongno-gu, Seoul, 03080, Seoul, Korea.

Purpose: To analyze the clinical course and treatment outcomes of patients with iatrogenic arterioportal fistula (APF) caused by radiofrequency (RF) ablation of hepatocellular carcinoma (HCC).

Materials And Methods: Among the 1,620 hepatocellular carcinoma patients treated by RF ablation between January 2012 and August 2017, 99 who developed APF after RF ablation were included in this retrospective study. Depending on the extent of portal vein enhancement on arterial phase images, APF was classified as massive or nonmassive. The patients' clinical course was investigated and statistically evaluated by univariable and multivariable analyses.

Results: Thrombocytopenia (odds ratio [OR] = 3.939; 95% confidence interval [CI], 1.141-13.598) was the only risk factor for developing massive APF. Eleven patients underwent embolotherapy (technical success rate, 90.9%) and no patients experienced serious adverse events within 30 days of the procedure. Patients with massive APF (66.7%) had a significantly higher chance of a Child-Pugh score increase than did the patients with nonmassive APF (13.6%) (P < .001). Massive APF had a significantly lower chance of natural regression than did nonmassive APF (P < .001). Child-Pugh B (OR = 17.739; 95% confidence interval, 2.361-133.279) and massive APF without treatment (OR = 11.061; 95% confidence interval, 1.257-97.341) were independent risk factors for liver failure that led to death of liver transplant within 1 year after RF ablation.

Conclusions: Massive APF caused by RF ablation is mostly irreversible and significantly worsens patients' outcomes, but may be effectively treated with embolotherapy.
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http://dx.doi.org/10.1016/j.jvir.2019.10.020DOI Listing
May 2020

Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review.

Rofo 2020 Nov 26;192(11):1025-1035. Epub 2020 Mar 26.

Clinic for Diagnostic and Interventional Radiology, Klinikum Stuttgart, Germany.

Background:  Postoperative lymphatic leakage (PLL) is usually managed by conservative and/or surgical treatments but these procedures can be challenging to perform and potentially clinically ineffective. Therefore, conventional lymphangiography (CL) has emerged as an important alternative. The aim of this review is to present the available outcome data on CL in the management of PLL.

Method:  A systematic literature search (PubMed) using the MeSH term "lymphangiography" was performed and the search was restricted to literature published between January 2007 and August 2019. Identification, screening, and assessment for eligibility and inclusion were conducted in accordance with PRISMA.

Results:  From the initially obtained 1006 articles (identification), 28 articles with a total of 201 patients were finally included (inclusion). The methodological quality of all included articles corresponds to level 4 (Oxford Centre for Evidence-based Medicine - Levels of Evidence, March 2009). PLL occurs after oncological and non-oncological surgery in the form of chylothorax, chylous ascites, and cervical, thoracic, abdominal and peripheral lymph fistula and/or lymphocele. The technical success rate of CL is 75-100 %. Access for CL is transpedal (176 patients) or intranodal (25 patients). Lipiodol is used as the contrast material in all articles, with a maximum amount of 20 ml for transpedal CL and 30 ml for intranodal CL. The X-ray imaging modalities used for CL are fluoroscopy, radiography and/or CT. Two articles report CL-associated major complications and CL-associated morbidity and mortality. The PLL cure rate is 51-70 % for transpedal CL (time to PLL cure: 2-29 days) and 33-100 % for intranodal CL (time to PLL cure: 2-< 30 days). Bailout procedures in the case of clinically ineffective CL include a range of treatments.

Conclusion:  CL is feasible, safe, and effective in the management of PLL. Lipiodol as the contrast material is essential in CL because the highly viscous iodinated poppy-seed oil has not only diagnostic but therapeutic effects. Guidelines and randomized controlled trials are further steps towards defining the ultimate value of CL.

Key Points:   · PLL is a difficult-to-treat and potentially life-threatening surgical complication.. · CL has emerged as an alternative to conservative/surgical treatment of PLL.. · CL is feasible, safe, and effective in the management of PLL. · Lipiodol-based CL can be regarded as a therapeutic procedure.. · Guidelines and randomized controlled trials are further important steps..

