IVR 会誌 Jpn J Intervent Radiol Vol.19 No.4 2004

State of the Art
Percutaneous Vertebroplasty

1.Osteoporotic Vertebral Fracture : Clinical Features
Department of Orthopaedic Surgery, Kurume University School of MedicineKawachi, Kimiaki Sato, Kensei Nagata

We report the clinical features of an osteoporotic vertebral fracture. Such fractures are generally considered benign. The symptoms subside with conservative therapy, and complications seldom occur. However the diagnosis sometimes is difficult, because the presentation may be subtle in that symptoms are not particularly noteworthy. Although spinal cod compression as a result of the fracture is a recognized complication, the incidence is extremely low. Surgical decompression is indicated when there are persistent neurological defects.
Recently, some interesting observations have been reported. The risk of vertebral fracture is increased among patients in whom a prior vertebral fracture has been identified : patients who incur an vertebral fracture are at substantial risk for an additional fracture within the next year. And patients with radiographic evidence of a vertebral fracture show an increased mortality rate.
These are the points to be especially considered when deciding on conservative or surgical treatment.

Key words
● Osteoporosis
● Vertebral fracture
● Clinical features

2.Imaging Evaluation for Percutaneous Vertebroplasty
Department of Radiology, St. Luke’s International Hospital
Akihiro Uemura, Yuji Numaguchi, Masaki Matsusako, Nobuo Kobayashi, Shinichi Yamashita

Percutaneous vertebroplasty (PVP) has been used for the treatment of osteoporotic fractures and metastatic tumors of the vertebral bodies. In addition to the technical aspects, the success of PVP depends much on the process of preprocedural evaluation of the patients. Imaging evaluation plays a pivotal role in the process, but the clinical application has not been established. We demonstrate spectra of the imaging findings associated with PVP in the settings of preprocedural patient evaluation, postprocedural follow-up and technical consideration.

Key words
● Percutaneous vertebroplasty
● MR
● Osteoporosis
● Bone cement
● Polymethylmethacrylate
● Spine, tumor

3.Percutaneous Vertebroplasty Using CT Fluoroscopic Guidance
Department of Radiology, Kanazawa University
Takeshi Kobayashi, Tsuyoshi Takanaka, Osamu Matsui

Percutaneous vertebroplasty is a minimally invasive procedure that offers a marked therapeutic option for patients suffering from osteoporotic or tumor-related vertebral fractures and pain. This procedure is very attractive, but not easily performed by doctors who have not mastered bone intervention. In Japan, we developed this procedure under CT-fluoroscopic guidance in 1997. The purpose of this development is to increase the safety of this treatment. CT-fluoroscopy well demonstrates not only the root of puncture and a bone needle, but also the distribution of injected bone cement and its leakage. We describe the practical aspects of this technique and recent results and complications of this treatment.

Key words
● Percutaneous vertebroplasty
● CT-fluoroscopic guidance
● Osteoporosis

4.Percutaneous Vertebroplasty under Fluoroscopic Guidance Using Bi-plane DSA
Department of Radiology, Kurume University School of Medicine
Norimitsu Tanaka , Toshi Abe, Yusuke Uchiyama, Shuji Nagata, Naofumi Hayabuchi

The aim of this article is to overview the efficacy and durability of percutaneous polymethylmethacrylate (PMMA) vertebroplasty under fluoroscopic guidance using bi-plane DSA in treating osteoporotic compression fractures. Eighty-one patients underwent 184 percutaneous injection of PMMA into a vertebra over a 24-month period. Fifty-nine patients with osteoporotic fractures underwent percutaneous injection of PMMA into 131 veretebral levels. All procedures were performed under fluoroscopic guidance using biplane DSA and local anesthesia. Fluoroscopic guidance allowed the 11G (in case of biopsy) or 13G bone biopsy needle via a transpedicular approach. Intraosseous venography was always performed through the needle before the injection of PMMA. The patient’s pain level was assessed before and after vertebroplasty with use of a visual analogue scale (VAS) of 0-10. Fifty-five patients (93%) reported significant pain relief and 34 patients (58%) reported complete pain relief. Pain relief was reported also in patients with old compression fractures that had avascular necrosis or intravertebral cleft. Percutaneous vertebroplasty of osteoporotic compression fracture under fluoroscopic guidance using biplane DSA is a minimally invasive procedure that provides immediate and sustained pain relief.

