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Objective: A type 2 endoleak (T2EL) is the most frequently occurring endoleak type after endovascular aneurysm repair (EVAR). Residual T2ELs may cause aneurysm rupture; however, the management of a T2EL remains controversial. This study evaluated sac branch preemptive embolization using N-butyl-2-cyanoacrylate, aiming to prevent T2ELs and sac shrinkage., Methods: Twelve consecutive patients underwent elective preemptive embolization during EVAR at our hospital between August 2018 to March 2019. Their demographic information, operative details, and sac diameters were examined at 6 months after EVAR., Results: No procedural complications were observed. There were no in-hospital deaths among the 12 patients. Sac shrinkage was observed in this cohort (53.8-52.1 mm, p = 0.01). A total of 33 lumbar arteries were occluded with this procedure, and 2 patients had residual T2ELs at 6 months., Conclusions: A T2EL in preemptive sac branch embolization during EVAR has advantages in terms of safety and reduction. Although no clear evidence is available for the management of T2ELs, this study proposes a new standard to prevent it and improve the long-term outcomes after EVAR. However, embolization remains imperfect and further research is necessary.

Objective: We evaluated radiological findings and clinical significance of right aortic arch with mirror-image branching (RAMI) in adults using data from computed tomography (CT) examinations., Material and Methods: We reviewed recorded reports and CT images obtained from university and branch hospitals for RAMI in adults. The RAMI incidence in adults found on CT was assessed. Associated congenital and acquired cardiovascular diseases were evaluated., Results: A total of 27 cases (14 men, 13 women; mean age, 59.4 ± 18.3 years) of RAMI were found. Among 107,014 cases in three hospitals, the RAMI incidence in the first, second, and third Tokai University hospitals were 0.018%, 0.012%, and 0.012%, respectively. Eight cases had high aortic arches and four cases had aortic diverticulum (AD) in proximal descending aorta. Three cases had a history of tetralogy of Fallot. One case with an absent left pulmonary artery and three cases with an aberrant left brachiocephalic vein were found incidentally. Two cases were associated with AD aneurysm and vascular ring formation. One case had stenosis of the left subclavian artery due to injury., Conclusion: Cases of RAMI found in CT examinations in adults were extremely rare. Some cases were associated with congenital anomalies and/or acquired cardiovascular disease.

Objective: We describe our initial clinical experience regarding the use of a 3D roadmap during balloon-occluded retrograde transvenous obliteration (BRTO) in three patients., Methods: Between June 2016 and July 2016, three BRTO procedures were performed in three patients with gastric varices. Preprocedural intravenous dynamic CT was performed, and portal venous phase CT images were postprocessed to obtain volume rendering (VR) images. A 3D roadmap was developed by overlaying the VR images onto the real-time X-ray fluoroscopy images. This 3D roadmap was used for interventional guidance during the BRTO procedure., Results: Using a 3D roadmap, the catheterization of the gastrorenal shunt was successfully accomplished. In addition, in all three patients, the sclerosant could reach the gastric varices without the administration of iodinated contrast medium. Fluoroscopy time and the iodinated contrast dose administered in the present cohort were also substantially lower than in our previous cohorts that did not use a 3D roadmap., Conclusion: Using a 3D roadmap during BRTO enables easier and faster catheter manipulation, thereby helping to reduce both radiation exposure and the need to administer iodinated contrast medium.

Unlabelled: Objection: To evaluate of Kommerell diverticulum (KD) in adults during routine CT examinations., Material and Methods: Eighty-seven cases of left aortic arch with aberrant right subclavian artery (LAARS) and 28 cases of right aortic arch with aberrant left subclavian artery (RAALS) were found on routine CT examinations using 64-128 multidetector CT. We assessed the incidence of KD and measured the size of KD, and compared the results between both groups. We evaluated associated congenital and acquired cardiovascular diseases on both groups., Results: The incidence of KD in each group was as follows: RAALS 100 % and LAARS 48.3 % and incidence of KD in RAALS group was significant higher than in LAARS group. The mean KD size was as follows: RAALS 32.8 mm and LAARS 17.8 mm and, the size of KD in RAALS group was larger than that in LAARS group. Two cases were associated with congenital heart disease. Several cases were associated with acquired aortic diseases including aortic aneurysm, dissection, severe atherosclerosis and aortitis., Conclusion: KD was common among adults with an ASA and some adults were associated with aortic diseases.

