Jpn J Intervent Radiol Vol.29 No.1 2014

State of the Art
The Role and Fundamentals of Emergency Interventional Radiology

An Introduction  
Department of Radiolody, Wakayama Medical University
Motoki Nakai

1. Interventional Radiology for Emergency Disease of Central Nervous System and Head & Neck

Department of Radiology, Nara Medical University
Takeshi Wada, Hiroyuki Nakagawa, Kimihiko Kichikawa
Department of Radiology and Interventional Neuroradiology, Ishinkai Yao General Hospital
Katustoshi Takayama, Kaoru Myochin

Interventional neuroradiology (Neuro IVR) for emergency disease includes acute ischemic stroke, ruptured cerebral aneurysm, sinus thrombosis, dural arterial venous fistula, nasal bleeding, and head and neck trauma. Acute ischemic stroke and ruptured cerebral aneurysm are the most frequent among these diseases. Recently devices for Neuro IVR are remarkably advanced, and the indication and procedures for these diseases are changing.
Especially for the past few years, mechanical thrombectomy devices for acute ischemic stroke are rapidly improving. Interventional radiologists should understand updated indications and techniques of Neuro IVR.
In this article, we review current treatment options for acute ischemic stroke focusing on the latest advances in the field of mechanical thrombectomy and also outline the current strategy of coiling for ruptured cerebral aneurysm based on the recent literature and our experience.

Key words

  • Interventional neuroradiology
  • Acute ischemic stroke
  • Ruptured cerebral aneurysm

2. Endovascular Therapy of Emergent Aortic Pathologies

Department of Radiology, Mie University Hospital
Noriyuki Kato, Takashi Hashimoto, Takatoshi Higasigawa, Shuji Chino

Endovascular therapy including stent-graft repair has been established as one of choices for the treatment of various aortic pathologies. It has been also recognized as powerful first-line treatment for aortic emergency because of its relatively low invasiveness. Acute type B aortic dissection complicated with malperfusion is benefitted most from endovascular therapy. On the other hand, type B aortic dissection complicated with aortic rupture seems still challenging due to it complex hemodynamics. Ruptured aortic aneurysms, especially ruptured thoracic aortic aneurysms, are also benefitted from endovascular therapy. Although there remains some limitations and controversies, aorto-bronchial or aorto-enteric fistulae and infectious aortic aneurysms can be treated with endovascular therapy. To improve the results and it should be mandatory to organize medical staffs, outside hospitals, and facilities including backups of devices.

Key words

  • Aorta
  • Emergency
  • Endovascular therapy

3. Emergency Interventional Radiology in the Management of Gastrointestinal and Intraperitoneal Hemorrhage

Department of Radiolody, Wakayama Medical University
Akira Ikoma, Motoki Nakai, Hiroki Minamiguchi, Tetsuo Sonomura, Morio Sato

Transcatheter arterial embolization (TAE) is considered a safe and effective primary interventional procedure for gastrointestinal and intraperitoneal hemorrhage. TAE can provide instant and definite hemostasis. However, attention must be paid to avoiding ischemic complications, such as bowel infarction. An increasing number of patients have been treated with TAE using metallic coils and n-butyl-2-cyanoacrylate (NBCA). Several recent studies have reported that NBCA, a permanent liquid embolic material, is a useful alternative to gelatin sponge or microcoils in treating uncontrollable acute arterial hemorrhage. This review describes the indications, pitfalls, embolic materials, and methods of TAE for the management of gastrointestinal and intraperitoneal hemorrhage.

Key words

  • TAE
  • Gastrointestinal hemorrhage
  • Intraperitoneal hemorrhage
  • NBCA
  • Pseudoaneurysm

4. Endovascular Treatment in the Management of Obstetric and Gynecologic Emergencies

Departments of Radiology, Kitasato University School of Medicine
Reiko Woodhams, Takuro Yamane, Go Ogasawara
Kaoru Fujii, Toshimasa Hara, Keiji Matsunaga, Yusuke Inoue
Department of Cardiovascular Surgery, St. Marianna University School of Medicine
Hiroshi Nishimaki
Department of Traumatology and Critical Care Medical Center, National Hospital Organization Osaka National Hospital
Kenichiro Ishida

