Jpn J Intervent Radiol Vol.25 No.4 2010

State of the Art
Dynamic Regional Anatomy

Respect of Anatomy  Yoshito Takeuchi

1. Anatomy of Aorta, Peripheral Artery

Department of Radiology, National Cerebral and Cardiovascular Center
Tetsuya Fukuda

 Understanding the normal anatomy, common variants, and important anomalies of aortic arch, abdominal branches of aorta, and iliac arteries is a prerequisite for safe, efficient procedure of angiography as well as interventional radiology. The number of great vessels that arise from aortic arch may be as few as two or as many as six. The left anterior oblique position is typically used to image the aortic arch. The branches of abdominal aorta may be divided into four groups : ventral, lateral, dorsal and terminal, while the dorsal branches supply the body wall. The terminal branches supply the pelvis and lower limbs. The femoral artery begins behind the inguinal ligament, midway between the anterior superior iliac spine and symphysis pubis, and passes down the front and medial side of thigh, where it passes through an opening in adductor magnus to become popliteal. The first 3 or 4 cm of the femoral artery are clinically called “common femoral artery”. The common femoral artery is enclosed, with the femoral veins, in the femoral sheath. Understanding the anatomy of common femoral artery is very important for safe, efficient interventional procedures.

Key words

  • Aorta
  • Peripheral artery
  • Access route


2. Anatomical Consideration of Large Veins and Central Venous Access

Department of Radiology, Center for Endovascular Therapy, Kobe University Hospital
Noriaki Sakamoto, Masato Yamaguchi, Takuya Okada, Kenta Izaki, Kazuro Sugimura, Koji Sugimoto
Department of Diagnostic Radiology, National Cancer Center Hospital
Yoshito Takeuchi, Keitaro Sofue

 Central venous access is one of the most basic interventional procedures and interventional radiologists must know the regional anatomy concerning the procedure.
 In this paper we describe regional anatomy of the subclavian and internal jugular vein that are most often used for the central venous access, with demonstrating the ultrasonic anatomy of the veins.
 We also specify some complications that should be avoided in the procedure.

Key words

  • Central vein
  • Anatomy
  • Venous access


3. Overview of the Vasculature of the Hepatic Hilum

Department of Diagnostic Imaging, Cancer Institute Hospital
Kiyoshi Matsueda
Shinichi Hori

 We demonstrate an overview of the vasculature of the hepatic hilum, an anatomically important part of the liver. Extending the hepatic hilum from the right end of the hepatoduodenal ligament attachment to the left end of the fissure for the ligamentum venosus, which is located at the end of the hepatogastric ligament attachment, we could easily understand the vascular structures that enter and leave the liver. We should emphasize the importance of the plate system, when we analyze the kinetics of hepatic blood flow as well as the vascular network in the hepatic hilum. Spatial recognition of the normal vascular arrangement in the hepatic hilum and knowledge about a wide variety of anatomical subtypes would be helpful to improve the clinical practice of IVR.

Key words

  • Hepatic hilum
  • Hepatogastric ligament
  • Hilar plate


4. Puncture of Peritoneal and Retroperitoneal Lesions

Department of Radiology, Shiga University of Medical Science
Akira Furukawa, Shuzou Kanasaki, Tetsuya Toyama, Akinaga Sonoda
Shinichi Ohta, Toyohiko Tanaka, Norihisa Nitta, Kiyoshi Murata
Department of Radiology, Kohka Public Hospital
Tsutomu Sakamoto

 Image-guided percutaneous approach to intra-abdominal and intra-pelvic lesions has been widely used for the purpose of lesion biopsy and abscess drainage. Especially percutaneous abscess drainage has become a rapid and safe primary procedure for most abdominal infected fluid collections that used to require open surgery. In the majority of cases, lesions can be reached percutaneously avoiding intervening organs and vital structures under imaging guidance ; however, several locations, such as subphrenic, posterior epigastric, peripancreatic and deep intrapelvic spaces present technical difficulties. In this article, image-guided percutaneous approach to intra-abdominal and intra-pelvic lesions is demonstrated with an emphasis on the special techniques to reach problematic locations. In addition, the basic anatomy and the current concept of the retroperitoneum are reviewed.