Background: Massive hemoptysis mostly arises from the bronchial arteries; however, bleeding can also occur from a lesion in injured pulmonary arteries, such as pulmonary artery aneurysm/pseudoaneurysm (PAA/PAP), during pulmonary infection., Case Report: A 66-year-old man was admitted with a diagnosis of lung abscess in the right lower lobe that was complicated with pyothorax. Intravenous administration of antibiotics and thoracic drainage successfully controlled the infection and inflammation until day 16, when the patient began to exhibit hemoptysis and bloody pleural effusion. Enhanced computed tomography (CT) with multi-planer reconstruction (MPR) images showed a highly enhanced mass inside the abscess fed by the pulmonary artery, suggesting PAA/PAP. Pulmonary angiography confirmed PAA/PAP, and embolization with coils successfully stopped both the bleeding into the sputum and pleural effusion, with a collapsed aneurysm visible on chest CT scan., Conclusion: Clinicians should consider the possibility of PAA/PAP in the differential diagnosis of hemoptysis during the treatment of patients with lung abscess. MPR CT is helpful for the diagnosis of PAA/PAP and its feeding vessels.

Superior mesenteric artery syndrome (SMAS) is characterized by an arteriomesenteric duodenal compression commonly resulting from significant weight loss. Vomiting is the most frequent symptom. SMAS can be complicated by massive gastric dilatation. Patients with cerebral palsy have various factors that can predispose them to SMAS. In this paper, we report a rare case of SMAS complicated by duodenal, peritoneal and retroperitoneal emphysema in a patient with cerebral paralysis, referring to the relevant literature. In this case, severe vomiting associated with epilepsy and weight loss may have contributed to the development of duodenal emphysema.

Purpose: To evaluate the incidence of supernumerary renal arteries in horseshoe kidney (HSK) patients, focusing on number and diameters using computed tomographic angiography (CTA)., Material and Methods: Thirty-nine patients with HSK and 103 patients with normal kidney (NK) underwent 64 or 128 multidetector CT. Based on 2-dimensional CT, including multiplanar reconstruction, maximum intensity projection, and volume-rendered images with a 0.5-mm reconstruction interval on CTA, we assessed the incidence of supernumerary renal arteries, and large ( > 3 mm in diameter) supernumerary renal arteries, and compared the results between the HSK and NK patients using a chi-square test., Result: The mean number of renal arteries was 3.87 in HSK patients and 2.41 in the NK patients. The incidence rates of supernumerary arteries and supernumerary arteries greater than 3 mm were 92.3 %, 69.2 % in HSK patients and 33%, 8.7% in NK patients. Supernumerary and large supernumerary renal arteries had significantly higher incidence rates in the HSK patients than in the NK patients on CTA (p = 0.003, < 0.001)., Conclusion: Supernumerary and large supernumerary renal arteries were frequently found among the HSK patients on CTA.

Paratracheal air cyst (PTAC) is rather frequently detected on thoracic multi-detector computed tomography (MDCT) in daily practice. Accessory cardiac bronchus (ACB) is a rare anomaly; however, the incidence rate is increasing with the use of recent high quality MDCT scanners. We report a case of combined PTAC and ACB that was incidentally detected by MDCT. Three dimensional CT images revealed anatomical details.