This article describes the role of endovascular treatment in the management of obstetrical and gynecologic emergencies. Interventional techniques for obstetrical and gynecologic emergencies consist of arterial balloon occlusion and arterial embolization. The operator is supposed to be decisive regarding the choice of interventional technique, and embolic material depending on the patient’s vital signs and cause/site of bleeding. Understanding of the intra-pelvic collateral pathway is essential for obstetrical and gynecologic arterial embolization because of the possibility of bleeding via rich collateral vessels. Postpartum hemorrhage (PPH) is one of the most critical causes of obstetric emergency. Recently, endovascular treatment has been focused on as an effective and safe technique to save PPH patients. Atonic bleeding is the most common cause of primary PPH. Secondary PPH is due to various causes and is less frequent and less critical compared to primary PPH. The main embolic materials chosen for PPH are gelatin sponge and NBCA. Gelatin sponge is commonly chosen first. NBCA can be appropriate for traumatic bleeding, pseudoaneurysm, recanalization after gelatin sponge embolization, and acquired AVM/AVF. Of gynecologic emergencies, tumor bleeding is the predominant indication for endovascular treatment. Various feeding arteries including the mesenteric artery can be the origin of bleeding because of tumor invasion. IPM/CS may be considered for bleeding from the mesenteric artery.

Key words

  • TAE
  • Arterial balloon occlusion
  • PPH
  • NBCA
  • IPM/CS
  • Gelatin sponge

5. Interventional Radiology for the Management of Urological Emergencies

Department of Radiology and Center for Endovascular Therapy, Kobe University Hospital
Takuya Okada, Masato Yamaguchi, Akhmadu Muradi, Naoto Katayama
Eisuke Ueshima, Keitaro Sofue, Koji Idoguchi, Koji Sugimoto

Embolization and other endovascular procedures are highly effective and well-tolerated procedure to manage a variety of urological emergencies. The most well-known procedure is embolization of traumatic renal injury. Iatrogenic renal injury is recently increasing due to the popularity of partial nephrectomy. Renal artery occlusion and bleeding from renal tumor are also indications for endovascular procedures. Although rare, uretero-ilio arterial fistula and post-traumatic nonischemic priapism are well treated with this technique. Interventional radiologists should be well acquainted with these urological emergencies.

Key words

  • Traumatic renal injury
  • Iatrogenic renal injury
  • Uretero-ilio arterial fistula

6. Interventional Radiology for Trauma

Department of Radiology and Emergency and Disaster Medicine1), Gifu University Hospital
Hiroshi Kondo, Masayuki Kanematsu, Satoshi Goshima,Yukichi Tanahashi
Nobuyuki Kawai, Kota Sakurai, Kunihiro Shirai1), Shinji Ogura1)

Transcatheter arterial embolization has been remarkably advanced and established as a treatment of choice for the management of traumatic bleeding. Expanding the knowledge of treatment strategies for trauma based on accurate diagnosis is crucial for maintaining our skills and improving patient outcome. This review article focuses on the technical aspects of emergent interventional radiology for the treatment of hepatic, splenic and pelvic trauma.

Key words

  • Taranscatheter arterial embolization
  • Blunt abdominal trauma
  • Damage control surgery

Original Article

Efficacy of Hybrid Revascularization Procedures for Peripheral Arterial Disease

Department of Radiology and Surgery1), Tottori Prefectural Kosei Hospital
Masayuki Endo, Masayuki Hashimoto, Shunsuke Fukino1), Takahumi Hamasaki1)
Naotaka Uchida1), Wataru Kodama1), Yuko Tanaka1), Tomohiro Kurashiki1)
Department of Cardiovascular Surgery, Shimane Prefectural Central Hospital
Satoshi Kamihira
Department of Radiology, Faculty of Medicine, Tottori University
Toshio Kaminou, Toshihide Ogawa

Purpose: To evaluate the feasibility and efficacy of hybrid therapy in patients with peripheral arterial disease.
Materials and methods: Between April 2009 and November 2012, 15 patients (15 limbs) with peripheral arterial disease underwent hybrid therapy. The patients comprised 10 men and 5 women, with an average age of 79 years. Technical success rate, clinical success rates, patency rates, incidence of postoperative complications, and any additional therapy were evaluated.
Results: Technical success rates were 100%. Clinical success rates were 86%. Mean ABI at rest increased significantly from 0.35±0.29 to 0.84±0.21 (p < 0.05). With a mean follow-up period of 477 days, the 1-year primary patency rate was 90%. One patient died of acute renal failure after hybrid therapy. One patient underwent secondary intervention.
Conclusion: Hybrid procedures are often useful for treatment of patients with peripheral arterial disease having multilevel lesions and complex problem.

