IVR 会誌 Jpn J Intervent Radiol Vol.19 No.1 2004

State of the Art
IVR for Deep Vein Thrombosis and Pulmonary Thromboembolism

1.Pathogenesis and Epidemiology of Deep Vein Thrombosis and Pulmonary Thromboembolism
First Department of Internal Medicine, Mie University School of Medicine
Norikazu Yamada

 Venous thromboembolism(VTE) is a complex vascular disease with multifactorial pathogenesis that results in two major clinical manifestations, deep vein thrombosis and pulmonary thromboembolism. Deep vein thrombosis mostly arises in the deep vein of the calf and spreads upwards. Pulmonary thromboembolism occurs as a complication of deep vein thrombosis. The factors traditionally implicated in the pathogenesis of venous thrombosis are venous stasis, endothelial injury and hypercoagulability.
 In epidemiology, VTE is very common in Western countries but is considered to be rare in Japan. Recently VTE has been rapidly increasing in Japan and the frequency is almost equal to that of the Western countries in the patients with highest risk factors of VTE.
Key words
● Deep vein thrombosis
● Pulmonary thromboembolism
● Risk factor
● Epidemiology

2.Interventional Radiology for the Treatment of Deep Venous Thrombosis
-Trans Femoral Approach-
Department of Radiology and Center for Advanced Medical Technology, Nippon Medical School
Hiroyuki Tajima, Satoru Murata, Kazuo Ichikawa, Yutaka Abe, Yasushige Komada,
Ken Nakazawa, Tsuyoshi Fukunaga, Shirou Onozawa, Ryuusuke Murakami, Jian Wang, Minoru Machida, Tatsuo Kumazaki

 Catheter directed thrombolysis for the treatment of acute deep vein thrombosis has been proven effective in clearing acute deep venous thrombosis, which may allow the preservation of venous valve function and prevention of subsequent venous occlusive disease. The use of adjunctive mechanical thrombectomy and clot aspiration provides comparable procedural success and may reduce the required thrombolytic dose and infusion duration. Clinical usefulness of trans-femoral venous approach is also stressed in this article.
Key words
● Thrombolysis
● Thrombosis, venous
● Femoral veins
● Thrombectomy

3.IVR for Deep Vein Thrombosis -Popliteal Approach-
Department of Radiology, Wakayama Medical University
Department of Internal Medicine, Kihoku Hospital, Wakayama Medical University*

Hiroki Minamiguchi*, Shinya Sahara, Motoki Nakai, Katsuyuki Yamada,
Nobuyuki Kawai, Hirohiko Tanihata, Masashi Kimura, Morio Sato

 The therapeutic goals for acute deep vein thrombosis(DVT) include prevention of pulmonary embolism(PE), restoration of unobstructed blood flow through the thrombosed segment, prevention of recurrent thrombosis, and chronic venous insufficiency so-called post-thrombotic syndrome.
 Traditional therapy for iliofemoral DVT has been systemic heparin followed by warfarin with compression stockings. Recently, there is growing evidence to support early intervention with thrombolysis in selected patients with acute and chronic DVT. Early thrombus removal is a logical approach to improve the long-term outcome of DVT. Patients can be treated aggressively with catheter-directed thrombolysis and mechanical thrombectomy followed by insertion of stents, with low morbidity and mortality. Especially we are encouraged to do endovascular procedures via the popliteal vein. Post-procedural care is also important. Long-term results are a waited but, certainly in the short-term, results are encouraging.
 With the growing interest in catheter-directed thrombolysis for iliofemoral DVT, iliac vein compression syndrome as an anatomic risk factor for left-sided iliofemoral DVT is being identified with increasing frequency.
 The focus of this article is to provide our understanding of the most satisfactory imaging method, approaches to intervention, use of stents, and postoperative care for the treatment of DVT.
 As the goal of thrombolytic therapy is the prevention of chronic sequelae from DVT, interventional radiologists need to make certain that all the resources and energies expended in this effort do not fall short of this goal.
Key words
● Deep vein thrombosis
● Catheter-directed thrombolysis
● Mechanical thrombectomy
● Iliac vein compression syndrome

