Jpn J Intervent Radiol Vol.25 No.1 2010

State of the Art
Basic Skill for IVR That You Cannot Ask for Teaching Anymore Now

An Introduction Kenji Takizawa

1. Intra-operative Patient Management in Interventional Radiology

Department of Radiology, Ohtawara Red Cross Hospital
Toshiya Kariyasu, Kimiyoshi Mizunuma, Kohki Kato, Makiko Tomabechi
Department of Radiology, Ebara Hospital
Shunsuke Sugawara

 The main purpose of premedication in IVR is to relieve anxiety. The indications of atropine sulfate in non-vascular Interventional Radiology need to be discussed. Attainment of an immediate effect initiation against pain and hypotension is important.

Key words

  • Premedication
  • Intra-operative patient management
  • Interventional Radiology


2. The Manner of Seldinger’s Method That We Think Best

Divison of Diagnostic Radiology, National Cancer Center
Yoshito Takeuchi, Hiroyuki Tokue, Keitaro Sofue, Noriaki Sakamoto

 Percutaneous catheter technique is of course based on the epoch-making technique applied by Sven-Ivar Seldinger in 1953. The latest developments of interventional radiology have been made possible by this technique. Plastic needles, sheath introducers and other new devices have changed somewhat the original technique. Accordingly, the way of performing Seldinger’s technique is no longer uniform. We present the manner of Seldinger’s method that we think best.

Key words

  • Seldinger’s method
  • Angiography
  • Common femoral artery


3. Gelatin Sponge : General Principles and Handling Characteristics

Department of Radiology, Iwate Medical University
Miyuki Sone, Akio Akahane, Tomohiro Suzuki, Kenichi Kato, Ryoichi Tanaka, Tatsuhiko Nakasato

 Gelatin sponge particles have been used as temporary embolic materials for more than 30 years. This embolic material has wide therapeutic applications such as chemoembolization for hepatocellular carcinoma, uterine artery embolization for symptomatic leiomyomas, and bleeding control for trauma, gastrointestinal bleeding, or postpartum hemorrhage. Gelatin sponge has established safety and efficacy profiles based on extensive clinical experience. It remains an important tool in interventional radiology, : however, differences in properties between various preparation techniques should be noted to avoid specific complications. This article aimed to provide basic information and describe the handling characteristics of gelatin sponge particles.

Key words

  • Gelatin sponge
  • Embolic material
  • Embolization


4. Metallic Coil Embolization

Department of Diagnositic Radiology, School of Medicine, Keio University
Subaru Hashimoto

 Embolization using metallic coils is one of the most fundamental techniques employed in interventional radiology. Metallic coils for percutaneous vascular occlusion were invented by Dr. Cesar Gianturco in 1975 and have gained widespread acceptance in the field of interventional medicine ever since. Recently, various types of pushable coil are available either in fibered or non-fibered forms. Mechanically detachable coils, electrically detachable coils and hydraulic detachable coils are also available to achieve controlled and more accurate placement. Metallic coil embolotherapy is applied in patients with arterial aneurysm, arterio-venous malformation and fistula, various bleeding disorders, patent ductus arteriosus and other congenital heart diseases, abdominal aortic aneurysm to cope with type 2 endoleak, hypersplenism, renovascular hypertension, nephrosis, autosomal dominant polycystic kidney disease, hepatic malignancy undergoing hepatic arterial infusion chemotherapy in an attempt to achieve hepatic arterial re-distribution or to avoid gastro-duodenal and pancreatic complications, porto-systemic shunt, and so on. Metallic coils are placed exactly at the desired target location using scaffold technique, anchoring technique, and coaxial technique, under flow control with use of an occlusion balloon catheter, or with the aid of a coil anchor. All interventional radiologists are required to gain familiarity with these techniques.

Key words

  • Metallic coil
  • Embolization
  • Aneurysm


5. Basic Balloon Angioplasty for Peripheral Arterial Disease and Hemodialysis

Department of Radiology, The Jikei University School of Medicine
Shunichi Sadaoka, Masanori Nagase, Hirokazu Ashida, Ken Koyama, Shinsuke Takenaga

 In interventional radiological history, the first percutaneous transluminal angioplasty(PTA)was attempted by the renowned radiologist Dr. Dotter. Recently, almost all procedures are performed with not only balloon PTA but also further techniques. But this balloon PTA is still one of the basic interventional techniques along with stenting or transarterial embolization, so now we often draw on this technique for periprocedures of stent placement, or dilatation for in-stent stenosis.
 In principle, we cannot avoid a vascular accident like an elastic recoil or dissection, or long term restenosis. Therefore, we could use a newly designed balloon for an area like the lower popliteal one as it is one of the most difficult locations in which to place a stent.
 In this article, we would like to explain the structure, principle and basic technique of the balloon PTA. In addition we have reviewed new balloon techniques including the cutting balloon, cryoplasty, and drug eluting balloon.

