Jpn J Intervent Radiol Vol.21 No.2 2006

State of the Art
IVR for Uterine Fibroids 2006

1. Uterine Fibroid Embolization
Department of Radiology, Saiseikai Shiga Hospital
Tetsuya Katsumori

Uterine artery embolization (UAE) has become accepted as a safe and effective treatment for symptomatic fibroids with large detailed studies. In this article, this minimally invasive treatment was mainly reviewed on the basis of peer-reviewed English articles. Patient selection was one of important factors for successful outcomes. Therefore, controversial issues of the indication, including fertility, larger uterus and fibroid, adenomyosis, pedunculated subserosal fibroid, and repeated embolization were discussed. Technical aspects and peri-procedural management were reviewed, focusing on embolic agents and angiographic endpoint. The goal of this treatment is the durability of improvement in fibroid related symptoms. Hence, current publication of the outcomes, including symptoms control, recurrence, further gynecological interventions, and complications at long term follow-up as well as comparison between embolization and traditional surgical treatments such as hysterectomy and myomectomy were particularly discussed.

Key words
● Embolization
● Fibroid
● Uterus
● Uterine artery

2. Uterine Artery Embolization for Symptomatic Uterine Leiomyoma
-How to Treat Difficult Anatomy and Ovarian Artery-

Departments of Surgery and Gynecology1), Yamachika Memorial General Hospital
Tetsuya Sato, Ikuko Honda1), Hideo Adachi1)

The problems that must be addressed regarding uterine artery embolization include“long durability”and“fertility”. To keep“long durability”after the treatment, complete infarction of all the lesions affected by uterine leiomyoma and adenomyosis is required. On the other hand, to keep good fertility, the vascular impairment of endometrium should be restricted to a minimum. After analysis of the indication and results of UAE in 895 cases,(1) vascular anatomy of the uterine artery and ovarian artery, (2) choice of catheter and technical keypoint,(3) embolic particles and endpoint of embolization, and (4) ovarian arterial embolization are discussed.

Key words
● Uterine artery embolization
● Gelatin sponge
● Uterine arterial anatomy

3. Fertility and Pregnancy after Uterine Artery Embolization for Leiomyoma
Department of Gynecology and Surgery1), Yamachika Memorial General Hospital
Ikuko Honda, Tetsuya Sato1), Hideo Adachi
Reproduction Center, Sanno Hospital
Yoshimune Kobayashi, Masato Inoue

The indication of uterine artery embolization (UAE) for leiomyoma in women who wish to conceive is still controversial. In order to evaluate the effects of UAE on fertility and pregnancy, we examined the outcomes of 15 women including 14 infertile patients who underwent embolization. The average age of women was 37.1 years (range 25~43). Five patients had prior myomectomy and two had 2 prior myomectomies. Seven pregnancies occurred in 6 women (40.0%) whose average age was 37.1 years. The pregnancies resulted in one live birth by cesarean delivery, 2 ongoing pregnancies, 2 miscarriages (16.7%) and 2 elective terminations, and 1 of these developed a placental abnormality resulting in hysterectomy. The average time from embolization to conception was 23.1 months (range 2~48). Three spontaneous pregnancies occurred subsequent to the spontaneous expulsions of the submucosal myomas after UAE. Although ovarian function after UAE seemed to be maintained in patients aged〈44 years, serious complications were endometrial abnormalities which impair fertility further. The results of our hysteroscopic evaluations in 7 infertile patients were that intrauterine adhesions (Asherman’s syndrome) were demonstrated in four patients and endometrial atrophy in one patient. Therefore, UAE is not recommended as an infertile treatment for myomas. However, UAE for women who wish to conceive has to be decided when their myomas are thought to be not indicated for surgery and patients must be informed about the risks on fertility and pregnancy. Cautious and close follow-up is necessary for endometrial impairment after embolization and abnormal placentation during pregnancy.

