IVR 会誌 Jpn J Intervent Radiol Vol.18 No.2 2003

State of the Art
With the Help of Imaging, Stick the Needle into the Lesi

1. Percutaneous Radiofrequency Ablation for Hepatocellular Carcinoma
Department of Gastroenterology, University of Tokyo
Shuichiro Shiina, Takuma Teratani, Shinpei Sato, Ryosuke Tateishi, Takeshi Kinbara, Takashi Ishikawa, Miho Kanda, Noriyo Yamashiki, Shuntaro Obi, Kazuhiro Noso, Yutaka Yata, Masao Omata.

RFA has recently been introduced in the treatment of liver tumors. RFA is generally performed on cases as follows : 1) unresectable lesions or refusal of surgery, 2) absence of PVTT and extrahepatic metastasis, 3) Plt >_50,000 and PT <_50%, 4) absence of uncontrollable ascites. RFA can be used even in cases in which there are more than 3 lesions or a lesion over 5b in diameter if a skillful operator takes charge of the case, if liver function is relatively good, and if the patient has a good compliance. We performed RFA in 636 patients with HCC by the end of 2001. We did not exclude RFA in any case in which lesions were located in delicate places. The final CT showed residual tumor only in 0.3% of the cases. Number of treatment sessions was 2.3 times and hospital stay was 14.3 days on average.
With a mean follow-up of 16 months, local recurrence developed only in 1.7% of the cases. Complications occurred in 5.8% of the cases. There was no mortality related to RFA. RFA seemed feasible, efficacious, and considerably safe. RFA will play a major role in the treatment of HCC.
Key words
● Radiofrequency ablation
● Hepatocellular carcinoma
● Liver tumor percutaneous
● Interventional ultrasound

2. Open MR-guided Percutaneous Cryosurgery : Treatment for Renal Tumors, Liver Tumors and Uterine Fibroids using Argon-based Cryosystem
Department of Radiology, Jikei University School of Medicine, Kashiwa Hospital
Takuji Mogami, Michiko Dohi, Junta Harada
Department of Radiology, Jikei University School of Medicine
Kunihiko Fukuda
Department of Radiology, Hokkaido University Hospital
Tadashi Shimizu, Kazuo Miyasaka

Tissue damage through the application of low temperature is presumably the oldest thermal ablation method in medicine. The important characteristics of cryosurgery in comparison with other thermal ablation methods are the simple control of ice formation, the analgesic effect of cold, and the absence of undesirable toxic products. Recently, an argon-based cryosystem with MRI compatible needle shaped cryoprobe has been developed that permits a percutaneous approach.
However, for treatment of deep structures that cannot be directly visualized, imaging devices such as US, CT and MRI are required for monitoring the ablated area. MRI has the capability to depict the iceball with high accuracy and excellent contrast between freezing and non-freezing area by an extreme decrease in T1 and T2 relaxation time. In addition, MRI provides near real-time images for probe insertion. As a consequence, a combination of argon-based cryosystem and MRI is an effective method for treating tumors.
Using an argon-based MR-compatible cryosystem, we performed percutaneous cryosurgery for 14 renal tumors, 4 liver tumors and 12 uterine fibroids. All procedures were safely and accurately carried out without significant complications, and the results of treatment were sufficient. Open MR-guided percutaneous cryosurgery proved to be a feasible procedure.
Key words
● Cryosurgery
● Percutaneous procedure

3. Direct Puncture Sclerotherapy for Arteriovenous Malformation(AVM)
Department of Plastic Surgery, Maebashi Red Cross Hospital
Kunie Ouchi
Department of Plastic Surgery and Radiology1), Doai Memorial Hospital
Kunie Ouchi, Toshihiko Wakita1)
Oizumi Academia Clinic
Shin-ichi Wakita

We have treated arteriovenous malformations of subcutaneous soft tissue with arterial embolization and percutaneous sclerotherapy. Recently we have performed sclerotherapy under monitoring by color-doppler ultrasonography(US) with puncture guided by color-doppler US resulting in better results than conventional blind puncture. Although we have used HistoacyR(NBCA) as an embolus in embolosclerotherapy to reduce the lesional blood flow, other choices such as Spongel, arterial injection of sclerosants, balloon occlusion and manual compression are also useful. Especially arterial injection of sclerosants has a powerful and long-lasting effect in reducing the lesional blood flow.
However although interventional treatment is helpful for reducing or removing AVM lesion, it cannot completely dissolve soft-tissue hypertrophy caused by AVM. We describe sclerotherapy guided by color-doppler US, arterial injection of sclerosants and operation.
Key words
● Embolosclerotherapy
● Arterial injection of sclerosant

