Educational Abstracts

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Modified retroperitoneal access for percutaneous

intervention after pancreaticoduodenectomy

Vascular Malformation
EO sclerotherapy

Arterial and direct approaches to

arteriovenous fistulae converging on the
varix: Illustrative cases

Pua Uei, Lawrence Quek

Hideki Hyodoh, Hirokazu Washio, Kazusa Hyodoh,

Shoichi Inagawa1, Shuhei Yamashita2, Mika Kamiya2,

Department of Diagnostic Radiology, Tan Tock Seng

Hospital, SGP

Taishi Satoh, Yuriko Kawaai, Kazunori Aratani,

Norihiko Yoshimura1, Harumi Sakahara2,

Maki Onodera, Mayumi Asai, Mitsuharu Tamakawa,

Hidefumi Aoyama1

Masamitsu Hatakenaka

Department of Diagnostic Radiology, Sapporo Medical

University, JPN

Peribiliary arterial plexus; Normal anatomy and

clinical significance for vascular intervention
of hepato-biliary-pancreatic system
Yasuhiro Ushijima1, Akihiro Nishie1, Yoshiki Asayama1,
Kousei Ishigami1, Daisuke Kakihara2,
1

Yukihisa Takayama , Nobuhiro Fujita ,

3

Kanehiro Hasuo , Hiroshi Honda

Department of Clinical Radiology, Graduate School of

Medical Sciences, Kyushu University, JPN

Department of Molecullar Imaging and Diagnosis, Graduate

School of Medical Sciences, Kyushu University, JPN
3

Department of Radiology, Niigata University Medical and

Dental Hospital, JPN

Department of Radiology, Hamamatsu University School of

Medicine, JPN

Department of Radiology, National Center of Global Health

and Medicine, JPN
Peribiliary arterial plexus is a plexiform vascular system that
develops around the main bile duct and feeds it. Peribiliary
arterial plexus is not usually visualized when performing
vascular intervention of hepato-biliary-pancreatic system, but
becomes prominent under various pathological conditions.
Therefore, the recognition of peribiliary arterial plexus is
important for vascular intervention in this part.
In this exhibition, first, we present normal anatomy of
peribiliary arterial plexus in computed tomography (CT),
digital subtraction angiography (DSA), CT hepatic angiography
(CTHA) and rotational 3-D angiography (3-DA). Next, we
show prominent peribiliary arterial plexus under various
pathological conditions including hilar lymphnode metastasis,
pseudoaneurysm in the bile duct, bile duct cancer, occlusion
of hepatic artery and congenital vascular malformation, and
finally discuss clinical significance of this vascular system.

The purpose of this exhibit is to illustrate a safe percutaneous

A pictorial display and review were made in the focused on

Purpose: To demonstrate arterial and direct approaches for

approach that can be used to access the surgical bed after

how to treat/manage the vascular malformation (VM) using

embolization of arteriovenous fistulae (AVFs) converging on a

pancreatico-duodenectomy. Pertinent anatomical and technical

Ethanolamine Oleate sclerotherapy.

details will be illustrated.

This exhibit will review: a) the various imaging (MR, CT, US)

Whipple operation or pancreatico-duodenectomy is a

techniques for VM. b) the management of nidus flow; its theory

commonly performed curative surgery for pancreatic head

and tips. c) the risks and complications of sclerotherapy. d) the

and distal common bile duct cancers. While peri-operative

limitation of sclerotherapy. The exhibit affords the observer an

mortality has improved over the past decades, the high peri-

important tip in VM management.

operative morbidity remains unchanged. Percutaneous image

guided procedures plays an important role in patients with
pancreaticoduodenectomy, with procedure ranging from
percutaneous drainge of deep surgical bed abscesses in the
early peri-operative period to image guided biopsy or ablation
of suspected tumor recurrence. In our experience, percutaneous
access to the region around the excised pancreatic head is
particularly challenging. Besides the deep location of the area
with numerous surrounding structures, the post-surgical
anatomy (e.g. Roux loops) sometimes precludes conventional
percutaneous routes that have been described for routine
pancreatic intervention.
An advantage that can be exploited after pancreaticoduodenectomy

possibility of treating already known venous malformation in his

mandible and neck. Contrast-enhanced dynamic study of magnetic
resonance imaging raised a suspicion of an arteriovenous shunt
(AVS) with a varix in the retro-oropharynx. Arteriography and
embolization was offered due to possible airway obstruction in
case of hemorrhage and difficulty of immediate tracheostomy
because of venous malformation surrounding the thyroid gland.
Informed consent was given. Arteriography revealed an AVF with
two feeders converging onto the surface of a large varix. Arterial
embolization with n-butyl-cyanoacrylate (NBCA) was performed to
perfect obliteration of the lesion.
Case2: a lady in her third decade sought a possibility for having a
second baby after an AVS was detected in the pelvis. Arteriography
revealed an AVF with multiple feeders converging onto the surface
of a large varix in the retroperitoneum and draining veins in the
pelvis. It seemed impossible to achieve complete occlusion of the
lesion in a single session by either arterial or venous approach.
To reduce radiation exposure as small as possible, a laparotomy

is the resection of the entire duodenum together with the

and direct puncture of the enlarged draining vein immediately

pancreatic head. With the C-loop of the duodenum removed, the

downstream of the varix was performed and embolization was

region over the excised pancreatic head is very amenable for

done with NBCA and the aid of coils. Complete occlusion of the

direct right lateral retroperitoneal approach. In our approach,

for safe placement of large profile instruments such as large
bore drainage catheters and ablation devices without fear of
surrounding organ or vascular injury. To optimize the trajectory
and maximally displace intra-peritoneal from retroperitoneal
structures, we combine left lateral decubitus positioning with
salinoma creation in the anterior pararenal space. We find that
this approach to be highly replicable and safe for assessing the
region of the excised pancreatic head.

retroperitoneal AVF was achieved and she had a second baby one
year later with normal vaginal delivery.
Case3: A lady in her 7th decade presented herself with a enlarging
mass in the suprascapular region. Arteriography revealed an AVF
with multiple feeders draining into a large varix. Direct puncture
of the varix was made and shunting segment was embolized with
coils to complete closure of the fistula.
Case4: A man in his 8th decade presented himself with
myelopathy of the lower extremities. Arteriography revealed a
lumbar epidural AVF with multiple fine feeders converging onto
an epidural varix. Venous approach via the hemiazygos vein was
failed and trans-pedicular direct puncture of the varix was done.
The feeders and varix was embolized with NBCA and the aid of
coils to complete obliteration of the lesion.
Conclusion: AVFs converging onto the varix may be completely
embolized with arterial or direct approaches.

352

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Educational Abstracts

only the anterior pararenal fat is trangressed. This allows

Educational Abstracts

varix, a good candidate for this modality of therapy.

Case1: a boy in his second decade visited our hospital to seek a

Poster Exhibition

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Check Cholangiogram following

percutaneous metallic biliary stent
placement. Is it really necessary?

Percutaneous transluminal biopsy using

7-F forcep for diagnosing malignant biliary
obstruction

Mirrizi syndrome like presentation due to of

hepatic artery pseudoaneurysm

C-arm Cone-beam CT guided Non-vascular

Interventional Radiological Procedures:
Initial Experience

Raza Sayani, Muhammed Ali, Muhammed Azeemuddin,

Young Hwan Kim, Eun Jung An

Raza Sayani, Darakshan Kanwal, Muhammed Ali,

Koji Mikami

Department of Diagnostic Radiology, Keimyung University

School of Medicine, KOR

Zahid Anwar, Haq Tanveer

Department of Radiology, Suita Municipal Hospital, JPN

Tanveer Ul Haq
Department of Radiology, Aga Khan University Hospital,
PAK

PURPOSE OF STUDY: To review our experience with

percutaneous biliary stenting and to determine if the routinely
conducted check cholagiogram two to three day following stent
placement was necessary or not.
MATERIAL AND METHOD: Retrospective review of patients
who had undergone metallic biliary stent placement between
January 2005 and December 2011 was performed at Radiology
Department of Aga Khan University Hospital. Three most
common indications for biliary stent placement were biliary
obstruction due to carcinoma of gall bladder, carcinoma of head
of pancreas and cholangiocarcinoma. Post biliary stenting an
8 Fr external drain is left in place and is removed after check
cholangiogram usually after two to three days.
RESULTS: There were 131 subjects (61 males, 70 females),
with a mean age of 63 years (range, 27-94 years). 107 check
cholangiogram were performed. Eighty-two of 107 check
cholangiogram demonstrated a patent stent with free
flow resulting in safe external catheter removal. 23 check
cholangiograms revealed either sludge or hemorrhage because
of which the drains were not removed initially and were
removed after few days. The serum bilirubin level improved in
most patients. In 24 patients data was not available from our
departmental records.
CONCLUSION: Percutaneous biliary stenting external drain is
a well documented step which is helpful in prevention of sepsis
during immediate post procedure period. It also helps to drain
any sludge or hematoma secondary to interventions. Check
cholangiogram are additional advantage which may not be
useful in most cases however it gives satisfactory confirmation
of patency of stent but may be omitted if others share similar
experience to ours.

Department of Radiology, Aga Khan University Hospital,

PAK

Purpose: To evaluate usefulness of the percutaneous

Acute cholecystitis leading to development of a pseudoaneurysm

Purpose: To describe our initial experience of non-vascular

transluminal biopsy using 7-F forcep for diagnosing malignant

in an arterial branch of the hepatic artery is a very uncommon

interventional radiological procedures under the C-arm cone-

biliary obstruction.

complication however a pseudoaneurysm resulting in

beam CT (CBCT) guidance XperGuide.

Material and methods: One hundred seven consecutive

compression of gall bladder neck leading to its distention and

patients (62 men and 45 women; mean age: 71 years) with

inflammation is virtually unreported.

obstructive jaundice underwent transluminal forceps biopsy

We report a case of a 60 years male patient who presented

after percutaneous transhepatic biliary drainage. The lesions

in emergency department with right hypochondrial pain. He

involved the common bile duct (n=33), common hepatic

was known case of infective endocardititis and had history

duct (n=13), hilum (n=17), right or left intrahepatic bile

of liver abscesses in part which were drained. Patient was

duct(n=32), multiple sites( extra- and intrahepatic ducts,

slightly icteric. Initial ultrasound showed hepatic artery

n=7), or anastomotic sites(n=5). In each patient, average

pseudoaneurysm causing compression of neck of gall

three specimens were taken with 7-F biopsy forceps. The final

bladder leading to gross distention of gall bladder and mild

diagnosis was confirmed with pathologic findings, or clinical

intrahepatic duct dilatation. No definite calculi were seen

and radiologic follow-up.

within the gall bladder. Findings were further confirmed by

Results: The final diagnoses of malignancy were

CT scan and selective transcatheter arterial embolization of

cholangiocarcinoma in 63 patients, GB cancer with direct

pseudoaneurysm and percutaneous cholecystostomy were

invasion of biliary tree in 7, ampullar of Vater cancer in 2, HCC

performed. We describe in detail the clinical presentation,

in 1, GB cancer with lymphatic metastasis in 1, and pancreatic

imaging findings and associations with hepatic artery

head cancer in 1 patient. The final diagnoses of benign disease

pseudoaneurysms.

were postoperative biliary stricture in 2 patients, cholangitis

in 13, and unknown cause of biliary stricture in 17 patients.
Pathologic classifications of malignancies established by

Material and Methods: 7 patients were treated under C-arm

CBCT guidance. These patinets included 5 drainage cases
(iliopsoas abscess, pancreatic tail abscess, intra-peritoneal
abscess, pleural empyema, pelvic fluid collections), and 3 spinal
nerve root block cases.CBCT images were acquired using
a Philips Allura Xper FD20 system and X-per CT (Phillips
Medical Systems, Eindhoven, the Netherlands). The C-arm
system has two different movement modes for acquisition
in CBCT: a propeller movement of the 5-second rotational
acquisition and a roll movement of the 10-second rotational
acquisition.XperGuide supports percutaneous needle procedures
in the interventional suite by superimposing live fluoroscopy
on the acquired CBCT images, providing information on the
needle path and target. Live 3D image guidance and feedback
on any deviations from the desired path gives the operator full
control and confidence in guiding the needle along the correct
path.
Entry point view: XperGuide indicates the skin to target
distance from site to site, and the planned virtual needle path
can be viewed on the XperCT slices, to verify its feasibility.

forceps biopsy included 67 adenocarcinoma, 1 adenosquamous

Based on the predefined point-to-point path, the system

cell carcinoma, 1 hepatocelluar carcinoma. There were 6 false-

determines the optimal projection for visualizing the needle

negative diagnoses. The diagnostic performance of transluminal

forceps biopsy in malignant biliary obstruction had a sensitivity
of 92%, specificity of 100%, PPV of 100%, NPV of 84.2% and
accuracy of 94.2%. No major complications related to the biopsy
procedures occurred.
Conclusion: Percutaneous transluminal forceps biopsy is a
safe procedure that is easy to perform through a transhepatic
biliary drainage tract. It is highly accurate technique for
diagnosis of malignant biliary obstruction.

advancement, and automatically rotates the C-arm to the

needle insertion position. Progression view: The needle
inserted under fluoroscopic guidance must be angled until the
circles given by XperGuide are superimposed on each other and
then fixed using a needle holder. The C-arm then rotates to a
perpendicular view, superimposing the fluoroscopy image on
the XperCT images. The user-defined needle trajectory is shown
in real time on the image as the needle advances, allowing any
deviation from the projected path to be corrected immediately.
Results: The technical success rate was 100%.The mean total
exposure dose was 195.9mGy. The fluoroscopy time ranged
from 3 minutes 6 second to 14 minutes 50 seconds. No severe
complications were seen.
Conclusion: C-arm CBCT is the useful image guidance for nonvascular interventional radiological procedures, alternative to
CT image guidance.

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Role of enhanced CT in assessing the

source of arterial hemorrhage in patients
with pelvic fracture. Comparison with
angiography

Cement leakages in percutaneous

vertebroplasty: An analysis on
postoperative CT

Percutaneous vertebroplasty in patients

with multiple myeloma

The effectiveness of interlock detachable

coils for tanscatheter occlusion in various
target organ

Satoshi Suzuki1, Noboru Tanigawa2, Rie Yagi2,

Shicheng He, Teng Gaojun, Fang Wen, Guo Jinhe,

Keigo Chosa, Akira Naito, Yasuyuki Tsuchida,

Seo Yeon Park1, Jae Kyu Kim1, Jang Hyeon Song1,

Miyuki Nakatani , Atsushi Komemushi , Syuji Kariya ,

Deng Gang, Zhu Guangyu

Yoshiko Kohata

Hye Doo Jung1, Nam Yeol Yim1, Jae Hoon Lim2,

Yasuhide Kitazawa3, Satoshi Sawada2

Department of Radiology, the Affiliated Zhongda Hospital,

Southeast University, CHN

Department of Radiology, Chugoku Rosai Hospital, JPN

Nam Kyu Chang1

Purpose: To evaluate the influencing factors of the cement

leakage in vertebroplasty for treatment of osteoporosis vertebral
compression fracture (OVCF) and vertebral metastases (VM).
Methods: Retrospective analysis was conducted on 653
vertebrae in 356 patients treated with vertebroplasty in our
hospital from May 2007 to January 2011. 251 patients (198
women, 53 men) had 438 vertebrae with painful OVCF, 105
patients (55 women, 50 men) had 215 vertebrae with metastases.
CT was done before procedure and within 3 days after PVP
to determine cortical defects or osteolysisto and to observe
polymethylmethacrylate (PMMA) distribution in vertebrae and
whether leakage. PVP was performed under C-arm fluoroscopy
guidance only after local anesthesia. Ideally, the tip of the
needle was placed in the anterior third of the vertebral body
close to the midline. The ratio of powder of PMMA (g) / acrylate
monomer (ml) / powder of barium sulfate (g) as 15:10:3 was
selected for PMMA mixture and injection. Volume of PMMA
injected in each vertebral body and types of cement leakage
were compared between the OVCF and the VM by z test. The
correlation between cortical defects and cement leakages around
vertebrae was assessed with a Pearson correlation coefficient.
Results: The successful rate of technique of PVP was 100%.
The mean volume of PMMA injected in each vertebra was 5.0
2.03ml in OVCF group, and was 4.0 1.67ml in VM group (P <
0.05). Asymptomatic PMMA leakages were demonstrated by CT
respectively in 93 vertebrae (21.2%) in OVCF group and in 53
vertebrae (28.8%) in VM group (P < 0.05). Cement leakages into
disk were respectively found in 58 vertebrae in OVCF group
and 16 vertebrae in VM group (P=0.025). Cement leakages into
paravertebral vein were respectively found in 12 vertebrae
in OVCF group and 26 vertebrae in VM group (P < 0.0001).
Correlation was found between cortical defects and cement
leakage into paravertebral soft tissue in OVCF group (r=0.14)
or in VM group (r=0.27), between end plate defects and cement
leakage into disk in OVCF group (r=0.29) or in VM group
(r=0.31).
Conclusions: Cement extravasation is a frequent occurrence in
vertebroplasty and is well-tolerated in most of patients. Cement
leakage was significantly more frequent in the patients with VM
than those with OVCF, especially leakage into paravertebral
vein. Cement leakage into disc or paravertebral soft tissue was
significantly more frequent in vertebrae with end plate, cortical
defects or osteolysis.

PURPOSE: Percutaneous vertebroplasty is a minimally

Department of Emergency and Critical Care Medicine,

Saiseikai Noe Hospital, JPN

Department of Diagnostic Radiology, Chonnam National

University School of Medicine, KOR
2
Department of Emergency Medicine, Chonnam National
University School of Medicine, KOR

Department of Radiology, Kansai Medical University, JPN

Department of Emergency and Critical Care Medicine,

Kansai Medical University, JPN

Purpose: To evaluate the diagnosis of enhanced CT in

identifying the source of arterial hemorrhage in patients with
pelvic fracture.
Materials and Methods: The patient population included 15
patients with pelvic fracture who underwent pelvic enhanced
CT and subsequently angiography between January 2004
to August 2008. The analysis of enhanced CT involved the
presence and site of extravasation, hematoma and fluid
collection. We defined these three findings as bleeding. And
the analysis of angiography was done an angiologist who wre
unaware of enhanced CT findings. Five distinct regions of the
pelvis identified as potential sites of hemorrhage were divided
on the basis of anatomical landmarks. The regions were the
upper pelvic region, the gluteal region, the pelvic sidewalls,
the pre-sacral space, the small pelvic region. Finally, we
investigated concordance between the extravasation, hematoma
and fluid collection of enhanced CT and angiographic findings.
Result: Enhanced CT allowed us to indentify contrast
extravasation in 10/15(66.7%) patients with 15 sites.
7/15(46.7%) sites of extravasation were corresponding with
angiographic findings. Hematoma was indentified 15/15(100%)
ptatients with 36 site. 16/36(44.4%) sites of hematoma were
corresponding with angiographic findings. Fluid collection was
identified 8/15(53.3%) patients with 11 sites. 4/11 (36.4%) sites
were corresponding with angiographic findings. Enhanced
CT overall revealed 62 sites of bleeding and angiography
revealed 28/62(45.2%). As for five divided regions, the highest
concordance region between enhanced CT and angiography
was the upper pelvic region in 10/12(83.3%). The next were
the pre-sacral space in 4/7(57.1%) and the pelvic sidewalls in
11/23(47.8%). The lower concordance region were the small
pelvic lesion in 2/9 (22.2%) and the gluteal region in 1/11(9.1%).
Conclusion: We evaluated the diagnosis of enhanced CT in
identifying the source of arterial hemorrhage in patients
with pelvic fracture. The upper pelvic region is the highest
concordance region between the findings of enhanced CT and
angiography. And the lower concordance regions were the small
pelvic region and the gluteal region.

356

invasive procedure involving the injection of bone cement

within a collapsed vertebral body. Vertebral destruction
secondary to multiple myeloma is a significant clinical issue.
The purpose of this review is to assess the effectiveness of
percutaneous vertebroplasty as a treatment for the severe
refractory pain in patients with multiple myeloma.
METHOD: From June 2000 to December 2011, 7 patients (4
women, 3 men; age range 55-82 years; mean age 66.1) with
multiple myeloma suffering from severe back pain due to
vertebral compression fractures underwent percutaneous
vertebroplasty with polymethylmethacrylate (PMMA) at
our hospital. A total of 18 vertebrae were treated under
computed tomography (CT) guidance. The indication triad
for vertebroplasty consists of localized back pain, pain when
pressure is applied to the spinous process of the fractured level
and magnetic resonance imaging (MRI) bone edema, findings
suggestive of microfractures in a pathologically changed
vertebral body. Clinical outcomes were assessed on a visual
analog scale (VAS) after vertebroplasty.
RESULT: Technical success was achieved in all cases. In two
patients, we treated only one vertebral lesion, in one patient
we treated two vertebral bodies, in two patients we treated
three vertebral bodies, and in two patients we treated four
vertebral bodies. All patients experienced improvement in
symptoms after the procedure as demonstrated by improved

Purpose: To investigate the effectiveness of Interlock

Detachable Coils (IDC) for transcatheter occlusion in various
target organ.
Material and methods: A retrospective review of eighteen
patients during the initial 7 months period of IDC embolization
was performed. All patients in whom IDC were used are
diagnosed the etiology of disease in abdominal CT angiography
or angiography. The procedure was done via 4Fr Renigade
microcatheter during infusion of the physiologic solution.
Results: Total 124 coils were deployed in all 18 patients. Coils
were used for exclusion of the spelnic arterial aneurysm (n=4)
and renal arterial aneurysm (n=2), embolization of internal
iliac artery for stability of stent-graft and prevent endoleak
during endovascular aneurysm repair (n=3), embolization
of false lumen for prevent endoleak during endovascular
aneurysm repair of type B aortic dissection (n=1), target vessel
embolization due to active bleeding (n=4), and embolization
of tumor supply vessel in AML of right kidney (n=1) and HCC
(n=3). In which a follow up angiogram had shown the complete
or near complete occlusion of all target vessels. No serious
complications occurred, except one case had a partial splenic
infarction after the embolization of splenic arterial aneurysm.
All patients had an uneventful admission course.
Conclusion: Transcatheter coil emoblization with Interlock
Detachable Coils (IDCs) can be performed safely and effectively
in various organs.

VAS. The mean VAS score decreased significantly from 6.12.3

pre-vertebroplasty to 11.2 post-vertebroplasty. No major
complications occurred.

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CONCLUSION: Percutaneous vertebroplasty is a safe and

clinically effective treatment for pathologic vertebral fractures
from multiple myeloma and now forms an important part of
the multimodality treatment for these patients.

357

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Recanalization after endovascular treatment

for vertebral artery dissection

Urgent endovascular revascularization for

acute cerebral arterial occlusion

Successful transcatheter embolization of

a ruptured pancreaticoduodenal artery
aneurysm with median arcuate ligament
syndrome

Successful embolization with n-butyl

cyanoacrylate for spontaneous internal
thoracic artery rupture complicating
myelodysplasctic syndrome

Kenichi Watanabe1, Takeshi Kinkori2

Daisuke Sakamoto1, Tsuyoshi Matsumoto1,

Soichiro Hase1, Ryota Inai1, Mitsuhiro Takemoto1,

Noriaki Sakamoto, Masato Yamaguchi, Takuya Okada,

Kazutaka Uchida , Manabu Shirakawa , Norio Arita

Susumu Kanazawa

Kazuro Sugimira, Koji Sugimoto

Radiology and Center for the Vascular Therapy, Kobe

Universiyt Hospital, JPN

Department of Radiology, Okazaki City Hospital, JPN

Department of Neurosurgery, Okazaki City Hospital, JPN

Department of Neurosurgery, Gohshi Hospital, JPN

Department of Neurosurgery, Hyogo College of Medicine,

JPN

Shinichiro Matsubara , Akihito Mitsumori ,

2

Department of Radiology, Japanese Red Cross Society

Himeji Hospital, JPN

Teruaki Okuno, Koji Idoguchi, Akhmadu Muradi,

We experienced two recanalization cases despite initial

endovascular trapping for vertebral artery dissection.
A 49-year-old male, suffering from severe headache, was admitted
to our hospital. Right vertebral artery dissecting aneurysm was
revealed by 3D-CTA. The aneurysm was located PICA distal
segment of the vertebral artery. The aneurysm was gradually
enlarged in a month. We decided to perform endovascular
trapping of the vertebral artery under balloon flow control. The
PICA was preserved successfully. Two months later, the followup MRA revealed slight recanalization of occluded vertebral
artery. Next month, without any symptoms, the MRA showed
complete recanalization of right vertebral artery as well as the
contralateral vertebral artery occlusion with dissection. Nonhemorrhagic intracranial vertebral artery dissection usually has
a good prognosis, about 80% of the cases shows good recovery. It
is advisable to intervene, however, when careful observation of
the lesion reveals gradual enlargement of the aneurysm.
A 39-year-old female was transferred to our hospital due to
subarachnoid hemorrhage. The 3D-CTA showed right vertebral
artery, non-dominant side, dissection with PICA involved
aneurysm formation. The right PICA has sufficient collateral
flow from the opposite side. The endovascular embolization of
the aneurysm with parent artery occlusion was performed under
balloon flow control. Eight months later, the follow-up MRA
disclosed a slight recanalization of the affected vertebral artery.
Additional proximal coil embolization of parent artery underwent
next month. After this 2nd treatment the occlusion of ipsilateral
vertebral artery was maintained completely. Dense packing
with a certain length of coil mass along the vessel is essential to
archive the complete occlusion of the parent vertebral artery even
on non-dominant side. Among several causes of recanalization
after endovascular trapping, the hemodynamic change of the
parent artery may play the most important role. Even insufficient
coil packing could block the antegrade flow of the artery because
of the pressure from the contralateral vertebral artery via
the union, especially in cases of short segment embolization.
Although it seems the vertebral artery is completely occluded, but
in fact the flow only stops temporally on the balance of pressure
gradient. The flow easily resumes in course of time. To avoid
this situation, sufficient coil mass should be delivered in certain
length of the parent artery, which as a result means beyond the
'normal-to-normal' vessel concept. In such cases PICA or some
fine perforating arteries could not be avoided to sacrifice.

358

Introduction: Recanalization is a powerful predictor of stroke

We report a case of a ruptured pancreaticoduodenal artery

Purpose: The purpose of this case report is to describe

outcome in patients with arterial occlusion. Intravenous (IV)

(PDA) aneurysm with median arcuate ligament syndrome.

extremely rare case of spontaneous rupture of the internal

recombinant tissue plasminogen activator (rt-PA) is limited

A 63-year-old male patient was admitted to our hospital with

thoracic artery (ITA), which was successfully treated by

by its recanalization rate, which may be improved with an

a brief syncope. On admission, abdominal CT examination

selective arterial embolization with n-butyl cyanoacrylate

endovascular approach. We retrospectively reviewed 17

revealed a high density hematoma in the retroperitoneal

(NBCA).

patients who underwent urgent percutaneous transluminal

space. Selective superior mesenteric artery (SMA)

Material: A 53-years-old male with myelodysplasctic syndrome

balloon angioplasty (PTA).

angiography disclosed an aneurysm in the posterior inferior

(MDS) had pain in his back and left shoulder ten days prior to

Methods: Between March 2011 and January 2012, We

pancreaticoduodenal artery (PIPDA). The celiac axis was

admission to our hospital, without apparent previous injury,

performed endovascular procedure in 17 consecutive patients

occluded and blood was flowing to the liver and spleen via

which gradually became worse. A contrast-enhanced computed

with a persistent arterial occlusion at the end of IV rt-PA

the enlarged pancreaticoduodenal arcade from the SMA.

tomography (CT) demonstrated a mediastinal hematoma

infusion or with contraindication to receive IV rt-PA. We used

Transcatheter embolization of the aneurysm was performed

and left hemothorax with extravasation of contrast media.

intraarterial urokinase with mechanical disruption, angioplasty

successfully. The duodenal intramural hematoma decreased

Emergent angiography and CT during arteriography revealed

of the thrombus, and clot retrieval.

over time and he left our hospital on his feet 59 days after.

extravasation from the left ITA without any evidence of

Results: There were 10 men and 8 women. Ages ranged from

aneurysmal changes in the vessel.

47-86 years. Thrombolysis in Cerebral Ischemia grading

Result: By advancing a 2.0 Fr microcatheter into a bleeding

system (TICI) 2b to 3 was achieved in 16 out of the 18 subjects

branch of ITA, a 1.2cc of 20% NBCA mixture embolization was

(89%). There were three operative complications, including

performed because the patient was in hemorrhagic shock with

symptomatic subarachnoid hemorrhage in 1 patient. Favorable

coagulopathy disorder. We achieved complete homeostasis soon

outcomes (mRS 3) at 1 month were obtained in 9 patients

after the embolization. The patient was fully recovered and left

(50%).

our hospital without any complications.

Conclusion: Urgent endovascular treatment with multimodal

Conclusion: Although rare, spontaneous rupture of the ITA

devices for patients a persistent arterial occlusion at the end

can occur in patients with MDS. In patients with coagulopathy

of IV rt-PA or contraindication to receive IV rt-PA is a safe and

disorders, transarterial embolization using NBCA should be

effective treatment option.

considered as a first choice treatment.

Poster Exhibition

Poster Exhibition

Department of Radiology, Okayama University Graduate

School of Medicine, JPN

359

Poster Exhibition

PE014

PE013

PE015

PE016

Fogarty balloon application technique in

dislodging residual thrombus at the sheath
entry point in the graft during using single apex
puncture

Comparison of open-cell stent and closedcell stent for treatment of central vein
stenosis or occlusionin in hemodialysis
patients

Problems of implantable venous port

inserted through left internal jugular vein

Kotaro Yasui1, Yuka Tsuboi1, Keisuke Maruyama2,

Seung Boo Yang1, Dong Erk Goo1, Yong Jae Kim1,

Nae Jin Han1,2, Deok Ho Nam2, Dong Erk Goo1,2,

Jae Hong Seo2, Chul-Won Choi3, Sang Cheul Oh2,

Makoto Hiramatsu2, Ritsuya Momoki2, Akira Hasegawa1,

Gap Cheol Kim2

Yong Jae Kim1,2, Seungboo Yang1,2, Deuklin Choi1,2

Jae-Kwan Lee4

Tsuneharu Morito1, Setsuko Ishihara1, Izumi Togami1

Department of Radiology, Soonchunhyang University

Hospital, KOR

Endovascular treatment of hemodialysis

access dysfunction

Department of Radiology, Okayama Saiseikai General

Hospital, JPN
2

Department of Internal Medicine, Okayama Saiseikai

General Hospital, JPN

Purpose: To report endovascular treatment of hemodialysis

access dysfunction in our hospital.
Methods and Materials: 75 angiography of hemodialysis access
were performed in 50 patients (man; 29, woman 21: 68 yeas
in median; 31-89 years) in total between September 2009 and
March 2011. Of those, endovascular intervention was tried to
dilate or recanalize the access in 74 sessions immediately after
the angiography. Primary success rate of intervention, access
flow rate measurement before and after intervention, degree of
stenoses, and access diameter were analyzed.
Results: 12 complete or localized occlusion, and 63 stenoses
were detected. Of those 75 sessions with occlusion or stenoses,
67 sessions were successful procedure to recanalize or dilate
failured hemodialysis access. In one sessions, we didnt
perform angioplasty because the access had not demonstrated
significant stenosis. In one session with multiple access
stenoses, we couldnt advance balloon catheter into the stenosis
portion. (technical failure). Overall technical success rate was
90.5% (67/74). Technical success rate for non-occlusion lesion
was 98.4% (61/62). The access flow before angiography and
the diameter of the accesses were not significantly different
between occlusion group and stenosis group of the accesses.
Conclusion: Endovascular intervention for hemodialysis access
failures have been successful in the non-occlusive group in all
cases but one with multiple stenoses. We consider that early
recognition and intervention of access failure are important to

360

Department of Radiology, Kyung Hee University Hospital at

Gangdong College of Medicne, Kyung Hee University, KOR

Radiology, Korea University Guro Hospital, KOR

Department of Oncology, Korea University Guro Hospital,

KOR
3

Department of Hematology, Korea University Guro Hospital,

KOR
4

Department of Obstetrics and Gynecology, Korea University

Guro Hospital, KOR
Objective: To evaluate the effectiveness of the Fogarty balloon
application in dislodging residual thrombus at the sheath entry
point in the graft during using single apex puncture to declot
thrombosed hemodialysis loop grafts.
Materials and Methods: The apex puncture technique was
used in 520 sessions to declot 376 hemodialysis loop grafts
(M: F=150: 226; mean age: 58 years). The Fogarty balloon
application technique that uses the Fogarty balloon to fill the
apex, was used to compress or displace the sheath entry point
residual thrombus that did not wash away spontaneously by
arterial flow. The frequency of the technique applied, technical
success, complications and primary patency were evaluated.
Results: Sheath entry point thrombi were washed away
spontaneously in 281 of 520 (54%) procedures, and 184 (35.4%)
procedures underwent Fogarty balloon application. For a
variety of reasons, the Fogarty balloon application technique
was not performed in the remaining 55 (10.6%) procedures.
The technique was successful in 171 of 184 (92.9%) procedures,
and failed in 13 procedures, thus requiring additional sheath
insertion for the removal of sheath entry point thrombi.
Complications included sheath dislodgement from the apex
during Fogarty ballooning in 1 procedure, and puncture site
bleeding in 1 procedure. Primary patency was 60%, 35.2% and
15.3% at 3, 6 and 12 months, respectively.
Conclusions: The Fogarty balloon application technique is safe
and useful for the removal of residual thrombus at the apical,
peri-sheath zone during declotting occluded hemodialysis loop
grafts.

Purpose: The purpose of this study is to compare long-term

results and determine the outcomes of open-cell stent versus
closed-cell stent for central vein stenosis or occlusion in
hemodialysis patients.
Materials and methods: The records of 2418 patients who
underwent endovascular treatment for central vein stenosis
or occlusion in hemodialysis patients from 1997 to 2011 were
reviewed. Stent placement was performed in 401 patients if
conventional balloon angioplasty was unsatisfactory, due to
elastic recoil (> 30% residual stenosis and continued filling of
collateral veins around the lesion) or occurrence of restenosis
within 3month after balloon angioplasty for the same lesion.
When the thrombus in the central vein was present, the
treatment of choice was primary stent placement. There were
257 open-cell stent and 144 closed-cell stent. Angiographic
findings including lesion site, central vein stenosis or occlusion,
and presence of thrombosis and complication were evaluated.
Primary patency and mean patency of stent were compared
between two stent groups by Kaplan-Meier survival analysis.
Result: The technical success rate of stent placement was
99.3% (398 of 401 procedures). Mean procedure time for
recanalization was 53.2min. The vessel most commonly treated
was the innominate vein (n = 306), followed by subclavian vein
(n= 89), and jugular vein (n = 6). For open-cell stent group,
central vein stenosis in 159 patients and central vein occlusion
in 98 patients. For closed-cell stent group, central vein stenosis
in 78 patients and central vein occlusion in 66 patients. There
were two complications of central migration of a stent that
required additional stent placement and two cases of procedurerelated central vein rupture. For Open-cell stent group, the
primary patency rate was 86.4%, 64.8%, 28.8% and 9.3% at 3,
6, 12 and 24 months. For closed-cell stent group, the primary
patency rate was 69.1%, 38.7%, 16.0% and 6.5% at 3, 6, 12 and
24 months. Closed-cell stents and open-cell stents had mean
patencies of 8.5months and 10.9months, respectively (p = .002).
An intergroup analysis demonstrated significant difference
involving subclavian vein group (p < .001), in case of stenosis
(p = .042) and occlusion (p = .020) and in case of absence of
thrombosis group (p = .006).
Conclusion: The use of open-cell stent for central vein stenosis
or occlusion in hemodialysis patients who have incomplete
balloon PTA results is associated with good long-term patency
than closed-cell stent.

Purpose: To evaluate problems occurred during and after

placement of implantable port through left internal jugular
vein and to demonstrate the solutions.
Materials and Methods: We placed 277 ports in 266
patients through left internal jugular vein under US and
fluoroscopic guidance. They were 31 men and 235 women. We
retrospectively reviewed images obtained during insertion
and procedural report to evaluate problems in placement
and methods for overcoming. We evaluated the complication
developed due to anatomic characteristics during maintenance
by medical records and chest CT scans.
Results: Problems during placement were difficult insertion by
bending of the peel-away sheath along course of the vein (n=13)
and wedging of catheter tip in azygos vein (n=8). Technical
success was 100% using various techniques to overcome the
problems. Thrombosis in superior vena cava (SVC) was noted
on follow-up CT scan in 8 cases and associated stenosis or
thrombosis of the left innominate vein was noted in 4 cases.
It developed in patients with initial location of catheter tip in
SVC and related with upward migration of tip at erect position
and wedge in wall of SVC during return on supine position.
Conclusion: Anatomic characteristics of left internal jugular
vein is a kind of obstacles in placement of implantable port,
but the problems would be overcome by various interventional
techniques and deep insertion of catheter in right atrium.

Poster Exhibition

Poster Exhibition

keep the access patency long.

Department of Radiology, Kyungbuk University Hospital,

KOR

Department of Radiology, Soonchunhyang University

School of Medicne, KOR

In-Ho Cha1, Tae-Seok Seo1, Jun-Suk Kim2,

361

Poster Exhibition

PE018

PE017

PE019

PE020

Study of optimal location of catheter tip

for central venous access using bronchial
carina

Usefulness of Endovascular Intervention for

Transposed Brachio-Basilic Arteriovenous fistula
Failure

A case of using high pressure balloon 12mm

diameter 4cm by the parallel wiremethod for
the central vernous stenosis

A superficial brachial artery incidentally

detected during vascular access
intervention: A case report

Yong Sun Jeon1, Jang Yong Kim2, Soon Gu Cho1,

Jitsuro Tsukada1, Yoshiaki Narimatsu1, Akira Nishiyama1,

Taichi Kurose1, Hajime Okazaki1, Yoshio Monzen1,

Masato Tanikake1, Katsumi Hayakawa1, Fumie Satou1,

Kee Chun Hong

Hiroaki Sato , Shintaro Shibutani

Koichi Wadazaki

Hiroyuki Tatekawa1, Yuko Kadoya2, Masatomo Yashiro2

Radiology, Inha University School of Medicine, KOR

2
Department of Vascular Surgery, Inha University Hospital,
KOR

Background: This study is to measure the length between

Purpose: The incidence of stage 5 chronic kidney disease (CKD)

In late years, the supply of a large-diameter peripheral cutting

requiring immediate hemodialysis treatment. It is well known

balloon have been canceled, and therefore only the metallic

that autogenous fistula is superior access method compared

stent implantation was effective means for central vernous

to prosthetic grafts in access survival rates. Although using

stenosis of the hemodialysis patient. We were able to get good

cephalic AVF is the first choice for vascular access, patients

expansion using high pressure balloon 12mm diameter 4cm,by

often require alternative access procedures due to vessel

the parallel wire method for the subclavian vein stenosis of the

damage, previously used or poor caliber veins. We present our

hemodialysis patient, who had been treated by other devises

hospital result of the transposed brachio-basilic AVF (TBBAVF)

manytime.

with endovascular intervention (IVR) treatment in the upper

And this was the high pressure balloon which could expand

arm in terms of fistula patency.

the blood vessel in higher than 20 standard atmosphere and

Methods: All patients who underwent TBBAVF from June

expanded the subclavian vein at 12 standard atmosphere

2006 to February 2011 at our institution were retrospectively

enough this time, and we were able to finish balloon dilatation

reviewed. Data collected included patient demographics,

with no complication.

primary disease of CKD, method of IVR treatment, primary

This product is useful, but it is order industrial product, and

patency rate, and secondary patency rate. Primary and

we report the use experience of it.

bronchial carina and SVC-RA junction(LBSAJ) through chest

CT scan in adult Korean population and to evaluate optimal
location for catheter tip during central venous access using
bronchial carina.
Method: Study subjects were enrolled randomly among
patients who underwent chest CT scan from 2010 to 2011.
Patients who had any lung disease were excluded before
randomization. The patients clinical characteristics and
imaging data were reviewed. The length between bronchial
carina and SVC-RA junction was measured through 3D
workstation.
Result: Two hundred and thirty eight cases were enrolled.
There were 114 Men and 124 women. The mean age was 56.7
14.8 years old. Mean body weight was 61.1 11.1Kg. Mean
height was 161.3 10.8cm. Mean LBSAJ was 30.8 9.0mm.
For men, the mean age was 58.414.4 years old. Mean body
weight was 65.711.4Kg. Mean height was 168.5 4.4cm.
Mean LBSAJ was 34.9 8.3mm. For women, the mean age
was 55.1 14.9 years old. Mean body weight was 56.8
8.9Kg. Mean height was 154.610.1cm. Mean LBSAJ was
27.1 8.0mm. The LBSAJ in man was longer than that in
women(P<0.05).
Conclusions: The optimal location of catheter tip should be
adjusted according to purpose of catheter and patients' LBSAJ.

Department of Radiology, Kawasaki Municipal Hospital, JPN

2
Department of Surgery, Kawasaki Municipal Hospital, JPN

Department of Diagnostic Radiology, Hiroshima Prefectural

Hospital, JPN

Department of Radiology, Kyoto City Hospital, JPN

Department of Nephrology, Kyoto City Hospital, JPN

Department of Radiation Oncology Hiroshima Prefectural

Hospital, JPN

secondary patency rate were calculated using Kaplan-Meier

method.
Results: Twenty five cases of upper arm TBBAVF were created
in 24 patients (64% male). Seven cases were lost to follow-up
because they had never visited our hospital after the dialysis
introduction in outside hospital. The follow-up period ranged
1-45 months, with a mean of 16.4 months. Twelve of 18 cases
had previous surgical access attempt and 6 cases (33%) had
a TBBAVF as their initial fistula. Fifteen fistulas were used
for hemodialysis (HD) and 3 were never used. Of three never
used for HD, two patients died before HD initiation. One
fistula was occluded 6 months later, therefore prosthetic grafts
fistula placement was performed. There were three patients
formation. Ten of 18 patients had IVR treatment for TBBAVF

The superficial brachial artery arises from the axillary artery

and the brachial artery and runs superficially to the median
nerve in the upper arm continuing to the radial artery. The
superficial brachial artery is considered to be a residual blood
vessel at the time of development of upper extremity arteries,
and its incidence has been reported to be about 10%. We report
a special case in which the superficial brachial artery was
incidentally detected during vascular access intervention and
examine its clinical significance.
Artificial dialysis was initiated in a 40-year-old woman because
of diabetic nephropathy and renal failure. Acute obstruction
of an autologous blood vessel internal shunt (a radiocephalic
arteriovenous fistula) created in the periphery of the left
forearm was repaired by intervention. Before percutaneous
transluminal angiography (PTA), angiography of the upper
extremity arteries was performed through a femoral artery
approach. A catheter was advanced up to around the brachial
artery in the cubital fossa and angiography was performed.
An artery running parallel to the brachial artery was depicted
through its anastomotic branch, and the distal part of this
vessel continued to the radial artery. The proximal part of the
vessel arose from the axillary artery, which was diagnosed as a
superficial brachial artery.
The presence of a superficial brachial artery may cause
unexpected problems such as obstacles to angiography and
approaches in interventional radiology for the shunt created
in the forearm. Preoperative evaluation and examination of
ultrasonographic and 3D computed tomography angiographic
images is necessary.

Poster Exhibition

death within 60 days of surgery, which was unrelated to fistula

Poster Exhibition

failure. A total of nineteen balloon angioplasty was performed

in those patients (1 to 5 times per patient) and 1 patient had a
stent placement for secondary IVR. Primary patency rates at 6,
12, and 24 months were 63%, 47%, and 30%, while secondary
patency rates at 6, 12, and 24 months were 94%, 77%, and 64%.
Conclusion: IVR treatment for TBBAVF failure significantly
improved patency rate in our hospital. Although TBBAVF
itself have good primary patency rates, the combination of IVR
treatment might contribute to improve patency rate.

