Treatment of fat-poor renal angiomyolipoma with ectopic blood supply by fluorescent laparoscopy:A case report and review of literature

BACKGROUND Renal angiomyolipoma and renal cell carcinoma are the most common benign and malignant tumors of the kidney respectively,and the preoperative differential diagnosis is crucial due to the wide difference in treatment methods.Fat-poor renal angiomyolipoma is a relatively rare type of in renal angiomyolipoma.Its fat imaging features are not obvious,and it is easily misdiagnosed as renal cell carcinoma.CASE SUMMARY We report the case of a 41-year-old man who complained of osphyalgia.Subsequent abdominal computed tomography scans revealed that a heterogeneous mass was seen in the lower pole of the right kidney,with the size of about 53 mm×47 mm.And showed two right renal arteries,with the mass supplied by an ectopic vessel from the abdominal aorta.Fluorescent laparoscopic blockade of the right renal heterotopic artery and partial nephrectomy was performed.Based on histological and immunohistochemical findings,the tumor was diagnosed as fatpoor renal angiomyolipoma.CONCLUSION The use of fluorescent laparoscopy can effectively help intraoperative management,and the fluorescence pattern provided by intravenous indocyanine green can help suggest the final diagnosis,effectively guide the surgical decisionmaking,and avoid preoperative imaging diagnosis leading to nephrectomy for benign renal tumors,through fluorescent navigation of tumor supply vessel precise block,minimize the loss of renal function.

The origin of blood supply for cavernous hemangioma of the liver

OBJECTIVE: To investigate the origin of blood supply to cavernous hemangioma of the liver (CHL). METHODS: To observe the relation of cavernous hemangioma of the liver to the hepatic artery and portal vein, we performed serial selective hepatic arteriography in 22 patients. Five patients after ligation of the right hepatic arteries underwent portography and liver staining by in jection of methylene blue into the portal veins and 2 patients had hepatic specimens resected, which were made into a model cast by filling the hepatic veins (yellow) and portal venous branches (blue) with methyl methacrylate after vascular lavage. RESULTS: Serial selective hepatic arteriography showed that hepatic arteries and hemangioma were displayed simultaneously, and that hemangioma was supplied by one to numerous arterial branches. In the portal phase of portography, contrast medium failed to enter the tumor and the intrahepatic branches of the portal vein were pushed aside by the tumor; in the liver parenchymal phase, however, the tumor appeared to be a low-density area. Hepatic arteriography and portography revealed that the fistula between the artery and portal vein may not be existed. The liver stained with methylene blue showed that the normal hepatic parenchyma could be stained with deep blue; in contrast, the tumor was not stained at all. The casting specimens showed that the eroded tumor left a round vacant area because of its total shedding, and no blue stained branches of the portal vein extended into the tumor. CONCLUSION: Blood supply of CHL may originate from the hepatic artery.

Applied anatomical study of the vascularized ulnar nerve and its blood supply for cubital tunnel syndrome at the elbow region

Cubital tunnel syndrome is often accompanied by paresthesia in ulnar nerve sites and hand muscle atrophy. When muscle weakness occurs, or after failure of more conservative treatments, anterior transposition is used. In the present study, the ulnar nerve and its blood vessels were examined in the elbows of 18 adult cadavers, and the external diameter of the nutrient vessels of the ulnar nerve at the point of origin, the distances between the origin of the vessels and the medial epicondyle of the humerus, and the length of the vessels accompanying the ulnar nerve in the superior ulnar collateral artery, the inferior ulnar collateral artery, and the posterior ulnar recurrent artery were measured. Anterior transposition of the vascularized ulnar nerve was per- formed to treat cubital tunnel syndrome. The most appropriate distance that the vascularized ulnar nerve can be moved to the subcutaneous tissue under tension-free conditions was 1.8 ± 0.6 cm （1.1-2.5 cm）, which can be used as a reference value during the treatment of cubital tunnel syndrome with anterior transposition of the vascularized ulnar nerve.

INVESTIGATION OF BLOOD SUPPLY OF BRONCHOGENIC CARCINOMA DERIVING FROM PULMONARY ARTERY

Microfil perfusion technique was used to investigate the blood supply of bronchogenic carcinoma deriving from pulmonary artery on 20 fresh specimens of lung cancer, including 11 squamous carcinoma, 6adenocarcinoma, 1 alveolar cell carcinoma and 2undifferentiated carcinoma cases. The results showed that the appearance and quantity of pulmonary blood supply of bronchogenic carcinoma depended on and changed with the site, activity,growth mode as well as the local condition of tumor nodules; pulmonary artery supplied blood to the Periphery of the tumor and its iunermost part as well; vessels from pulmonary artery in tumor nodules were generally less in number than those in the surrounding normal lung tissues around. The results suggested that the tumor blood supply from pulmonary artery should he evaluated comprehensively and dynamically; during interventional chemotherapy via pulmonary artery, patients should bc selected carefully and the catheter for infusion placed in suitable position so as to gain the best therapeutic effect.

