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Syphilis can cause a wide range of systemic manifestations, such as papular rash, malaise, weight loss, muscle aches, generalized lymphadenopathy, and meningitis. However, pulmonary involvement in patients with secondary syphilis is thought to be relatively rare. Moreover, bone involvement in patients with secondary syphilis is also considered rare, and only a few cases of involvement of lung and bone in such patients have been reported. In this paper, we report a case of secondary syphilis with pulmonary involvement in the form of multiple nodules with low attenuation areas, lymphadenopathy and multiple bone lesions detected on computed tomography and 18F fluorodeoxyglucose-positron emission tomography/computed tomography.

Background Acute obstruction of the hepatic vein (HV) or the portal vein (PV), particularly when it occurs during liver surgery, is potentially fatal unless repaired swiftly. As surgical interventions for this problem are technically demanding and potentially unsuccessful, other treatment options are needed. Case presentation We report two cases of acute, surgically uncorrectable HV or PV obstruction during liver resection or living donor liver transplantation (LDLT), which was successfully treated with urgent intraoperative placement of endovascular stents using interventional radiology (IVR). In Case 1, a patient with colonic liver metastases underwent a non-anatomic partial hepatectomy of the segments 4 and 8 with middle hepatic vein (MHV) resection. Additionally, the patient underwent an extended right posterior sectionectomy with right hepatic vein (RHV) resection for tumors involving RHV. Reconstruction of the MHV was needed to avoid HV congestion of the anterior section of the liver. The MHV was firstly reconstructed by an end-to-end anastomosis between the MHV and RHV resected stumps. However, the reconstruction failed to retain the HV outflow and the anterior section became congested. Serial trials of surgical revisions including re-anastomosis, vein graft interposition and vein graft patch-plasty on the anastomotic wall failed to recover the HV outflow. In Case 2, a pediatric patient with biliary atresia underwent an LDLT and developed an intractable PV obstruction during surgery. Re-anastomosis with vein graft interposition failed to restore the PV flow and elongated warm ischemic time became critical. In both cases, the misalignment in HV or PV reconstruction was likely to have caused flow obstruction, and various types of surgical interventions failed to recover the venous flow. In both cases, an urgent IVR-directed placement of self-expandable metallic stents (SEMS) restored the HV or PV perfusion quickly and effectively, and saved the patients from developing critical conditions. Furthermore, in Cases 1 and 2, the SEMS placed were patent for a sufficient period of time (32 and 44 months, respectively). Conclusions The IVR-directed, urgent, intraoperative endovascular stenting is a safe and efficient treatment tool that serves to resolve the potentially fatal acute HV or PV obstruction that occurs in the middle of liver surgery.

Purpose: The efficacy and safety of percutaneous transhepatic portal embolization (PTPE) with dehydrated ethanol was determined by measuring the liver lobe volume before and after the procedure. Materials and Methods: A total of 38 patients (25 men, 13 women; mean age: 62.0 ± 10.8 years) who underwent PTPE with dehydrated ethanol between April 2005 and March 2011 participated in this study. Dehydrated ethanol containing 17% lipiodol was injected into the target portal vein branch under balloon occlusion, and the portal vein was subsequently embolized. The liver lobe volume was measured via contrast-enhanced computed tomography, and the percent increase in the unembolized lobe volume was then calculated. In addition, PTPE-related complications were surveyed, and the procedural safety was evaluated. Results: The mean percent increase in the unembolized lobe volume after PTPE was 33.8% ± 20.2%. The procedure could not be completed in one patient because of an insufficient increase in the unembolized lobe volume. No serious post- PTPE complications were observed. Conclusion: These data suggest that PTPE with dehydrated ethanol is a safe and effective method for enlarging the planned residual liver volume before extensive liver resection.

When performing endovascular aortic repair (EVAR) procedures, clinicians sometimes encounter cases in which the indications for EVAR are beyond the instruction for use (IFU). In EVAR, proximal neck fixation is the most important factor. This report describes several techniques and tips for EVAR in cases presenting with a difficult short neck or angled neck, especially when using the Gore Excluder®. Endo-wedge techniques (EWT), including non-sheath-assisted EWT with sheath-assisted strategies, are presented. We describe the scrum technique, which is a special procedure that is only feasible when using the Gore Excluder®. In this technique, intentional wire bending around the proximal neck portion occurs by pushing from both sides of the guidewire. This technique is applicable in cases with a sharply angled neck. The scrum with EWT is a more precise strategy for cases with a short or angled neck. Other troublesome cases include limb occlusion caused by weak points in the Gore Excluder® body and legs. The very rare complication of stent-graft collapse is also reviewed.

Patients with polymyositis (PM) or dermatomyositis (DM) frequently show interstitial pneumonia (IP), which is sometimes rapidly progressive or resistant to treatment, thereby significantly affecting the prognosis. The diagnosis and response evaluation of IP are commonly performed qualitatively based on imaging findings, which may cause disagreement among rheumatologists in the evaluation of early lesions and atypical interstitial changes. To determine whether IP could be diagnosed in a quantitative manner during the early stage of PM/DM using a workstation that allows quantitative image processing. Thoracic computed tomography (CT) images of 20 PM/DM patients were reconstructed into a three-dimensional (3D) image using an image processing workstation. The CT values of the constituent voxels were arranged in a histogram of -1000 to +1000 Hounsfield units (HU). The most frequent lung field density was -900 to -801 HU, and relative size was as follows: IP (+) group 0.45 and IP (-) group 0.53. Between -1000 and -701 HU, relative size was not significantly different between the IP (+) group and IP (-) group. Between -700 and -1 HU, the relative size of the lung field was significantly larger in the IP (+) than in the IP (-) group, demonstrating its IP-diagnosing ability. Particularly, within the range from -700 to -301 HU, the macroscopically-assessed ground glass opacity was consistent with the CT value, which, in turn, was closely correlated with KL-6, the pre-existing marker for IP diagnosis. The results of this study may lead to the establishment of quantitative methods of evaluating IP and possible elucidation of the pathogenesis of IP.

Introduction We report a case of aortocaval fistula successfully treated by hybrid operation. Case description A 73-year-old female suffering from malignant lymphoma and painful leg edema was transferred to our institution. Computed tomography revealed an aortoiliac aneurysm. The inferior vena cava was compressed by displacement of the abdominal aortic aneurysm. The bilateral internal iliac and ovarian veins were markedly dilated. Diagnosis was an aortoiliac aneurysm with aortocaval fistula. The treatment options were open surgery or an intervention with bypass surgery. Because of narrow iliac access for a bifurcated stent graft, aorto-uni stentgraft treatment followed by bypass surgery was finally decided. Following stent graft insertion and iliofemoral artery bypass, the aneurysms and fistula were successfully excluded without endoleaks. To treat the inferior vena cava compression, the kissing technique was used to place bare metallic stents across the bilateral common iliac veins and inferior vena cava, which improved the clinical symptoms. Discussion and Evaluation In this aortocaval fistula caused by AAA, a minimally invasive treatment of stentgraft and bypass surgery with venous flow recovery was chosen as a hybrid treatment. Intravascular intervention was the most suitable in this situation. Bare stent placement for venous occlusion was also effective for revascularization of vena cava flow. Conclusion Recent advances in endovascular devices, including stent grafts and bare metallic stents, will be helpful for effective noninvasive treatment for aortocaval fistula circulation.