Jpn J Intervent Radiol Vol.27 No.3 2012

State of the Art
Interventional Radiology in the Management of Critical Limb Ischemia: Multi-Disciplinary Team Approach and “Total Vascular Care”

An Introduction  
Terumitsu Hasebe
Department of Radiology, Tokai University Hachioji Hospital / Tokai University School of Medicine

1. A Concept of "Total Vascular Care" for Critical Limb Ischemia:
The Importance of Aggressive Below-the-knee Interventions
and a Multi-disciplinary Team Approach

Department of Radiology, Toho University Sakura Medical Center
Shusuke Kasuya, Noriko Kitamura, Rumiko Kasai, Hitoshi Terada
Department of Radiology, Tokai University Hachioji Hospital / Tokai University School of Medicine
Kazunobu Hashida, Jun Endo, Terumitsu Hasebe*
*Corresponding Author: Terumitsu Hasebe

In the management of critical limb ischemia (CLI)-limb salvage, it is very important to understand the paradigm shift of “total vascular care” and new therapeutic strategies in collaboration with multidisciplinary specialists, including vascular surgeons, cardiologists, plastic surgeons, and nurses. The purpose of this paper is: 1. To review the recent therapeutic strategies of “total vascular care” for CLI, 2. To explain the conventional antegrade approach in below-the-knee (BTK) interventions for CLI, 3. To highlight utilization of the percutaneous retrograde tibial approach, which is particularly valuable in difficult cases where a conventional approach has failed. The major teaching points of this paper are: 1. The availability of multiple interventional devices and techniques can offer patients treatment options in diseased arterial territories that have traditionally not been amenable to treatment, particularly in tibial and pedal interventions. 2. Management of CLI requires a multidisciplinary approach rather than a turf battle to preserve radiologists' critical role in vascular interventions.

Key words

  • Critical limb ischemia(CLI)
  • Percutaneous transluminal angioplasty(PTA)
  • Below-the-knee interventions
  • Controlled antegrade and retrograde subintimal tracking(CART)

2. Endovascular Therapy for Patients with Critical Limb Ischemia

Kansai Rosai Hospital Cardiovascular Center
Shin Okamoto, Osamu Iida

EVT has emerged as an attractive alternative to bypass surgery for patients with critical limbs ischemia (CLI), achieving similar limb salvage rates as well as mortality to bypass surgery. Many reports suggest good results of endovascular therapy (EVT) for femoro-popliteal and infrapopliteal lesion as well as iliac ones. EVT should be conducted for limb salvage under familiarity with these data and our-own skills.

Key words

  • Endovascular therapy
  • Critical limb ischemia
  • Superficial femoral artery
  • Infrapopliteal artery

3. Endovascular Therapy in Patients with Critical Limb Ischemia

Department of Interventional and Diagnostic Radiology, Tsuchiya General Hospital
Tomoyasu Sato

Endovascular therapy (EVT) has been recognized as a useful and low invasive technique for treating the patients with critical limb ischemia. Antegrade ipsilateral approach is needed to recanalize chronic total occlusions of the superficial femoral artery and lower leg arteries. Ipsilateral approach is not difficult and not troublesome if the operator is familiar with this procedure. To recanalize long chronic total occlusion, a bidirectional approach is quite useful. Additional distal puncture is needed in some cases. Trans-collateral wiring and catheterization can be done in some cases. Once the wires pass through the total occlusion, balloon angioplasty can be done without difficulty. Though the long-term patency of these recanalized arteries is not satisfactory, it is enough that those arteries are kept opened until wound healing is achieved. EVT has an important role in the treatment of critical limb ischemia.

