Jpn J Intervent Radiol Vol.28 No.3 2013

State of the Art
Perioperative Management and Outpatient Care of Vascular Interventional Radiology

An Introduction  
Department of Endovascular Treatment, General Foundation Institute for Training and Medical Seimeikai Narumi Hospital
Hiroshi Noda

1. Carotid Artery Stenting-periprocedural Management and Follow-up for Outpatient

Department of Radiology and Interventional neuroradiology, Ishinkai Yao General Hospital
Katsutoshi Takayama, Kaoru Myouchin
Department of Radiology, Nara Medical University
Takeshi Wada, Kimihiko Kichikawa

Carotid artery stenting (CAS) for carotid stenosis has been effective not only in patients at high risk, but also those at conventional risk for carotid endarterectomy (CEA) and is becoming an alternative to CEA. However, the incidence of periprocedural stroke is higher with CAS than with CEA. Reducing the incidence of periprocedural stroke and other periprocedural complications also has become a necessary goal to permit CAS to be performed safely. On the other hands, CAS specific periprocedural complications including bradycardia, hypotension, stroke, hyperperfusion syndrome, and central retinal artery occlusion also exist. It is very important for CAS physicians to understand and manage CAS specific complications. Optimal management could reduce the periprocedural complication rate to a minimum. From our CAS experience of over 450 cases, we describe in detail how to manage the periprocedural periods and follow-up for out-patients after CAS.

Key words

  • Carotid artery stenting
  • Patient management
  • Follow-up for outpatient

2. Endovascular Therapy for Patients with Chronic Lower Limb Arterial Obstruction

Department of Interventional and Diagnostic Radiology, Tsuchiya General Hospital
Tomoyasu Sato

Endovascular therapy "EVT" has been recognized as a useful and low invasive technique for treating patients with PAD, especially critical limb ischemia patients. Most of these patients also have cardiovascular and/or cerebrovascular disease, and their prognosis is poor. To manage their general condition is quite important to avoid complications during the procedure. Antegrade ipsilateral approach is needed to recanalize chronic total occlusions of the superficial femoral artery and lower leg arteries. To recanalize long chronic total occlusion, a bidirectional approach is quite useful if antegrade recanalization fails. Additional distal puncture is needed in some cases. Trans-collateral wiring and catheterization can be done in some cases. Once the wires pass through the total occlusion, balloon angioplasty can be done without difficulty after wire rendez-vous technique. Angiosome related recanalization is sometimes very effective for ulcer healing. Though the long term patency of these recanalized arteries is not satisfactory, it is enough that those arteries are kept open until wound healing is obtained. EVT has an important role in the treatment of critical limb ischemia.

Key words

  • Critical limb ischemia(CLI)
  • Diabetic foot
  • Endovascular therapy(EVT)
  • Angiosome

3. Perioperative Management and Outpatient Care of Acute Limb Ischemia That Interventional Radiologists Should Know

Department of Endovascular Treatment, General Foundation Institute for Training and Medical Seimeikai Narumi Hospital
Hiroshi Noda

For the treatment of acute lower limb ischemia, the most important issues are early evaluation, diagnosis, and revascularization. I described in this paper that in order to rescue patients with acute lower limb ischemia, interventional radiologists should recognize them. These include evaluation and diagnosis of acute lower limb ischemia, and perioperative patient care, and outpatient care for the prevention of recurrence for acute lower limb ischemia. Then, I believe that the interventional radiologists involved in perioperative management, trust from the surgeon will become strong.

Key words

  • Acute limb ischemia
  • Perioperative patients care
  • Interventional radiologists

4. Care and Management of Patients with Abdominal Aortic Aneurysm Treated by Endovascular Aortic Aneurysm Repair

Department of Radiology, Nara Medical University
Shinichi Iwakoshi, Shigeo Ichihashi, Hirofumi Itoh, Kimihiko Kichikawa
Department of Stentgraft and Endovascular Therapy, Matubara Tokusyukai Hosipital
Masahide Takahashi, Shoji Sakaguchi
Department of Radiology, Okinawa Chubu Hospital
Wataru Higashiura

Endovascular aortic aneurysm repair (EVAR) has become widely used in the last decade in Japan. Many reports have demonstrated that EVAR is superior to open repair (OR) in terms of the early and mid-term outcomes. The techniques and technologies of EVAR are rapidly advancing and we must catch up with the trends. We should know not only techniques and technologies, but also the care and management of the patients treated by EVAR. A lot of randomized control trials and surveys tell us what to do and not to do for the patients of EVAR. In this paper, we introduce many of them and show our protocols.

