Jpn J Intervent Radiol Vol.23 No.1 2008

State of the Art
Interventional Radiology of Orthopedics

1. Imaging-Guide Bone Biopsy in a Clinical General Hospital

Department of Radiology, Pathology1), and Orthopedics2), Tenri Hospital
Akira Sano, Takanori Taniguchi, Tomohisa Hashimoto, Takuya Okada
Haruka Uezono, Ryo Sakamoto, Tsutomu Okada, Naoaki Kusunoki
Takanori Higashino, Satoshi Noma, Yoichiro Kobashi1), Hidekazu Nishimatsu2)

The authors have described imaging-guide biopsy of the spine, presenting cases represented out of approximately 160 cases done in a clinical general hospital. We have mainly utilized medium-bore needles, 14 or 16G Ostycut (Bard, Germany) and Ossiris (Hakko, Japan), along with imaging-guide of multidetector row CT scanner with or without fluoroscopy. Several variations on approach were chosen, such as posterolateral, transpedicular, or costovertebral approach in the prone position for the lumbothoracic spine, anterolateral approach in the supine position for the lower cervical spine, and posterior lateral, medial, or median approach in the prone position for the sacrum. The results were successful, namely 86% in confined 50 patients, and safe with only one patient showing limited retroperitoneal hemorrhage. More knowledge about fluoroscopy-guide transpedicular approach is needed, because axial CT does not necessarily provide the tomogram appropriate for CT-guide puncture, due to lordotic or kyphotic curvature of the spines. However, one should primarily try to find the posterolateral or costovertebral approach for the lumbothoracic spine, as it is shorter to penetrate up to the body than the transpedicular approach.

Key words

  • Imaging-guide biopsy
  • Spinal diseases
  • Ostycut, Ossiris


2. Percutaneous Vertebroplasty for Painful Spinal Tumors

Department of Radiology and Orthopaedic Surgery1),Anesthesiology and Intensive Care Medicine2),Kanazawa University School of Medicine
Wataru Koda, Tsuyoshi Takanaka, Osamu Matsui, Norio Kawahara1)
Hideki Murakami1), Satoru Demura1), Keisuke Yamada2), Chisui Mukawa3)
Department of Radiology, Ishikawa Prefectural Central Hospital
Takeshi Kobayashi

Percutaneous vertebroplasty is a minimally invasive, therapeutic procedure for painful spinal tumors. This technique involves percutaneous injection of bone cement, most commonly polymethylmethacrylate (PMMA), into affected vertebral bodies under radiological guidance from CT scanning or fluoroscopy and provides marked and rapid pain relief in a high percentage of patients with vertebral column neoplasms. While the overall risk is relatively low, potential complications include damage to nerve roots or the spinal cord, with radiculopathy or paralysis, leakage of material into the epidural or paravertebral spaces and passage of material into the venous system with embolization to the pulmonary vasculature. Appropriate patient selection for percutaneous vertebroplasty and continuous monitoring of blood pressure and oxygen saturation during this procedure are essential for effectiveness and safety. We described the practical aspects of percutaneous vertebroplasty for spinal tumors, such as its indications, techniques, especially under CT-fluoroscopic guidance, and effects.

Key words

  • Percutaneous vertebroplasty(PVP)
  • Spinal tumor
  • CT fluoroscopic guidance
  • Pain relief


3. The Present State of Percutaneous Vertebroplasty in Japan

Department of Radiology, Kansai Medical University
Atsushi Komemushi, Noboru Tanigawa, Satoshi Sawada
Department of Radiology, Kanazawa University
Wataru Koda
Department of Orthopaedic Surgery and Radiology1),Ishikawa Prefectural Central Hospital
Hidetoshi Yasutake, Takeshi Kobayashi1)
Department of Radiology, Kyoto Renaiss Hospital
Keiji Shimoyama
Department of Radiology, St. Marianna University School of Medicine
Kenji Takizawa
Department of Radiology, Kurume University School of Medicine
Norimitsu Tanaka
Department of Radiology, Chugoku Rousai Hospital
Akira Naito
Department of Radiology, St. Luke’s International Hospital
Yuji Numaguchi, Nobuo Kobayashi

We surveyed the present state of percutaneous vertebroplasty in Japan by a using questionnaire method. Eight representative institutions and 658 procedures of percutaneous vertebroplasty in Japan were investigated about indications, preprocedural examinations, techniques, postprocedural care, emergency support and others. The present state of percutaneous vertebroplasty in Japan was clarified.

