IVR 会誌 Jpn J Intervent Radiol Vol.19 No.2 2004

State of the Art
Image-Guided Cryotherapy

1.Ultrasound-Guided Cryoablation of Unresectable Liver Cancer
Department of Surgery, Keio University School of Medicine
Go Wakabayashi, Minoru Tanabe, Masakazu Ueda, Motohide Shimazu, Shigeyuki Kawachi, Masaki Kitajima

Although the definition of unresectability varies among institutions, ablative therapy for unresectable liver cancer is widely accepted as a choice of treatment modality. Argon-based cryoablation is newly developed technology with which large tumor and/or multiple tumors can be ablated a effectively using multiple probe freezing, being an optimal ablative device for unresectable liver cancer. Precise targeting is the key factor for ablative therapy. Therefore clear image of real-time monitoring is essential during the procedure. Ultrasound-guided cryoablation is an ideal ablative therapy because it provides clear real-time images. We use guide needle method for ultrasound-guided cryoablation in order to perform precise targeting under clear real-time monitoring. Our preliminary results from 100 cases of cryoablation for unresectable liver cancer show an acceptable local recurrence rate and post-operative morbidity rate. Argon-based cryoablation can be the choice of treatment for liver cancer that is not indicated for other ablative therapy.
Key words
● Hepatocellular carcinoma
● Ablation
● Metastatic liver cancer
● Cryosurgery

2.IPercutaneous Cryoablation for Malignant Lung Tumors Under CT Fluoroscopic Guidance
Department of Diagnostic Radiology, Department of Thoracic Surgery1), Keio University, School of Medicine
Seishi Nakatsuka, Masafumi Kawamura1), Hiroaki Sugiura, Keiko Nakano, Yotaro Izumi1), Koichi Kobayashi1), Masahiro Jinzaki, Subaru Hashimoto, Sachio Kuribayashi

After discussing appropriate image guide and method for percutaneous cryoablation for malignant lung tumors, our preliminary experience under CT fluoroscopic guidance is reported.
All procedures were percutaneously performed under local anesthesia with a multi-detector row CT scanner using intermittent multi-slice CT fluoroscopy. A coaxial technique using a 21-gauge fine needle and an 8 to 11-gauge coaxial needle was applied to penetrate a tumor, and a cryoprobe was inserted into the needle.
Tumors were frozen into iceballs using high-pressure argon and Joule-Thomson effect. Ground glass opacities developed around the cryoprobes while thawing the tumors, indicating injured pulmonary parenchyma.
Thirty-one patients with 51 primary or secondary pulmonary malignancies underwent percutaneous cryoablation. The procedure was well tolerated by all patients. No major complication was observed and minor complications included pneumothoraces(all cases were asymptomatic but a few patients required chest tube placement), bloody phlegm, slight fever and elevation of leukocyte counts.
Our preliminary experience confirms the feasibility, safety and efficacy of percutaneous cryoablation for malignant lung tumors.
Key words
● Cryoablation
● Lung cancer
● Metastatic lung tumor
● CT fluoroscopyAbstract

3.MRI-Guided Percutaneous Cryoablation of Hepatocellular Carcinoma
Department of Radiology, Hokkaido University Hospital
Tadashi Shimizu, Akihiro Sawada, Yoshinao Kodama, Yusuke Sakuhara, Daisuke Abo, Kazuo Miyasaka

: To report the results of MRI-guided percutaneous cryoablation for hepatocellular carcinoma(HCC).
MATERIALS AND METHODS : Using an MR-compatible cryoablation system, MRI-guided percutaneous cryoablation is performed. Treatments are guided and monitored with an open MRI.
RESULTS : 16 HCCs in 15 patients were treated. The average age was 61.4 years. The maximum diameters of tumors ranged from 1.2 to 4.5b, average 2.5b. Superparamagnetic iron oxide was administered intravenously in 15 cases for 16 treatments to delineate the tumor clearly. In all cases, cryoprobes were located safely and accurately using MRI guidance. Follow-up periods ranged from 4.5 to 27 months, average 13.8 months. There were local recurrences in 3 cases. In one case, the frozen area was not large enough. The tumor was not detected clearly in the second case. In the third case, recurrence occurred just beside the portal vein. Complications were as follows. All patients experienced mild fever. There was 1 case of pneumothorax, one patient suffered hemothorax and transitory pleuritis occurred in 2. In one case the frozen area ruptured 4 months after cryoablation. It was an aseptic necrosis and cured by percutaneous drainage.
CONCLUSION : MRI-guided percutaneous cryoablation is a safe and effective modality for HCC.
Key words
● Cryoablation

4.Novel Minimal Invasive Therapy for Uterine Fibroids : MR-Guided Percutaneous and Transvaginal Cryotherapy
Department of Radiology, Department of Gynecology1), Jikei University School of Medicine, Kashiwa Hospital
Takuji Mogami, Junta Harada, Shigemitsu Kobayashi1), Makoto Yasuda1)
Department of Radiology, Jikei University School of Medicine
Michiko Dohi, Kunihiko Fukuda