362

363

Poster Exhibition

PE021

PE022

PE024

PE023

Bronchial artery embolization for

hemoptysis since 2000

Initial evaluation of slow injection of

Miriplatin for hepatic tumors

The efficacy of arterial embolization in

renal angiomyolipoma in management of
symptoms and complications

Transarterial embolization for traumatic pelvic

fractures in our institution

Katsumi Hayakawa, Masato Tanikake

Shinichi Ohta, Shigetaka Sato, Ayumi Shirahase,

Nam-Kyu Chang, Soo-Hyeon Kim, Nam-Yeol Yim,

Hideaki Kobayashi1, Junichi Ideue1, Hiroto Hakamada1,

Department of Radiology, Kyoto City Hospital, JPN

Satomi Mori, Ken Aoki, Yoko Murakami,

Jae-Kyu Kim

Tomohide Yoneyama1, Koichi Okubo, Kimiaki Koga2,

Shobu Watanabe, Yuki Tomozawa, Hideji Otani,

Department of Radiology, Chonnam National University

Hwasun Hospital, KOR

Takanori Imakiire2

Yukihiro Nagatani, Naoaki Kono, Akinaga Sonoda,

Toyohiko Tanaka, Norihisa Nitta, Masashi Takahashi,

Department of Radiology, Imakiire General Hospital, JPN

Department of Orthopedic Surgery, Imakiire General

Hospital, JPN

Kiyoshi Murata
Department of Radiology, Shiga University of Medical
Science, JPN
PURPOSE: The purpose of the study is to evaluate the

Purpose: Transarterial chemoebolization (TACE) for hepatic

immediate and long-term results in 34 transarterial

tumors is performed using Miriplatin as anticancer drug,

embolization procedures in the period beween 2000 and 2011

however the dose of drug that could be injected was lower than

for the control of hemoptysis in the comparison with the earlier

expected. This study was performed to evaluate if slow injection

studies between 1977 -1989, and 1990 - 1998.

PATIENTS: The first period included 63 patients (43 men/
20 women) with 24 - 82 years of age, and the second period
included 34 patients (24 men/ 9 women) with 33 - 83 years of
age, and the current period-34 patients(19 men and 15 women)
with 52-82 years.
RESULT: The immediate success rate for control of hemoptysis
at least one month were 86.1% in the first period, 86.0% in the
second period and 94% in the current period.
The long term follow-up beyond the one month was available
in 26 patients and the follow-up period was 48 months (1-140
months). 50% patients (13/26) showed complete remmison (CR),
19% patients (5/26) showed partial remission (PR) (hemosputa
without hemoptysis), and recurrence (R) was observed in 8
patients (31%). In the first study period, CR was 50%, PR was
22%, R was 28%.
CONCLUSION: The immediate result improved in the
current period, reflecting development of the microcatheter
techniques. The long term results were similar to the earlier
study periods, reflecting that the long term results depending
the continuation to the therapy of the underlying pulmonary
disease.

of Miriplatin could increase the overall dose of drug injected.

Method and Materials: Patients were divided into 2 groups;
Conventional TACE (CTACE) group and slow injection
(SLTACE) group. All patients received 67% mixture of
Miriplatin and saline/Iopamidol injected through the
microcatheter. CTACE using Miriplatin was performed by
manual injection. While SLTACE of Miriplatin was performed
using an automatic injector at the rate of 12 ml per hour.
Embolization in both groups was achieved using gelatin
particles. The quantities and doses of Miriplatin were compared
in two groups. Dose injected was calculated by dividing
the total dose injected by the number of segmental arteries
supplied by the artery where catheter tip was. For example, if
catheter tip was in RHA, the dose injected was divided by 4,
similarly if the tip was in A8 it was divided by 1. Short-term
therapeutic efficacy was calculated using RECIST.
Results: 24 CTACE were performed in 19 patients (M:F=14:5,
mean age: 73.2, 19 HCC), and 13 SLTACE were performed in 12
patients (M:F=10:2, mean age: 71, 10 HCC and 2 metastases).
The mean dose of Miriplatin injected was 44.7 22.6mg and
45.3 17.3mg (not significant) in CTACE and SLTACE group
respectively. The corrected mean doses were 33.3 18.8mg and
34.3 15.5mg (not significant) in CTACE and SLTACE group
respectively. Using RECIST the results of tumor response in
24 CTACE and 7 SLTACE cases were: 0 CR, 1 PR, 18 SD, and

Poster Exhibition

up periods were 43.5 16.7days and 43.3 11.2 days after the
therapy in CTACE and SLTACE group respectively.

clinical symptoms and prevent hemorrhage in patients with

angiomyolipoma (AML). This study was conducted to evaluate
the efficacy of arterial embolization of AMLs.
MATERIALS AND METHODS: During recent 10 years
19 patients (mean age 55.2 years; 16 women and 3 men)
underwent the transarterial embolization for the treatment
of AMLs. 10 patients had multiple AMLs in both kidneys (2
patients had tuberous sclerosis), 8 patients had single AML,
and 1 patients had 2 AMLs in both kidneys. 13 patients had
clinical symptoms such as flank pain or tumor rupture with
active bleeding. 6 patients had no symptom. The size of AMLs
ranges from 5 to 24 cm. All lesions were embolized by using
microcatheters with PVA, microcoils, or amplatz vascular
plug. The efficacy of embolization was determined over a
mean follow-up of 52 months (range, 1-90 months), in terms of
decreased size of tumor which was measured by using RECIST
and modified RECIST, improvement of clinical symptoms and
presence of complications.
RESULTS: In 19 patients, the mean percentage of size decrease
was 22.8% in RECIST and 23.8% in modified RECIST. But,
AML size increased after embolization in 3 patients (RECIST)
and in 2 patients (mRECIST). In 13 symptomatic patients,
the flank pain or bleeding improved after embolization with
decrease in tumor size. In 6 non-symptomatic patients, the
tumor size decreased after embolization and there were no

P u r p o s e : To e v a l u a t e t h e r e s u l t s o f t r a n s a r t e r i a l
embolization(TAE) for traumatic pelvic fractures in our
institution.
Materials and Methods: Evaluated cases of traumatic pelvic
fracture were transported to our institution from December
2011 until January 2009. Injury causation, diagnostic CT,
severity, time required for starting TAE, embolized artery,
embolic material, postoperative changes in vital signs
before TAE, prognosis and complications were evaluated
retrospectively.
Results: Injury causations were six traffic injury cases and
10 fell cases. 16 patients were underwent TAE. Technical
success rate was 93.8%, clinical success rate was 87.5%.
Bilateral internal iliac artery were in 13 patients confirmed
the extravasation of the preoperative CT scan. 14 cases were
embolized Bilateral internal iliac artery, 1 case the right iliac
artery, one case was the left lateral sacral artery. In 10 cases
gelatin spongel was used for embolic material, in 5 cases
microcoils in combination and in one case used only microcoils.
Lifethreatening complications were not observed. Prognosis and
preoperative evaluation of injury severity was not correlated. 1
patient died the next day, and 1 patient died three days later,
both cases were in the course of DIC.
Conclusion: TAE for traumatic pelvic fractures was considered
an effective treatment. The presence of DIC is considered a
prognostic factor.

clinical symptoms or complications during follow up periods.

CONCLUSIONS: Arterial embolization in AMLs is an effective
treatment in improvement of clinical symptoms and prevention

Poster Exhibition

5 PD. 0 CR, 0 PR, 5 SD, and 2 PD respectively. Mean follow-

PURPOSE: Arterial embolization was performed to reduce

of complications likely to occur, as well as decrease in mass

size.

Limitation: small series of patients with a short follow-up

Conclusion: Slow injection of Miriplatin is possible and safe
with similar response at short-term follow-up when compared
to conventional injection during TACE. Doses injected by the
slow techniques were not significantly different from those in
conventional technique. Larger series with long term tumor
response rate comparison are recommended.

364

365

Poster Exhibition

PE025

PE026

PE027

PE028

Superselective embolization for colonic

diverticular bleeding: The impact of CT on
detecting hemorrhage on angiography and
technical success of transcatheter embolization

Vaginal spontaneous expulsion of SF after

UAE

Transcatheter arterial embolization using

N-butyl cyanoacrylate for emergency
gastrointestinal hemorrhage: A multicenter
study

Trans-arterial embolization for posterior

gastric-wall bleeding

Yuko Takeguchi1, Mitsuhiro Kishino2, Ken Takahashi3,

Nguyen Hoai Thu

Tsuyoshi Kawai1, Toshio Kaminou1, Yasufumi Ohuchi1,

Eisuke Ueshima, Takeki Mori, Yuki Sanda,

Interventinal Radiology, Medic Center Vietnam, VNM

Kimihiko Sugiura1, Shinsaku Yata1, Akira Adachi1,

Tomoyuki Gentsu, Megumi Kinoshita, Koji Sugimoto

Masayuki Endo1, Shohei Takasugi1, Shuichi Yamamoto1,

Department of Radiology, Kobe Red Cross Hospital/Hyogo

Emergency Medical Center, JPN

Yoshio Kitazume , Yoshiro Himeno , Isamu Ohashi ,

Hitoshi Shibuya2

Kensuke Matsumoto1, Mika Kotani1, Toshihide Ogawa1,

Department of Radiology, Musashino Red Cross Hospital,

JPN

Takashi Ihaya2, Masayuki Hashimoto3, Kiyoshi Nakamura4

Tokyo Medical and Dental University, JPN

Department of Radiology, Tottori University Faculty of

Medicine, JPN

Tsuchiura Kyodo General Hospital, JPN

Department of Radiology, San-in Rosai Hospital, JPN

Department of Radiology, Tottori Prefectural Kousei Hospital, JPN

Purpose: To evaluate the clinical factors that effect on

P u r p o s e : To e v a l u a t e r e t r o s p e c t i v e l y t h e s e q u e l l a e

detecting hemorrhage on angiography and technical success

of submucosal fibroids expulsion after Uterine Artery

of superselective embolization for colonic diverticular bleeding

Embolisation

(CDB).

Meterial and Methods: From a population of 1896 UAE

Materials and Methods: We reviewed the eight procedures

procedures performed from November 1999 to November

Purpose: To assess the clinical usefulness of transcatheter

arterial embolization with n-butyl cyanoacrylate (NBCA) for
acute gastrointestinal (GI) bleeding.
M a t e r i a l s a n d M e t h o d s : We retrospectively studied

Purpose: We evaluated the effectiveness of trans-arterial

embolization (TAE) for posterior gastric-wall bleeding.
Methods: Of 19 patients undergoing TAE for gastric bleeding
in our hospital from July 2004 to November 2011, 4 with
posterior gastric-wall bleeding were assessed. We discuss the
backgrounds, feeding arteries, embolization materials and

performed in six patients who had severe acute diverticular

2009,73 patients were found to have spontaneous expulsion of

hemorrhage in recent two years, and investigated clinical

submucosal fibroids after Uterine Artery Embolisation .Medical

factors that influenced identifying bleeding point on

records , Color Doppler Ultrasound and magnetic resonance

angiography and technical success of transcatheter

images were evaluated for clinical informations and tumor

embolization. The presence of extravasation on CT scan, the

characteristics, respectively .

time taken from last melena to starting angiography, shock

Results: Vaginal spontaneous expulsion of submucosal fibroids

index and blood hemoglobin just before angiography on each

after Uterine Artery Embolisation was asymptomatic in 13% of

right colic artery (n=6), ileocaecal artery (n=6), jejunal artery

posterior gastric-wall bleeding. All procedures were completed

patient were retrospectively evaluated.

case and symptomatic in 87% of case.Among symptomatic cases

(n=2), ileal artery (n=1), sigmoid artery (n=2), superior rectal

successfully. Splenic abscesses occurred in 3 cases and partial

Result: The location of bleeding point was detected on contrast

90% had bulk expulsion and 10% had sloughing expulsion.92%

enhanced CT scan in 7 of 8 procedures. The extravasation

of patients had tumor expulsion at home and 8% had an

was identified on angiography and selectively transcatheter

emergency room .

arterial embolization was performed in 4 of 8 procedures.

Conclusions: Almost women tolerate spontaneous expulsion of

The embolization was successful in 3 of these 4 procedures

submucosal fibroids well, no massive uterine bleeding need be

(patients), however in another patients recurrent bleeding

aware of the UA re-embolisation or operative intervention.

occurred after the embolization, and additional angiography

was performed twice, but bleeding point was not detected.
Finally, colonectomy was done in this patient. The other
2 patients in which bleeding on angiography could not be
detected were conservatively treated, and cured without
recurrent bleeding. In our cases, the time which took from
last melena to angiography, shock index and blood Hb just
before angiography had no relation to detecting bleeding on
angiography.

the outcomes of 39 patients who underwent emergency

transcatheter arterial embolization for acute GI bleeding in
our three hospitals. They were consisted of 28 men and 11
women, and their mean age was 69.8 years old. Origins of
bleeding was right gastric artery (n=5), left gastric artery (n=5),
pancreaticoduodenal artery (n=6), gastroduodenal artery (n=4),

artery (n=1), and obturator artery (n=1). Cause of bleeding

was related to peptic ulcer (n=8), colon diverticulum (n=10),
ruptured pseudoaneurysm (n=12), GI neoplasms (n=7), AVM
(n=1), and aortoenteric fistula (n=1). Of the 39 patients, 29
patients showed hemodynamic instability and 10 patients
had coagulopathy. We used NBCA in such a combination with
microcoils (n=12), gelatin particles (n=3), and both materials
(n=2) prior to NBCA administration for flow control. After the
microcatheter was advanced close to the corresponding vessel,
NBCA-Lipiodol mixture (1:1-1:5) was injected. Outcomes
including technical success, hemostasis and complications were
evaluated.
Results: Successful embolization was achieved in all cases.

nonsteroidal anti-inflammatory drugs. Two splenic arteries

and two short gastric arteries were treated by TAE for

pancreatic necrosis in one. Of the 3 cases, 2 needed additional

surgeries, but the other in which a posterior gastric-wall
ulcer penetrated into splenic-hilum tissue could be managed
conservatively.
Conclusion: Although mainly the left gastric artery contributes
to gastric bleeding, other arteries are also occasionally involved.
With TAE for the splenic artery or short gastric artery, major
complications such as splenic abscess are frequent. However,
TAE can suppress active gastric bleeding, at least temporarily.
As to damage control and the bridge to surgery, TAE for gastric
bleeding is a very important method and we advocate its active
use.

blood although successful embolization, and died on the same

day. He had a history of abdominal aortic graft implantation,
and an aortoduodenal fistula was found at autopsy. In other

detected on contrast enhanced CT scan, it is highly possible

38 cases, bleeding was stopped and hemodynamic stabilization

embolization is effective.

Results: Their mean age was 62.8 (45-83) years and all were
male. One was positive for H. pyroli and two were taking

The only one case with upper GI bleeding continued to lose

Conclusion: If extravasation in patient with CDB can be

to identify hemorrhage on angiography and transcatheter

complications in these cases.

Poster Exhibition

Poster Exhibition

Department of Radiology, Hakuai Hospital, JPN

was exhibited after embolization. Although three patients

with ruptured pseudoaneurysm died within 30 days because
of multi-organ failure, rebleeding was observed in none of all
38 patients. There was no major complication in all cases, and
neither end-organ damage nor organ ischemia related to the
procedure was observed except three cases of asymptomatic
gastric ulcer formation.
Conclusions: NBCA embolization is a feasible technique for
acute GI bleeding and it can prevent recurrent bleeding with a
low risk of critical gastrointestinal ischemia.

366

367

Poster Exhibition

PE029

PE030

PE032

Imipenem/cilastatin sodium (IPM/CS) as

an embolic agent of transcatheter arterial
embolization: The usefulness for colonic
diverticula hemorrhage

A case of endovascular treatment of

an arteriovenous fistula from internal
mammary artery as a rare complication
following median sternotomy

Coil embolization of a type 1 endoleak

developed after the successful stentgrafting of a celiac trunk pseudoaneurysm
following a liver transplantation

Fumie Kashimi1, Hiroshi Nishimaki2, Reiko Woodhams3,

Etsuji Sohgawa 1, Yukimasa Sakai 1, Toshiyuki Cho 1,

Katsuyuki Yamada2, Asari Sai1, Ken Kageyama1,

Hideaki Kakizawa1, Masaki Ishikawa1, Wataru Yamasaki2,

Takaya Takeguchi, Kenji Ibukuro, Shoko Abe,

Shuji Date1, Fuminari Tatsugami1, Keizo Tanitame1,

Kimiko Tobe, Hozumi Fukuda

Atsushi Jogo1, Shinichi Hamamoto1, Akira Yamamoto1,

Tohru Takeshita1, Norifumi Nishida1,
Toshiyuki Matsuoka1, Yukio Miki1

Miho Ishikawa1, Daisuke Komoto1, Yukiko Honda1,

Department of Radiology, Mitsui Memorial Hospital, JPN

Hiroaki Terada1, Kentaro Ide3, Hideki Ohdan3, Kazuo Awai1

Keiji Matsunaga , Masakazu Takigawa , Kazui Soma

1

Department of Emergency & Critical Care Medicine, Kitasato

University School of Medicine, JPN
2

Cardiovascular Surgery, St.Marianna University School of Medicine, JPN

Department of Diagnostic Ragiology, Kitasato University

School of Medicine, JPN

4
Department of Ragiology, National Hospital Organization
Sagamihara National Hospital, JPN
Purpose: To evaluate the usefulness of imipenem/cilastatin
sodium(IPM/CS) as an embolic agent of transcatheter arterial
embolization(TAE) for colonic diverticula hemorrhage.
Material and Methods: Seven patients (eight procedures) who
underwent TAE using IPM/CS for colonic diverticula hemorrhage
in our hospital were retrospectively reviewed. They consisted
of five men and two women. Average age of the patients was 62
years (range: 44-79 years). The origin of the hemorrhage in these
patients was from the ascending colon. IPM/CS was selected as
an embolic agent when the catheter cannot be super-selectively
advanced to bleeding vessels. The composition of 0.5g IPM/CS
and 5ml of non-ionic iodine-containing contrast was used as
an embolic agent. Other embolic agents including metallic coil,
gelatin sponge, or N-butyl cyanoacrylate(NBCA) were used when
we could not obtain hemostasis with IPM/CS. Technical success
was determined by stasis of extravasation, or stasis of blood
flow to the sites where were considered as origins of bleeding.
Complications, re-bleeding, conversion to the surgical operation,
and clinical outcome were analyzed.
Results: Active extravasation was observed in 6 patients at
angiography. All procedures were technically successful. Three
patients obtained hemostasis with IPM/CS one of whom had rebleeding on the 2 days after TAE. Hemostasis was obtained at the
repeated TAE with IPM/CS in combination with NBCA. Regarding
this patient, IPM/CS in combination with NBCA was used at
the repeated TAE and hemostasis was obtained. Four patients
obtained hemostasis with IPM/CS in combination with other
embolic agents including NBCA (2), gelform(2),or microcoil(1).
One patient underwent laparotomy because of peritoneal
stimulation sign on the next day after TAE with IPM/CS, gelatin
sponge and NBCA. However, neither necrosis nor perforation was
observed at the operation and the patient recovered.
Conclusion: The advantage of IPM/CS as an embolic agent is
considered to be a low possibility of causing ischemia when used
on its own, or when used with other embolic agents for colonic
diverticula hemorrhage. This effect is considered due to the mild
embolic effect as well as the effect of which may protect intact
vessels from other embolic agents and prevent over- embolization.
However, using only IPM/CS will result in incomplete hemostasis.
Therefore, in the challenging situation of super-selective access
to bleeding vessels, preceding administration of IPM/CS may be
usable at the first attempt of TAE as an embolic agent as well as
a preventive agent for ischemia from further embolic agents after
IPM/CS.

368

Department of Radiology, Osaka City University Graduate

School of Medicine, JPN
2
Department of Radiolody, Yodogawa Christian Hospital,
JPN

Chihiro Tani1, Yuko Nakamura1, Yoko Kaichi1,

Management of hemorrhagic pancreatic

pseudocyst with hemosuccus pancreaticus
by transcatheter arterial embolization

Department of Diagnostic Radiology, Hiroshima University, JPN

Departmet of Radiology, Hiroshima City Hospital, Hiroshima, JPN

Departmet of Surgery, Hiroshima University, JPN

Purpose: We demonstrate a case of endovascular treatment of

Introduction: Immediately following liver transplantation,

Purpose: Hemosuccus pancreaticus (HP) is known as a

an arteriovenous fistula (AVF) from internal mammary artery

the hepatic arterial supply is very important for both the

rare cause of intermittent gastrointestinal (GI) bleeding. If

(IMA) as a rare complication following median sternotomy.

Method: A 70-year-old woman with a history of aortic valve
replacement found the thrill of her right chest wall after
one year later following cardiac surgery. First, we decided
to observe the present patient because she did not have
any complications associated with the thrill. Though, her
chest pain was getting worse and worse. Contrast enhanced
computed tomography (CECT) showed the fistula from IMA
to lateral thoracic vein. The diagnosis of arteriovenous fistula
(AVF) was subsequently suspected as a rare complication of
the median sternotomy. She was admitted to our hospital for
endovascular treatment of the fistula.
RESULTS: Under local anesthesia, transcatheter arterial
coil embolization (TAE) was performed via a femoral artery.

hepatic parenchymal- and peribiliary supply. The usefulness

of vascular covered stent grafts to address hepatic artery
pseudoaneurysms (PSA) that develop after liver transplantation
has been reported. This facilitates the exclusion of the PSA
while maintaining the hepatic arterial blood flow, however, the
efficacy of this method remains to be established. We report the
successful treatment by coil embolization of a type 1 endoleak
after the successful exclusion of a celiac trunk PSA in a patient
who had undergone a liver transplant.
Case repor t: This 58-year-old man with hepatocellular
carcinoma and non-compensatory liver cirrhosis had
undergone a living-donor left hepatic lobe transplant. His
previous medical history included esophageal transection and
splenectomy for esophageal varices. Two weeks after liver
transplantation, a computed tomography (CT) scan showed

5F catheter with side hole on the tip of the catheter was

a non-ruptured 15-mm PSA at the celiac trunk surrounded

introduced to right subclavian artery, and then microcatheter

by fluid. After coil embolization of a dorsal hepatic-, left

was advanced to the right internal mammary artery which

gastric-, and a right inferior phrenic artery that branched

was inflow of the fistula through the side hole. It was possible
to advance just before the fistula and to embolize the inflow
artery with micro-coils. The postoperative course was
uneventful and no recurrence of the fistula has been observed
during 4 months.
CONCLUSION: We reported a rare case of an AVF from IMA.
It was diagnosed a rare complication of the median sternotomy.
The fistula was successfully occluded with coil embolization.
Angiography with selective embolization allows good control of
the secondary fistula without any complications.

from the celiac trunk to prevent type 2 endoleak, we placed 2

polytetrafluroethylene-covered coronary stents to exclude the
PSA while preserving the anatomical hepatic arterial blood
flow. Although immediately after the procedure there was
a tiny type 1 endoleak at the distal end of the stent grafts,
a CT scan obtained 3 days later showed complete exclusion
of the PSA. However, CT performed 2 weeks later revealed
recurrence of the PSA. Celiac arteriography showed a type 1
endoleak at the proximal end of the stent grafts. We advanced
a 3-Fr microcatheter into the PSA through the endoleak and
embolized the aneurysmal sac and the tract of the endoleak
with 5 microcoils. A post-procedure celiac arteriography
confirmed hepatic arterial inflow with complete exclusion of the
PSA. Follow-up CT scans obtained 2 weeks and 3 months after
coil embolization showed no PSA recurrence.
Discussion: We discuss possible factors resulting in type
1 endoleaks after the successful exclusion of a celiac trunk
PSA by stent grafting. As our documented 3-month follow-up
results do not confirm the effectiveness of coil embolization to
address recurrent PSA, we also provide the results of longer
term follow-up periods in this presentation.

extravasation is not detected on angiography in the patient

with HP caused by hemorrhagic pancreatic pseudocyst, the
precise location of the bleeding points could not be found. So
we investigated the factors to identify the extravasation on
angiography in hemorrhagic pancreatic pseudocyst with HP and
the relation between recurrent bleeding and embolic materials.
Materials: We reviewed the seven procedures performed in two
patients (Patient A: 5 procedures, Patient B: 2 procedures) with
hemorrhagic pancreatic pseudocyst with HP diagnosed by both
endoscopy and contrast enhanced CT scan.
Results: The extravasation was identified on angiography
and transcatheter arterial embolization was performed in 3 of
the 7 procedures. The hemorrhage in the pseudocyst had been
detected on contrast enhanced CT scan about 3 hours before
angiography in 2 of these 3 procedure. As the clinical symptoms
suggested bleeding in the pseudocyst, the angiography was
immediately performed without CT scan in another procedure.
The extravasation in the posterior superior pancreaticoduodenal
artery was observed on the second angiography in Patient A,
and we performed isolation of bleeding point by microcoils,
because we prevented to migrate the embolization materials
such as gelatin sponge into the main pancreatic duct. However,
recurrent bleeding occurred repeatedly after the embolization.
The extravasation in the dorsal pancreatic artery was identified
finally on the fifth angiography and the artery was embolized
with N-buthyl-2-cyanoacrylate (NBCA)- Lipiodol mixture. The
bleeding was observed in gastroduodenal artery (GDA) on
the first angiography in Patient B, but GDA was accidentally
occluded by injury during angiography and the embolization
could not be performed. The recurrent bleeding occurred a few
months later but angiography did not reveal extravasation.
However, we embolized the recanalized GDA with NBCALipiodol mixture and microcoils. The GI bleeding was stopped
after the embolization using NBCA- Lipiodol mixture in both
patients.
Conclusion: Angiography should be performed immediately
when hemorrhagic pancreatic pseudocyst is clinically suspected
as a cause of active GI bleeding in patients with HP. NBCALipiodol mixture may be effective as embolic materials to
prevent the recurrent bleeding from the hemorrhagic pseudocyst.

369

Poster Exhibition

Poster Exhibition

PE031

Poster Exhibition

PE034

PE033

PE035

A case report: Combination therapy of

B-RTO and PTO for a gastric varix with a
large and complex gastro-renal shunt

Rupture of a hepatic metastasis from

gastrointestinal stromal tumor successfully
treated by transcatheter hepatic artery
embolization

Ascending aortic infected pseudoaneurysm

with aortocutaneous fistula along to
epicardial pacing wire controlled with
transcatheter arterial embolization

Saphenous vein graft aneurysms treated by

endovascular coil embolization with double
catheter technique

Kazuki Hashimoto1, Nao Kikkawa1, Hideki Kaneko1,

Jae hyun Kwon, Tae Eun Kim

Ken Nakazawa, Satoru Murata, Hiroyuki Tajima,

Shiro Onozawa, Takahiko Mine, Tatsuo Ueda,
Hidenori Yamaguchi, Ayako Akiba, Daisuke Yasui,
Shinitirou Kumita

Rieko Shuto1, Hiro Kiyosue2, Norio Hongo2,

Kazuyo Kita , Kazuyo Suzuki , Kazuhito Toya ,

Yoshinori Isobe1, Satomi Senoh2

Department of Radiology, Dongguk University Ilsan Hospital,

KOR

Department of Radiology, National Hospital Organization

Tokyo Medical Center, JPN

Department of Radiology, Nippon Medical School, JPN

Miyuki Maruno2, Hiromu Mori2, Shinji Miyamoto3

1

Department of Radiology, Oita Oka Hospital, JPN

Department of Radiology, Oita University Faculty of

Medicine, JPN
3

Department of Cardiovascular Surgery, Oita University

Faculty of Medicine, JPN

Department of Emergency and Critical Care, National

Hospital Organization Tokyo Medical Center, JPN

A fifty-year-old man with huge gastric varices and severe

We describe a rare case of spontaneous rupture of a hepatic

Introduction: We present a case of coil embolization of

alcoholic cirrhosis was consulted from another hospital as a

metastasis from gastrointestinal stromal tumor(GIST) of

an ascending aortic infected pseudoaneurysm with an

difficult case of treatment to our hospital. We planned the

stomach that was treated successfully by hepatic arterial

aortocutaneous fistula along to the epicardial pacing wire in a

combination of procedures with percutaneous transhepatic

embolization. A 69-year-old man, who had been underwent

70-year-old woman.

portal vein approach and balloon occluded retrograde

partial gastrectomy due to gastric GIST at three years ago

The aortocutaneous fistula is extreamly rare and, reported

transvenous obliteration (BRTO). The approach to the

and wedge resection of stomach recurrence and left lateral

as postoperative infection of the aorta and infected aortic

intrahepatic portal vein seemed difficult under US guided

segmentectomy of the liver for liver metastasis at one year ago,

aneurysms. In the past reports, the pseudoaneurysms fistulize

because the intrahepatic portal vein was thin and the

presented with severe right lower quadrant abdominal pain

directly to the epidermis. According to our knowledge, this is

intrahepatic artery was compensately dilated. We inserted a

radiating to right shoulder. Computed tomography revealed

the first report of an aortocutaneous fistula through a fibrin

microcatheter into the umbilical portion of left hepatic artery

multiple low density metastatic lesions at both lobes of the

tunnel around the epicardial pacing wire from aortic ascending

as a landmark for the puncture to the left intrahepatic portal

liver and massive intraperitoneal hemorrhage. A low density

pseudoaneurysm.

vein under the fluoroscopy. The gastric varices showed grade

metastatic lesion in the segment 6 of the liver abutting liver

Case report: A 70-year-old woman was hospitalized for fever

4 in the Hirotas classification. The large left gastric vein

capsule showed irregular margin at medial portion of the mass

of unknown origin. She was suffering from Takayasu aortitis

and posterior and short gastric veins as the afferent veins

lesion. Subsequent hepatic angiography showed hypervascular

at the age of 40. She was undergone bilateral aorto-femoral

were seen. The large inferior phrenic vein and additional two

round tumor staining at right lobe inferior tip of the liver.

bypass surgery at the age of 42 and was received coronary

subphrenic veins were noticed as the efferent veins. First, we

Transcatheter embolization of the segment 6 hepatic artery

artery bypass grafting and pacemaker implanting at the age

embolized the branch of left gastric vein and posterior gastric

was subsequently performed, and the patient made an

of 47. She had left breast cancer near the pulse generator

related with the gastric varices to decrease the portal flow

uneventful recovery. Although hepatic rupture due to

which was treated with chemotherapy. On the fifth day of

by coils and N-butyl cyano acrylate. Transvenous approach

metastatic cancer is extremely rare, transcatheter arterial

hospitalization, repeated massive bleeding on left chest wall

to the left inferior phrenic vein was done using the double

embolization (TAE) is an appropriate and useful treatment for

was occurred. It was suspected as bleeding from the breast

balloon coaxial catheter system and one of two subphrenic

massive hemorrhage caused by spontaneous rupture of liver

cancer. Angiography was performed 18days after start bleeding,

vein could be embolized by coils but another one was hard to

metastasis.

and revealed an ascending aortic pseudoaneurysm. Contrast

insert the microcatheter through the inferior phrenic vein. The

enhanced CT showed an aortocutaneous fistula through a fibrin

latter was able to embolized through the inferior vena cava

tunnel around the epicardial pacing wire which exited from

with transfemoral approach. The balloon occluded retrograde

the ascending aortic pseudoaneurysm to the ulcer near by the

varicography was visualized gastric varices clearly, and BRTO

pulse generator from the ascending aortic pseudoaneurysm.

with 50% glucose and 5% EOI was performed. The inflated

We planned to use TEVAR with fenestrated graft, but it was

balloon was remained overnight.

unavailable. Then, trans catheter embolization was chosen as

Result: The gastric varices was confirmed completely

the palliative therapy. The embolization was performed 20 days

thrombolized on contrast enhanced CT after one week.

after beginning of bleeding. The pseudoaneurysm had a narrow

Background and purpose: Saphenous vein graft (SVG)

aneurysm is a rare but can be a fetal complication after
coronary bypass surgery. Standard treatment for SVG
aneurysm has not been established. Here, we describe two
cases of SVG aneurysms successfully treated by endovascular
embolization with coils.
Case presentation: Case 1 70 year-old male having a history
of coronary bypass surgery 18 years ago showed a large SVG
aneurysm with massive mural thrombus on a screening chest
CT. Although ligation of the SVG graft was performed, the
aneurysm was gradually enlarging. Endovascular trapping
with coils was performed with using double catheter technique
for placing the coils densely for a short segment. Complete
obliteration of the aneurysm was obtained, and follow-up
CT and chest X ray showed no regrowth of the aneurysm
for 2 years follow-up period. Case 2 72 year-old male with
a history of coronary bypass surgery several years ago was
admitted with chest pain. Chest CT showed a large SVG
aneurysm with perianeurysmal hematoma. Endovascular
embolization was performed. Coils were densely placed,
with using double catheter technique, from the orifice of the
aneurysm to the proximal portion of the SVG graft for a short
segment. Complete obliteration of the aneurysm was obtained,
and follow-up CT and chest X ray showed no regrowth of the
aneurysm for 1 years follow-up period.
Conclusion: Endovascular coil embolization with double
catheter technique is a less invasive and useful treatment
option for the SVG aneurysm.

Poster Exhibition

Poster Exhibition

PE036

neck, we selected the neck with 4 french catheter and advanced

coaxial catheter into the pseudoaneurysm. The pseudoaneurysm
was embolized using Interlock coil (fibered IDC coil, Boston
Scientific) and Tornado microcoil (Cook). After the procedure,
the bleeding was stopped and not recurred. 15 days after the
embolization, she received training rehabilitation, and the
infection was almost controlled. However 4 months after the
embolization, she died of sepsis. We will report this unique case
with some considerations.

370

371

Poster Exhibition

PE037

PE038

PE039

PE040

Use of the triple co-axial system in coil

embolization for lower gastrointestinal
bleeding

Transcatheter arterial embolization for huge

abdominal wall hematoma in coagulopathic
patient

Coil embolization of superior mesenteric

artery aneurysms: Case report

Embolization for arterial lesions with 5%-EO

Masashi Shimohira, Takuya Hashizume,

Hidekatsu Tateishi, Yutaka Masuda, Keita Honya,

Keigo Morinaga, Mahiro Hayashi, Miho Gomyo,
Kaori Iwamoto, Mitsuteru Tsuchiya, Toshiya Kariyasu,
Toshiaki Nitatori

Akihiko Shiraishi, Ryouhei Kuwatsuru, Yuhki Yamashiro,

Daisuke Tsuge

Naoki Hirokawa, Tomokazu Hasegawa,

Hiroyuki Ogino, Yuta Shibamoto

Department of Radiology, Nagoya City University Graduate
School of Medical Sciences, JPN

Department of Radiology, Juntendo University Faculty of

Medicine, JPN

Department of Radiology, Faculty of Medicine Kyorin

University, JPN

Yoshikazu Wasio, Masato Saitoh, Kazunori Aratani,

Taishi Satoh, Yoko Usami, Masamitsu Hatakenaka,
Masato Hareyama
Department of Radiology, Sapporo Medical University,
School of Medicine, JPN

Transcatheter arterial embolization (TAE) has been performed

Purpose: We present a case of the coagulopathic patient who

Visceral artery aneurysms are rare but potentially lethal

We investigated efficacy of embolization for the arterial lesions

for lower gastrointestinal bleeding. Super-selective TAE

had frequent abdominal wall bleeding with massive ascites

disease entities. The clinical significance of identifying and

with 5 % ethanolamine olate (5% EO). Six lesions of 5 cases

is important to acquire complete hemostasis and avoid

due to liver failure.

appropriately treating these entities is to prevent aneurysm

consisted of giant hepatic aneurysm, renal angiomyolipoma

mesenteric ischemia. A new microcatheter with a 1.9-Fr. tip

Case report: 68 years old man with the history of hepatitis

rupture into the peritoneal cavity or hepatobiliary and

(AML) of 2 children, bronchial arterial AVM of child, and

that does not taper (MARVEL; Tokai Medical, Kasugai, Japan)

C was diagnosed of hepatic cell carcinoma and underwent

gastrointestinal tract.

pancreatic AVM. Surgery were either rejected or unable for

has recently become available and this new microcatheter can

hepatectomy. During the postoperative period, he underwent

The augmented use of ultrasonography, CT and MR imaging

the risk in all cases. 5% EO was adopted because the use of

be inserted into a 2.7-Fr.-distal, 2.9-Fr.-proximal microcatheter

anticoagulant therapy for portal vein thrombosis. On the 50th

has raised the prevalence and incidental identification of

ethanol was limited for childrens AML, the number of coils

(Sniper 2 high-flow; Terumo, Tokyo, Japan). We present a case

day after the operation, the patient had hypovolemic shock.

visceral artery aneurysms. We report two cases of superior

was limited for giant aneurysm, and AVMs were needed for

of acute lower gastrointestinal bleeding that was successfully

Contrast enhanced CT demonstrated massive ascites and

mesenteric artery aneurysm suitable for endovascular

complete obliteration with liquid obstructing material. 5%

managed by this new triple co-axial technique. A 37-year-old

huge hematoma in left lower abdominal wall. Angiography

treatment. Both cases were identified with asymptomatic

EO was injected with arterial flow reduction in all cases. In

male patient was admitted to undergo polypectomy for a polyp

confirmed extravasation from left inferior epigastric artery.

true aneurysm arising from common celiacomesenteric

addition, out-flow vessels and arteriovenous shunts were

of the ascending colon. During polpectomy, intestinal bleeding

Transcatheter arterial embolization (TAE) using gelatinsponge

trunk and were incidentally identified. Aneurysm exclusion

obstructed for 5% EO to stay in lesions. Technical success was

occurred, and the bleeding was considered from a branch of

and microcoil was performed successfully. However, the

can be accomplished with coil embolization on the basis of

achieved in all cases. EOI was used alone in 3 lesions of 2 cases

an artery. Endoscopic hemostasis was attempted, but it was

patient had repeating hemorrhage in abdominal wall and

dimensional criteria. Postprocedural imaging showed complete

(AML and pancreatic AVM), and EOI with other obstructing

difficult because of too much blood. Thus, TAE was considered

retroperitoneal space. Additional TAE performed two times.

exclusion of flow within the aneurysm sac. On follow up

material was administered in combination in 3 lesions of 3

necessary. It was approached via the right femoral artery with

We succeeded performing additional embolization, the patient

examination, CT demonstrates coil artifact with no gross

cases; AML with arterialvenous shunt was used with coil and

a 4-Fr sheath. Then, a 4-Fr. modified cobra catheter (Terumo,

died from liver failure 10 days later.

evidence of aneurysm sac, MR angiography may be useful tool

gelatin sponge (GS), hepatic aneurysm was used with coil, and

Tokyo, Japan) was placed in the superior mesenteric artery

Discussion: Hemorrhage is well known as a major

for evaluation of aneurysm after coil embolization.

bronchial arterial AVM was used with ethanol, GS, and coil.

(SMA). Angiography of the SMA revealed extravasation from

complication of hemophilia and anticoagulant therapy.

Average amount of EOI was 10ml (6-16 ml). Pancreatitis and

the distal portion of a branch of the right colic artery. A 2.7-

We consider that this patient had coagulopathy due to

pseudo aneurysm were occurred after treatment in 2 cases,

Fr. microcatheter was inserted to the right colic artery, and

anticoagulant therapy and liver disfunction. We also suppose

and treated adequately. All cases remained free of disease

then a 1.9-Fr. no-taper microcatheter could be inserted to the

that ruptured arteries are related with high abdominal wall

during observation period. 5% ethanolamine olate using the

vasa recta where extravasation occurred. Coil embolization

pressure due to massive ascites. TAE seemed to be effective

arterial flow reduction cause obliteration of arterial lesions.

was performed with a Guglielmi detachable coil (GDC; Boston

treatment for life-threatening abdominal wall hematomas for

However, strict follow-up will be necessary for complication

Scientific Japan, Tokyo). This 1.9-Fr. no-taper microcatheter

the patient who had no surgical indication.

because of the treatment.

had just one marker, so we found the detach point by voltage

change, and placed 2 GDCs successfully. Angiography of the
TAE, the patient had no signs of mesenteric ischemia and did

Poster Exhibition

Poster Exhibition

right colic artery showed no extravasation any longer. After

well during a 4-months follow up period.

372

373

Poster Exhibition

PE042

PE041

PE043

PE044

Successful coil embolization of a

pancreaticoduodenal artery aneurysm and
celiac trunk stenosis with microballoon
occlusion test

Thrombin injections to treat postmyomectomy pseudoaneurysms: Report of

two cases

Endovascular treatments of stent-graft

placement of hemorrhage after hepatectomy:
Report of 2 cases

Incidence and imaging findings of

complications following endovascular
aneurysm repair for abdominal aortic
aneurysm

Michio Yamasaki1, Katsuji Imoto1, Akitoshi Inoue1,

Wataru Yamasaki1, Masaki Urashima1, Kenji Kajiwara2,

Fumiyasu Tsushima, Koichi Shibutani, Shinya Kakehata,

Hiroko Seino, Hiroyuki Miura, Shuichi Ono,
Yosihiro Takai

Jun Sakurai

Kentarou Itabashi , Tsutomu Sakamoto ,

Tae Onari , Akiko Matsuura , Noriaki Matsuura ,

Akira Furukawa2, Kiyoshi Murata3

Hideaki Kakizawa3, Kazuo Awai3

Department of Radiology, Kohka Public Hospital, JPN

Department of Radiology, Tokyo Metropolitan University,

JPN

Hiroshima City Hospital, JPN

Asa City Hospital, JPN

3
Hiroshima University Hospital, JPN

Department of Radiology, Kagawa Prefectural Central

Hospital, JPN

Department of Radiology, Hirosaki University Graduate

School of Medicine, JPN

Department of Radiology, Shiga University of Medical

Science, JPN

Purpose: With the advent of multi-detector CT (MDCT)

Introduction: Although thrombin injections have been used to

Massive arterial hemorrhage caused by pseudoaneurysm

in the clinical settings, the incidence of asymptomatic

treat pseudoaneurysms, their safety and effectiveness remain to be

rupture is a lifethreatening complication of hepatectomy.

pancreaticoduodenal artery aneurysms is increasing. These

etiologies are variable, but the trunk of celiac artery stenosis
is sometimes concomitant with this disease. The isolation
technique of coil embolization is ideal except the risk of
ischemia in the celiac artery territory. Microballoon occulusion
test before the coil placement of aneurysm is presumed
to be useful to predict the collateral circulation after the
embolization, and we used this technique in a case.
Material and methods: A 64-year old male with a history of

artery pseudoaneurysms who were treated with intra-arterial and

trans-vaginal direct thrombin injections.
Case 1: This 37-year-old woman developed a 60 x 60 x 50 mm pelvic
pseudoaneurysm after undergoing open abdominal myomectomy. On
a pelvic angiogram, the main parent arteries of the pseudoaneurysm
were confirmed to be the right uterine artery and the bilateral
ovarian arteries, the aneurysm had a small neck and the blood flow
inside the pseudoaneurysm was slow. We advanced a microcatheter
into the pseudoaneurysm via the right uterine artery and injected

Recently, many authors have recommended stentgraft

placement as a first-line treatment option, especially in case
of extrahepatic artery hemorrhage in which the patient's
anatomy permits. We herein report two cases of stent-graft
placement of hemorrhage after hepatectomy. Active bleeding on
angiography was defined as the presence of a pseudoaneurysm.
Stent-graft placements were performed in two patients with
a proper hepatic artery pseudoaneurysm. The 3 and 3.5 mm
stent-graft (GraftMaster) were placed across the lesion. Active

chronic pancreatitis was admitted to our hospital. Contrast

a total of 10,000 IU of thrombin. The final angiogram showed

bleeding and a pseudoaneurysm were completely eliminated

enhanced MDCT manifested a pancreaticoduodenal aneurysm

complete occlusion of the pseudoaneurysm. During the 5-month

by stent-graft placement in all patients. A transient increase in

which measured 12*12 mm in diameter and stenosis of

the trunk of celiac artery as concomitant finding. He was
asymptomatic with the aneurysm, but hoped non-invasive
treatment. We introduced microballoon(Attendant [balloon
diameter 4.5 mm, length 10 mm]; Clinical Supply, Gifu, Japan)
to the aneurysm neck and angiogram of superior mesenteric
artery (SMA) via 5-Fr guiding catheter was performed under
microballoon inflation. Rich collateral circulation in the
liver and spleen despite the stenosis of the celiac trunk was
demonstrated.
Results: Through a microcatheter, the aneurysm was excluded
by coil embolization distal-to-proximal using three fiberedinterlocking detachable coils and a C-Stopper Coil. After the
procedure, angiogram of SMA revealed rich circulation in the
celiac territory. No clinical manifestations suggesting liver
dysfunction, splenic infarction, and bowel ischemia were noted.
Conclusion: Microballoon occulusion test bef ore the
embolization is useful for avoiding ischemic complication.

follow-up there were no signs of recurrence or complications.

