IVR 会誌 Jpn J Intervent Radiol Vol.18 No.4 2003

State of the Art
Emergency Interventional Radiology

1. Emergency Interventional Radiology : Hepatic Injury
Departments of Radiology & Surgery1)
Ootawara Red Cross Hospital
Kimiyoshi Mizunuma, Atsuo Shimizu, Kohki Kato, Nobuyuki Tateno Tetsu Amemiya1) , Junichi Matsui1)

Transcatheter Arterial Embolization(TAE) against hepatic injury is very effective. Though cases with caval or large hepatic vein injury are contraindicated, in most cases with hepatic injury, TAE is the first choice as the therapeutic procedure.
To select the conservative therapy, injury estimation and follow-up by imaging, and interventional procedures(TAE & percutaneous drainage) are essential.
Key words
● Hepatic injury
● Interventional procedure
● Transcatheter Arterial Embolization

2. Embolization for Splanchnic Aneurysms and Pseudoaneurysms
Department of Radiology, National Defense Medical College
Yukihiro Hama, Tatsumi Kaji, Shoichi Kusano

Splanchnic aneurysm and pseudoaneurysm are a heterogeneous group of clinically significant illnesses that have become recognized with increasing frequency because of the more common imaging of the abdomen. Considerable knowledge exists regarding some of these diseases, whereas the understanding of others is anecdotal. It is important for interventional radiologists to understand the diagnosis and treatment strategies. Current management strategies, pitfalls, and follow-up methods are discussed. Emphasis is placed on the role of nonsurgical management with careful follow-up with use of the plain x-ray films after coil embolization.
Key words
● Splanchnic aneurysm
● Therapeutic embolism
● Interventional procedures

3. Gastrointestinal Arterial Hemorrhage ; Diagnosis and Radiological Intervention
Department of Radiology, Shiga University of Medical Science
Akira Furukawa, Michio Yamasaki, Toyohiko Tanaka, Norihisa Nitta, Ryutaro Takazakura, Masaru Sakoda, Kiyosumi Maeda, Masashi Takahashi, Kiyoshi Murata
Department of Radiology, Kouseikai Takeda Hospital
Shuzo Kanasaki
Department of Radiology,Shin Kori Hospital
Kenji Yokoyama
Department of Radiology, Omi Kusatsu Hospital
Tamotsu Nagata
Department of Radiology, Saiseikai Noe Hospital
Yasuo Onaka
Department of Radiology, Koka Public Hospital
Tsutomu Sakamoto

Gastrointenstinal hemorrhage can be acute continuous, intermittent or chronic and requires interventional or surgical management in around 25% of cases. When a site and cause of hemorrhage is not determined by endoscopy, the diagnosis is challenging. Radionuclide bleeding scan are indicated in a patient with acute intermittent type of gastrointestinal hemorrhage and angiography is applied in a patient with more active continuous hemorrhage. Vasopressin infusion and embolotherapy are two major radiological interventional techniques for acute gastrointestinal hemorrhage. Vasopressin infusion is technically less difficult and causes bowel infarction infrequently. However, a relatively high rate of rebleeding and systemic sequelae such as hypertension, coronary ischemia, pulmonary edema and peripheral acrocyanosis are problematic. Embolotherapy provides instant and definite hemostasis and avoids problems of rebleeding, catheter dislodgement and cardiovascular complications. Attention should be paid to avoid bowel infarction that may occur with inappropriate subselective embolization, particularly, at the lower gastrointestinal tract. With the advent and development of a microcatheter system, embolotherapy is now feasible for both upper and lower gastrointestinal hemorrage. It is considered a safe and effective primary interventional approach to gastrointestinal hemorrhage at any site. Vasopressin infusion therapy should be indicated in patients where embolotherapy is not feasible or has failed.
Key words
● Gastrointestinal hemorrhage
● Vasopressin
● Embolization
● Angiography
● Nuclear bleeding scan

4. Acute Superior Mesenteric Artery Occlusion : CT Appearance and Thrombolytic Therapy
Department of Radiology and Surgery1), Kyoto Second Red Cross Hospital
Masato Fujita, Hiroyuki Hata, Hiroko Maeda, Masato Yamashita
Naoki Kakihara1), Keigo Miyata1), Ryoji Iizuka1), Osamu Ikawa1), Atsushi Takenaka1)