4. CT-guided Biopsy of the Spine : Usefulness of Medium or Small Caliber Needles and Variations on Approach
Division of Diagnostic Radiology, Department of Radiology Department of Pathology1) and Orthopedics2), Tenri Hospital,
Akira Sano, Ryota Kawasaki, Naokazu Miyamoto, Toshiyuki Imagunbai Hirokazu Kurekawa, Hisanobu Kouyama, Shinichi Matsumoto, Yoichirou Kobashi1), Eiichi Hirofuji2)

Authors presented experiences of CT-guided spinal biopsy mainly using Ostycut bone biopsy needles. Forty-five patients underwent 50 biopsies according to the indication of probable spinal metastasis in the patients with known malignancies(Group 1), unknown spinal abnormalities
(Group 2), and sampling materials for bacteriology in the patients with spinal abscesses(Group 3), of which locations biopsied included 2 of cervical, 13 of thoracic, 19 of lumbar, 6 of sacral spine, as well as 10 intervertebral discs. The success rate for diagnosis was 88.2%(G1), 91.3%(G2) and 50.0%(G3), respectively, or 84.8% on average. No major complications such as hemorrhages or neurological abnormalities were encountered in a series of procedures. Medium or small caliber needles such as 14G or 16G of Ostycut or Super-core were very useful and safe for spinal abnormalities, although a Rotex II fine needle may be good enough to sample paraspinal soft tissue tumors. On puncture, variations on approach used were posterolateral, transpedicular, or transcostovertebral in a prone position to lumbar or thoracic lesions, anterolateral in a supine position to a C7 body lesion, and three different directions to sacral lesions. Knowledge of appropriate needles along with variations on approach is essential for successful CT-guided biopsy of the spine.
Key words
● Spines
● Biopsies
● CT-guided
● Ostycut

5. Percutaneous Vertebroplasty in the Treatment of Painful Vertebral Diseases.
Department of Radiology, Hiroshima University School of Medicine
Akira Naito, Naoyuki Toyota, Hideaki Kakizawa, Katsuhide Ito

Percutaneous vertebroplasty is a newly developed treatment for many focal vertebral lesions. The principal indications of vertebroplasty are osteoporotic vertebral body compression fractures, osteolytic metastases, multiple myelomas, and painful or aggressive vertebral hemangiomas. This technique involves percutaneous puncture via a needle into a vertebral body and the injection of polymethylmethacrylate bone cement guided by a combination of CT and fluoroscopy.
In 80~90% of patients with osteoporotic vertebral collapse, complete or partial pain relief is obtained within 72 hours. The improvement is sustained at 48 months, and no deterioration of collapse is observed. In 70~97% of patients with malignant diseases, complete or partial pain
relief is obtained within 48 hours.
This technique provides increased strength and substantial immediate pain relief in vertebrae weakened by a variety of bone diseases. Vertebroplasty appears to be a safe and effective treatment.
Key words
● Vertebroplasty
● Polymethylmethacrylate
● Vertebral compression fracture
● Osteolytic metastasis

Original Article
Usefulness of Gently Catheter for GDA-Coil Fixation Method
Department of Radiology, St. Marianna University School of Medicine
Kenji Takizawa, Yoshikazu Hoshikawa, Kazunori Kuroki
Yoshihide Kanemaki, Nobuyasu Kanai, Minako Uchino, Yasuo Nakajima

 The purpose of this paper is to evaluate the usefulness of Gently catheter(GC) with slit and side-hole developed to reduce the technical burden of gastroduodenal artery(GDA)-coil fixation method(GDA-method) in hepatic arterial infusion chemotherapy with an implantable port. The GDA-method using GC was performed with only one time procedure in 42 patients with liver cancer. The procedure succeeded in 41 patients. There were five patients who had catheter-related complications, namely:dislodgement of GC in one patient, catheter kinking in one, transsection in one, and gastroduodenal ulcer in two, during the observation periods. The slit on GC exactly closed after GC placement in all the patients. The embolization of GDA around the catheter through the side- hole on GC using 0.035 inch platinum coil reduced the total number of used coils. Newly developed GC seemed to be useful to reduce the technical burden of the GDA-method, and does not disturb the advantages of the GDA-method.
Key words
●Gently catheter
●Catheter placement
●Hepatic arterial infusion
●Liver cancer

Original Article
Superselective Adrenal Arterial Embolization of Aldosteronomas
-Analysis of Therapy-Abandoned, Failed and Recurrent Cases-
Department of Radiology, Faculty of Medicine, Kagoshima University
Hirofumi Hokotate, Hiroki Inoue, Yasutaka Baba, Shinsaku Tsuchimochi, Masayuki Nakajo,
Department of 1st Pathology, Faculty of Medicine, Kagoshima University
Yoshihisa Umekita, Hiroki Yoshida