Key words

  • CLI
  • Endovascular therapy
  • PTA

4. Current Surgical Strategy for Critical Limb Ischemia

Department of Surgery, Tokyo Dental College Ichikawa General Hospital
Hirohisa Harada, Takahiro Shoji, Junichi Matsui

Among peripheral arterial disease (PAD) patients the proportion of the critical limb ischemia with below-the-knee (BK) lesions is markedly increasing in consequence of the growing number of diabetic patients. Although the indication of endovascular therapy for occlusive disease in iliac and superficial femoral arterial lesions has been established, such treatment for BK lesions still shows a poor long-term outcome in spite of its early benefits for limb salvage. Although endovascular therapy has surpassed surgical bypass in the iliac and even in the femoral area, the indication of distal bypass surgery in the BK area for critical ischemia has been established. For complex PAD cases involving multiple lesions from iliac to BK we are performing “hybrid surgery” in that vascular surgeons perform both EVT and bypass surgery simultaneously in the operating room and are achieving good results. The number of critical limb ischemia cases is likely to keep increasing in future, and thus we need to be engaged in multidisciplinary treatment therapies to improve outcomes.

Key words

  • Critical limb ischemia
  • Bypass surgery
  • Peripheral arterial disease

5. Significance of the Angiosome Concept in Revascularization from the Viewpoint of a Microcirculation Specialist

Department of Plastic Surgery, Tojun Hospital
Takuyuki Komoda

Emphasis has been placed on the angiosome concept in revascularization of limb salvage therapy. However, not all cases of revascularization apply this concept in the clinical setting. In fact, some cases can be healed without using angiosomes. We examined the significance of the current angiosome concept from the viewpoint of a microcirculation specialist. Endovascular treatment (EVT) and bypass surgery which can recover blood flow cannot save some ischemic limbs of diabetic patients receiving maintenance dialysis, most likely due to complications of macroangiopathy and impaired microcirculation. Though the collateral circulation to the lesions is essential as a route of blood flow for cases without using angiosomes, it is damaged due to impaired microcirculation, decreasing the blood flow to the site. An effective way to prevent this may be the application of EVT to below knee lesions to reconstruct or newly construct angiosomes in the leg and foot. A greater limb salvage rate is expected when EVT is aggressively applied from the leg to the foot in EVT only cases with insufficient blood flow volume or when EVT in the foot is applied to bypass surgery cases. However, further studies are needed to determine long-term results of revascularization of foot lesions.

Key words

  • Angiosome
  • EVT
  • Bypass
  • Impaired microcirculation

6. Treatment of Critical Limb Ischemia Using Endothelial Stem and Progenitor Cells

Division of Vascular Regeneration, Unit of Regenerative Medicine, Institute of Biomedical Research and Innovation1)
Vascular Regeneration Research Group, Institute of Biomedical Research and Innovation2)
Department of Regenerative Medicine Science, Tokai University School of Medicine3)
Yasuyuki Fujita1,2), Atsuhiko Kawamoto1,2), Takayuki Asahara2,3)

Peripheral artery disease (PAD) is mainly caused by atherosclerosis and is associated with significant morbidity and mortality. Arteriosclerosis obliterans (ASO) is the most common cause of PAD affecting the lower limbs. Additional causes of PAD are Buerger’s disease and collagen diseases involving vasculitis. Currently, the standard treatment for CLI is medication, surgical or endovascular revascularization. However, such interventions can be performed in only 50% of CLI patients and the CLI-resolved ratio is only 25% one year after the initial treatment. Among the CLI patients in whom attempts at revascularization have failed, 30% lose their legs and 25% die within one year after treatment. Therefore, the development of novel therapeutic strategies is urgently needed to improve the poor prognosis of CLI patients. Bone marrow-derived endothelial progenitor cells (EPCs) have been identified as a potential new therapeutic option for neovascularization. The preclinical findings have encouraged clinical researchers to explore the safety, feasibility and efficacy of cell-based therapies including unselected bone marrow-derived mononuclear cells and EPCs in patients with CLI in several small clinical trials. The results of these clinical trials revealed that cell-based therapies for no-option CLI patients are relatively safe, feasible and possibly effective. Recently, large-scale, randomized, placebo-controlled, double-blind studies are in progress to further confirm this evidence.

