Preoperative Three-dimensional Computed Tomography Angiography Research Articles

Robot-assisted thoracoscopic right upper lobectomy with displaced B3 and absence of minor fissure: a case report.

B3 downward-shifting is a rare bronchial anomaly characterized by abnormal pulmonary arteries associated with downward displacement of B3 and complete fusion between the right upper and middle lobes. We report a case of robot-assisted thoracoscopic right upper lobectomy in a patient with lung cancer with B3 downward-shifting. An 81-year-old male was diagnosed with non-small cell lung cancer in S3 of the right upper lung. Preoperative three-dimensional computed tomography angiography revealed a B3 bronchus derived from the middle lobe bronchus and an anterior segmental pulmonary artery variation. Robot-assisted thoracoscopic surgery right upper lobectomy with ND2a-1 was performed via four-port incisions and an assist incision. No interlobar fissure was observed between the right upper and middle lobes. After dissecting B1+2, the displaced B3 root was dissected. The displaced A3a was difficult to dissect because of an extremely severe complete fissure. Therefore, we dissected the bronchus preceding from the cranial side. To confirm a minor fissure, indocyanine green was administered intravenously, and the interlobar boundary was identified as the line separating the dark and green lung parenchyma. The boundary was divided using mechanical staples. No surgical complications occurred. Using three-dimensional reconstruction imaging and systemic indocyanine green administration, we successfully performed a right upper lobectomy through robot-assisted thoracic surgery.

Novel thoracoscopic segmentectomy combining preoperative three-dimensional image simulation and intravenous administration of indocyanine green

OBJECTIVESThe aim of this study is to assess prospectively the validity and feasibility of segmentectomy using preoperative simulation and intravenous indocyanine green (ICG) with near-infrared (NIR) light thoracoscope to ensure a sufficient surgical margin.METHODSThis study was a prospective, single-centre, phase II, feasibility study. From February to July 2021, 20 patients were enrolled in this study. All patients underwent preoperative three-dimensional computed tomography angiography and bronchography using simulation software. The dominant pulmonary artery of the targeted segment was selected to determine the dissection line and measure the surgical margin to the tumour. Intraoperatively, after the planned dissection of the pulmonary artery, ICG (0.3 mg/kg) was administered intravenously and observed with NIR, and dissection was performed along the line determined by preoperative simulation. Postoperatively, the pathological margin was compared with the simulation margin.RESULTSAll surgeries were performed via an uniport (3.5–4.0-cm skin incision). The regions of segmentectomy were S2, S3, S6, S9 + 10 and S10 of the right side and S1 + 2 + 3, S3, S3 + 4 + 5, S6 and S8 of the left side. The difference between the simulation margin and the pathological margin was not significant (simulation 30.5 ± 10.1 vs pathological 31.0 ± 11.0 mm, P = 0.801). The simulation margin was well correlated with the pathological margin (R2 = 0.677). The proportion of cases successfully achieving the pathological margin of error of plus or minus 10 mm of the simulation margin was 90% (18 of 20 cases).CONCLUSIONSThe combination of preoperative three-dimensional computed tomography simulation and ICG–NIR was effective for securing a sufficient margin in segmentectomy.

Evaluation of vascular anatomy for colon cancer located in the splenic flexure using the preoperative three-dimensional computed tomography angiography with colonography.

