Jpn J Intervent Radiol Vol.22 No.2 2007

State of the Art
Diagnosis and IVR of Peripheral Arterial Occlusive Disease

An Introduction
Syoji Sakaguchi

1. Diagnosis and Treatment of Peripheral Arterial Disease : Recent Advance
Department of Radiology, Nara Medical University
Kimihiko Kichikawa, Wataru Higashiura, Shoji Sakaguchi, Takeshi Nagata, Kiyoshi Nishimine, Koichi Ide

 Recently the number of patients with peripheral arterial disease (PAD) has increased in Japan due to advancing age and exposure to atherosclerosis risk factors. The American College of Cardiology (ACC) / American Heart Association (AHA) Task Force on Practice Guidelines, and TASC II recommendation provide overall treatment strategy for PAD. ABI measurement and US examination in vascular lab play important roles in screening of PAD and MRA and/or CTA may be considered to diagnose anatomic location and presence of significant stenosis.
The treatment of PAD should include to control risk factors and to cure limb ischemia with medication, exercise and revascularization with IVR and/or surgical procedure. IVR plays a major role to treat PAD, and recent development of devices and recanalization techniques provides widening of indication and high technical and clinical success rate of IVR. It is very important to collaborate with cardiologists, vascular surgeons, IVRists and plastic surgeons for the treatment of PAD. We describe the recent overview of diagnosis and treatment of PAD.

Key words
・ACC/AHA Guideline

2. Ultrasonographic Diagnosis of Peripheral Arterial Occlusive Disease
Department of Endoscopy and Ultrasound, Nara Medical University
Toshiko Hirai
Department of Radiology, Nara Medical University
Shoji Sakaguchi, Wataru Higashiura, Kimihiko Kichikawa

 Ultrasonography gives us detailed anatomic information (the status of the vascular wall, absence or presence of stenosis and /or obstruction, and other vascular abnormalities) and functional (flow) information noninvasively.
 Ultrasonography plays the main role in the diagnosis of peripheral arterial occlusive disease in the vascular laboratory.
 We describe in this paper the ultrasonographic diagnosis of peripheral arterial occlusive disease and the role of ultrasonography in vascular intervention.

Key words
・Peripheral arterial occlusive disease

3. CT and MR Angiography of Peripheral Arterial Disease
Department of Diagnostic Radiology, Keio University School of Medicine
Kazuhiro Matsumoto, Masahiro Jinzaki, Kozo Sato, Seishi Nakatsuka, Subaru Hashimoto, Sachio Kuribayashi

 Imaging evaluation of peripheral arterial disease requires the visualization of the detailed structural changes between the abdomino-pelvis and lower calf in order to decide on therapeutic management. Conventional angiography remains the technique of choice for fur ther examination of peripheral arterial disease ; however low-invasive methods provide an excellent alternative. In this chapter, we describe recent advances in vascular imaging techniques. Computed tomography (CT) and magnetic resonance (MR) both provide useful information. Because of the improved spatial resolution of multidetector-row CT, CT angiography is helpful in assessing structural changes and measuring the diameter of the vascular lumen for the planning of endovascular intervention. MR can be performed using several techniques, specifically time-of-flight and MR digital subtraction angiography with contrast material.

Key words
・Peripheral arterial disease
・CT angiography
・MR angiography

4. Current Issues in Interventional Treatment of Iliac Arterial Occlusive Disease- Criteria, Techniques, and Result
Department of Radiology, Iwate Medical University
Ryoichi Tanaka