Key words

  • Autologous stem/progenitor cell transplantation
  • Clinical trials
  • Critical limb ischemia

7. Principles of Foot Care for Patients with Critical Limb Ischemia

Department of Gerontological Nursing, Division of Health Sciences and Nursing,
Graduate School of Medicine, The University of Tokyo
Makoto Oe, Hiromi Sanada

One of the causes of foot amputation is foot ulcers, making it important to prevent foot ulcers in patients with critical limb ischemia. Foot care of critical limb ischemia patients is based on control of peripheral vascular disease. Ischemic symptoms such as pain and claudication as well as blood flow such as the ankle brachial index and the toe brachial index need to be monitored, while smoking cessation, physical exercise and pharmacotherapy are also vital. Education regarding the importance of recognizing the risks of ulcers and the significance of treatment of peripheral arterial disease is also important. In addition, traumatic injury, which can cause ulcers, needs to be prevented. In addition to using appropriate footwear and loose socks, attention must be paid to skin injuries resulting from onychopathies and lesions caused during care for toenails.
If ulcers develop, even though the basics of topical treatment are the same as those for other chronic ulcers, removal of necrotic tissues and moist wound healing before revascularization should be avoided. Caution must be also exercised regarding compression therapy for venous ulcers and pressure reduction (excessive elevation of feet) applied to regions with pressure ulcers.
Recently, the wellbeing of patients with chronic wounds has been receiving increasing attention. Patients with critical limb ischemia may suffer a decline of mental wellbeing due to fear of foot amputation and pain. Care must also be improved for the mental wellbeing of patients suffering critical limb ischemia.

Key words

  • Foot care
  • Critical limb ischemia
  • Wound management


Original Article

Transcatheter Arterial Chemoembolization with Drug-eluting Superabsorbent Polymer Microsphere Loaded Epirubicin for Hepatocellular Carcinoma Refractory to Conventional Chemoembolization

Department of Radiology, GateTower Institute for Image Guided Therapy
Akihiko Seki, Shinich Hori, Atsushi Hori

The purpose of this retrospective study was to investigate the safety and clinical outcomes of transcatheter arterial chemoembolization (TACE) using drug-eluting superabsorbent polymer microsphere loaded epirubicin (DEM-TACE) for advanced hepatocellular carcinoma (HCC) patients refractory to TACE using epirubicin-Lipiodol mixture and gelatin sponge (Lip-TACE). Between March 2008 and February 2011, 59 patients with unresectable HCC refractory to Lip-TACE were enrolled to undergo DEM-TACE. The number of Lip-TACE sessions until judgment of resistance ranged from 2 to 13 (mean, 5.1). Tumor responses were evaluated by computed tomography according to the European Association for the Study of the Liver criteria. Overall survival and time to treatment failure were calculated using the Kaplan-Meier method. Toxicity was assessed according to CTCAE version 4.0 criteria. The mean number of DEM-TACE treatment sessions was 2.2 (range, 1-4), and the mean dose of epirubicin per session was 18 mg (range, 2-50). Response rates were 55.9 and 39.0% after 3 and 6 months, respectively. The median overall survival and time to treatment failure after initial DEM-TACE were 24.0 and 6.5 months, respectively. Overall, 10.2% of patients experienced grade 3 or 4 adverse events. Switching the drug carrier and the embolic agent from Lipiodol and gelatin sponge to superabsorbent polymer microsphere is a safe, well-tolerated, and efficacious treatment strategy for salvage TACE in HCC patients refractory to Lip-TACE.

