Jpn J Intervent Radiol Vol.29 No.4 2014

State of the Art
Interventional Radiology and Palliative Care

An Introduction
Kazuhiko Nakamura

1. Introduction to Palliative Care

Department of Palliative Care and Pain Management, Cancer Institute Hospital
Department of General Surgery, St. Luke’s International Hospital1)
Hiroki Sakurai, Keiiciro Ohta1)

Palliative care is an approach designed to improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. Palliative care is never defined by whether or not to treat.
Pain is an unpleasant symptom that three quarters of cancer patients experience. Cancer pain is categorized mainly into three types:; somatic, visceral, and neuropathic pain. Mainstays of treatment are NSAID or acetaminophen, opioid, and analgesic adjuvants. Appropriately selection of medication leads to favorable analgesia.
Almost 60% of cancer patients suffer nausea and/or vomiting. It is important to select antiemetics based on the underlying mechanism. Opioid naïve patients are recommended to take antiemetics; however, long-term use should be avoided to prevent extrapyramidal symptoms.
Dyspnea is an uncomfortable sensation directly connected to a fear of death. It is caused by a complex of etiology, perception, and emotion, so that a multi-dimensional approach is needed.
To relieve these sufferings, adequate management based on adequate assessment is essential.

Key words

  • Palliative care
  • Pain
  • Nausea/vomiting
  • Dyspnea

2. Interventional Radiology for Palliative Care

Department of Diagnostic Radiology, National Cancer Center Hospital
Yasuaki Arai, Miyuki Sone

Various techniques of interventional radiology are potentially beneficial to provide better management for patients in the palliative stage; however, they have not been used as standard treatments for palliative care. One reason is that the efficacy of interventional radiology for palliative care is not yet sufficiently evidence-based, and another is that interventional radiology is still unfamiliar to many medical staff members as well as patients. To overcome this situation and to make interventional radiology standard, establishing evidence of interventional radiology to achieve adoption in the guidelines is crucial. The Japan Interventional Radiology in Oncology Study Group (JIVROSG) serves as a multi-institutional clinical trial group that has performed a number of clinical trials of interventional radiology and has contributed to making Japan the leading nation in generating evidence in interventional radiology for palliative care. We should recognize the important role of Japan in this field, and make our best efforts to establish interventional radiology in it.

Key words

  • Interventional radiology
  • Interventional oncology
  • Interventional palliation
  • Palliative care

3. Palliative Interventional Radiology for Respiratory Symptom

Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital
Yozo Sato, Yoshitaka Inaba

Dyspnea is a common symptom of patients with cancer and decreases the quality of life. There are several palliative medical therapies for dyspnea including morphine. However, these treatment effects are sometimes limited. Palliative management by interventional radiology (IR) can contribute to improvement of this symptom.
Pleural effusion is one of the most common causes of dyspnea in cancer patients. Percutaneous thoracic drainage is the first-choice IR for pleural effusion and subsequent pleurodesis is widely applied to prevent a reaccumulation of fluid. Also, pleuroperitoneal shunt for pleural effusion may be alternative IR. Here, we describe the indications, treatment effects, and complications of these palliative IR (including pleurodesis). Furthermore, recent topics of medical therapies are mentioned in this manuscript.

Key words

  • Pleural effusion
  • Percutaneous thoracic drainage
  • Pleuroperitoneal shunt

4. Palliative Interventional Radiology for Refractory Malignant Ascites

Department of Diagnostic Radiology, National Cancer Center
Shunsuke Sugawara, Yasuaki Arai, Miyuki Sone, Hiroaki Ishii
Shinich Morita, Yoshiaki Watanabe, Keisuke Chihaya

Patients with advanced malignant tumor frequently develop refractory ascites caused by peritoneal carcinomatosis, multiple liver metastasis, obstruction of portal vein (PV) or inferior vena cava (IVC)/hepatic vein (HV) and that causes uncomfortable symptoms such as abdominal distention and appetite loss. Palliative interventional radiology (IR) techniques such as paracentesis, cell-free and concentrated ascites reinfusion therapy (CART), peritoneovenous shunt (PVS), PV stenting and IVC/HV stenting can provide improvement of these symptoms. To make optimal use of IR for ascites, indications should be decided based on physical examination, expected prognosis, speed of ascites re-accumulation, cytology of ascites, serum-ascites albumin gradient and radiological findings. Paracentesis and CART can provide palliation without serious adverse events and CART can also prevent protein loss, although, the efficacy is temporary. PVS is one of the aggressive treatment options to obtain continuous palliation; however, PVS placement can cause some fatal acute adverse events (e.g. heart failure, 3-12% and disseminated intravascular coagulation, 2-5%). Therefore, appropriate selection of patient and close postoperative management are mandatory for PVS placement. Vascular stenting is effective IR for patients with ascites resulting from obstruction of PV or IVC/HC; however, care should be taken for comorbid peritoneal carcinomatosis, which may contraindicate IR.