The mortality rate in patients with acute occlusion of the superior mesenteric artery(SMA) remains high. It is difficult to make a diagnosis at an early stage of this disease, because specific clinical signs are not present until bowel necrosis has occurred. Computed tomography(CT) is useful in the diagnosis of acute abdomen, but is not able to reveal signs of the early stage of acute occlusion of the SMA and viability of the ischemic bowel wall. Most patients with this disease are treated by surgery, but when signs of bowel necrosis are not present, local thrombolysis may be selected as an effective therapy. If the thrombus is successfully lysed, it is difficult to decide whether surgical resection of the affected intestine is necessary in order to obtain cure. When signs of bowel necrosis are detected by checking symptoms and laboratory data every few hours, surgery should be undertaken.
We treated six patients with acute occlusion of the SMA in the last three years. Five of them underwent local thrombolysis. We performed angiographic CT after successful lysis in the most recent case, while contrast material was infused into the SMA. Because enhancement of the mucosal side of the bowel wall was seen on angiographic CT, we could be confident that the bowel was viable.
Key words
● Mesenteric ischemia
● Superior mesenteric artery occlusion
● CT
● Thrombolysis

5. Emergent Interventional Radiology for the Treatment of Pelvic Trauma
Department of Radiology and Center for Advanced Medical Technology, Nippon Medical School
Hiroyuki Tajima, Satoru Murata, Kazuo Ichikawa, Yutaka Abe, Ken Nakazawa, Tsuyoshi Fukunaga
Shirou Onozawa, Jian Wang, Ryuusuke Murakami, Hiroshi Kawamata, Tatsuo Kumazaki

This review article focuses on the technical aspects of emergent Interventional Radiology for the treatment of pelvic trauma. The important role of hemostatic transcatheter arterial embolization of ruptured internal iliac artery for the treatment of massive retroperitoneal hemorrhage associated with severe pelvic fracture is emphasized. The anatomical understanding of this area and functional evaluation of hemodynamics are also very important for the definition of clinical indication of this therapy. The contribution of recent advancement of angiographic catheters, embolic materials, and medical equipment for this treatment is stressed, and limitations and side effects of this procedure are also discussed.
Key words
● Trauma
● Catheters and catheterization
● Interventional procedure

Original Article
The Program for Standardization of Postangiographic Care after Transfemoral Angiography
Division of Radiology1), Division of Public Health and Preventive Medicine2), Department of Diagnostic Information and Socioenvironmental Medicine, Yamagata University School of Medicine
Akiko Shibata1), Yukio Sugai1), Tsugio Honma1), Michito Adachi1
Akira Fukao2), Takaaki Hosoya1)

 Uur purpose is to define a standard of postangiographic care after cerebral and thoraco-abdominal transfemoral angiography with 4 or 5 French catheters. We performed the following process ; 1) investigate the association of duration of bedrest and the incidence of bleeding complication in present state using medical records, 2) review previous studies related to early ambulation following angiographic procedure and those bleeding complications, 3) compare the frequency of bleeding complications and patient’s comfort among three different bedrest time groups. On the basis of the investigation of our present care and the results of the previous studies, we conducted a non-randomized comparative study to compare the incidence of bleeding complications between the present ambulation(8 hours ; 4 hours bedrest with pressure dressing and additional 4 hours bedrest without pressure dressing) and the interventional ambulation(4 hours ; 3 hours bedrest with pressure dressing and additional 1 hour bedrest without pressure dressing). As a result, we found that the early ambulation did not increase bleeding complications at least, while the incidence of post-procedural lumbago decreased. In conclusion, we achieved the standardization of post angiographic care by mutual consent of our colleagues through the detailed preparations.
Key words
●Early ambulation
●Pressure dressing

Original Article
Long-Term Outcomes of a Totally Implantable Central Venous Access System in the Forearm
Department of Radiology, Kochi Municipal Central Hospital
Nobuaki Tsuboi, Sojiro Morita, Tomoaki Yamanishi
Department of Radiology, Kochi Medical School
Satoshi Morishita
Department of Radiology, Kochi Hata Kenmin Hospital
Yoshihiro Noda