Key words

  • Percutaneous abscess drainage
  • Image guided
  • Retroperitoneum


5. Anatomy of the Chest related to Interventional Procedures

Department of Diagnostic Radiology, National Cancer Center Hospital
Hiroyasu Fujiwara, Yasuaki Arai, Yoshito Takeuchi
Department of Radiology, Okayama University Hospital
Kentaro Shibamoto, Susumu Kanazawa

 Chest consists mainly of chest wall and thoracic cavity. Chest wall is composed of chest spine, sternum and muscles. These structures protect lung, heart and other mediastinal organs. Intercostal space is a popular access route to perform many kinds of interventional procedures in the chest. There are three large cavities in the chest : bilateral pleural cavities and pericardial cavity. Drainage of pleural effusion, pericardial effusion and abscess is frequently performed and is very important in clinical practice. Anatomical knowledge is essential to undertake safe interventional procedures. To minimize complications such as massive hemorrhage or nerve injury, we have to know where larger arteries or important nerves are running. This article provides anatomical knowledge and several comments related mainly to non-vascular interventional procedures.

Key words

  • Chest
  • Anatomy
  • IVR


6. Spine and Spinal Cord

Department of Anesthesiology,Tokyo Medical University
Kiyoshige Ohseto

 Pain clinic treatment mainly consists of the nerve blockade. Recently, the visualization of the needle by under−fluoroscopy, ultrasound guidance and CT−guided nerve blockade has become common to reach the intended nerve site safely while watching the needle. This means that radiologists could perform the same maneuver such as test or treatments using the same equipment. We assume that radiologists can obtain even a better outcome, if applying nerve blockade.

Key words

  • Spine
  • Nerve blockade
  • Under−fluoroscopy

Original Article

Long-term Results of Endovascular Repair of Abdominal Aortic Aneurysms with Zenith AAA Endovascular Graft

Department of Radiology, Cardiothoracic Surgery1), Mie University Hospital
Shuji Chino, Noriyuki Kato, Mikito Inouchi
Kan Takeda, Takatsugu Shimono1), Hideto Shimpo1)

Background : The purpose of this study is to show long-term results of endovascular repair of abdominal aortic aneurysms with Zenith AAA Endovascular Graft in a Japanese population.
Patients and Methods : Fifteen patients with abdominal aortic aneurysms, who underwent endovascular repair with Zenith AAA Endovascular Graft before approval by the Ministry of Health, Labor and Welfare, were included in this study. All but one patient were within the anatomical inclusion criteria of the instruction for use. Five patients were deemed as low-risk, and the other ten as high-risk.
Results : There were no perioperative deaths. During the mean follow-up of 66 months, 10 patients(67%)died of various causes including malignancies. However, there was no death related to the abdominal aortic aneurysm. Five-year and seven-year survivals were 53% and 53%, respectively. Those of low-risk patients were 100% and 100%, while those of high-risk patients were 30% and 30%.
Conclusions : Endovascular repair of abdominal aortic aneurysms with Zenith AAA Endovascular Graft may be durable in limited patients. However, further evaluation should be undertaken to prove its efficacy in high-risk patients.

Key words

  • Abdominal aortic aneurysm
  • Endovascular repair
  • Stent-grafts
  • Long-term results
  • Zenith AAA Endovascular Graft

Original Article

An Observation Study of Radiation Exposure to Nurses during Interventional Radiology Procedure

Department of Radiology, Nursing Section1), the Third Department of Internal Medicine2),
Kansai Medical University
Atsushi Komemushi, Noboru Tanigawa, Atsuko Aoki1), Makiko Miyamoto1)
Yuko Kikukawa1), Takanori Tokuda, Yugo Ando2), Kazuko Aoki1), Lushu Kim1)
Mieko Matsuoka1), Shuji Kariya, Koshi Ikeda, Keita Utsunomiya
Yoko Harima, Hanako Matsuoka1), Satoshi Sawada
Department of Radiology, Saiseikai Izuo Hospital
Akira Sano
Graduate School of Engineering, Osaka City University
Sadao Komemushi