Citation Format: · Sommer CM, Pieper CC, Itkin M et al. Conventional Lymphangiography (CL) in the Management of Postoperative Lymphatic Leakage (PLL): A Systematic Review. Fortschr Röntgenstr 2020; 192: 1025 - 1035.
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http://dx.doi.org/10.1055/a-1131-7889DOI Listing
November 2020

Successful thoracic duct embolisation in a child with recurrent massive pericardial effusion diagnosed as a lymphatic anomaly.

Cardiol Young 2020 Apr 24;30(4):571-573. Epub 2020 Feb 24.

Department of Radiology, Seoul National University Hospital, Seoul, South Korea.

A 29-month-old girl had idiopathic massive pericardial effusion for over 6 months. Lymphangiography was performed for chronic and recurrent pericardial effusion and pulmonary lymphangiectasia, suspected based on CT findings. Magnetic resonance lymphangiography revealed chylolymphatic reflux from a tortuously dilated thoracic duct in the mediastinum to the pericardial space, suggesting primary chylopericardium with lymphangiectasia. Pericardial effusion resolved immediately after thoracic duct embolisation at the lower thoracic level. However, pericardial effusion recurred after 5 months, which resolved after additional embolisation of the abnormal lymphatic collateral vessels from the remnant upper thoracic duct. Here, we report an unusual case with chylous massive pericardial effusion diagnosed by magnetic resonance lymphangiography and treated with percutaneous embolisation.
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http://dx.doi.org/10.1017/S1047951120000323DOI Listing
April 2020

Cone-Beam Computed Tomography-Hepatic Arteriography as a Diagnostic Tool for Small Hypervascular Hepatocellular Carcinomas: Method and Clinical Implications.

Korean J Radiol 2020 03;21(3):306-315

Department of Radiology, Seoul National University Hospital, Seoul, Korea.

Objective: This study proposes a novel reference standard for hypervascular hepatocellular carcinomas (HCCs), established by cone-beam computed tomography-hepatic arteriography (CBCT-HA) and two-year imaging follow-up, and discusses its clinical implication on tumor staging and understanding the intrahepatic distant recurrence (IDR) in relation to dynamic computed tomography (CT).

Materials And Methods: In this retrospective study, 99 patients were enrolled, who underwent CBCT-HA during initial chemoembolization for HCC suspected on CT. All patients underwent chemoembolization and regular clinical and imaging follow-up for two years. If IDR appeared on follow-up imaging, initial CBCT-HA images were reviewed to determine if a hypervascular focus pre-existed at the site of recurrence. Pre-existing hypervascular foci on CBCT-HA were regarded as HCCs in initial presentation. Initial HCCs were classified into three groups according to their mode of detection (Group I, detected on CT and CBCT-HA; Group II, additionally detected on CBCT-HA; Group III, confirmed by interval growth). We assessed the influence of CBCT-HA and two-year follow-up on initial tumor stage and calculated the proportion of IDR that pre-existed in initial CBCT-HA.

Results: A total of 405 nodules were confirmed as HCCs, and 297 nodules initially pre-existed. Of the initial 297 HCCs, 149 (50.2%) lesions were in Group I, 74 (24.9%) lesions were in Group II, and the remaining 74 (24.9%) lesions were in Group III. After applying CBCT-HA findings, 11 patients upstaged in T stage, and 4 patients had a change in Milan criteria. Our reference standard for HCC indicated that 120 of 148 (81.1%) one-year IDR and 148 of 256 (57.8%) two-year IDR existed on initial CBCT-HA.

Conclusion: The proposed method enabled the confirmation of many sub-centimeter-sized, faintly vascularized HCC nodules that pre-existed initially but clinically manifested as IDR. Our reference standard for HCC helped in understanding the nature of IDR and the early development of HCC as well as the clinical impact of tumor staging and treatment decision.
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http://dx.doi.org/10.3348/kjr.2019.0060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7039721PMC
March 2020

Initial Experience and Potential Advantages of AFX2 Bifurcated Endograft System: Comparative Case Series.

Vasc Specialist Int 2019 Dec 31;35(4):209-216. Epub 2019 Dec 31.

Department of Radiology, Seoul National University College of Medicine, Seoul, Korea.