  • Peripheral arterial disease
  • Hybrid therapy
  • Angioplasty
  • Endovascular surgery

Original Article

Guidewire Introducer in a Y-connector Reduces Friction from the Delivery Wire during Coil Embolization of Cerebral Aneurysms - In Vitro Evaluation

Department of Neurosurgery, Fukuoka University Chikushi Hospital
Kimiya Sakamoto, Kanji Nakai, Hiroshi Aikawa, Masanori Tsutsumi
Hiromichi Oishi, Minoru Iko, Yoshihisa Matsumoto, Taichiro Mizokami
Takafumi Mitsutake, Ayumu Etou, Kiyoshi Kazekawa
Department of Neurosurgery, Nagasaki Kita Tokushukai Hospital
Masanari Onizuka

Background and Purpose: Coil embolization is an effective and less invasive treatment of intracranial aneurysms and tight coil packing is important for avoiding recurrence due to coil compaction. However, tight coil packing increases resistance and the subsequent risk for aneurysmal rupture. We investigated the coil insertion pressure and the effectiveness of the adjunct use of a micro-guidewire introducer in the final stage of tight coil packing.
Methods: Using an in vitro model, we measured the chronologic changes in resistance to the insertion of 3 types of widely used finishing coils, namely, GDC-10 UltraSoft-, Micrus ULTIPAQ-, and ED coil-10 Extra Soft coils. We also measured the mechanical pressure to assess the effectiveness of the micro-guidewire introducer.
Results: At all but the first 1-cm interval, there were significant differences among the 3 coil types. Use of the introducer decreased the required insertion pressure by 25-30% when Micrus coils were placed (p < 0.001).
Conclusion: It is important to select the appropriate coil type at the final stage of coil embolization. A micro-guidewire introducer helps to decrease the insertion pressure.

Key words

  • Aneurysm
  • Coil embolization
  • Resistance
  • Insertion
  • Introducer

Original Article

A National Epidemiological Survey of Vascular Anomalies in Japan: Results of a Pilot Surve

Department of Diagnostic Radiology 2 and Diagnostic Radiology 11), Kawasaki Medical School
Yusuke Matsui, Hidefumi Mimura, Shigeru Watanabe1)
Department of Diagnostic and Interventional Radiology and Pathology2),
Osaka University Graduate School of Medicine
Keigo Osuga, Eiichi Morii2)
Department of Signal Transduction, Research Institute for Microbial Diseases, Osaka University
Nobuyuki Takakura
Division of Plastic and Reconstructive Surgery, Department of Developmental and Reconstructive Medicine, Graduate School of Biomedical Sciences, Nagasaki University
Sadanori Akita
Department of Plastic, Reconstructive and Aesthetic Surgery, Chiba University
Naoaki Rikihisa
Department of Epidemiology, Infectious Disease Control and Prevention,
Institute of Biomedical and Health Sciences, Hiroshima University
Junko Tanaka
Center for Vascular Anomalies, KKR Sapporo Medical Center Tonan Hospital
Satoru Sasaki

No systemic epidemiological surveys have been performed on vascular anomalies in Japan. We planned to perform the first large, multicenter survey to assess the current status of medical practice for vascular malformations. In this study, we present the results of a pilot survey. This study focused on 343 patients from 5 institutions (130 men and 213 women; mean age, 27.4 years). The lesions had most commonly appeared at birth (23.3%) or by the age of 5 years (23.3%). The lower extremities were the most commonly involved area (36.0%), followed by the head and neck (35.5%). Pain and swelling were the most common symptoms (47.8 and 48.4%, respectively). Venous malformation was the most common subtype of vascular malformation (64.4%). Sclerotherapy, the most common treatment, was performed in 164 patients (47.8%). The symptoms were cured or alleviated in 82.6% of patients who underwent treatment.

Key words

  • Vascular anomalies
  • Vascular malformations
  • Epidemiological survey