 Purpose : Superselective adrenal arterial embolization(SAAE) for aldosteronomas is less invasive than surgery. However it is not a perfect therapy with a success rate of about 80%. We evaluated the technical and anatomical problems of the cases in which the therapy was abandoned, failed or resulted in recurrence of hyperaldosteronism later.
Materials and methods : The study included 45 patients with an aldosteronoma. Forty three were subjects and evaluated for indication of SAAE. The remaining 2 patients selected operation from the first.
Results : SAAE was abandoned because of difficulty in identification of the feeding artery(ies), insertion of the catheter into the fine feeding artery(ies) or other reasons in 8 patients(right : left=1 : 7), failed due to incomplete embolization in 6 of 35 patients(right : left=2 : 4) and resulted in recurrence in 2 patients(right : left=2 : 0). Pathological examinations of the adrenals in 7 operated patients revealed 30-80% necrosis of the adenoma in 4 patients and hemorrhage and/or 20% necrosis of the adjacent adrenal tissue in 2 patients.
Conclusion : The left aldosteronoma is more difficult to be treated by SAAE due mainly to inadequate identification of the feeding arteries or difficulty of insertion of the catheter into the fine vessels than the right one.
Key words
●Adrenal gland
●Primary aldosteronism

Case Report
One Case of Uterine Fibroids Supplied from the Inferior Epigastric Artery Collateral during Uterine Artery Embolization
Division of Radiology, Haibara General Hospital
Hajime Kato, Masatoki Ozaki

 We report a case of uterine fibroids supplied from the right inferior epigastric artery collateral. She is a 35-year-old gravida 0, para 0 woman without a history of abdominal operations. She has multiple subserosal uterine fibroids and pretreatment uterine volume is 1510j. In this case, although bilateral uterine arteries were patent, the right inferior epigastric artery supplied the uterine fibroids of uterine fundus. Uterine artery embolization(UAE) was performed with gelatin sponge particles. She received additional embolization of the right inferior epigastric artery. Collateral arteries other than ovarian arteries are rare during UAE. For the inferior epigastric arteries, only one case of the absent uterine artery with replacement by the round ligament artery, which arose from the inferior epigastric artery, is reported during UAE. We suggest that the inferior epigastric arteries should be important as collateral vessels to uterine fibroids during UAE.
Key words
●Uterine fibroids
●Inferior epigastric artery
●Uterine artery embolization(UAE)

Case Report
Three Cases of Renal Arteriovenous Malformations Treated with Transcatheter Arterial Embolization : Usefulness of the Microcatheter System
Department of Radiology and Urology1), Kyoto City Hospital
Masato Tanikake, Katsumi Hayakawa, Toshiki Shiozaki, Hitoshi Kitahara
Syuichi Hida1), Takahito Souma1)
Department of Radiology, Nagahama City Hospital
Souichi Kubo

 We report three cases of cirsoid type renal arteriovenous malformations(AVMs) that were treated with transcatheter arterial embolization(TAE) using a microcatheter system.
Embolization was performed with only absolute ethanol in one case, and with a combination of absolute ethanol and a microcoil in two cases. Since the microcatheter system is available for the treament of renal AVMs at present, transcatheter embolization can be performed at the level of peripheral vessels such as the renal segmental arteries and interlobar arteries while preserving as much renal function as possible.
Transcatheter embolization using the microcatheter system is a safe and effective treatment for renal AVMs.
Key words
●Renal arteriovenous malformations
●Transcatheter embolization 

Case Report
Iatrogenic Femoral Artery Branch Injury ; Successful Embolization in One Case
Departments of Radiology and Neurosurgery1), Saiseikai Fukuoka General Hospital
(Present : Nakatsu Municipal Hospital*)
Hiroyuki Nomiyama*, Shunichi Matsumoto, Naonobu Kunitake
Itsuma Kamoi, Sadahiko Takahashi1)

Pseudoaneurysm associated with catheter introduction is a well-recognized complication. The main causes of pseudoaneurysm are insufficient hemostasis and anticoagulant therapy after therapeutic angiography. We experienced an unusual iatrogenic pseudoaneurysm of a branch of the femoral artery. That is, a pseudoaneurysm caused by the accidental puncture of the superficial iliac circumflex artery followed by inadvertently introducing a guidewire. We performed transcatheter arterial embolization(TAE) with coils to successfully treat this pseudoaneurysm. We consider that TAE is the choice of treatment for injury of a branch of the femoral artery.
Key words
●Femoral artery injury