Key words

  • Hepatocellular carcinoma
  • TACE
  • Drug-eluting microsphere
  • Epirubicin
  • SAP-MS

Original Article

Transcatheter Arterial Chemoembolization with Epirubicin and Lipiodol for Unresectable Hepatocellular Carcinoma
-Subgroup Analysis of Japanese Patients in a Cooperative Study between Korea and Japan-

Department of Diagnostic Radiology and Hepatobiliary and Pancreatic Oncology Division1),
National Cancer Center Hospital
Yasuaki Arai, Takuji Okusaka1)
Division of Hepatobiliary and Pancreatic Oncology, National Cancer Center Hospital East
Masafumi Ikeda
Cancer Information Services and Surveillance Division,
Center for Cancer Control and Information Services, National Cancer Center
Seiichiro Yamamoto

Background & aim: A single-arm expanded treatment efficacy and safety study of transcatheter arterial chemoembolization (TACE) for unresectable hepatocellular carcinoma (HCC) was conducted in Japan and Korea (Korea-Japan study), and showed a markedly favorable efficacy with mild toxicity. The aim of this study was to elucidate the efficacy and safety of TACE in the Japanese subgroup and investigate the relationship between the doses of epirubicin and Lipiodol and treatment efficacy and safety.
Methods: The subjects were 73 Japanese patients with unresectable HCC enrolled in the Korea-Japan study. The patients underwent TACE using an emulsion of epirubicin and Lipiodol, followed by injection of gelatin particles. TACE was repeated on demand.
Results: In 73 evaluable patients, the response rate was 82% by the modified response evaluation criteria for solid tumors. The median time-to-progression, median overall survival, and 2-year survival were 8.8 months, 36.9 months and 76.7%, respectively. The major grade 3 - 5 toxicities were an increased AST level (38%), increased ALT level (36%), and thrombocytopenia (14%), but all toxicities were generally transient. The patients treated with higher dose of epirubicin and Lipiodol tended to have a higher proportion of liver dysfunction, lower response rate and shorter time to progression, but tolerated these agents well.
Conclusion: TACE exerted a markedly favorable efficacy and was well-tolerated regardless of the doses of epirubicin and Lipiodol in Japanese patients with unresectable HCC.

Key words

  • Hepatocellular carcinoma
  • Transcatheter arterial chemoembolization
  • Epirubicin
  • Lipiodol
  • Survival

Case Reports

Endovascular Stent Treatment of Visceral Malperfusion Associated with Aortic Dissection: Report of Four Cases

Department of Radiology, Nagoya University Graduate School of Medicine
Kojiro Suzuki, Kenichi Kawakami, Yasuyuki Ookouchi
Akira Takada, Yoshine Mori, Shinji Naganawa

Aortic dissection is complicated by peripheral vascular ischemic symptoms in 20-40% of patients. The management of visceral ischemic complication is important because of the increased mortality of patients with renal and mesenteric ischemia. We report 4 cases of endovascular branch vessel and aortic true lumen stenting for visceral malperfusion (renal artery 2; renal failure 2, superior mesenteric artery 2; ischemic colitis 1 and acute mesenteric ischemia 1). In all cases, stent placement was successfully performed, and reperfusion was obtained. Withdrawal from dialysis was achieved in 2 of 2 cases with renal artery involvement. Ischemic colitis disappeared in one case with superior mesenteric artery involvement. However, one superior mesenteric artery case had recurrent aortic dissection 2 hours after stent placement, and was died of multiorgan failure 28 days later. There was no complication associated with the procedure. Visceral artery stenting could provide a safe and effective treatment for visceral malperfusion associated with stable aortic dissection.

Key words

  • Aortic dissection
  • Visceral malperfusion
  • Stent

Case Reports

Needle Tract Implantation of Hepatocellular Carcinoma after Percutaneous Transhepatic Portal Vein Embolization

Department of Diagnostic Radiology and Internal Medicine1) and Surgery2) and Clinical Laboratory3), National Hospital Organization Shikoku Cancer Center
Makoto Kajihara, Yoshifumi Sugawara, Tadaaki Takahashi, Shinya Sakai
Seijin Nadano1), Minoru Tanada2), Koji Ohta2), Rieko Nishimura3)
Department of Radiology, Ehime Prefectural Central Hospital
Takeshi Inoue
Department of Radiology, Minami-Matsuyama Hospital
Shoji Aono