Arterial blood supply of hepatocellular carcinoma is associated with efficacy of sorafenib therapy

Aim:There are some previous reports concerning the relationship between prognosis of patients treated with sorafenib and parameters of computed tomography(CT)and magnetic resonance imaging(MRI).This study presents monocentric experience with sorafenib in the treatment of hepatocellular carcinoma(HCC)patients and will try to identify predictive factors for survival based on the correlation of results from imaging and survival.Methods:A total of 38 HCC patients treated from April 2009 to December 2010 with sorafenib were included in this study.HCCs were classified as good arterial supply and poor arterial supply according to the enhancement intensity on CT scan or MRI.Clinical data were collected and survival time was analyzed by Kaplan-Meier method.A Cox’s regression model was performed to reveal predictive factors for survival.Results:Among the 38 patients treated with sorafenib,mean age was 53.3±11.1 years and 35(92.1%)were males.Tumors in 17 patients were classified as good arterial supply,while the remaining 21 patients belonged to poor arterial supply.The median survival time(MST)was 10.7 months[95%confidence interval(CI),8.7-12.7]and the 1-year overall survival(OS)was 41.0%.The MST and 1-year OS in patients with a good arterial supply of tumors were 12 months(range:4-20 months)and 52.9%,compared with that of 7 months(range:1-16 months)and 23.8%in patients with a poor arterial supply of tumors(P=0.002).Patients who had tumors at Barcelona Clinic Liver Cancer(BCLC)stage B had longer MST and higher OS than those who had tumors at BCLC stage C,but there was no statistical difference between these two stages.On multivariate analysis,only arterial supply of the tumors remained statistically predictive for OS(hazard ratios 0.22,95%CI,0.07-0.67,P=0.008).Conclusion:Arterial blood supply is an independent predictor for survival in patients treated with sorafenib,and patients with a good arterial supply of tumors benefit more than those with a poor arterial supply of tumors.

Evaluation of the dual vascular supply patterns in ground-glass nodules with a dynamic volume computed tomography

BACKGROUND In recent years,the detection rate of ground-glass nodules(GGNs)has been improved dramatically due to the popularization of low-dose computed tomography(CT)screening with high-resolution CT technique.This presents challenges for the characterization and management of the GGNs,which depends on a thorough investigation and sufficient diagnostic knowledge of the GGNs.In most diagnostic studies of the GGNs,morphological manifestations are used to differentiate benignancy and malignancy.In contrast,few studies are dedicated to the assessment of the hemodynamics,i.e.,perfusion parameters of the GGNs.AIM To assess the dual vascular supply patterns of GGNs on different histopathology and opacities.METHODS Forty-seven GGNs from 47 patients were prospectively included and underwent the dynamic volume CT.Histopathologic diagnoses were obtained within two weeks after the CT examination.Blood flow from the bronchial artery[bronchial flow(BF)]and pulmonary artery[pulmonary flow(PF)]as well as the perfusion index(PI)=[PF/(PF+BF)]were obtained using first-pass dual-input CT perfusion analysis and compared respectively between different histopathology and lesion types(pure or mixed GGNs)and correlated with the attenuation values of the lesions using one-way ANOVA,student’s t test and Pearson correlation analysis.RESULTS Of the 47 GGNs(mean diameter,8.17 mm;range,5.3-12.7 mm),30(64%)were carcinoma,6(13%)were atypical adenomatous hyperplasia and 11(23%)were organizing pneumonia.All perfusion parameters(BF,PF and PI)demonstrated no significant difference among the three conditions(all P>0.05).The PFs were higher than the BFs in all the three conditions(all P<0.001).Of the 30 GGN carcinomas,14 showed mixed GGNs and 16 pure GGNs with a higher PI in the latter(P<0.01).Of the 17 benign GGNs,4 showed mixed GGNs and 13 pure GGNs with no significant difference of the PI between the GGN types(P=0.21).A negative correlation(r=-0.76,P<0.001)was demonstrated between the CT attenuation values and the PIs in the 30 GGN carcinomas.CONCLUSION The GGNs are perfused dominantly by the PF regardless of its histopathology while the weight of the BF in the GGN carcinomas increases gradually during the progress of its opacification.