Key words

  • Percutaneous vertebroplasty
  • Osteoporosis
  • Vertebral compression fracture


4. Percutaneous Vertebroplasty : The Present Status in the US and Europe

Department of Radiology, Kurume University School of Medicine
Norimitsu Tanaka, Toshi Abe, Shuji Osada, Yusuke Uchiyama, Naofumi Hayabuchi

We describe the present status of percutaneous vertebroplasty (PV) in the US and Europe. PV was developed in France. Over 80,000 procedures of PV are now performed in the US per year, and the number is increasing, which suggests not only the efficacy but also the safety of PV. Good patient selection promotes successful PV, and new adjacent level vertebral fracture after PV is problematic. Guidelines of the Society of Interventional Radiology and FDA for PV are discussed and new implant materials are introduced.

Key words

  • Percutaneous vertebroplasty
  • Osteoporosis
  • Vertebral compression fracture


5. Radiofrequency Ablation for Bone Malignancies

Department of Radiology, Mie University Graduated School of Medicine
Atsuhiro Nakatsuka, Koichiro Yamakado, Haruyuki Takaki, Junji Uraki, Kan Takeda

RF ablation has proved to be a useful therapeutic option for the treatment of musculoskeletal neoplasms. Unresectable malignant bone tumors cause refractory pain that affects patients’ quality of life. Pain relief is achieved within 4 weeks in 90~100% of patients treated by RF ablation. In this article, we describe our experience of RF ablation for bone malignancies.

Key words

  • Radiofrequency ablation
  • Bone malignancies
  • Painful bone tumor


6. Percutaneous Radiofrequency Ablation for Benign Bone Tumor

Diagnostic and Interventional Radiology and Nuclear medicine, Gunma University Graduate School of Medicine
Masaya Miyazaki, Hiroyuki Tokue, Satoshi Hirasawa, Takahito Nakajima, Makoto Amanuma, Keigo Endo
Department of Radiology, Gunma General Hospital
Jun Aoki, Hideo Morita
Department of Radiology and Orthopedic Surgery1), Gunma University Hospital
Yoshinori Koyama, Tetsuya Shinozaki1)

Osteoid osteoma is a benign bone tumor typically less than 2㎝ in size. These lesions are difficult to identify precisely ; this can necessitate substantial resection of the surrounding normal bone. Recently, radiofrequency ablation (RFA) has been used for the treatment of osteoid osteoma, and satisfactory clinical results have been reported. However, the clinical benefit of RFA for osteoid osteoma has not yet been established. In this report we demonstrate the basic concepts and clinical applications, and evaluate the technical safety and efficacy of this procedure.

Key words

  • Benign bone tumor
  • Osteoid osteoma
  • Radiofrequency ablation


7. CT-guided Percutaneous Laser Disk Decompression for Cervical and Lumbar Disk Hernia

Department of Radiology and Emergency Medicine, Jikei University School of Medicine, Kashiwa Hospital1)
Kanichiro Shimizu, Tutomu Koyama1), Junta Harada
Department of Neurosurgery, Jikei University School of Medicine
Toshiaki Abe

Introduction : Percutaneous laser disk decompression under X-ray fluoroscopy was first reported in 1987 for minimally invasive therapy of lumbar disk hernia. In patients with disk hernia, laser vaporizes a small portion of the intervertebral disk, thereby reducing the volume and pressure of the affected disk. We present the efficacy and safety of this procedure, and analysis of fair or poor response cases.
Materials and Methods : In our study, 226 cases of lumbar disk hernia and 7 cases of cervical disk hernia were treated under CT guided PLDD.
Japan Orthopedic Association (JOA) score and Mac-Nab criteria were investigated to evaluate the response to treatment. Improvement ratio based on the JOA score was calculated as follows.
Results : Overall success rate was 91.6% in cases of lumbar disk hernia, and 100% in cases of cervical disk hernia.
We experienced two cases with postoperative complications. Both cases were treated conservatively. The majority of acute cases and post operative cases were reported to be ”good” on Mac-Nab criteria.
Cases of fair or poor response on Mac-Nab criteria were lateral type, foraminal stenosis or large disk hernia.
Conclusion : CT-guided PLDD is a safe and accurate procedure. The overall success rate can be increased by carefully selecting patients.