Case 2: This 35-year-old woman developed a 27 x 25 x 25

serum transaminase levels was observed in one patient with

mm small-necked pseudoaneurysm after laparoscopy-assisted

transaminase levels before stent placement.

myomectomy. We were unable to advance the microcatheter

into the pseudoaneurysm via the parent left uterine artery due
to its tortuosity. As the blood flow inside the pseudoaneurysm
was slow, we injected thrombin trans-vaginally. An 18-gauge
percutaneous transhepatic cholangial needle was inserted into
the pseudoaneurysm under ultrasound guidance and a total of
5,000 IU of thrombin was injected stepwise. The pseudoaneurysm

early stent thrombosis. The other patient had normal serum

CONCLUSION: The endovascular treatments of stent-graft
placement can be performed safely in most patients and are
effective treatment options for extrahepatic artery hemorrhage
after surgical hepatectomy. Moreover,stent-graft placement
is better than TAE for preserving intrahepatic arterial flow
without rebleeding from the extrahepatic artery.

imaging findings of the complications following endovascular

aneurysm repair (EVAR) for the patients with abdominal
aortic aneurysm (AAA).
MATERIALS AND METHODS: Between April 2009 and
October 2011, 72 patients (52 men and 20 women) with followup period of more than 1 month were treated by EVAR.
Major complications were those that required surgical or
radiologic interventions and minor complications were those
that resolved spontaneously. The complications and imaging
findings from computed tomography (CT) were reviewed.
RESULTS: Sixteen patients (22.2 %) had complications
following EVAR. Of these, eleven (15.3 %) were major
complications and the others ( n = 5, 6.9 %) were minor.
Regarding the major complications, endoleaks were the most
common complication ( n = 5, 6.9 % ) and 3 patients with type
II endoleak required transcatheter arterial embolization and 2
patients with type I endoleak required additional EVAR using
infrarenal aortic extension ( n =1 ) and iliac leg extension ( n =
1 ) for the enlargement of AAA. Device occlusion ( n = 3, 4.2 % )
and stenosis ( n = 1, 1.4 % ) which were required interventions
for iliac leg device, and external iliac artery dissection ( n

was completely occluded and there were no signs of recurrence or

= 2, 2.8 % ) which were required surgical repair ( n = 1 ) or

complications during the one-month follow-up period.

Discussion: For the safe treatment of pseudoaneurysms by

the complications were fatal resulting in death.

transcatheter angioplasty ( n = 1 ) were less common. None of

thrombin injections, a small aneurysmal neck and slow flow inside

CONCLUSION: The complications following EVAR that were

the aneurysm, as was the case in our patients, may be significant

required intervention occurred in 15.3 % of the patients. We

factors to obtain complete occlusion. We considered thrombin

injections appropriate in our patients because coil packing of their
relatively large aneurysms would have required the placement

should accurately recognize these conditions and apply the

suitable interventions to these patients.

Poster Exhibition

Poster Exhibition

established. We report 2 patients with post-myomectomy uterine

PURPOSE: To retrospectively investigate the incidence and

of many coils, raising the risk of rupture due to mechanical

forces exerted by the coils, and because the injection of n-butyl
2-cyanoacrylate (NBCA) would have involved large volumes of
NBCA, whose delivery can be difficult. Our thrombin doses were
higher than in earlier reports and our follow-up periods were short.
At present, the appropriate dosages for- and the long-term results
obtained by the injection of thrombin to treat pseudoaneurysms
are unclear. Efforts are underway to address these issues and to
establish the safety and effectiveness of this treatment in patients
with pseudoaneurysms.

374

375

Poster Exhibition

PE045

PE046

Emergency endovascular repair for acute

aortic syndrome

Transarterial embolization with N-butyl-2cyanoacrylate to treat a type 2 endoleak

following endovascular repair of abdominal
aortic aneurysms

3 cases report underwent TEVER to AEF

Motoki Nakai1, Hirotatsu Sato1, Akira Ikoma1,

Kenji Kajiwara1, Wataru Yamazaki2, Noriaki Matsuura2,

Shinya Ikeda1, Shoei Sai1, Zirou Munetika1,

Hiroki Sanda , Hinako Sakaguchi , Kohei Nakata ,

1

Masaki Urashima , Toshihiko Suzuki , Keiji Yunoki ,

Minoru Honda2

Morio Sato , Yoshiharu Nishimura , Yoshitaka Okamura

Department of Radiology, Wakayama Medical University,

JPN

Department of Thoracic and cardiovascular surgery,

Wakayama Medical University, JPN

Department of Diagnostic Radiology, Hiroshima University

Hospital, JPN

Purpose: Between July 1999 and November 2011, endovascular

Introduction: Type 2 endoleaks after endovascular aneurysm

repair (EVAR) are due to retrograde flow from aortic side
branches into the aneurysmal sac. Some persistent type 2
endoleaks result in further expansion of the aneurysm and
require secondary intervention. Treatment options include
transarterial-, translumbar-, and transcaval embolization
and open surgical repair. We present our experience with
transarterial embolization using N-butyl-2-cyanoacrylate (NBCA)
to treat a type 2 endoleak that appeared after EVAR.
Case Report: This 87-year-old man had been treated 16 months
earlier with an Excluder bifurcated endprosthesis for an
abdominal aortic aneurysm (sac diameter 56 mm, neck diameter
25 mm, neck length 35 mm). At 3-month follow-up a type 2
endoleak was observed, there was no sac expansion. However, at
9 months and 15 months the leakage persisted and the aneurysm
had increased to 62mm and 66 mm. Therefore, we judged
therapeutic intervention to be warranted.
Preoperative MDCT and angiography revealed that the main
route of the endoleak was via a left fourth lumbar communicated
with a left iliolumbar artery. After transarterial embolization
using this route we succeeded in placing a microcatheter into
the aneurysmal sac. We obtained angiographic evidence that
the endoleak involved 3 vessels, the right third lumbar- and both
fourth lumbar arteries. We injected 3.0 ml of NBCA mixed with
iodized oil at a 1:8 ratio to fill simultaneously the aneurysmal sac
and the proximal portions of the involved lumbar arteries. On
a CT scan obtained immediately after the procedure a quantity
of admixed NBCA-iodized oil was visualized in the iliopsoas
muscle and the patient complained of back pain and weakness
in the muscles of his left lower leg. These symptoms improved
spontaneously. MDCT scans obtained 3 and 6 months after the
procedure showed complete occlusion of the type 2 endoleak and
no further enlargement of the aneurysmal sac.
Discussion: We successfully treated a type 2 endoleak by
transarterial embolization using the injection of an NBCA-iodized
oil mixture into the aneurysmal sac. Earlier studies also found
this technique effective. Care must be taken to avoid over-flow
of the mixture into the feeding arteries. We are in the process of
establishing the appropriate amount and the ratio of the NBCAoil mixture and the infusion rate.
In conclusion, this technique may be an option for treating type
2 endoleaks that develop after EVAR if the main feeding arterial
route can be identified on MDCT or angiographic images.

aortic repair (EVAR) was performed in 154 patients, of which

21 underwent the procedure under emergency conditions. Here
we report the results of these emergency EVAR procedures.
Subjects and Methods: Twenty-one patients (10 males and
11 females; mean age, 63.4 years; range, 37-90 years) who
underwent emergency EVAR for acute aortic syndrome were
included in this study. Involved sites included the thoracic
aorta (n = 10), abdominal aorta (n = 5), iliac artery (n = 3),
brachiocephalic artery (n = 2), and superior mesenteric artery
(SMA; n = 1). The conditions requiring emergency EVAR
included ruptured aortic aneurysms (n = 7), aortoenteric fistula
(n = 4), traumatic aortic injury (n = 4), aortobronchial fistula
(n = 2), aortic dissection (n = 1), ureteroiliac arterial fistula
(n = 1), iliac arteriovesical fistula (n = 1), and ruptured SMA
pseudoaneurysm (n = 1). The devices used were the MatsuiKitamura stent-graft (n = 4), an aortic extender (cuff; n = 7),
an iliac extender (n = 3), the zenith main body graft (n = 2), the
excluder main body graft (n = 1), a stent-graft for the bile tract (n
= 3), and a homemade stent-graft (n = 1).
Results: The primary technical success rate was 100%, 30day mortality was 14.3%, and 6-month mortality was 42.9%.
The rate of stent-graft infection (sepsis) was 33.3%, that of reintervention (addition of coil embolization or stent-graft) was
19.0%, and that of surgical conversion was 4.8%. Twelve of the
patients died. Causes of death included sepsis (graft infection)
in 4 patients, cancer in 4, multiorgan failure (hemorrhagic
shock, disseminated intravascular coagulation) in 2, and other
Conclusion: Acute aortic syndrome is significantly associated
with early and late mortality. EVAR offers a minimally
invasive and effective treatment option for patients with lifethreatening acute aortic syndrome. However, aortic syndromerelated deaths continue to occur throughout the follow-up
period. Postoperative control of graft infection and continued
surveillance is important to improve the survival rate of such
patients.

376

Department of Radiology, Hiroshima City Asa hospital, JPN

Department of Radiology, Hiroshima City Hospital, JPN

3
Department of Cardiovascular, Hiroshima City Hospital, JPN

Department of Radiology, Showa University School of

Medicine, JPN
2

Totsuka Kyouritsu Second Hospital, JPN

Hirotatsu Sato1, Motoki Nakai1, Akira Ikoma1,

Hiroki Sanda1, Hinako Sakaguchi1, Kohei Nakata1,
Hiroki Minamiguchi1, Nobuyuki Kawai1,
Tetsuo Sonomura1, Morio Sato1, Yoshiharu Nishimura2,
Yoshitaka Okamura2
1

Department of Radiology, Wakayama Medical University, JPN

Department of Thoracic and Cardiovascular Surgery,

Wakayama Medical University, JPN

Ad vanced esophageal cancer with aortic in vasion is

Aortobronchial fistula is a rare condition with life-threatening

difficult to treat, and surgery is not indicated. Therefore,

gross hemoptysis that should be immediately diagnosed and

chemoradiotherapy (CRT) is performed for the cancer. However,

treated. Here we report 2 patients with aortobronchial fistula

advanced esophageal cancer with aortic invasion may develop

who were successfully treated by an endovascular procedure

into an aorto-esophageal fistula (AEF) during treatment,

using stent-grafts. Patient 1 was a 30-year-old man presented

leading to rapid deterioration due to massive hematemesis.

with bleeding from tracheal stoma, who had undergone a

We successfully performed thoracic endovascular aortic repair

tracheotomy because of cerebral palsy. Contrast-enhanced

(TEVAR) for the prevention of fatal hemorrhage due to AEFs

CT revealed a pseudoaneurysm of the brachiocephalic artery

in two patients strongly suspected of having aortic invasion of

(BCA). Urgent angiography demonstrated extravasation

esophageal cancer and in one patient developing an AEF during

from BCA to the trachea. A 10 mm 60 mm Fluency stent-

CRT for esophageal cancer.

graft (Bard Peripheral vascular, Inc. Arizona, Tempe) was

An 81-year-old man was diagnosed with esophageal cancer

deployed to successfully exclude the pseudoaneurysm using

and admitted to our surgical gastroenterology department for

the transfemoral approach. Bleeding stopped after stent-graft

treatment. The cancer was considered to be T4N1M0, stage IVa,

deployment. The postoperative course was uncomplicated

based on detailed examination. Chest CT revealed an ulcer-

and the patient was discharged on day 30. Patient 2 was a

like projection (ULP) in the aortic wall adjacent to the tumor,

69-year-old man who had undergone tracheal tumor resection

strongly suggesting aortic invasion by the esophageal cancer.

and tracheoplasty for laryngeal cancer 2 months previously.

Thus, the patient underwent TEVAR.

Bleeding from the tracheal stoma occurred in the patient.

A 66-year-old woman was diagnosed with esophageal cancer

Contrast-enhanced CT revealed a small pseudoaneurysm of

(T4N1M0, stage III) and admitted to our gastroenterology

BCA. Two 10 mm 7 cm Excluder iliac extender stent-grafts

department f or treatment. Follow-up chest CT af ter

(W. L. Gore & Associates, Inc., Flagstaff, AZ) were deployed

chemotherapy showed a ULP in the aortic wall adjacent to the

to exclude the pseudoaneurysm via the right carotid artery

tumor, strongly suggesting aortic invasion by the esophageal

under general anesthesia, and the right subclavian artery was

cancer. TEVAR was thus performed.

subsequently embolized using microcoils via the right brachial

A 72-year-old woman was diagnosed with esophageal cancer

artery. Bleeding stopped after treatment. The postoperative

(T4N4M0, stage IV) and started CRT. The patient subsequently

course was complicated by sepsis, and the patient was

noticed a sudden onset of back pain, and had massive

discharged 60 days after treatment. Endoluminal stent-graft

hematemesis. She was urgently transferred to our hospital,

repair resulted in total exclusion of the aortobronchial fistula,

and was found to have an AEF by contrast-enhanced CT. The

and bleeding from the tracheal stoma stopped immediately

patient was saved by successful TEVAR.

after stent-graft deployment. BCA remained patent and no

Intra-aortic stent placement is not a definitive treatment for

ischemic complications developed. Both the patients required

AEFs, but is worth considering. The technique is less invasive

long-term antibiotic administration after endovascular

than thoracotomy, and can be a palliative or temporary

treatment. Thus, endovascular management of aortobronchial

treatment forming a bridge before switching to a more

fistula is feasible.

appropriate treatment even in patients whose general condition

is poor. At present, however, there are no large-scale studies
of this technique. Herein, we report the efficacy of TEVAR in
AEFs with a review of the relevant literature.

377

Poster Exhibition

causes (cerebral hemorrhage, etc.) in 2.

Two cases of aortobronchial fistula

successfully treated by endovascular repair

Takashi Hashizume , Noritaka Seino , Takehiko Gokan ,

Masaki Isikawa , Hideaki Kakizawa , Kazuo Awai

Hiroki Minamiguchi , Nobuyuki Kawai , Tetsuo Sonomura ,

Poster Exhibition

PE048

PE047

Poster Exhibition

PE049

PE050

Aneurysm of systemic arterial supply to

the normal basal segments of the left lower
lobe: Endovascular treatment with an aortic
stentgraft

EVAR with chimney technique for abdominal

Aortic aneurysm with hostile aortic neck

Yoshiro Hori1, Youhei Ikeda1, Suguru Sato1,

Yong Sun Jeon1, Jang Yong Kim2, Anthony W Lee3,

Motohiko Yamazaki , Toru Takano , Shoich Inagawa ,

1

Masaru Takekubo2, Osamu Namura2, Kazuhiko Hanzawa2,

Masanori Tsuchida2, Hidefumi Aoyama1

Department of Radiology, Niigata University Medical and

Dental Hospital, JPN
2
Department of Thoracic and Cardiovascular Surgery,
Niigata University Medical and Dental Hospital, JPN

378

Radiology, Inha University School of Medicine, KOR

Department of Vascular Surgery, Inha University, KOR

Vascular Surgery, 3Christine E. Lynn Heart and Vascular

Institute, USA

Stent-graft repair of symptomatic

penetrating atherosclerotic ulcer isolated at
the aortic arch

Emergency endovascular stent graft repair

of tracheoinnominate artery fistula: A case
report
Takahiro Ogi1, Tetsuya Minami1, Junnichiro Sanada1,
Keiichi Nagai1, Hiroshi Ohtake2, Ryuta Kiuchi2,
2

Yuji Nishida , Mondo Kuroda , Iku Ikeno , Go Watanabe ,

Osamu Matsui1
1

Department of Radiology, Kanazawa University Graduate

School of Medical Science, JPN

Ha Hun Song1, Young-Joo Kim2

1

Department of Radiology, Cheju Halla General Hospital,

KOR

Department of Radiology, Uijongbu St. Mary's Hospital,

KOR

Department of General and Cardiothoracic Surgery, Kanazawa

University Graduate School of Medical Science, JPN
3

Department of Pediatrics, Kanazawa University Graduate

School of Medical Science, JPN
Abdominal aortic aneurysm(AAA) with hostile aortic neck is

BACKGROUND: Tracheoinnominate artery fistula is a rare,

Purpose: Acute symptomatic penetrating atherosclerotic

not a good candidate for conventional endovascular aneurysm

but lethal complication after tracheostomy. In recent years,

ulcer (PAU) carries potential risk of severe complications and

repair(EVAR). Recent paper showed that EVAR with Chimney

endovascular stent graft repair has been attempted for

unpredictable prognosis. We present our recent experience of

technique(Ch-EVAR) showed reasonable outcome. 81 year old

emergency management of hemorrhage.

treating this controversial disease with stent-graft repair.

man presented with 7.5cm sized AAA during evaluation of

CASE DESCRIPTION: We report a 26 years old man with early

Materials and methods: Over 17-month period (March 2009 to

gastric ulcer. Aortic neck was 30mm in diameter, 10-15mm in

hypoxic encephalopathy who developed a tracheoinnominate

August 2010), we have treated 4 patients of acute symptomatic

length and angulated by 100 degree. EVAR was performed with

artery fistula causing massive hemorrhage long-term after

PAU with a stent-graft which was made of nickel titanium

chimney stenting to both renal arteries. Patient recovered after

tracheostomy. Because of the high risk of open surgical repair,

alloy (Nitinol) and polyester fabric. There were 2 men and 2

transient hematuria. Patient was free of type I endoleak and

endovascular stent graft repair was planned. After temporary

women with a mean age of 72 years. All patients presented

renal insufficiency in 1 year follow up. Authors experienced the

control of hemorrhage, endovascular placement of a stent graft

with associated intramural hematoma (n: 2) and 2 patients

successful Ch-EVAR as a treatment of AAA with hostile aortic

into the innominate artery through the internal carotid artery

had hemothorax as well.

neck and report it.

was performed. The patient was successfully managed and

Results: Immediate exclusion of ulcer was achieved in all

recovered uneventfully.

patients. No procedure related complications were occurred.

CONCLUTIONS: We suggest that the endovascular stent graft

Except one patient who died 3 months after stent-graft

repair may be a therapeutic option for emergency management

placement due to aspiration pneumonia, the rest of 3 patients

of tracheoinnominate artery fistula.

showed no sign of endoleak during follow up period (mean: 7

months).
Conclusion: Stent-graft repair was safe and effective for
preventing potential complications of acute symptomatic PAU
from occurring.

Poster Exhibition

We describe a case of successful occlusion of an aneurysm of the

anomalous systemic artery arising from the descending aorta
with an aortic stentgraft and fibered coils.
Case Presentation: We report the case of a 58-year-old man
with an aneurysm of systemic arterial supply to the normal
basal segments of the left lower lobe (LLL) of the lung. He was
asymptomatic and had no episodes of hemoptysis. An aneurysm
was identified on an annual check-up chest radiograph. Contrastenhanced computed tomography (CT) revealed an aneurysm
with mural calcification and partial thrombosis originating from
an anomalous artery, which arose from the descending thoracic
aorta. The artery distal to the aneurysm gave off branches to the
normal basal segments of the LLL. The affected segments lacked
the normal pulmonary arterial branches, although an arterial
branch was detected in segment 6. The pulmonary bronchi
and veins were anatomically normal. Because of the potential
risk of massive hemoptysis due to aneurysm rupture and
pulmonary hypertension, we decided to perform endovascular
treatment. First, distal arterial branches that were supplying
the left lower basal segments were embolized with multiple
fibered coils to decrease the blood flow and prevent retrograde
filling by unexpected collaterals. Then, the anomalous artery
arising from the descending aorta was covered with an aortic
stentgraft. Finally, thoracic aortography was obtained, which
showed total occlusion of the aneurysm of the anomalous artery.
The postprocedure course was uneventful, and the patient was
discharged 4 days after the placement of an aortic stentgraft.
Contrast-enhanced CT after 3 months showed no blood flow
of the anomalous artery and the reduction of aneurysm size.
Development of the bronchial artery as a collateral channel was
not seen. The patient remained asymptomatic.
Discussion: Transarterial therapeutic coil embolization of such
an artery was first reported by Bruhlmann et al. in 1998 in a
patient whose lung was supplied by both the aberrant artery
and the pulmonary artery. Although there have been a few case
reports of aneurysm of the anomalous artery, endovascular
treatment with an aortic stentgraft has not been reported
previously. In this case, the aortic stentgraft was chosen to cover
the area proximal to the aneurysm, because the aneurysm was
very close to the aorta.
Conclusion: Endovascular treatment with an aortic stentgraft
and coil embolization is a feasible alternative treatment option
for patients with this rare congenital anomaly.

Soon Gu Cho , Kee Chung Hong

Norihiko Yoshimura , Takeshi Okamoto ,

Poster Exhibition

PE052

PE051

379

Poster Exhibition

PE053

PE054

PE055

A new method hybrid-therapy for type IA

major endoleak after EVAR: Combination
with NBCA-Lipiodol, coils, and Zenith TX2
extension cuff deployment

Histopathologic features after gelatin

sponge embolization in a rabbit renal model:
Correlation with arteriographic findings

Endvascular aneurysmal models at the

external iliac artery of dogs

Fundamental study of the intra luminal flow

between the catheter tip and side hole of an
indwelling catheter

Yoshiaki Katada1, Shunichi Kondo2, Taichi Kondo3,

Jung Suk Oh1, Hae Giu Lee1, Ho Jong Chun1,

Kenichi Matsunaga1, Chiaki Takasawa2, Kazumasa Seiji2,

Ryota Kawasaki1, Naokazu Miyamoto1,

Toshio Matsuhashi3, Kei Takase2, Shouki Takahashi2

Masato Yamaguchi2, Takuya Okada2, Masahiko Fujii2,

Tsuyoshi Yamabe , Jun Hirota , Miwako Nozaki

Choi Byung Gil , Choi Young Jin

Department of Radiology, Dokkyo Medical University

Koshigaya Hospital, JPN

Department of Cardiovascular Surgery, Iwaki Kyoritsu

General Hospital, JPN

Department of Radiology, The Catholic University of Korea,

KOR
Pathology, The Catholic University of Korea, KOR

Department of Radiology, Takeda Hospital, JPN

Department of Radiology, Tohoku University Hospital, JPN

Department of Radiology, JR Sendai Hospital, JPN

Department of Cardiovascular Surgery, Hayama Heart

Center, JPN

Purpose: Transcatheter embolization with coils and other agents

has been described as a treatment method for type II endoleak
after endovascular aortic aneurysm repair (EVAR). Type I
endoleak has not been treated commonly with such therapies,
although most investigators believe they warrant definitive
intervention. Transcatheter embolization and EVAR technique
are commonly done separately. But at the same time making
them, it is possible to expand endovascular treatment. The liquid
adhesive n-butyl 2-cyanoacrelate (NBCA) is often used to treat
congenital artreiovenous malformations. The purpose of this
case report is to report our initial experience of new method of
treating type IA major endoleak with EVAR technique combined
with metallic coil and NBCA-Lipiodol embolization technique.
Materials and Methods: The patient was an 85 year-old woman.
EVAR for the AAA over 9cm was performed three years ago
using Zenith stentgraft. The EVAR was terminated without
endoleak, but the type IA endoleak was appeared at followup CT. In this first type IA endoleak, the additional EVAR was
performed, but the endoleak did not disappear completely in this
treatment. After that, the endoleak sac expansion (maximum
AAA diameter was 10cm) was observed in the follow-up CT scan,
and additional therapy has been considered. Interventional
therapy was performed under local anesthesia, and was
undertaken using the technique described below.
Total number of 25 coils was placed and NBCA-Lipiodol was
injected into the endoleak sac, and complete disappearance
of blood inflow within the endoleak sac had been achieved.
After this, from the right femoral artery approach, the Zenith
performed. At the final angiography, the type IA major endoleak
was completely disappeared, and the cast of NBCA-Lipiodol was
existed at the endoleak channel and was present a wedge shape.
Results: Postoperative CT scan even after 1 day, 1 and 3 months
after, the endoleak has completely disappeared and no migration
of the NBCA-Lipiodol cast with coil also has been indicated.
Discussion: Our new method of hybrid-therapy combination
EVAR technique and embolization technique using coils and
NBCA suggests that it may be an effective and safe method of
treatment of type IA major endoleak after EVAR.

380

Department of Radiology, Hyogo Brain and Heart Center at

Himeji, JPN
2

PURPOSE: The correlation of histopathological changes with

angiographic features following gelatin sponge embolization has
yet to be elucidated. This experiment was to investigate underlying
histological findings correlated to postembolization arterial
changes.
MATERIALS AND METHODS: Sixteen rabbits were included
in the experiment and divided to 8 groups (two rabbits in each
group) according to the time for arteriographic and histopathologic
evaluation. Selective embolization was performed with porcine
derived gelatin sponge (Spongostan) particles (about 1 1 1 mm)
into unilateral lower poles of kidneys. The rabbits in each group
underwent aortography before sacrifice 1D,3D, 1W, 2W, 3W, 4W,
3M, or 5M after embolization. Microscopic findings of embolized
kidneys were compared with the arteriographic features.
RESULTS: Gelatin emboli were observed in the segmental
arteries until 3 weeks after embolization. Vasculitis, an acute
inflammatory manifestation, which appeared as localized vascular
wall destruction and extravasation of emboli accompanied with
extensive mononuclear cells infiltration was the most severe on
3 weeks. The embolized arteries were recanalized on microscopic
examination as early as 3 weeks. Acute inflammatory processes
and foreign body reactions were subsided at 4 weeks. The
recanalized arteries showed smaller lumens than those of normal
arteries due to thick intima with spindle cells and organized
thrombus lined with endothelial cells. After 4 weeks, some
interlobar and segmental arteries distal to the embolized arteries
manifested mild to moderate thickenging of intima which resulted
in narrowing of the lumens. On arteriogram, recanalization of
embolized arteries with focal stenosis was observed from 3 weeks.
The segmental and interlobar arteries showed uneven diameter.
Small collateral arteries were observed on both of arteriograms
and microscopic examinations from 4 weeks after embolization.
CONCLUSION: Gelatin sponge embolization induced
acute inflammation and resorption of emboli. The resultant
recanalization of embolized arteries showed luminal stenoses due
to intimal thickening and organized thrombus. Some arteries distal
to embolized vessels manifested variable intimal thickening. These
pathological features are thought to correlate with focal stenosis
of the embolized arteries and uneven stenosis of distal arteries
following gelatin sponge embolization on arteriography.
This work was supported by grant No. RTI04-01-04 from the
Regional Technology Innovation Program of the Ministry of
Commerce, Industry, and Energy (MOCIE).

Introduction: Establishing an aneurysm model using simple

and easy operative techniques is desirable for development
of new endovascular treatment devices such as stentgrafts.

Introduction: To evaluate the variations of the intraluminal

flow between the catheter tip and side-hole of an indwelling
catheter by varying the size of the side-hole, the length between

We tried to develop an aneurysm model using the arteries of

the catheter tip and the side-hole, and the angulation at the

adult beagle dogs, a relatively large animal which we thought

side-hole or catheter tip.

would be easier to handle, and a simple and less complicated

Materials & Methods: 5- and 6-F indwelling catheters with a

endovascular procedures. Additionally, we evaluated the

side-hole, the location of which varied from 3 to 7 cm from the

generated aneurysm model histologically, and determined

tip of the catheter according to the size of the side-hole, which

the factors that were necessary for creating more dilated

aneurysms.
Materials and Methods: Experimental animals consisted
of 16 beagle dogs that weighed an average of 14.0 kg. The
animals were divided into four groups( S,E,B+S,B+E group).
8 beagles were S and E groups without balloon dilation . S
group was injected normal saline into right external iliac
artery of these dogs. S group served as a control group. E
group was injected elastase into left external iliac artery of
the same dogs. 8 beagles were B+S and B+E groups with
balloon dilation. After balloon dilation, B+S group was injected
normal saline into right external iliac artery of these dogs
and B+E group was injected elastase into left external iliac
artery of the same dogs. After four weeks, both sides of the
external iliac artery were havested. Before procedure and
harvest, we measured the external iliac artery diameter using
an abdominal ultrasonography from a surface of a body. We
evaluated the dilation rate of the external iliac artery diameter
and histologically, disappearance of the internal elastic lamina,
degeneration and disappearance of medial smooth muscle and
the external elastic lamina, and neointimal thickening.
Results: Inner diameters were dilated more in B+E group
compared to the other groups. B+E group internal elastic
lamina was almost disappeared with considerable degeneration
and disappearance of external elastic lamina.
Conclusion: We succeeded in developing an aneurysm
model, using the arteries of adult beagle dogs and a simple
endovascular procedure. Histologically, both internal and
external elastic lamina degeneration were regarded as
important factors to make more dilated aneurysmal model.

varied among 2 mm, 3 mm, and 4 mm, were prepared. The

catheters were cut at 2 cm proximally from the side-hole, and
the proximal lumen was occluded with heat, and connected to
an extension tube. The nonionic iodinated contrast agent was
injected through the extension tube into the side-hole under a
pressure of 90 mmHg using the pressure bag method. The flow
rate was calculated by measuring the volume of the contrast
excreted from the catheter tip. The flow rates under various
situations were measured. The deformity of the side-hole
when the catheters were angulated at the side-hole was also
analyzed.
Results: The flow rate of the angulated catheter tip varied from
-1.6 to +1.6 (mean: -0.12) ml/min at 45 degrees, and from -2.2
to +1.4 (mean: -0.72) ml/min compared with the flow rate at 0
degrees. The flow rates of 5-F catheters with lengths of 3, 4, 5,
6, and 7 cm without a side-hole were 20.0, 20.2, 21.6, 22.0, and
22.4 ml/min, respectively. The same test using 6-F catheters
revealed an increase of the flow from 17.9 to 28.7 % compared
with the 5-F catheters of the same length. The flow rates of
5-F catheters with side-holes of 2, 3, and 4 mm were 27.8,
25.7, and 29.4 ml/min, and that of 6-F catheter was 36.7, 31.1,
and 35.7ml/min, respectively. The deformity of the side-hole
when the catheter was angled at the side-hole was observed
in all catheters, including widening, widening and narrowing,
twisting, twisting and widening, twisting and narrowing, and
kinking. The mean decrease of the flow rate was 4.4% in total,
although the decrease flow rate in kinking tends to be higher
(mean: 8.9%).
Conclusion: The intraluminal flow between the catheter tip
and the side-hole depends on its length and on the French size.
The influence of the angulation at the catheter tip, the size of
the side-hole, and the deformity of the side-hole were minimal.

381

Poster Exhibition

TX2 extension-cuff was deployed, and the post ballooning was

Kazuro Sugimura2, Koji Sugimoto2

Department of Radiology and Center for Endovascular

Therapy, Kobe University Graduate School of Medicine, JPN

Poster Exhibition

PE056

Poster Exhibition

PE057

PE058

PE060

Experimental evaluation in arterial embolic

effect in normal swine spleen : Comparison
between soluble gelatin sponge (RM-G) and
gelatin sponge (spongel)

Preliminary application of imipenem/cilastatin

sodium (IPM/CS) as an embolic agent for
transcatheter arterial embolization in a swine
model: Comparison with gelatin sponge

Time dependent relation between 99mTclabeled RBC scanning and mesenteric

angiography for the evaluation of active
lower gastrointestinal bleeding

Malignant colorectal obstruction managed

by means of a dual-design expandable
metallic stent before laparoscopic colorectal
surgery

Akira Ikoma1, Nobuyuki Kawai1, Morio Sato1,

Raza Sayani, Muhammed Ali, Tanveer Ul Haq,

Gyoo-Sik Jung1, Won-Young Son1, Byeong-Ho Park2,

Maseeh Uz Zaman

Je-Ryang Juhn3

Tetsuo Sonomura1, Yoshitaka Kanayama2, Yasuo Sakai2

Reiko Woodhams1, Hiroshi Nishimaki2, Fumie Kashimi3,

Masakazu Takigawa4, Yukio Tamura5, Kazui Soma3,
Yusuke Inoue1
1

Department of Radiology, Aga Khan University Hospital,

PAK

Hiroyuki Minamiguchi , Motoki Nakai , Kouhei Nakata ,

Department of Radiology, Wakayama Medical University,
JPN

Central Research Institute, Jellice Co., Ltd., JPN

Department of Diagnostic Radiology, Kiatasato University School of Medicine, JPN

2
Department of Cardiovascular Surgery, St. Marianna University School of Medicine, JPN
3
Department of Critical Care and Emergency Medicine, Kitasato University School of
Medicine, JPN
4
Department of Radiology, National Hospital Organization Sagamihara National
Hospital, JPN
5
Department of Suregry, Kitasato University School of Medicine, JPN

Department of Radiology, Dong-A University College of

Medicine, KOR
3

Department of Radiology, Inje University College of

Medicine, KOR

Purpose: To compare the embolic effect and tissue injury of

Purpose: To evaluate the characteristics of imipenem/cilastatin

OBJECTIVE: The purpose of this study was to compare 99mTc-

sodium (IPM/CS) as an embolic agent for transcatheter arterial

labeled RBC scanning with mesenteric angiography for the

Materials and Methods: Twenty healthy young swine were

arterial embolization with soluble gelatin sponge (TAE-60)
group, the transcatheter arterial embolization with spongel
(TAE) group. The splenic artery was embolized using spongel
(diameter, 2mm;) or soluble gelatin sponge(Regenerative
medicine-gelatin; RM-G; diameter, 2mm). By means of
50 kDa of regenerative medicine-gelatin (RM-G), RM-G
sponges were prepared by freeze-drying and heating to
temperatures of 130C for cross-linkage. The end point of
embolization is disappearance of splenic stain. We perfomed
splenic artery embolization from main trunk.For each group,
angiographies were performed on spleen immediately after
the embolic procedure and on 30 ,60, 120 minutes and 3 days
after embolization. This was followed by macroscopic and

embolization (TAE) by comparing to gelatin sponge.

Materials and Methods: Firstly, suspension of 0.5g of IPM/
CS in 5 ml of non-ionic iodine-containing contrast agent was
prepared by pumping using syringes for 10 seconds. The sizes
of IPM/CS particles in the suspension were microscopically
examined. Secondly, the IPM/CS suspension was infused in
a branch of the superior mesenteric artery (SMA), inferior
mesenteric artery (IMA), and renal artery (RA) of a swine
through the micro-catheter until blood flow stagnated. As a
control, the suspension of particles from one sheet of gelatin
sponge mixed with 10 ml of non-ionic iodine-containing contrast
agent by pumping using syringes (GS) was infused in other
branches of SMA, IMA, and RA. Angiography was undergone
24 hours after embolization and then the swine was sacrificed.
The specimens from the small intestine, large intestine, and
kidney were histologically examined.

evaluation of active lower gastrointestinal bleeding and to see

whether their relation is time dependant.
MATERIALS AND METHODS: From March 2001 to June
2011, 70 patients (46 men, 24 women; age range, 12-87years)
were evaluated with 99m-Technetium labeled RBC scan
followed by mesenteric angiography. Subsequent successful
embolization of the bleeding vessel was performed in 36
patients. The data was also evaluated for time difference
between both the procedures and effect of time interval on the
yield of mesenteric angiography.
RESULTS: Findings were positive on both examinations in
31 patients and negative on both examinations in 7 patients.
Findings were positive on 99mTc-labeled RBC scan and
negative on subsequent mesenteric angiography in 27 patients.
Findings were negative on 99mTc-labeled RBC scanning and

histopathological examinations of the spleen. Each spleen was

Results: The mean size of the IPM/CS particle was 130 m.

positive on angiography in 5 patients. Fifty eight of 70 (82.9%)

removed and cut into 10-cm-thick sections, and the damaged

At angiography performed 24 hours after embolization, the

99mTc-labeled RBC scans were positive whereas thirty six of 70

volume ratio was calculated.

Results: In the TAE group, angiography of splenic artery on 30 ,
60 ,120 minutes and 3 days after embolization shows occlusion
of major branch. In the TAE-60 group, the recanalization of the
major branch was detected in the angiography on 60 minutes
after embolization. The changes of the color of resected spleens
were more prominent in the TAE-group on the macroscopic view.
The spleen damage volume ratio in TAE-group was significantly
higher than in the TAE-60 group.
RM-G and spongel. The longer occulusion time is, the more
strong ischemic changes are. Soluble gelatin sponge (RM-G :
50kDa/130C) has a enough embolic effect until 60 minutes and
it can become a new temporal embolic agent.

was observed. RA and SMA embolized with GS showed the

stasis of blood flow, but the IMA embolized with GS showed
recanalization. The histopathologic examination of the small
intestine embolized with IPM/CS showed necrosis at the tip
of the villus. Meanwhile, 1/2 to 1/3 from the tip of the villus
in the small intestine embolized with GS showed necrosis.
The large intestine embolized with IPM/CS showed erosion
of the superficial mucosa. The large intestine embolized with
GS showed necrosis of entire thickness of the mucosa and sub
mucosa. At the histopathologic examination of the kidney, the
region embolized with IPM/CS showed partial ischemic necrosis
weaved with normal tissues. On the other hand, the region
embolized with GS showed segmental ischemic necrosis.
Conclusion: The IPM/CS suspension caused shorter
embolization and less tissue damage than the GS suspension.

(51.4%) mesenteric angiographies were positive. In thirty nine

of 70 (55.7%) 99m-Technetium labeled RBC scans findings were
matched on subsequent mesenteric angiography. When this
correlation was further evaluated according to the time interval
between the RBC scan and mesenteric angiography, seventeen
of 19 ( %) RBC scans were matched when the time interval is <

Purpose: To evaluate the efficacy of a dual-design expandable

metallic stent for the management of malignant colorectal
obstruction before laparoscopic colorectal surgery.
Material and method: The dual-design expandable metallic
stent consisted of two stents, an outer partially nylon covered
stent and an inner bare nitinol stent. The outer stent was
placed into the obstruction which was followed by coaxial
placement of the inner bare stent at the same sitting. Under
the fluoroscopic guidance, ten patients with malignant
colorectal obstruction were managed by means of implanting
the stent followed by elective laparoscopic surgery. The results
of the nine cases are presented.
Results: Stent placement was successful in all ten cases,
and obstructive symptoms resolved within three days after
stent placement. All patients underwent elective one-stage
laparoscopic surgery after 8 days (range, 5-10 days), and
cleansing of the colon were observed in all patients. In one
patient, colon perforation occurred during laparoscopic surgery,
which was switched to open surgery. There were no other
postoperative complications.
Conclusion: The dual-design expandable colorectal stent is
effective for preoperative decompression in the laparoscopic
colorectal surgery for the treatment of malignant colorectal
obstruction.

1 hour. During 1-2 hour time interval 11 0f 16 ( %) scans were

matched, 2-5 hour 7 of 15 ( %) scans and > 5 hour interval 4 of
20 ( %) scans were matched.
C O N C L U S I O N: 99m-Te c h n e t i um l a be l ed R BC s ca n s

Poster Exhibition

Conclusion: The degration period were different between

recanalization of SMA, IMA, and RA embolized with IPM/CS

Department of Radiology, Kosin University College of

Medicine, KOR
2

soluble gelatin sponge with spongel

assingned into two groups (ten in each): the transcatheter

Poster Exhibition

PE059

can correctly identify the bleeding site if the mesenteric

angiography is performed within an hour of the scan. Utilizing
this golden hour can significantly reduce the negative
angiography rate once the bleeding site is identified on the RBC
scan.

Therefore, IPM/CS has a possibility to be a safe embolic agent

for TAE of the small and large intestinal bleeding in which
GS has a risk of causing ischemia. However, the possibility of
insufficient embolization is concerned because of the small size
of the particle and mild embolic effect compared to GS.

382

383

Poster Exhibition

PE061

PE062

PE063

PE064

Evaluation of TAE for intrapelvic

hemorrhage after heavy particle
radiotherapy of colon cancer at Komagome
Hospital

Imipenem/cilastatin sodium (IPM/CS)

as an embolic agent of transcatheter
arterial embolization: The usefulness for
gastrointestinal bleeding due to neoplasm

Radiologic placement of gastroduodenal

stents for the treatment of malignant
gastroduodenal obstruction : Comparison
of the results according to the stent types

Percutaneous jejunostomy for relief

of afferent loop syndrome of recurrent
pancreatic carcinoma: A case report

Takayoshi Kimura, Yasunobu Takaki, Ikuyo Endo,

Reiko Woodhams1, Hiroshi Nishimaki2, Masakazu Takigawa3,

Joo Hyeong Oh, Se Hwan Kwon, Ji Young Ahn

Jae hyun Kwon

Mizuka Suzuki, Aya Yamamoto, Noriko Kamata

Fumie Kashimi4, Takurou Yamane1, Kenichirou Ishida1,

Radiology, Kyung Hee University Medical Center, KOR

Department of Radiology, Tokyo Metropolitan Cancer and

Infectious Diseases Center Komagome Hospital, JPN

Toshimasa Hara1, Gou Ogasawara1, Kaoru Fujii1,

Department of Radiology, Dongguk University Ilsan Hospital,

KOR

Yusuke Inoue1, Kazui Soma4

1

Department of Diagnostic Radiology, Kiatasato University School of Medicine, JPN

Department of Cardiovascular Surgery, St. Marianna University. School of Medicine, JPN
3
Department of Diagnostic Radiology, National Hospital Organization Sagamihara National
Hospital, JPN
4
Department of Critical Care and Emergency Medicine, Kitasato University School of
Medicine, JPN

Purpose: The purpose of this study was to retrospectively

evaluate the outcomes of transcatheter arterial embolization
(TAE) for intrapelvic hemorrhage after heavy particle
radiotherapy of colon cancer.
Methods: Nine consecutive TAE cases in five male and one
female patients (mean age 54.7 years, range 41-73 years)
performed at our hospital between July 2008 and November
2011 were evaluated. Stages of colon cancer were 1 (n=2), 2
(n=1), 3a (n=1), 3b (n=1) and unclear (n=1). Median time from
the heavy particle radiotherapy to intrapelvic hemorrhage
was 10.2 mon (5-18 mon). There were three cases of recurrent
hemorrhage in which the interval from the first TAE to the
recurrent hemorrhage was 93 days (22-182 days).
Results: TAE was performed with gelfoam and/or microcoils.
Recurrent hemorrhage was observed in three patients, but reembolization was successfully completed in each case, except
for the initial case of which the hemorrhage point was not
identified. In the following cases, the bleeding blood vessels
were branches of internal iliac artery. Average time required
for interventional radiology was 77 min (29-211 min). No major
complications of TAE were observed in the patients, including
re-bleeding cases.
Conclusions: TAE was a safe and effective treatment for
intrapelvic hemorrhage after the heavy particle radiotherapy
in patients with colon cancer. From our experiences, approach
to internal iliac artery for TAE was helpful. Risk of recurrence
hemorrhage should be considered and careful follow-up is

384

Purpose: To evaluate and compare the effectiveness of

radiologic placement of gastroduodenal stents for the treatment
of malignant gastroduodenal obstruction according to the stent
types.
Material and method: From July 2001 to April 2010, 88
radiologic placement of gastroduodenal stents were attempted
in 64 patients (M:F, 44:20; mean age, 65.9 years) with
malignant gastroduodenal obstructions. Stent types were
classified as uncovered stent (Group I), partially covered stent
(Group II) and covered stent (Group III). The technical and
clinical success, complication rates and stent patency rates
were evaluated and compared according to the stent types. The
follow-up period was 1 ~ 760 days (mean, 61.8 96.1 days).
Results: Radiologic stent placement was technically successful
in 82 of 88 cases (93.2%). Clinical success rates was 90.3% in
Group I (28/31), 91.4% in Group II (32/35) and 93.8% in Group
III (15/16). During follow-up, total complication rates according

Nineteen months after a pylorus preserving pancreatico

duodenectomy (PPPD) for pancreatic carcinoma, a 73-yearold woman developed recurrent tumoral strictures of the bile
ducts and afferent Roux-en-Y limb with resultant jaundice and
cholangitis. Percutaneous transhepatic biliary drainage was
performed first.
Fifteen days after PTBD, the patient developed nausea,
vomitting and general weakness. Abdominal CT scan revealed
distension of the afferent loop.
The patient refused operative decompression for afferent loop
syndrome.
Percutaneous jejunostomy was performed to relieve the afferent
loop syndrome.
PTBD catheter was positioned into efferent loop for internal
drainage. Therapeutic options of tumoral occlusion of afferent
loops are reviewed.

to stent types were 25.8% (Group I), 31.4% (Group II) and 31.3%
(Group III). The primary stent patency rates according to stent
types (Group I/II/III) at 1, 3, 6, 12 months were (81.9/88.0/92.9)
at 1 month, (68.3/55.2/66.3) at 3 months, (34.1/31.6/33.2) at
6 months and (34.1/21.1/33.2) at 12 months. There were no
statistically significant differences in the clinical success rates,
total complication rates and primary stent patency rates among
the three stent types.
Conclusions: The radiologic placement of gastroduodenal
stents for the treatment of malignant gastroduodenal
obstruction is feasible and safe and provides acceptable clinical
results. Additional studies are desirable for collection of more

Poster Exhibition

Poster Exhibition

required.