Key words
● Percutaneous vertebroplasty
● Bi-plane DSA
● Fluoroscopic guidance
● Osteoporosis
● Compression fracture

5.Interventional Radiology in the Treatment of Painful Bone Tumor
Department of Radiology, Kansai Medical University
Noboru Tanigawa, Hiroyuki Kojima, Syuji Kariya, Yuzo Shomura, Mitsuharu Sougawa, Satoshi Sawada

Cancer-associated pain is often the most debilitating aspect of malignant disease. Because of the lack of effective treatment options, it is a difficult clinical problem to manage. Treatment of pain from metastatic disease is often palliative in nature and is often limited in effectiveness. Percutaneous vertebroplasty and radiofrequency ablation of bone tumor are relatively new techniques of spinal fractures or bone metastases used essentially to relieve pain. In this paper, we described our methods of percutaneous vertebroplasty and radiofrequency ablation of painful metastatic bone tumor, and our clinical results.

Key words
● Bone metastases
● Vertebroplasty
● Radiofrequency ablationAbstract

Original Article
Radiation Exposure to Physicians during Interventional Radiologic Procedures : Evaluation for Neuroembolization, Percutaneous Coronary Intervention, and Hepatic Infusion Catheter Implantation
Department of Radiology, Teikyo University School of Medicine
 Shigeru Suzuki, Shigeru Furui
Department of Environmental Health, National Institute of Public Health
 Ichiro Yamaguchi
Department of Radiology, Fukuoka University School of Medicine
 Masatoshi Okazaki
Department of Radiology, Osaka University Faculty of Medicine
 Hironobu Nakamura
Department of Radiology, Kohka Public Hospital
 Tsutomu Sakamoto
Department of Radiology, Aichi Medical University
 Tsuneo Ishiguchi
Department of Medicine, Teikyo University School of Medicine
 Takaaki Isshiki
Department of Radiology, Toranomon Hospital
 Hidenori Takebe
Department of Radiological Technology, Saitama Cancer Center
 Kunihiko Morozumi
Department of Radiology, Teikyo University Hospital
 Masafumi Yamagishi
Department of Radiology, Osaka University Hospital
 Kazuya Yamaguchi
Department of Radiology, Fukuoka University Hospital
 Kunihiro Matsumoto

: We evaluated radiation exposure to physicians during three kinds of interventional radiology procedures.
Material and Methods : Doses were assessed for 32 procedures(12 neuroembolizations, 11 percutaneous coronary interventions [PCI], and 9 hepatic infusion catheter implantations) at four institutes. Skin doses and effective doses were evaluated with thermoluminescent dosimeters at the physician’s chest inside and outside a protector, glabella, and finger. The ratios of glabella dose and finger dose to chest dose outside the protector were compared among the three kinds of procedures.
Result : In neuroembolization, effective dose was 0.04±0.03 mSv, and doses were 0.14±0.18 mSv at the finger, and 0.16±0.18 mSv at the glabella. In PCI, effective dose was 0.04±0.05 mSv, and doses were 0.48±1.74 mSv at the finger, and 0.20±0.30 mSv at the glabella. In hepatic infusion catheter implantation, effective dose was 0.04 ±0.03 mSv, and doses were 0.22±0.14 mSv at the finger, and 0.08±0.06 mSv at the glabella. The relative glabella dose in neuroembolization was larger than in hepatic infusion catheter implantation(p<0.05), and the relative finger dose in hepatic infusion catheter implant was larger than in PCI(p<0.001).
Conclusions : The doses for physicians in these procedures were thought to be acceptable in general. Occupational radiation exposure in interventional radiology is thought to be affected by the kind of procedure performed. Therefore, it is necessary to assess it, and take measures to reduce it for procedures that may involve extended fluoroscopy time.

