Jpn J Intervent Radiol Vol.21 No.1 2006

State of the Art
Basic Knowledge about Medicalreimbursement System and Diagnosis Procedure Combination in the Field of Interventional Radiology

1.Fundamental Knowledge of Medical Insurance for Interventionalists
Department of Radiology, Ohtawara Red Cross Hospital
Kimiyoshi Mizunuma

Almost all medical services in Japan are covered by the national health insurance. Accordingly, Japanese medical doctors have to know about the medical insurance system, total amount & patient payment of medical acts, contents of outlays, etc. In this paper, practices of the medical insurance in interventional radiology, and the activities of the Japanese Society of Interventional Radiology regarding the medical insurance system are introduced.
Key words
● Socioeconomic issue
● Medical insurance system
● Interventional Radiology

2. A Study of DPC and Future Hospitals in Japan Compared with DRG/PPS
Daiyukai General Hospital, Daiyukai Medical Foundation
Shinichi Ito, M.D., Ph.D., CEO & Chairman

The Federal Government of Japan introduced the DPC (Diagnosis Procedure Combination) as an ace in the hole of medical reimbursement system reform.
I considered how it would affect Japanese hospitals in the future, compared to the DRG/PPS (Diagnosis Relating group/Prospective Payment System) which is already used in the United States.
DPC is a useful way of hospital management and using it is a revolutionary reform in the Japanese reimbursement system.
However, it has numerous drawbacks, such as the range of comprehensive adaptation, the treatment of expensive material, making the data detailed and so on.
We need a lot more study and reform.
Key words
● Medical reimbursement

3. Management of DPC (Diagnosis Procedure Combination) System for IVR in University Hospital
Department of Radiology, Kawasaki Medical School
Department of Medical Professions, Kawasaki Medical School Hospital1)
Shigeki Imai, Shigeru Watanabe, Takenori Yamashita, Tsutomu Tamada, Atsushi Uechi1)

The DPC (Diagnosis Procedure Combination) system was introduced from the summer of 2003 in Kawasaki Medical School hospital. With the introduction of this DPC system, allover hospitalization medical expense was slightly increased.
When the IVR and surgical operation are compared, hospitalization period of the IVR is shorter. Consequently, this system and the IVR affinity are good. It is important to minimize the complication rate of the IVRs to deal with this DPC problem.

Key words
● DPC(Diagnosis Procedure Combination)
● University Hospital

4. Use of DPC(Diagnosis Procedure Combination)in the Field of Interventional Radiology
Department of Radiology, Surgery1) and Director2), Nikko Memorial Hospital
Masahiro Shinohara1, Yasushige Tsuji1, 2), Takafumi Mochizuki, Masayoshi Tomita

The DPC method of reimbursement for medical fees has been used in our hospital on an experimental basis from April 2004. For the most part, there were no problems in the field of Interventional Radiology (IVR). However, a large deficit was created by cases where anticancer drugs and other expensive drugs were used in large quantities or extended hospitalization was necessitated by unexpected circumstances.

Key words

5. Clinical Pathways for Interventional Radiology
Department of Diagnostic and Interventional Radiology, San-in Rosai Hospital
Takashi Ihaya
Department of Nursing, Tottori Red Cross Hospital
Youko Oohama, Toshiko Takagi
Department of Nursing, San-in Rosai Hospital
Sachie Suizu

A novel medical payment system so called diagnosis-procedure combination (DPC) was introduced and it triggered the sreater development and implementation of clinical pathways especially in national and university hospitals in Japan. We have prepared clinical pathways for the interventional procedures such as transcatheter arterial embolization, radiofrequency ablation, port implantation, percutaneous ethanol injection, CT-guided biopsy and percutaneous biliary drainage. The implementation of clinical pathways in the field of interventional radiology produced not only a significant decrease in the length of the hospital stay and cost but also improved the quality of care through the promotion of team-based care.

Key words
● Clinical pathway
● Interventional Radiology

Special Contribution
Evolving Technologies in Interventional Radiology : A Look into the Future

Krishna Kandarpa, MD, PhD
Radiologist-in-Chief, U Mass Memorial Medical Center, Professor and Chairman Department of Radiology
The University of Massachusetts Medical School

In the West, chronic ailments such as cancer, and cardiovascular, neurological, and musculoskeletal diseases, will continue to drive medical developments for the foreseeable future. Our visualization of the future includes applications that palliate or preferably cure these diseases.
It is highly likely that the use and preference for imaging modalities will change with time. Imaging will evolve to provide both morphologic and functional definition of normal and diseased states so that the term ‘image-guided’therapy might be soon replaced by the term“information-guided”therapy. Many exciting new devices and techniques are being developed and tested. However, one can never be certain when, and which,‘disruptive’technology will result in a fundamental paradigm shift in the practice of interventional radiology.