Imipenem/cilastatin sodium (IPM/CS) as an embolic agent

of transcatheter arterial embolization: The usefulness for
gastrointestinal bleeding due to neoplasm
Purpose: To evaluate the usefulness of imipenem/cilastatin
sodium (IPM/CS) as an embolic agent of transcatheter arterial
embolization (TAE) for gastrointestinal bleeding due to
neoplasm.
Materials and Methods: Eight patients (11 procedures) who
underwent TAE using imipenem/cilastatin sodium (IPM/CS) for
gastrointestinal bleeding due to neoplasm were retrospectively
analyzed. They consisted of 7 men and 1 woman, and their
age ranged from 43 to 83 years old (average; 64.510.8).
The causes of bleeding were gastric cancer (3), invasion of
pancreatic neoplasm to the intestine (3), and malignant
lymphoma (2). Indication for TAE were active bleeding observed
at angiography, or repeated bleeding which required blood
transfusion with no extravasation at angiography. IPM/CS was
chosen as an embolic agent when oozing like extravasation from
the tumor was observed or when the tumor feeding arteries
which were strongly suspected as bleeding origins and had a
potential of recurrent bleeding were observed. Composition
of 0.5g of IPM/CS and 5 ml of non-ionic iodine-containing
contrast agent was used as an embolic agent. Technical success
was determined by stasis of extravasation, or stasis of blood
flow to tumors which were considered as origins of bleeding.
Complications, recurrence of bleeding, conversion to the surgical
operation, and clinical outcome were analyzed.
R esul t s: A ll procedures were technically successf ul.
T h e em bo l ized a r t e r i es we r e l e f t g as t r i c a r t e r y ( 2 ),
pancreaticoduodenal arcade (4), jejunal artery (5), and
gastroepiploic artery (1). Average amount of IPM/CS used
was 0.880.58 g. Recurrence of bleeding was observed in 4
patients. Three out of 4 underwent additional TAE with IPM/
CS and obtained hemostasis. The other had hemostasis with
observation. Average time to recurred bleeding was 8.39.5
days. Neither necrosis, ischemia, nor other complications
were observed. There was no conversion to the operation. Five
patients died because of original disease progression. There was
no death relating to TAE.
Conclusion: IPM/CS was considered safe and useful embolic
agent for gastrointestinal tumor bleeding. Repeated TAE may
be necessary because of the mild effect of embolization and
tumor progression, and can be performed safely.

reliable data.

385

Poster Exhibition

PE065

PE067

PE066

PE068

Successful embolization for hematemesis

due to venous rupture in posttheraputic
patient of esophageal cancer

Acquired uterine vascular malformation;

Efficacy of trancatheter arterial emblization

Uterine artery embolization using

progressively increasing size calibrated
gelatin sponge particles alone for
symptomatic uterine fibroids

Uterine artery embolization for symptomatic

fibroids with high signal intensity on T2weighted imaging

Atsushi Ogasawara1, Norihiro Onari1, Jyunji Moriya1,

Koichiro Futatsuya1, Satoru Ide1, Yu Murakami1,
Shingo Kakeda1, Yukunori Korogi1, Aiichiro Higure2,
Koji Yamaguchi2

Seung Boo Yang1, Dong Erk Goo1, Yong Jae Kim1,

YunGyu Song1, Hong Jang1, Jae Ryang Juhn2

Man-Deuk Kim, Myungsu Lee, Mu Sook Lee,

Sung Il Park, Jong Yun Won, Do Yun Lee,
Kwang Hun Lee

Gap Cheol Kim

1

Department of Radiology, Soonchunhyang University

Hospital, KOR

Department of Radiology, Kyungbuk University Hospital,

KOR

Regarding the complication in esophageal cancer patients with

Purpose: To evaluate the clinical efficacy and the potential

maintenance of childbearing capacity in patients with bleeding
acquired uterine arteriovenous malformations (AVMs) treated by
percutaneous transarterial embolization.
Materials and Methods: This retrospective study analysis was
performed on the medical records of all 21 patients (mean ages:
30.9 years, range: 22-45 years) who underwent percutaneous
transarterial embolization of both uterine arteries in the treatment
of a symptomatic UVMs between January 2003 and June 2007.
All but one patient underwent one embolization session. All 21
patients initially presented with vaginal hemorrhage. There
recent obstetrical history prior to embolization showed dilatation
and curettage(D&C) after missed abortion(n=16), cesarean
section(n=3), normal vaginal delivery(n=1), and post treatment of
the ectopic pregnancy(n=1). All patients underwent an abdominal
and transvaginal ultrasound examination or CT or MRI before
embolization. Embolization was performed by the unilateral femoral
artery approach with catheter and angiographic techniques. After
insertion of a 5-French introducer sheath(Terumo,Tokyo, Japan),
the targeted internal iliac artery was catheterized using a 5-French
Cobra catheter(Terumo, Tokyo, Japan). Depending on the vascular
anatomic findings during angiography, it was decided whether or
not to use an additional microcatheter to catheterize the feeding
uterine artery. Bilateral uterine artery embolization was performed
using gelfoam and/or additional microcoils. Angiographic success
was defined as successful embolization of the vascular malformation
with stasis of blood flow in the feeding main uterine artery and no
residual opacification of the UVMs. Ultrasonographic success was
defined as eradication of UVMs and restoration of normal uterine
vasculature. Clinical success was defined as definitive resolution of
abnormal vaginal bleeding. Post procedural complications included
all adverse events related to the embolization procedure.
Results: A total of 22 procedures were performed in 21 patients.
One patient required repeat embolization that is not embolized
due to prominent high flow AVM in first session. Clinically
in all patients the bleeding was controlled immediately after
embolization. No complications occurred in all patients who were
treated with uterine artery embolization at a follow up period
(Mean: 20 months, range : 1-42 months)Of all patients who
underwent successful embolizations, all returned to a normal
menstrual cycle and one later became pregnant.
Conclusion: Uterine arterial embolization is a safe and effective
treatment of a bleeding acquired uterine vascular malformations.
This procedure allows for preservation of uterine function with
the possibility of future pregnancy and should be considered as a
primary treatment option.

hematemesis in posttheraputic patients of esophageal cancer

have been reported, but almost of them were transarterial
embolization. We report a case of hematemesis that was
caused by venous rupture and successfully embolized.
A 58-year-old man underwent operation for esophageal
cancer using retrosternal reconstruction method 8 years ago
and successive postoperative chemoradiotherapy. Five years
ago he underwent reoperation and radiotherapy for cervical
lymph node metastasis. He was admitted to our hospital for
continuous hematemesis and the urgent endoscopy showed
bleeding in the reconstructed cervical esophagus, but due to
severe esophageal stenosis endoscopic hemostatic measures
could not be done. The enhanced CT and DSA revealed a
venous pseudoaneurysm of left brachiocephalic vein. During
DSA rupture of the pseudoaneurysm and hypovolemic shock
occurred and then embolization of brachiocephalic vein using
fiberd platinum coils and microcoils was executed. He was
discharged without recurrent hematemesis in hospital days,
but he expired due to recurrent hematemesis and rapid

Poster Exhibition

deterioration 1 week later.

386

Radiology, Severance Hospital, Yonsei University, KOR

OBJECTIVE: The purpose of this study was to assess the

Purpose: The aim of our study was to evaluate the

safety and effectiveness of uterine artery embolization(UAE)

effectiveness of uterine artery embolization (UAE) for treating

using progressively increasing size calibrated gelatin sponge

symptomatic fibroids with high signal intensity (SI) on T2-

particles alone for symptomatic uterine fibroids.

weighted imaging (T2WI).

MATERIAL AND METHODS: During 10 months,20

Materials and Methods: Among 537 cases, 14 patients with

patients(age range,27-45 years;mean age,39.5years) with

high SI fibroids on T2WI (T2 high group) were retrospectively

symptomatic uterine fibroids underwent UAE.Only gelatin

enrolled and compared with 28 randomly selected patients

sponge particles were used in all patients.Begining with 350-

with low SI fibroids on T2WI (control group). High SI of a

500um particles and progressively increasing 500-710um and

predominant fibroid on T2WI was defined as having the same

then 710-1000um particles to endpoints. The improvement

or higher SI than the myometrium. Patients ages ranged from

of clinical symptoms was assessed by questinnaire.Reduction

28 to 52 years (mean, 38.1 years). All patients underwent MRI

of the largest tumor , uterine volume reduction ,infarction

before and after UAE.

rates of all fibroids and the largest tumor were assessed

Results: Of the patients in the T2 high group, 13 (92.9%)

using MR imaging.The follow-up period ranged from 2 to 8

out of 14 patients demonstrated complete necrosis of the

months(mean,4.9 months)

predominant fibroids. The mean volume reduction rates of

RESULTS: Menorrhagia imporved markedly in 20(100%) of

the predominant fibroids in the T2 high group was 63% three

20 of patients.Bulk-related symptoms improved markedly or

months after UAE, which was significantly greater than that

moderately in 20(100%) of 20 of patients.MR imaging revealed

of the control group (p<0.05). Changes in symptom scores

that the mean uterine volume reduction rates were 54.3%

for menorrhagia and dysmenorrhea after UAE (baseline

and the mean largest tumor volume reduction rates were

score minus follow-up score) were -4.9 and -7.5, respectively,

64.3%.Enhanced MRI 1 month after UAE showed that 100%

representing significant resolution of symptoms (p < 0.001).

infarction of all fibroids was 94.1%+/9.84;100% infarction

Conclusion: UAE is effective for high SI fibroids on T2WI.

of dominent fibroid was 92%+/12.25.Vaginal expulsion of

The mean volume reduction rate of predominant fibroids three

uterine fibroid was in one patient.No major complications were

months after UAE was greater in the T2 high group than in

observed in any women.

the control group.

Department of Radiology, Busan Paik Hospital, KOR

CONCLUSION: UAE using progressive increasing size

calibrated gelatin sponge particles alone is a safe and effective
treatment for symptomatic fibroids.Further comparative study
between calibrated gelform particles and other established

Poster Exhibition

Department of Radiology, University of Occupational and

Environmental Health, JPN
2
Department of Surgery1 University of Occupational and
Environmental Health, JPN

bleeding due to venous rupture is rare. Many IVR therapies for

Department of Radiology, SungKyunKwan University School

of Medicine, KOR

postsurgical chemo-radiation therapy, the gastrointestinal

embolic agents is required.

Key Words: uterine artery embolization .calibrated gelatin
sponge particles.fibroids.uterus.outcomes

387

Poster Exhibition

PE069

PE072

Congenital extrahepatic portosystemic

shunt: Diagnostic imaging strategies
considering therapeutic options

Correlation of pre-operative doppler

identification of perforators of the
anterolateral thigh flap with surgery

The emissary venous drainages from

cavernous sinus: Imaging anatomy and
variations evaluated by contrast-enhanced
MR imaging at 3.0-Tesla

Usefulness of non-enhanced 3D-CT with

partial maximum intensity projection
technique for planning of embolotherapy
for pulmonary AVMs

Shunsuke Nosaka1, Osamu Miyazaki1,

Mandeep Kang1, Puneet Tuli2, Gautam Biswas2,

Shuichi Tanoue1, Hiro Kiyosue1, Junji Kashiwagi1,

Hiroki Higashihara, Keigo Osuga, Noboru Maeda,

Tetsuro Nakazawa, Kaisyu Tanaka,
Masahisa Nakamura, Noriyuki Tomiyama

Seisuke Sakamoto , Hiroyuki Kanazawa ,

Niranjan Khandelwal

Ryuichi Shimada , Kenichiro Tomonari , Rika Tanoue ,

Akinari Fukuda2, Mureo Kasahara2, Hidekazu Masaki1

Hiromu Mori1

Department of Radiology, National Center for Child Health

and Development, JPN
2

Department of Transplant Surgery, National Center for Child

Health and Development, JPN

Introduction: Congenital extrahepatic portosystemic shunt

(CEPS) is an anomaly with diversion of portal venous blood into a
systemic vein. There are two types of CEPS based on the hepatic
portal perfusion either complete shunt (Type I) or partial shunt
with remaining hepatopetal flow (Type II) proposed by Morgan
and Superina. In symptomatic type I shunt, liver transplantation
(LT) might be only curative treatment. Whereas in type II shunt,
surgical or endovascular occlusion is selected. Although modern
imaging techniques provide sufficient information of portosytemic
shunt, definitive evaluation of a small hepatopetal flow is difficult.
Therefore, transcatheter angiography is necessary for preoperative
evaluation.
Our angiography protocol: Transcatheter angiography needs both
arterial and venous approaches. Usually, transarterial portography
is performed with femoral puncture. For venous approach to
introduce balloon occlusion catheter into the draining vein (shunt),
internal jugular vein or femoral vein is selected. Transarterial
portography and portal pressure measurement are performed
without and with balloon occlusion. Balloon occluded direct
portography is performed to evaluate hepatopetal flow.
Purpose: To demonstrate our experience of transcatheter
angiography for CEPS.
Materials and methods: Retrospective analysis of consecutive 10
patients with diagnosis of CEPS. There were five in each of male
and female patients, with mean age of 5-year-old. The factors
analyzed were site of draining vein, site of venous approach,
result of balloon occluded pressure measurement, result of balloon
occluded transarterial and/or direct portography, procedure related
complication, and therapeutic outcomes.
Results: Site of draining vein is inferior vena cave in 5, left renal
vein in 3, and right internal iliac vein in 2. Site of venous approach
is right internal jugular vein in 6, and right femoral vein in 2 and
left femoral vein in 2 patients. Result of balloon occluded pressure
measurement is successful in 5 with pressure ranging from19-29
mmHg, failed in 3 (small sized balloon for shunt diameter) and not
performed in 2. Hepatopetal flow was recognized in 5 of 10 patients
underwent balloon occluded transarterial portography and in 6
of 8 patients underwent balloon occluded direct portography. No
procedure related complication was encountered. At the time of
analysis, 2 patients underwent LT, 4 patients underwent surgical
ligation and 1 patient underwent endovascular coil embolization.
Conclusions: Transcatheter angiography and pressure
measurement with balloon occlusion for the patient with diagnosis
of CEPS is mandate for precise therapeutic planning. We advocate
balloon occluded direct portography and pressure measurement
with appropriate selection of balloon size.

388

Department of Radiodiagnosis and Imaging, Postgraduate

Institute of Medical Education and Research, IND
2

Department of Reconstructive Surgery, Postgraduate

Institute of Medical Education and Research, IND

Department of Radiology, Oita University Faculty of

Medicine, JPN
2
Department of Radiology, Oita Diagnostic Imaging Center,
JPN

Department of Diagnostic and Interventional Radiology,

Osaka University Graduate School of Medicine, JPN

Purpose: Cavernous sinus (CS) is a main dural sinus which

Purpose: CT with contrast material is often used for

based flaps have been found to have advantages over the conventional

plays a role of crossroad with receiving cerebral, meningeal,

preoperative assessment and planning for pulmonary

muscle, musculocutaneous and fascio-cutaneous flaps. Free perforator

and orbital venous blood flow and draining (or which drains)

arteriovenous malformations (PAVMs). However, pulmonary

Background: In the present era of reconstructive surgery, perforator

flaps are mainly used as thin flaps, consisting only of skin and
subcutaneous tissue. The anterolateral thigh (ALT) flap has been
extensively used with considerable versatility. It is supplied by
the perforator(s) arising from the descending branch of the lateral
circumflex artery in its proximal third. The perforator may pass
through the vastus lateralis muscle (musculocutaneous) or in the
intermuscular septum between the rectus femoris and vastus lateralis
(septocutaneous) to supply the skin. The main drawback to the ALT
flap is the variability in the anatomical location of the perforator(s)
which makes accurate pre-operative localization necessary to avoid
inadvertent injury to the vessel during surgery. We undertook this
prospective study (after IRB approval) to correlate the pre-operative

into extracranial venous structures. The venous blood from CS

mainly drains into sigmoid sinus and jugular vein via petrosal
sinuses, meanwhile other several emissary venous drainage
exist through the foramens and canals at the skull base. It
is important to know the normal anatomy and variations of
these emissary veins especially for diagnosis and endovascular
treatment of vascular lesion involving CS and para-CS veins.
In this paper, the imaging anatomy and normal variations of
emissary venous drainages from CS were evaluated on highresolution images at 3.0-Tesla MRI.
Materials and Methods: Twenty-four cases without any lesions

localization of dominant perforators of the ALT flap using color

affecting CS or para-cavernous veins were examined by using

Doppler with the intra-operative findings.

Materials and methods: Patients with various composite tissue

sequences at 3.0-Tesla MRI. Two neuroradiologists evaluated

defects who required a full thickness vascularized tissue transfer

formed the study group (after informed consent). Pre-operative
localization of the perforators was done using colour Doppler with
a multi-frequency linear probe of 7.5-12 MHz. The intermuscular
septum was identified and any vessel piercing the fascia was marked
on the skin. Once the perforator was identified intra-operatively, its
accuracy with respect to the pre-operative marking was checked.
Results: 15 perforator based ALT flaps were lifted in 15 patients
(12 male, 3 female) ranging in age from 13-60 years. Alt flap was
used to reconstruct defects in the head and neck region (n=7), upper
extremity (n=2) and lower extremity (n=6). A total of 42 perforators
were localized by Doppler in 15 patients, ranging in number from 1-6
per patient (average: 2.8). 20 perforators were localized in the supero-

fat-suppressed, contrast-enhanced, 3D fast-gradient-echo

the 56 sides (28 patients) of CS on a viewer with focusing on
the normal anatomy and variations of the emissary venous
drainage routes from CS.
Results: The fat-suppressed 3D fast-gradient-echo MR images
clearly demonstrated the emissary venous structures at
skull base in all cases. The foramen ovale emissary veins and
foramen lacerum emissary veins are depicted in 48 sides (100%).
The foramen spinosum emissary vein (middle meningeal vein)
in contiguity with foramen ovale are depicted in 34 sides (71%),
foramen Vesalius emissary veins are in 10 sides (11%), and
carotid canal venous plexus are in 49 sides (88%). The extraforaminal venous channel from foramen lacerum emissary

lateral quadrant, 18 in infero-lateral quadrant and 1 and 3 perforators

vein draniing into inferior petrosal sinus or contralateral

in the supero-medial and infero-medial quadrants respectively,

foramen lacerum emissary vein could also be identified through

of a 3cm circle drawn around the mid-point of a line joining the

antero-superior iliac spine and supero-lateral border of patella. The
perforators were musculo-cutaneous in 12 (80%) and septo-cutaneous
in 3 patients(20%). Time taken to perform the complete examination
ranged from 45-60 minutes. Perforators localized with color doppler
matched correctly with the intra-operative findings in all 15 pts.
Conclusion: Color Doppler is a non-invasive, highly accurate modality
for the pre-operative localization of perforators supplying the ALT
flap.

petroclival fissues or clivus in 20 sides (36%).

Conclusion: The fat-suppressed 3D fast-gradient-echo image
at 3.0-Tesla is useful for evaluating the emissary venous
structures from CS at skull base. There are several variations
in emissary venous drainages via foramen lacerum and
foramen Vesalius. The venous channels through clivus are
identified in some frequency.

vasculature is well demonstrated in the lung window setting

without need of contrast material, and thus, risks of adverse
effects by contrast material itself or paradoxical emboli through
PAVMs can be avoided. The purpose of this study was to
determine the usefulness of non-enhanced 3D-CT angiography
for planning of embolotherapy for PAVMs.
Materials and Methods: Between February 2004 and October
2011, twenty patients (male: 9, female: 11, mean age: 39.5 y.o.)
with 41 PAVMs underwent non-contrast CT using a multidetector-row CT prior to coil embolotherapy. A high-resolution
tailored 3D-CT angiogram was reconstructed on a workstation
with partial maximum intensity projection (MIP) in the lungwindow to assess the angioarchitecture of the lesions for
preoperative planning of embolotherapy. For each lesion,
location, number, and diameter of feeding arteries and draining
veins were measured. It was determined whether there was
any side-branch close enough to the sac to anchor the first coil
to prevent coil migration. The difference between diameter of
the first coil and the feeding artery was measured. It was also
determined whether the feeding artery was long enough for
the placement of a sufficient number of coils before a major
segmental branch to avoid significant pulmonary infarction.
Based on these findings, diagnostic pulmonary angiography
and coil embolotherapy were performed.
Results: A total of 50 feeding arteries were embolized.
Mean diameter of the feeding arteries and drainage veins
were 3.6mm and 4.6mm, respectively. Sixteen and eighteen
feeding arteries with the side branch to anchor were depicted
on CT and angiography, respectively (16/18:88.9%). Fifteen
feeding arteries were embolized by anchoring the first coil
in the side branch(anchor technique). The mean difference
between diameter of the first coil and the feeding artery was
1.51.47mm. All 41 lesions could be identified on angiography,
and embolization procedures could be executed as planned by
partial MIP images.
Conclusion: Preoperative planning using 3D-CT with noncontrast material is useful for coil embolization of PAVMs.

389

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Poster Exhibition

PE071

PE070

Poster Exhibition

PE073

PE076

Preoperative embolization for distal

pancreatectomy with en bloc celiac axis
resection: Evaluation of development of collateral
blood flow by duplex doppler ultrasonography

Unenhanced MR angiography with time-spatial

labeling inversion pulse for evaluating visceral
artery aneurysms after endosaccular packing
with detachable coils: Preliminary results

Evaluation of caliber and enhancement of

arteries on digital subtraction angiography
using Iopamidol, gadodiamide, and carbon
dioxide: An animal experimental study

Pitfalls during intra-arterial CT-angiography:

SGH experience

Daisuke Abo1, Yusuke Sakuhara1, Yu Hasegawa1,

Miyuki Maruno, Hiro Kiyosue, Shuichi Tanoue,

Sadao Hayashi1, Yasutaka Baba1, Shunichiro Ikeda1,

Kenneth Chye Whatt Yeo, C.G. Padre,

Takeshi Soyama , Tha KinKhin , Megumi Sato ,

3

Norio Hongo, Junji Kashiwagi, Hiromu Mori

4

Mutsumi Nishida , Eiichi Tanaka , Satoshi Hirano ,

Satoshi Terae1, Hiroki Shirato1

Department of Radiology, Oita University Faculty of

Medicine, JPN

Department of Radiology, Hokkaido University School of Medicine, JPN

Department of Radiology, Hokkaido University Hospital, JPN
3
Department of Clinical Laboratory and Tranfusion, Hokkaido
University Hospital, JPN
4
Department of Surgical Oncology, Hokkaido University, JPN
2

Purpose: To evaluate the development of collateral blood flow

after embolization of the common hepatic artery (CHA) and left
gastric artery (GA) in preparation for distal pancreatectomy with
en bloc celiac axis resection (DP-CAR) by using duplex Doppler
ultrasonography (DDU).
Materials and methods: From January 2007 to December 2010, 31
patients underwent preoperative embolization of the CHA and the
left GA in preparation for DP-CAR for locally advanced pancreatic
body cancer. Of these patients, 17 (8 men and 9 women, median age
67 years, age range 53-77 years) underwent DDU before, 1-2 days,
and 5-7 days after embolization, and were included in this study.
The diameter, maximum flow velocity (Vmax) and flow volume

Purpose: To evaluate the ability of three-dimensional MR

angiography with a time-spatial labeling inversion pulse
(Time-SLIP) for assessment of visceral artery aneurysms after
endosaccular packing with detachable coils, compared with
digital subtraction angiography.
Materials and Methods: Eight patients (6 females and 2 males;
mean age, 61.5 years) with visceral artery aneurysms (5 renal
artery aneurysms and 3 splenic artery aneurysms) treated by
endosaccular packing during the periods between February
2008 and March 2011 were studied by three-dimensional MR
angiography with Time-SLIP. Digital subtraction angiography

(FV) of the proper hepatic artery (PHA), gastroduodenal artery

(DSA) was performed in all patients within 5 days before or

(GDA) and right gastroepiploic artery (GEA) were measured, and

after MR angiography. Occlusion rate of the aneurysm was

compared among different time intervals using Friedman test.

Results: No significant change in the diameters of PHA, GDA, and

evaluated by MIP images and source images of Time-SLIP

right GEA, after embolization, was observed.

complete occlusion, neck remnant, and body filling, and was

The median Vmax of PHA, GDA, and Rt. GEA before embolization
were 61.3 cm/sec (range 34.6-178), 67.6 (39.7-144), and 47.6 (6.172.6), respectively. The values 1-2 days after embolization were
53.0 (22.4-80.5), 55.9 (20.6-95.3), and 24.3 (8.2-56.9), respectively.
Those values 5-7 days after embolization were 44.6 (19.4-115),
58.6 (13.3-111) and 22.5 (11.6-78.2), respectively. Compared to preembolization state, significant decrease in Vmax was observed 1-2
days and 5-7days after embolization in all three arteries.
The median FV of PHA, GDA, and right GEA before embolization
were 144 ml/sec (range 40-369), 105 (49-466), 25.5 (14.3-61.1),

MR angiography, which was classified into three categories as

compared with DSA findings as the gold standard.
Results: DSA showed complete occlusion in 4 patients, neck
remnant in two, and body filling in two patients. Occlusion rate
based on Time-SLIP MR angiography highly corresponded with
DSA findings. Time-SLIP MR angiography detected residual
flow in all 4 residual aneurysms, but one aneurysm with dome
filling was underestimated as neck remnant.
Conclusion: Although further experience in larger number
of cases are necessary, this study suggests that unenhanced

respectively. The values 1-2 days after embolization were 167 (24.5-

MR angiography with Time-SLIP is an useful technique for

371), 128 (59-444), and 17.4 (7.2-69.5), respectively. Those values

evaluating visceral artery aneurysms after endosaccular

5-7 days after embolization were 141 (36.9-370), 162 (26.7-530) and
12.1 (0-45), respectively. FV of PHA showed no significant change
after embolization. Compared to pre-embolization state, FV of GDA
significantly increased in 5-7days after embolization. Significant
decrease in FV of right GEA was observed in 1-2 days after
embolization. FV of right GEA continued to decrease in 5-7 days.
Conclusion: The collateral blood flow volume to the liver from
the superior mesenteric artery (SMA) to PHA via the GDA, is
preserved 1-2 days and 5-7 days after embolization. The collateral
blood flow volume to the stomach, from the SMA to the right GA
via the GDA, may increase in 5-7 days after the embolization. We
believe that preoperative embolization is necessary and DP-CAR
should be waited for at least 5-7days after embolization.

390

embolization.

Kouhei Shinmura , Tomoko Ueyama , Eriko Tanimoto ,

S. Ocfemia, A.S. Muthupalani, O.D. Laroco,

Yutaro Kiyao , Masayuki Nakajo

C.K. Ho, S.Y. Wong, H.G. Lo

Department of Radiology, Faculty of Medicine, Kagoshima

University, JPN
2
Department of Radiologic Technology, Faculity of Medicine,
Kagoshima University, JPN

Department of Diagnostic Radiology, Singapore General

Hospital, SGP

Purpose: Iodinated contrast media are currently used in digital

Introduction: The IVR-CT Toshiba Hybrid System was acquired

by the Interventional Radiological Centre (Diagnostic Radiology) of
the Singapore General Hospital in June 2008.The system consists
of the Aquilion 16 MDCT and the Toshiba Infinix VC-1 C-arm
angiographic unit.
Intra-arterial CT Angiography is the acquisition of axial data set
arterial images following the direct injection of contrast media into
the selected artery, via an angiographic catheter.
Purpose: This paper aims to highlight the common errors
encountered during Intra-arterial CT Angiography.
Method: Since 2008, a total of 306 Intra-arterial CT Angiography
(IA-CTA) scans were performed together with conventional Digital
Subtraction Angiography (DSA).
The total case breakdown is as follows: July-December 2008 (n=19),
January-December 2009 (n=106), January-December 2010 (n=111)
and January-June 2011 (n=60).
The imaging parameters used for the IA-CTA acquisitions for each
case performed was recorded in a separate logbook and any pitfalls
or errors encountered during the image acquisition highlighted as a
footnote in each case record.
The team then recalled each acquired study that had a recorded
error and, following image post-processing on the Vitrea postprocessing workstation, noted down and tabulated the resultant
images into a few broadly identified error categories.
These post-processed images were compared with the equivalent
DSA images from the same patient case study, and the results
further refined into more specific error causes.
Successful IA-CTA requires a thorough evaluation and investigation
of the entire imaging process. The use of a post-processing
workstation is therefore critical in helping to assess the reliability
of the acquired CTA images.
Results: Successful intra-arterial CTA provides relevant diagnostic
information as an adjunct to conventional DSA.
As the successful treatment plan of the patients underlying medical
condition sometimes hinges on the results of the diagnostic imaging
study, coupled with the fact that most, if not all, of these studies do
not allow for repeat imaging (as the possibility of systemic contrast
media overload, as well as excessive radiation exposure to the
patient is of utmost concern here), the challenge is thus to get the
imaging protocols and acquisition correct the first time around.
From our study, acquisition protocols, contrast media injection
settings and final catheter positioning were found to be the main
reasons for the failure of obtaining IA-CTA images of adequate
diagnostic value.
Conclusion: IA-CTA pitfalls and errors can only be identified after
completion of image reconstruction and image post processing, and
correlating the results to the referenced conventional DSA images.

subtraction angiography (DSA). However, iodine contarast

allergy prevents its use for DSA. Gadlinium or Carbon dioxide
were used as an alternative contrast agent of DSA in such cases.
The aim of this stuy was to examine the diffecrence in visibility
of renal and celiac arteries and nephrogram on DSA among 3
different contrast agents; iodinated agent (Io), gadolinium (Gd)
and carbon dioxide (CO2) by an animal experimental study.
Materials and Methods: Three swine underwent percutaneous
catheterization and DSA. Celiac and bilateral renal angiograms
with both Io (iopamidol) and Gd (gadodiamide) were obtained
by the same injection dose of a total 8 mL at 4ml/sec for
celiac arteries and a total 6mL at 3 mL/sec for renal arteries,
respectively. DSA with CO2 was performed with manual
injection of 20 mL of CO2. Celiac and bilateral renal angiograms
with the 3 different contrast agents were evaluated using a
commercially available software (Image J: public domain, Javabased image processing program developed at the National
Institutes of Health, USA). The arterial caliber was measured
with a profile curve for each contrast agent made by Image-J.
The enhancement of the arteries or nephrograms was expressed
as the difference between the maximum and minimum density
over the ROI area. Wilcoxon signed-rank test was used to
analyze the arterial caliber, enhancement of the artery and the
nephrogram.
Results: The enhanced arterial calibers of main celiac and
renal arteries were were larger on Io-DSA (9.741.05mm), than
Gd-DSA (9.321.15mm) and CO2-DSA (9.313.43mm) {Io-DSA
vs. Gd-DSA; significant (P=0.028) and Io-DSA vs. CO2-DSA;
not significant (P=0.31)}.The arterial enhancement was also
significantly higher on Io-DSA (41423.3) than Gd-DSA (1437.4)
(P=0.007). The nephrogram was also significantly higher dense
on Io-DSA (11812.8) than Gd-DSA (274.7)(P=0.043).
Conclusion: These results suggest that although Gd and CO2
can be used as an alternative to Io, the difference in image
quality among them should be kept in mind when the caliber
of visceral arteries, enhancement and nephrogram are assessed
for diagnosis and therapeutic intervention.

391

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PE075

PE074

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PE078

PE080

Aberrant branches of the superior

mesenteric artery detected by MDCT
angiography of abdominal aorta

Usefulness of CT during celiacography

using 320-detector row CT before
transcatheter arterial chemoembolization
for hepatocellular carcinoma

Use of Time-Resolved Magnetic Resonance

Angiography for assessment after coil
embolization

Evaluation of peak systolic velocity for

screening of internal carotid artery stenosis

Nantiskarn Chanpen, Kiat Arjhansiri

Takanori Taniguchi, Naoaki Kusunoki, Kensuke Uotani,

Yong Sun Jeon1, Jang Yong Kim2, Soon Gu Cho1,

Radiology, Faculty of Medicine, Chulalongkorn University,

THA

Tsuyoshi Suga, Nobuyuki Mori, Hirotaka Tomimatsu,

Kenichiro Kurosaka, Masashi Shimohira,

Takuya Hashizume, Kengo Ohta, Kazushi Suzuki,
Yuta Shibamoto

Gosuke Okubo, Akiko Kawasaki, Naoto Katayama,

Yusuke Yokota, Yuko Nishimoto, Satoshi Noma

Background: The anatomy of superior mesenteric artery (SMA)

is complicated and has numerous variations. Awareness of

Department of Radiology, Tenri Hospital, JPN

Department of Radiology, Nagoya City University Graduate

School of Medical Sciences, JPN

Purpose: Before transcatheter arterial chemoembolization

Transcatheter coil embolization is performed for treatment

(TACE) for hepatocellular carcinoma (HCC), it is important to

of the aneurysm and the arteriovenous malformation (AVM).

aberrant branches of SMA can result in accurate interpretation

detect tumors using CT during hepatic arteriography (CTHA) and

of disease and vascular involvement, optimal selection of

CT during arterial portography (CTAP). Both are required for the

treatment options or operative planning, and help avoid

iatrogenic injury from surgical and interventional radiological
procedures.
Objective: To determine different aberrant arterial branches
of SMA and their order of frequencies by using MDCT
angiography of the abdominal aorta in order to achieve
accurate diagnostic interpretation and for safety of surgical,
laparoscopic and interventional procedures.
Material and Methods: A total of 199 MDCT angiography of
abdominal aorta or whole aorta studies from 1 January 2007 to
31 December 2009 were retrospectively reviewed by consensus
of two radiologists. Interobserver reliability is obtained using
-statistics. Assessment for the presence of aberrant arterial

correct diagnosis, because CTHA shows some false lesions such as

arterioportal shunts and CTAP does not contain the information
of tumor vascularity, however it is time and effort consuming to
take both CTHA and CTAP. 320-detector row CT (area-detector
CT: ADCT) has prominent advantages for time and space
resolution compared with conventional CT. We can obtain both
CTHA-like imaging and CTAP-like imaging at one examination
with CT during celiacography using ADCT (CTCG), because
CTCG individually scans CTHA-like imaging during early phase
by arterial flow via hepatic artery and CTAP-like imaging during
delayed phase by venous flow via splenic and portal veins. The
purpose of this study is to report the usefulness of CTCG before
TACE for HCC.

After coil embolization, assessment of recanalization is really

important. CT is popular modality for follow-up after coil
embolization. However, there is an artifact problem from coil,
and sometimes it would be difficult to assess recanalization.
To solve this problem, assessment by Magnetic Resonance
Angiography (MRA) was reported in intracranial aneurysms
recently. We have experienced two cases, one was the
pulmonary AVM and the other was the common-internal iliac
artery aneurysm, which could be evaluated the recanalization
by Time-Resolved MRA successfully.
Case1: A 70 year-old female patient who had large pulmonary
AVM underwent coil embolization. After coil embolization,
however her partial pressure of arterial oxygen was still low.
Then, at 2 month later, the Time-Resolved MRA was performed

Method: 120 HCCs before TACE were examined in this study.

and it showed drainer vein clearly. Thus, the recanalization

name of each aberrant arteries of mesenteric circulation were

A half of them were evaluated by CTCG and another half were

was suspected. Then, the angiography was performed and it

evaluated by CTHA and CTAP. CTCG scanned with the following

recorded.

protocol. 50ml of iodinated contrast medium was injected from

showed recanalization. Thus, re-coil embolization was added.

Result: One hundred sixty-three patients (81.8%) have classic

celiac trunk at a rate of 5ml/sec, and five-phase CT scanned with

branches of SMA was performed. The number and specific

normal branches of SMA. Thirty-six patients (18.1%) have

single arterial variant identified, and none has multiple arterial
variant from SMA. Identified aberrant branches of SMA are
replaced right hepatic artery (8.5%), celiacomesenteric trunk
(3.5%), inferior pancreatic artery (2.5%), common hepatic artery
(2%), right gastroepiploic artery (0.5%), splenic artery (0.5%)
and cystic artery (0.5%). Associations of single arterial variant
of SMA with other variation of mesenteric circulation are found
in 7 patients.
Conclusion: Aberrant branches of SMA in Thai people
present in 18.1% of cases. The highest incidence is replaced
right hepatic artery arising from SMA (8.5%). Incidence
and order of frequency are conformed to previous reports in
other nationalities. There is also associated variation of other
mesenteric circulation in 3.5% of cases presented with aberrant

delay times of every 10 seconds after the start of injection to 50

seconds. The first-phase images were like pure CTHA images, and
the fourth- or fifth-phase images enhanced by splenic and portal
venous flow with minimum influence of arterial flow were like
CTAP images. Time-density curve of HCCs and liver parenchyma
obtained by CTCG was compared with the average of the density
of HCCs and liver parenchyma by CTHA and CTAP.
Result: HCCs before TACE were well enhanced on the first-phase
images of CTCG compared with the early-phase images of CTHA.
Liver parenchyma was enhanced same level on the fourth- or
fifth-phase images of CTCG compared with the images of CTAP.
The density of HCCs on the fourth- or fifth-phase images of
CTCG was as same level as the delayed-phase images of CTHA
and is higher than the images of CTAP. But the detectability

the drainer vein was disappeared completely.

Case2: An 80 year-old male patient who had the right
common-internal iliac artery aneurysm underwent coil

Radiology, Inha University School of Medicine, KOR

Department of Vascular Surgery, Inha University, KOR

Background: There has been debates about accuracy of PSV

>125cm/s, which has been used to diagnose >50% internal
carotid artery stenosis(ICAS). This study was conducted to
evaluate accuracy of PSV>125cm/s in diagnosis of ICAS.
Methods: Study subjects were enrolled from screening study
data base, which was done in our hospital from November
2008 to June 2011. The Screening study was conducted to
healthy senior volunteers to screen ICAS. The subject who has
PSV >125cm/s was evaluated by carotid CT scan. The clinical
characteristics were surveyed.
Results: One hundred forty eight subjects were diagnosed with
ICAS using duplex scan from 2000 subjects who underwent
screening tests. Twenty six with 31 lesions underwent carotid
CT scan. There were hypertension in 73%, diabetes mellitus
in 23%, ischemic heart disease in 23%, lipid disorder in 23%,
and smoking history in 69%. 11 lesions showed >50% ICAS
while 20 showed <50% ICAS. The mean PSV was 254.9cm/s for
ICAS >50% in this study. The false positive rate was 65%. The
reasons for the false positive rate were severe angulation of
carotid artery, Doppler angle, presence of distal ICAS and poor
Doppler window.
Conclusion: Peak Systolic Velocity >125cm/s overdiagnoses
ICAS(>50%) in carotid duplex scan.

embolization. After that, follow-up CT was performed every

3 months. Then, at 1 year later, the size of aneurysm seemed
to get bigger by CT. Thus, the Time-Resolved MRA was
performed and it showed vascular flow inside of aneurysm.
Then, the angiography was performed and the vascular flow
inside of aneurysm was described just like the Time-Resolved
MRA. Then, re-coil embolization was performed, and the
vascular flow inside of aneurysm was disappeared.
In conclusion, the Time-Resolved MRA could show vascular
flow almost like angiography. We think it should be useful
especially in case with a severe coil artifact.

of HCC on the fourth- or fifth-phase images of CTCG was not

inferior to that of CTAP, because the density of liver parenchyma

arterial branch from SMA, while none has shown multiple

is significantly higher than the density of HCCs.

aberrant branches from SMA.

Conclusion: CTCG substituted for both CTHA and CTAP, and it

392

After that, the Time-Resolved MRA was performed again, and

Kee Chun Hong2

Poster Exhibition

Poster Exhibition

PE079

provided us with sufficient information before TACE for HCC.

393

Poster Exhibition

PE081

PE082

PE083

PE084

Balloon test occlusion of internal carotid

artery: Angiographic findings correlated
with test result

A case of spinal epidural arteriovenous

fistula with perimedullary venous drainage

Successful management of infected

pseudoaneurysm of the vertebral artery by
coil embolization after controlling the local
inflammation

Transarterial chemoembolization for

recurrent hepatocellular carcinoma after
particle-beam radiotherapy

Kazufumi Kikuchi, Takashi Yoshiura, Akio Hiwatashi,

Satoshi Takahashi1, Takahiro Otani1,

Tomoyuki Asano1, Manabu Hashimoto1,
Taku Sugawara2, Naoki Higashiyama2, Kazuo Mizoi2

Yoshihiro Takada1, Manabu Shirakawa2,

Kenta Izaki1, Shinichi Matsumoto1, Hiroki Kawaguchi1,

Osamu Togao, Koji Yamashita, Hiroshi Honda

Department of Clinical Radiology, Graduate School of
Medical Sciences, Kyushu University, JPN

Department of Radiology, Akita University School of

Medicine, JPN

Department of Neurosurgery, Akita University School of

Medicine, JPN

Yoshie Akahane , Soichi Odawara , Miya Mouri ,

Tomonori Kanda1, Tomohisa Hashimoto1,

Takayuki Katsuura3, Mayuko Yamasaki3,

Yoshitaka Abe1, Shuji Adachi1, Masao Murakami2,

Yoko Igarashi , Yuki Wakata , Kazutaka Uchida ,

Koji Sugimoto3

Shigeyuki Okitsu1, Kumiko Ando3, Yasuhide Suesada1,

Reiichi Ishikura , Norio Arita , Shozo Hirota

1

Department of Radiology, Meiwa Hospital, JPN

Department of Diagnostic Radiology, Hyogo Cancer Center, JPN

Department of Radiology, Hyogo Ion Beam Medical Center, JPN

Center for Endovascular Therapy, Kobe University Hospital, JPN

Department of Neurosurgery, Hyogo College of Medicine,

JPN

Purpose: To correlate the result of balloon test occlusion (BTO)

of internal carotid artery with angiographic findings.
Methods: Cerebral angiograms of 42 patients (M/F = 17/25)
who underwent preoperative BTO were retrospectively
analyzed. During the manual carotid compression on the tested
side, the contralateral internal carotid artery and the vertebral
artery were sequentially injected with a contrast agent.
Visualization of the anterior cerebral artery (ACA) and the
middle cerebral artery (MCA) on the tested side was graded on
a 5-point scale (Grade 0-4), and classified as either poor (Grade
0-2) or good (Grade 3-4). A chi-square test was used to compare
the ACA and MCA visualization and BTO result.
Results: Five patients (12%) were BTO-positive while the
remaining 37 patients (88%) were BTO-negative. The ACA
visualization was poor/good in 3 (60%)/2 (40%) cases among
BTO-positive patients, while it was poor/good in 1 (3%)/36 (97%)
cases among BTO-negative patients. The MCA visualization
was poor/good in 5 (100%)/0 (0%) cases among BTO-positive
patients, while it was poor/good in 4 (11%)/33 (89%) cases
among BTO-negative patients. For both the ACA and the MCA,
a significant association was found between the degree of

Purpose: To present a case of spinal epidural arteriovenous

fistula(AVF) treated by embolotherapy using a NBCA-lipiodol
mixture.
Case repor t: A 66-year-old female presented with muscle
weakness of the lower extremities, gait disturbance and bladder
and rectal disturbance. Sagittal T2-weighted MR images
revealed diffuse hyperintensity of the thoracic-lumbar spinal
cord and serpentine flow voids around the cord. DSA and conebeam CT revealed an angioarchitecture of the AVF between
L4 retrocorporeal anastomosis and the epidural venous plexus
with a reflux into the radicular vein and the perimedullary
veins. Transarterial embolization was performed using a
NBCA-lipiodol mixture, and the reflux into the radicular
vein disappeared. One week after embolization, MRI findings
improved and the patient was able to walk. The bladder and
rectal dysfunction remained.
Conclusion: Spinal epidural AVF shows both MRI and DSA
findings mimicking dural AVF. The cone-beam CT clarifies the
precise angioarchitecture of the AVF including the fistulous
point.