Key words

  • EVAR
  • Care of patients
  • Follow up

5. Vascular Access Interventional Therapy

Vascular Access Center, Sendai Social Insurance Hospital
Yasuo Goto

Perioperative period management of Vascular Access Interventional Therapy (VAIVT).
In order to manage VAIVT efficiently, various systems including an STS hospital-and-clinic-cooperation path or clinical path of a "vascular access interventional therapy" have been created. In our hospital, a good relationship has been established between departments related to VAIVT. This cooperation is not something that can be established by IVRist alone. It is the result of efforts of the persons involved in many departments including not only kidney disease center, and vascular access center, dialysis room, but also vascular surgery which is taking a part of surgical reconstruction of VA at the time of VAIVT failure, outpatient department of kidney disease center, a hospital-and-clinic-cooperation room, etc.
IVRists should be actively involved in creating a good relationship with the other departments.

Key words

  • Vascular access
  • Clinical path
  • Hospital-and-clinic-cooperation

6. Periprocedural and Clinical Managements of Inferior Vena Caval Filters

Department of Diagnostic Radiology, Tokai University School of Medicine
Jun Koizumi, Chihiro Itou, Naoko Mori, Tatsuya Sekiguchi

Because anticoagulation remains the primary treatment for venous thromboembolism, vena caval filter placement is generally indicated for the patients with contraindications to, failure or adverse events of anticoagulation. After the report of the international cooperation of pulmonary embolism registry (ICOPER) II where vena caval filters were associated with a significant reduction in the 90-day mortality in the patients with massive pulmonary thromboembolism, the patients with severe pulmonary thromboembolism, persistent pulmonary hypertension and poor cardiopulmonary function reserve are included into the relative indications of vena caval filter placement. Several temporary filters were developed after PREPIC study, where the initial beneficial effect of vena caval filters for the prevention of pulmonary thromboembolism was counterbalanced by an excess of recurrent deep venous thrombosis without any mortality difference. However, unsatisfactory results of temporary filters including the migration, infection, difficulties in case of tough clots’ capture etc. facilitated the development and prevalence of retrievable (optional) filters. The indications and timing of the retrieval should be investigated in the future.

Key words

  • Inferior vena cava filter
  • Periprocedure and clinical management
  • Anticoagulation

Original Article

Techniques to Prepare Epirubicin-Lipiodol Emulsion for Transcatheter Arterial Chemoembolization of Hepatocellular Carcinoma
-Additional Survey of the Japanese Institutions in a Cooperative Study between Korea and Japan-

Department of Diagnostic Radiology, National Cancer Center Hospital
Yasuaki Arai
Department of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East
Masafumi Ikeda

Background: The single-arm study of transcatheter arterial chemoembolization (TACE) for unresectable hepatocellular carcinoma (HCC) between Korea and Japan showed a markedly favorable efficacy with mild toxicity, and its results will be regarded as valuable data to obtain regulatory approval for this treatment modality. However, the details of the technique to prepare epirubicin-lipiodol emulsion have not been clarified. Therefore, we conducted an additional survey of the technique in the Japanese institutions participating in the cooperative study.
Method: The following items were included in the questionnaire sent to the 19 institutions.
1) Number of patients enrolled in the Korea-Japan cooperative study.
2) Whether preparation of epirubicin-lipiodol emulsion is changed in individual cases or not.
3) Detailed technique to prepare epirubicin-lipiodol emulsion
4) The volume ratio of lipiodol and the emulsion for mixture
Results: Seventy-five patients were enrolled from 19 institutions. In each institution, the technique to prepare epirubicin-lipiodol emulsion was standardized. Although there were slight differences in individual institutions, in most the emulsion consisted of a small volume of epirubicin solution and contrast medium mixed with lipiodol in a 1:1 to 1:2 ratio.
Conclusion: Techniques to prepare epirubicin-lipiodol emulsion are largely standardized, and the minimal differences are recognized in the allowable range considering the favorable efficacy and mild toxicity shown by the Korea-Japan cooperative study.