Purpose: The AFX2 endograft is a unibody, bifurcated stent graft that can be used to lower complications in certain patients. In this study, we retrospectively reviewed consecutive cases in which the AFX2 system was used to overcome the challenges of narrow distal aorta, as well as to reduce procedure time and contrast medium dose. Furthermore, we compared the results with matched patients treated using the Endurant II endograft system.

Materials And Methods: This was a retrospective observational study of nine patients with abdominal aortic aneurysm (AAA) who underwent endovascular aneurysm repair (EVAR) using the AFX2 device between June 2017 and April 2018 at Seoul National University Hospital. The patients had narrow distal aorta (n=3), reversed tapered neck (n=1), iliac artery aneurysm (n=2), chronic kidney disease patients (n=2), and impending rupture (n=1). Seven matched patients were treated using the Endurant II graft.

Results: In the AFX2 group, the mean procedure time was 87.2 minutes, mean blood loss volume was 157.7 mL, and mean volume of contrast medium used was 48.3 mL. In the Endurant II group, the mean procedure time was 140.0 minutes, mean blood loss volume was 175.0 mL, and mean volume of contrast medium used was 119.3 mL.

Conclusion: Our preliminary experiences with selected AAA patients treated using the AFX2 endovascular repair system showed good outcomes compared with similar patients treated using the Endurant II system. Therefore, the AFX2 may be a good option to perform EVAR in patients of advanced age who have chronic kidney failure or narrow distal aorta.
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http://dx.doi.org/10.5758/vsi.2019.35.4.209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6941765PMC
December 2019

Facing the Truth: Penetration of Vital Organs during Thoracic Duct Embolization.

Authors:
Saebeom Hur

J Vasc Interv Radiol 2020 01;31(1):80-81

Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Korea. Electronic address:

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http://dx.doi.org/10.1016/j.jvir.2019.10.004DOI Listing
January 2020

Effectiveness of drug-eluting bead transarterial chemoembolization versus conventional transarterial chemoembolization for small hepatocellular carcinoma in Child-Pugh class A patients.

Ther Adv Med Oncol 2019 8;11:1758835919866072. Epub 2019 Aug 8.

Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.

Background: This study aimed to compare the therapeutic effectiveness including progression-free survival (PFS), overall survival (OS), and safety of conventional transarterial chemoembolization (cTACE) and drug-eluting bead transarterial chemoembolization (DEB-TACE) in a superselective fashion for the patients with nodular hepatocellular carcinoma (HCC) ( ⩽ 5) and Child-Pugh class A.

Methods: A total of 198 consecutive patients with nodular HCCs ( ⩽ 5) and Child-Pugh class A liver function who were initially treated with cTACE ( = 125) or DEB-TACE ( = 57) were included retrospectively. The primary endpoint was PFS. Secondary endpoints included time-to-target lesion progression (TTTLP), OS, and safety.

Results: The median follow up was 62 months (range, 1-87 months). The PFS was significantly longer in the cTACE group than in the DEB-TACE group (median, 18 months 7 months; hazard ratio [HR] = 0.658, log-rank  = 0.031), whereas OS was comparable (log-rank  = 0.299). TTTLP was significantly longer in the cTACE group than in the DEB-TACE group (median, 34 months 11 months; log-rank  < 0.001). In the stratification analysis based on tumor size, the cTACE group showed significantly longer TTTLP than the DEB-TACE group in the 1.0-2.0 cm and 2.1-3.0 cm subgroups (HR = 0.188, log-rank  < 0.001 and HR = 0.410,  = 0.015, respectively) but not in the 3.1-5.0 cm and 5.1-10.0 cm subgroups (all  > 0.05). Postembolization syndrome occurred more frequently in the cTACE group than in the DEB-TACE group ( = 0.006).

Conclusions: DEB-TACE is followed by significantly shorter PFS than cTACE in patients with nodular HCCs ( ⩽ 5) and Child-Pugh class A, although OS is comparable. Postembolization syndrome occurs more frequently in cTACE than in DEB-TACE.
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http://dx.doi.org/10.1177/1758835919866072DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6689910PMC
August 2019

Clinical Outcomes of Transcatheter Arterial Embolisation for Chronic Knee Pain: Mild-to-Moderate Versus Severe Knee Osteoarthritis.

