Jpn J Intervent Radiol Vol.24 No.4 2009

State of the Art
Diagnosis and Interventional Radiology in Vasculitis

An Introduction Ichiro Sakamoto

1. Diagnostic Approach for Angiitis and IVR : Pathology

Director of Research and Education1), Cerebrovascular and Neurology Center2)
National Hospital Organization, Fukuoka-Higashi Medical Center
Katsuo Sueishi1), Yasuhiro Kumai2), Ayaka Fukurono2)

 This issue reviews the pathological characteristics of systemic angiitis syndrome, particularly of large- and medium-sized vessels, including Takayasu’s arteritis, giant cell arteritis, classical polyarteritis nodosa, Buerger’s disease and inflammatory abdominal aortic aneurysm, which interventional radiologists may have difficulty in differentiating from each other. As the recent advances in imaging technology allow us to assess vascular alterations, not only quantitatively but also qualitatively, mutual collaboration and communication between clinicians and pathologists are more necessary than ever for making more precise diagnoses of angiitis.

Key words

  • Primary angiitis syndrome
  • Pathology
  • Chapel Hill Consensus


2. Cerebral Vasculitis and its Simulators : Diagnostic and Interventional Radiology

Department of Radiology, National Hospital Organization Nagasaki Medical Center
Hideki Ishimaru, Kazuaki Nakajima, Yohjiro Matsuoka, Ayami Sakamoto, Takayuki Sakugawa
Department of Radiology, Nagasaki University
Minoru Morikawa
Department of Radiology, Sasebo Municipal Hospital
Michiko Inuzuka, Seigo Kimura

 Cerebral vasculitis, although rare in general, is an important cause of cerebral ischemia, because the treatment strategy is different from that of usual cerebral infarction. On the other hand, a variety of common and uncommon nonvasculitic disorders may mimic vasculitis angiographically or clinically. It is also important to distinguish these vasculitis simulators from true vasculitis in order to avoid the unnecessary and harmful side effects of corticosteroid and immunosuppressant, the mainstay of drug therapy for vasculitis. The diagnosis is often difficult. Angiography is expected to demonstrate the underlying vascular pathology ; however, many vasculitides affect small arteries beyond the spatial resolution of conventional angiography. The most important role of the diagnostic imaging is the identification of brain lesions consistent with cerebral vasculitis. Multiple lesions in more than one vascular territory should raise this suspicion, although no specific pattern for this entity exists. In large and medium-sized vessel vasculitis, MRI can directly demonstrate mural thickening and enhancement, which is considered to specific for active inflammation. We propose here a classification for cerebral vasculitis and simulators according to the size of the affected brain vessels, which would help us to make a differential diagnosis. We also review the endovascular techniques for this entity, and its indications.

Key words

  • Cerebral vasculitis
  • Vasculitis simulator
  • Diagnostic imaging


3. Pulmonary Vasculitis

Radiopathological Science Department of Radiology, Yamaguchi Univercity Graduate School of Medicine
Nobuyuki Tanaka, Naofumi Matsunaga

 Pulmonary vasculitis is classified based on the caliber of the vasculature by using the classification of Chapel Hill Consensus Conference (CHCC) held in 1992. In this article, small vessel vasculitis was mainly discussed. Imaging findings, especially high-resolution CT (HRCT) findings, of these entities are variable and nonspecific. Extensive ground-glass attenuation (GGA) and airspace consolidation is seen due to diffuse alveolar hemorrhage induced by capillaritis in microscopic polyangiitis (MPA), systemic lupus erythematosus (SLE), and Goodpasture’s syndrome. GGA and airspace consolidation tend to distribute in the inner and middle lung areas. Centrilobular opacities may be recognized due to hemorrhage along the centrilobular arteries. Multiple nodules or airspace consolidation with or without cavity are usually seen in Wegener’s granulomatosis. In Churg-Strauss syndrome, GGA and consolidation in the peripheral lung areas, which are the characteristic findings for eosinophilic lung diseases, may be the predominant finding. Nodules with CT-halo sign and thickening of the interlobular septa may sometimes be seen. It should be noted that diffuse alveolar hemorrhage is rare in Wegener’s granulomatosis and Churg-Strauss syndrome. Knowledge of these HRCT findings will facilitate correctly diagnosing pulmonary vasculitis among many diffuse infiltrative lung diseases.

