Jpn J Intervent Radiol Vol.25 No.2 2010

State of the Art
Introduction of Intervention for the Venous System

An Introduction  Osamu Ikeda

1. Central Venous Access

Department of Diagnostic Radiology, National Cancer Center
Keitaro Sofue, Yasuaki Arai, Yoshito Takeuchi, Masahide Takahashi

 Central venous access is frequently used in various situations, including total parenteral nutrition, measuring central venous pressure, administration of vasoactive drugs, and continuous infusion of anticancer agents. Therefore, this is one of the most basic procedures that must be performed certainly and safely to carry out the standard treatment in any field. On the other hand, there have been a few reports of some complications associated with this procedure. Recently, image-guided puncture has become the standard of this procedure, and interventional radiologists perform it in many hospitals. Good practice of central venous access is an essential procedure for interventional radiologists. To maintain the pride of our profession, we should learn all kinds of techniques so to be able to complete this procedure in any situation.

Key words

  • Central venous access
  • Image-guided puncture
  • Subclavian vein


2. Stent Therapy for Superior Vena Cava Syndrome

Department of Radiology and Interventional Radiology Center, Daiyukai General Hospital
Takeshi Nagata, Hideo Uchida
Department of Radiology, Nara Medical University
Shiro Makutani, Hiroshi Anai, Kimihiko Kichikawa

 Superior vena cava syndrome(SVCS)is a distressing manifestation of benign or malignant disease obstructing the superior vena cava(SVC). Almost all cases of SVC are caused by obstruction of SVC due to advanced unresectable malignant tumors such as lung cancer and mediastinal tumor. The stent placement for the obstructed portion is very effective to release immediately the obstruction of SVC and play an important role as palliative therapy to obtain an improved QOL. This paper reports the indications, procedure, therapeutic results and complications of stent therapy for SVC based on our experiences of 74 cases.

Key words

  • Superior vena cava syndrome
  • Unresectable malignant tumor
  • Stent


3. Update on Inferior Vena Cava Filters

Department of Radiology, Nippon Medical School
Ken Nakazawa, Hiroyuki Tajima

 Inferior vena cava filter placement is an effective method to prevent recurrence of pulmonary thromboembolism. The indications of vena cava filter placement are still unclear, and so we need to examine validity in every individual case. We describe herein the variety, indications, methods and complications of inferior vena cava filter placement.

Key words

  • Embolism, pulmonary
  • Venae cavae, filters
  • Thrombosis, venous


4. Interventional Radiology for the Treatment of Acute Massive Pulmonary Thromboembolism

Department of Radiology and Coronary Care Unit1), Nippon Medical School
Hiroyuki Tajima, Satoru Murata, Ken Nakazawa, Tsuyoshi Fukunaga, Shiro Onozawa, Takahiko Mine
Tatsuo Ueda, Masaki Tachi, Jyunko Shibukawa, Kazuo Ichikawa, Tsuyoshi Yamamoto1), Keiji Tanaka

 Acute massive pulmonary thromboembolism is a life-threatening condition with a high mortality rate due to acute right ventricular failure and cardiogenic shock. Anticoagulation is the most traditional treatment for pulmonary thromboembolism, but may not be sufficient for massive thromboemboli. Systemic thrombolytic therapy and surgical embolectomy are the usual therapeutic options in this situation. Catheter directed thrombolysis and catheter embolectomy are now available to treat the most severe cases of massive pulmonary thromboembolism. There currently are 3 categories of catheter-tip embolectomy for removing or fragmenting pulmonary thromboemboli : (1) aspiration thrombectomy, (2) fragmentation, and (3) rheolytic thrombectomy. The success of these techniques depends on a thorough understanding of the mechanism of each devices and familiarity with the relevant catheterization techniques. Although no controlled clinical trials are available, data from cohort studies indicate that the clinical outcomes after surgical and catheter embolectomy may be comparable. We hereby present a review of currently available equipment and techniques, and describe our work with hybrid treatment using a combination of mechanical fragmentation, local fibrinolysis and clot aspiration.

Key words

  • Thrombolysis
  • Thrombectomy
  • Fragmentation


5. Budd-Chiari Syndrome

Department of Radiology, The Jikei University School of Medicine
Shunichi Sadaoka, Hideomi Yamauchi, Hirokazu Ashida, Ken Koyama, Aakari Sadaoka, Masahiro Nagase

 Budd-Chiari syndrome is a rare condition, which is thought to affect a couple of hundred patients in Japan per year. It is defined as portal hypertension owing to occlusion or stenosis of main hepatic vein or IVC intrahepatic portion. We will discuss this entity and write about our recent case. Budd-Chiari syndrome is divided into three categories : hepatic type, IVC type, or mixed type. The main strategy to treat this condition used to be medical management, or making shunts. But, recently TIPS, PTA, and transplantations are available. Among them IVR is coming to be the procedure of choice. Therefore we have to know about this condition.

