Jpn J Intervent Radiol Vol.31 No.4 2016

State of the Art
Up-to-date Interventional Radiology for Peripheral Arterial Disease

An Introduction
Manabu Nakata

1. Basic Technical Tips of Endovascular Treatment for Aorto-iliac Arterial Diseases

Department of Radiology and IVR center, Nara Medical University
Shigeo Ichihashi, Shinichi Iwakoshi, Wataru Kitatsuji, Natsuhiko Saito
Yutaka Yoshiyama, Takeshi Matsumoto, Hidehiko Taguchi, Kimihiko Kichikawa

With an advent of aging society, endovascular treatment has been chosen as the first treatment option for a large number of peripheral arterial disease (PAD) patients complaining intermittent claudication or critical limb ischemia. Endovascular treatment can offer high initial treatment success and durable long term result with significant symptom relief especially in the aorto-iliac segment. This chapter focuses on literature review, basic procedure step, and bail-out method after complication.

Key words

  • PAD
  • IVR
  • Aorto-iliac

2. The Latest Evidence of Endovascular Therapy for Femoropopliteal Lesions

Kansai Rosai Hospital Cardiovascular Center
Yosuke Hata, Osamu Iida, Masaaki Uematsu

Over 20 million people are estimated to suffer from peripheral artery disease (PAD) and its morbidity will grow rapidly in the world. 50-70% of patients with symptomatic PAD have femoropopliteal (FP) disease. In FP region, the recommendations for EVT are different in several guidelines, because of remarkable progress in new techniques and devices of endovascular therapy (EVT). Therefore, the standardization for FP-EVT has not yet been established. We introduce the current indications and EVT procedures, and review the latest evidence of new devices.

Key words

  • Endovascular therapy
  • Femoropopliteal region
  • New devices

3. Important Role of Endovascular Therapy and Wound Healing for Critical Limb Ischemia

Department of Cardiology, Saiseikai Yokohama City Eastern Hospital
Norihiro Kobayashi, Keisuke Hirano

Critical limb ischemia (CLI) is the most advanced stage of peripheral vascular disease, and endovascular therapy (EVT) for CLI is challenging. However, numerous CLI patients have a severe background and no distal artery to connect the bypass, and so EVT is an important strategy of revascularization for CLI. The final goal of the treatment of CLI is not obtaining long-term treated vessel patency but achieving wound healing and improvement of quality of life. Although wound healing is an essential endpoint, it has not been so stressed as other endpoints such as amputation free survival, limb salvage, and major adverse limb events. In this article, we discuss actual EVT treatment for CLI in daily practice and the important role of wound healing to improve patients’ clinical outcomes.

Key words

  • Critical limb ischemia
  • Endovascular therapy
  • Wound healing

4. IVR for Subclavian Artery Disease

Department of Cardiology, Kokura Memorial Hospital
Yoshimitsu Soga

Endovascular therapy (EVT) for subclavian artery disease (SCAD) has been shown to be effective and is widely used as first-line treatment. Additionally, endovascular techniques and devices have been advancing. Some studies have already shown that primary EVT for SCAD is safe with long-term durability. However, these are small samples. Here, a largescale,
multicenter retrospective study was performed to evaluate the safety and efficacy in 556 patients. From this database, procedure success was achieved in 96.8%. The perioperative complication rate was 9.2%. Stroke was found in 1.8%. Primar y, assisted-primar y and secondary patencies at 3 years were 83.2±1.8%, 91.5±1.3% and 98.2±0.6%, respectively. There was no significant difference in primary patency between stenosis and occlusive lesions. On multivariate analysis, critical hand ischemia, cerebrovascular disease, current smoker, lesion length, and, the use of intravascular ultrasound were independent predictors of primary patency. The 3-year overall survival was 86.7%. There were 89 deaths during follow-up. Of them, cardiovascular death accounted for 49%. Finally, primary EVT for SCAD seemed to achieve acceptable outcomes regarding perioperative complication and long-term patency.

Key words

  • Subclavian artery disease
  • IVR
  • Stent

5. IVR of Atherosclerosis of Renal Arteries

Department of Cardiology, Nagano Red Cross Hospital
Department of Cardiovascular Medicine, Shinshu University Hospital
Yusuke Miyashita

Renal artery interventional treatment is very important for the patients who have real indication of treatment. Two major studies indicated that renal artery interventional treatment is not effective. But many enrolled patients of these studies did not have real indication. Renal artery intervention has some risks of injury to the aorta and renal artery. And renal artery intervention also has much risk of distal embolization. Some techniques, novel renal artery stent, and adequate devices reduce such risks of renal artery intervention.