The aim of this study is to reveal the vascular branching variation in SFC(splenic flexure cancer) patients using the preoperative three-dimensional computed tomography angiography with colonography (3D-CTAC). We retrospectively analyzed patients with SFC who underwent preoperative 3D-CTAC between January 2014 and December 2019. Among 1256 colorectal cancer (CRC) patients, 96 (7.6%) manifested SFC. The arterial branching from the superior mesenteric artery (SMA) was classified into five patterns, as follows: (type 1A) the left branch of middle colic artery (LMCA) diverged from middle colic artery (MCA) (N = 47, 49.0%); (2A) the LMCA diverged from the MCA and the accessory middle colic artery (AMCA) (N = 26, 27.1%); (3A) the LMCA independently diverged from the SMA (N = 16, 16.7%); (4A) the LMCA independently diverged from the SMA and AMCA (N = 3, 3.1%); (5A) only the AMCA and the LMCA was absent (N = 4, 4.1%). Venous drainage was classified into four patterns, as follows: (type 1V) the SFV flows into the inferior mesenteric vein (IMV) then back to the splenic vein (N = 50, 52.1%); (2V) the SFV flows into the IMV then back to the superior mesenteric vein (SMV) (N = 19, 19.8%); (type 3V) the SFV independently flows into the splenic vein (N = 3, 3.1%); (type 4V) the SFV is absent (N = 24, 25.0%). 3D-CTAC could reveal accurate preoperative tumor localization and vascular branching. These classifications should be helpful in performing accurate complete mesocolic excision and central vessel ligation for SFC.

Role of Computational Fluid Dynamics for Predicting Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: Study Protocol for a Multicenter Prospective Study.

Delayed cerebral ischemia (DCI) is a significant cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). Recently, we reported the possibility that computational fluid dynamics (CFD) could predict DCI in terms of the cross-sectional area and flow velocity of the ipsilateral extracranial internal carotid and distal parent arteries in a single-center retrospective study. This is a multicenter, prospective, cohort study. Patients with aneurysmal SAH will undergo CFD analyses using preoperative three-dimensional computed tomography angiography, and we will investigate hemodynamic features of cerebral arteries in an acute stage of SAH. Primary outcome measures will be CFD features in patients with subsequent occurrence of DCI. Secondary outcome measures will be CFD features in patients with subsequent occurrence of cerebral vasospasm and cerebral infarction and the relationships with eventual modified Rankin scale score at 3months. The present protocol for a multicenter prospective study is expected to provide a novel diagnostic method to predict DCI before aneurysmal obliteration in an acute stage of SAH.

Distance Between the Falciform Ligament and Distal Dural Ring as a Surgical Landmark for the Treatment of Paraclinoid Aneurysms

It is difficult to completely comprehend the anatomy of the structures surrounding the paraclinoid region before aneurysm and tumor treatment therein. When treating paraclinoid aneurysms, it is important to determine the location of the aneurysm as intradural or extradural. Thus, accurate prediction of the position of the distal dural ring (DDR) is necessary. To this end, we focused on the falciform ligament (FL), which is easily visualized on images based on its anatomic features. We measured the distance between the FL and the DDR in patients undergoing paraclinoid aneurysm operations. Between January 2017 and July 2018, 15 patients who underwent clipping for paraclinoid aneurysm treatment were retrospectively identified. The distance between the FL and the DDR was measured using a microscale at the time of the operation. The patients comprised 14 women and 1 man. The mean aneurysm diameter was 7.29 ± 2.21 mm and the median size was 6.5 mm. Eleven of the aneurysms were on the left and 4 were on the right side. The mean distance between the FL and the DDR was 3.50 ± 0.17 mm and the median distance was 3.50 mm. The distance between the FL and the DDR was almost the same across cases (3.5 mm). The position of the FL can be easily predicted using preoperative three-dimensional computed tomography angiography based on its anatomic features. In this study, the DDR was located 3.5 mm proximal to the FL along the internal carotid artery. This information is useful for predicting the position of the DDR.

Utility of Split-bolus Single-phase Protocol for Pulmonary Artery and Vein Separation Preoperative 3D-CTA in Lung Cancer Video-assisted Thoracic Surgery

There are many variations in branching and running of pulmonary artery (PA) and pulmonary vein (PV). It is desirable to separate as a surgical simulation of lung cancer and important to grasp before video-assisted thoracic surgery (VATS) to perform quick and safe. Therefore, the purpose of this study was to evaluate objective and subjective image quality (contrast attenuation, separation ability, and vascular visualization) of PA and PV of splitbolus single-phase protocol (SBSPP) in preoperative three-dimensional computed tomography angiography (3DCTA). CT value of PA was 410.2±71.0 Hounsfield unit (HU), PV was 245.1±24.8 HU, difference between CT value of PA and CT value of PV was 164.5±60.9 HU. Subjective image quality of PA and PV could be visualized until more than the segmental branch level. SBSPP can obtain sufficient CT value for separate visualization of PA and PV, and before VATS useful PA and PV 3D-CTA imaging.