Objective: The aim of this study was to evaluate the relationship between urolithiasis and characteristics of renal shape in adult patients with horseshoe kidney (HSK) diagnosed on multidetector row computed tomography (MDCT)., Methods: We evaluated 36 patients with HSK and urolithiasis (Group A) and 70 patients with HSK without urolithiasis (Group B) whose disease was diagnosed on non-contrast MDCT. Two radiologists measured minimum width of the renal isthmus and maximum length of the renal pelvis and evaluated coexisting neoplastic diseases on axial computed tomographic (CT) images with 5-mm reconstruction, and we compared those measurements between the Groups A and B., Results: The overall mean maximum length of the renal pelvis, 12.7±9.2 mm, did not differ significantly between the 2 groups. Minimum isthmus width was larger in patients with HSK and urolithiasis (11.0±5.6 mm), than those without urolithiasis (9.5±5.1 mm). No patient in either groups had a urological renal tumor., Conclusions: Patients of HSK might have tendency of a high incidence of stone formation. Because urolithiasis is a risk factor for tumors of the renal pelvis, monitoring of patients with HSK requires careful attention to isthmus width on CT images.

Objective: We evaluated body weight as an accurate indicator for determining contrast load using nonionic monomeric contrast material in indirect CT venography., Materials and Methods: One hundred and thirty-two patients (mean age 51 years) underwent indirect CT venography to exclude the possibility of DVT. We used 150 ml of isohexol (iodine, 300 mgI/ml) administered at a rate of 3.0 ml/s. Scanning delay was 180 s from the time of initiation of contrast injection. Scans were obtained in a caudal-to-cranial direction starting from the ankle. Hounsfield unit (HU) measurements were recorded at the common femoral and popliteal veins. Using linear regression analysis, we calculated the correlation the coefficient between the CT attenuation and the iodine dose per body weight of each patient. We also recorded the presence of DVT and measured the CT attenuation of the clots., Results: Average contrast dosage per weight was 765.3 mgI (from 420.5 -1184.2 mgI). Average measurements of HU at the common femoral and popliteal veins were 114.4 ± 17.8 HU and 109.9 ± 21.4 HU, respectively. The regression coefficients were 0.62 and 0.41 for the common femoral and popliteal veins, respectively. DVT was detected in 33 of 132 patients. The average HU of the thrombus was 47.7 ± 13.3 HU., Conclusion: Indirect CT venography for detecting DVT initiated 180 s after the start of infusion of contrast material (150 ml) and a contrast injection at a rate of 3 ml/s produced high mean levels of venous enhancement. However, correlation between dose of contrast material per patient weight and CT attenuation of veins was fairly low.

Objective: We evaluated the computed tomography (CT) features of juxtapapillary duodenal diverticula (JPDD) with complications in patients who had acute abdomen., Materials and Methods: Nineteen JPDD were evaluated in 14 patients (mean age: 50 years), who had acute abdomen on contrast-enhanced helical CT with a diagnosis of complicated JPDD by endoscopic retrograde cholangiopancreatography (ERCP). The size, number, and contents of the JPDD, pacreticobiliary ductal dilation, biliary stones, and other associated findings were evaluated on CT scans., Results: Eighteen of the 19 JPDD (94.4%) containing air were demonstrated by CT. Their diameter ranged from 20 to 40 mm (mean: 30 mm). Common bile duct dilation was visualized in 12 patients and biliary stones were found in 8 patients. The other findings were cholecystitis, cholangitis, pancreatitis, and liver abscess. The most serious complication was perforation into the retroperitoneal space caused by diverticulitis associated with an enterolith., Conclusion: Complicated JPDD were well depicted on CT scans, and various findings were revealed. CT evaluation of complicated JPDD was useful for management of these patients.

Objective: To evaluate the frequency and appearance of azygos arch valves after short and long scanning delays and high injection rates of contrast material (CM) using a 64-slice multi-detector-row computed tomography (MDCT)., Methods: We retrospectively reviewed the findings from 264 contrast-enhanced MDCT chest examinations. The rate of injection for 300 mg I/ml CM was 3.0 ml/sec; the short and long scanning delays were 20 and 180 sec, respectively. The presence of residual CM in the azygos arch valves and reflux of CM into the azygos arch were recorded. A chi-square test was used to compare the frequency of residual CM in azygos arch valves and reflux of CM into the azygos arch in both groups., Results: Of the 132 examinations with short scanning delays, 91 (68.9%) demonstrated residual CM in azygos arch valves and 103 (78.0%) demonstrated reflux of CM into the azygos arch. A significantly higher frequency of reflux of CM into the azygos arch and residual CM in azygos arch valves was seen with short scanning delays than with long scanning delays (P<0.05). However, no reflux of CM into azygos arch was seen with long scanning delays., Conclusions: Both reflux of CM into azygos arch valve and residual CM in the azygos arch were frequently seen using short scanning delays.