Key words
● Uterine artery embolization
● Fertility
● Asherman’s syndrome

Original Articles
Preliminary Results of Embolotherapy Using Superabsorbent Polymer Microspheres (SAP-MS) for Treatment of Mediastinal and Hilar Lymph Node Metastases
Gate Tower Institute for Image Guided Therapy
Shinichi Hori, Yasuhiro Hata, Takashi Sugiura, Kumiko Hiraishi

Transcatheter arterial embolization therapy with superabsorbent polymer microsphere (SAP-MS) was employed for treatment of mediastinal and hilar lymph node metastases.
A total of 9 patients with mediastinal or hilar lymph node metastases of various origins were enrolled in the study. A microcatheter was inserted into the bronchial, intercostal, and internal thoracic arteries and CT was taken during angiography to confirm their vascular territories. In 4 patients antineoplastic agents were combined. Embolization procedure was terminated when tumor stain disappeared in DSA. In 6 patients, regression of lymph node was observed after embolization. Symptoms of dyspnea and/or pain were improved in 4 of 7 symptomatic patients.
No remarkable complications were observed during or after procedure.
We consider this method to be feasible and effective in the management of mediastinal and hilar lymph node metastases.

Key words
●Lymph node metastases
●Transcatheter arterial embolization
●Embolic agents

Original Articles
Initial Experience of Hepatic Arterial Infusion Chemotherapy of Cisplatin in Advanced Hepatocellular Carcinoma-Analysis of 19 Cases
Department of Radiology and Medicine1), Ureshino Medical Center
Akifumi Nishida, Kenichiro Fukui, Tsugumi Wada, Hideo Tsuruta1), Junichi Shiozawa1), Hiroaki Hazama1), Hitoshi Nishiyama1)
Department of Radiology, Higashisaga National Hospital
Naohiro Matsuyama

Purpose : To evaluate the effect of hepatic arterial infusion chemotherapy with cisplatin for advanced hepatocellular carcinoma accompanied by intrahepatic metastases or portal vein tumor thrombosis, which would not be feasible for hepatic resection, radiofrequency ablation, percutaneous ethanol injection or transcatheter arterial chemoembolization.
Materials and Methods : From July 2004 to July 2005, nineteen patients with advanced hepatocellular carcinoma received hepatic arterial administration of 65m/g cisplatin. There were 14 men and 5 women with a mean age of 72 years (range, 53~86 years). The treatment was repeated every 4~6 weeks.
Results : Of nineteen enrolled patients, six (32%) achieved a partial response, six (32%) showed no change, and seven (37%) progressively worsened. Adverse reactions such as nausea, appetite loss and fever were generally brief and reversible, with the exception of three deaths due to hepatic failure.
Conclusion : Hepatic arterial infusion chemotherapy with cisplatin had antitumor activity, and may be a useful therapeutic option for patients with advanced hepatocellular carcinoma. Careful consideration of the indications is necessary to avoid complications.

Key words
●Hepatocellular carcinoma
●Hepatic arterial infusion chemotherapy

Original Articles
Usefulness of NSAIDS (nonsteroidal anti-inflammatory drugs) in Sharp Pain Management of Transcatheter Hepatic Arterial Embolization
Department of Diagnostic Imaging, Shizuoka City Hospital
Kotaro Shimada, Shinichi Miyamoto

Transcatheter hepatic arterial embolization (TAE) is frequently performed for hepatocellular carcinomas and metastatic liver tumors. But side effects such as fever and abdominal pain are often evoked during and after the procedure. We evaluated whether the preoperative administration of NSAIDS (nonsteroidal anti-inflammatory drugs) was useful for pain control in TAE. The study population consisted of 13 patients with NSAIDS and 12 patients without NSAIDS. The pain was digitalized by the pain score and was analyzed statistically. 10 patients out of 13 in the group with NSAIDS showed no pain. And 5 patients out of 12 in the group without NSAIDS showed no pain. In no case of the group with NSAIDS was additional pain killer injected during the procedure. On the other hand, 7 cases of the group without NSAIDS needed pain killer. No patient of the group with NSAIDS presented fever after TAE. On the other hand, 4 patients of the group without NSAIDS developed fever after TAE. In conclusion, preoperative administration of NSAIDS was usefull for pain control and prevention of fever in TAE.