Key words

  • Budd-Chiari syndrome
  • Interventional radiology(IVR)
  • Percutaneous transluminal angioplasty(PTA)


6. Pelvic Venous Intervention : Ovarian Varices(Pelvic Congestion Syndrome)and Spermatic Varicocele

Department of Radiology, Aichi Medical University
Yuichiro Izumi, Tsuneo Ishiguchi, Akira Kitagawa, Eisuke Katsuda, Yukihiko Oshima
Joe Matsuda, Junko Kimura, Makiyo Hagihara, Seiji Kamei, Toshiki Kawamura

 Pelvic congestion syndrome with an incompetent ovarian vein is a condition that in some particular patients carries significant morbidity. While incompetent and dilated ovarian vein is a common finding in routine CT and MR imaging, ovarian venography remains the “gold standard” for evaluation. Percutaneous transcatheter embolization offers a minimally invasive, safe, and effective treatment for pelvic congestion syndrome. Bilateral embolization, if necessary, using a sclerosing agent and coils has been shown to be associated with better results. Radiologists should be aware of the clinical manifestations of the pelvic congestion syndrome so that appropriate patients will be referred for the treatment.
Another subject is spermatic varicocele causing swelling and pain of the scrotum that may be associated with sperm abnormalities causing male infertility. Transcatheter embolization is a safe and effective treatment with a low recurrence rate. As a treatment for infertility, however, careful patient selection is mandatory because only patients with abnormal sperm parameters will benefit from treatment.

Key words

  • Pelvic pain syndrome
  • Pelvic venous incompetence
  • Male infertility


7. Adrenal Venous Sampling

Department of Radiology and Second Division, Department of Medicine1), Hamamatsu University School of Medicine
Shuhei Yamashita, Hatsuko Nasu, Mika Kamiya, Kosuke Yogo1)
Miho Yamashita1), Yutaka Oki1), Harumi Sakahara

 Primary aldosteronism has an estimated prevalence of 5〜10% of all patients with hypertension. Aldostrone producing adenoma or unilateral hyperplasia is usually treated with unilateral laparoscopic adrenalectomy. Adrenal venous sampling is the standard reference for determining the indication of adrenalectomy. In this article, we describe the indications and technical procedure of adrenal venous sampling, and discuss the interpretation of the obtained results.

Key words

  • Adrenal venous sampling
  • Primary aldosteronism
  • Hypertension


Original Article

A Multipurpose Vascular Model System with Pulsation

Department of radiology, University of Yamanashi
Takuji Araki, Hiroki Okada, Kazufumi Kimura, Hajime Sakamoto, Tsutomu Araki

Purpose : The purpose of this study was to design an inexpensive system of an artery model with pulsation for training in procedures such as transcatheter arterial coil embolization or experiments. The system was made to fulfill the following requirements.(1)imitating the pulsation of the arterial blood flow,(2)minimal change of the pressure in the system after embolization,(3)feasibility of microcatheter manipulation,(4)non-visualization of artery models’wall under fluoroscopy without the use of contrast materials.
Materials and Methods : For the first requirement(1), silicone artery models with a tubing pump were provided to imitate the pulsating arterial blood flow. For(2), this system had an adjustment system for keeping the intraluminal pressure constant even when the flow in the vessel model stopped after embolization. The adjustment system controlled the intraluminal pressure by fluid level in another drainage route standing vertically besides the main artery model route. The artery model runs through a water phantom with a small amount of contrast materials not to be visualized under fluoroscopy.
Results : Intraluminal pressure was controlled in this system and was well relative to flow rates. The pressure changed minimally under the clamp test at a range of 8 to 16mmHg. The artery model was not visualized under fluoroscopy without contrast materials. This system was available for training of coil embolization using a silicone aneurysm model, though there was a minimal frictional resistance between the silicone and coils. The cost of this system was about ¥300.000.
Conclusions : This multipurpose vascular model system with pulsation was inexpensively made and had feasibility for training of procedures such as coil embolization.