Cardiovasc Intervent Radiol 2019 Nov 23;42(11):1530-1536. Epub 2019 Jul 23.

Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea.

Purpose: This retrospective study was conducted to compare the clinical outcomes of transcatheter arterial embolisation for chronic knee pain in patients with mild-to-moderate versus severe knee osteoarthritis.

Materials And Methods: This study included patients (n = 41) who were refractory to conservative treatments and who underwent transcatheter arterial embolisation using imipenem/cilastatin sodium between June 2017 and July 2018. A total of 71 knees, including 30 bilateral cases, were treated and categorised into two groups according to the Kellgren-Lawrence grade: mild-to-moderate osteoarthritis (n = 59, Kellgren-Lawrence grade 1-3) and severe osteoarthritis (n = 12, Kellgren-Lawrence grade 4). The clinical outcomes were measured by the visual analogue scale score.

Results: There were no significant differences in age, body mass index or baseline visual analogue scale scores between the two groups. The mean visual analogue scale scores in the mild-to-moderate osteoarthritis group were significantly decreased at 1 day, 1 week, 1 month, 3 months, and 6-months (5.5 at baseline vs. 3.2, 3.1, 2.9, 2.2, and 1.9, after treatment; all P = .00). These improvements were maintained at a mean of 10 ± 3 months (range 6-19 months) post-treatment. The visual analogue scale scores were significantly decreased in the severe osteoarthritis group for 1 month post-treatment (6.3 at baseline vs. 4.1, 4.1, and 4.4 at 1 day, 1 week, and 1 month; all P < .01). However, a decrease in pain was not statistically significant from 3 to 6 months (5.4 and 5.9 at 3 months and 6 months, respectively).

Conclusion: Transcatheter arterial embolisation effectively relieved pain in patients with mild-to-moderate osteoarthritis. In patients with severe osteoarthritis, pain severity decreased for 1 month but gradually increased to the initial severity score within 3 months.

Level Of Evidence: 4, Case series.
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http://dx.doi.org/10.1007/s00270-019-02289-4DOI Listing
November 2019

Back to the Future: Lipiodol in Lymphography-From Diagnostics to Theranostics.

Invest Radiol 2019 09;54(9):600-615

Division of Interventional Radiology, Department of Radiology, University of Pennsylvania, Philadelphia, PA.

Lipiodol is an iodinated poppy seed oil first synthesized in 1901. Originally developed for therapeutic purposes, it has mainly become a diagnostic contrast medium since the 1920s. At the end of the 20th century, Lipiodol underwent a transition back to a therapeutic agent, as exemplified by its increasing use in lymphangiography and lymphatic interventions. Nowadays, indications for lymphangiography include chylothorax, chylous ascites, chyluria, and peripheral lymphatic fistula or lymphoceles. In these indications, Lipiodol alone has a therapeutic effect with clinical success in 51% to 100% of cases. The 2 main access sites to the lymphatic system for lymphangiography are cannulation of lymphatic vessels in the foot (transpedal) and direct puncture of (mainly inguinal) lymph nodes (transnodal). In case of failure of lymphangiography alone to occlude the leaking lymphatic vessel as well as in indications such as protein-losing enteropathy, postoperative hepatic lymphorrhea, or plastic bronchitis, lymphatic vessels can also be embolized directly by injecting a mixture of Lipiodol and surgical glues (most commonly in thoracic duct embolization). The aim of this article is to review the historical role of Lipiodol and the evolution of its clinical application in lymphangiography over time until the current state-of-the-art lymphatic imaging techniques and interventions.
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http://dx.doi.org/10.1097/RLI.0000000000000578DOI Listing
September 2019

Cone-Beam CT-Guided Chemoembolization in Patients with Complete Response after Previous Chemoembolization but Subsequent Elevated α-Fetoprotein without Overt Hepatocellular Carcinoma.

J Vasc Interv Radiol 2019 Aug 22;30(8):1273-1280. Epub 2019 Jun 22.

Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, South Korea.

Purpose: To evaluate the performance of C-arm computed tomography (CT)-guided chemoembolization in patients with hepatocellular carcinoma (HCC) with serum α-fetoprotein (AFP) level > 20 ng/mL but with no overt tumor on CT and/or magnetic resonance imaging.