Key words
●Interventional Radiology
●Occupational exposure
●Thermoluminescent dosimeter

Original Article
Efficacy and Problems of Temporary Vena Cava Filter Placement for Deep Venous Thrombosis
Department of Radiology, Miyazaki Medical College, University of Miyazaki
Tatefumi Sakae, Haruyuki Koga, Eiji Furukoji, Kenichiro Yamaguchi
 Hiroshi Sugimura, Shozo Tamura
Koga Hospital 21
Reiji Ochiai

 Recently, temporary vena cava filter is often used for treatment of deep venous thrombosis (DVT). We evaluate the efficacy of supplementary use of a temporary vena cava filter for prevention of pulmonary thromboembolism.
We performed temporary vena cava filter placement in 21 patients on 23 occasions comprising 8 males and 13 females(age range from 15 to 80, average 48.0 years old). The filters we used were Antheor(Boston Scientific Corporation, USA). The filters were inserted via the internal jugular vein. The conditions requiring temporary filters to avoid PTE include DVT of juxta-operative period of malignant tumors, pregnancy, before orthopedic operations to lower extremities, renal vein thrombosis, and during thrombolytic treatment for DVT. All cases were diagnosed clinically with or without venography and had a past history or suspicion of PTE. No episodes of PTE were recognized during the placement of vena cava filters. One patient died of the underlying disorder. No serious complication was encountered. Filters were easily removed except for in two cases, where a massive thrombus attached to the filter and required thrombolysis, thrombectomy and fragmentation of the thrombus for successful removal.
 The temporary vena cava filter was effective for prevention of PTE. But careful consideration of the indications is necessary for the use of temporary vena cava filter.

Key words
●Temporary IVC filter

Original Article
Experience with Transcatheter Arterial Infusion for Liver Metastases from Gynecological Cancer
Department of Therapeutic Radiology & Oncology, Graduate School of Medicine, Kyoto University
Takashi Sakamoto, Yasushi Nagata, Norio Araki, Masakazu Ogura
Heitetsu Sai, Masahiro Hiraoka

: To evaluate the clinical effect of transcatheter arterial infusion(TAI) chemotherapy for liver metastases from gynecologic cancer.
Materials and Methods : Twelve patients with gynecologic cancer were treated between 1990 and 2002. Five patients had cervical cancers, 4 corpus cancers, 3 ovarian cancers, one peritoneal carcinoma and one primary indistinct carcinoma in the abdomen. TAI was performed via the proper hepatic artery using Cisplatin(CDDP) or Carboplatin(CBDCA), Doxorubicin hydrochloride(ADR) or Epirubicin hydrochloride(EPI), Mitomycin C(MMC) and 5-Fluorouracil(5-FU).
Results : Local responses were no CR, 7 PR, and 4 NC, respectively. The median survival intervals after infusion were 22 months. The median intervals were cervical cancer 12 months, corpus cancer 23 months, and ovarian cancer 17 months. No severe complications were recognized.
Conclusion : TAI for liver metastases from gynecologic cancer can be performed safely and may be useful.

Key words
●Transcatheter arterial infusion
●Metastatic liver tumor
●Gynecological cancer

Original Article
Evaluation of Fusion Imaging Using a Combined SPECT/CT System: Assessment of Drug Distribution in Patients whose Catheter Was Fixed into a Branch of the Hepatic Artery
Department of Diagnostic Radiology1 and Gastroenterological Surgery1)
Kumamoto University Graduate School of Medical and Pharmaceutical Sciences
Osamu Ikeda, Shinichiroh Kusunoki, Takeshi Nakaura, Shinya Shiraishi
Kouichi Kawanaka, Seiji Tomiguchi, Yasuyuki Yamashita, Hiroshi Takamori1)
Akira Chikamoto1), Keiichiroh Kanemitsu1)

: The purpose of this study was to compare perfusion patterns of hepatic arterial infusion chemotherapy on intra-arterial CT(CTA) -and fusion images obtained with a combined single-photon emission computed tomography/computed tomography(SPECT/CT) system.
Materials & Methods : Eight patients with metastatic liver tumor and multiple hepato-cellular carcinomas(HCC) who bore implantable port systems for hepatic arterial infusion chemotherapy underwent fusion imaging using a combined SPECT/CT system and CTA. Abdominal SPECT was performed in all patients using 99mTc-MAA(185 Mbq) injected at a rate of 1 p/x, identical to the chemotherapy infusion rate, through an implantable port. For CTA, the injection rate was 0.5 p/w. We compared the fused- and CTA images for their display of intrahepatic- and extrahepatic perfusion. A catheter with a side hole directed toward the common hepatic artery was fixed in the branch of the hepatic artery. This allowed for the distribution of anticancer agents to the whole liver.
Results : In all patients the homogeneous type of distribution was observed on CTA images ; in 3 of these, fused images revealed lobar hypoperfusion ; stenosis of the right hepatic artery was a result of postoperative changes in two patients. One patient with segmental hypoperfusion on fused images manifested stenosis of the right hepatic artery resulting from intimal injury.
Conclusion : Fusion image visualized non-uniform drug distribution in patients whose catheter was fixed into the branch of hepatic artery. In patients with stenosis of the hepatic artery, non- uniform drug distribution may occur. Slow infusion examination using radioisotope with image fusion facilitates accurate evaluation of drug distribution within the liver.