Key words

  • Malignant ascites
  • Interventional radiology
  • Palliative therapy

5. Interventional Radiology for Palliation of Gastrointestinal Obstruction

Department of Diagnostic Radiology, Fukuiken Saiseikai Hospital
Shiro Miyayama

Gastrointestinal obstruction is a problematic condition in patients with end-stage malignancies. Metallic stent placement for inoperable esophageal, gastroduodenal, and colonic obstruction is an alternative therapeutic option instead of bypass surgery or nasogastric tube insertion. With advances in stent technology, metallic stent placement can be performed less invasively with high levels of technical and clinical success regardless of the indication for stenting or etiology of the obstruction. However, several complications associated with stent placement in the gastrointestinal tract frequently occur; therefore, interventional radiologists should be well aware not only of the devices and techniques but also complications and patient care.

Key words

  • Gastrointestinal obstruction
  • Palliative care
  • Metallic stent placement
  • Complication

Special Contribution

Development of a Robot for CT Fluoroscopy-guided Intervention: Free Physicians from Radiation

Department of Radiology, Okayama University Medical School
Takao Hiraki, Susumu Kanazawa
Okayama University Graduate School of Natural Science and Technology
Tetsushi Kamegawa, Takayuki Matsuno

Computed tomography (CT) fluoroscopy is a useful imaging modality for guiding various interventional procedures (e.g., ablation, biopsy, and drainage). However, radiation exposure is a major disadvantage of CT fluoroscopy guidance. Even if a physician uses 17-cm forceps, radiation exposure to their hand is 7.0 μGy/s (120 kV; 30 mA). The average activation time for CT fluoroscopy in a lung biopsy has been reported to be approximately 90 s. It is expected that the activation time would be longer for more complex procedures such as ablation for large tumors. Therefore, radiation exposure during CT fluoroscopy is a serious concern for physicians.
Robotic surgery, which is the preferred surgical method for 80% of prostate cancer surgeries in the United States, has been shown to reduce procedural complications. We hypothesized that robotic technology might be more easily applied to CT-guided interventions. If physicians performed CT-guided interventions using a robot that they controlled from a location far from the CT gantry, radiation exposure to physicians could be minimized. However, issues such as metal artifacts and the limited workspace may hinder the development of a robot for CT-guided interventions. More specifically, the robot must be constructed of non-metal materials and it must fit in a small space within the CT gantry. Despite these limitations, we have developed a prototype model of the robot.
The prototype has 5 degrees of freedom and can be remotely operated with a joystick controller. Phantom experiments using the prototype showed no radiation exposure to the operating physician during the procedure. In this article, we will provide an overview of the development of this prototype model, present the limitations of the prototype, and discuss future prospects.

Key words

  • Robot
  • IVR
  • CT-guided
  • Radiation exposure

Original Article

Long-term Outcomes Following Endovascular Therapy for Critical Limb Ischemia with Tissue Loss

Department of Radiology and Cardiovascular Center1), Kansai Rosai Hospital
Daigo Kanamori, Osamu Iida1), Tatsuya Watanabe1), Masashi Fujita1), Masaki Awata1)
Shin Okamoto1), Takayuki Ishihara1), Kiyonori Nanto1), Yukika Mizukami1)
Tatsuya Shiraki1), Takuma Iida1), Takashi Kanda1), Keisuke Okuno1)
Akihiro Sunaga1), Takuya Tsujimura1), Masaaki Uematsu1), Kaname Tomoda