Key words

  • Hepatocellular carcinoma
  • Transcatheter arterial chemoembolization
  • Epirubicin
  • Lipiodol
  • Emulsion

Case Reports

Jejunal Varices Treated by Modified B-RTO Procedure with Manual Compression: A Case Report

Department of Radiology and Pediatric General and Urogenital Surgery1),
Faculty of Medicine, Juntendo University
Tatsuro Inoue, Ryohei Kuwatsuru, Akihiro Hotta, Kana Yamazaki
Daisuke Tsuge, Akihiko Shiraishi, Tsubasa Takahashi1), Atsuyuki Yamataka1)

Ectopic varix is an important cause of gastrointestinal bleeding that can occur in patients who have undergone laparotomy. Ectopic varix is difficult to identify as the source of a gastrointestinal bleed and control of the bleeding is often challenging. Here we present the case of a woman with recurrent gastrointestinal bleeding that occurred 20 years after choledocojejunostomy for biliary atresia, in whom jejunal varices were revealed as the cause of bleeding by abdominal contrast-enhanced CT and non-contrast-enhanced MRA. We were able to treat the varices by retrograde transvenous obliteration with manual compression, which we termed the modified B-RTO procedure. This case shows that the high curability of B-RTO and similar treatments make these methods useful for ectopic varix as well as gastric varix.

Key words

  • Percutaneous retrograde sclerotherapy
  • Ectopic varix
  • Gastrointestinal bleeding

Case Reports

A Case of Celiac Artery Aneurysm Successfully Treated with Endovascular Stent-Graft Placement

Department of Radiology, Mie University Hospital
Takatoshi Higashigawa, Noriyuki Kato, Takashi Hashimoto
Mikito Inouchi, Shuji Chino, Hajime Sakuma

A man in his forties who had a celiac artery aneurysm was treated with endovascular therapy. The diameter of the aneurysm was 19mm and the length of the proximal neck was 7mm. The aneurysm extended from the celiac artery through the common hepatic artery. Localized dissection was found at the origin of the common hepatic artery. The distal end of the common hepatic artery was occluded and the retrograde blood flow from the superior mesenteric artery via the pancreatic arcade supplied the proper hepatic artery. The aneurysm was treated with a combination of embolization of the left gastric artery and left inferior phrenic artery with coils, and endovascular placement of a covered stent. The covered stent was placed from the orifice of the celiac artery through the proximal portion of the splenic artery to exclude the aneurysm. Although a tiny type II endoleak persisted, shrinkage of the aneurysm to 15mm in diameter was confirmed on follow-up CT obtained 15 months later.

Key words

  • Celiac artery aneurysm
  • Endovascular therapy
  • Stent-graft

Case Reports

A Case of Massive Lateral Abdominal Wall Hematoma Caused by Injury to the Superficial Circumflex Iliac Artery due to Blunt Trauma

Department of Radiology and Emergency Medicine1), Saiseikai Fukuoka General Hospital
Yuko Matsuura, Daisuke Okamoto, Shunichi Matsumoto, Takashi Toba
Shunsuke Kamei, Tsunehiro Matsubara1), Takachika Ito1), Hirofumi Norio1)
Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University
Yoshiki Asayama

Abdominal wall hematoma can occur for various reasons such as blunt trauma and iatrogenic injury. Abdominal wall hematomas can be of 2 types: rectus sheath hematomas, which are common, and lateral abdominal wall hematomas, which are rare, and only a few cases of such hematomas have been reported. Lateral abdominal wall hematomas resulting from injury to the superficial iliac artery have rarely been reported; however, cases of such hematomas resulting from injury to the deep iliac or inferior epigastric arteries are common.
Here we report a case of massive lateral abdominal wall hematoma caused by injury to the left superficial circumflex iliac artery due to blunt trauma.

Key words

  • Lateral abdominal wall hematoma
  • Superficial circumflex iliac artery
  • Blunt trauma

Co-medical Corner

Radiation Protection During Aortic Stent Grafting: Including Comparison Between Mobile C-arm and Floor-mounted Angiographic Equipments

Department of Radiology, Tottori University Hospital
Katsuhiko Hirota, Naoki Iwata, Masaki Tsuda, Takurou Tanaka

Key words : Aortic stent grafting, Entrance surface dose, Geometrical layouts