Percutaneous transhepatic portal vein embolization (PTPE) is performed to reduce the risk of postoperative liver failure after major liver resection. Although some adverse events of PTPE were reported in previous papers, needle-tract implantation has not been reported. We report a case of hepatocellular carcinoma (HCC) with needle tract implantation of the right thoracic wall and diaphragm, which is strongly suspected to have been caused by PTPE.
A man in his at late 50s was admitted to our hospital with a solitary HCC in segment VIII of the liver. Preoperative PTPE through puncturing the right portal vein under sonographic guidance was successfully performed without complications using a mixture of gelatine sponge and lipiodol. Right hepatic lobectomy was performed 22 days later. 13 months after PTPE, contrast-enhanced CT and MR image showed needle-tract implantations in the intercostal muscles and diaphragm at the puncture site of PTPE. He underwent resection of the right thoracic wall tumor and diaphragm. Pathological examination confirmed metastatic HCC.

Key words

  • Percutaneous transhepatic portal vein embolization (PTPE)
  • Hepatocellular carcinoma (HCC)
  • Needle tract implantation

Case Reports

Rasmussen Aneurysm: Report of Two Cases Treated with Transcatheter Embolization

Department of Radiology and Pulmonology1), National Center for Global Health and Medicine
Kimei Azama, Kanehiro Hasuo, Takashi Okafuji, Tomohiro Nakayama
Hironori Kamano, Yoriko Egami, Ryo Somehara, Noriyuki Takatsu
Tatsuya Wada, Nobuyuki Kobayashi1)
Department of Radiology, Kohnodai Hospital, National Center for Global Health and Medicine
Hiroyoshi Maeda

Rasmussen aneurysm is defined as a pseudoaneurysm resulting from erosion of the pulmonary artery at the tuberculous cavity. We present two patients with a Rasmussen aneurysm who presented massive hemoptysis. In one patient, an aneurysm was detected by pulmonary computed tomographic angiography, and the pulmonary artery proximal to the aneurysm was embolized using microcoils. Hemoptysis resolved after embolization and there was no recurrence. In another patient, the aneurysm was detected by arteriography. The pulmonary artery was embolized with a microcoil, and systemic collateral arteries were embolized using polyvinyl alcohol and gelatine sponge particles. Hemoptysis recurred one week after, but there was no recurrence of the aneurysm. Transcatheter embolization seems a safe and effective method for treatment of Rasmussen aneurysm.

Key words

  • Rasmussen aneurysm
  • Embolization
  • Pulmonary tuberculosis

Case Reports

A Case of Peritoneal and Pleural Dissemination after Transpulmonary Radiofrequency Ablation with Transarterial Chemoembolization for Hepatocellular Carcinoma

Department of Radiology and Gastroenterological Medicine1), Kouseiren Takaoka Hospital
Kumi Ozaki, Koji Nobata, Yasuhiro Kawamori
Yasushi Horichi, Kiyohide Kitagawa, Mitsuhiro Terada1)

In this study, a case of peritoneal and pleural dissemination after radiofrequency ablation was reported. A man in his 60’s with hepatitis B virus infection was diagnosed with hepatocellular carcinoma (HCC) measuring approximately 18 mm in diameter in the posterior segment, which was observed in computed tomography (CT) images. HCC was treated by radiofrequency ablation using a cooled-tip needle and with CT-guided transpulmonary approach combined with transarterial chemoembolization. Technical success was achieved immediately after the procedures, and no complication was identified. CT images obtained 8 and 10 months after radiofrequency ablation showed a subphrenic nodular lesion and pleural mass, both of which gradually enlarged during the follow-up periods, although local reoccurrence was not recognized. Fourteen months after the radiofrequency ablation, peritoneal dissemination was confirmed at laparotomy and by histological diagnosis.

Key words

  • Hepatocellular carcinoma
  • Radiofrequency ablation
  • Dissemination