Key words

  • Percutaneous transluminal angioplasty
  • Balloon angioplasty
  • Balloon catheter
  • Critical limb ischemia


6. Basics of Vascular Stents and Stent grafts

Department of Radiology, Nara Medical University
Kimihiko Kichikawa, Shoji Sakaguchi, Wataru Higashiura, Hirofumi Itoh, Shigeo Ichihashi
Takeshi Nagata, Kiyoshi Nishimine, Katsutoshi Takayama, Hiroyuki Nakagawa

 We describe here the basic interventional therapy using stents and stent grafts. Recently vascular stents and stent grafts have achieved significant advances in the treatment of peripheral arterial disease, renal and carotid artery stenosis and aortic aneurysms. Compared with surgical treatment, imaging is considered to be important for case selection, planning and device selection in interventional procedures. Eventually, commercial stents and stent grafts have become available with acceptable outcomes. Endovascular stent grafting shows potential as a safe and useful treatment for aortic disease, but further investigations should attempt to determine its efficacy over a longer follow-up period.

Key words

  • Stent
  • Stent graft
  • Vascular disease


7. Knowledge and Method of Administering Anticancer Agents for Intraarterial Infusion

Division of Diagnostic Radiology, Shizuoka Cancer Center
Takeshi Aramaki, Michihisa Moriguchi, Takahiro Tsushima
Akihiro Sawada, Kouiku Asakura, Masahiro Endo

 As described previously in various reports, in the treatment of cancer, the effect of life prolongation by intraarterial infusion may be less evident than that by systemic chemotherapy. Furthermore, most reports indicate that it is unlikely to be applicable to first-line chemotherapy as well as standard chemotherapy. Meanwhile, it is well known that intraarterial infusion therapy achieves a high response rate and has been widely recognized as treatment in addition to the standard chemotherapy(systemic chemotherapy).
 Patients who undergo systemic chemotherapy have already been treated with high-dose anticancer agents, and they are more likely to be exposed to additional risks rendering them vulnerable to adverse events if they receive additional intraarterial infusions. Furthermore, some anticancer agents have a limited maximum dose. Such agents should not be used for intraarterial infusion if they have already been administered to patients for systemic chemotherapy. Among the anticancer agents, anthracycline, platinum anticancer agents, and mitomycin C have been commonly used for intraarterial infusion, but these agents may induce unique adverse reactions depending on the total dose.

Key words

  • Intraarterial infusion chemotherapy
  • Maximum total dose
  • Anticancer agent


Original Article

Transcatheter Arterial Chemoembolization for Unresectable Hepatocellular Carcinoma with Drug-eluting Microspheres Loaded with Cisplatin : Initial Evaluation of Safety and Efficacy

Department of Radiology1), Internal Medicine2), GateTower Institute for Image Guided Therapy
Akihiko Seki1), Shinich Hori1), Toshio Kawauchi1), Seiji Narumiya2)
Department of Radiology, Rinku General Medical Center
Atsushi Hori

We evaluated the early results of transcatheter arterial chemoembolization(TACE)with superabsorbent polymer microspheres(SAP-MS)loaded with chemotherapeutic agents in patients with unresectable hepatocellular carcinoma(HCC). Between February 2008 and April 2009, 39 patients(31 male and 8 female, mean age 74.6 years)were treated with TACE using SAP-MS loaded with cisplatin(IAC-SAP TACE)as second or later line therapy. Before the IAC-SAP TACE therapy, all the patients had been treated with multiple sessions of conventional TACE with epirubicin, lipiodol, and gelatin sponge particles, but they had relapsed more frequently. The diameter of the maximum treated lesions ranged from 10 to 140mm(mean 50.2mm), and 37 patients(94.9%)had multiple liver tumors. A total of 56 sessions of IAC-SAP TACE were performed(mean, 1.6 sessions per patient). Response rate after one month of initial IAC-SAP TACE was 46.2% and 23.1% by EASL and RECIST criteria. The median overall survival time was 341 days(range, 66〜401 days)calculated using the Kaplan-Meier method. No major complications were observed and 34 patients(87.2%)had no postembolization syndrome(fever, abdominal pain, and/or vomiting). IAC-SAP TACE was a safe therapeutic option for advanced multiple HCC. We are currently planning a phase II trial of IAC-SAP TACE as first line therapy for unresectable HCC