 Percutaneous transluminal angioplasty the metallic stents is a standard procedure for the treatment of iliac arterial occlusive disease. Recently, Trans-Atlantic Inter-Society Consensus (TASC) II was published. TASC is a consensus paper on the management of peripheral vascular disease and outlines the standard treatment strategy.
 In TASC II, the inclusion criteria of iliac arterial disease were expanded and interventional radiology (IVR) has become to play a major role. Especially, some types of occlusion became to be considered as the favorable lesion for the interventional treatment. The recanalizing technique of the occlusion is important and the technique of retrograde, antegrade, and bidirectional recanalization should be learned. The pull-through technique is also important for good technical result.
 With the development of metallic stent, the long-term result of iliac artery interventions became good. However, in some severe lesions, back-up or alternative treatment should be prepared to avoid major complications. Not only basic technique of angioplasty such as using covered stent or balloon occlusion but also some techniques of embolization should be learned. And we should know when to stop the interventional procedure and convert to the surgical procedure. We should also think about the indications before the procedure.

Key words
・Iliac artery
・Percutaneous transluminal angioplasty(PTA)

5. Endovascular Intervention for Femoropopliteal Arterial Disease
Department of Radiology, Narumi Hospital, Narumi-Kenkyujo-Seimeikai
Hiroshi Noda, Hiraku Yodono, Kunihiro Matsuo, Atsushi Shinohara

 The SFA is the most commonly diseased artery in the body. Much of PAD cases involve the SFA. The decision to intervention in the SFA is complicated. I think that a patient of a critical limb ischemia should be treated in endovascular intervention as much as possible because of cardiovascular risk is high. As for the device, a thing of fine is good. Recently, SMART stent shows good results for SFA lesion but only for the use that they limited. Technique is necessary for usage of a guidewire and balloon catheter and also approach. In addition if I say, subintimal angioplasty is a special method, but it is the good method that an applied range is wide.

Key words
・Femoropoplital artery
・Subintimal angioplasty

6. Endovascular Treatment of Infrapopliteal Occlusive Disease in Patients with Critical Limb Ischemia
Department of Radiology, National Cardiovascular Center
Tetsuya Fukuda

 Chronic limb ischemia generally results from multilevel atherosclerotic disease in the lower extremity vasculature. In addition, involvement of the tibioperoneal arteries is normally encountered. Although surgical revascularization remains the gold standard because of its excellent durability, there is increasing enthusiasm for endovascular treatment of below - the-knee occlusive disease in patients with critical limb ischemia.
 It is important to understand that the clinical success of this modality has been superior to its angiographic success because after healing of wound was achieved, recurrence of stenosis may not be associated with recurrence of ulcer. Then, plain old balloon angioplasty was often opted for the endovascular treatment, although the cumulative patency rate was not good.
 New devices such as cryoplasty, laser atherectomy using ecximer laser, drug-eluting stent, and absorbable metal stents are now available in the US for the treatment of infrapopliteal occlusive disease due to atherosclerotic disease.

Key words
・Below the knee
・Critical limb ischemia
・Percutaneous peripheral interrvension

7. Combined Endovascular and Open Surgical Procedures for the Management of Lower Extremity
Department of Vascular Surgery, Tanaka Kitanoda Hospital
Takashi Nakamura

 Endovascular treatment of aortoiliac occlusive disease is among the most durable procedures and has been shown to be a reliable source of inflow for open infrainguinal revascularizations. The combination of endovascular and operative treatment modalities confers the benefits of both techniques, and therefore the incorporation of endovascular techniques into open vascular operations has become a routine practice. In this article, we describe our experience with intraoperative endovascular procedures in conjunction with infra-inguinal arterial reconstruction procedures. The benefits and drawbacks of this combined approach are discussed.

Key words
・Multilevel arterial occlusive disease
・Endovascular intervention
・Infrainguinal surgical reconstruction
・Combined procedure

Original Article
Transcatheter Embolotherapy of Systemic-to-pulmonary Artery Collateral Vessels in Patients with Cyanotic Congenital Heart Disease
Department of Radiology, Shimotsuga General Hospital
Hisao Toei
Department of Radiology, Jichi Medical School and Hospital
Yoshiyuki Yoshida, Takeshi Shinozaki, Hideharu Sugimoto