Key words

  • Small vessel vasculitis
  • Antineutrophil cytoplasmic antibody(ANCA)
  • High-resolution CT(HRCT)


4. Abdominal Vasculitis

Department of Radiology, Oita University Hospital
Hiro Kiyosue, Hiromu Mori, Fumito Okada, Shuichi Tanoue, Rieko Shuto, Yoshiko Sagara
Department of Internal Medicine, Oita University
Koji Ishii

 Abdominal vasculitis is relatively rare but can involve all of the visceral vasculature in abdominal organs, causing various symptoms depending on the size of the involved vessels and the target organs. Intestinal hemorrhage or peritoneal/retroperitoneal hemorrhage occurs with aneurysm formation and ulceration secondary to vasculitis, which can be managed by adequate interventional techniques. Percutaneous balloon angioplasty is one of the effective treatments of renovascular hypertension due to Takayasu’s arteritis. In this article, the authors demonstrate general features of several vasculitis involving abdominal organs, and the role of diagnostic and interventional radiology.

Key words

  • Arteritis
  • Embolization
  • Aneurysm


5. Diagnosis and IVR -Aortic Disease

Department of Radiology, Nagasaki University Hospital
Hideyuki Hayashi, Ichiro Sakamoto, Eijun Sueyoshi, Masataka Uetani

 The purpose of this paper is to describe in detail the imaging and clinical appearances of Takayasu arteritis, followed by a description of the clinical and imaging features of other forms of large-vessel vasculitis such as infected aneurysm, Behçet disease and inflammatory abdominal aneurysm. To become familiar with these conditions and imaging features is essential to make the correct diagnosis. Indications and some comments on endovascular treatment of these conditions are also given. Endovascular treatment offers a potentially less invasive alternative to surgery ; however, further investigation with longer-term follow-up is strongly recommended.

Key words

  • Vasculitis
  • Takayasu arteritis
  • Stent-graft


6. Diagnosis and Treatment of Thrombophlebitis

Department of Radiology, Saitama Cardiovascular and Respiratory Center
Toshiko Hoshi, Tetsu Kanauchi, Hiroko Matsumoto, Miyuki Ueda

 Superficial thrombophlebitis and deep venous thrombosis (DVT) are the same pathological entity.
 Superficial thrombophlebitis is diagnosed by clinical symptoms, and so it does not need any diagnostic imaging. Some systemic diseases, such as Behçet disease and anti-phospholipid antibody syndrome are often associated with thrombophlebitis.
 DVT is a common disease, and it is important to make an accurate diagnosis of DVT. Conventional venography used to be the gold-standard of DVT diagnosis, although low-invasive methods nowadays have become popular. In this paper we describe recent vascular imaging techniques of DVT, ultrasonography, CT and MRI, and treatment of DVT.

Key words

  • Thrombophlebitis
  • Deep venous thrombosis(DVT)
  • Diagnosis


Original Article

A Multicenter Prospective Survey on Image-guided Endovascular Management for Non-functioning Hemodialysis Shunt