Experimental Study on Anatomic Reduction of Lateral Pterygoid Muscle(Simulated Manipulation Fracture Reduction)and Condylar Free Reduction for Condylar Fracture

[Objectives]To compare the fracture healing of keeping lateral pterygoid muscle anatomic reduction(simulated manipulation fracture reduction)with condylar free reduction in the treatment of condylar fractures.[Methods]Twenty-four New Zealand rabbits were randomly divided into two groups to mandibular condylar neck fracture model was established.one team keep the lateral pterygoid muscle,the other excise it.Cervical vascular perfusion was done with ink before animals executed after operation 2,4,6 and 8 weeks.Bilateral anteroposterior and mediolateral condylar diameters measured.Changes of operation side condylar proliferating layer,microvessel number and bone parameters were observed and analyzed after slices and HE staining.[Results]The mediolateral condylar diameters of operation side were significantly smaller than health side in condylar free reduction group at the 4,6,8 weeks(P<0.05),but there was no statistical difference in the anteroposterior condylar diameters at each time point(P>0.05).There were no significant differences in the anteroposterior and mediolateral condylar diameters of the anatomic reduction lateral pterygoid muscle group compared between the operation side and health side(P>0.05).The number of microvessel in condylar free reduction group were smaller than those in anatomic reduction lateral pterygoid muscle group(P<0.05).There were significant differences in BV/TV,Tb.Th,Tb.Sp between the condylar free reduction group and the anatomic reduction lateral pterygoid muscle group(all P<0.05),and the Tb.N were significantly differences between two groups at the 4,6,8 weeks(P<0.05).[Conclusions]When the condyle is fractured it should keep lateral pterygoid muscle(manipulation fracture reduction)as possible,which is important in the fracture healing and functional recovering of mandibular.

Role of Early Arterial Phase Multislice Helical CT Angiography in Evaluation of Hepatocellular Carcinoma

Objective: To investigate the clinical application of early arterial phase multislice CT angiog raphy (MSCTA) of hepatic vessels in evaluation of middle or advanced stage hepatocellular carcinoma. Methods: Trigger Bolus program was used to carry out MSCTA in early and late arterial phases and portal vein phase with single breath holding. Hepatic vessels were reconstructed from the original images of early arterial phase by post processing. The blood supply of tumor and normal liver tissue and the appearances of venous thrombosis and arteriovenous shunts were analyzed. Results: The MSCTA with early arterial phase could perfectly display the origin, shape and amount of feeding vessels to normal liver tissue and tumor in middle or advanced stage hepatocellular carcinoma. It had the ability of displaying the arteriovenous shunts better than that in conventional dual phased liver scanning. Conclusion: MSCTA of hepatic vessels with early arterial phase acquisition using multislice helical CT in middle or advance stage hepatocellular carcinoma has favorable and promising application. It can be used as an imaging method for comprehensive assessment of the hepatocellular carcinoma before treatment.

Interventional treatments for hepatic hemangioma:A state-of-the-art review

Hepatic hemangiomas(HHs)are the most common benign tumors of the liver.These tumors are mainly asymptomatic and do not require treatment.Nevertheless,there are some special cases that require therapeutic intervention,and surgery and intervention are currently the primary treatment modalities.Despite significant advances in the development of minimally invasive techniques and their popularization,interventional treatment of HH is still the preferred choice.In the present review,we discuss the pathological properties,type of blood supply,and treatment indications for HH and assess the status and progress of the existing interventional treatments.

Implantation of a drug delivery system during surgery for patients with primary hepatocarcinoma

BACKGROUND: Postoperative regional chemotherapy is one of the most effective methods to decrease the recurrent rate and improve the prognosis of primary hepatocarcinoma (PHC). This study was undertaken to assess the optimal pathway to implant the drug delivery system (DDS) in the different ways of resecting PHC so as to offer a valuable reference to clinical implantation of the DDS. METHODS: One hundred and ninety cases were divided into two groups according to whether the tumors were resected completely (A) or not (B). Groups A and B were subdivided into three groups a, b and c according to the pathway selected for DDS implantation. The patients in subgroup a received DDS implantation through both the hepatic artery and portal vein (A+P-implanted group), the patients in subgroup b received DDS implantation through the portal vein (P-implanted group), and the patients in subgroup c received DDS implantation through the hepatic artery (A-implanted group). RESULTS: The 1- and 3-year recurrent rates of subgroup c in group A were higher than those of subgroup b, and there was no significant difference between subgroups a and b. Compared with subgroups a and c, the 1- and 3-year survival rates of subgroup b were similar to those of group a but higher than those of group c. The 1- and 3-year survival rates between subgroups a and b in group B were significantly different. The prognosis of subgroup c was lower than that of subgroup a and no significant difference was observed between subgroups b and c. CONCLUSIONS: The DDS should be implanted into the portal vein when PHC is resected completely. It may be better to implant it into both portal vein and hepatic artery if the tumor cannot be completely resected.