Key words

  • Vascular model system with pulsation
  • Simulation training
  • Silicone artery model


Case Report

Effective Portal Stent Placement Using “Kissing” Technique by Transileocolic Approach for Jejunal Variceal Bleeding in Afferent Loop Caused by Local Recurrence of Hilar Cholangiocarcinoma : A Case Report

Department of Diagnostic Radiology, Graduate School of Biomedical Sciences, Hiroshima University
Masaki Ishikawa, Hideaki Kakizawa, Masashi Hieda, Chihiro Tani
Department of Radiology, National Hospital Organization, Kure Medical Center
Naoyuki Toyota
Department of Medical Imagings, Kouseiren Hiroshima General Hospital
Toshihiro Tachikake
Department of Radiology. Hiroshima City Hospital
Noriaki Matsuura
Department of Radiology, Onomichi General Hospital
Katsuhide Ito

Malignant portal vein stenosis or occlusion can lead to portal hypertension with complications such as intestinal variceal bleeding. We report herein a patient successfully treated by transileocolic portal venous stent placement using kissing technique for malignant portal vein obstruction with associated small bowel varices. The case had liver dysfunction and anemia caused by melena. Portography showed severe stenosis of the bilateral first branches of the portal vein from recurrent hilar cholangiocarcinoma and dilated jejunal veins supplying varices as the suspected cause of intestinal bleeding. Double self-expandable metallic stents were placed in bilateral branches of the portal vein across a main portal vein using the “kissing” technique by transileocolic approach. Portography after stent placement showed relief of the portal vein stenosis and disappearance of the jejunal venous collaterals. Liver dysfunction and symptoms were improved after the procedure. Kissing stenting via an transileocolic approach is an effective option for malignant obstruction of bilateral portal vein branches.

Key words

  • Portal vein stent implantation
  • Transileocolic venous approach
  • Kissing stent


Case Report

Ehlers-Danlos Syndrome Type IV Treated with Coil Embolization for a Splenic Pseudoaneurysm : A Case Report

Department of Radiology and Vascular Surgery1), Kurume University School of Medicine
Seigo Yoshida, Masamichi Koganemaru, Toshi Abe, Ryoji Iwamoto
Naofumi Hayabuchi, Tomoyuki Okazaki1), Hidetoshi Akashi1)
Department of Radiology, Tobata Kyoritsu Hospital
Daiji Uchiyama

Ehlers-Danlos syndrome(EDS)is a disorder affecting connective tissue including joint lesions, skin and artery lesions. Patient with EDS often develop aneurysm/pseudoaneurysm. Surgical and endovascular interventions are fraught with complications and high morbidity.
We report a case of EDS typeⅣ(also known as the arterial type or ecchymotic type)with a splenic pseudoaneurysm. Although this patient experienced vascular trauma of splenic artery during catheterization, he was successfully treated by transcatheter arterial embolization(TAE), with detachable coils obtained. Initially, endovascular interventions proved to be preferable to open surgery due to the minimum trauma in EDS typeⅣ patient ; however, upon further examination, the current mode of treatment is therapeutic plane in detail.

Key words

  • Ehlers-Danlos syndrome type IV
  • Coil embolization
  • Splenic pseudoaneurysm

Technical Note

Initial Experience Using a 3 French Pigtail Catheter for Aortography

Department of Radiology, General and Cardiothoracic Surgery1), Kanazawa University Hospital
Kumi Ozaki, Junichiro Sanada, Hiroshi Ohtake1), Keiichi Kimura1), Satoshi Kobayashi
Tetsuya Minami, Takahiro Ogi, Go Watanabe1), Toshifumi Gabata, Osamu Matsui

We report our experience using a 3 French pigtail catheter(CX catheter-A II; Cathex ; Kanagawa, Japan)for aortography. The 3 French pigtail catheter is made of nylon, and the distal portion forms a loop, 8mm in diameter, in which 12 holes are spirally punctured. The inner and outer diameters are 0.87mm and 1.17mm, respectively, while the length of the catheter can be either 70㎝ or 110㎝. The catheter has a lumen of 0.87mm, and accepts a 0.032inch guidewire. The maximum injection pressure allowed is less than 1200 psi. The maximum injection rate is 16ml/s in the 70㎝ catheter and 12ml/s in the 110cm catheter. The image quality obtained with the 3 F pigtail catheter was sufficient to diagnose and complete procedures during various kinds of examinations. After angiographic procedures, the brachial or femoral artery was manually compressed for 5 minutes, and the patient was confined to bed rest with compression by a plaster cast or a cross bandage for 120 min, with no complications noted at the puncture site. The 3 F pigtail catheter is feasible and useful for aortography.

Key words

  • 3 French
  • Pigtail catheter
  • Aortography