Tissue damage through the application of low temperature is presumably the oldest thermal ablation method in medicine. The important characteristics of cryotherapy in comparison with other thermal ablation methods are the simple control of ice formation, the analgesic effect of cold, and the absence of undesirable toxic products. Recently, argon-based cryosystem with an MRI compatible needle-shaped cryoprobe has been developed that permits a percutaneous or transvaginal approach.
MRI has the capability to depict the iceball with high accuracy and excellent contrast between frozen and non-frozen areas by an extreme decrease in T1 and T2 relaxation times.In addition, MRI provides near real-time images for probe insertion. As a consequence, the combination of argon-based cryosystem and MRI is an effective method for treating tumors.
Using an argon-based MR-compatible cryosystem, we performed percutaneous and transvaginal cryotherapy for 12 uterine fibroids. All procedures were safely and accurately carried out without significant complications, and the results of treatment were sufficient. MR-guided cryotherapy proved to be a feasible procedure for treatment of uterine fibroid.
Key words
● Cryotherapy
● Percutaneous procedure
● Uterine fibroid

5.MRI-Guided Percutaneous Cryoablation for Renal Cell Carcinoma
Department of Radiology, Hokkaido University Hospital
Akihiro Sawada, Tadashi Shimizu, Yoshihisa Kodama, Yusuke Sakuhara, Daisuke Abo, Kazuo Miyasaka

The standard treatment of renal cell carcinoma(RCC) is radical nephrectomy. Recently, nephron-sparing approaches have been accepted because of the ability to completely excise the tumor without loss of the uninvolved renal portion or compromise of the cancer resection. Renal cryoablation is a successful nephron-sparing treatment alternative for slected patients with small renal tumors. Percutaneous renal tumor cryoablation with MRI guidance has been proven to be technically feasible with minimal morbidity.
An open-type MR machine was used for the guidance of percutaneous insertion of MR compatible cryoprobes and for monitoring of the freezing process. An argon-based cryosystem was used. Eleven RCCs in 6 cases were treated. Nine tumors were ablated completely ; partial ablation was undertaken in 1 case with 2 tumors to avoid possible injury of adjacent organs. The age of these patients ranged from 35 to 72 years(mean, 55.8 years). The maximum diameters ranged from 1.5b to 4.8b(mean, 3.1b). Successful treatment was defined as the lack of tumor enhancement with intravenous contrast material on MRI or CT. Mean follow-up was 20.1 months(range 1.4 to 28.4). There was no residual viability detected in 7 tumors. Serum creatinine remained essentially unchanged before and after the cryoablative procedure.
MR-imaging guided percutaneous cryoablation may be an additional treatment option for RCC.
Key words
● Cryoablation
● Renal tumors
● Magnetic resonance (MR), guidance
● Percutaneous procedure

Original Article
CT-Guided Drainage of Postoperative Abscess : Analysis of Factors Affecting Availability and Duration of Drainage
Department of Radiology, Fuchu Keijinkai Hospital
Toshitaka Tsukiyama
Department of Radiology, Mitsui Memorial Hospital
Rei Ishii, Hozumi Fukuda, Kenji Ibukuro

 Purpose : We analyzed factors affecting availability and duration of CT-guided drainage for postoperative fluid collections.
 Materials and Methods : We treated 117 fluid collections (100 cases) with CT-guided drainage within 2 months after abdominal or retroperitoneal surgery. For those cases, we evaluated the availability of CT-guided drainage by multivariate analysis. Then, we analyzed the duration of drainage by survival analysis.
 Results : General availability was 73.5%, and median periods of drainage were 22 days. The significant factor for availability of CT-guided drainage was the location of primary disease (Logistic regression analysis : p<0.05). In cases in which the location of the primary disease was not upper gastrointestinal tract, the availability of CT-guided drainage was 64.8%. Patient’s age and coexistence of postoperative complications affected the periods of drainage (proportional hazard model : p<0.05). In cases in which the patient’s age was over 70 years and postoperative complications had arisen, median periods of drainage were 30 days and 26 days respectively. No other factors were significant (p>0.05).
 Conclusion : CT-guided drainage is an effective alternative treatment for postoperative abscess. However, location of primary disease affects the availability of CT-guided drainage. Furthermore, high age(over 70 years old) and coexistence of postoperative complications prolong the duration of drainage.
Key words
●Postoperative abscess

Original Article
Bleeding from Brachial Artery Representing Acute Painful Swelling of the Upper Arm
Department of Radiology, Shimotsuga General Hospital
Hisao Toei
Department of Radiology, Jichi Medical School and Hospital
Yoshiaki Watanabe
Shiki City Hospital
Makoto Furuse