Effect of acupoint injection with bone marrow mesenchymal stem cells on the blood flow in rats with hind limb ischemia

Objective To find out the best injection method of the bone marrow mesenchymal stem cells （BM-MSCs） transplantation in the treatment of a rat model with hind limb arterial ischemia. Methods Twenty-four SD rats were randomly divided into four groups： normal control group, model group, BM-MSCs acupoint injection group （Al group） and BM-MSCs muscular injection group （Ml group）. Acupoints of ＂Sanyinjiao＂（三阴交 SP 6） , ＂ Housanli＂ （后三里 ST 36）, ＂Zhaohai＂ （照海 Kl 6）, ＂Huantiao＂ （环跳 GB 30） and ＂Yanglingquan＂ （阳陵泉 GB 34） were selected for Al group, and five nonacupoints were selected on gastrocnemius and adductor of ischemic hind limbs in the Ml group. BMMSCs were injected to the latter two groups. The ischemic hind limb rat model was established using the method of blocking the femoral artery and its branches. The changes of blood flow （perfuse unit, PU） in the affected hind limb and the healthy hind limb were consecutively monitored with laser Doppler flowmetery. The PU index （PUI, the PU ratio of the affected hind limb to the healthy hind limb blood perfusion to describe the visual increment of the blood flow. Besides, the levels of vascular endothelial growth factor （VEGF） and basic fibroblast growth factor （bFGF） were detected, and the expressions of VEGF and bFGF were observed by immunohistochemical semiquantitative analysis. Results Compared with the model group and the Ml group, the PUI was significantly higher in the Al group on the 3^rd, 14^th and 21^st day after injection of BM-MSCs （P〈0.05, P〈0.01）. Compared with the model group, the serum VEGF, bFGF levels and the immunohistochemical expressions of VEGF and bFGF in the Al and Ml groups were significantly increased （all P〈0.01）. Conclusion After injection of BM-MSCs through the acupoint, the recovery speed of perfusion in the ischemic rat hind limbs was fast. Compared with the muscular injection, it can significantly improve the blood flow in the ischemic rat hind limbs.

Retinal blood flow velocity in patients with active uveitis using the retinal function imager

Background Previous studies suggest a link between macular edema and retinal blood flow velocity （RBFV）. The effects of inflammation in the retinal blood vessels are not clearly understood. We want to evaluate the differences in retinal blood flow velocities of patients with active uveitis and healthy controls using the retinal function imager （RFI） and determine the correlation between retinal blood flow velocity and central macular thickness in uveitis patients. Methods Twenty-eight eyes of 24 patients with active anterior uveitis and 51 eyes of 51 normal control subjects were enrolled. Retinal blood flow velocities evaluated by RFI and central macular thickness evaluated by optical coherence tomography （SLO-OCT） were obtained. Differences among the groups were assessed using Stata statistical software. Results Ten eyes had uveitic cystoid macular edema （CME）. Median （first quartile, third quartile） venous velocity for uveitic eyes with CME, uveitic eyes without CME, and controls were 2.09 （1.92, 2.44）, 2.64 （2.32, 2.86）, and 2.82 （2.39, 3.53） mm/s respectively. Median （first and quartile） arterial velocity for uveitic eyes with CME, uveitic eyes without CME, and controls were 3.79 （3.61, 4.09）, 3.46 （2.86, 4.12）, and 3.93 （3.35, 4.65） mm/s. Uveitic eyes with CME had significantly lower venous velocity than controls （P=0.044）. There was a strong linear relationship between venous velocity and central retinal thickness （P=0.007）. Conclusions Retinal venous velocities were significantly decreased in eyes with uveitic CME relative to controls.Decreased venous velocity was correlated with increased central retinal thickness in uveitic eyes.