Key words

  • Hepatocellular carcinoma
  • Transcatheter arterial chemoembolization
  • Cisplatin
  • SAP-MS
  • Drug-eluting microspheres


Case Report

Successful Stent-assisted Coil Embolization for Pseudoaneurysm of the Left Subclavian Artery-A Case Report-

Department of Radiology, Cardiovascular Surgery1), Japanese Red Cross Kumamoto Hospital
Takeshi Sugahara, Koya Nakashima, Kazuchika Yonenaga, Toshiaki Watanabe1),
Toshiya Koyanagi1), Kanako Ito, Akiko Kobori, Yuji Baba

Apatient in his 70s with symptoms of hoarseness and left upper chest pain was admitted to our hospital and was diagnosed with pseudoaneurysm of the left subclavian artery, induced by the arterial wall invasion of metastasis from an unknown primary malignant tumor. The maximum diameter of the pseudoaneurysm was 5.5cm, and more than 60% of the left common carotid artery stenosis was caused by compression from the pseudoaneurysm. The surgical repair of the left subclavian pseudoaneurysm was considered to be difficult by cardiovascular surgeons and intolerable for the patient, whose general condition was poor. Therefore, a minimally invasive endovascular repair with stent-assisted coil embolization was chosen. By trans-femoral and brachial approaches, the wide-neck of the pseudoaneurysm was initially covered by the bare stent, and subsequently trans-stent coiling of the aneurysm cavity was performed. Although complete embolization of the aneurysm cavity could not be achieved, the left chest pain was relieved and there was no sign of further growth or rupture of the pseudoaneurysm one month after the treatment. This technique can be used as one of the treatment options for the repair of symptomatic subclavian artery pseudoaneurysm in a patient with intolerance for invasive open surgery.

Key words

  • Stent-assisted
  • Coil embolization
  • Pseudoaneurysm
  • Subclavian artery


Case Report

A Case of Hemobilia due to a Pseudoaneurysm Caused by a Pancreatic Pseudocyst

Department of Radiology, Internal Medicine1), Himeji St. Mary’s Hospital
Kenichi Omae, Tatsuhiko Iishi, Shunji Fujie, Takashi Noto1)
Department of Radiology, Chugoku Central Hospital
Yoshitomo Ando
Department of Radiology, Okayama University Medical School
Minako Marunaka, Kentaro Shibamoto, Susumu Kanazawa

Pseudoaneurysm is a rare but critical complication of pancreatic pseudocyst. A man in his 40’s with abdominal pain was admitted to our hospital. Abdominal CT shows hemobilia due to a pseudoaneurysm caused by a pancreatic pseudocyst. Emergency angiography was performed and pseudoaneurysm was demonstrated in the gastroduodenal artery region. Transcatheter arterial embolization therapy was successfully performed with coils.

Key words

  • Pseudoaneurysm
  • Hemobilia
  • Pancreatitis

Technical Note

Interlocking Detachable Coil : Problem Solving and Troubleshooting

Department of Radiology, Toho University Sakura Medical Center
Toho University School of Medicine
Terumitsu Hasebe, Noriko Kitamura, Shusuke Kasuya, Rumiko Kasai
Hideyasu Kudo, Tomoya Nakatsuka, Hideo Morita, Hitoshi Terada

The IDC coil is an effective device that allows controlled embolization to be performed, especially in aneurysms and high-flow arteriovenous fistulas.
Once the conventional microcoil emerges from the catheter tip, a stage of irreversibility is soon reached because catheter withdrawal means coil deployment. IDC coil, which is the controlled-release coil, has been developed to overcome this major limitation. The IDC is released when the coil pusher is advanced until the radiopaque marker on its distal end is superimposed on the proximal marker of the microcatheter. When necessary, the coil can be easily retrieved before the two markers, and may be pushed forward again. However, this system sometimes causes premature detachment, which is a considerable risk, and coil repositioning can cause problems. In this paper, we summarized the possible IDC-related complications and introduced some basic troubleshooting procedures for these problems.

Key words

  • Interlocking detachable coil
  • Complications
  • Troubleshooting