4.Inferior Vena Cava Filter
Department of Radiology, Tokyo Saiseikai Central Hospital
Kenichi Kodera, Tsuneyuki Takashina

 An inferior vena cava filter is an effective mechanical device to prevent pulmonary embolism . Indications for the filter placement are contraindication to anticoagulation and failure of anticoagulation to prevent pulmonary embolism. Because inferior vena cava filter increases the rate of recurrent deep vein thrombosis, we should comply with the strict indication. Recently temporary and retrievable filters have been developed rapidly, but their indications are not well established yet.
Key words
● IVC filter
● Pulmonary thromboembolism
● Deep vein thrombosis

5.Recent Advance in Interventional Radiology for Acute Massive Pulmonary Thromboembolism
Department of Radiology and Center for Advanced Medical Technology,
First Internal Medicine and Intensive Care Unit1), Nippon Medical School

Hiroyuki Tajima, Satoru Murata, Ken Nakazawa, Kazuo Ichikawa
Yutaka Abe, Tsuyoshi Fukunaga, Tatsuo Kumazaki, Tsuyoshi Yamamoto1)
Morimasa Takayama1), Keiji Tanaka1), Teruo Takano1)

 Recent advance in Interventional Radiology for the treatment of acute massive pulmonary thromboembolism was described.
 Patients who have a large volume of clots and are hemodynamically compromised, or persistently hypoxemic should be considered for more aggressive intervention.
The procedures include :(1) local infusion of urokinase or recombinant tissue plasminogen activator(2) thrombectomy with a modified pigtail catheter(3) clot aspiration with a PTCA guiding catheter.
 This hybrid treatment by mechanical fragmentation using a rotating pigtail catheter with local fibrinolysis and manual clot aspiration achieved a rapid and safe improvement of the hemodynamic situation in patients with acute massive pulmonary thromboembolism. This therapy appears to be especially useful in patients at high risk of right ventricular failure, and is a minimally invasive alternative to surgical embolectomy.
Key words
● Embolism, pulmonary
● Thrombectomy
● Catheters and catheterization
● Thrombolysis

6.Medical Therapy of Deep Venous Thrombosis and Pulmonary Thromboembolism
Department of Orthopaedic Surgery, Takarazuka Dai-ichi Hospital
Satoru Fujita

 Patients with venous thromboembolism(VTE) should be treated with unfractionated heparin, at first bolus dose of intravenous 5000U, then intravenous 1400U/h or intravenous 80U/oh or subcutaneous 17500U twice daily, with an adjusted APTT(activated partial thromboplastin time) between 1.5 to 2.5 control. Warfarin should also be initiated as soon as possible, with an adjusted INR(international normalized ratio) between 2.0 to 3.0 control. Duration of unfractionated heparin therapy should be at least 4 to 5 days, and unfractionated heparin can be discontinued when the INR has been in the therapeutic range(2.0 to 3.0). Duration of warfarin therapy for patients with a first episode of VTE should be 6 weeks to 3 months if they have a reversible risk factor and 3 months to 6 months if they have idiopathic VTE. Warfarin should be continued for a longer period in patients with recurrent VTE, or continuing risk factors such as cancer. Thrombolytic therapy is indicated in patients with deep venous thrombosis or massive pulmonary embolism, as shown by shock and/or hypotension. Dose of urokinase should be between 240000U to 960000U daily, and duration of urokinase therapy should be 5 to 7 days. The rate of major bleeding in patients treated by thrombolytic therapy was two times higher than that by unfractionated heparin therapy.
Key words
● Anticoagulation therapy
● Deep venous thrombosis
● Pulmonary thromboembolism

Case Report
Three Cases of Celiac Trunk Stenosis by Median Arcuate Ligament Compression
Department of Radiology, Division of Medical Intelligence and Informatics,
Programs for Applied Biomedicine, Graduate School of Biomedical Science, Hiroshima University
Department of Radiology, Chugoku Rousai Hospital*