Key words : Interventional Radiology, Image-guided therapy, Imaging-modalities,
       Functional imaging, Therapeutic devices

Original Articles
Transcatheter Arterial Embolization for Hemorrhage after Pancreatic Resections

Department of Radiology, Faculty of Medicine, University of Yamanashi
Takuji Araki, Atsushi Nambu, Hiroto Nakajima, Atsuko Ito
Tatsuaki Tsukamoto, Tsutomu Araki

Purpose : To assess the outcome of transcatheter arterial embolization for hemorrhage after pancreatic resection and evaluate factors for mortality.
Methods and materials. Ten patients with hemorrhage after pancreatic resections in our hospital from 1995 to 2005 were treated by transcatheter arterial embolization using coils. And one patient was additionally treated with N-buthyl cyanoacrylate. The technique we used was embolization at both distal and proximal portions of peudoaneurysms or packing of pseudoaneurysms.
Results : Mean interval between hemorrhage and surgery was 25.6 days. The procedures of embolization were successful in all case, but three patients died within 3 days after embolization. Two of the three had, before embolization, severe liver dysfunction or seveve ventricular fibrillation due to hemorrhagic shock. Their angiograms showed disruptions and pseudoaneurysms of common hepatic arteries and slow blood flow of portal veins. The other patient with occlusion of the left branch of the portal vein had a hepatic abscess following hepatic infarction after embolization of the common hepatic artery.
Stenosis or disruption of the portal vein, poor blood flow of the hepatic artery after embolization and severe complications of hepatic failure or severe shock before embolization, may have great influence on the prognosis.
Conclusion : Three of ten patients had been died after embolization. We should treat hemorrhage after pancreatic resections by transcatheter arterial embolization preserving the blood flow of the hepatic artery in the case of abnormal blood flow of the portal vein or in patients with severe patient’s co-morbidities.

Key words
●Transcatheter arterial embolization
●Pancreatic resection

Case Reports
A Case of Central Venous Catheter Fracture Caused by Pinch-off Syndrome

Department of Radiology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
Tomohiro Matsumoto, Takuji Yamagami, Takeharu Kato, Tatsuya Hirota
Rika Yoshimatsu, Tsunehiko Nishimura

Central venous catheters (CVCs) are now frequently used when long-term venous access is needed for administration of chemotherapeutic agents, parental nutrition, and for vascular access. The so-called pinch-off syndrome occurs when a long-term CVC is compressed between the clavicle and the first rib. The compression can cause transient obstruction of the catheter and may result in fracture and embolization. We report a complete fracture of CVC caused by pinch-off, with resultant migration of the distal segment of the catheter into the right atrium. In this case, the distal segment of the catheter was successfully removed using a microsnare which had been inserted via a percutaneous transfemoral approach.

Key words
●Central venous catheter
●Pinch-off syndrome
●CV reservoir

Transcatheter Arterial Embolization with N-butyl 2-cyanoacrylate(NBCA)for Postoperative Residual
Arteriovenous Malformation of the Ileum

Department of Radiology, Saiseikai Kawaguchi General Hospital
Naoki Ito
Department of Surgical Nephrology, Gastroentelogy and Hepatology1), Itabashi Chuuo Medical Center
Tetsurou Ando, Makoto Akamatsu, Tomonori Kawase, Taro Yamanaka1)

A 69-year-old woman on hemodialysis, suffered gastrointestinal bleeding 5 months after an operation for arteriovenous malformation (AVM). Embolization for gastrointestinal AVM is often done to achieve temporary preoperative hemostasis. A residual small AVM of the ilocolic artery was pointed out on angiography, and it was embolized with n-butyl 2-cyanoacrylate (NBCA). An abnormal vessel from the nidus to the drainage vein can be radically embolized.

Key words
●Small intestine

Spontaneous Rupture of Internal Mammary Artery ; Successful Embolization in One Case
Department of Radiology and Internal Medicine1), Saiseikai Fukuoka General Hospital
Makiko Koike, Shunichi Matsumoto, Naonobu Kunitake
Koji Yamashita, Tetsuro Akashi1)

Awoman in her 70’s, with no history of traumatic injury, was referred to us with right abdominal pain of sudden onset. Unenhanced CT and MRI showed a hematoma in the abdominal wall. Additionally, contrast-enhanced CT and MRI depicted an enhancing structure within the hematoma, indicating a pseudoaneurysm. Right internal mammary artery (IMA) arteriography demonstrated a psudoaneurysm originating from the distal branch of right IMA. On the basis of these imaging findings, the patient was diagnosed as having abdominal wall hematoma due to spontaneous rupture of right IMA. Embolization of right IMA both distal and proximal to the pseudoaneurysm, together with coil packing of the aneurymal sac, were performed to isolate the pseudoaneurysm. CT obtained one month after the procedure showed complete thrombosis of the pseudoaneurysm and interval shrinkage of the hematoma. This is a rare case of spontaneous rupture of IMA causing abdominal wall hematoma, in which the ruptured IMA was successfully treated with embolotherapy.

Key words
●Internal mammary artery
●Transcatheter arterial embolization