Purpose : The purpose of this study was to prospectively measure the level of radiation exposure among nursing staff during interventional radiology procedures.
Methods : All interventional radiology procedures performed at our institution between April 20 and June 19, 2009 were included in this study.
Radiation exposure was measured as the equivalent dose penetrating tissue to a depth of 10㎜ using electronic personal dosimeters attached outside(Ha)and inside(Hb)lead aprons. Effective dose(HE)was estimated by calculating from Ha and Hb.
Results : In total, data from 68 procedures were included in this study. Four nurses performed 71 nursing cares. The mean Ha was 0.70±1.0μSv, while the mean Hb was 0.06±0.2μSv. The mean HE was 0.14±0.3μSv.
Conclusion : The present findings indicate that during interventional radiology procedures, nurses were exposed to very low levels of radiation.

Key words

  • Radiation exposure
  • Nurse
  • Nursing care

Original Article

Percutaneous Catheter Drainage of Postoperative Pelvic Lymphoceles

Department of Radiology, Gynecology1)
National Hospital Organization Kure Medical Center and Chugoku Cancer Center
Naoko Takeuchi, Naoyuki Toyota, Yuko Nakamura, Hiroko Nakamura1)
Yousuke Kawakami1), Osamu Samura1), Masatoshi Kumagai1)
Kazuhiro Takehara1), Tomoya Mizunoe1)

Treatment is sometimes required for symptomatic pelvic lymphoceles. We assessed the efficacy of percutaneous catheter drainage alone for pelvic lymphoceles. Sixteen symptomatic lymphoceles in 13 patients were treated by percutaneous catheter drainage without sclerotherapy between May 2006 and September 2009. All lymphoceles developed after radical pelvic lymphadenectomy for gynecologic malignant tumor. Technical success rate was 100% and clinical success rate was 85%. Two recurrences(15%)occurred in non-infected cases. No recurrence was observed in infected cases. Mean duration of catheter drainage was 11.6 days(range, 3〜28 days), and mean volume of drainage at catheter removal was 18.4㎖/day(range, 0〜70㎖/day). No major complications were encountered. Percutaneous catheter drainage alone seems to be a safe and effective procedure for pelvic lymphoceles, especially in infected cases.

Key words

  • Lymphocele
  • Lymphocyst
  • Percutaneous drainage
  • Lymphatic system
  • Infection

Case Report

A case report ; Damage Control Transcatheter Arterial Embolization was Very Effective for Massive Hemorrhage due to Rupture of the Axillary Artery from Blunt Extremity Trauma

Department of Radiology and Radiation Oncology, Hirosaki University Graduate School of Medicine1)
Department of Radiology2), Emergency and Critical Care Medicine3), Cardiovascular Surgery4),
National Hospital Organization Disaster Medical Center
Kohei Morimoto1,2), Takayuki Hattori2), Iwao Uejima2)
Nobuaki Kiryu3), Tetsuya Niino4), Shuichi Ono1)
Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine,
Department of Radiology, St Marianna University Yokohama Seibu Hospital
Junichi Matsumoto

 Awoman in her 80s was suffering from blunt right upper extremity trauma with fracture of the surgical neck of the humerus. She was transported to our hospital in shock, and rupture of the main trunk of the axillary artery was diagnosed by whole body contrast CT examination. The medical examination revealed hemodynamic instability, and we decided to perform transcatheter arterial embolization. With interventional radiology, bleeding was well controlled and her general condition improved. Therefore, revascularization surgery could be performed successfully and she recovered without loss of her upper extremity.
 Limb fracture is frequently encountered in emergency care, but vascular trauma with fracture is uncommon, and rupture is very rare. When the main trunk of an extremity artery is ruptured, the patient’s life might be threatened by massive hemorrhage. In the emergency setting, interventional radiology is very useful for hemostatic control, but the procedure should be completed as quickly as possible before the patient’s condition deteriorates further. In this context, radiologists should be knowledgeable about the concept of damage control intervention.

Key words

  • Blunt extremity trauma
  • Damage control
  • Interventional Radiology