 We reviewed four patients with acute painful swelling of the upper arm as a result of bleeding from the brachial artery.
In two patients, hemorrhages were caused by iatrogenic brachial artery puncture(one for emergency hemodialysis, the other for blood gas analysis).
The other patients had systemic(vascular) disease; one had polyarteritis nodosa, and the remaining one had neurofibromatosis type 1.
To avoid iatrogenic hemorrhage, patients on anticoagulation therapy, hemodialysis or those with various vascular disease such as vasculitis should be observed carefully during and after brachial artery puncture.
Although the bleeding site was located in the lower brachial artery(cubital portion), swelling was more prominent at the upper arm than the lower arm.
We considered that the factor contributing to this fact was the bicipital aponeurosis lying anterior to the brachial artery at the level of the cubital joint.
Transcatheter embolization of ruptured pseudoaneurysm using microcoils was useful in two patients.
Key words
●Brachial artery
●Upper arm swelling
●Transcatheter embolization

Original Article
Superselective Embolization of the Vasa Recta for Acute Colonic Hemorrhage : Utility of Colonoscopic Clip Placement
Department of Radiology, Department of Gastroenterology1), Akita Red Cross Hospital
Joichi Heianna, Takaharu Miyauchi, Hiroo Yamano1), Satoshi Maeda1)
Hiroo Matushita1), Yasushhi Imai1)
Department of Radiology, Akita University of Medicine
Etuko Tate, Manabu Hashimoto, Jiro Watarai

 Purpose : We evaluated the usefulness of superselective embolization in a group of patients with acute colonic hemorrhage.
 Materials and Methods : Subjects were seven patients who underwent superselective embolization for acute colonic hemorrhage that could not be stopped endoscopically. Hemorrhage was caused by diverticular disease in six patients and by polypectomy in one patient. Microcatheters were used in all procedures, and embolization was performed at the level of the vasa recta or the marginal artery. When angiography did not show extravasation of contrast medium, we performed superselective embolization at the vasa recta near a clip placed on the bleeding point by colonoscopy. The following embolization materials were used : Gelfoam particles only(n=2),microcoils only(n=2), Gelfoam and microcoils(n=3).
 Results : Technical success and immediate hemostasis were achieved in all patients.One patient rebled a month after TAE but was treated with endoscopic intervention. Prolonged clinical success was achieved in 86%(6/7) of patients. No signs of bowel infarction or stenosis were seen after superselective embolization.
 Conclusion : Superselective embolization for acute colonic hemorrhage is a very effective procedure. The advantages of this technique are minimization of the embolized area and direct control of hemostasis.
Key words
●Colonic hemorrhage
●Vasa recta

Case Report
A Case of Partial Renal Ablation by
Transcatheter Arterial Embolization with Absolute Ethanol for a Urinoma Due to Renal Injury
Department of Radiology, Chugoku Rosai Hospital
Masaki Ishikawa, Shoko Ito, Makoto Iida, Yoshiko Koohata
Department of Radiology, Hiroshima University School of Medicine
Naoyuki Toyota, Akira Naito, Hideaki Kakizawa, Katsuhide Ito

 We report a case of partial renal ablation treated by transcatheter arterial embolization by absolute ethanol for a urinoma due to renal injury. A 14-year-old man sustained blunt trauma at the right lateral abdomen. Although CT revealed right kidney injury, conservative therapy was done. Ten days later, a urinoma developed around the separated lower portion of the kidney. This urinoma also caused hydronephrosis at the upper portion of the kidney. We put a 6F occlusion balloon catheter into the right renal artery and advanced a 3F microcatheter into the ventral branch by the coaxial system. Total amount of 3p absolute ethanol was injected into the lower part of kidney through the catheter. No complications occurred. Ten days later, the urinoma decreased. Fifty days later, the unioma disappeared. Renal dysfunction did not develop. Partial renal ablation was safe and effective for a urinoma due to renal injury in this particular young patient.
Key words
●Renal ablation
●Transcatheter arterial embolization

Case Report
A Case of Iatrogenic Common Femoral Artery Pseudoaneurysm Successfully Treated by Percutaneous Ultrasound-Guided Thrombin Injection
Department of Radiology Department of Medicine1), Saiseikai Shiga Hospital
Kentaro Akazawa, Tetsuya Katsumori, Tadashi Mihara, Motoo Tanaka1)
Department of Radiology, Kyoto Prefectural University of Medicine
Takuji Yamagami, Tsunehiko Nishimura

 A 57-year-old man with hepatocellular carcinoma underwent transcatheter arterial embolization via the right common femoral artery. Subsequently he developed right groin hematoma, worsening pain at the puncture site and right leg edema. Ultrasound showed an iatrogenic pseudoaneurysm measuring 1.5b at the right common femoral artery. As contrast-enhanced CT showed pseudoaneurysm and a small thrombosis in the right external iliac vein, he was given anti-coagulant therapy. Repeat ultrasound-guided compression repair failed to treat the pseudoaneurysm. Therefore, we performed percutaneous ultrasound-guided thrombin injection without complication. Contrast-enhanced CT obtained 5 days after the treatment did not show any recurrence of the pseudoaneurysm. We think percutaneous ultrasound-guided thrombin injection is a safe and effective treatment of post-catheterization pseudoaneurysm.
Key words