Materials And Methods: From May 2010 to May 2017, 34 patients with HCC (25 men and 9 women; mean age, 59.7 y) who had elevated serum AFP levels (> 20 ng/mL) but no overt tumor on 6-mo imaging studies and had shown complete response (CR) after previous chemoembolization underwent C-arm CT-guided conventional chemoembolization. Three radiologists retrospectively reviewed the imaging studies (preprocedural images, C-arm CT scans, and follow-up images) in consensus, and clinical data including AFP levels were retrospectively obtained. Tumor detection by C-arm CT and treatment response after chemoembolization were assessed.

Results: HCC was imaged at the time of chemoembolization in 24 of 34 patients (70.6%). C-arm CT detected tumors in 25 patients (73.5%); 23 detections were true positives, 2 were false positives, and 1 was a false negative (diaphragm metastasis). Among the 23 patients with true-positive results, the first follow-up enhanced imaging studies showed CR (n = 17), partial response (n = 1), progressive disease (n = 4), and indeterminate status (n = 1; treated by percutaneous ethanol injection).

Conclusions: C-arm CT-guided chemoembolization may help to detect and treat recurrent tumors in patients who have shown CR after previous chemoembolization but subsequently, during follow-up surveillance, had serum AFP levels > 20 ng/mL without an overt tumor evident on imaging studies.
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http://dx.doi.org/10.1016/j.jvir.2019.03.020DOI Listing
August 2019

Lymphatic Embolization for Primary Chylous Reflux of Genitalia in 2 Cases.

J Vasc Interv Radiol 2019 Jul 22;30(7):1140-1143. Epub 2019 May 22.

Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea.

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http://dx.doi.org/10.1016/j.jvir.2018.12.706DOI Listing
July 2019

The Efficacy of Lymph Node Embolization Using N-Butyl Cyanoacrylate Compared to Ethanol Sclerotherapy in the Management of Symptomatic Lymphorrhea after Pelvic Surgery.

J Vasc Interv Radiol 2019 02;30(2):195-202.e1

Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, Korea.

Purpose: To compare the efficacy of lymph node (LN) embolization using N-butyl cyanoacrylate versus ethanol sclerotherapy in the management of symptomatic postoperative pelvic lymphorrhea.

Materials And Methods: Thirty-three patients with 40 instances of symptomatic postoperative lymphorrhea were treated with either LN embolization or sclerotherapy at Seoul National University Hospital from January 2009 to July 2017 and were retrospectively included (LN embolization group: 24 lymphoceles of 19 patients, mean age of 59.29 years; sclerotherapy group: 16 lymphoceles of 14 patients, mean age of 60.95 years). The types of operations were hysterectomy and bilateral oophorectomy with pelvic lymph node dissection (n = 9), radical prostatectomy (n = 3), and renal transplantation (n = 2) for the sclerotherapy group and radical prostatectomy (n = 10) and hysterectomy and bilateral oophorectomy with pelvic lymph node dissection (n = 9) for the LN embolization group. The 3 most common indications of treatment were lower extremity edema (n = 11), pain (n = 11), and fever (n = 8). The amount of leak before treatment (initial daily drainage) and clinical outcomes, including the clinical success rate in 3 weeks, treatment period, and complication rate were compared between both groups.

Results: LN embolization showed a higher 3-week clinical success rate than sclerotherapy in a univariate analysis (83.3% and 43.8%, P = .026). There was no statistically significant difference in the treatment period and the complication rate (7.1 days and 12.3 days, P = .098; 8.3% and 25.0%, P = .184).

Conclusions: LN embolization is more effective for treating postoperative pelvic lymphorrhea than sclerotherapy with similar safety.
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http://dx.doi.org/10.1016/j.jvir.2018.09.038DOI Listing
February 2019

The Feasibility of Mesenteric Intranodal Lymphangiography: Its Clinical Application for Refractory Postoperative Chylous Ascites.

J Vasc Interv Radiol 2018 09;29(9):1290-1292

Department of Radiology, Seoul National University Hospital, 101 Daehak-ro, Jongro-gu, Seoul 110-744, Republic of Korea.

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http://dx.doi.org/10.1016/j.jvir.2018.01.789DOI Listing
September 2018