Horizontal distance of anterior communicating artery aneurysm neck from anterior clinoid process is critically important to predict postoperative complication in clipping via pterional approach.

Background:The difficulty of clipping aneurysm of the anterior communicating artery (AcomA) depends on the size, direction, positional relationship with the parent artery, and height from the anterior frontal base. Cases of clipping unruptured AcomA aneurysm through pterional approach were analyzed to investigate the importance of the horizontal distance from the base of the anterior clinoid process.Methods:Twenty-six consecutive unruptured AcomA aneurysms were treated by clipping through pterional approach in 10 males and 11 females aged 37–77 years (mean 61.8 years). Size and direction of the aneurysm, and vertical distance from the anterior frontal base and horizontal distance from the base of the anterior clinoid process were measured by preoperative three-dimensional computed tomography angiography (3D-CTA). Correlations with occurrence of clinical complications and computed tomography (CT) abnormalities after operation were investigated.Results:The aneurysms had a mean size of 4.7 mm (range 2.1–8.9 mm). Three patients suffered complications and all had anosmia. Three patients had CT abnormality and all were contusion. The mean horizontal distance from the base of the anterior clinoid process was −4.7 mm (range −12.3–3.5 mm). The patients were divided into the anterior and posterior groups with the boundary set at −5 mm. There were no significant complications between two groups (P = 0.26). There were statistically significant CT abnormalities in posterior group (P = 0.025).Conclusion:The horizontal distance from the base of the anterior clinoid process is important to predict CT abnormalities and complications in clipping of AcomA aneurysm through pterional approach.

Risk factor analysis and decision-making of surgical strategy for V3 segment anomaly: significance of preoperative CT angiography for posterior C1 instrumentation

Background ContextAwareness of vascular anomalies is crucial to avoid iatrogenic injuries during surgical procedure. Although V3 segment anomaly has been well described, the incidence of V3 segment anomaly has been rather variable in the literature, and there are few reports regarding the adequate surgical strategy for each type of V3 segment anomaly. PurposeThis study aimed to analyze the incidence of V3 segment anomaly and demonstrate the importance of recognizing vertebral artery (VA) anomaly in deciding the surgical strategy for C1 screw placement. Study DesignA retrospective cohort study was carried out. Patient SampleThe sample included 147 patients who underwent C1 posterior instrumentation and preoperative three-dimensional computed tomography angiography (3D CTA). Outcome MeasuresThe primary outcome of this study was the incidence of V3 segment anomaly using preoperative CTA, and the secondary outcome was the risk factor analysis of the V3 segment anomaly. MethodsThere were 147 patients who underwent C1 posterior instrumentation to treat various kinds of upper cervical disease. The 3D CTA of the patients were assessed preoperatively to identify the anomaly of the VA. Each surgical technique of C1 posterior instrumentation was decided upon the shape and the course of the VA around the atlas. ResultsDuring the study period, 11 cases of V3 segment anomaly (7.5%) were found on 3D CTA. Persistent intersegmental artery was found in nine cases and was the most common variant of VA anomaly. Early branch of posterior inferior cerebellar artery was found in three cases. Most of V3 segment anomaly was found unilaterally, but there were two cases with bilateral V3 anomaly. Seven cases (63.6%) were associated with congenital bony abnormality around craniovertebral junction (CVJ), such as occipital assimilation, Klippel-Feil syndrome, and os odontoideum. V3 segment anomaly was significantly common in the cases with bony abnormality (29.2% (7/24) vs. 3.6% (4/123), p<.05). Compared with patient without bony abnormality, the odds ratio was 10.78 (95% CI: 2.88–40.37) for those with congenital bony abnormalities. Rheumatoid arthritis was not a risk factor of V3 segment anomaly (p=.391). ConclusionsThe course of the VA is heterogenous, and the V3 segment anomaly of the VA is more common in the cases with congenital bony abnormalities around CVJ. Therefore, preoperative radiological studies should be performed to identify V3 segment variations and reduce the risk of VA injury. To avoid significant morbidities associated with VA, surgical technique of C1 posterior instrumentation should be decided depending upon the V3 segment anomaly. A more optimal entry point and trajectory for C1 fixation can be selected.