Key words

  • Renal artery
  • Stent
  • Atherosclerosis

General Remark

The Dawn of Angiography -Thoracic and Abdominal Aortography

Prof. Emeritus, University of Hokkaido
Yutaka Morita

The year of 1929 is an epoch for the historical development of aortography. Both of the articles, the catheterization into the right atrium through the cubital vein by Forrsmann W. and the translumbar aortography by DosSantos R., were published in 1929 and then the thoracic aortography and the abdominal aortography began. In this paper, chronologies of classification, indication and complication of the thoracic and abdominal aortography are descrived. And the development of supporting tools and manners for aortography are also mentioned.

Key words

  • Aortography
  • Cardiac angiography
  • Translumbar aortography

Case Reports

A Case of a Superior Mesenteric Artery Pseudoaneurysm after Pancreatoduodenectomy: Effectiveness of the Balloon Occlusion Test before Embolization

Department of Radiology, Shiga University of Medical Science
Kai Takaki, Akitoshi Inoue, Shinichi Ohta, Yugo Imai, Tatsuya Nakagawa
Ryo Uemura, Yshihide Tanoue, Yuki Tomozawa, Shobu Watanabe, Yoko Murakami
Hideji Otani, Akinaga Sonoda, Norihisa Nitta, Kiyoshi Murata

Pseudoaneurysm is one of the severe complications after pancreatoduodenectomy (PD) and ruptured pseudoaneurysms are often fatal. Interventional radiology plays an important role in the treatment of pseudoaneurysm, and organ ischemia by embolization should be avoided. Balloon occlusion test is an effective technique to simulate circulation post embolization and is also useful to judge whether to perform embolization without any complications.
Bloody ascites was found in the drainage tube in a man in his 60's with pancreatic fistula on the 17th day after PD. An emergency CT was performed and pseudoaneurysms were found on the superior mesenteric artery (SMA). An angiogram showed a fusiform aneurysm and two saccular aneurysms on the SMA.
The SMA was seen through collateral circulation on the inferior mesenteric angiogram with balloon-occlusion in the SMA. There were no abdominal symptoms for 30 minutes while a balloon occluded the SMA. Therefore, embolization for the SMA pseudoaneurysms was performed. As a result, there have been no abdominal symptoms or recurrences of pseudoaneurysms for 22 months after the embolization.

Key words

  • Superior mesenteric artery aneurysm
  • Pancreatoduodenectomy

Case Reports

Successful Embolization Using N-butyl Cyanoacrylate for Iatrogenic Profunda Femoris Artery Injury During Total Hip Arthroplasty with Coagulopathy: A Case Report

Department of Radiology and Orthopedic Surgery1), Saiseikai Utsunomiya Hospital
Rakuhei Nakama, Toshiaki Yagami, Yuki Kitta1), Isao Kono, Kazukiyo Arakawa
Koki Usui, Koki Kato, Keiichi Tanimura, Masanori Honda

Total hip arthroplasty (THA) is one of the most frequently performed orthopedic surgeries. Although THA is relatively safe, a complication that sometimes occurs is severe bleeding. Transcatheter arterial embolization (TAE) is the first-choice treatment for bleeding, but surgery is also sometimes used. A woman in her 80s was admitted to our hospital, and THA with the direct anterior approach was performed. After the operation, severe bleeding from a drain persisted. Extravasation was found around the operation wound on enhanced computed tomography, and so emergency TAE was performed. Angiography revealed extravasation from a branch of the profunda femoris artery. Because coagulopathy was present, we selected N-butyl cyanoacrylate (NBCA) as the embolus material. There were no complications associated with TAE for this patient. For TAE performed for bleeding after THA, a gelatin sponge or micro-coil is often selected as the embolus material. As in cases of severe trauma, it is important to select NBCA as the embolus material for postoperative bleeding after THA, taking into consideration the patient’s coagulation status.

Key words

  • Embolization
  • NBCA
  • Total hip arthroplasty

Case Reports

Successful Coil Embolization of Congenital Intrahepatic Portosystemic Venous Shunt using Double Microcatheter Single Vascular Access Technique: A Case Report

Department of Radiology and Gastroenterology, Saitama Medical Center, Jichi Medical University
Kohei Hamamoto, Emiko Chiba, Katsuhiko Matsuura
Tomohisa Okochi, Keisuke Tanno, Takeharu Asano, Osamu Tanaka
Department of Radiology, Totsuka Kyoritsu Daini Hospital
Minoru Honda
Department of Radiology, Asahi General Hospital
Jun Isogai

We report the case of a woman in her 40s with an asymptomatic, congenital intrahepatic portosystemic venous shunt diagnosed during a routine examination for uterine cervical cancer. Contrast-enhanced computed tomography (CT) and superior mesenteric arterial portography showed a complex intrahepatic portosystemic venous shunt with concomitant portal vein aneurysm near the hepatic hilum. The shunt appeared likely to be difficult to occlude via the usual endovascular procedure because the shunt point was narrow and short. Therefore, we performed coil embolization using a double microcatheter single vascular access technique and successfully treated without any complications.

Key words

  • Portosystemic shunt
  • Coil embolization
  • Double microcatheter technique