 In this study, we describe large-scale studies evaluating long-term results of a totally implantable central venous access system in the forearm. 1329 patients ; 781 males, 548 females, an average age of 64.0(11-99 years)were implanted with this system. The main purpose of this system was to administer anti-cancer agents. Technical success was achieved in 1345 of 1350 procedures(99.6%). The median follow up period was 92 days(1 to 2131 days) after the placement.
Complications were observed in 201 cases(14.9%) ; drip insufficiency in 59(4.4%), periportal infection in 39(2.9%), phlebitis in 30(2.2%), system occlusion in 22(1.6%), subcutaneous injection in 16(1.2%), system breakage in 12(0.9%), thrombosis of the subclavian vein in 12(0.9%), sepsis in 5(0.4%), port inversion in 3(0.2%), and catheter migration into azygos vein in 3(0.2%).
We conclude that this system is safe and efficacious with acceptable complications, and that it is an attractive method compared with other available methods of totally implantable central venous access systems.
Key words
●Central venous access
●Implantable port

Case Report
IOcclusion of Intrahepatic Port-systemic Venous Shunt by Balloon-occluded Retrograde Transvenous Obliteration(B-RTO)
-A Case Report of Chronic Recurrent Hepatic Encephalopathy-
Department of Radiology, Hidaka General Hospital
Motoki Nakai
Department of Radiology, Naga Hospital
Mitsunori Masuda
Department of Radiology, Mimihara General Hospital
Nozomu Takeuchi
Department of Radiology, Wakayama Medical University
Masako Maeda, Masaki Terada, Morio Sato

The case is a 68-year-woman who was hospitalized with hepatic encephalopathy. Enhanced CT and PTP(Percutaneous transhepatic portography) revealed intrahepatic port-systemic venous shunt(PV shunt) between the left branch of the portal vein(P3) and left hepatic vein. We performed B-RTO(Balloon-occluded Retrograde Transvenous Obliteration) via the left hepatic vein. After B-RTO, the P-V shunt disappeared, NH3 decreased, and hepatic encephalopathy disappeared. We observed no decrease in liver function or complications. B-RTO is effective for P-V shunt(hepatic encephalopathy).
Key words
●Intrahepatic port-systemic venous shunt
●Balloon-occluded Retrograde
Transvenous Obliteration(B-RTO)
●Hepatic encephalopathy

Case Report
A Case Report of Multinodular Hepatocellular Carcinoma with Splenic Metastasis
Department of Radiology, Sapporo Medical University
Kazunori Aratani, Kazumitsu Koito, Takeshi Ichimura, Naoki Hirokawa
Masato Hareyama
Radiation Oncology, Imaging and Diagnosis, Sapporo Medical
University Graduate School of Medicine
Mutsumi Nishida, Masato Haruyama

 We report a case of multinodular hepatocellular carcinoma(HCC) with splenic metastasis. A seventy-eight-year-old man with general malaise and appetite loss was transferred to our hospital for further evaluation. The CT showed multiple hepatocellular carcinoma nodules in the liver and spleen. The patient underwent arterial infusion chemotherapy using an infusion pump via both the hepatic and splenic arteries, as well as radiofrequency ablation for the hepatic tumor. These treatments resulted in a complete response, which has been maintained for 17 months after the treatment. Although a case of multiple nodular HCCs with distant metastasis to the spleen is very rare and usually represents end-stage disease, we stress that interventional treatments may be an option for obtaining a long survival even in such an advanced condition.
Key words
●Hepatocellular carcinoma
●Splenic metastasis
●Arterial infusion chemotherapy

Case Report
A Case of Huge Renal Artery-to-IVC Fistula Treated by Transcatheter Arterial Embolization with Detachable Coils
Department of Radiology, Akita Red Cross Hospital
Department of Radiology2), Second Internal Medicine3), Akita University
Joichi Heianna1), Manabu Hashimoto2), Takaharu Miyauchi1), Hiroyuki Watanabe3)
Mamoru Miura3), Jiro Watarai2)

 We reported a case of a huge renal artery-to-inferior vena cava(IVC) fistula that was successfully treated by transcatheter arterial embolization(TAE) with two detachable coils twisted around each other. A65-year-old woman, who had undergone nephrectomy for right renal tuberculosis 25 years ago, was admitted with clinical symptoms of heart failure. Computerized tomographic scan showed a large aneurysm arising from the remnant right renal artery. Angiography revealed a high-flow renal artery-to-IVC fistula. TAE was performed for occlusion of the fistula. We placed two detachable coils twisted around each other to make a frame in the right renal artery. Then, we placed some small coils for compact occlusion. The clinical course after embolization was satisfactory.
Key words
●Renal artery-to-IVC fistula
●Transcatheter arterial embolization
●Detachable coil