Efficacy analysis of endovascular aneurysm repair and open surgery repair in patients with abdominal aortic aneurysm

Objective To analyze and compare the clinical efficacies of endovascular aneurysm repair (EVAR) and open surgery repair (OSR) in patients with abdominal aortic aneurysm (AAA). Methods The clinical data of 271 patients with AAA who received surgery at the First Hospital of China Medical University between January 2004 and December 2014 were retrospectively analyzed. Of the 271 patients, 153 patients undergoing EVAR were allocated into the EVAR group and 118 patients undergoing OSR into the OSR group, respectively. All the patients underwent a primary screening of preoperative ultrasonography and were diagnosed by three-dimensional computed tomography angiography (CTA), then urgent and severe patients were confirmed by abdominal enhanced CT. The procedures of EVAR: guide wire was inserted into the abdominal arota from femoral artery incision and branched stent was placed. The procedures of OSR: AAA was resected by median abdominal incision, thrombi and sclerosis plaques in endovascular wall were cleared, and end-to-end abdominal aortic anastomosis and end-to-side iliac aortic anastomosis were performed using Y-shaped blood vessel prosthesis. All the patients were followed up by telephone interview up to December 31, 2014. The operation situation, complications at postoperative day 30, short-term complications (between postoperative 3 months and 3 years), medium- and long-term complications (more than postoperative 3 years), mortality and survival rate were observed. Measurement data with normal distribution were presented as ±s and analyzed using the t test, and count data were analyzed using the chi-square test or Fisher exact probability. Survival curve was drawn by the Kaplan-Meier method, and survival rate was analyzed using the Log-rank test. Results All the patients were confirmed as with AAA by preoperative three-dimensional CTA. The operation time, volume of intraoperative blood loss, volume of intraoperative blood transfusion, time for out-off-bed activity, duration of hospital stay and hospital expenses were (179±64)minutes, (79±36)mL, 0, (5.7±3.1)days, (12±6)days, (179 018±65 796)yuan in the EVAR group and (205±40)minutes, (402±297)mL, (410±367)mL, (8.3±2.1)days, (18±11)days, (77 853±21 164)yuan in the OSR group, with significant differences between the 2 groups (t=-32.464, -51.719, -294.350, -11.833, -10.957, 2 778.748, P 0.05). The number of patients complicated with postoperative heart failure and I-shaped inner leakage were 0 and 8 in the EVAR group and 4 and 0 in the OSR group, with a significant difference between the 2 groups (P 0.05). The number of patients complicated with chest pain and abdominal distension were 0 and 0 in the EVAR group and 4 and 4 in the OSR group, with a significant difference between the 2 groups (P 0.05). The 3-, 5-, 10-year survival rates in the EVAR group and in the OSR group were 94.35%, 89.52%, 60.48% and 93.33%, 91.42%, 69.52%, respectively, showing no significant difference between the 2 groups (χ2=0.103, 0.239, 2.033, P>0.05). Conclusion EVAR has an advantage of micro-invasion in perioperative management, and both of EVAR and OSR are effective for the treatment of AAA with equivalent incidence of complications and long-term survival rate. Key words: Abdominal aortic aneurysm; Endovascular aneurysm repair; Open surgery; Efficacy