Key words
●Combined SPECT/CT system
●Fusion imaging
●Hepatic arterial infusion chemotherapy

Case Report
Case of a Report, Successful Treatment for a Symptomatic Postoperative Pelvic Lymphocele by Sclerotherapy
Department of Radiology, Graduate School of Biomedical Science, Hiroshima University
Keigo Chosa, Akira Naito, Naoyuki Toyota
Hideaki Kakizawa, Hideki Itakura, Katsuhide Ito

 We report a case of successful sclerotherapy for a lymphocele. A 45-year-old female developed a symptomatic pelvic lymphocele after hysterectomy and lymphadenectomy due to cervical cancer. We placed a 7 Fr. pigtail drainage tube into the lymphocele, and injected absolute ethanol and minocycline. Despite this sclerotherapy, the volume of the excreted fluid increased. Then we used OK-432, after which the fluid volume markedly decreased. The tube was withdrawn 81 days later, and the symptoms ceased. No complications occurred. Sclerotherapy for a postoperative pelvic lymphocele is effective and safe.

Key words
●Pelvic lymphocele

Case Report
Gastric Lipoma with Recurrent Hemorrhage ; Successful Embolization in One Case
Department of Radiology, Department of Internal Medicine1), Nakatsu Municipal Hospital
Department of Radiology, Matsuyama Red Cross Hospital*
Hiroyuki Nomiyama*, Hiromu Hidaka, Kinya Yamada1)

 A 45-year-old female with gastric lipoma suddenly developed hematomesis. Gastric endoscopy was then performed and revealed an open ulcer located in the centre area of the surface of tumor. Argon plasma coagulation was first performed, but was not effective. An angiogram for transcatheter arterial embolization(TAE) was then achieved, and revealed no extravasation. As we suspected that the posterior gastric artery(PGA) could feed the tumor, we performed TAE for PGA and treatment was successful, although it was complicated by splenic infarction. Lipoma is an uncommon gastric benign tumor. Cases of bleeding gastric lipomas are very rare in Japan. Most of them were cured by operation, but treatment by TAE has not been reported yet. We consider TAE as one of the effective treatments for bleeding gastric lipoma by identifying its distributing arteries.
 PGA originates from the splenic artery and is mostly described as supplying the posterior wall of the superior of the gastric body, the fundus. But some authors consider that PGA might be more extensive. And a sended branch to the spleen superior pole was reported. Considering this case, we therefore think that attention must be paid before embolizing PGA to avoid complications.

Key words
●Gastric lipoma
●Posterior gastric artery

Case Report
A Successfully Resected Case of Advanced Breast Cancer after Arterial Infusion Chemotherapy with Arterial Redistribution
Yutaka Morita
Department of Surgery, Section of Radiological Technology1), Otaru Municipal Hospital
Takashi Kawamata, Kunihiro Hirose, Yoshito Watanabe
Hajime Mitsuhashi1), Toshiaki Kojima1)

 Effective arterial infusion chemotherapy with arterial redistribution for advanced breast cancer is reported in a case. A 51-year-old-woman with huge left breast and axillarly tumors(T4N1 StageⅢb) was admitted to our hospital. After arterial redistribution for the left lateral thoracic artery and the periphery of the left internal thoracic artery, arterial infusion chemotherapy consisting of 30m adriamycin was performed. After 3 doses of the above chemotherapy, radical mastectomy with muscular resection(Bt+Ax+Ic+Mj+Mn)was performed. Clinical effectiveness was comfirmed by the internal thoracic arteriogram and microangiogram of the resected tumor. In this paper, the vascular anatomy of the breast and the techniques of arterial redistribution are described, and the effectiveness of RI-AG(radionuclide angiogram) is evaluated. The RI-AG was not suitable for evaluation of blood supply because the arterial infusion chemotherapy brought about hypovascular changes. Therefore this RI-AG method would be troublesome, and further research and clinical experience are needed.

Key words
●Arterial infusion chemotherapy
●Arterial redistribution
●Advanced breast cancer