 Purpose : To evaluate the value of systemic arteriography and transcatheter embolization in patients with cyanotic congenital heart disease.
 Materials and methods : We analyzed clinical records and angiographic findings in six patients (2 male, 4 female). Four patients had severe stenosis of pulmonary trunk due to tetralogy of Fallot, two with atresia of the pulmonary trunk.
 Results : The main symptom was frequent hemoptysis in five patients and cardiac failure due to bronchopulmonary shunts in one. Bronchial arteriography and transcatheter embolization were performed successfully with gelfoam and/or microcoils, with immediate control of bleeding or bronchopulmonary shunts obtained in all patients. In three patients, recurrent hemoptysis was observed 5~8 month later, but re-embolization was performed successfully. In one patient, hypervascularization was also noted in the left internal mammary and left lateral thoracic artery, and was successfully treated with additional embolization.
 Conclusion : Transcatheter embolization of systemic-to-pulmonary artery collateral vessels is very useful to treat hemoptysis and bronchopulmonary shunts in patients with obstruction or severe stenosis of the pulmonary artery.However, these vessels may serve as collateral vessels from systemic arteries with high pressure to pulmonary arterial system with low pressure, and may be an important source of blood supply to the lungs.
 Therefore, the high risk of recurrence should be considered in such patients.

Key words
・Cyanotic congenital heart disease
・Post cardiac surgery
・Bronchial artery
・Systemic collateral arteries
・Transcatheter arterial embolization

Case Report
Removal of a Central Venous Catheter Associated Thrombi by Using an Intravascular Retrieval Basket : A Case Report
Department of Radiology, Department of 1st Internal Medicine1), Iwate Medical University
Kenichi Katoh, Miyuki Sone, Tatsuhiko Nakasato
Shigeru Ehara, Toshimi Chiba1)

 Deep venous thrombosis is one of the most severe complications associated with central venous catheterization, and removal of catheters may become difficult due to thrombosis. We report an elderly woman with central venous catheter associated thrombi. In this case, removal of the central venous catheter was difficult due to large thrombi after anticoagulation and thrombolysis. We could successfully remove the central venous catheter by using a retrieval basket.

Key words
・Retrieval basket

Case Report
A Case of Chronic Mesenteric Ischemia Treated by Endovascular Stent Placement in the Inferior Mesenteric Artery after Pylorus-preserving Pancreaticoduodenectomy for Papillocarcinoma
Department of Radiology, Gastroenterology1), Radiology2), Otsu Redcross Hospital
Akihiro Furuta, Hisato Kobayashi, Maya Arimoto, Hironori Shimizu, Seiko Kasahara, Takahiro Takahashi, Keizo Akuta, Kentaro Ishii1), Masahide Tojo1), Makoto Hirata2), Hajime Monzen2)
Department of Radiolory, Yamaguchi University
Naofumi Matsunaga

 Awoman in her sixties visited our hospital because of postprandial pain and vomiting. She had a history of papillocarcinoma and had undergone pylous-preserving pancreaticoduodenectomy four years earlier. For three years, she had often experienced abdominal distention after meals, diarrhea, and abdominal pain. Contrast-enhanced CT scan depicted mechanical obstruction caused by postoperative adhesions, gas within the bowel wall and portal venous system. It also demonstrated occlusion of the superior mesenteric artery and stenosis of the inferior mesenteric artery at its origin. The gastro-duodenal artery had been resected. The diagnosis was small bowel ischemia due to underlying chronic mesenteric ischemia (CMI). The symptoms improved with conservative therapy.
 In order to prevent further complications, direct stenting was performed in the inferior mesenteric artery with a 6mm Palmaz Genesis successfully. One year after the procedure, she has no abdominal symptoms and is free from re-stenosis of the inferior mesenteric artery detectable on contrast- enhanced CT or ultrasound.
 The Palmaz Genesis stent provided good result for inferior mesenteric artery stent placement for the treatment of CMI.

Key words
・Chronic mesenteric ischemia
・Inferior mesenteric artery