Use of donor-specific red blood cell transfusions for patients undergoing liver transplantation during the COVID-19 pandemic

Background:Increased risks have been found for patients undergoing liver transplantation due to the blood supply shortage following the ongoing coronavirus disease 2019(COVID-19)pandemic.Hence,exploring a method to alleviate this dilemma is urgent.This phase I,nonrandomized,prospective trial aimed to evaluate the safety and feasibility of using donor-specific red blood cell transfusion(DRBCT)as an urgent measurement to alleviate the blood supply shortage in deceased donor liver transplantation(DDLT).Methods:The outcomes of 26 patients who received DRBCT and 37 patients in the control group who only received 3rd party packed red blood cells(pRBCs)transfusion between May 2020 and January 2021 were compared.Results:Patients receiving DRBCT did not develop transfusion-related complications,and the incidence of postoperative infection was similar to that in the control group(23.1%vs.18.9%,P=0.688).Because the patients received the red blood cells from organ donors,the median volume of intraoperative allogeneic red blood cell transfusion from blood bank was 4.0 U(IQR 1.1-8.0 U)in the DRBCT group,which is significantly lower than that(7.5 U,IQR 4.0-10.0 U)in the control group(P=0.018).The peak aspartate aminotransferase(AST)level was significantly lower in the DRBCT group than in the control group(P=0.008)and so were the AST levels in the first two days after the operation(P=0.006 and P=0.033).Conclusions:DRBCT is a safe and effective procedure to lower the need for blood supply and is associated with a reduction in AST levels after transplantation.DRBCT is beneficial to patients receiving life-saving transplantation without sufficient blood supply during the COVID-19 pandemic.

Effect of superior retinacular artery damage on osteonecrosis of the femoral head

Background Osteonecrosis of the femoral head （ONFH） is the result of dysfunctional blood supply, but associations between specific damaged arteries, imaging changes and clinical sign require more understanding. We investigated characteristics of ONFH that pertain to blood supply, imaging appearance, and clinical feature to judge the prognosis of ONFH.

Dynamic gadoteridol-enhanced MR imaging in the end of growing long bone of piglets

Background It is of value to identify the non-invasive means that can accurately reflect the blood supply of epiphysis and is more sensitive in detection of early ischemia of epiphysis than the conventional gadoteridol （Gd）-enhanced SE TlWI. The aim of this study was to evaluate the blood supply of various anatomic regions at the end of normal growing long bone using dynamic Gd-enhanced MR imaging and compare the sensitivities between dynamic Gd-enhanced MR imaging and conventional Gd-enhanced SE TlWl in the detection of decreased blood perfusion of early epiphyseal ischemia. Methods Twenty-seven two-week-old piglets were used in this study. For the study of the end of normal growing long bone, unilateral MR imaging of the distal femur and proximal tibia was performed on eleven piglets. The comparison was made among various anatomic regions （physeal and epiphyseal cartilage, metaphyseal spongiosa, the secondary ossification center and metaphysis） using MRI in terms of the enhancement ratio and speed. Their relationships with the histological findings, including RBC/mm^2 and vessel distribution, were evaluated. To examine ischemic femoral head, 16 piglets were divided into two groups, with the control group having 8 piglets （involving 16 normal hips） and an ischemic group having 8 piglets （involving 16 hips with hyperabduction）. In the ischemic group, MR imaging was performed on the hips in the hyperabduction immobilized persistently for 30 minutes. After MRI, the piglets were allowed to ambulate freely for 1 day and the same MR scanning was then repeated in a neutral position. The difference in enhancement ratio and speed of the femoral head between the control and ischemic group were evaluated. Results With regard to the end of normal growing long bone, the enhancement ratio of the metaphyseal spongiosa was greatest among all the anatomic regions （P 〈0.001）. The enhancement ratio of physeal cartilage was greater than that of epiphyseal cartilage （P 〈0. 001）, which was the lowest in all tissues （P 〈0.001）. The enhancement speed of the spongiosa was greater than that of physis but the difference was not significant （P 〉0.05）. The enhancement speed of physis was greater than that of epiphyseal cartilage （P 〈0.05）, which was the lowest among all the tissues （P 〈0.05）. The enhancement ratio and speed were found to be related to the histological findings, including RBC/mm^2 （R 〉0.75） and distribution of vessels in the tissues. With ischemic femoral head, the enhancement ratios of physis, anterior part and posterior part of capital femoral epiphysis were significantly lower （P 〈0.05） and enhanced more slowly （P 〈0.05） than those of normal femoral head on dynamic Gd-enhanced MR imaging. On conventional Gd-enhanced SE TlWl, however, no apparent decrease in enhancement ratio and speed in ischemic hips was found （P 〈0.05）, when they were compared with those in the normal hips. Conclusions Dynamic gadoteridol-enhanced MR imaging can reveal the blood supply in various anatomic regions of the end of normal growing long bone. It is more sensitive than conventional Gd-enhanced SE TlWl in the detection of early epiphyseal ischemia.