Objective: Although endovascular therapy (EVT) has been widely applied for patients with critical limb ischemia (CLI), the long-term results have not been systematically studied.
Method: We reviewed patients with CLI who were treated with EVT from January 2007 to December 2012. Outcomes included overall survival, freedom from major amputation rate, and freedom from reintervention rate.
Result: EVT was performed in 570 limbs of 459 patients (73±10 years, 64% male). Diabetes mellitus was present in 72% of patients and 52% were on dialysis. One- and 5-year overall survival rates were 81% and 45%, freedom from major amputation rate was 91% and 87%, and freedom from reintervention rate was 58% and 28%, respectively. Factors associated with death were age (hazard ratio [HR]: 1.04, P=0.001), non-ambulatory status (HR: 2.95, P<0,001), Rutherford 6 (HR: 1.87, P=0.013), heart failure (HR: 2.78, P<0.001), hemodialysis (HR: 1.82, P=0.018), and serum albumin score (HR: 0.50, P=0.001). Major amputation was associated with age (hazard ratio [HR]: 0.97, P=0.013), non-ambulatory status (HR: 4.07, P<0,001), vascular calcification (HR: 4.63, P<0.050), serum albumin score (HR: 0.61, P=0.050) and serum CRP(C-reactive protein) score (HR: 1.07, P<0.001). Reintervention was associated with hemodialysis (HR: 1.80, P<0.001) and number of run-off vessels below-the-knee.
Conclusion: Despite both high mortality and high reintervention rates, freedom from major amputation was acceptable after EVT for CLI with tissue loss. Revelation of risk factors on outcomes plays an important role not only in estimating their future occurrence, but also in deciding which revascularization strategy to pursue for CLI patients with tissue loss.

Key words

  • Critical limb ischemia
  • Endovascular therapy
  • Long-term Outcomes


Case Reports

A Case of Ruptured Pseudoaneurysm with Traumatic Pancreatic Transection Successfully Treated with Transcatheter Arterial Embolization

Departments of Radiology and Surgery1), National Center for Global Health and Medicine
Masafumi Toguchi, Tsuyoshi Tajima, Kanehiro Hasuo, Toshifumi Masuda
Takafumi Okafuji, Yoriko Egami, Hiroko Tsukano, Hiroaki Wakiyama
Tatsuya Wada, Mayuko Doi, Yuusuke Kawata, Ooki Miyake1)

In patients with traumatic pancreatic injury, especially in cases complicated with pancreatic transection, the mortality rate is reported to be as high as 13%. Therefore, these patients are usually treated by pancreatectomy. On the other hand, the patients with traumatic pancreatic injury combined with pancreatic transection are rarely treated by transcatheter arterial embolization (TAE). We herein report a case of a ruptured pseudoaneurysm related to traumatic pancreatic transection that was successfully treated by TAE.

Key words

  • Ruptured pancreatic pseudoaneurysm
  • Pancreatic transection
  • TAE


Case Reports

Two Cases of Venous Malformation Successfully Treated with Emboloscelerotherapy

Department of Radiology and Otolaryngology1), Graduate School of Medical Science of the Ryukyus
Tomomi Koga, Kimei Azama, Takayuki Sakugawa, Yogi Akira
Yuko Iraha, Kouta Shingaki1), Sadayuki Murayama
Department of Radiology, Okinawa Prefectural Nanbu Medical Center
Fumikiyo Ganaha

We report two patients with venous malformation (VM) who were successfully treated by embolosclerotherapy. Case 1 is a woman in her 20s, who presented with right upper arm pain due to a brachial intramuscular VM. She underwent two sessions of percutaneous sclerotherapy, however, the pain relief was insufficient. Since her VM appeared to be an ‘intermediate-flow’ lesion based on the findings of dynamic MRI, we tried embolosclerotherapy consisting of feeding-artery-embolizations using gelatin sponge particles and following percutaneous sclerotherapy using ethanol. The treatment effect was significant, and prolonged pain control was obtained without any additional treatment. Case 2 is a woman in her 20s who had the tongue and buccal mucosal VMs. She suffered from bleeding due to biting of the oral cavity VMs. We treated these lesions with 2 sessions of embolosclerotherapy. In this case, to avoid mucosal necrosis we did not use ethanol, and 3% polidocanol was used as a sclerosant. Additional percutaneous sclerotherapy was repeated 3 times in every 4 months at the outpatient clinic. After these treatments, both the tongue and buccal mucosal lesions shrank enough to be resected.

Key words

  • Venous malformation
  • Emboloscelerotherapy
  • Artery embolization


Co-medical Corner

Usefulness of 3D-Roadmap Utilizing the Overlay System for Aortic Endografting

Department of Radiology and Cardiovascular Surgery1),
National Cerebral and Cardiovascular Center
Shohei Doi, Hiromichi Yokoyama, Masanobu Yamada
Naoki Moriyama, Kiyoshi Motomura, Yoshinori Hirase
Tatsuya Satou, Tetsuya Fukuda, Hitoshi Matsuda1)

Key words : 2D-3D image overlay, 3D-roadmap, EVAR