Juichi Tsushima, Ichiro Hino1), Yoshiaki Narimatsu2), Nobunari Hayashi3)
Izumi Amano4), Akira Naitou5), Shunichi Sadaoka6), Kazunori Kuroki7), Yasuo Gotoh8)
Katsuhiko Matsuura9), Kei Takase10), Shuji Kariya11), Takashi Satoh12)
Department of Radiology, Yao Tokushukai General Hospital, Kitakami Orthpedics Radiology Clinic1)
Department of Radiology, Kawasaki Municipal Hospital2), IVR consultant3)
Nagoya Vascular Access Amano Memorial Clinic4), Department of Radiology, Chugoku Rousai Hospital5)
Department of Radiology, Jikei University School of Medicine6)
Department of Radiology, Shonan Memorial Hospital7)
Department of Radiology, Sendai Shakai Hoken Hospital8)
Department of Radiology, Saitama Medical Center Jichi Medical University9)
Department of Diagnostic Radiology, Tohoku University10)
Department of Radiology, Kansai Medical University11), Meiko Kyoritsu Clinic12)

Purpose : To prospectively evaluate the safety and efficacy of endovascular management for non-functioning hemodialysis shunt.
Background : From January through December 2004, hemodialysis patients with forearm native fistulae or grafts, referred for endovascular treatment, were consecutively and prospectively enrolled. Shunts with a past history of endovascular therapy were excluded.
Patient characteristics, type of access, lesion characteristics, procedures, complications, and clinical outcomes were registered.
19 institutions participated in this survey with the approval of their respective ethics committees.
Results : 317 patients were registered and 306 underwent endovascular treatment. The clinical initial success rate was 92.2%(283 of 306), with a technical success rate of 85.6%(262 of 306), and a 1-year primary patency rate of 50.34%. The one-year primary, primary assisted and secondary patency rates were 50.3%, 78.4% and 83.7% respectively. There were significant differences between the primary patency rate and primary assisted patency rate (p<0.0001), and between the primary patency rate and secondary patency rate (p<0.0001).
Minor complications occurred in 23 patients, including two losses of vascular access. No patients required hospitalization.
Conclusion : Endovascular management for non-functioning hemodialysis shunts results in a high initial success rate with minimal complications. Although the primary patency rate is insufficient, repeated endovascular management results in good primary assisted patency and secondary patency.

Key words

  • PTA
  • Endovascular management
  • Hemodialysis shunt


Original Article

Intradiscal Abscess Drainage Using C-arm Cone-beam Computed Tomography (C-arm CT)

Department of Radiology, Showa University School of Medicine1)
Department of Radiology, Showa University Fujigaoka Hospital2)
Department of Radiology, Southern Tohoku General Hospital3)
Noritaka Seino1), Toshi Hashimoto1,2), Minoru Honda1), Takashi Hashizume1,3)
Shouei Sai1), Masaaki Kawahara1), Syu Takaya1), Makoto Saiki1), Junpei Suyama1)
Yoshimitsu Ohgiya1), Masanori Hirose1), Takehiko Gokan1)

Purpose : The purpose of this study was to demonstrate that intradiscal abscess drainage using C-arm cone-beam computed tomography (C-arm CT) is an efficient and safe procedure.
Background : Recent progress in CT imaging using a flat panel detector mounted on a C-arm allows operators to visualize both high-density and low-density structures. C-arm CT provides the interventional radiologist with a three-dimensional data set for image-guided procedures. This technique may facilitate the three-dimensional planning and monitoring of non-vascular interventions such as biopsy and drainage.
Methods and Materials : Intradiscal abscess drainage using C-arm CT (Siemens AXIOM Artis dTA) was performed in five patients (5 men and 1 woman, ranging in age from their 40s to their 70s) with seven spondylodiscitic abscesses. Seven intradiscal abscesses and one paravertebral abscess were drained with 6-8 F catheters. In all cases, the catheter was inserted using the Seldinger technique.
Results : Successful placement of the drainage catheter was achieved in each patient without procedural complications. The duration of drainage was 14〜60 days. A specific organism was isolated in three of the five patients. A complete evacuation of all abscesses was achieved with no recurrence during the follow-up period.
Conclusion : Intradiscal abscess drainage using C-arm CT is considered to be an efficient and safe procedure.

Key words

  • C-arm CT
  • Flat-panel detector
  • Three dimensional dataset
  • Intradiscal abscess
  • Percutaneous catheter drainage