Renovascular hypertension (RVH) in children is a relatively rare disease, but it is important in that it is a treatable condition when properly diagnosed. Percutaneous transluminal renal angioplasty (PTRA) with or without stenting is widely applied to adult patients with RVH. However, limited information is available as to PTRA with stenting in pediatric patients. We experienced a case of RVH in a 12-year-old girl, who had severe hypertension (180/110 mmHg). Bilateral renal artery stenosis was demonstrated by 3D-CT, MR angiography and selective renal arteriography. Renal function and plasma renin activity were normal. Angiotensin blockade was refrained for fear of functional deterioration of the kidney. Medical treatment with amlodipine insufficiently lowered the pressure to 140-160/80-100 mmHg, so we performed PTRA. Stenotic lesion and pressure gradient was still present after balloon angioplasty on both sides, prompting us to place LUMINEXX® stents on both renal arteries. Blood pressure dropped dramatically after the intervention. Amlodipine was discontinued, and then, enalapril and warfarin were administered to prevent neointima and thrombus formation. Her blood pressure and renal function was stable 18 months after PTRA. Oversized self-expanding stent such as LUMINEXX® stent could be used for renal artery stenting even in pediatric patients with RVH.

Objective: We evaluated the usefulness of radiological reporting that combines continuous speech recognition (CSR) and error correction by transcriptionists., Materials and Methods: Four transcriptionists (two with more than 10 years' and two with less than 3 months' transcription experience) listened to the same 100 dictation files and created radiological reports using conventional transcription and a method that combined CSR with manual error correction by the transcriptionists. We compared the 2 groups using the 2 methods for accuracy and report creation time and evaluated the transcriptionists' inter-personal dependence on accuracy rate and report creation time. We used a CSR system that did not require the training of the system to recognize the user's voice., Results: We observed no significant difference in accuracy between the 2 groups and 2 methods that we tested, though transcriptionists with greater experience transcribed faster than those with less experience using conventional transcription. Using the combined method, error correction speed was not significantly different between two groups of transcriptionists with different levels of experience., Conclusion: Combining CSR and manual error correction by transcriptionists enabled convenient and accurate radiological reporting.

Case: A 73 year old female had been diagnosed as primary biliary cirrhosis and Sjögren's syndrome since the age of 50. With persisting hyperammonemia, the patient was admitted on several occasions for the management of hepatic encephalopathy. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the abdomen showed varices in the splenic hilar region and a splenorenal shunt. A balloon-occluded retrograde transvenous obliteration (B-RTO) using 5% ethanolamine oleate plus iopamidol (EOI) was performed for treatment of recurrent hepatic encephalopathy. Celiac and superior mesenteric angiograms prior to B-RTO demonstrated a hepatofugal portal circulation through the splenic varices, splenorenal shunt, left renal vein and inferior vena cava. Immediately following the B-RTO, the portal circulation became restored to a hepatopetal blood flow and no visualization of the splenic varices and splenorenal shunt was verified. On day 2 post-B-RTO, blood NH3 level was noted to have decreased from 134 to 61 μg/dL, indicating an improvement of hyperammonemia. The liver parenchymal blood flow using the dynamic CT time-concentration curve showed a decrease in hepatic artery blood flow and a marked increase in portal flow following the B-RTO. The patient has since been free from any signs of hepatic encephalopathy due to hyperammonemia for over 5 years following the B-RTO., Conclusions: B-RTO may be considered useful for the treatment of severe recurrent hepatic encephalopathy due to the collateral shunt in portal hypertension.