Jpn J Intervent Radiol Vol.29 No.2 2014

State of the Art
Interventional Radiology for Nontraumatic Bleeding

An Introduction  
Department of Diagnostic Radiology, Japan Red Cross Kyoto Daiichi Hospital
Hiroyuki Morishita

1. Interventional Radiology for Hemoptysis

Department of Diagnostic Radiology, Kyoto City Hospital
Katsumi Hayakawa, Masato Tanikake

Massive hemoptysis is one of the most dreaded of all respiratory emergencies and can have a variety of underlying causes. Bronchial artery embolization (BAE) is a relatively safe treatment for refractory hemoptysis. However, non-bronchial systemic arteries can be a significant source of massive hemoptysis and a cause of recurrence after successful BAE. Moreover, a highly-advanced catheter technique is required because of the smaller arterial size, advanced patient’s age and a dangerous complication such as spinal cord injury. In this review, we discuss the indications and contraindications for IVR with the pathophysiologic features of massive bleeding, the importance of MD-CT and CTA before BAE, the technique with the characteristics of the various embolic agents used in the procedure, short-term and long-term results and possible complications.

Key words

  • Hemoptysis
  • Bronchial artery embolization
  • Non-bronchial systemic artery

2. IVR for Non-traumatic Arterial Bleeding of Gastrointestinal Tract

Division of Radiology, Department of Pathophysiological Therapeutic Science, Faculty of Medicine, Tottori University
Shinsaku Yata

Non-traumatic arterial bleeding of gastrointestinal (GI) tract is associated with potential morbidity and mortality. When it fails to achieve hemostasis by an endoscopic measure, transcatheter arterial embolization (TAE) is a good treatment option with a high rate of hemostasis and a low rate of ischemic complication. Various kinds of embolic materials including gelatin sponge particles, metallic coils, and N-butyl-2-cyanoacrylate (NBCA) may be used. Each embolic agent has its own characteristics, benefits and drawbacks that interventionalists need to be familiar with. The choice of embolic agent depends on a combination of the bleeding location, vascular anatomy, achievable catheter position, and the operator’s preference. Evaluation of the angiographic findings is also important. Not only direct signs of GI bleeding like extravasation of contrast medium, but also indirect signs including pseudoaneurysm, vessel spasm or cutoff, and increased vascularity must not to be missed. Provocative angiography or empiric embolization may be useful when the bleeding site cannot be identified angiographically. Compared with TAE, intraarterial vasopressin infusion therapy has disadvantages of a high recurrent bleeding rate and a long-term placement of catheter, but is still probably preferable for diffuse lesions.

Key words

  • Gastrointestinal tract bleeding
  • Embolization
  • Embolic materials

3. Interventional Radiology for Non-traumatic Hepatic and Pancreatic Bleeding

Department of Diagnostic Radiology, Japan Red Cross Kyoto Daiichi Hospital
Hiroyuki Morishita, Takaaki Itou
Department of Radiology, North Medical Center, Kyoto Prefectural University of Medicine
Yoshito Takeuchi

Vascular embolization is now used as a surgical alternative for non-traumatic and traumatic arterial bleeding.
In this report, we describe the outline of percutaneous hemostatic procedures for non-traumatic hepatic or pancreatic arterial bleeding.

Key words

  • Liver
  • Pancreas
  • Emergency
  • Hemostasis

4. Non-traumatic Spontaneous Retroperitoneal Hemorrhage

Department of Radiology and Center for Endovascular Therapy, Kobe University Graduate School of Medicine
Keitaro Sofue, Masato Yamaguchi, Naoto Katayama, Akhmadu Muradi
Eisuke Ueshima, Yutaka Koide, Takuya Okada, Koji Idoguchi, Koji Sugimoto