Key words

  • PLDD
  • Minimally invasive therapy
  • CT guidance

Original Article
Biliary Intervention by Percutaneous Trans-gallbladder and Cystic Ductal Cholangio-drainage, Experience of 15 Cases

Department of Radiology, Surgery1) and Gastroentelogy2), Suita Municipal Hospital
Department of Radiology, Toyonaka Municipal Hospital*
Taku Yasumoto*, Shigekazu Yokoyama1), Kouji Nagaike2), Tohru Hashimoto

Purpose : To evaluate the usefulness of biliary Intervention by percutaneous trans-gallbladder and cystic ductal cholangio-drainage (PTGBCD).
Materials and Method : PTGBCD was attempted in fifteen consecutive patients with malignant biliary obstruction, acute cholangitis, or cholecystitis. In all Patients, percutaneous teanshepatic cholangio-drainage (PTCD) or endoscopic retrograde biliary drainage (ERBD) was technically difficult. Following percutaneous trans-gallbladder drainage (PTGBCD), a seeking catheter was inserted into the common hepatic or common bile duct via the cystic duct, and biliary interventions were subsequently performed.
Results : In fourteen patients (93.3%) PTGBCD was successful, and in thirteen patients (86.7%) the subsequent biliary interventions were accomplished Including expandable metallic biliary endoprosthesis (EMBE) (n=6), lithotripsy (n=4), choledochal drainage (n=2) and biliary biopsy (n=1). No major complications were experienced in any patients.
Conclusions : Biliary intervention through PTGBCD route is a feasible and effective in the management of biliary diseases unsuited to PTCD or ERBD.

Key words

  • Trans- cystic duct
  • Biliary drainage
  • Biliary intervention

Case Report
A Case of Retroperitoneal Hematoma Caused by Ruptured Ovarian Artery

Department of Radiology and Surgery1), Urasoe General Hospital
Yuko Iraha, Fuyuki Shibata, Kaname Kurashita1)
Department of Radiology, Graduate School of Medical Science, University of the Ryukyus
Sadayuki Murayama

 A woman in the 7th decade of life was admitted with sudden abdominal pain and vomiting, and consequent hypovolemic shock. Abdominal computed tomography (CT) demonstrated a massive hematoma extending into the right retroperitoneal space with extravasation of contrast medium. Subsequent angiography revealed a ruptured atypical abdominal artery, and coil embolization to stop bleeding was successfully performed. The atypical artery was surmised to be the right ovarian artery.

Key words

  • Spontaneous retroperitoneal hematoma
  • Ovarian artery rupture

Case Report
A Case of Delayed Traumatic Renal Pseudoaneurysm Successfully Treated with TAE Using Particulate Embolic Materials and Metallic Coils

Department of Radiology, Kawasaki Medical School
Daigo Tanimoto, Takenori Yamashita, Akira Yamamoto, Shigeru Watanabe
Naoto Egashira, Hiroki Higashi, Masayuki Gyoten, Tsutomu Tamada, Shigeki Imai

 A 60-year-old man fell from a 2m high stepladder in a construction accident. Computed tomography (CT) revealed a large hematoma and deep laceration in the left kidney, while angiography did not show extravasation at the left renal artery. However gross hematuria was observed 20 days aftrer the first angiography. As CT revealed a pseudoaneurysm (size, 35㎜), TAE (transcatheter arterial embolization) concurrently using particulate embolic materials and metallic coils was performed. Recurrent hematuria was not observed following TAE and favorable therapeutic effects were achieved. This suggests that traumatic renal pseudoaneurysm may have a delayed onset, and requires regular follow-up.