Department of Radiology, Hyogo College of Medicine, JPN

Introduction: Appropriate time to treat the infected

pseudoaneurysm is still unknown. We report a case of infected
pseudo aneurysm of the left vertebral artery. The aneurysm
was successfully treated by coil embolization after the local
inflammation was controlled by antibiotics.
Case report: A 81-years-old man presented with swelling in
left mandible to occipital lesion. Computer tomography (CT)
showed cellulitis in these regions and plan to underwent
medical treatment. After one week of treatment, CT still
showed cellulitis, and CT angiogram (CTA) showed a
pseudoaneurysm of the left vertebral artery. We chose
to control the cellulitis first, and the patient was treated
with antibiotics. After one month of treatment, CT
showed regression of the cellulitis. But CTA showed the
pseudoaneurysm increased in size. We planed to perform coil
embolization to the infected pseudoaneurysm and after four
months, the pseudoaneurysm disappeared on CT.
Conclusion: Depending on the situation, the pseudoaneurysm
was successfully treated using coils after controlling the local

visualization (poor/good) and BTO result (p<0.05, respectively).

inflammation in our case. Close follow up of both inflammation

Conclusion: Our results suggested that poor visualization

and size in infected psuedoaneurysm by CT and CTA was

of ACA or MCA on angiogram during carotid compression is

useful to decide the time to treat the infected pseudoaneurysm.

associated with higher risk of positive BTO result. Conversely,

no BTO-positive case was found among cases with good MCA
visualization. Results of BTO may be predicted by angiographic

394

395

Poster Exhibition

Poster Exhibition

findings.

Purpose: To evaluate the outcome of the transarterial

chemoembolization (TACE) for recurrent hepatocellular
carcinoma (HCC) after particle-beam radiotherapy.
Materials and Methods: From July 2004 to March 2011,
twenty-five patients with HCC received proton or carbon ion
therapy at Hyogo Ion Beam Medical Center referred from our
hospital. Among them, 17 patients subsequently developed local
recurrences detected by dynamic contrast-enhanced CT with or
without tumor marker elevation. Recurrence sites were outside
the clinical target volume (CTV) in 11 patients and within the
CTV in 6. Nineteen TACE procedures as salvage therapy were
performed in 10 patients (7 males and 3 females with a median
age of 74.9 years). Fifteen TACE procedures were performed for
recurrence outside CTV and 4 procedures for within CTV. The
numbers of procedures performed per patient were 1, 2, 3 and
4 in 6, 1, 1 and 2 patients, respectively. The median interval
between the particle-beam radiotherapy and the TACE was 650.5
days (range, 190 - 1261 days). Technical success rates, objective
response rates, complications related to the procedures and
clinical outcome were analyzed. The objective response rates
were evaluated on the CT or MRI more than 1 month after the
procedure using the Response Evaluation Criteria in Cancer of
the Liver (RECICL).
Results: All embolizations were successfully performed, and the
technical success rate was 100% accordingly. The local effects
evaluated as complete response (CR), partial response (PR),
stable disease (SD), and progressive disease (PD) were in 2, 4, 8,
and 5 procedures, respectively. Therefore objective response rate
(CR + PR) was 31.6% (6/19). The CR + PR lesions were less than
two in tumor number or less than 2cm in tumor size. Particularly,
two CR lesions were solitary recurrence within CTV. A major
adverse event, liver abscess, was occurred in one patient. Minor
complications including fever, abdominal discomfort, slightly
elevation of serous bilirubin or transaminase were observed
in all patients. Four patients died 112 - 583 days (median, 259
days) after the embolization due to hepatic failure in 3 patients
and acute coronary syndrome in one. Two patients were shifted
to best supportive care 109 and 296 days after the TACE due to
liver dysfunction. The followed up periods of the remaining four
patients were 25 to 362 days (median, 132.1 days).
Conclusion: In this limited series, TACE may be effective for the
treatment of small and oligo-local recurrences of HCC after the
particle-beam radiotherapy.

Poster Exhibition

PE085

PE086

PE087

The analysis about the short term response

of transcatheter chemoembolization for
unresectable hepatocellular carcinoma with
drug-eluting beads

Transarterial chemoembolization
with additional cisplatin infusion for
hepatocellular carcinoma invading the
hepatic vein

Hepatocellular carcinoma within the Milan

criteria in patients with Child-Pugh class C
disease: Superselective chemoembolization
versus supportive care

Nam-Kyu Chang, Jae-Myeong Jo, Nam-Yeol Yim,

PE088

Initial treatment outcome after transcatheter

arterial chemoembolization via renal
capsular artery for hepatocellular carcinoma

Hyo-Cheol Kim, Seabeom Hur, Seung Moon Joo,

Hyo-Cheol Kim, Seabeom Hur, Seung Moon Joo,

Masaki Ishikawa, Hideaki Kakizawa, Yoshiko Matsubara,

Jae-Kyu Kim

Jin Wook Chung, Jae Hyung Park, Hwan Jun Jae

Jin Wook Chung, Jin Wook Park, Hwan Jun Jae

Hideo Unetani, Hisayuki Kodama, Yoko Kaichi,

Department of Radiology, Chonnam National University

Hwasun Hospital, KOR

Department of Radiology, Seoul National University Hospital,

KOR

Department of Radiology, Seoul National University Hospital,

KOR

Daisuke Komoto, Miho Ishikawa, Keizo Tanitame,

Yuko Nakamura, Chihiro Tani, Yukiko Honda,

Miyuki Takasu, Fuminari Tatsugami, Syuji Date,
Kazuo Awai
Department of Diagnostic Radiology, Hiroshima University,
JPN

Purpose: Transcatheter arterial chemoembolization (TACE)

is widely used to treat HCC who are suitable candidates for
curative treatments. Recently, a drug-eluting bead has been
developed. Some experiences have suggested that DEB offers
superior anticancer activity as compared with conventional
TACE. We wanted to analyze the short term response after
drug-eluting bead therapy in patients with unrectable
hepatocelluar carcinoma and its related factors.
Material and methods: We retrospectively reviewed 37 case
received drug-eluting bead therapy between November 2010
and May 2011. These patients were checked abdominal CT
when treatment after 1 month. 26 patients (21 men, 5 women;
age range, 41-85) were eligible for the study. We retrospectively
reviewed the age, sex, tumoral size, tumoral number, AFP
and several scoring systems (child-Pugh, CLIP, OKUDA and
BCLC score). We analyzed tumoral response according to EASL
criteria.
Result: The rate of objective response was 92% (24 of 26
patients). 13 patients (50%) showed complete response. 11
patients (42%) showed partial response and the others (8%)
showed progressive disease.
Compared with that of the each response groups, tumoral
number (p=0.029), BCLC stage (0.039) and okuda score
(p=0.002) showed significant differences.
Conclusion: After drug-eluting bead therapy, expected better

Decompensated liver cirrhosis (Child-Pugh class C) is one of

PURPOSE: To evaluate initial outcome of transcatheter

contraindication criteria to transarterial chemoembolization

arterial chemoembolization (TACE) via right renal capsular

artery (RCA) for hepatocellular carcinomas (HCCs).

less frequent than portal vein invasion. We evaluated the

(TACE) in patients with hepatocellular carcinoma (HCC). We

clinical effectiveness of transarterial chemoembolization (TACE)

evaluated the safety and clinical outcome of superselective

MATERIALS AND METHODS: Between March 2006 and May

in patients with hepatic vein invasion and compared treatment

TACE in patient with Child-Pugh class C within the Milan

2011 we performed TACE for 11 HCCs fed by right RCA in 8

outcomes between conventional TACE and modified TACE

criteria in a single center. From January 2000 to December

patients (5 men and 3 women). Previous treatments included

(conventional TACE followed by additional cisplatin infusion).

2009, a total of 4,842 patients with HCC were referred to the

partial hepatectomy (n=3), percutaneous ethanol injection

From January 2000 to December 2009, a total of 4,842 patients

angiography unit of our institute for initial TACE according

therapy (n=1), radiofrequency ablation (n=1), and hepatic

with newly diagnosed HCC were treated by TACE according

to our prospectively collected HCC database. We identified 38

arterial infusion chemotherapy (n=1), respectively. The median

to our prospectively collected HCC database. We identified 107

HCC patients with Child-Pugh class C had HCCs within the

number of times of previous TACE was 5.5 (range, 3 to 8).

HCC patients with hepatic vein invasion and Child-Pugh class

Milan criteria at initial TACE. During the same period, 17

Clinical stages evaluated by General Rules for the Clinical

A. Sixty and forty-seven patients received conventional TACE

patients who had Child-Pugh class C disease and HCCs within

and Pathological Study of Primary Liver Cancer in Japan

and modified TACE, respectively. No significant differences

the Milan criteria at initial diagnosis of HCC were treated by

(GRCPS-PLC) were II in 3 patients, III in 4 patients, and IVB

were observed in major complications between the groups. The

supportive care. Superselective TACE at subsegmental hepatic

in 1 patient, respectively. One patient had single lesion and 7

median survival period in the modified group was longer than

artery level was achieved in 35 (92%) of 38 patients who

patients had multiple lesions.

that of the conventional group (9.7 months [95% CI, 4.3-15.1] vs

received TACE. There were no procedure-related deaths within

We performed embolization using 1 or 2-mm-diameter gelatin

6.7 months [95% CI, 4.8-8.5], p = 0.047). By subgroup analysis,

4 weeks after the TACE procedure. The median survival in the

particles, following arterial infusion of suspension of cisplatin

modified TACE markedly increased survival of patients with

TACE group was longer than that in the supportive care group

and iodized oil or emulsion of epirubicin and iodized oil after

a diffuse tumor type (8.9 months [95% CI, 5.9-11.9] vs 3.8

(13.6 months [95% CI, 8.8-18.4] vs 3.0 months [95% CI, 0.0-6.1],

selective catheterization of the right renal capsular artery.

months [95% CI, 2.5-5.0], p = 0.000) and patients without

respectively; P< .001). Treatment with TACE (hazard ratio,

The mean doses of cisplatin and epirubicin were 10 7.6mg

metastasis (20.9 months [95% CI, 12.2-29.5] vs 7.3 months [95%

0.237; 95% CI: 0.111-0.504; P< .001) was independent predictive

and 15mg ; we mixed 10 mg of anticancer agents with 1.0 ml

CI, 4.1-10.5], p = 0.005). Multivariate analysis identified three

factors associated with better overall survival in multivariate

of iodized oil. We evaluated the treatment effect by using a

independent predictive factors for mortality: diffuse tumor type

analysis. In subgroup with high serum bilirubin (>3.0mg.dL),

treatment effect (TE) of the GRCPS-PLC. The median follow-up

(p = 0.001), metastasis (p = 0.009), and modified TACE protocol

the median survival in the TACE group was longer than that

periods was 13.3 months (range, 4.3to 31.0).

(p = 0.003). Conclusion: TACE with additional cisplatin infusion

in the supportive care group (11.0 months [95% CI, 9.0-13.0] vs

RESULTS: The rate of TE1, TE2, TE3, and TE4b in initial TE

demonstrated a survival benefit over conventional TACE in

4.4 months [95% CI, 1.6-7.2], respectively; P=.009). Conclusion:

was 18.2% (2/11), 27.3% (3/11), 18.2% (2/11), and 36.3% (4/11),

patients with HCC invading the hepatic vein and could be

Superselective TACE can treat HCC within the Milan criteria

respectively. Complications related TACE encountered a small

a safe and feasible treatment option for HCC patients with

safely and effectively in patients with Child-Pugh class C

amount of iodized oil accumulation in the upper pole of the

hepatic vein invasion.

disease.

right kidney in 1, liver abscess in 2, vomit/nausea in 2, fever

elevation in 3, and epigastric pain in 1 patient. Five patients
died and 3 patients were alive in the follow-up periods.
CONCLUSION: The initial treatment outcome of TACE via the
RCA would be approximately equal to those of TACE via the
other extrahepatic arteries.

396

397

Poster Exhibition

Poster Exhibition

response in lower tumoral number and earlier stage.

Va s c u l a r i n v a s i o n i s o n e o f t h e c omm o n f ea t u r es o f
hepatocellular carcinoma (HCC); hepatic vein invasion is much

Poster Exhibition

PE089

PE091

Catheter placement via superior mesenteric

artery for hepatic arterial infusion

Masayuki Murata, Katsuyuki Nakanishi

Daisaku Inoue, Yozo Sato, Hidekazu Yamaura,

Takuro Machida, Takashi Meguro, Shoichi Horita,

Sung Wook Shin, Sung Ki Cho, Dongil Choi,

Mina Kato, Takayuki Kurinobu, Takeshi Sato,

Ryoki Fujisawa, Syuji Ikari, Takashi Kato,

Hyunchul Rhim, Kwang Bo Park, Hong Suk Park,

Hisaaki Kato, Yoshitaka Inaba

Hidetoshi Kagaya, Hideaki Nakamura

Sung Wook Choo, Young Soo Do, In-wook Choo

Department of Diagnostic & Interventional Radiology, Aichi

Cancer Center Hospital, JPN

Department of Internal Medicine, Hokkaido Gastroenterology

Hospital, JPN

Department of Radiology, Samsung Medical Center,

Sungkyunkwan University School of Medicine, KOR

Purpose: Hepatic arterial infusion (HAI) chemotherapy with

Purpose: Although various conservative therapies, including

chemotherapy and chemoradiotherapy, have been tried for
patients with surgically unresectable, advanced pancreatic
carcinoma, satisfying efficacy has not been obtained to date.
Recently, several investigators have revealed the effect of a new
approach, Hepatic and Splenic Arterial Infusion Chemotherapy
(HSAIC) accompanied with Transcatheter Peripancreatic
Arterial Embolization (TPPAE) to the disease. We repot here
results of HSCIA with TPPAS to the patients with advanced
pancreatic carcinoma in our hospital and estimate the value of
the new treatment.
Patients and Methods: From May 2003 to October 2011, we
performed HSAIC accompanied with TPPAE for 27 patients
with surgically unresectable, advanced pancreatic cancer (9
Stage4a and 18 Stage4b with metastatic liver tumor). All the
patients were applied to the standard of the committee of ethics
at our institute and gave sufficient informed consents before
the procedure. HSAIC with TPPAE was briefly performed as
follows. A catheter was interventionaly inserted into splenic
artery of patients without liver metastases or into both splenic
and proper hepatic arteries with hepatic lesions to distribute
anti-cancer agents. Continuous infusion of 5-FU (250mg/m2)
through day 1 to 7 and day 14 to 21 with intermittent injection
of Gemcitabine (1000mg/m2) at day 1, 8, and 15 was repeated.
Concurrent radiation therapy (50.4 Gy/28 fr) was done for some
of the patients of Stage IVa without distant metastases. For the
patients with liver metastases, S-1 medication (100mg/m2) was
given from day 1 to 14.
Results: At the end of 2 courses of the therapy, total response
(complete or partial response) rate was 66.7 % (no complete
response, 18 partial responses, 5 stable disease and 4 nonprogressive diseases). Survival in all patients was 6 to 23 months
with median survival of 12.0 months. One year survival rate was
45.9%. The response rate was 77.8 % (7 partial responses) in 9
patients of Stage 4a. Their median survival was 18.0 months. In
18 patients of Stage 4b complicated with liver metastases, these
were 61.1 % (11 partial responses) and 12.0 months, respectively.
Conclusion: In this series, higher response rate and longer
median survival were recognized in patients treated by HSAIC
with TPPAE, compared with conventional chemotherapy. These
results suggest that HSAIC with TPPAE is valuable for patients
with advanced, surgically unresectable pancreas carcinoma in
order to improve their prognosis.

Purpose: Patients with hepatocellular carcinoma (HCC), on

Purpose: The aim of this study was to clarify whether

there is a difference in survival rate and prognostic factor
between transcatheter arterial chemoembolization (TACE)
and hepatectomy for localized hypervascular hepatocellular
carcinoma (HCC).
Materials and methods: Ninety nine consecutive patients with
HCC treated in TACE using angiography and multidetector CT
system or hepatectomy as an initial treatment or a first time
recurrence time treatment from 2001 to 2003 according with
following criteria were enrolled in this study. The criteria were
solitary, hypervascular, and nodular HCC without vascular
invasion. And the maximum diameter was less than 5 cm. The
diagnosis was done using CT arterial portography and CT
hepatic arteriography. TACE was done by conventional methods
using chemotherapeutic agent, Lipiodol, and gelatin sponge
particles. Thirty seven patients and sixty two patients were
treated with TACE and hepatectomy respectively. As a matter of
course, a first choice treatment for localized HCC is hepatectomy
and significantly older patients and patients with poorer liver
function were treated with TACE. Observation period was
until the end of 2010. Cumulative survival rate was calculated
by Kaplan-Meier method and univariate analysis was done in
logrank test about each value. Multivariate analysis was done
by using a Cox proportional-hazards model.
Results: The 1, 3, 5 and 7-year cumulative survival rates
of TACE were 100%, 89%, 62%, and 44%, respectively and
hepatectomy were 95%, 81%, 66%, and 45%, respectively. No
difference was found in cumulative survival rate between
0.0416) and tumor diameter (>= 2.5 cm) (P = 0.0164) in TACE
and tumor diameter (< 2.5 cm) (P = 0.0355) in hepatectomy
were identified as significant prognostic factors by univariate
analysis. Multivariate analysis identified age (< 70 years old),
tumor diameter ((>= 2.5 cm), treatment range (>= segment) and
operator in TACE and tumor diameter (< 2.5 cm) in hepatectomy
as being significantly related to survival.
Conclusion: There is no difference in survival rate and
there are differences in prognostic factor between TACE and
hepatectomy for localized hypervascular HCC.

398

primary and metastatic liver tumors. A indwelling catheter is

usually placed through the celiac artery. However, the catheter
placement via the superior mesenteric artery (SMA) is required
depending on the case. But, it was often refused considering the
occurrence of SMA thrombosis. We evaluated the usefulness and
safety of the catheter placement via SMA retrospectively.
Materials and methods: From April 2000 to March 2011, portcatheter placements for HAI were performed in 772 cases at
our institute. Catheter placement via SMA was required in
22 patients, metastatic liver cancer in 21 (primary site; colon /
stomach /esophagus /hypopharynx 15 /4 /1 /1) and primary liver
cancer in 1.
Method for catheter placement corresponding to arterial
anatomy, technical success rate, complications including vessel
obstruction were investigated.
Results: There were 3 types of method for catheter placement
corresponding to arterial anatomy: (a) a catheter was placed in
a replaced right hepatic artery (RHA) arising from SMA (n=11);
(b) a catheter was placed through a pancreatic arterial arcade
via SMA (n=9); (c) a catheter was placed through a celiac artery
formed a common trunk with SMA (celiacomesenteric type)
(n=2). In case with type (a) method, all case had a blood flow
from replaced RHA to the tumor with predominance of right
lobe. The celiac artery or common hepatic artery was obstructed
in the certain past history in case with type (b).
All port-catheter placements were accomplished and could be
used for chemotherapy, therefore, the technical success rate was
100%.
Duration of port-catheter use ranged from 13 to 616 days (median
170 days). Arterial occlusion occurred in two cases (9%) 29 and
84 days after placement. Both of the cases were categorized into
type (b). In one case, the obstruction could be recanalized by
using urokinase and HAI was able to be resumed.
There were no major complications including SMA thrombosis.
Conclusion: Catheter placement via SMA is technically
available procedure and acceptable for clinical use with
sufficient safety.

Transarterial chemoembolization for very early

and early stage hepatocellular carcinomas
infeasible for radiofrequency ablation: Longterm outcomes and factors affecting survival

which it is not feasible to perform radiofrequency ablation

(RFA), often resort to transarterial chemoembolization (TACE).
The aim of this study is to analyze the long-term outcomes and
factors contributing to survival after TACE of very early and
early stage HCC infeasible for RFA.
Materials and Methods: From October 2006 through October
2009, 69 patients with very early or early-stage HCCs
infeasible for RFA underwent TACE. The most frequent reason
for the infeasibility of RFA was tumor inconspicuity. Tumor
response according to the amended RECIST criteria and tumor
progression patterns were evaluated. Long-term survival rates
were calculated by the Kaplan-Meier method, and the factors
contributing to survival were determined by univariate and
multivariate analyses.
Results: At 6-month and 1-year follow-ups, tumor response
rates were 17.4% and 28.9%, respectively. The most common
tumor progression pattern was local tumor progression at
target tumor sites. The 1-, 3-, and 5-year overall survival rates
were 88.1%, 60.5%, and 48.8%, respectively. The 1-, 3-, and
5-year progression-free survival rates were 52.5%, 30.0%, and
14.5%, respectively. Child-Pugh class was the independent risk
factor for mortality. Child-Pugh class, best overall response,
and tumor progression pattern were predictive factors for
progression-free survival.
Conclusion: TACE is an effective first-line treatment of
HCC infeasible for RFA, especially when liver function was
preserved.

Poster Exhibition

TACE and hepatectomy (P = 0.7661). Age (< 70 years old) (P =

port-catheter system has been accepted as a treatment for

Value of arterial infusion chemotherapy

for patients with unresectable, advanced
pancreatic carcinoma

PE092

Transcatheter arterial chemoembolization

for localized hypervascular hepatocellular
carcinoma using angiography and multidetector
CT system: Comparison with hepatectomy
Department of Diagnostic Radiology, Osaka Medical Center
for Cancer and Cardiovascular Diseases, JPN

Poster Exhibition

PE090

399

Poster Exhibition

PE093

PE095

PE096

The effect of a lidocaine injections

into the hepatic artery for reducing
abdominal pain after transcatheter arterial
chemoembolization (TACE)

Development of a double lumen balloon

microcatheter with a side hole for
intraarterial infusion chemotherapy and/or
embolization

Anti-tumor effect of the slow infusion of

miriplatin-lipiodol suspension by using an
automatic injector

Retrospective analysis of feasible and technical

aspects of transarterial chemo-embolization for
non-resectable hepatocellular carcinoma using
3 french catheter system

Min Kyu Kim, Hye In Kim, Jei Hoon Yoo, Sung Ho Kang,

Masamichi Koganemaru, Toshi Abe, Norimitsu Tanaka,

Yuki Tomozawa, Shinichi Ohta, Shobu Watanabe,

Jae Sik Lim, Sung Il Park, Jong Yoon Won

Masaaki Nonoshita, Ryoji Iwamoto, Masashi Kusumoto,

Akinaga Sonoda, Shuji Otani, Keiko Tsuchiya,

Department of Radiology, Yonsei University Health System,

KOR

Naofumi Hayabuchi

Norihisa Nitta, Masashi Takahashi, Kiyoshi Murata

Department of Radiology, Kurume University School of

Medicine, JPN

Department of Radiology, Shiga University of Medical

Science, JPN

Kazutoshi Kamiyama1, Masakatu Turusaki1,

Mitsunari Maruyama1, Hiroshi Mori1, Shinji Andou1,
Megumi Nakamura1, Takeshi Yoshizako1,
Hajime Kitagaki1, Naruhito Okada2

Purpose: To introduce a newly developed double lumen balloon

PURPOSE: Miriplatin hydrate (miriplatin), a fat-soluble

hepatic artery for reducing abdominal pain after transcatheter

microcatheter with a side hole for intraarterial infusion

platinum complex, has the capability of being suspended in

arterial chemoembolization.

chemotherapy and/or embolization. Here we describe the

lipiodol. Although it is often considered for intra-arterial,

Methods and Materials: From May to August 2011, 62 patients

feasibility and clinical efficacy of this new technique.

manual infusion, the high viscosity of suspended miriplatin-

(M:F=39:23, 44-76 years) who received TACE (transcatheter

Materials and Methods: In seven patients with malignant

lipiodol inhibits its flow in peripheries of tumors. In this

arterial chemoembolization; chemoagent + lipiodol + gelform).

tumors underwent intraarterial infusion chemotherapy with

study, we evaluated the anti-tumor effect of slow infusion of

or TACI (transcatheter arterial chemoinfusion; chemoagent

this balloon microcatheter, as superselective catheterization

miriplatin-lipiodol suspension by using an automatic injector.

was considered difficult or failed. The balloon was placed on

METHODS: Nine rabbits were randomly assigned to three

the distal side of the site where the target artery branched,

equal groups 2 weeks after of VX2 tumor transplantation to the

an occlusion device was subsequently advanced to occlude

liver. We prepared a suspension of miriplatin in lipiodol (0.1ml/

the tip of the main lumen without occlude the side hole. After

kg) at concentration of 20mg/mL. We then performed intra-

inflation of the balloon, the contrast material and/or anti-cancer

arterial infusion on the three groups in the according ways;

drugs would be able to infuse to the target artery with distal

slow infusion group using an automatic injector, a conventional

protection by the balloon.

infusion group, and a saline control group. In the slow infusion

Results: Successful intraarterial infusion chemotherapy and/

group, the miriplatin-lipiodol suspension was connected to an

or embolization was performed in all patients using the double

adjustable injector and was slowly infused with a set rate at

lumen balloon microcatheter. There is no complication with this

0.02mL per minute. In the conventional infusion group, the

technique.

suspension was delivered by a manual infusion, taking care

Conclusion: Our findings suggest that this technique is useful

to avoid prevent reflux. The tumor growth rate was calculated

for effective chemotherapy and/or embolization in cases where

among three therapeutic groups on the basis of 0.5Tesla

superselective catheterization of target arteries is difficult.

magnetic resonance imaging, and the platinum concentration

Purpose: To evaluate the effect of a lidocaine injection into the

+ lipiodol) were included. For reducing pain, 21 patients only

received intravenous (IV) narcotic analgesics during TACI or
TACE (Group A). 22 patients received IV narcotic analgesics
and lidocaine injection through the hepatic artery after TACI
(Group B; TACILidocaine inj). 19 patients received IV
narcotic analgesics and were injected with lidocaine before
TACE (Group C; TACILidocaine inj.Gelform embo.). We
measured the degree of pain complained by each patient using
NPIS (Numerical Pain Intensity Scale) and compared using
a statistical soft ware (SPSS, Chicago III, 95% confidence
interval).
Results: Patients who were injected with lidocaine into the
hepatic artery during TACI or TACE felt less pain and used less
narcotic analgesics than patients who only received narcotic
analgesics. We also found that patients who were injected with
lidocaine before TACE felt less pain than patients who were
injected with lidocaine during TACI did.
The average of pain after TACE was as follows ; A group 6, B
group 3.5. Group C 2.5 by NPIS.
Abdominal pain missing time was also as follows; A group 72
hours, B group 36 hours, C group 12 hours.
The narcotic analgesic drugs were administered after TACE
during hospitalization, A group was injected 6 times, B group
was injected 3.5 times, C group was 1.5 times
The severity of pain is significantly different between
Group A and B during all periods, except 4hours(p=0.218),
12hours(p=0.77) and 36hours(p=0.728). The severity of pain in
Group C (p=0.00) is weaker than that of Group A,B reaching
statistically significance.
Conclusion: Lidocaine injections into the hepatic artery before

in the surrounding normal liver tissue and in the tumors was

measured one week after intra-arterial infusion.
RESULTS: Among the three groups, the tumor growth rate
tended to be lower in the slow infusion group. The tumor
platinum concentration in the slow infusion group tended to
be higher than that of the conventional infusion group. On
the other hand, the normal tissue platinum concentration
tended to be lower in the slow infusion group. Moreover, in
the slow infusion group, the tumor platinum concentration
was significantly higher than the normal tissue platinum
concentration.
CONCLUSION: We suggest that the slow infusion of
miriplatin-lipiodol suspension may be more effective and exert
less influence on liver function.

Department of Radiology, Shimane University School of

Medicine, JPN
2
Department of Radiology, Ohda Municipal Hospital, JPN

Purpose: The purpose of this study was to evaluate feasibility

and technical aspect of transarterial chemo-embolization
(TACE) for non-resectable hepatocellular carcinoma (HCC)
using 3 french (Fr.) catheter system that might be less invasive
than over 4 Fr. system for the patient.
Method: From April 2009 to October 2011, total 328 patients
with HCCs were performed TACE procedure using both
3Fr. catheter system (S-ONE sheath and FANSAC catheter;
Terumo-Clinical supply, Gifu, Japan) and micro-catheter fitted
to 3Fr. system.
First, we assess the catheter selectivity to reach the target
arteries classification with proper hepatic artery (PHA), main
hepatic branch (ex. RHA and/ or LHA), segmental artery, and
subsegmental or sub-subsegmental artery. The feasibility is
calculated the rates by these methods: (1) numbers of artery
that we could reach the target artery/ total procedures using
3Fr. system, and (2) the rate that we could successfully
accomplish the procedures without changing over 4Fr. system,
and (3) the reasons why changing over 4Fr. system.
Result: We experience 323 cases and perform TACE/TAI
All patients with HCC were performed TACE from PHA(27
patients), RHA/LHA (103 patients) , segmental (31 patients) ,
and subsegmental / sub-subsegmental arteries (162 patients) .
(1) the rate that we could reach the target artery using 3Fr.
system was 93%. We could not reach the target arteries in 22
patients including 11/ 8/ 3 patients from sub-subsengmental,
subsegmental arteries, and RHA / LHA, respectively.
We changed over 4Fr. system in 5 patients, therefore, (2) the
rate that we could successfully accomplish the procedures
without changing over 4Fr. System was 98 %. The reasons
why changing over 4Fr. system were included 5 patients with
hematomas and 1 patients with severe atherosclerosis.
Conclusion: There were a few difficult patients to perform
TACE using 3Fr. system, however, it might be feasible that
most of patients with HCC were successfully performed TACE
from target arteries using 3Fr. system.

TACE or TACI is a useful method for reducing abdominal pain

of patients. It can also reduce the total amount of narcotic
analgesics and adverse effects related to them.

400

401

Poster Exhibition

Poster Exhibition

PE094

Poster Exhibition

PE097

A case of transarterial embolization for the

intraoral bleeding from recurrence of lingual
cancer

PE098

A case of hemangiopericytoma liver

metastases treated by bland embolization
using noble embolic microsphere Beads

Nao Kikkawa1, Satomi Senoo2, Hiroshi Ootsuru3

1

Department of Radiology, National Hospital Organization

Tokyo Medical Center, JPN

A case of hepatic angiomyolipoma with

subcapsular hemorrhage
Tatsuhiko Iishi1, Kenichi Oomae1, Seiichirou Norikane1,

Kazuhito Toya1, Yoshinori Isobe1, Kazuki Hashimoto1,

Kazuyo Suzuki1, Kazuyo Kita1, Hideki Kaneko1,

PE099

PE100

CT findings of recurrent hepatocellular

carcinoma following transarterial
chemoembolization using Miriplatinsuspension

Emima Bekku, Takeshi Aramaki, Michihisa Moriguchi,

Kouiku Asakura, Akihiro Sawada, Masahiro Endo

Bon Shouji2, Hideki Aoki3, Rie Yamasaki4,

Division of Diagnostic Radiology, Shizuoka Cancer Center,

JPN

Rena Nagashima1, Hiroshi Miura2, Takeshi Hashimoto3,

Takuya Hara3, Jun Koizumi3, Makoto Ootaki1,
Norihito Watanabe4

Department of Emergency Medicine National Hospital

Organization Tokyo Medical Center, JPN

Takeshi Ogata5, Susumu Kanazawa5

Department of Radiology, Iwakuni clinical center, JPN

Department of Internal Medicine, Iwakuni clinical center,

JPN
3

Department of Surgery, Iwakuni clinical center, JPN

Medicine, JPN

Department of Pathology, Iwakuni clinical center, JPN

Department of Oral and Maxillofacial Surgery National

Hospital Organization Tokyo Medical Center, JPN

Department of Radiology, Tokai University Hachioji Hospital,

JPN
2
Department of Radiology, Hino Municipal Hospital, JPN

Department of Radiology, Okayama University, JPN

Department of Diagnostic Radiology, Tokai University of

Case: A 50-year-old man.

Purpose: Intracranial malignant hemangiopericytomas

Hepatic angiomyolipoma (AML) is a rare hepatic mesenchymal

Chief complaint: Intraoral bleeding.

(MHP) are uncommon, and there are few case reports on the

tumor. We report a case of hepatic AML with subcapsular

Progress: Patient felt the pain for the lower right of the

treatment of the multiple liver metastases. Here we report

hemorrhage.

tongue, consulted nearby medical facilities, and had the ulcer

on a case of multiple liver metastases from intracranial

The patient was a 70-year-old woman, complaining of right

of a tongue pointed out. Our hospital was introduced to him.

MHP treated with bland embolization using noble embolic

lower back pain.

In response to the biopsy, he was diagnosed as a lingual cancer

microsphere called Beads.

Late in December 2010, after the table tennis during the

and received the operation. He had metastases in the right

Materials and method: A 70-year-old woman had received the

day, went to hot springs, and then drove herself home. After

cervical lymph node. So he received a systemic chemotherapy

intracranial tumor resection for MHP. Thirty-four months

returning home, the right lower back pain occured suddenly,

and irradiation, but cancer recurred to the cervix and the

after surgery, multiple hypervascular liver metastases were

and she was transported by ambulance to our hospital.

axilla. Although his axillary metastasis was controlled by

revealed. Because the multiple metastases were occurred in

CT scan showed a 9cm tumor on the right hepatic lobe with

subsequent medical treatment, since the cervical recurrence

bilobar, we conducted to treat them with TAE.

extravasation of the contrast agent imaging and subcapsular

increased, the transarterial infusion of cisplatin was planned.

We performed the TAE using; firstly gelatin sponges (Gelpart)

hematoma. The tumor had no typical findings of hepatocellular

Since the bleeding from a tumor to into the mouth was

alone, secondary gelatin sponges (Gelpart) and iodized oil, and

carcinoma (HCC), and we suspected AML, because of low-

increasing and extravasation was revealed by angiography,

thirdly hand-crashed gelatin sponges (Spongel) and iodized oil.

density area was found inside it which was considered fat

the transarterial embolization (TAE) was performed and it

Every 1 month after TAE, enhanced CT was performed. The

component.

succeeded in the arrest of hemorrhage. The transarterial

tumor size was slightly increased and the vascularity of the

Transcatheter arterial embolization (TAE) was performed for

infusion of cisplatin was succeedingly made by the TAE. His

tumor was not changed. Therefore we decided to perform the

gelatin sponge particles from A7, 8.

intraoral bleeding settled down and, also in the palpation top,

next TAE with Embozene microsophere.

After TAE, the tumor reduced markedly, but considering

the tumor became soft. However, he died from advance of a

Results: TAE was performed using 100m and 75m of

the possibility of malignancy precaution, and prevention of

tumor about one month after TAE.

Embozene microsophere. After this TAE, many liver tumors

rebleeding, the resection of right hepatic lobe was performed.

Conclusion: We experienced useful TAE which suppresses

lost the vascularity and the tumor progression was suppressed.

The tumor was diagnosed AML with histopathological

intraoral bleeding from recurrence of the lingual cancer.

Conclusion: This case suggests the bland embolization

diagnosis, because of the component showed a mixture

using noble microsphere beads is possibly useful for the

of foamy cells and fat cells and blood vessels, and in the

hypervascular liver tumor for the intractable case of usual

immunostaining, showed HMB-45 (+), S-100 (-), respectively.

TAE.

One month after surgery, she was discharged in good passage.

Department of Gastroenterology, Tokai University Hachioji

Hospital, JPN

P u r p o s e : We r e p o r t C T f i n d i n g s o f r e c u r r e n t
hepatocellular carcinoma(HCC) following transarterial
chemoembolization(TACE) using Miriplatin-suspension that
are reflected particular distribution of Miriplatin-suspension.
Method: Between May 2012 and September 2012, 30 patients
with HCC were treated with TACE using Miriplatin-suspension.
There were 17 men and 13 women that and mean patient age
was 72 years (range, 53-84). All patients had liver cirrhosis.
This was related to hepatitis C in twenty-three patients, and
to hepatitis B in one patient; Four patients are alcoholic liver
cirrhosis, two patients are non-alcoholic steatohepatitis(NASH).
Lipiodol-CT(LpCT) was performed 1 week after the procedure
in all patients to determine the distribution of the iodized oil
suspension. We evaluated CT, magnetic resonance image(MRI)
and angiography of these cases.
Result: Recurrence of 23 nodules confirmed by CT and/
or MRI. The period to the recurrence were 1-5.5 months,
mean 3 months. In the two recurrence which are adjacent to
hypoattenuating area of the suspension, Miriplatin-suspension
are stagnant in the feeding artery mold-shaped evaluated by
angiography and/or CT. In the other two locally progressed
in the hypovascular portion HCC or surrounding after the
therapy, accumulation of Miriplatin-suspension in portal
venules directly entered or connected the tumor.
Conclusion: By the study before release, it was proved that

Poster Exhibition

Miriplatin-suspension in the border area between normal

parenchyma and tumor. However, these our cases suggests that
the therapy can be proximal embolization due to distribution
of Miriplaitin-suspension in the interlobular artery for long
time, or that it can make portal blood supply to the tumor after
TACE due to phagocytosis of Miriplaitin-suspension.

402

403

Poster Exhibition

Miriplaitin-suspension was distributed in the interlobular

artery in a month and that like macrophage cells phagocytize

Poster Exhibition

PE101

PE102

Transcatheter treatments for hepatocellular

carcinoma in cardiac cirrhosis associated
with congenital heart disease: Three case
reports

Retrograde subintimal angioplasty via

popliteal artery in long CTO of SFA

PE103

PE104

Endovascular management of recurrent

acute thromboembolism after surgical
revascularization: How we do it

Endovascular management of iliac

artery aneurysms with stent-grafts and
embolization coils
Emi Shindo, Hiroshi Kawamata, Takahiro Mine,

Young Kwon Cho, Kim Yun Jung, Choi Yun Sun,

Nam Yeol Yim, Jae Kyu Kim, Byeong Chan Lee,

Kentaro Kishimoto , Hiroki Higashihara , Noboru Maeda ,

Woo Jeong Joo, Kim Hyun Sook

Hyeong Wook Kim, Jang Hyeon Song, Nam Kyu Chang,

Kazuhiro Furukawa, Fukiko Morita, Susumu Okada,

Noriyuki Tomiyama1, Masanori Miyazaki2, Hiroki Kondo3,

Department of Interventional Radiology, Eulji Medical Center,

Eulji University, KOR

Hye Doo Jung

Ryuzo Bessho

Department of Diagnostic Radiology, Chonnam National

University Hospital, KOR

Department of Radiology, Nippon Medical School ChibaHokusoh Hospital, JPN

In nowadays, endovascular management is regarded as

Purpose: To assess the efficacy, safety and mid-term outcome

Masahisa Nakamura1, Keigo Osuga1, Kaisyu Tanaka1,

1

Shuichiro Uehara4
1

Department of Radiology, Osaka University Graduate

School of Medicine, JPN
2

Department of Gastroenterology and Hepatology, Osaka

University, JPN
3

Department of Pediatrics, Osaka University, JPN

Department of Pediatric Surgery, Osaka University, JPN

We introduce and demonstrate the practical tips and barriers

of the retrograde subintimal angioplasty via popliteal artery

Purpose: Along with prolongation of the patient survival of

complicated congenital cardiac disease, long-term complications
such as cardiac cirrhosis due to chronic liver congestion have
been increased. Herein, we report three cases of hepatocellular
carcinoma (HCC) in cardiac cirrhosis treated by transcatheter
chemoembolization (TACE) or infusion chemotherapy (TAI).
Method: Case 1: A 31-year-old man underwent interventricular
septoplasty for single left ventricle at the age of one. He
presented with multiple HCCs with thrombosis of the left
branch of portal vein (Stage3B, Child-Pugh score 7/B), and
received TAI using cisplatin twice. Case 2: A 14-year-old man
underwent Fontan surgery for single right ventricle at the age
of one. He presented with a solitary HCC with thrombosis of
the subsegmental branch of portal vein (Stage2, Child-Pugh
score 5/A), and received subsegmental TACE using epirubicin
lipiodol mixture. Case 3: A 19-year-old woman underwent
Fontan surgery for single right ventricle at the age of two. She
presented with two HCCs in both lobes (Stage2, Child-Pugh
score 9/B), and received subsegmental TACE using epirubicin
lipiodol mixture.
Results: According to the modified RECIST, tumor response
was judged as stable disease, complete response, and complete
response in Case 1, 2, and 3, respectively. According to

approach for the chronic total occlusion (CTO) of superficial

femoral artery (SFA) on 11 limb of 9 patietns and analysis the
variable factors that influence on the success rate and longterm patency of vascular lumen after retrograde subintimal
angioplasty via popliteal artery approach. The inclusion criteria
are 1. Critical limb ischemia on ipsilateral leg, 2. Complete
occlusion of SFA from OS, 3. Shape of the stump: blunted and
calcified occlusion, 4. Relatively intact ipsilateral popliteal and
infrapopliteal run-off vessels, 5. Failed antegrade subintimal
guidewire passage through short stump of os of SFA via
contralateral approach. The results are successful in 8 limbs
and failure in 3 limbs. The factors of failure are 1. Acute Instent
Re-thrombosis after long SFA stent, 2. Failed Reentry via
Popliteal artery approach, 3. Acute Instent Thrombosis after
Manual hemostasis of punctured Ipsilateral Popliteal artery.
The conclusions are 1.Retrograde subintimal angioplasty via
popliteal artery approach seems to be safe and effective way in
case of failure with antegrade subintimal guidewire passage,
2.The adequate reentry and the proper position of stent

first line treatment option for peripheral arterial occlusive

disease (PAOD), such as atherosclerosis or thromboembolism.
However, in patients who have long and complex lesion, we
should consider surgery as well. Surgical treatment for PAOD
including the Fogarty thromboembolectomy and bypass
graft using prosthesis or autogenous vein. Unfortunately,
some patients, who have surgery for PAOD, experience
recurrent thromboembolism after successful operation. For
these patients, re-operation may not be easy, because usually
physical status is insufficient to endure repetitive surgery.
In such instance, endovascular management using catheter
directed thrombolysis, balloon catheter, and stent could be
one of good treatment method. However, this procedure may
be challenging, because usually, the lesion is longer and the
vascular anatomy has been changed.
In this presentation, we will present (A) basic information
about various surgical methods, and (B) show some cases
which show post-operative recurrent acute thromboembolism

of endovascular management of iliac artery aneurysms (IAAs).

Methods and materials: Six patients (4 male, 2 female; age,
67-83 years) with 9 IAAs underwent endovascular repair
between February 2004 and July 2011. The treatment methods
differed depending on the anatomic locations of the aneurysms.
Iliac stent-grafts with internal iliac coil embolization for 6
aneurysms, bifurcated aortic stent-grafts with internal iliac
coil embolization for 2 aneurysms, and internal iliac coil
embolization alone for 1 aneurysm were performed. Homemade stent-grafts were used for four of eight aneurysms. The
results were analyzed retrospectively.
Results: The procedural technical success was 100%. There
were no serious complications. Isolation of aneurysms was
achieved in all cases. No reintervention was necessary. No
endoleak and no enlargement of aneurysms was seen during a
mean follow-up of 36 months (range 3months to7years).
Conclusion: Endovascular management of IAAs is safe and
feasible with the acceptable mid-term results.

and technical tips for endovascular management.

implantation are important to preserve the long-term luminal

patency, 3.Acute instent re-thrombosis could be managed by
using true lumen reentry device with additional proximal stent
insertion and angioplasty.