Planning of segmentectomy using three-dimensional computed tomography angiography with a virtual safety margin: Technique and initial experience

ObjectivesIn preoperative segmentectomy simulation for primary lung cancer, it is important to identify the intersegmental pulmonary veins and the relationship between them and the surgical safety margin. We have adopted a method that incorporates a virtual safety margin into three-dimensional computed tomography angiography images in order to plan adequate segmentectomy for lung cancer patients. In this study, we describe the new preoperative planning technique and review cases in which we performed segmentectomy based on its results. MethodsWe reviewed clinical, radiological, and pathological records and selected patients who underwent segmentectomy for a primary lung cancer lesion with a diameter of 2cm or less. These segmentectomies were planned using preoperative three-dimensional computed tomography angiography with a virtual safety margin. ResultsA total of 17 primary lung cancers in 16 patients (11 male and 5 female, aged 52–82 years) were removed by segmentectomy, planned using the new technique. In 6 of 17 tumors (35%) were non-solid type adenocarcinomas, 3 tumors (18%) were partly solid type adenocarcinomas, 6 tumors (35%) were solid type adenocarcinomas and 2 tumors (12%) were squamous cell carcinomas. Pathological examination revealed no positive surgical margins and no lymph node metastases in any patients. ConclusionsThree-dimensional computed tomography angiography with a virtual safety margin was able to non-invasively visualize the three-dimensional distances and the relationships between the primary tumor and intersegmental pulmonary veins. It was able to aid in the preoperative planning of a suitable segmentectomy procedure for patients with a primary lung cancer lesion of 2cm or less in diameter.

Treatment Strategy of a Huge Ameloblastic Carcinoma

Ameloblastic carcinoma is a very rare malignant odontogenic tumor. We report a case of secondary-type ameloblastic carcinoma that extended transversally over almost half of the side of the face. Malignant transformation and identification of the malignant region in the large tumor were achieved using L-3-[F]fluoro-α-methyltyrosine (FAMT)-positron emission tomography (PET); FAMT is transported into cancer cells by L-type amino acid transporter 1 and shows high specificity for malignant tumors. The malignant region determined by microscopic evaluation of resected samples was similar to the region showing high FAMT uptake in PET. Using preoperative FAMT-PET and magnetic resonance imaging, we were able to achieve total resection of the very large tumor, while avoiding excessive resection that could cause severe functional loss or a poor aesthetic facial appearance. We used a modified Weber-Fergusson incision along the nasolabial fold to the labiajugal fold and reconstruction with a pectoralis major muscle flap, and this gave a good aesthetic outcome. Safe surgical resection was possible because preoperative three-dimensional computed tomography angiography was used to identify the position of the main trunk of the external carotid artery, which was closely aligned with the tumor in a posterior direction in the infratemporal fossa region.

A Case of Large Anterior Paraclinoid Aneurysm with Intraoperative Premature Rupture

We report here troubleshooting of intraoperative premature rupture with large anterior paraclinoid aneurysm, which was successfully clipped. A 61-year-old woman with left nasal hemianopia was referred to our institute. Preoperative three-dimensional computed tomography angiography and a left internal carotid artery angiogram showed a large left anterior clinoid aneurysm adjacent to the anterior clinoid process. Aneurysm was ruptured prematurely and tentative clipping of the dome of the aneurysm was done incidentally to stop bleeding and to reduce the volume of the aneurysm. The anterior clinoid process and superior wall of the orbit were drilled out safely, since the tentative clipping had created sufficient space between the aneurysm and the anterior clinoid process to perform the procedure. The proximal neck was observed and tandem clipping was applied to the aneurysm. Intraoperative and postoperative angiography revealed complete disappearance of the aneurysm.