Key words

  • Renal injury
  • Pseudoaneurysm
  • Transcatheter arterial embolization

Case Report
A Case Report of Coronary-to-bronchial Artery Anastomosis Induced by Repeated Bronchial Artery Embolization

Department of Radiology, Saitama Cardiovascular and Respiratory Center
Tetsu Kanauchi, Toshiko Hoshi, Miyuki Ueda, Hiroko Matsumoto

 We report a middle-aged woman with bronchiectasis in whom a coronary-to-bronchial artery anastomosis was induced by repeated bronchial artery embolization (BAE) for hemoptysis. She had undergone BAE 4 times. In the 5th session, new mediastinal anastomosing branches and coronary-to-bronchial artery communication were present. Embolization via anastomosing branch was performed carefully. No cardiac complications occurred. Repeated BAE induces neovascularization from non-bronchial arteries and complex mediastinal anastomosis. Coronary-to-bronchial anastomosis should be kept in mind to avoid myocardial infarction in BAE. Ascending aortography is desirable for checking the presence of this anastomosis in BAE.

Key words

  • Bronchiectasis
  • Bronchial artery embolization
  • Coronary to bronchial artery anastomosis

Case Report
Endovascular Coil Embolization of Superior Mesenteric Artery Aneurysms : A Case Report

Department of Radiology, Tokyo Women's Medical University
Kazufumi Suzuki, Ryohei Kuwatsuru, Yuka Matsuo, Mari Kohno
Toshiro Hayano, Takayuki Yamada, Norio Mitsuhashi

 A neurysms of the superior mesenteric artery are uncommon but lethal. The authors treated a patient with 3 such aneurysms accompanied by abdominal pain. Multi-detector-row computed tomography (MDCT) revealed aneurysms on the superior mesenteric artery, which arises as a branch from the celiomesenteric trunk. To keep the mesenteric arterial blood flow patent, we treated the patient with endovascular coil embolization. Follow-up MDCT scan indicated no aneurysm recurrence.

Key words

  • Superior mesentric artery aneurysm
  • Celiomesenteric trunk
  • Coil embolization

Case Report
Transcatheter Coil Embolization of Bronchial Artery Aneurysms in a Patient with Bronchiectasis

Department of Radiology and Respiratory Medicine1), Yokohama Minato Red Cross Hospital
Yasuhiko Iryo, Fumikiyo Ganaha, Takeo Irie, Kenichi Takara
Yoichi Otani, Yumi Fujii1), Masahiko Tanoue1)

Awoman in her 70's presented with hemoptysis due to bronchiectasis. Contrast-enhanced CT showed an enlarged bronchial arteries and three unruptured bronchial artery aneurysms. Transcatheter bronchial artery embolization was performed in order to obtain hemostasis. The occlusion of aneurysms was also intended to prevent aneurysm rupture and successfully achieved by the distal and proximal embolizations using microcoils. Nine months later, hemoptysis recurred due to the development of collateral circulation from the left inferior phrenic artery, and the patient underwent additional embolization. The co-existent systemic-to-pulmonary-artery shunt was successfully occluded with liquid coils, and the collaterals were subsequently embolized using Gelfoam particles and microcoils.

Key words

  • Bronchial artery aneurysm
  • Embolizations
  • Bronchiectasis
  • Hemoptysis

Case Report
A Case Report : Usefulness of Embolic Protection Device to Prevent Brain Infarction during Stent Placement and Thrombus Aspiration for Right Upper Extremity Thrombosis

Department of Radiology and Cardiology1) and Cardiovascular Surgery2),
Jichi Medical University Saitama Medical Center
Yoshiaki Watanabe, Katsuhiko Matsuura, Osamu Tanaka
Tomohiro Nakamura1), Hideo Adachi2)

We report a case of successful recanalization of widespread upper extremity arterial thromboembolism by using embolic protection device to prevent brain infarction during stent placement and thrombus aspiration. A 67-year-old male with diabetes mellitus was referred to our hospital for increasing pallor and pain in his right upper extremity. On enhanced CT, artery of the right upper extremity including the distal two-thirds of the right subclavian artery was obstructed with massive thrombi that might be caused by the underlying stenosis. Wallstent was placed in the right subclavian artery and thrombus aspiration was performed. Right vertebral artery was protected by an embolic protection device during the procedure to prevent migration of the thrombus into this artery. After angiography and stenting, aspiration from the proximal right subclavian artery showed thrombus in the blood.
Vertebral artery protection with an embolic protection device may be useful to prevent brain infarction during subclavian artery thrombotic lesion treatment.

Key words

  • Embolic protection device
  • Subclavian artery occlusion