Hideaki Kakizawa, Naoyuki Toyota, Akira Naito*
Kazushi Marukawa, Katsuhide Ito

 It is important to make a correct diagnosis of median arcuate ligament compression (MALC) when the celiac trunk is stenosed. We report three cases of celiac trunk stenosis due to MALC. Angiographic characteristics of MALC are the degree to which the stenosis usually changes, generally increasing with expiration and decreasing or disappearing with inspiration. A 35-year-old female who had abdominal pain underwent angiography, which diagnosed MALC syndrome. A 49-year-old male who had MALC underwent chemoembolization for hepatocellular carcinoma. A 5F catheter was easily introduced into the proper hepatic artery in full inspiration. A 64-year-old male who had MALC underwent implantation of a 5F catheter port system for metastatic liver tumors. This catheter was occluded probably due to blockade of hepatopetal flow. For the MALC cases, the intervention should be performed adequately considering hemodynamics.
Key words
●Median arcuate ligament
●Celiac trunk

Case Report
A Case of a Ruptured Accessory Middle Colic Artery Aneurysm with Regard to Polyarteritis Nodosa
Department of Radiology, Okayama Central Hospital
Hiroshi Shirai, Hiromi Miyazaki
Department of Diagnostic Radiology, Kawasaki Medical School
Shigeki Imai, Yasumasa Kajihara

 Polyarteritis nodosa(PAN) is a systemic necrotizing vasculitis affecting small and medium-sized muscular vessels. The diagnosis is difficult so that treatment is often delayed. The prognosis of untreated PAN is poor. While, in a small percentage of the patients, aneurysm rupture in an organ or retroperitoneal branch may be the first clinical evidence of the disease. This arterial complication causes fatal hemorrhage. A report is presented here on a rare case with ruptured visceral aneurysm, which was diagnosed to be caused by PAN angiographically. For this case, emergency TAE was successfully performed.
Key words
●Polyateritis nodosa
●Transcatheter arterial embolization

Case Report
Usefulness of Contrast-Enhanced 3D-MRA to Detect Bleeding Portion Before Trans-Catheter Arterial Embolization of Post Traumatic Pseudoaneurysm
Department of Radiology, Kumamoto Red Cross Hospital
Takeshi Sugahara, Ryuichi Saito, Ryuji Murakami
Department of Radiology, and Orthopedics1), Kumamoto Orthopedic Hospital
Osamu Shimomura, Nobuyuki Hirai1), Takuya Ikuta1)

 We report a rare case of a patient with pseudoaneurysm of the lateral femoral circumflex artery after blunt trauma. The location of hemorrhage was clearly demonstrated by contrast-enhanced three-dimensional MR angiography. Hemorrhagic portion was treated successfully by transcatheter embolization.
Key words
●Transcatheter embolization
●Contrast-enhanced 3D-MRA
●Deep femoral artery

Technical Note
Percutaneous Implantation of the Catheter-Port System for Hepatic Arterial Infusion Chemotherapy by Left Supraclavicular Approach
Department of Radiology, St. Marianna University School of Medicine
Kenji Takizawa, Yoshikazu Hoshikawa, Eimei Okamoto, Masao Koyama
Shunsuke Nakaji, Kyouko Nozaki, Kazunori Kuroki, Yasuo Nakajima

 Percutaneous implantations of the catheter-port systems(CPS) for hepatic arterial infusion chemotherapy by left supraclavicular approach were performed in three patients whose left subclavian arterial pulse was palpable there. In two of them, the conventional axillary approach was not feasible because of rahent factors. The connected ports were also subcutaneously implanted at left supraclavicular fossa. These procedures succeeded without any complications in all the patients. There were no CPS-related complications during the observation periods. We introduce the techniques of these procedures.
Key words
●Arterial infusion chemotherapy
●Liver cancer
●Implantable port