CTCAE v4.0, there were Grade 3 adverse effects including

hyperbilirubinemia (Case 2, 3).

Poster Exhibition

Poster Exhibition

heart failure (Case 1, 3), thrombocytopenia (Case 2, 3), and

Conclusions: Transcatheter treatments may have a palliative
role to control HCC in cardiac cirrhosis associated with
congenital heart disease. However, intensive periprocedural
management is necessary in patients with poor general
condition, as major adverse effects likely to occur.

404

405

Poster Exhibition

PE105

PE106

PE107

Short and mid-term results of endovascular

treatment for isolated iliac artery aneurysms

Successful percutaneous transluminal

angioplasty for web shaped iliac and
femoral artery stenosis

Recanalization of native artery in cases

with limb-threatening ischemia by occluded
bypass graft

Use of reversed iliac leg stent graft for the

treatment of isolated aneurysm of internal
iliac artery: A case report

Hiroki Nagayama1, Ichiro Sakamoto1, Akifumi Nishida1,

Seo Jae-Bin1, Myeong-Ki Seo1, Jae-Seong Choi2

Byeong-Ho Park1, Min-Kyoung Park1, Gyoo-sik Jung2

Kyung Sup Song1, Hyunsil Lee1, Kang Hoon Lee1,

Sang-Seob Yun2

Hideyuki Hayashi , Eijun Sueyoshi , Masataka Uetani ,

Kouji Hashizume , Kiyoyuki Eishi

Department of Internal Medicine, Boramae Medical Center,

KOR

Department of Radiology, Nagasaki University Hospital,

JPN

Interventional Radiology, Dong-A University Hospital, KOR

Department of Radiology, Kosin Medical School, KOR

Department of Cardiothoracic Surgery, Boramae Medical

Center, KOR

treatment for isolated iliac artery aneurysms (IAAs).

Materials and Methods: Between March 1998 and March
2011, 53 patients (12 women and 41 men; mean age 76.4 years)
underwent endovascular repair for isolated IAAs. General and
local anesthesia was used in 17 and 36 patients, respectively.
IAAs includes true aneurysms in 41 patients and false in 12
patients. 22 common iliac artery aneurysms (CIAAs) were
treated with proximal embolization of the internal iliac artery
(IIA) and bifurcated or tubular stent-grafting. The remaining
one IAA was treated with proximal embolization of the IIA,
aorto-uni-iliac stent-graft (SG), and F-F bypass. Eight internal
iliac artery aneurysms (IIAAs) were treated with proximal and
distal embolization of the IIAA, or coil packing and proximal
embolization of the IIAA. Nine IIAAs were treated with distal
embolization of the IIAA and bifurcated or tubular stentgrafting. Nine para-anastomotic aneurysms after surgical
AAA repair with a bifurcated graft (end-to-end anastomosis in
common iliac arteries) were treated with proximal embolization
of the IIA and tubular stent-grafting. Three para-anastomotic
aneurysms of the common iliac artery after surgical AAA repair
(common iliac artery ligation and end-to-side anastomosis in
external iliac or femoral arteries) were treated with proximal
and distal embolization of the aneurysm. The SGs that were
used included 11 custom-made and 31 commercially available
devices.
Results: Patients were followed up for a mean of 23.6 months
(range, 3 to 87). Technical success is 98%: Insertion of an
introducer device was unsuccessful due to narrow access route
in one patient. There was no 30-day mortality. There was no
period after endovascular repair. Type I endoleak was noted
in three of five patients with ruptured aneurysms. Severe
stenosis of distal SG was noted in one patient. Additional
intervention was performed in all of the four patients. Three
patients developed persistent buttock claudication. There were
no significant differences among CIAA, IIAA, and AAA repairrelated aneurysm groups in the changes of aneurysm diameter

Target Lesion: A 77-year-old woman visited our hospital

Occlusion of bypass grafts usually results in a recrudescence

Purpose: To report the technique of endovascular treatment

complaining of right leg claudication. She had the history

of ischemic symptoms ranging from claudication to limb-

using reversed iliac leg stent graft in the case of isolated

of myocardial infarction treated by percutaneous coronary

threatening ischemia. Previous reviews noted that those

aneurysm of internal iliac artery because of significant size

intervention which showed us 3 vessel disease. However, she

patients have higher incidence of major amputation as the

discrepancy between the common iliac artery and the external

did not have the history of diabetes and hypertension. Also,

next intervention after failure of vascular reconstruction. To

iliac artery.

she was not a smoker. The claudicating symptom developed

avoid this serious complication, an aggressive and effective

Method: Patient was an 85 year old man presenting

since 1 year ago. The ABI test revealed 0.64 for right leg, which

management regimen would be needed. However the available

asymptomatic growing aneurysm sized 6.5 x 6.2 cm at the right

corresponded to the right leg pain. The lower extremity CT

therapeutic options may not be enough to rescue the ischemic

proximal internal iliac artery. This aneurysm was fusiform and

scan demonstrated the findings as follow; 1) atherosclerotic

limb, and have offered suboptimal results. Restoration of

it originated from the origin of right internal iliac artery with

change of the aorta 2) about 75% stenosis with mural ulcer,

occluded bypass grafts with either thrombectomy or balloon

very short and wide neck. There was significant difference in

lower abdominal aorta 3) about 75% stenosis with mural ulcer,

angioplasty with or without stent has proved difficult.

diameter from the right common iliac artery (20.9 mm) to the

right CIA 4) diffuse more than 95% stenosis, right EIA 5) about

Sometimes it may be the best therapeutic option that is the

right external iliac artery (10.5 mm).

75% stenosis, right CFA 6) hypoplastic both PTA. Thereafter,

replacement of the failed graft with an entirely new bypass.

Procedures were for the endovascular exclusion of the

she was admitted to undergo percutaneous transluminal

Unfortunately, the results have been reported markedly inferior

a n e u r y s m. I t s d i s t a l w a s o c c l u d e d u s i n g A m p l a t z e r

angioplasty. The angiography revealed ectatic change of right

to those after primary bypass grafting.

Vascular Plug II (AGA Medical Corp, Plymouth, MN) via

common iliac artery with stenosis and web shaped external

The advances in interventional technique, such as subintimal

the contralateral left transfemoral approach. The reversed

iliac artery stenosis which continued to common femoral artery.

angioplasty with long-length lower profiled balloon, with or

iliac leg stent graft (Zenith Flex: TFLE-24-56-ZT, Cook,

We decided to perform percutaneous transluminal angioplasty

without stent, allow an endovascular recanalization of arterial

Bloomington, IN) was prepared on-site with strict sterile

for right iliac artery.

lesions previously seemed not indicated.

technique, unsheathing the 24-56 mm iliac leg stent graft

Strategy: We intended to perform percutaneous transluminal

Authors report two cases of successf ul endovascular

from its introducer, and it was mounted upside down in the

angioplasty for CFA, EIA in order. The challenging step was

recanalization of the native artery after a failed bypass

same introducer, showing reversed flared configuration. The

the wiring web shaped stenosis because there could be proper

graft with limb-threatening ischemia otherwise leading to

reversed iliac leg stent graft was deployed from the proximal

lumen and collateral lumen together. After obtaining images

amputation.

of right common iliac artery to the right external iliac artery,

by several different angles, we tried to get through with true

fully covering the origin of right internal iliac artery via the

lumen. We struggled and finally wiring was done successfully.

ipsilateral right transfemoral approach.

The ballooning steps were as the followings; 1) 5x60mm balloon

Result: Post-stent graft angiograms showed complete exclusion

dilatation for CFA 2) 5x60mm balloon dilatation for EIA-CFA

of the aneurysm of right internal iliac artery with no endoleak.

3) 5x60mm balloon dilatation for CIA-EIA. The stenting was

The patient had no complication following the procedure.

not done for its anatomical location being across leg-hip flexion

Conclusion: This technique using reversed iliac leg stent graft

point.

is a useful treatment option in patient with isolated internal

Final Result: The residual stenosis was within 20%. The

iliac artery aneurysm and significant size discrepancy between

right ABI was elevated to 0.90. In conclusion, we made

the common iliac artery and the external iliac artery.

angiographically and functionally successful percutaneous

transluminal angioplasty for right EIA and CFA which showed
web shaped stenosis.

after treatment.
Conclusion: Short and mid-term results of endovascular repair
for isolated IAAs are excellent. It should be regarded as a first
choice treatment option for IAAs.

406

407

Poster Exhibition

aneurysm rupture or aneurysm-related death for follow-up

Department of Radiology, St. Paul's Hospital, The Catholic

University of Korea, KOR
Department of Surgery, St. Paul's Hospital, The Catholic
University of Korea, KOR

Department of Cardiovascular Surgery, Nagasaki University

Hospital, JPN

Objective: To report short and mid-term results of endovascular

Poster Exhibition

PE108

Poster Exhibition

PE109

PE110

Emergency interventional treatment for iliac-entericureteral fistula presenting with major gastrointestinal
hemorrhage and hematuria after laparotomies and
radiotherapy for uterine cervical cancer

Embolization for the arteriovenous fistulas

in transplanted renal grafts

PE111

The endovascular treatment of visceral

artery aneurysms and pseudoaneurysms

A case of arterio-venous fistula(AVF) of a

grafted kidney treated by TAE
Noritaka Seino1, Shoei Sai1, Takashi Hashizume1,
Shinya Ikeda1, Jiro Munechika1, Hiroto Sasamori1,
Yoshimitsu Ohgiya1, Jumpei Suyama1, Takehiko Gokan1,

Tsuyoshi Tajima, Satoru Morita, Ken Kimura,

Yoshihiro Toyama, Takashi Norikane, Senri Itoh,

Hideharu Sugimoto , Hirotaka Sato , Shinichi Oki ,

Hiroshi Yamasaki, Ryouhei Kuwatsuru, Shuji Sakai

Takayuki Sanomura, Naruhide Kimura, Satoru Nakano,

Tsutomu Saito2, Yoshio Misawa2

Department of Diagnostic Imaging and Nuclear Medicine,

Tokyo Women's Medical University, JPN

Yoshihiro Nishiyama

Akira Kawai1, Manabu Nakata1, Hiroyasu Nakamura1,

1

Departmet of Radiology, Jichi University School of Medicine,

JPN
2
Departmet of Cardiovascular surgery, Jichi University
School of Medicine, JPN

PE112

Department of Radiology, Faculty of Medicine, Kagawa

University, JPN

Minoru Honda2, Toshi Hashimoto3

1

Department of Radiology, Showa University School of

Medicine, JPN
2

Department of Radiology, Totsuka Kyouritsu Daini Hospital,

JPN
3

Department of Radiology, Showa University Fujigaoka

Hospital, JPN
The formation of iliac-enteric-ureteral fistula is very rare. We
report a case of 74-year-old woman presented with sudden
onset of abdominal pain, major gastrointestinal hemorrhage
and hematuria after laparotomies and radiotherapy for
advanced cervical cancer.
Contrast-enhanced CT demonstrated a pseudoaneurysm of the
right external iliac artery and arterio-enteric-ureteral fistula
among the pseudoaneurysm, terminal ileum, and ureter.
Combination therapy of isolation of the pseudoaneurysm from
the arterial circulation with the use of coil and femorofemoral
bypass surgery was performed. Covered-stent placement was
not selected due to the high-frequency of the need of second
surgery for localized infection after the stenting, which could be
difficult because of the history of multiple laparotomies in this
patient.
Both hemorrhagic stool and macroscopic hematuria were
disappeared immediately after the treatment. The patient
remains well without symptoms.
We report an unusual case of pseudoaneurysm of the external
iliac artery and iliac-enteric-ureteral fistula managed
with successful emergency combination treatment of the
interventional therapy and the operation.

Purpose: It has been well known that arteriovenous fistulas

(AVFs) occur in patients who underwent renal transplant
surgery. The purpose of this study was to review retrospectively
the interventions for renal transplant recipients and to
elucidate the efficacy of transcatheter embolization for AVFs
which occurred in transplanted kidney, discussing from
literature review.
Subjects and Methods: From Nov 2001 to Oct 2011, there were
five patients (men 3, women 2; 11-42 years old with an average
of 30.2 years old) whom transcatheter arterial embolization
(TAE) was performed for AVF of the transplant kidneys in
our hospital. The typical abnormal signals were confirmed
on Doppler US in all cases, and TAEs were immediately
performed. We evaluated the clinical and technical success,
the cause of AVF, clinical manifestations, an elapsed time from
renal transplantation, angiographic findings, embolization
methods and the frequency of complications.
Results: Hematuria was found in two cases (40%) as a
symptom, but there was no case that resulted in a heart
failure symptom. As a cause of AVF, two cases were associated
with needle renal biopsy, but three cases were unidentified.
In a child, we performed TAE under general anesthesia. We
performed underwent angiography by an ipsilateral femoral
artery approach in three cases and by a contralateral approach
in two cases. Only one portion of AVF was depicted on selective
transplanted kidney arteriography in all cases. Selective
TAE was conducted with use of embolic materials which
including fibered microcoil (n=1), detachable coil (n=1), NBCA-

Poster Exhibition

(n=2). Angiography subsequent after the TAE confirmed a

disappearance of the abnormal vessels in all cases (100%). As
complications, a transient increase in serum Creatinine level
was found in one case (20%), but recovered spontaneously.
Follow-up Doppler US confirmed that there was no recurrence.
Conclusions: Also for AVFs which occur in renal transplant
recipients, TAE can be safely applied as well as those in the
non-transplanted kidneys. Interventional radiologists should
recognize that in transplanted kidneys AVF can occur with
causes except the needle biopsy.

408

This is a case of a 30th generation male patient. When he was

his twenties, he had living renal transplantation surgery. After
the surgery, his serum creatinine level fluctuated between
1.7mg/dl and 1.8mg/dl. However in March 2011, his serum
creatinine level rose to around 2 mg/dl and deterioration in
renal function was found. AVF was confirmed in his grafted
kidney by ultrasonography and MRI exam to search for the
cause, also weakening of renal artery vascular flow in the other
part of AVF was confirmed. He was hospitalized on June, 2011
for IVR cure for the purpose of improving renal function. On
admission, his serum creatinine level was 2.93mg/dl. IVR was
performed the next day. To preserve renal function, the exam
was begun with using minimum amount of contrast media.
Approached from right femoral artery, the artery of a grafted
kidney inosculated to right external iliac artery was chosen
and DSA was performed. Massive aneurysm in the periphery of
renal artery and vein early extraction were confirmed. In order
to acquire more detailed information, catheter was inserted to
the periphery of renal artery, and DSA and C-arm CBCT was
performed. From the result of DSA and C-arm CBCT, it was
diagnosed as AVF and huge varix of grafted kidney. Getting
through AVF by micro catheter, used IDC under flow control
of renal artery by balloon catheter, and packed the vein side
enough as anchor. Then embolization was performed to AVF
and proximal side of artery with coil(TRUFILL). Three IDC
and sixteen coils(TRUFILL) were used. Flow control of renal
artery with balloon catheter was deactivated and DSA was
performed, and AVF disappeared. He was discharged from the
hospital on July, 2011. In November, 2011, his serum creatinine
level had improved to 2.0mg/dl. This was the report of arteriovenous fistula(AVF) of a grafted kidney treated by TAE with
consideration from literature information.

409

Poster Exhibition

Lipiodol mixture (n=1), and combinations of these materials

Background: Visceral artery aneurysms and pseudoaneurysms

represent a rare disease with high mortality. Endovascular
treatments are now available for the management of visceral artery
aneurysms and pseudoaneurysms. The purpose of this study was
to review our 10-year experience of endovascular treatment, and to
analyze short- and long-term results.
Methods: From April 2002 to October 2011, twenty-two patients (17
men and 5 women, mean age 67.7 years, range 42-95) underwent
endovascular treatment with the diagnosis of visceral artery
aneurysm, were retrospectively reviewed. The indication for
intervention and means of intervention were determined by the
individual managing physician. In general, any degree of bleeding
was considered an indication for intervention. Presence of symptoms,
aneurysm size, and bleeding were considered when determining
management options. Initial success is defined as stopping the flow
within the aneurysm or successfully excluding it by the end of the
procedure. Short-term morbidity was defined as that which required
additional intervention within the first 30 days. Aneurysm-related
mortality was defined as that which was directly related to aneurysm
rupture or bleeding, or from complications related to intervention.
Results: Eight patients were asymptomatic and fourteen were
symptomatic. Bleeding was the indication for intervention in
10 aneurysms, and aneurysm size was a common indication for
intervention in true aneurysms. Pseudoaneurysms comprised
16 (73%) of all aneurysms. Four patients had pancreatitis, and
six patients had postoperative pancreatic fistula. Thirteen (59%)
aneurysms were located in the splenic artery, 2 (9%) in the hepatic,
5 (23%) in the gastroduodenal, 2 (9%) in the pancreaticoduodenal,
one (5%) in the superior mesenteric, one (5%) in the gastric artery.
Coiling was used alone in 16 aneurysms (73%), in combination with
gluing in one (5%), and gluing in five (23%) cases. Initial treatment
was successful in 20 aneurysms (the primary technical success rate
was 90%). Reintervention was required in one aneurysms with
recurrent bleeding within 30 days. Postoperative CT scans showed
splenic infarct in four after splenic artery aneurysm treatment,
and hepatic infarct in two patients after hepatic artery aneurysm
treatment. Thirty-day aneurysm-related mortality was 5% (one
death). Four patients were lost to follow-up within the first 30 days.
Five additional deaths occurred during follow-up, although none was
related to complications of the aneurysms.
Conclusion: The endovascular treatment for visceral artery
aneurysms is safe and effective in elective or emergent conditions.
Regardless of the etiology, endovascular treatment can provide
excellent long-term results.

Poster Exhibition

PE113

PE114

PE116

Delayed onset of renovascular hypertension

associated with Moyamoya disease treated
with percutaneous transluminal angioplasty

A severe case of median arcuate ligament

syndrome with successful angioplasty and
stenting

Endovascular stent and stentgraft repair

of a bleeding superior mesenteric artery
pseudoaneurysm and dissection associated with
pancreaticoduodenectomy: A case report

A case report of disapperance of

huge urinary bladder tumor treated by
chemoradiotherapy used intraarterial
implantable port system

Mitsuhiro Kishino1, Yoshio Kitazume1, Ken Takahashi2,

Keerati Hongsakul, Sorracha Rookkapan,

Motoki Nakai1, Hirotatsu Sato1, Akira Ikoma1,

Hiroki Sanda1, Hinako Sakaguchi1, Kohei Nakata1,

Masami Taguchi1, Kikuo Seo2, Nozomi Matsushita2

Yuko Takeguchi , Toshifumi Kudo , Hitoshi Shibuya

1

Department of Radiology, Tokyo Mediacal and Dental

University, JPN
2
Department of Radiology, Tsuchiura Kyodo Hospital, JPN
3
Department of Radiology, Japanese Red Cross Musashino
Hospital, JPN
4
Department of Vascular Surgery, Tokyo Medical and Dental
University, JPN

Jitpreedee Sungsiri
Department of Radiology, Prince of Songkla University, THA

Hiroki Minamiguchi , Nobuyuki Kawai ,

Tetsuo Sonomura1, Morio Sato1, Yoshiharu Nishimura2,
Yoshitaka Okamura2

Department of Radiology, Hachinohe RCH, JPN

Department of Urology, Hachinohe RCH, JPN

Department of Radiology, Wakayama Medical University,

JPN
2
Department of Thoracic and cardiovascular surgery,
Wakayama Medical University, JPN

Introduction: Moyamoya disease is an idiopatic cerebrovascular

Median arcuate ligament syndrome(MALS) is an uncommon

A superior mesenteric artery (SMA) pseudoaneurysm after

A 51 years old man was admitted in 12 January 2001,

occlusive disease characterized by progressive stenosis or occlusion

condition caused by external compression of the celiac trunk

pancreatic resection poses serious complications, including

emergently. He was sever anemia, acute renal failure, bilateral

hydronephrosis due to huge urinary bladder tumor with

at circle of Willis and development of fine collaterals (Moyamoya

vessels). And it is a rare disease but occurs with predilection
in child-young adult and affects more East Asian people. A few
studies, include from our institute already reported the incidence
of renal artery stenosis associated with Moyamoya disease as 5-7%.
We report two treated cases of de novo renal artery stenosis more
than ten years after cerebrovascular lesion had become stable.
Case 1: A 22 year-old female patient with drug resistant
hypertension was presented for elective PTRA. She was diagnosed
Moyamoya disease (Suzukis grade 4) and performed indirect

from median arcuate ligament. The symptom of this includes

rupture and hemorrhage. SMA dissection is a rare and

abdominal pain, nausea, vomiting and weight loss. Typically,

sporadically reported condition. This report presents a case of

bleeding. Blood transfusion & intravenous massive hydration

compression of celiac trunk is usually seen on sagittal view

a post-pancreaticoduodenectomy SMA pseudoaneurysm and

& nephrostomy was done immediately. He was recoverd

of the computer tomography and prominent on expiration,

dissection that was successfully treated by an endovascular

renal function & general condition gradually. 27 February

however, in severe case may be shown persistent compression

procedure with stent and stentgraft. The patient was a

2001 arterial implantable port system was inserted from

on expiration and inspiration. Traditionally, treatment of

73-year-old female who presented with intraperitoneal

right femoral artery to left internal iliac artery. Except for

left vesical arteries & lateral sacral artery were embolized

this syndrome is surgery incluidng opern or laparoscopic

bleeding from the abdominal drain and shock after undergoing

division of the median arcuate ligament to relieve the extrinsic

pancreaticoduodenectomy for pancreatic head carcinoma.

by many microcoils for selective chemotherapy. Intraarterial

compression. Percutaneous endovascular treatment is a novel

Contrast-enhanced CT revealed a pseudoaneurysm arising

chemotherapy was started 1 March to 1 November 2001.

technique and may be considered in selected case who fail

from the proximal sites in the SMA and dissection in the

Whole pelvic radiotherapy 40Gy with additional small pelvic

or cannot treat with traditional surgery. We report a case of

distal sites. Urgent angiography of the SMA demonstrated

radiotherapy was started 3 April to 24 May 2001. Total dose

severe compression of celiac trunk in median arcuate ligment

extravasation from the pseudoaneurysm to the abdominal

was 60 Gy by 30 fractions. Over all treatment time was 53

syndrome, presenting with chronic abdominal pain and weight

cavity. A bare stent (Wallstent RP full open 7mm diameter,

days. He left our hospital 26 May 2001. 12 July 2001 left side

loss, which was successfully treated by angioplasty with

23mm length) (Boston. Scientific Co., Natick, Mass.) was placed

nephrostomy tube was dropped out. First menu of intraarterial

stenting. The clinical symptom was improved.

in the distal dissection via the transfemoral approach. A 8 mm

chemotherapy was about half dose of M-VAC 2 course by 3

40 mm Fluency stent-graft (Bard Peripheral vascular, Inc.

week interval. Second menu was 12 to 16 April 2001 by EPI

done. Although pressure gradient was diminished, there was slight

Arizona, Tempe) was deployed to exclude the pseudoaneurysm

10mg with CBDCA 10mg. Third menu was 6 course of TPH-

residual stenosis despite high pressure inflation (up to 20atm).

by overlapping with the preceding bare stent by approximately

ADM 20mg under fluoroscope with DSA biweekly. Side effect

Subsequently, her blood pressure was gradually normalized.

5mm. The endoluminal stent and stentgraft repair resulted

was numbness of left foot because of reflux of anti-tumor drug

vascularization surgery at 3 years old. Since then, there were no

deterioration of neurological symptoms and also no cerebrovascular
lesions on MR angiography. However, her blood pressure had been
gradually elevated since she turned teens. Blood examination and
ultrasonography revealed RVH due to right renal artery stenosis.
Angiography showed severe stenosis at proximal part of right renal
artery, and then cutting balloon angioplasty and stenting was

Case 2: A 23 year-old female patient was presented for elective

PTRA. She had once already treated RVH due to left renal artery
stenosis at nine years old, and indirect vascularization surgery
for Moyamoya disease was performed at ten years old. At that
time there was no stenosis on right renal artery. Since then she
had been had slight high blood pressure (around 150mmHg),
which was able to control with anti-hypertensive drugs. But in her
twenties, her hypertension became worse and resistant with drugs.
Angiography revealed re-stenosis of left renal artery and de novo
stenosis of right renal artery. Then bilateral PTRA was performed,

in total exclusion of the pseudoaneurysm and dissection. The

to left lateral sacral arterial territory. He received regular

hemorrhage disappeared immediately after deployment of

outpatient treatment about every 6 week to exchange of

the stentgraft and blood flow to the bowel was preserved.

nephrostomy tube. Following whole body CT was done by each

The postoperative course was uncomplicated and the patient

6 to 12 months. The tumor was disappeared completely by

was discharged on day 30. The SMA remained patent and

recent CT & US. Reviewing of past CT the tumor had not been

no ischemic complications developed after the endovascular

finding from 2005 by retrospectivelly. Now his is 62 year old

repair. Endovascular management of postoperative SMA

with disease free.

pseudoaneurysm and dissection is therefore considered to be

Poster Exhibition

Poster Exhibition

PE115

feasible as an alternative to traditional surgical treatment.

with re-stenting for left and balloon PTA for right side. Several
days after the treatment, her blood pressure was normalized.
Conclusion: Renal artery stenosis associated with Moyamoya
disease can occur after cerebrovascular lesion had become stable.
It is very important to treat RVH so as to avoid brain hemorrhage
that is high risk for adult moyamoya disease patients. Our cases
and other few reports suggest that renal artery stenosis associated
moyamoya disease can resistant with dilatation or high risk for restenosis.

410

411

Poster Exhibition

PE117

PE118

PE119

PE120

Two cases of adrenal hemorrhage

successfully treated by TAE

A case of spontaneous renal rupture treated

by transcatheter arterial embolization

Bleeding from autologous iliaco-hepatic

bypass graft due to pancreatic fluid
leakage; Complete recovery with covered
stents designed for biliary duct

Transcatheter arterial embolization of

ruptured common hepatic artery aneurysm
from Behcet disease

Minobu Kamo, Sokun Fuwa, Eisuke Shibata,

Takayuki Sanomura1, Tsutomu Katoh1,

Ken Takahashi1, Mitsuhiro Kishino2, Yoshio Kitazume2,

Akihiro Hotta1, Ryohei Kuwatsuru1, Koichi Asahi1,

Shingo Okada1, Daisuke Tsuge1, Akihiko Shiraishi1,
Yoshinari Takasaki2

Gensuke Akaike, Yuka Morita, Sayaka Horiuchi,

Yoshihiro Toyama , Yoshihiro Nishiyama

Hitoshi Shibuya

Takafumi Haraguchi, Yukihisa Saida

Department of Radiology, St. Luke's International Hospital,

JPN

Department of Radiology, Sumitomo Besshi Hospital, JPN

Department of Radiology, Kagawa University, School of

Medicine, JPN

Department of Radiology, Tsuchiura Kyodo General

Hospital, JPN
2

Department of Radiology, Tokyo Dental and Medical

University, JPN

Department of Radilology, Juntendo University School of

Medicine, JPN
2

Department of Intrenal Medicine and Rheumatology,

Juntendo University, JPN

We report two cases of adrenal arterial hemorrhage which were

We report a case of spontaneous renal rupture in a 71-year-

Postoperative bleeding due to pancreatic fluid leakage is

Hepatic artery aneurysm is a rare and potentially life-

successfully treated by TAE.

old man who had been receiving warf arin f or atrial

infrequent but potentially lethal complication. Bleeding after

threatening entity. Transcatherer arterial embolization is

Case 1: A 70-year-old male with a history of bladder carcinoma

fibrillation. He presented with sudden onset of right flank

operation for pancreatic cancer from anastomotic site of iliaco-

the preferred treatment modality in patients at high risk for

with multiple metastases. Having left flank pain, he came to

pain. CT demonstrated a massive perirenal hematoma.

hepatic bypass graft making up for hepatic blood flow was

operative intervention. We report a case of ruptured common

the hospital. Abdominal dynamic CT revealed extravasation

Renal arteriography showed contrast media leakage at the

controlled with two covered stents designed for biliary duct.

hepatic artery (CHA) aneurysm treated successfully by

in the left adrenal mass. The diagnosis of active arterial

lower branch of the right renal artery. Transcatheter arterial

CASE: A 62-year-old male was operated on for pancreas

transcatheter arterial embolization. Thirty-four-year-old man

hemorrhage in the probable metastatic adrenal tumor was

embolization was performed using 3:1 mixture of absolute

head cancer. In the operation, the median arcuate ligament

who had Behcet disease for 10 years visited hospital with acute

made and emergent TAE was undergone. Selective left middle

ethanol and lipiodol, and using microcoils. Radiopacity of

compression was loosened though insufficiently to restore the

right abdominal pain. The patient had aortic replacement with

adrenal artery angiography depicted extravasation in the

lipiodol beneficial for monitoring the procedure. No major

blood flow of the celiac artery, while the hepatic blood flow was

celiac and superior mesenteric artery restoration for aortic

left adrenal gland area. Embolization was done using gelatin

complication occurred during the procedure.

predominantly supplied by the gastroduodenal artery (GDA).

dissection one and half years ago. Abdominal CT showed the

sponge.

Non-traumatic retroperitoneal hemorrhage is uncommon. It

Right great saphenous vein (GVS) was used as autologous

aneurysm of CHA mesasuring 60 mm, and a hematoma spread

Case 2: A 62-year-old female with no particular history. She

can be due to the rupture of an abdominal aneurysm, adrenal

bypass graft between the right common iliac artery and GDA to

caudally. The diagnosis was ruptured CHA aneurysm, and

had a sudden onset of back pain without any traumatic event.

bleeding, blood dyscrasia, hypertension, and renal disorders.

ensure the hepatic blood flow.

emergency angiography was performed. Celiac angiography

On abdominal dynamic CT, extravasation was seen in and

Most patients with spontaneous renal rupture have a renal

On the 5th post-operative day (POD 5), the CT scan showed

showed CHA aneurysm at approximately 2cm distal from the

around the cystic masses located in the right adrenal gland

tumor such as angiomyolipoma and carcinoma. But in this

hematoma at the anastomotic site of the graft and GDA,

root of CHA, and revealed extravasation from the aneurysm.

area. Abdominal CT taken several years ago showed two

case CT and DSA findings were not showed aneurysm or renal

where the extravasation of contrast media was found at the

Transcatheter arterial embolization was performed successfully,

middle-sized cysts in the same area (obviously not originating

tumor.

angiographic examination. FLUENCY (BARD, length 40mm,

with the 21 Tornado Embolization Microcoils in the distal

full span 10mm), a covered stent designed for biliary duct,

and 17 Guglielmi Detachable Coils in the proximal side of

suspected and emergent TAE was carried out. Prominent

was placed in the anastomotic site. Angiographcally, the

aneurysm. The patient remains asymptomatic for 9 months

extravasation was seen on selective right inferior adrenal

extravasation was diminished.

after embolization.

artery angiography. Metallic coil and gelatin sponge were used

Pancreatic and biliary fluid leakage was recognized at this

as embolic materials.

time, but inflammations were calming gradually and the

In both of the cases, the hemorrhage was controlled successfully

hematoma was getting smaller. On POD 31, massive bleeding

from the right kidney). Idiopathic adrenal hemorrhage was

with TAE without any complication. No recurrent bleeding has

through drainage tube occurred abruptly. Second emergent

occurred.

angiographic examination revealed active bleeding from the

Conclusion: We experienced rare cases of adrenal active

peripheral side of the stent. We had to preserve the blood

bleeding. TAE could be a useful treatment for controlling

flow of the bypass graft because the patient complained

arterial adrenal hemorrhage.

stomachache with organ ischemia when the bypass graft was

Poster Exhibition

Poster Exhibition

blocked with balloon catheter. When the FLUENCY (60mm

full span 10mm) was placed in the peripheral site with 2cm overlapping, the active bleeding disappeared and blood flow of
the graft was maintained.
CONCLUSION: Two covered stents designed for biliary duct
were successfully placed to control bleeding from the autologous
bypass graft, which made up for the lack of the hepatic blood
flow due to the median arcuate ligament compression. Covered
stents for the medium-sized arteries seemed to be mandatory
in case of life-threatening abdominal hemorrhage.

412

413

Poster Exhibition

PE121

PE122

PE123

Transcatheter arterial embolization with

n-butyl-2-cyanoacrylate for the spontaneous
rupture of a pheochromocytoma

Qantitative estimation of splenic infarction

using Murrays law before partial splenic
embolization

Balloon-occluded retrograde transvenous

obliteration: Outcomes and complications
in 75 patients

Balloon dilatation of primary and recurrent

portal venous stenosis after living donor
liver transplantation in children

Yuichi Wakabayashi, Yoshiki Nishida, Akihito Onishi,

Jun Koizumi1, Takeshi Hashimoto1, Kazunori Myojin1,

Minoru Honda1, Katsuhiko Matsuura2, Noritaka Seino3,

Yohsuke Suyama1, Seishi Nakatsuka1, Masanori Inoue1,

Keno Moriki, Yuri Kitamura

Chihiro Itou , Takuya Hara , Tatsuya Sekiguchi ,

Shouei Sai , Takashi Hashizume , Takehiko Gokan

Nobutake Ito1, Masashi Tamura1, Sota Oguro1,

Department of Radiology, Osaka Police Hospital, JPN

Yutaka Imai1, Bertrand Othee2

Subaru Hashimoto1, Sachio Kuribayashi1, Ken Hoshino2,

Department of Diagnostic Radiology, Tokai University

School of Medicine, JPN
2
Division of Vascular and Interventional Radiology,
Department of Diagnostic Radiology and Nuclear Medicine,
University of Maryland School of Medicine, USA

Introduction: The spontaneous rupture of a pheochromocytoma is

a rare and potentially lethal complication. Prompt diagnosis and
patient stabilization are crucial for survival. Surgical treatment
(adrenalectomy) is the first choice for treating a ruptured
pheochromocytoma. Surgical approaches involve either emergency
or elective surgery. Emergency surgery is commonly associated
with a high mortality rate, whereas no deaths have been reported
in patients who underwent elective surgery. What is the best
choice of treatment in case of massive bleeding and no evidence of
pheochromocytoma? To the best of our knowledge, there have been
cases in which TAE was performed for the spontaneous rupture of a
pheochromocytoma, and no deaths were reported.
Case presentation: We report the case of a 54-year-old Japanese
woman who experienced a pheochromocytoma rupture. The patient
was referred to our emergency room because of left lower abdominal
pain. At the time of admission, severe hypertension was observed.
Laboratory test results showed anemia and leukocytosis. Abdominal
computed tomography (CT) showed a large hematoma in the left
retroperitoneal space and ascites. After CT was performed, the
patient experienced decrease in blood pressure level that evolved
into hemorrhagic shock. Contrast-enhanced CT was immediately
performed, and it showed a large mass in the left adrenal gland
region, with intratumoral bleeding and extravasation that extended
from the retroperitoneal space to the intraperitoneal space. We
performed abdominal aortography and found active bleeding from
the left adrenal artery. Therefore, we performed transcatheter
arterial embolization (TAE) in the left adrenal artery by using
gelatin sponge but were unable to stop the bleeding. We used
n-butyl-2-cyanoacrylate (NBCA) and the bleeding stopped, but the
patients blood pressure level was unstable. We assumed that an
acute rupture of a pheochromocytoma must have occurred and
performed adrenalectomy on the next day. Pathologically, the tumor
was defined as a pheochromocytoma. The patient showed a good
postoperative outcome and was discharged from the hospital on the
73rd day.
Conclusion: For patients with hemodynamic instability, TAE can
be an effective and safe procedure for achieving hemostasis and
maintaining the patient in a stable condition until surgery can be
performed. In addition, TAE improves the prognosis significantly
by prolonging treatment time for diagnosis and enables the surgeon
to operate safely. To the best of our knowledge, the use of TAE with
NBCA for treating an acute pheochromocytoma rupture has not
been previously reported in the English literature.

414

Department of Radiology, Totsuka Kyoritsu Dai-ni Hospital,

JPN
2

Department of Radiology, Saitama Medical Center, Jichi

Medical University, JPN
3

Department of Radiology, Showa University Hospital, JPN

Tatsuo Kuroda2
1

Department of Diagnostic Radiology, Keio University School

of Medicine, JPN
2
Department of Pediatric Surgery, Keio University School of
Medicine, JPN

Purpose: For hypersplenism, portal hypertension, or

Purpose: To evaluate the clinical outcomes, technical problems,

PURPOSE: The purpose of this study was to review our

hematologic disorders, etc., partial splenic embolism (PSE) is

and complications associated with balloon-occluded retrograde

experience in balloon dilatation of primary and recurrent portal

often performed. However, severe complications such as splenic

abscess, gastritis, or pancreatitis may limit the indication.
To prevent abscess formation due to contamination of the
infracted splenic parenchyma with bacteria carried from
the gastrointestinal tract via the reversed portal circulation,
around 30% of normally vascularized splenic mass should be
preserved to keep the normal immune function and the normal
direction of blood flow through the splenic circulation. However,
the estimation of splenic infarction during PSE is often difficult.
According to Murrays law, flow rate is in accordance with the
vessel diameter (D) to the third power and the exponent varies
from 2.33 to 3.0 depending on whether the flow is turbulent
(2.33) or laminar (3.0). Thus, we compared splenic infarction
rates (SIR) based on D2 and D3 of splenic arteriography with
manual volumetry on postcontrast CT one week after PSE.
Materials and Methods: In twenty five patients (42-73, mean
59.6 y/o) with hypersplenism, PSE were performed using n-

transvenous obliteration (B-RTO) for patients with gastric

varices or portosystemic encephalopathy.
Method: B-RTO was performed in 50 patients (30 men and
20 women; age range, 35-84 years; mean age, 63.0 years) with
gastric varices, and in 25 patients (11 men and 24 women; age
range, 44-83 years; mean age, 64.2 years) with portosystemic
encephalopathy. Gastric varices/portosystemic encephalopathy
were associated with portal hypertension resulting from viral
liver cirrhosis (26/18 patients), alcoholic liver cirrhosis (11/5
patients), and other conditions. For patients with gastric
varices, 48 patients had gastro-renal (G-R) shunts and 2
patients had shunt tracts draining into the left inferior phrenic
vein. For patients with portosystemic encephalopathy, 12
patients presented with G-R shunts; 6, with spleno-renal (S-R)
shunts; 2, with both G-R and S-R shunts; 5, with shunt tracts
draining into the gonadal vein; and others. Under fluoroscopic
guidance, an occlusion balloon catheter was inserted into the
outlet of the shunt through a sheath placed in the right femoral

venous stenosis after living donor liver transplantation (LDLT)

in children and to evaluate its feasibility.
MATERIALS AND METHODS: From April 1995 to December
2011, 10 patients with portal venous stenosis following LDLT
were referred to our department. The patients included 7 males
and 3 females, and their ages ranged from 2 to 68 months (mean:
9.4months). Postoperative portal venous stenosis occurred
from 0.5 to 41 months (mean, 10 months) after LDLT. Balloon
dilatation was performed via the transileocolic venous approach
or percutaneous transhepatic approach. Even if portal vein
restenosis was pointed out on follow-up US or CT, the repeated
balloon dilatation was performed if needed.
RESULTS: A total of 19 sessions of balloon dilatation were
performed in 10 children with primary or recurrent portal
venous stenoses. Of 19 sessions, transileocolic venous approach
and percutaneous transhepatic approach were performed in 10
and 9, respectively. No major procedure-related complications

or jugular vein. The collateral veins were embolized using 50%

were observed. The technical success rate was 89.4% (17/19).

branch diameter (D) was measured. The SIR-D2 were

glucose or metallic coils in patients with gastric varices. The

Of 10 patients, 3 patients were treated successfully only by a

calculated as the addition of the embolized D2 divided by the

sclerosing agent comprised of a mixture of 10% ethanolamine

single session, 2 patients needed 2 sessions and 3 patients 3

oleate and an equal amount of contrast media. After balloon-

sessions because of restenosis. In 2 patients, the first attempt

butyl cyanoacrylate. On splenic arteriography each intrasplenic

sums of total D2 and SIR-D3 as the addition of the embolized

D3 divided by the sums of total D3. Both SIRs were compared
with actual SIR-CT.
Results: SIR-D2 (66.214.0%) and SIR-D3 (71.416.9%) did
not show any significant difference from SIR- CT (71.112.2%),
and significantly (<0.05) good correlations (r=0.48, r=0.49,
correspondingly) with SIR-CT.
C o n c l u s i o n: SIR ca n be est ima ted based on splen i c
arteriography before PSE and SIR-D3 provided better
simulation than SIR-D2 but without any significant difference
among them.

occluded venography, the sclerosing agent was injected via

the balloon catheter placed in the outlet of the shunt. The
balloon catheter was withdrawn on the next day. After B-RTO,
thrombosis of the varices or shunt tracts was assessed by CT.
Results: Technical success was achieved in all 75 patients.
Follow-up CT showed thrombosed gastric varices or shunt
tracts. The recurrence of the gastric varices was observed
in 1 patient. Portosystemic encephalopathy improved in 23
patients. No changes were observed in 1 patient. In another
patient, a recurrence of portosystemic encephalopathy was
observed. The extravasation of the contrast medium and portal
venous thrombosis were noted in 5 and 2 patients, respectively.
However, none of the patients developed any serious
complications.

was failed: in 1 patient, the second attempt from transileocolic

venous approach was succeeded after the failure of the first
attempt from transhepatic approach and, in the other patient,
the second attempt was not performed because the patient
remained asymptomatic due to sufficient development of
cavernous transformation. Finally, the primary and secondary
patency rate were 30.0% (3/10) and 90% (9/10), respectively.
CONCLUSION: Balloon dilatation was a safe and effective
procedure for portal venous stenosis after LDLT in children.
Almost all symptomatic patients with portal venous stenosis
achieved relief from their symptoms after dilatation without
life threatening complication. All recurrent stenoses were
successfully treated by repeated balloon dilatation.

Conclusion: B-RTO is believed to be a safe and effective

method of treatment for patients with gastric varices or
portosystemic encephalopathy.

415

Poster Exhibition

Poster Exhibition

PE124

Poster Exhibition

PE125

PE126

PE127

PE128

Correlation between diameter of splenorenal shunt and hepatic encephalopathy

Late variceal thrombosis after balloonoccluded retrograde transvenous

obliteration for gastric varices: Report of
two cases

Modified percutaneous transhepatic portal

embolization(PTPE) using a microcather:
Two cases report

Percutaneous transhepatic sclerotherapy

with n-butyl-2-cyanoacrylate for recurrent
gastric varices: A case report

Sachiko Achiwa, Hiroaki Maeda, Mayuko Yamasaki,

Osamu Tanaka1, Takuji Yamagami1, Yusuke Ichijo1,

Nobuyuki Takahashi1, Toshiyuki Irie2,

Yoshitaka Furukawa, Yasukazu Kako,

Hiroshi Miura , Rika Yoshimatsu , Masashi Yasuike ,

Masashi Kuramochi , Kensaku Mori , Masanari Shiigai ,

Keno Moriki, Yoshiki Nishida, Yuichi Wakabayashi,

Akihito Onishi, Yuri Kitamura

Satoshi Yamamoto, Kaoru Kobayashi,

Hiroyuki Oouchi2, Koji Ohno2, Takahiro Mori3

Manabu Minami1

Department of Radiolody, Osaka Police Hospital, JPN

Reiichi Ishikura, Shozo Hirota

Department of Radiology, Hyogo College of Medicine, JPN

Department of Radiology, Graduate School of Medical

Science, Kyoto Prefectural University of Medicine, JPN
2

Department of Radiology, Osaka General Hospital of West

Japan Railway Company, JPN

Department of Radiology, Institute of Clinical Medicine,

University of Tsukuba, JPN
2
Department of Radiology, Hitachi General Hospital, JPN

Purpose: Hepatic encephalopathy with portal hypertension

Purpose: To share a rare clinical experience of late variceal

Purpose: To evaluate the feasibility and efficacy of a modified

Purpose: There are few reports of the use of n-butyl-

is often caused by portosystemic shunt. In these cases,

thrombosis after balloon-occluded retrograde transvenous

PTPE technique using a microcatheter.