Key words
●Pain control

Case Report
Successful Transvenous Embolization of a Dural Arteriovenous Fistula Onset of Subarachnoid Hemorrhage : A Case Report
Department of Radiology, Emergency and Critical Care Medicine1), Nara Medical University
Kaoru Myouchin, Hiroyuki Nakagawa, Takeshi Wada, Katsutoshi Takayama, Masahiko Sakamoto, Toshiaki Taoka, Akio Hukusumi, Satoru Iwasaki, Kimihiko Kichikawa, Takeshi Matsuyama1), Kazuo Okuchi1)

Intracranial dural arteriovenous fistulas constitute approximately 10 to 15%of all intracranial vascular malformations, including approximately 6%of all supratentorial and 35%of infratentorial arteriovenous malformations. The natural history of these predominantly acquired lesions remains obscure. An arteriovenous fistula without retrograde cortical venous drainage has usually a benign clinical course, while an arteriovenous fistula with retrograde cortical venous drainage presents a high risk of aggressive clinical course with intracranial hemorrhage. We experienced a case of a dural arteriovenous fistula onset of subarachnoid hemorrhage successfully treated by transvenous embolization. We considered the differentiation regarding flow between arteriovenous fistula onset of subarachnoid hemorrhage and onset of intracranial hemorrhage in 11 cases from the literature including our case.

Key words
●Arteriovenous fistula
●Transvenous embolization
●Subarachnoid hemorrhage

Case Report
Selective Thrombolysis for Deep Vein Thrombosis-A Case of Rapid and Complete Thrombolysis of Extensive DVT with Protein S Deficiency-
Department of Radiology, Ikeda Municipal Hospital
Koh Tokunaga, Kyou Tuda, Souya Maejima

We report a case of a young male in his 10’s with extensive deep vein thrombosis treated by catheter directed thrombolysis. At first, a temporary filter catheter was introduced from the right subclavian vein, through which an infusion microcatheter and a pulse spray system were inserted. For a short period, complete thrombolysis was achieved only by urokinase introduced into the thrombus by the pulse method (3,000U/30w) and by continuous infusion (240,000U/day). After treatment, we revealed that the patient had protein S deficiency.

Key words
●Deep venous thrombosis
●Inferior vena cava filter
●Protein S deficiency

Technical Note
Initial Experience Using New W-Spiral Catheter (G-Spiral) Corresponding to 0.035 inch-GW for GDA-coil Fixation Method
Department of Radiology, St.Marianna University School of Medicine
Kyoko Okamoto, Kenji Takizawa, Kunihiro Yagihashi, Shunsuke Nakaji, Shinjiro Sakaino, Yukihisa Ogawa, Misako Yoshimatsu, Yasuo Nakajima

We report the initial experience using the new W-Spiral catheter (G-Spiral : GSP) for GDA-coil fixation method (GDA-method). This 5 Fr. catheter, corresponding to 0.035inch guidwire, contains spirally arranged shape-memory metal (W-Spiral) and the tip of a 4Fr. straight catheter and, additionally, a side-hole with marker. This catheter was successfully inserted
by GDA-method with the W-spiral at the last bifurcation of GDA and with the side-hole at the common hepatic artery without trouble. Three months after the method, complications such as dislodgement and arterial damage have not occurred. Newly developed GSP seems to be
useful and contribute to reduce the technical burden and complications after the procedure on GDA-method.

Key words
●GDA-coil fixation method
●Hepatic arterial infusion chemotherapy
●Implantable port