Spontaneous retroperitoneal hemorrhage (SRH) is defined as a retroperitoneal hemorrhage that occurs without proceeding trauma or any underlying pathology. Survival of patients with SRH depends on rapid and accurate diagnosis followed by imperative management, as the bleeding is often insidious and initially unrecognized. Management had mainly consisted of conservative treatment including cessation or reversal of the anticoagulation, fluid resuscitation, and transfusion previously. Although endovascular intervention of transarterial embolization (TAE) for retroperitoneal hemorrhage caused by trauma or iatrogenic injury is an established procedure, TAE for SRH has been controversial due to its unknown pathophysiology and occult diffuse microvascular bleeding. There is therefore no contemporary consensus to suggest when to attempt transarterial embolization in the treatment of SRH.

Key words

  • Spontaneous retroperitoneal hemorrhage
  • Contrast-enhanced computed tomography
  • Transarterial embolization

5. Nontraumatic IR of Obstetric and Gynecology

Department of Radiology amd Obstetrics and Gynecology1), St. Marianna University School of Medicine
Misako Nishio, Shingo Hamaguchi, Yukihisa Ogawa, Yasunori Arai
Kazuki Hashimoto, Yasuo Nakajima, Suguru Igarashi1), Nao Suzuki1)

Transcatheter arterial embolization has become a major treatment modality in a variety of obstetric and gynecologic applications.
We describe three items mainly ①The pitfall in IR obstetric hemorrhage ②Selection of embolic material ③Bleeding by tumor necrosis.

Key words

  • Gynecologic and obstetric hemorrhage

Case Reports

Endovascular Treatment using a Covered Stent for Life-threatening Hemorrhage of Cerrical Artery in Two Patients with Advanced Esophageal Cancer after Chemoradiotherapy

Department of Radiology and Esophago-Gastric Surgery1), Juntendo University Faculty of Medicine
Daisuke Tsuge, Akihiko Shiraishi, Tatsuro Inoue, Akihiro Hotta, Yuki Yamashiro
Kazuhiro Suzuki, Yoshiaki Kajiyama1), Ryohei Kuwatsuru

Two cases of thoracic artery extravasation were treated with covered stents. Both cases who had advanced esophageal cancer after irradiation were in hemorrhagic shock condition, because of life-threatening hemorrhage. Enhanced CT revealed extravasation of the left common carotid artery, accompanied by right aberrant subclavian artery in one case. Endovascular repair using covered stents resulted in complete exclusion of the pseudoaneurysm and control of the bleeding. Endovascular treatment with covered stents for hemorrhage of common carotid and subclavian arteries can be a safe and helpful treatment.

Key words

  • Covered stent
  • Hemorrhagic shock
  • Irradiation for esophageal cancer

Case Reports

Long-term Survival in a Patient with Unresectable Hepatic Metastatic Melanoma after Transcatheter Arterial Chemoembolization/Arterial Infusion Chemotherapy: A Case Report

Department of Radiology and Dermatology1), Kurume University School of Medicine
Tomoko Kugiyama, Masamichi Koganemaru, Ryoji Iwamoto, Masashi Kusumoto
Asako Kuhara, Masako Kaku, Hiroshi Saruta1), Toshi Abe

Here we describe the long-term survival of a patient with hepatic metastases from cutaneous malignant melanoma treated by repeated transcatheter arterial chemoembolization (TACE) and arterial infusion chemotherapy (TAIC). Hepatic metastases were observed as multiple nodular tumor stains without extrahepatic metastasis 29 months after surgery for cutaneous malignant melanoma. Successful control of the tumors was achieved in this patient, as was a high quality of life during chemotherapy. The patient died of multiple organ failure 36 months after the initial endovascular therapy. Understanding the form of liver metastases with digital subtraction angiography contributes to improved outcomes of endovascular therapy. The present case supports TACE/TAIC as an effective therapy against hepatic metastases from malignant melanoma, particularly those with a nodular appearance on angiography.

Key words

  • Malignant melanoma
  • Hepatic metastases
  • TACE
  • TAIC