2-cyanoacrylate (NBCA) in percutaneous transhepatic

balloon occluded retrograde obliteration (BRTO) is one of the

obliteration (B-RTO) for gastric varices.

Materials and methods: Two cases underwent PTPE before

sclerotherapy(PTS) for gastric varices.

therapeutic options. Portosystemic shunts have many variant

Case reports: Case 1 A 70-year-old man who had been treated

hepatic resection. After insertion of an 8F sheath by ipsilateral

We describe PTS with NBCA for recurrent gastric varices.

routes, for example, gastro-renal shunt (GRS), spleno-renal

for hepatitis C virus-related liver cirrhosis was admitted to our

approach, a 20mm diameter balloon catheter was positioned at

Case presentation: A 40-year-old man visited our hospital

shunt (SRS), mesocaval shunt, and so on. When we performed

hospital to treat large gastric varices with gastro-renal shunt.

the main right portal vein. A reversed-shape 2.8F microcatheter

complaining of black stool. Upper gastrointestinal endoscopy

BRTO for the cases with GRS, we succeed in insertion a balloon

During balloon occlusion of gastro-renal shunt, five-ml of

was advanced into the splenic vein via the balloon catheter,

revealed gastric varices (Lg-c, F2, Cw, RC-) therefore, variceal

catheter into their GRS. But in some of cases with SRS, we

absolute ethanol injected through a balloon catheter to embolize

the microcathter was then pulled back until the tip of the

bleeding was suspected. Contrast-enhanced CT showed that the

couldnt succeed in insertion a balloon catheter into SRS.

collateral pathways from gastric varices. After confirmation to

microcatheter engages the anterior or posterior portal branch.

left gastric vein was the inflow vein, with no draining vein that

Therefore it is necessary to understand the morphology of SRS

embolize collateral pathways from gastric varices, forty-ml of

A mixture of gelatin sponge pieces and iodized oil was injected

would allow catheter insertion being visualized. Therefore, PTS

before BRTO is performed. However, there are few anatomical

5% ethanolamine oleate with iopamidol was injected through

via the microcatheter while the balloon was inflated in the

was selected for treatment.

reports of SRS. Now, we investigate the anatomy of SRS using

a balloon catheter into the gastro-renal shunt and the inflated

main right portal vein.

In the first PTS, 5% ethanolamine oleate iopamidol (12ml)

MDCT imaging, and we examine the correlation between

balloon was left in place for thirty minutes. After confirmation

Results: In both cases, the procedures were technically

was injected into the left gastric vein under balloon inflation.

diameter of SRS and hepatic encephalopathy.

of gastric variceal thrombosis during balloon-occluded

successful without balloon-related complications. The balloon

However, recurrent gastric varices was detected within two

Method: 514 patients were performed dynamic contrast-

retrograde venography, the balloon catheter was withdrawn.

did not rupture during inflation.

months.

enhanced MDCT study for liver disease from October 2010

One week after B-RTO, gastric variceal thrombosis did not

Conclusion: The combined use of a large balloon catheter and a

In the repeat PTS, we infused 5%EOI (8ml) under balloon

until April 2011. Two radiologists diagnosed the form of SRS

confirmed by contrast-enhanced CT. However, gastric variceal

micocatheter for PTPE is a safe approach to prevent migration

inflation; as the blood flow persisted, we slowed it down by

and measured the diameter of SRS.

thrombosis has been confirmed by follow-up contrast-enhanced

of embolic material.

placing a metal coil and infused NBCA mixed with Lipiodol

We classified these into the following three types. Type 1;

CT obtained three months after B-RTO. Case 2 A 72-year-old

(mixing ratio 1:4, total volume 1.2ml) under balloon inflation.

SRS is connected to a left inferior phrenic vein (LIPV). Type

man with alcoholic liver cirrhosis was admitted to our hospital

The embolization was successful, and no recurrence has been

2; SRS is connected to a left gonadal vein. Type 3; SRS is

to treat large gastric varices with gastro-renal and gastro-

noted until now, five months after the procedure.

directly connected to a left renal vein. In type 1 we additionally

caval shunt. During balloon occlusion of both gastro-renal and

Conclusions: Percutaneous transhepatic sclerotherapy with

classified the following two subtypes. Type1a; SRS is connected

gastro-caval shunt, forty-ml of 5% ethanolamine oleate with

NBCA is effective for treating recurrent gastric varices.

to the upper part of LIPV. Type1b; SRS is connected to the

iopamidol and ten-ml of 50% glucose solution was injected

lower part of LIPV.

through a balloon catheter into the gastro-caval shunt and

Result: 51 of the 514 patients have SRS and there are total 55

the inflated balloons were left in place for sixty minutes. After

SRS (47 patients have one SRS, 4 patients have two SRSs). 22

confirmation of gastric variceal thrombosis during balloon-

of 55 SRS are Type1a, 11 SRS are Type1b, 8 SRS are Type2,

occluded venography, the balloon catheter was withdrawn.

and 14 SRS are Type3. The diameter in SRS is mean 9.76

One week after B-RTO, gastric variceal thrombosis did not

6.03mm, and that of encephalopathy group (14.318.00mm)

confirmed by contrast-enhanced CT. However, gastric variceal

is significantly greater than that of no encephalopathy group

thrombosis has been confirmed by follow-up contrast-enhanced

(8.875.23m). (Man-Whitney test; p = 0.028).

CT obtained three months after B-RTO.

Conclusion: We classified the form of SRS using MDCT

Conclusion: Late variceal thrombosis is one of the late

imaging (three types and two subtypes). We examined

phenomena which could occur after B-RTO.

Poster Exhibition

Poster Exhibition

Department of Gastroenterology and Hepatology, Osaka

General Hospital of West Japan Railway Company, JPN

the correlation between diameter of SRS and hepatic

encephalopathy. The diameter in SRS is mean 9.76 6.03mm,
and that of encephalopathy group is significantly greater than
that of no encephalopathy group.

416

417

Poster Exhibition

PE129

PE130

PE131

PE132

A case of percutaneous trans-splenic

embolization for esophageal-jejunal
anastomotic varices after total gastrectomy

Percutaneous transportal outflow-vesseloccluded sclerotherapy for gastric varices

unmanageable by balloon-occluded
retrograde transvenous obliteration

Combined interventional therapies of portal

venous stenosis without the significant
pressure gradient after pediatric livingdonor liver transplantation: A case report

Percutaneous Transhepatic Obliteration

(PTO) for rectal varices: Single center
experience

Takayuki Kurinobu, Yozo Sato, Hidekazu Yamaura,

Hiroki Minamiguchi, Nobuyuki Kawai, Morio Sato,

Akira Ikoma, Hiroki Sanda, Kouhei Nakata,
Motoki Nakai, Tetsuo Sonomura

Nobuyuki Kawai, Hiroki Minamiguch, Morio Sato,

Manabu Nakata, Waka Nakata, Hiroyasu Nakamura,

Mina Kato, Daisaku Inoue, Takeshi Sato, Hisaaki Kato,

Akira Ikoma, Hiroki Sanda, Kouhei Nakata,

Akira Kawai, Hidenori Kanazawa, Hideharu Sugimoto

Yoshitaka Inaba

Takami Tanaka, Motoki Naka, Tetsuo Sonomura,

Kazushi Kishi

Department of Radiology, Jichi Medical University, JPN

Department of Diagnostic and Interventional Radiology, Aichi

Cancer Center, JPN

Department of Radiology, Wakayama Medical University,

JPN

Department of Radiology, Wakayama Medical University,

JPN

A 60-year-old male received systemic chemotherapy with

We present percutaneous transportal outflow-vessel-occluded

Living-donor liver transplantation for pediatric patients is an

lymph node metastases of hepatic hilus after total gastrectomy.

sclerotherapy (PTOS) for unmanageable gastric varices

established technique of treatment of end-stage liver diseases.

He was admitted immediately because of massive melena and

by balloon-occluded retrograde transvenous obliteration

However the incidence of vascular complications after the

required blood transfusion several times.

(BRTO). Two patients first underwent coil embolization of the

living-related liver transplantation has increased with surgical

CT revealed metastatic lymph node involving intrahepatic

outflow vessel through a microcatheter advanced beyond the

complexity of short graft vascular segment.

and major branches of the portal vein and tumor thrombus

gastric varices via the percutaneous transhepatic approach,

A pressure gradient across the portal venous stenosis (PVS) of

formation. Endoscopy showed bleeding from varices of

followed by the injection of sclerosing agent to the varices

3 - 5mmHg is considered significant. We encountered a patient

esophageal-jejunal anastomosis, however bleeding could not be

after confirmation of static blood flow in the varices. No major

with severe PVS, where no significant pressure gradient

controlled endoscopically.

complication was encountered in either patient. One-year

existed. The stenosis was not resolved with percutaneous

Percutaneous trans-splenic embolization was attempted

follow-up gastroendoscopy showed no recurrence of gastric

transhepatic angioplasty (PTA) alone. Collateral pathways of

because trans-hepatic approach was considered impossible.

varices in either patient. This method is based on the treatment

the portal vein (PV) could contribute to decreased pressure

Under ultrasound guidance, splenic vein was punctured and

rationale of BRTO and can be performed without embolization

gradient and decreased blood flow through the main PV. The

esophageal-jejunal varices were embolized with ethanol and

of inflow vessels. Although PTOS is slightly more invasive than

patient required combination interventional therapy of PTA,

coils. He had no further melena after the procedure.

BRTO, PTOS can be used as an alternative catheter treatment

stenting, percutaneous transhepatic obliteration, and balloon-

Percutaneous trans-splenic embolization might be an effective

procedure for gastric varices that are unmanageable by BRTO.

occluded retrograde transvenous obliteration to resolve the

procedure for gastrointestinal varices when endoscopic and

stenosis with slow portal venous flow. We report an uncommon

percutaneous trans-hepatic approach is not possible.

case of PVS without significant pressure gradient after the

liver transplantation successfully managed with embolotherapy

418

419

Poster Exhibition

Poster Exhibition

of the collateral veins and endovascular repair.

We present here 2 cases of rectal varices due to portal

hypertension treated with PTO in our hospital.
Case 1: 81 years old female with liver cirrhosis due to hepatitis
C virus. She had a past history of EIS for the rupture of
esophageal varices and RFA for HCCs. Her chief complaint
was melena from rectal variceal bleeding and hepatic
encephalopathy. Contrast enhanced CT showed rectal varices
continuing to inferior mesenteric vein (IMV). PTO for rectal
varices was planned. Main draining vein of rectal varices was
left superior rectal vein.
We confirmed the stagnant segment of contrast medium infused
from microcatheter under balloon dilatation. After that 20mL
of 50% glucose and 36mL of 5% EOI was infused under balloon
dilatation. IDC and fibered coils were placed in the outflow vein.
After confirmation of the stasis of sclerosant for 30 minutes, we
withdraw the catheter and embolized the puncture route with
fibered coils. Pre-procedural portal pressure was 23 mmHg and
that of post-procedure was 29mmHg.
Contrast enhanced CT showed shrinkage and occlusion of rectal
varices. She never complains of rectal variceal bleeding, but she
has hepatic encephalopathy, RFA and TACE for recurrent HCCs.
Case 2: 79 years old female with liver cirrhosis due to hepatitis
C virus. She had a past history of TACE and RFA for HCCs.
Her chief complaint was melena from rectal variceal bleeding.
Contrast enhanced CT showed rectal varices continuing to
inferior mesenteric vein (IMV). PTO for rectal varices was
planned. Main draining vein of rectal varices was right superior
rectal vein.
We confirmed the stagnant segment of contrast medium infused
from microcatheter under balloon dilatation. After that 20mL
of 50% glucose and 13mL of 5% EOI was infused under balloon
dilatation. IDC coils were placed in the outflow vein. After
confirmation of the stasis of sclerosant for 30 minutes, we
withdraw the catheter and embolized the puncture route with
fibered coils.
Contrast enhanced CT showed shrinkage and occlusion of rectal
varices. She never complains of rectal variceal bleeding, but
she underwent TACE and RFA for recurrent HCCs. She passed
away because of liver and renal failure after 4 months of PTO.
PTO for rectal varices is feasible but those patients were tended
to be in severe liver dysfunction. We heve to be careful for
patients who were treated rectal varices with PTO even though
the procedure was successful.

Poster Exhibition

PE133

PE134

PE135

A case of megaloureter due to double

renal pelvis with postoperative leakage:
Successful treatment with TAE to residual
abnormal renal tissue

CT evaluation after ALN vena cava filter

placement

Accessory vein management in "failing to

mature" or malfunctioning arteriovenous
fistulae

Hiroyasu Nakamura, Manabu Nakata,

Norihiro Onari, Shingo Kakeda, Junji Moriya,

Jichang Kim, Jesu Jeon

Gi Young Ko, Tae Hwan Kim, Kyu-Bo Sung,

Department of Radiology, Catholic University Dajeon St

Mary's Hospital, KOR

Dong-Il Gwon, Hyun-Ki Yoon, Jin Hyoung Kim

Hideharu Sugimoto

Yu Murakami, Atsushi Ogasawara, Keita Watanabe,

Department of Radiology, Jichi Medical University, JPN

Haruka Ooki, Yukunori Korogi

Department of Radiology, University of Occupational and
Environmental Health School of Medicine, JPN

For the leakage after left upper pole heminephrectomy and

ureterectomy for left double renal pelvis and megaloureter, We
experienced rare one case that we performed transcatheter
arterial embolization for residual abnormal renal tissue. We can
include discussion of some documents and report it. The case is
a 23-year-old woman. She was showed left double renal pelvis
and ureter by urinary tract infection at 3 years old. Ectopic
ureter was suspected in a vagina, but it was left unsolved
because it was improved. She noticed an abdominal mass in the
days of the teens, but left it unsolved. Because an abdominal
swelling increased at 22 years old, she had a checkup in the
department urology of Jichi Medical University after way
in another hospital. In the computed tomography the renal
pelvis and ureter from left upper half kidney became dilated
remarkably and presented hydronephrosis and hydroureter.
The tip of megaloureter was seen to open in a vagina. Left
upper pole heminephrectomy and ureterectomy was performed.
The countercurrent by the vaginography during the operation
was unclear. After operation the persistent leakage from
residual abnormal renal tissue developed and the reoperation
was considered. But less invasive transcatheter arterial
embolization was chosen because thrombus in the left renal
vein developed and the reoperation was risky. We performed
selective embolization by gelatine sponge for the artery that
fed residual abnormal renal tissue. After transcatheter arterial
embolization the leakage disappeared, and the course of
about 3 months is without any sign of recurrence. The report
of postoperative transcatheter arterial embolization for this
disorder is rare. Transcatheter arterial embolization for the
postoperative leakage is less invasive and may be effective. we
should consider it as one of the treatment choices though the
accumulation of the future case is necessary.

Portal vein stent placement for deceased

donor liver transplantation

Radiology, Asan Medical Center, Ulsan College of Medicine,

KOR

Purpose: The ALN inferior vena cava (IVC) filter is a

Arteriovenous fistulae(AVF) is the preferred type of

Purpose: To evaluate the efficacy of portal vein (PV) stent

retrievable type filter; although it is recommended that the

hemodialysis access due to its lower complication rate,

placement for improving PV inflow in deceased donor liver

filter is removed within 11 days, the feasibility of delayed

excellent patency, lower morbidity associated their creation.

transplant (DDLT) recipients.

removal is also reported. For other permanent and retrievable

Despite these benefits, AVF comprise less than on third of all

Materials: Intraoperative (n=17) or percutaneous transhepatic

IVC filters, the penetration of the filter strut into the IVC

permanent vascular accesses for hemodialysis.

(n=15) PV stent placement was tried in 32 patients (7

wall, which may lead to difficulty of IVC filter retrieval or

Many AVFs fail to achieve an adequate flow or size for

pediatrics). Thirteen of the 17 intraoperative procedures were

serious complication, has been reported. We evaluated the

successful cannulation. Accessry vein is one of the most

performed during DDLT but four 1-8 days after DDLT. Access

IVC wall penetration with follow-up CT after ALN IVC filter

important cause of AVF failure.

into the PV was the inferior mesenteric vein. Indications of

placement.

Vascular surgeons are responsible for the accessory vein

intraoperative procedures were remained stenosis with or

Material and Methods: Among consecutive 13 patients (5

management in many medical centers. However, accessory

without partial thrombosis in the main PV (n=12), PV kinking

men, 8 women, mean age of 67.8 years) who underwent the

veins also can be treasted by variable methods in angiography

(n=3), PV tension (n=1), and extrinsic compression (n=1).

placement of the ALN IVC filter in 1 year, 8 patients who

room without cut down.

Percutaneous procedure was performed at a median of 111 days

underwent follow up CT were retrospectively evaluated. Four

I want to describe several methods treating accessory veins in

after DDLT. Except for two patients with incidentally detected

patients had CT examination within 1month after IVC filter

angiography room.

PV stenosis, 13 had specific symptoms related to PV flow

placement (early retrieve group), and the remaining 4 were

abnormality.

examined over 1month (up to 5 months) after filter placement

After the access into the PV and negotiation of the occluded

(late retrieve group). IVC penetration was defined over 2mm

or stenotic PV, primary stent placement (n=15) or balloon

protrusion of filter strut from IVC wall on CT.

angioplasty followed by stent placement (n=10) and vice versa

Results: IVC penetration was not observed in any patients

(n=6) was performed. Stents with 10-14 mm in diameter were

(0/4) of the early retrieve group; however, the filter penetration

used for adults and 6-10 mm in diameter for pediatric patients.

was observed in all patients (4/4) of the late retrieve group.

Four patients also underwent variceal vein embolization and

In one patent of the late retrieve group, the ALN filter was

two open thrombectomy prior to stent placement.

successfully retrieved without any complication.

Results: On venogram, occlusion was seen in 5 patients and

Conclusions: IVC penetration of ALN filter strut may occur

stenosis in 27 patients. PV stent placement was successful in

frequently over 1 month after filter placement.

31 patients (97%). Cannulation of the occluded PV failed in

one patient. Major procedural complication occurred in one
pediatric patient. The patient experienced acute thrombosis in
the stented PV 10 hours after stent placement and PV flow was
restored following intraoperative thrombectomy followed by full
expansion of the placed stent and variceal vein embolization.
Four of the 17 patients with intraoperative procedures died
within 3 months after DDLT with preserved PV inflow.
Remaining 13 patients are healthy without symptoms. During
a median follow-up of 29 months (range, 1-96), seven patients
died. Recurrence occurred in four patients, and 1 and 3-year
primary patency rates were 85 7%, respectively
Conclusion: PV stent placement as well as variceal vein
embolization seems to be an effective modality for improving
PV flow in DDLT recipients.

420

421

Poster Exhibition

Poster Exhibition

PE136

Poster Exhibition

PE137

Fluoroscopy-guided central venous port

placement; Efficacy of J-wire guided venous
access

PE138

PE139

PE140

Role of adrenal venous sampling in

localization & predicting surgically remedial
adrenal adenoma in patients with primary
hyperaldosteronism

Microwire method for adrenal venous

sampling

Efficacy and safty of preoperative portal

vein embolization with microfibrillar
collagen for hepatobiliary malignancies

Daisuke Itoh, Hisao Koga, Marie Osawa, Kohzoh Makita

Samuel Lau, Sonny Chiu, Danny Cho, Alex Chow,

Hironobu Sasaki1, Jiro Sato1, Wataru Gonoi1,

Department of Radiology, North Tokyo Health Insurance

Hospital, JPN

Sunny Lam

Takashi Kidouchi , Takeshi Nojo , Masaki Katsura ,

Hiroyuki Miura, Shuichi Ono, Hiromasa Fujita,

Radiology, Kwong Wah Hospital, HKG

Takana Yamakawa2, Shinichi Inoh3, Kuni Ohtomo1

Hiroko Seino, Yoshihiro Takai

Department of Radiology, Hirosaki University Hospital, JPN

Masaaki Akahane1, Kazuchika Hagiwara1,

1

Koichi Shibutani, Fumiyasu Tsushima, Shinya Kakehata,

1

Department of Radiology, University of Tokyo Hospital, JPN

Department of Radiology, Toranomon Hospital, JPN

Department of Radiology, Social Insurance Chuo General

Hospital, JPN

The purpose of this study was to assess the technical success

rate and adverse events associated with fluoroscopy-guided
central venous(CV) port placement.
Between Januray 2007 and October 2010, we performed 88
sessions of CV port placement via the axillary or subclavian
vein. In 36 of 88 cases, we used J-wire as the guide for venous
access.
The technical success rate was 98.9%(87/88). Arterial
puncture during procedure occurred in one patient. There was
no pneumothorax. Catheter-related infection occurred in three
patients. Catheter occlusion occured in six patients. Catheter
detachment occured in three patients.

Objective: In primary hyperaldosteronism, it is important

Purpose: To evaluate the usefulness of microwire technique to

PURPOSE: To evaluate the clinical efficacy and safety

to distinguish between unilateral and bilateral disease, as

facilitate drawing back of blood from right adrenal vein.

of preoperative percutaneous transhepatic portal vein

Method: From January 2003 to November 2011, adrenal

embolization (PVE) by ipsilateral approach,using microfibrillar

venous sampling was performed in 125 cases by single

collagen (MFC) as an embolic material for metastatic liver

radiologists. Double angled catheters dedicated for right

tumors of colorectal carcinoma and carcinomas of biliary tract.

adrenal vein with 4 Fr in diameter were used in all cases.

MATERIALS AND METHODS: PVE using MFC was

Drawing back of right adrenal venous blood could not

performed in 36 consecutive patients (30 men and 6

achieved in six cases even though the use of micro-catheter,

women;mean age 64 years,range 44 - 81 years) with small

change of the angle of the catheter, and slit at the tip were

estimated future liver remnants (FLRs) after planned major

tried. Microwire technique was performed in these six cases.

hepatectomy.Malignancy of all patients included bile duct

Microwire with 0.014 inch in diameter (Transend EX, Boston)

carcinoma (n = 23),gallbladder carcinoma (n = 5),metastasis

was inserted in the 4Fr catheter, then protruded 2-3 mm into

of colorectal carcinoma (n = 8).In one patient,diagnosed as a

the right adrenal vein. Then, venous blood was sampled from

gallbladder carcinoma,preoperatively, pathological diagnosis

management strategies differ. The correct diagnosis of surgically

correctable forms of primary hyperaldosteronism is therefore of
great importance. Adrenal venous sampling is considered the
only reliable technique that allows the clinician to define the
patients that should undergo unilateral adrenalectomy.
The purpose of this study was to analyze the feasibility, safety
and accuracy of AVS in predicting and lateralizing a surgically
remedial lesion, and to compare its findings with CT.
Materials & Methods: Reports of AVS were reviewed
retrospectively from January 2009 to September 2011. We
compared demographic factors, results of AVS and cross-

The patency rates of the system within 30, 180, 365 days were

sectional imaging studies. Biochemical evidence of adrenal vein

98.8%, 93.8%, 90.0%, respectively.

sampling was analyzed. Pathology and clinical outcomes were

the space between catheter and microwire with Y-shaped

as xanthogranulomatous cholecystitis was confirmed after

then correlated.
Results: A total of 30 patients, age 40-67 years, underwent 33

connector at the end of the catheter.

resection.PVE was performed with ultrasound guidance

AVS for primary hyperaldosteronism during the period.

Result: Venous blood can be sampled in all six cases. The

(ipsilateral ;35,contralateral approach;1).Total liver volume

sampled blood was confirmed to be from adrenal vein by high

(TLV) and future liver remnant (FLR) changes,hypertrophy

cortisol level.

ratio before and after PVE,procedure related complications

Conclusion: Microwire technique was useful to facilitate

were retrospectively analyzed.

drawing back of blood from right adrenal vein in difficult cases.

RESULTS: PVE was successful in all patients.There were no

AVS was successful in 25 (83.3%) of those 30 patients in the first

attempt. 5 patients need a second AVS, 2 due to unsuccessful
cannulation and the other 3 due to inconclusive biochemical
results. There was 1 complication of minor adrenal venous
dissection which as self-limiting and no death.
Among these 30 patients, there were 16 (53.3%) unilateral APA,
13 (43.3%) bilateral hyperplasia, and 1 (3.3%) pituitary-caused
hyperaldosteronism.
All patients had a prior CT scan(s), 19 patients were reviewed
to have unilateral nodules, 7 had bilateral disease, and 4 were
normal scan. Concordance between computed tomography and
adrenal vein sampling was observed only in 9 (30%) of the 30

major,procedure related complications.Mean absolute FLR

increased significantly (p<0.001) from 434 to 524 cm3,and
standardized FRL to TVL ratio was also increased significantly
(p<0.001) from mean 37.9 to 46.1 %.Mean standardized FLR
increase ratio was 8.2 %.
CONCLUSION: MFC as the embolic material is safe and
effective, in preoperative PVE for patients with hepatobiliary
malignancies,resulting in sufficient hypertrophy of the FLR.

Poster Exhibition

Poster Exhibition

patients.
Of the 16 patients with unilateral disease, 8 were still
pending surgery. 8 patients underwent successful laparoscopic
adrenalectomy, with pathology all reviewed to be cortical
adenoma. All these 8 patients were cured of hypokalemia and
showed a significant reduction in their blood pressure.
Conclusion: Adrenal venous sampling is superior to imagebased techniques in differentiation of primary aldosteronism
and in localization of hyperfunctioning adrenal adenoma.
Though an intricate procedure, AVS was technically feasible
and safe with increasing experience and proficiency of the
angiographer.

422

423

Poster Exhibition

PE141

PE142

Endovascular treatment of hepatic venoocclusive disease, a case report

PE143

A case of unretrievable vena cava filter

Mika Kamiya1, Koichiro Yamakado2, Shuhei Yamashita1,

3

Tatsuya Igarashi , Hatsuko Nasu , Kinya Kawamura ,

1

Tomo Kimura1, Joe Toda2, Shinshu Katayama2,

Harumi Sakahara

Asuka Tsuchiya

Department of Radiology, Hamamatsu University School of

Medicine, JPN
2

Department of Radiology, Mie University School of

Medicine, JPN
3

Department of Radiology, Fujieda Municipal Hospital, JPN

Department of Diagnostic Imaging, Ochanomizu Surugadai

Clinic, JPN
2

Department of Diagnostic Imaging and Interventional

Radiology, Tokyo Womens' Medical University, JPN

A case of IVC penetration after the

placement of Gunter Tulip vena cava filter
Yasuhiro Yunoki1, Hisao Masaki1, Atsushi Tabuchi1,
Hiroshi Kubo1, Daisuke Mimura1, Kousaku Nishigawa1,
Hiroki Takiuchi1, Yoji Kubo1, Yoshiko Watanabe1,
Kazuo Tanemoto1, Yasuhiko Kamata2, Yoji Neishi2,
Kiyoshi Yoshida2
1

Department of Cardiovascular Surgery, Kawasaki Medical

School, JPN

Management of refractory recurrent central

venous occlusion after Wallstent placement
in hemodialysis patient
Gyoo-Sik Jung1, Byeong-Ho Park2, Je-Ryang Juhn3
1

Department of Radiology, Kosin University College of

Medicine, KOR
2
Department of Radiology, Dong-A University College of
Medicine, KOR
3

Department of Cardiology, Kawasaki Medical School, JPN

Department of Radiology, Inje University College of

Medicine, KOR

PE144

Department of Hepatology, Hamamatsu University School

of Medicine, JPN
We report a patient of hepatic veno-occlusive disease treated

Purpose: To report the experience of unretrievable OptEase

We present here a case of IVC penetration after IVC filter

Central venous stenosis and occlusion in patient undergoing

with endovascular venous angioplasty. (case presentation)

inferior vena cava (IVC)filter.

placement.

hemodialysis are common complication that leads to significant

A 31-year-old woman was referred to our hospital with severe

Case and result: the patient, 38-year-old-female, was admitted

A female in her 30s was admitted to our hospital for further

morbidity and to dysfunction of the hemodialysis access.

fatigue and abdominal distention for a month. A contrast-

due to deep vein thrombosis. The protein S deficiency related

examination and treatment of a pulmonary thromboembolism

Surgical management options have high primary patency

enhanced CT scan revealed that the hepatic veins were

with pregnancy was found. OptEase IVC filter was implanted

with deep vein thrombosis. She was hemodynamically stable,

rates, but they are prone to significant morbidity, especially

completely occluded with thrombus and massive ascites

one day before delivery. Retrieval of the filter was done at 21

and anticoagulation therapy with heparin sodium was begun. A

considering the poor health status of most hemodialysis

was noted from the upper abdomen to the pelvis. Our pre-

days and 26 days after implantation. The hooks of the filter

week later, a follow-up CT examination showed an enlargement

patients. Percutaneous transluminal stenting is effective in the

interventional diagnosis was hepatic veno-occlusive disease

were tightly adherent to IVC wall. Slight downward migration

of the venous thrombus. Thrombolytic therapy with Urokinase

treatment of central venous stenosis or occlusion and shows

compatible with Budd-Chiari syndrome type 4. There were 2

was also seen. Finally, this filter was placed as permanent

was started after the placement of a retrievable IVC filter

improved long-term patency rates. Repeat intervention for the

treatment of choice, liver transplantation and percutaneous

one. Angiography, CT, and US showed no trapped thrombus or

(Gunther Tulip vena cava filter) in the infrarenal IVC. After the

treatment of stent reobstruction can be easily performed with

endovascular technique including venous angioplasty and

penetration of the hooks through IVC wall.

placement, the patient began to complain of lumbago on her

balloon dilation alone or additional stent placement. In order to

TIPS. We actually performed 2 sessions of endovascular

Coclusion: The relation between filter hooks and IVC wall

right-side. A further CT showed that one of the legs of the IVC

achieve successful repeat intervention, however, the occluded

intervention. On the first session, we approached the right

were unknown. The filter design, placed level, dwell time, and

filter penetrated the IVC wall and the tip of the leg touched the

stent should be traversed. Authors report a case of successful

hepatic vein (RHV) under CT fluoroscopic guidance to place the

migration should be discussed.

lumbar vertebra. This was a possible cause of her lumbago. In

management of the refractory recurrent central venous

very stiff guidewire from the RHV through the inferior/superior

spite of the anticoagulation therapy and thrombolytic therapy,

occlusion after Wallstent placement in hemodialysis patient, by

vena cava to the right internal jugular vein. We applied balloon

the venous thrombus worsened. A large thromboembolus was

using direct stent puncture technique.

angioplasty on the RHV. On the second session we delivered a

captured in the IVC filter, and the IVC was finally occluded.

bare stent to the proximal portion of the RHV. After 2 sessions

The patient received surgery for the removal of the IVC filter

of treatment, thrombus remained in the RHV, but her ascites

and the closing of the IVC. The postoperative course was

decreased dramatically and she returned to normal life with

uneventful. She underwent anticoagulation therapy with

oral administration of Warfarin and diuretics. (discussion)

warfarin sodium and compression therapy with an elastic

Hepatic venous occlusion is sometimes live-threatening and

stocking. The patient was discharged from our hospital under

results in death from hepatic failure. We should treat those

her own power on the 16th postoperative day.

patients with no delay. Endovascular venous angioplasty is

In retrospect, the placement of a retrievable IVC filter

useful and efficient, so it should be applied as soon as possible.

was absolutely essential to the treatment of this patient.

Prompt and accurate diagnosis is also necessary.

Some studies have reported cases of IVC penetration after

the placement of a Guenter tulip vena cava filter. Further
discussion is needed on the indication of ICV filter placement.

Poster Exhibition

Poster Exhibition

Future improvement of this device and its usage could possibly

lead to better future outcomes.

424

425

Poster Exhibition

PE146

PE145

An experimental study of radiofrequency

ablation with fine needle electrode combined
with injection of various solutions
1

Hiroshi Anai , Nobuyuki Kawai , Akira Ikoma ,

1

SPIO MR imaging for evaluation of

ablative margin for liver metastasis after
radiofrequency ablation
Noriyuki Miyamoto, Hiroshi Taguchi,

Satoru Sueyoshi , Toshihiro Tanaka ,

Kazuhide Hiramatsu, Yukihiko Sato

Hideyuki Nishiofuku1, Morio Sato2, Kimihiko Kichikawa1

Department of Radiology, Obihiro Kosei General Hospital,

JPN

Department of Radiology, Nara Medical University, JPN

Department of Radiology, Wakayama Medical University,

JPN

PURPOSE: Radiofrequency ablation (RFA) has been widely

adapted for the malignant tumors as a curative treatment
modality. However the size of the available electrode, ranged
from 12 to 17 gauge, is larger than that of the needle for
percutaneous ethanol injection. We developed a 21 gauge fine
needle electrode (FNE) for RFA with injection of solutions. The
aim of this study is to clarify the difference between RFA with
FNE combined with injection of various solutions.
MATERIALS&METHODS: RFA was applied with use of RF2000/3000 (Radiotherapeutics co.) and FNE. FNE with 3
side holes at the needle tip was completely insulated with
Teflon coating except for the last 2 cm of the needle tip. We
can infuse solutions through these side holes into the tissue.
RF ablation with FNE was applied in ten porcine livers with
continuous injection of solutions at 5 ml/min for 10 minutes
during RF ablation. Generator output was set at 50 watts.
We injected normal saline (NS), hypertonic saline (HS), 70%
ethanol (saline:absolute ethanol=3:7)(ET) and 50% acetic acid
(saline: acetic acid=1:1)(AA). We measured and compared the
coagulation size and volume macroscopically in RFA with FNE
combined with injection of each solution.
RESULTS: The mean coagulation size was measured 52x 33
mm in NS, 41x26mm in HS, 22x13 in ET and 56x40 mm in AA.
The mean coagulation volume was measured 39.4ml in NS,
18.7ml in HS and 1.8ml in ET and 60.6ml in AA. The size and
volume of the coagulation area in NS and AA were significantly
larger than that the other groups. However the coagulation
shape compared with other groups, especially AA. The shape
of the coagulation area in AA was wedged-shaped, which was
suspected segmental infarction due to the distribution of acetic
acid.
CONCLUSIONS: It is suggested that radiofrequency ablation
with fine needle electrode combined with injection of normal
saline create the ideal coagulation shape and obtain the
practical coagulation size and volume.

426

Usefulness of vessel guard (VG) technique

in cryoablation for lung tumors near the
large vessels
Masanori Inoue1, Seishi Nakatsuka1, Hideki Yashiro1,
Nobutake Ito1, Sota Oguro1, Subaru Hashimoto1,
Yotaro Izumi2, Kohei Hashimoto2, Yoshikane Yamauchi2,
Hiroaki Nomori2, Masafumi Kawamura3, Sachio Kuribayashi1
1

Department of Diagnostic Radiology, Keio University School

of Medicine, JPN
2
Division of General Thoracic Surgery, Department of
Surgery, Keio University School of Medicine, JPN
3
Division of General Thoracic Surgery, Department of
Surgery, School of Medicine, Teikyo University, JPN

PE148

Predictors of renal function after

percutaneous radiofrequency ablation of
renal tumor
Hideo Gobara1, Takao Hiraki1, Hiroyasu Fujiwara1,
Hiroaki Ishii1, Mayu Uka1, Koji Tomita1,
Yoshihisa Masaoka1, Hiroki Ihara1, Satoko Kogawa1
Hidefumi Mimura2, Susumu Kanazawa1
1

Department of Radiology, Okayama University Medical

School, JPN
2

Department of Diagnostic Radiology 2, Kawasaki Hospital,

Kawasaki Medical School, JPN

Purpose: We revealed that the existence of large vessels, 3.0

Purpose: The purpose of this study was to retrospectively

mm or larger in diameter, within 3 mm from the tumor was

evaluate change in renal function after percutaneous

determined as a statistically significant risk factor for local

recurrence after cryoablation of lung tumors. It is probably
due to the heat-sink phenomenon. Thereby, in order to improve
local control rate, we have performed VG technique: we
inserted another cryoprobe between the tumor and the vessel
or peripheral region of the tumor adjacent to the vessel. The
purpose of this study is to clarify the usefulness of VG technique.
Materials and Methods: Ethical approval for conducting
cryoablation was obtained from our institutional review board.
From October 2002 to December 2009, a total of 235 sessions
of cryoablation for 451 lung tumors in 145 consecutive patients
were performed. Tumors with large vessels greater than 3 mm in
diameter, within 3 mm from the edge of the target tumor were
included in this study.
Of 451 lung tumors, 59 tumors matched with the inclusion
criteria in 40 patients (26 men and 14 women; mean age, 57.3
years; age range, 27-82 years). The 59 tumors were treated in 55
sessions and devided into two groups according to the treatment
methods: VG group (treated with VG technique) and non-VG
group (treated without VG technique). Finally, 24 tumors (mean
tumor size, 17.0 mm; 22 metastatic tumors, 2 primary lung
cancer) were assigned to the VG group, and 35 patients (mean
tumor size, 14.2 mm; 35 metastatic tumors, 0 primary lung
cancer) to non-VG group.
We retrospectively analyzed and compared the local control rate
between two groups using Kaplan-Meier analysis and log-rank
test.
Results: The mean follow-up period was 535 days (range, 901832 days). The difference of mean tumor size between two
groups (17.0 mm in VG group VS 14.2 mm in non- VG group )
are statistically significant (P=0.038). The 1, 3, and 5 year local
control rate in VG group (76.9%, 76.9%, and 64.1%, respectively)
were superior to those in non-VG grouop (57.4%, 38.3%, and
28.7%, respectively). The total local control rate was 70.8%
and 54.3% in VG group and non-VG group, respectively. The
intergroup difference of local control rate was statistically
significant (p=0.028).
Conclusion: VG technique improves local control rate in

radiofrequency (RF) ablation of renal tumor and establish the

prediction equations for renal function after treatment.
Materials and Methods: From Jun 2002 to August 2010,
we performed 118 RF ablation sessions for renal tumors in
our institution. This study included 54 RF ablation sessions
performed for 66 renal tumors in 43 patients (25men, 26
women; mean age, 58.0 years). We reviewed medical chart and
CT images, and recorded many patients and procedural values.
Glomerular filtration rate before (pre-GFR) and 1 month after
RF ablation (post-GFR) was calculated using Cockcroft-Gault
formula. All ablation sessions were done under CT fluoroscopy
guidance using an internally cooled electrode (Cooltip,
Covidien, Mansfield, MA). Numerous values were evaluated
using pared t-test or two-way repeated measured analysis of
variance (ANOVA). Prediction equation was calculated using
multiple, stepwise, linear regression analysis.
Results: A maximum tumor diameter was 23.5 10.9 mm
(range 10 - 65 mm). Seventeen of 43 patients (40%) had a
solitary kidney. The tumor located exophytic in 38 sessions
(70%), central in 10 (19%), mixed in 6 (11%). A mean post-GFR
(66.2 mL/min, range 11.4 - 159.3) was significantly (p = 0.0002)
lower than pre-GFR (72.2 mL/min, range 19.3 - 157.9). There
were several significant risk factors including solitary kidney
(p = 0.033), maximum tumor diameter (more than 30 mm, (p =
0.037), and tumor number treated at the same session (more
than 2 tumors per session; (p = .014). Age ((p = 0.089), sex ((p
= 0.44), and central location (p = 0.16) were not significant
risk factors for GFR decrease. Stepwise multiple regressions
in variables revealed that GFR after the RF ablation of renal
tumor was predicted best by the following equation: post-GFR
(mL/min) = [0.90 x pre-GFR (mL/min)] + [-0.48 x maximum
tumor diameter (mm)] + [-5.73 x tumor number/session] + [-5.65
x solitary kidney (solitary = 1, bilateral = 0)] +21.95 (p < 0.0001,
r2=0.90).
Conclusion: Solitary kidney, maximum tumor diameter, and
tumor number treated at the same session were good predictors
for GFR after RF ablation of renal tumor.

cryoablation for the lung tumors close to the large vessels.

427

Poster Exhibition

Poster Exhibition

area ablated with FNE in NS was most spherical or oval

Purpose: Evaluation of the ablative margin (AM) after

radiofrequency (RF) ablation for liver metastasis is not easy
because of the difficulty of differentiating between viable tumor
and necrotic tissue on enhanced CT. We evaluated the clinical
usefulness of MR imaging using superparamagnetic iron
oxide (SPIO) for assessing the AM after RF ablation for liver
metastasis.
Materials and Methods: Eight patients (4 men and 4 women,
age 38-78 years) with 14 liver metastases were enrolled in
this study. The liver metastases originated from colorectal
carcinoma (number of patients, n=4), breast carcinoma
(n=2), gastrointestinal stromal tumor (GIST) (n=1), and
gastrointestinal carcinoid (n=1). The tumor size ranged from
10 to 38 mm (mean:19mm).All patients underwent RF ablation
one day after SPIO-enhanced MR imaging. RF ablation was
performed using real-time contrast-enhanced sonography. The
tumor, AM, and nonablated liver parenchyma were evaluated
by unenhanced T2WI and T2*WI MR imaging acquired 1-2
days after RF ablation. A hypointense rim around the central
hyperintense area was defined as AM. The size of the tumor and
thickness of the AM were analyzed. The signal intensity of the
tumor, non-ablated liver, and paraspinal muscle were measured
after RF ablation. Signal-to-muscle signal ratios were calculated
for tumors, AM, and nonablated liver parenchyma.
Results: The AM appeared as a hypointense rim in 10 nodules
on T2WI, and in all 14 nodules on T2*WI. AMs were more
clearly visualized on T2*WI than on T2WI. The AM status
was judged as margin plus in 12, zero in 1, and minus in
1.The length of the AM could be measured in 12 nodules and
the minimal thickness of AMs ranged from 2.5 to 7.0 mm. No
significant difference was seen between tumor diameter before
RF ablation and after RF ablation; however, after RF ablation
there were three nodules that were larger (>5mm) than before
RF ablation on T2*WI. The post-RF-ablation signal-to-muscle
ratio of the AM was significantly lower than the those of the
tumor and nonablated liver parenchyma. During the followup period (2-18 months), local tumor progression was detected
in one tumor (local recurrence rate, 7.1%), the case in which
the AM status was minus. Distant intrahepatic recurrence was
noted in 2 patients (25%).
Conclusion: This technique is feasible for visualization of the
AM and prediction of local tumor progression after RF ablation
for liver metastasis.

PE147

Poster Exhibition

PE150

PE149

Therapeutic effectiveness and safety of

radiofrequency ablation of hepatocellular
carcinoma in the hepatic dome with the CTguided transpulmonary approach

Experimental study of radiofrequency

ablation using a new type of internally
cooled electrode with an adjustable tip in ex
vivo pig liver

Radiofrequency ablation for renal abscess

A case of diaphragmatic hernia caused by

radiofrequency ablation for hepatocellular
carcinoma that developed intestinal obstruction
after transcather chemo-embolization

Kumi Ozaki1, Koji Nobata1, Yasuhiro Kawamori1,

Masakatsu Tsurusaki1, Shinji Ando1,

Toshiyuki Matsuoka1, Akira Yamamoto1,

Shinici Hamamoto1, Etsuji Sogawa1, Ken Kageyama1,
Yukio Miki1, Atsushi Yoshida2, Taro Iguchi3

Tomoaki Yamanishi1, Taiji Tamura2, Yasuhiro Ogawa2,

Yasushi Horichi , Kiyohide Kitagawa , Mitsuhiro Terada

Kazutoshi Kamiyama , Shigetaka Nakai ,

Tomomi Hashimoto3, Kazushi Ohara3,

Department of Radiology, Kouseiren Takaoka Hospital, JPN

2
Department of Gastroenterological Medicine, Kouseiren
Takaoka Hospital, JPN

Megumi Nakamura1, Hajime Kitagaki1

1

Department of Radiology, Shimane University School of

Medicine, JPN
2

ME Center, Shimane University Hospital, JPN

Department of Radiology, Shimane University Hospital, JPN

Purpose: To determine the therapeutic effectiveness and

safety of radiofrequency (RF) ablation with CT-guided
transpulmonary approach for the treatment of hepatocellular
carcinomas (HCCs) in the hepatic dome that were undetectable
at ultrasonography.
Materials and methods: Between April 2010 and November
2011, 14 consecutive patients (eight males, six females; mean
age, 73.2 7.4 years; age range, 57-88 years) with 18 HCCs
(mean size, 13.8 7.7 mm; size range, 5-38 mm) in the hepatic
dome were treated by RF ablation using cooled-tip electrodes
and with CT-guided transpulmonary approach combined with
(n= 15) or without (n= 3) transarterial chemoembolization.
Two radiologists retrospectively evaluated in consensus the
primary technical success rate and the presence or absence
of local tumor progression as well as the complications at CT
and/or chest X-ray performed immediately and approximately
7 days after RF ablation and at regular follow-up CT.
Results: The technical success of CT-guided RF ablation
immediately after procedures was obtained in all cases in
17 treatment sessions. There was no local recurrence at the
follow-up points (mean, 175.3 122.5 day; range, 4-350 day).
Minor complications were observed in 14 of the 17 treatment
sessions (76.5%); pneumothorax (n=11) (64.7%), pleural
effusion (n=4) (21.1%), and/or injury of pulmonary parenchyma
along the electrode tract (n=3) (15.8%). Major complication
was observed in one of the 17 treatment sessions (5.3%); tumor
seeding. No pneumothorax requiring drainage was observed.
Conclusions: RF ablation using CT-guided transpulmonary
approach is an effective and safe technique for the treatment
of HCCs in the hepatic dome.