Unique variation of the hepatic artery identified on preoperative three-dimensional computed tomography angiography in surgery for gastric cancer: Report of a case

Hepatic artery injury is one complication associated with surgery for gastric cancer. This complication does not occur frequently, but it can cause serious problems. Anatomical variations of the hepatic arteries are thought to be a factor in such injuries. Recognizing vascular variations before the operation is thus very important. This report presents a case with a rare variation of the hepatic arteries identified on three-dimensional computed tomography (3D-CT) angiography before gastric cancer surgery. Hepatic artery injury was avoided as a result of the recognition of this extremely rare variation. Preoperative 3D-CT angiography is useful for preventing the complications associated with hepatic artery injury during surgery for gastric cancer.

未破裂脳動脈瘤に対するＯｖｅｒｎｉｇｈｔ手術を目標としたＫｅｙｈｏｌｅ ｃｌｉｐｐｉｎｇ術の開発

Forty-eight patients with 52 unruptured aneurysms were treated by 50 keyhole clipping procedures. The 32 middle cerebral artery aneurysms were treated through the pterional keyhole approach using an outer canthal skin incision. The 16 internal carotid artery aneurysms and 4 anterior communicating artery aneurysms were treated through supraorbital keyhole craniotomy via an eyebrow skin incision (Perneczky method). Preoperative three-dimensional computed tomography angiography with the osteotomy technique was used to determine the best location and size for the keyhole in each patient. No scalp hair shaving, drainage placement, or anti-convulsant medication were needed. The mean sizes of the pterional and supraorbital keyholes were 25×23 mm and 29×21 mm, respectively. The outcomes on the modified Rankin Scale were Grade 0 in 46 cases, Grade 1 in 3 cases with frontalis muscle weakness, and Grade 3 in 1 case with lacunar infarction. Most of the patients were discharged on the 2nd or 3rd postoperative day. Keyhole clipping surgery is another treatment option for relatively small unruptured anterior circulation aneurysms and may require only overnight hospitalization.

Anomalous Vertebral Artery at the Extraosseous and Intraosseous Regions of the Craniovertebral Junction

This study examined the extraosseous and intraosseous anomalies of vertebral arteries in patients who underwent surgery of the craniovertebral junction. To describe the usefulness of three-dimensional computed tomography angiography for evaluating vertebral artery anomalies before surgery. Previous studies using catheter angiograms have identified anomalous courses of the vertebral artery at the craniovertebral junction. Studies using computed tomography reconstruction also showed deviation of the vertebral artery groove at the C2 isthmus, demonstrating a risk of vertebral artery injury for C1-C2 transarticular screw placement. These analyses provided us with useful information for identifying anomalies of the vertebral artery, but they could not visualize the artery and its circumferential osseous tissue simultaneously, nor could they analyze the reciprocal anatomy of both tissues. Thirty-one consecutive patients who submitted to surgery at the craniovertebral junction were evaluated before surgery by three-dimensional computed tomography angiography. Eleven of the patients had congenital osseous anomalies at the craniovertebral junction including os odontoideum and ossiculum terminale. Anomalous vertebral arteries at the extraosseous region were visualized by three-dimensional reconstruction images, and the intraosseous deviation of the vertebral artery at the C2 isthmus was evaluated by multiplanar reconstruction images. Extraosseous and/or intraosseous vertebral artery anomalies were detected in 9 cases. Eight of the 9 cases had osseous anomalies at the craniovertebral junction. Abnormal courses of the vertebral artery at the extraosseous region were detected in 4 cases: 2 had fenestration and 2 had persistent first intersegmental artery. Asymmetry of bilateral vertebral arteries was found in 5 cases: the right was dominant in 3 cases and the left in 2 cases. A high-riding vertebral artery at the C2 isthmus was detected in 5 cases. Based on these findings, we modified our surgical approach and the screw placement; consequently, no vertebral artery injury occurred. In patients having osseous anomalies at the craniovertebral junction, the frequency of vertebral artery anomalies at the extraosseous and intraosseous regions is increased. With preoperative three-dimensional computed tomography angiography, we can precisely identify the anomalous vertebral artery and reduce the risk of intraoperative injury to the vertebral artery, in advance.