PURPOSE: To evaluate the performance of radiofrequency (RF)

ablation using a new type of internally cooled RF electrode with
an adjustable active tip according to adjustment of the active tip
length in an ex vivo pig liver model, and to evaluate the effect of
the ablation zone with direct injection of lipiodol to ablation site.
MA TERIALS AND ME THODS: We performed ex vivo
experiments by RF ablation zones in a extracted pig liver using
a new type of RF electrode that had an adjustable active tip
(adjustable electrode; VCT-2030, RF Medical Co. Ltd., Seoul,
Korea) with 0.5, 1.0, 1.5, 2.0, 2.5, 3.0 cm active tip adjustments.
We also performed an in ex vivo study with the induction of RF
ablation using the adjustable electrode with 2.0 cm and 3.0 cm
active tip adjustments after direct injection of 2.0 mL and 3.0mL
lipiodol, respectively. The size and the ratio of the two axes of
the ablation zone were macroscopically evaluated and were
compared.
RESULTS: The mean lengths of the long axis using adjustable
active tips of 1.0,1.5, 2.0, 2.5, and 3.0 cm were 1.1, 1.6, 2.2,
2.6, and 3.2 cm, respectively. The mean lengths of the short
axis using adjustable active tips of 1.0,1.5, 2.0, 2.5, and 3.0 cm
were 1.2, 1.5 1.9, 2.2, and 2.6 cm, respectively. Although all of
active tips over 1.0 cm achieved break down and over 60C
at tip temperature, it was impossible to maintain enough
impedance using 0.5 cm. There was no significant difference
in ablation performance between the use of conventional and
adjustable electrodes using 2.0 and 3.0 cm. The mean lengths
of the long axis using tips of 2.0 and 3.0 cm were 2.6 and 4.0cm,
respectively. The mean lengths of the short axis using tips of 2.0
and 3.0 cm were 2.2and 3.9 cm, respectively. The ablation zone
using both 2.0 and 3.0 cm adjustable active tips were larger
than without lipiodol compared with direct injection of lipiodol
according to the distribution of lipiodol spreading.
CONCLUSION: Using a new type of internally cooled RF

Department of Radiology, Osaka City University, Graduate

School of Medicine, JPN
2

Department of Nuclear Medicine, Osaka City University,

Graduate School of Medicine, JPN

Kenta Oogi2, Hitomi Iwasa2, Yuuko Kataoka2,

Toshiji Saibara3, Shinji Iwasaki3, Akira Hirose3
1

Department of Radiology, Kochi Prefectural Aki Hospital,

JPN
2
Department of Radiology, Kochi Medical School, JPN
3

Department of Gastroenterology and Hepatology, Kochi

Medical School, JPN

We report a case of refractory renal abscess that was

Radiofrequency ablation (RFA) is commonly used for treating

successfully treated by radiofrequency ablation. A woman in her

hepatic malignancies. Severe complications can happen like

Department of Urology, Osaka City University, Graduate

School of Medicine, JPN

50s was admitted with high fever and the right back pain. She

intraperitoneal bleeding, pneumothorax, hemothorax, liver

had a history of ESWL for bilateral renal stones 15 years before

abscess, and bile duct injury. Diaphragmatic hernia caused by

and subsequent renal dysfunction. In September, 2010, right

RFA for hepatocellular carcinoma (HCC) is relatively rare, and

back back pain and fever of the 39 degrees level developed. The

we report a case of diaphragmatic hernia caused by RFA for

right kidney abscess with the calculus was recognized by CT.

HCC that developed intestinal obstruction after transcather

The condition was relieved by administration of antibiotics and

chemo-embolization (TACE).

the abscess drainage. However, condition recurred two weeks

The patient was 75-year-old woman. She was admitted for

after a discharge. The same things were repeated three times

HCC treatment arising from a cirrhotic liver was found in

by January of the next year after a first discharge. She refused

contrast-enhanced computed tomography (CT) to have a

right nephrectomy because renal dialysis might be followed.

solitary HCC 1.2cm at its greatest dimension in Couinaud

Then RFA was chosen. After an abscess cavity was reduced by

segment 5. We conducted transcatheter chemo-embolization

drainage, CT guided RFA was performed using LeVeen Needle

and percutaneous ultrasound-guided RFA for this hepatic

with 3cm in diameter in February of this year. Roll off was

lesion. 15 months later, chest X lay and CT revealed small

achieved twice and a procedure was completed without any

diaphragmatic hernia. Beacause of no symptom and hepatic

complication. It passed for nine months after a discharge and

insufficiency, conservative therapy was chosen. 19 months later,

recurrence of the condition is not found.

she was admitted for treatment new HCC 2.1cm at its greatest
dimension in Couinaud segment 6. We conducted transcatheter
chemo-embolization again. No complications were seen during
its procedure. 7 days later, she suffered severe vomitting and
dyspnea. CT revealed a prolapsed small intestine through the
right diaphragm, and emergency surgery was performed. We
confirmed that the small intestine had slid into the right cavity
through a 5cm defect of the diaphragm. She was received a
repair of diaphragmatic hernia with no resection of small
intestine. She was discharged 17 days after surgery.
This case illustrates the fact that RFA may produce severe
late complications. Patients who have undergone RFA for a
hepatic tumor adjacent to the diaphragm should be carefully
followed up for possible diaphragmatic hernia, even after a long
postoperative interval.

electrode, we could induce different volumes of the RF ablation

zone by means of adjusting the length of the exposed active
tip over 1.0 cm, where performance was similar to the use
of a conventional internally cooled RF electrode. And also, it
was possible to make larger ablation zone according to the
distribution of lipiodol after direct injection.

428

429

Poster Exhibition

Poster Exhibition

PE152

PE151

Poster Exhibition

PE153

PE155

PE156

Development of bone cement needle in

coaxial structured

Distal upper extremity arteries using

assistive devices(warm water) angiography

The necessity of microcatheter of special

length; A case report

Genital bleeding due to pelvic arteriovenous

fistula, successfully treated with three
stepped interventional procedures: Case
report

Shingo Hamaguchi, Misako Yoshimatsu,

Ji Sang Jung1, Yoo Jei Hoon1, Kang Sung Ho1,

Lim Jae Sik1, Lee Eul Sun1, Kim Man Deuk2,
Won Jong Yoon2

Taku Yamamoto, Shigeru Watanabe, Akira Yamamoto,

Hiroki Sasaki1, Masaaki Akahane1, Jiro Sato1,

Masaki Katsura1, Kazuchika Hagiwara1, Wataru Gonoi1,
Takashi Kidouchi1, Masamichi Takahashi2, Kuni Ohtomo1

Yukihisa Ogawa, Yasunori Arai, Atsuko Fujikawa,

Kenji Murakami, Iwao Uejima, Yasuo Nakajima
St. Marianna University School of Medicine, JPN

Purpose: In Percutaneous Vertebroplasty (PVP), high frequent

Radiology, Severance Hospital, KOR

Department of Radiology, Yonsei University, KOR

Akihiko Kanki, Teruyuki Torigoe, Kazuya Yasokawa,

Daigo Tanimoto, Hiroki Higashi, Tsutomu Tamada,
Katsuyoshi Ito
Department of Radiology, Kawasaki Medical School, JPN

Department of Radiology, The University of Tokyo Hospital,

JPN
2
Department of Radiology, Tokyo Metropolitan Bokutoh
Hospital, JPN

Purpose: To determine whether using a warm water bag as an

A man in his sixties with right femoral intramuscular

Purpose: To share a clinical experience of multi-stage

assistive device improves the accuracy of distal upper extremity

abscess needed to perform emergency transcatheter arterial

endovascular treatment for retroperitoneal arteriovenous

angiography

embolization (TAE) to avoid massive bleeding during surgical

fistula (AVF).

Materials and Methods: From 2009.9 - 2011.2, 56 patients

debridement. We planned TAE of right medial femoral

Case report: 58-year-old woman visited our hospital with a chef

underwent upper extremity angiography by inserting the H1

circumflex artery and the right obturator artery. However,

complaint of genital bleeding. Multi-detector row CT (MDCT)

catheter up to the brachial artery and afterwards a warm water

bilateral femoral artery couldnt be used as approach artery

revealed pelvic AVF which had a large number of tortuous

bag was placed in their palm to elevate the hand temperature.

due to Y-graft replacement for his abdominal aortic aneurysm.

and dilated vessels in the retroperitoneal space including the

After inserting 3/12cc of contrast material, upper extremity

We had to perform TAE via left brachial artery. We tried

uterus. The patient was considered a poor candidate for surgery

angiography was performed and the extent and number of

to perform TAE using following catheter system; a 90cm-

due to the location of fistula and tortuous and aneurismal

visualized vessels were measured and classified into 5 grades.

length guiding sheath and a 115cm-length parent-catheter,

vessels lying nearby the fistula. On the day before her

Results: Among the 56 cases, none were 0 or grade 1, 7 cases

but micro-catheter couldnt reach the target arteries for

scheduled admission, massive genital bleeding occurred. She

were grade 2, 13 cases were grade 3, and 26 cases were grade 4.

TAE because of elongation of approach route due to severe

was admitted emergently and treated conservatively. Massive

The total average grade was 2.8. In the test group composed of

tortuosity of the discending aorta and kinking of prosthetic

genital rebleeding occurred on the 5th hospital day and her

31 cases in which warm water bags were used, none were grade

vascular graft. Therefore we used a microcatheter of special

1st emergent embolization was performed. Arteriography

0-2, 5 cases were grade 3, and 4 cases were 3.8. The average

length (160cm length) and TAE was successfully performed.

revealed high flow AVF with very severe elongation and

grade of the test group was 3.8. In the control group, none were

In the case have to approach from brachial artery and target

tortuosity of related arteries and veins. The 1st embolization

grade 0 or grade 1, 7 cases were grade 2, 8 cases were grade 3,

vessels are lower abdomen or lower extremity, the tortuosity

was performed via the right femoral artery and right carotid

prototype.

and none were grade 4. The average grade of the control group

of aorta for approach route should be checked before procedure

vein approach, but the fistula could not be reached. On the 14th

In cadaver experiment, we measured following test items about

was 2.5.

and if severe tortuosity of aorta is revealed, using of the

hospital day, she had another episode of genital bleeding. A 2nd

prototypes.

Conclusion: For sufficient visualization of distal vessels at

microcatheter of special length should be considered.

arteriography was performed, which showed reduced flow of

cement leakage to external vertebral body is problem, and the

rise of internal vertebral body pressure is considered as one of the
causes.
Presenter developed the PVP punctual needle which has coaxial
structure and multiple side holes at end tip. Bone cement (PMMA)
can be injected while suppressing the increase of internal
vertebral body pressure in one needle method. This time, we
report the experimental results which prototype needle was
experimented in cadaver and improved prototype needle was
experimented in phantom.
Method: Totally 8 prototype needles were prepared. All needles
are coaxial structure metal pipe which has main port and side
port at handle, and which has multiple side holes at end tip. The
number of side holes is 10 holes or 36 holes. These side holes
diameters also is various to 0.3mm, 0.5mm and 1.0mm. Clearance
between coaxial pipes also is different according to 95m and
115m. Among all candidate prototypes, we selected 8 kinds

Simultaneous opening of the clearance of coaxial pipe in the

injection to vertebral body, internal vertebral body pressure during
cement injecting, opening status of side holes after the puncture,
and others. According to test results, we also did improvement of
the prototype needle.
After that, we measured and evaluated with internal pressure
during cement injecting in phantom for the improved prototype
needles.
Results: In cadaver experiment, we confirmed simultaneous
opening of the coaxial pipe with all prototype needles when
vertebral body got punctured by these . The side hole blockage did
not depend on the hole diameter. Temporary rising of the pressure
was observed during cement injection, but the pressure decreased
immediately. Based on the test result, we improved the prototype.
In phantom experiments with improved model, we confirmed
suppression of the pressure variations before and after injection of

upper extremity angiography, using warm water bags to

AVF compared to the 1st arteriography. The 2nd embolization

elevate hand temperature is an effective method. This method

was performed via the left femoral artery and vein. Follow-

not only avoids the side effects due to high viscosity of contrast

up MRI study on the 23rd hospital day revealed patency of

material, but also prevents unnecessary radiation exposure due

the fistula, which was confirmed by her 3rd arteriography

to repeated angiography.

on the 25th hospital day, although the flow of AVF was much
lower than the flow observed in her 2nd arteriography. The 3rd
embolization was performed via the left femoral artery. Finally,
obstruction of the fistula was confirmed on follow up MRI
performed on the 33rd hospital day.
Conclusions: The main goal of the endovascular treatment of
AVF is complete obstruction of fistula, however, super-selective
catheterization of vessels nearby fistula can be challenging
because of elongation and tortuosity of related vessels. Multistage endovascular treatment may be an option of choice in the
management of pelvic AVF.

cement as we expected.
Conclusions: The developed prototype needle for injection of bone
cement could be expected to inhibit the rising of internal vertebral
body, and may contribute to improving the safety of PVP.

430

431

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PE160

Embolotherapy for pulmonary arteriovenous

malformations in the patient of hereditary
hemorrhagic telangiectasia complicated
with hepatic arteriovenous malformations

A case of transcatheter arterial embolization

with n-butyl 2-cyanoacrylate for congenital
pelvic arteriovenous malformation

Case report; Lower limb ischemia caused

by steal phenomenon due to large pelvic
AVM

Ethanolamine oleate sclerotherapy

combined with transarterial glue
embolization for extra-cranial arteriovenous
malformations

Katsuhiko Matsuura1, Kohei Hamamoto1,

Hidefumi Fujisawa, Takako Fukushita, Kumiko Koyama,

Keiichiro Ohba, Kazuya Matunari, Shinya Yagi,
Kota Watanabe, Shoh Funaki, Megumi Tanisaka,
Noriko Sunaoshi, Tamio Kushihashi

Yusuke Yokota1, Takanori Taniguchi1, Kensuke Uotani1,

Akiko Kawasaki, Naoto Katayama1, Takeshi Nishina2,

Akira Kitagawa, Arisa Shimizu, Shuji Ikeda,

Yuichiro Izumi, Eisuke Katsuda, Makiyo Hagihara,
Junko Kimura, Seiji Kamei, Toyohiro Oota,
Tsuneo Ishiguchi

Daisuke Nakatsuka2, kazuo Yamanaka2, Satoshi Noma1

Department of Radiology, Aichi Medical University, JPN

Tomohisa Ohkouchi , Akira Ishii , Hitoshi Sugawara ,

Osamu Tanaka1
1

Department of Radiology, Saitama Medical Center, Jichi

Medical University, JPN
2
Department of Internal Medicine, Saitama Medical Center,
Jichi Medical University, JPN

Background: Transcatheter embolization is the major therapeutic

modality for pulmonary arteriovenous malformations (PAVMs)
in the patient of hereditary hemorrhagic telangiectasia (HHT).
Although this procedure is relatively safe, it is reported the
case which developed acute pulmonary hypertension and high
output heart failure after embolization of PAVMs in HHT patient
complicated with hepatic arteriovenous malformations (HAVMs).
The proposed mechanism is that the occlusion of PAVMs (right-toleft shunts) could worsen the high cardiac output state caused by
the large systemic left-to-right shunt due to HAVMs. However, the
relationship between pulmonary hypertension and embolization of
PAVMS in the patients complicated with HAVMs are unclear. We
report here the clinical courses and radiological findings during
the transcatheter embolization of PAVMs in two HHT patients
complicated with HAVMs.
Case reports: Case one is a 65-year old male who diagnosed with
HTT based on Curacao clinical criteria, referring for our hospital
for embolization of PAVMs. He had multiple PAVMs in bilateral
lung (3 in right lobes and 2 in left lobe) and HAVMs. He complained
the exertional dyspnea, and an arterial blood samples showed
hypoxia (PaO2 of 60.1 mmHg). Transcatheter coil embolization
was performed in three sessions. The pulmonary arterial pressures
(PAPs) were measured before and after embolization at each session.
All PAVMs were completely embolized without major complication.
There was no evidence of elevation of PAPs during embolization at
any sessions. After embolization, his symptoms and hypoxia were
obviously improved (PaO2 of 78.2 mmHg). Case two is a 62-year
old female with familial HHT, was hospitalized for embolization of
PAVMs. She had the history of receiving aortic valve replacement
in twice because of recurrent infectious endocarditis, and was
treated with medical therapy for chronic heart failure. Additionally,
she complained exertional dyspnea (NYHA grade II). Computed
tomography showed multiple PAVMs in bilateral lung (2 in right
lobes and 1 in left lobe) and HAVMs. Transcatheter coil embolization
was performed in two sessions. As with the first case, all PAVMs
were embolized completely without major complication, increase
of PAPs, and acute progression of chronic heart failure. After
embolization, her symptoms were slightly improved.
Conclusion: The transcatheter embolization is safe and effective
treatment of PAVMs in the patient of HTT, even in the cases
complicated with HAVMs. Nevertheless, multi-step embolization
might be considered in the cases with multiple PAVMs to avoid
abrupt hemodynamic changes, which could lead to acute pulmonary
hypertension and high output heart failure.

432

Department of Radiology, Showa University Northern

Yokohama Hospital, JPN

Naoki Kusunoki1, Yuko Nishimoto1, Nobuyuki Mori1,

Tsuyoshi Suga1, Hirotaka Tomimatsu1, Gosuke Okubo1,

Department of Radiology, Tenri Hospital, JPN

Department of Cardiovascular Surgery, Tenri Hospital, JPN

Congenital pelvic arteriovenous malformation (AVM) is

We report a case of lower limb ischemia occurred after

Purpose: To assess the safety and effectiveness of ethanolamine

extremely rare, especially in males. Herein we report a case

treatment of large pelvic AVM.

oleate (EO) sclerotherapy combined with transarterial glue

of male pelvic AVM in treated with IVR. A 53-year-old man

The patient was a 61-year old woman. When she was 53 year

(liquid adhesive agent) embolization for treatment of extra-

presented with left flank abdominal pain and hematuria which

old, she had an operation of intravenous leiomyomatosis in

cranial arteriovenous malformations (AVMs).

was suspected in ureterolithiasis. Non-contrast enhanced

lung and right atrium. In preoperative study, a large pelvic

M a t e r i a l s a n d M e t h o d s : Tw e n t y -f o u r pa t i e n t s w i t h

computed tomography (CT) yielded no ureteral stone and left

AVM was detected. After then, she was followed in ambulatory

symptomatic AVMs in the head and neck (15), extremity (5) and

pelvic mass 3cm in diameter. Dynamic contrast enhanced CT

care.

trunk (4) with the mean age of 44 years (range, 18-78) treated

showed left pelvic venous sack with multiple feeding arteries

8 year later, she presented severe symptoms of heart failure,

with EO sclerotherapy were retrospectively assessed. AVMs

from left internal iliac arterial branch. So, it was diagnosed

and high right atrium pressure. We suspected that enlarged

were classified according to the angiographic morphology of the

pelvic AVM. Transcatheter embolization was planned for

AVM caused heart failure.

nidus. There were 7 type II (arteriolovenous fistulae), 6 type

IIIa (arteriolovenulous fistulae with non-dilated fistula), 11 type

treatment. Pelvic aortography demonstrated three feeding

We deployed stent graft on abdominal aorta and bilateral

arteries, fine multiple arterioles shunt to the nidus, large

common iliac artery to reduce arterial inflow to the AVM from

IIIb (arteriolovenulous fistulae with dilated fistula). EO was

nidus, and dilated draining internal iliac vein. We inserted a

inferior mesenteric artery and right internal iliac artery. Her

delivered by percutaneous direct puncture or by catheterization

5F catheter though the left internal iliac artery and used a 2.0F

symptoms ware relieved.

into the draining vein under balloon occlusion. Transarterial

microcatheter for superselective embolization. Furthermore,

3 month later, she presented intermittent claudication of right

embolization using n-butyl cyanoacrylate was performed to

to avoid pulmonary artery thrombosis, left internal iliac vein

lower limb, and ABI was 0.63.

reduce arterial flow before sclerotherapy.

was occluded with balloon catheter. Each three feeding artery

Pressure gradient was detected between proximal and distal

Results: Three (13%) of 24 patients were cured, 17 (71%) had

and multiple shunt were embolized by n-butyl 2-cyanoacrylate

site of stent graft. We performed PTA and stent placement in

partial remission, and four (16%) had no remission. Treatment

(NBCA). Post embolization pelvic aortography demonstrated

the stent graft.

was considered effective (cure and partial remission) in 20

complete occlusion in feeding arteries and no venous shunt. A

However pressure gradient was remained. Collateral

patients (83%). Four patient (16%) experienced transient minor

follow up CT at one month showed no opacification of the pelvic

circulation into the pelvic AVM from right iliac circumflex

complications including self-healing skin ulcer (3) and localized

AVM. TAE with NBCA is good treatment option for pelvic AVM.

artery, right inferior epigastoric artery, right deep femoral

deep venous thrombosis (1). There was no major complication.

We discuss the clinical and treatment for pelvic AVM, and

artery was confirmed. It was suspected that lower limb

Conclusion: EO sclerotherapy combined with transarterial

review the literature.

ischemia caused by steal phenomenon due to pelvic AVM. We

glue embolization is safe and effective for treating extra-cranial

performed coil embolization of right iliac circumflex artery

AVMs with acceptable risk of minor complications.

that had higher inflow to the AVM. After the treatment, her
symptom was relieved. ABI also improved to1.01.
Steal phenomenon due to AVM is well known in brain and
spinal cord. To our knowledge, the present case is the first

Poster Exhibition

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PE159

report representing steal phenomenon due to pelvic AVM

caused lower limb ischemia.

433

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PE162

PE163

PE164

Treatment for the pancreatic arteriovenous

malformation involving gastric varices: A
case report

A new technique of transarterial N-ButylCyanoacrylate embolization for facial highflow arteriovenous malformations with
multiple small feeders

Risk factors for systemic air embolism

complicating percutaneous CT-guided lung
biopsy: Multicenter case-control study in
Japan

Analysis of factors influencing accuracy

and complications in CT-guided lung biopsy

Asari Sai, Norifumi Nishida, Ken Kageyama,

Toshinori Hirai1, Osamu Ikeda1, Hiroyuki Uetani1,

Yutaka Nakasone1, Yoshitaka Tamura1, Ryosei Minoda2,
Eiji Yumoto2, Yasuyuki Yamashita1

Hiroaki Ishii1, Takao Hiraki1, Hideo Gobara1,

Miyuki Nakatani, Noboru Tanigawa, Shuji Kariya, Atsushi

Yukimasa Sakai, Toshiyuki Matsuoka, Yukio Miki

Yoshitomo Ando7, Soichiro Hase8, Toshihiro Iguchi9,

Department of Radiology, Osaka City University Graduate

School of Medicine, JPN

Atsushi Jogo, Etsuji Sohgawa, Shinichi Hamamoto,

Hisayuki Cho, Akira Yamamoto, Toru Takeshita,

Department of Diagnostic Radiology, Graduate School of

Medical Sciences, Kumamoto University, JPN

Department of Otolaryngology-Head and Neck Surgery,

Graduate School of Medical Sciences, Kumamoto University,
JPN

A 69-year-old woman was admitted to our hospital for the

F a c i a l a r t e r i o v e n o u s m a l f o r m a t i o n ( AV M ) i s a r a r e

treatment of esophageal and gastric varices. She had a history

developmental lesion in the head and neck vascular anomaly.

of liver cirrhosis with hepatitis C virus infection. Dynamic

We report a new technique of transarterial N-Butyl-

computed tomography (CT) revealed the hypervascular lesion

Cyanoacrylate (NBCA) embolization in two patients of facial

in the body of pancreas, and dilated the gastric varices which

high-flow AVM with multiple small feeders. The AVM was

drained from the retrogastric vein to the gastrorenal (GR)

located at the tongue or cheek in each case. They presented

shunt.

with life threatening oral bleeding and facial pain, respectively.

Celiac angiography revealed a racemose vascular network

With conventional and scatter techniques, NBCA-lipiodol

in the body of pancreas, and also revealed early filling of the

mixture was selectively injected into the feeding arteries

portal vein and the gastric varices in the early arterial phase.

without complications. Scatter technique is the new method

We diagnosed it as the pancreatic arteriovenous malformation

to continuously deliver NBCA on the flow as small particles

(AVM), that elevated the portal venous pressure and caused the

from the proximal portion of the feeding artery to the multiple,

progression of the gastric varices.

small fistulas. In the patient with tongue AVM, a minor

At first, we performed the transcatheter arterial embolization

bleeding occurred 30 months after the initial embolization.

(TAE) of the pancreatic AVM with NBCA and metallic coils by

Her bleeding does not recur after the second embolization. In

two sessions. The wedged hepatic venous pressure (WHVP) was

the patient with cheek AVM, his symptom disappeared after

decreased from 24mm Hg to 19mmHg. Next, we successfully

the initial embolization and the AVM lesion was not observed

performed the balloon-occluded retrograde transvenous

on 12-month follow-up MRI. For treatment of facial AVMs, the

obliteration (B-RTO) from the GR shunt using 40mL of 5%

new technique of transarterial NBCA embolization appears to

ethanolamine oleate with iopamidol (EOI), and the final WHVP

be a safe and effective method.

was 23mmHg.
Although the pancreatic AVM is a rare disease, it becomes one
of the causes of portal hypertension and gastric varices. Like
this case, having TAE of the pancreatic AVM before B-RTO
,could reduce the portal venous pressure, and B-RTO followed
TAE could be performed safely and successfully.

Hiroyasu Fijiwara1, Hidefumi Mimura2, Kotaro Yasui3,

4

Tetsuya Doke , Takashi Mukai , Hironori Kurokawa ,

Department of Radiology, Kansai Medical University, JPN

Takayuki Yabuki10, Kenichi Omae11, Nobuhisa Tajiri12,

Susumu Kanazawa1
1

Department of Radiology, Okayama University Medical

School, JPN
2
Departments of Diagnostic Radiology 2, Kawasaki Hospital,
Kawasaki Medical School, JPN
3
Departments of Radiology, Okayama Saiseikai General
Hospital, JPN
4
Departments of Radiology, Fukuyama Medical Center , JPN
5
Departments of Radiology, Okayama Medical Center, JPN
6
Departments of Radiology, Tsuyama Chuo Hospital, JPN
7
Departments of Radiology, Chugoku Chuo Hospital, JPN
8
Departments of Radiology, Himeji Red Cross Hospital, JPN
9
Departments of Diagnostic and Interventional Radiology,
Fukuyama City Hospital, JPN
10
Departments of Radiology, Okayama Red Cross Hospital, JPN
11
Departments of Radiology, Iwakuni Medical Center, JPN
12
Departments of Radiology, Mitoyo General Hospital, JPN

PURPOSE: This study aimed to analyze factors influencing

accuracy and complications in patients who underwent computed
tomography (CT)-guided lung biopsy at our medical center.
METHOD: This study included 215 patients (137 men, 78
women; mean age, 68 years; range, 29-89 years) who underwent
CT-guided lung biopsy between January 2006 and April 2011.
The biopsy needle was a semiautomatic 18-gauge spring-loaded
cutting needle.
Final diagnosis, when surgical resection was performed, was
histopathological diagnosis from the lung lesion specimen, and
when resection was not performed, was clinical diagnosis after
>6 months of follow-up.
The accuracy of lung biopsy was assessed by comparison of
biopsy results and final diagnosis.

Objectives: To determine risk factors for systemic air embolism

complicating percutaneous computed tomography (CT)-guided
lung biopsy.
Design: Case-control study
Setting: Eleven institutions in Japan, from April 2000 to April
2011
Participants: 10 cases of systemic air embolism complicating
percutaneous CT-guided lung biopsy; 2206 controls.
Main outcome measures: Odds ratios for systemic air
embolism complicating percutaneous computed tomography
(CT)-guided lung biopsy.
Results: Univariate logistic regression analysis showed that

CT of the entire lung with 5-mm slices was performed

immediately after biopsy and a simple chest radiograph was
taken in the upright position five hours after biopsy to evaluate
the presence of possible complications.
RESULT: The technical success rate was 100% (215/215), and
the tissue sampling success rate was 99.1% (213/215).
CT fluoroscopy was used in 71.6% of cases.
Tw o p a t i e n t s w h o s e s a m p l e c o u l d n o t b e d i a g n o s e d
histopathologically and twenty-two patients whose final
diagnosis was undetermined were excluded from evaluation of
accuracy.
Accuracy of CT-guided lung biopsy was 92.7%. The accuracy
of CT-guided lung biopsy was significantly increased with

crude odds ratio (95% confidence intervals) was 5.25 (1.11

malignant lesion and significantly increased with use of CT

to 24.8) in the lesions in the lower lobe and in the cases of

fluoroscopy. Other factors, including lesion size, lesion depth from

parenchymal hemorrhage during the procedure. Multivariate

(95% confidence intervals) was 13.3 (1.11 to 158.9) in lesions
in the lower lobe and 25.4 (3.37 to 192.4) in the use of biopsy
needles > 20 gauge.
Conclusions: Parenchymal hemorrhage during the procedure,
the use of larger biopsy needle, and lesions in the lower
lobe could be risk factors for systemic air embolism in the
population studied. Although the present study was inherently
preliminary, our findings may be a clue for minimizing the risk
of this complication.

pleura, lesion location and patient position, had no significant

influence on accuracy. The only complications were Grade 1 and
2 pneumothorax and Grade 1 pulmonary bleeding. The incidence
of pneumothorax and bleeding was significantly increased with
smaller lesion size and significantly increased with greater lesion
depth. When CT fluoroscopy was used, bleeding was significantly
increased (p<.001).
CONCLUSION: The accuracy of CT-guided lung biopsy was
significantly increased with malignant lesion and significantly
increased with use of CT fluoroscopy. The incidence of
pneumothorax and bleeding was affected by lesion size and
lesion depth. CT fluoroscopy used, bleeding was significantly
increased.

434

435

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logistic regression analysis showed that adjusted odds ratio

Poster Exhibition

Komemushi, Rie Yagi, Satoshi Suzuki, Satoshi Sawada

Poster Exhibition

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PE166

PE168

Transjugular liver biopsy in patients with

dual grafts living donor liver transplantation

Can vascular surgery be performed outside

of theatre

Analysis of the venous thromboembolism

that occurred in six months in the
Asahikawa Medical University Hospital

A decadal follow up of percutaneous MRI

guided cryoablation for renal tumor

Gi-Young Ko1, Guangshao Cao2, Jin-Hyoung Kim1,

Andrew John Renner1, Sandra Leith2

Tomonori Yamada, Kouji Takahashi, Toshihiro Yamaki,

Kotaro Ouchi1, Shinji Yamazoe1, Kanichiro Shimizu1,

Hyun-Ki Yoon1, Dong-Il Gwon1, Kyu-Bo Sung1

Hatsune Hiranuma, Naofumi Watanabe,

Takuji Mogami1, Junta Harada1, Takashi Hatano2,

Tomoaki Sasaki, Youko Takada, Rie Murata,

Koichi Kishimoto2

Keigo Kobayashi, Tamio Aburano

Department of Radiology, Asahikawa Medical University,

JPN

Radiology, Asan Medical Center, Ulsan College of Medicine,

KOR

Department of Radiology, Royal Adelaide Hospital, AUS

2
Department of Vascular Surgery, Royal Adelaide Hospital,
AUS

Department of Interventional Radiology, Henan Provincial

People's Hospital, CHN

Purpose: To evaluate the efficacy of transjugular liver

Purpose: Hybrid techniques are now commonplace in Vascular

Purpose: Venous thromboembolism (VTE) increases year by

biopsy (TJLB) in patients with dual living donors liver

Surgery with open access to the vessels required for safe access

year in our country, and the number of deads in pulmonary

transplantation (LDLT) and to analyze the necessity of biopsy

or combined surgical/endovascular procedures. High quality

thromboembolism (PTE) reaches approximately 2,000 cases in

from dual grafts.

imaging & endovascular equipment is often not available in

2005. In the Asahikawa Medical University Hospital, we work

Materials: 173 sessions (73 patients) of biopsy, including TJLB

operating theatres (OR) necessitating performance in the

on early detection, early treatment of VTE . We examined VTE

(56 sessions; 28 patients), percutaneous biopsy (95 sessions;

Interventional Radiology (IR) suite. Concerns have been raised

which occurred to the Hospitalized patient in the Asahikawa

40 patients), and open biopsy (22 sessions; 21 patients) were

that the IR suite is not a suitable sterile environment and will

Medical University Hospital.

reviewed. The patients with TJLB had received dual left lobes

increase the risk of infection.

Method: About VTE detected in CT/US in a hospital for six

(n=23), right and left lobes (n=4) or dual left lateral segments

Methodology: Over a 12 month period, data was collected &

months from 2011/2/1 to 7/31, We examine the total number of

(n=1). TJLB was performed in dual grafts using a Quick-Core

analysed on all patients who underwent cutdown onto femoral

the VTE, sex ratio, the average age, a thrombotic part, disease

biopsy needle or a biopsy forceps in cases with unfavorable

artery and arteriovenous fistulae (AVF) in both OR & IR

severity, an opportunity of the detection, the total number of

vena cava-hepatic venous angle. Technical success rate of

Suites. Surgical procedures at any other sites were excluded.

IVC filter which we inserted in VTE patients.

TJLB, adequacy for histologic diagnosis, and consistency

Sites were assessed for immediate & delayed signs of infection

Result: In six months, we detect the VTE patient of 66 cases

of histologic diagnosis between dual grafts according to

up to 30 days post-procedure using Australian Infection

(22 men, woman 44, average age 67.9 years old). At the

CT enhancing patterns, were analyzed. For the analysis of

Control definitions.

time of detection of VTE, there were 14 patients having a

consistency of histologic diagnosis, data from percutaneous

Results: A total of 204 patients were identified (46 IR, 159

clot in pulmonary artery. In addition, the patient having a

biopsy and open biopsy were also included.

theatre). 18 patients developed infection (9%). 13 of the 18

respiratory symptom was four patient. In 18 patients, a CV

Results: Except for 23 nontarget grafts, TJLB was successful

(72%) were diagnosed and treated in the community. There

catheter caused VTE. About the severity of PTE, all cases were

in 83 (93%) of 89 target grafts using a Quick-Core biopsy

was no significant difference (Chi-square = 0.2) in infection

submassive or minor PE. It was 36 cases that a vein clot was

needle (n=68) or a biopsy forceps (n=15). Liver tissues were

rate between the IR (2 (4%); 1 deep, 1 superficial) and OR (16

discovered in less than IVC. It was 15 cases that a clot existed

adequate for histologic diagnosis in 78 (94%) of 83 grafts. Liver

(10%); 4 deep, 12 superficial).

more proximally than a popliteal vein. As for the opportunity

tissues of dual grafts were available in 99 sessions, including

Conclusion: Despite its remote position and relatively

of the detection, it is as follows. 34 cases were detected in CT

27 TJLB sessions. Histologic diagnoses were inconsistent

uncontrolled surrounding environment, the IR is a suitably

accidentally, and 13 cases were detected in high level D dimer

in 21 sessions with consistent (n=14) or inconsistent (n=7)

sterile environment for hybrid procedures. In decisions with

value, and four cases were detected in respiratory organs

enhancing patterns of dual grafts. Consistency of histologic

regard to the safest place to perform a procedure, sterility

symptom, and six cases were detected in preoperative clot

diagnosis was significantly correlated with enhancing patterns

is not a concern. This study also reiterates that careful

search CT and nine cases were discovered in postoperative

of dual grafts(p<0.001).

community follow up is required when auditing surgical site

clot search CT. IVC filter was detained by 14 cases and was

Conclusion: TJLB is effective for obtaining adequate liver

infection.

removed in 4 cases.

tissue for histologic diagnosis in dual LDLT recipients. Biopsy

Conclusion: In the Asahikawa Medical University Hospital,

from each of dual grafts is recommended because of the

66 VTE patients were found in a half year. There was not the

possibility of inconsistent histologic diagnoses of dual grafts

patient who resulted in death. However, a clot already existed

regardless of enhancing patterns.

in pulmonary artery at the time of detection in 14 cases. The

Department of Radiology, Jikei University Kashiwa Hospital,

JPN
Department of Urology, Jikei University Kashiwa Hospital,
JPN

Purpose: We present chronological changes after percutaneous

MRI guided renal cryoablation up to 120 months.
Methods: Between March 2001 and May 2002, we performed
percutaneous MRI guided cryoablation of solitary renal
tumor in 13 patients (size range from 2 to 4.5 cm (mean
2.9cm)) for clinical trial of national approval of CryoHit unit
(Galil Med.,Israel) in Japan. We followed them with CT after
treatment every 3 to 6 months and evaluated retrospectively
tumor regression, fatty degeneration, calcium deposits at
cryoablated area. Follow-up duration was up to 120 months.
In addition, we evaluated the pathologic changes in operative
patients.
Results: Of the 13 patients, one died of other causes and 3
recurred. For the patients with recurrence, partial or total
neprectomy were performed. We performed long term followup for 9 patient except for the above 4 patient. Eight of the
tumors were almost disappeared. Five of 9 patients were
replaced by fatty degeneration. Seven of 9 patients had
calcification at the ablated lesion. There was no recurrence or
metastasis in 12 patients. In addition, the pathologic changes
in operative cases demonstrated colliquative necrosis of the
tumors and infarct, scar, fibrosis, fat necrosis of the renal and
perirenal tissues. The renal arteries were partly accompanied
with recanalization.
Conclusions: After renal cryoablation, ablated area gradually
decreased in size, and almost all the tumors were disappeared.
CT imaging reveals characteristic changes in the appearance
of ablated area, such as fatty degeneration and calcification.

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further prevention and early detection are necessary.

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Innovation of 3D navigation system using

MRI; Future step for cryoablation of
prostate cancer

Safety and effectiveness of radiologists

administered intravenous conscious
sedation in interventional radiology (IR)
procedures

Case report Retrieval of the fractured

guide wire in liver abscess cavity via
percutaneous transhepatic route

Incarcerated umbilical hernia after the

Denver peritoneovenous shunt operation: A
case report

Shinji Yamazoe1, Nobutaka Abe2, Kotaro Ouchi1,

Ferdinand Shiu Kay Chu, Kwan Yin Francis Cho

Koki Kato 1, Masanori Honda 1, Keiichi Tanimura 1,

Department of Radiology, Queen Mary Hospital, HKG

Kazukiyo Arakawa1, Kouki Usui1, Isao Kouno1,

Kengo Ohta, Masashi Shimohira, Takuya Hashizume,

Kazushi Suzuki, Kenichiro Kurosaka, Yuta Shibamoto

Kanichiro Shimizu , You Matsui , Takuji Mogami ,

Junta Harada1

Toshiaki Yagami1, Chiaki Shibayama1,

Hiroharu Shinozaki2, Nobuyoshi Nisizawa2

Department of Radiology, Jikei University Kashiwa Hospital,

JPN
2
Ap pl i c at i on Dev el o pment Of f i ce, H i t ac hi M ed i c al
Corporation, JPN

Purpose: Cryoablation is thought of one of focal therapies

for localized prostate cancer in the cases of non-surgical
indication. The cryo-needle was inserted by trans-rectal US
(TRUS) guidance like as Brachy therapy. But it is difficult
to puncture the site of prostate cancer accurately, because
prostate cancer was not detected by US. The aim of our study
is to develop 3D navigation system using DWI with relative
signal intensity statistical thresholding for tumor (rSI) to
support a puncture of the needle.
Methods: Previously, we reported about rSI using a 1.5 T MRIsystem (Hitachi ECHELON-vega), and could detect precise
location of prostate cancer. This time, we tried to superimpose
these rSI images to the guide image of 3D navigation system
and we were able to make trans-perineal virtual puncture
images using this novel system. We displayed prostate cancer
with red-colored region, and a virtual needle was inserted into
prostate cancer at several positions and angles.
Results: We could integrate rSI images into 3D navigation
system of prostate MRI. And we succeeded to display transperineal virtual puncture images using this system.
Conclusions: It is important to develop 3D navigation
system using rSI. In the future, if we could synchronize this
navigation system with TRUS images, accurate punctures into

438

Department of Radiology, Saiseikai Utsunomiya Hospital,

JPN
2
Department of Surgery, Saiseikai Utsunomiya Hospital, JPN

Introduction: Interventional radiological (IR) procedures could be

painful and patients comfort may be enhanced by the appropriate
use of sedation. It is a common practice in Hong Kong, that
intravenous conscious sedation is administered by radiologists.
We aim to study the safety and effectiveness of intravenous
administration of sedation in two commonly performed IR
procedures.
Method: Between January 2009 to December 2010, forty-five
patients underwent percutaneous radiofrequency ablation (RFA)
of liver tumour. Between January 2009 to October 2011, thirtyone patients underwent percutaneous bone biopsy (BBx). They
were sedated by an initial intravenous administration Diazepamlipuro and Pethidine according to our standard protocol. Data
such as clinical response, change in blood pressure / blood oxygen
saturation (SaO2), the need for oxygen therapy / antidote were
retrospectively analysed.
Results: Forty-five patients underwent RFA of liver tumour. In
three (6.7%) patients the procedure failed due to either inadequate
sedation or significant drop in blood pressure. Three (6.7%)
patients required antidote. Twenty-two (48.9%) patients had
significant drop in Sa02 below 95%, while four (8.9%) of those
dropped below 90%. Twenty (44.4%) patients required oxygen
therapy to maintain a Sa02 above 95%.
Seven (15.6%) patients had a drop in systolic blood pressure to 1020% below the original level, while fifteen (33.3%) had a drop of
20% or more. One (2.2%) patient had a 10-20% increase in systolic
blood pressure.
Thirty-one patients underwent BBx. All were adequately sedated
by our protocol. None of the patient required an antidote. Only one
(3.2%) patient required oxygen therapy to maintain a SaO2 of 95%
or above.
Seven (22.6%) patients had a drop in systolic blood pressure to 1020% below the original level, while three (9.7%) had a drop of 20%
or more. Three (9.7%) patients had a 10-20% increase in systolic
blood pressure, and one (3.2%) patient had a 20% or more increase.
There was no fatality. Resuscitation was not required at any
stage. Significant blood pressure drop / increase either recovered
spontaneously or after antidote; and one RFA patient required
plasma volume expander. Significant drop in SaO2 recovered either
spontaneously or with oxygen therapy and / or antidote.
Conclusion: In our experience, intravenous conscious sedation
given by radiologists is safe and effective. The RFA patients had a
higher failure rate, blood pressure and SaO2drop and requirement
of antidote. BBx patients had a higher likelihood of blood pressure
increase probably due to BBx being an intrinsically more painful
procedure.

We report a case of retrieval of the fractured guide wire in liver

We report a case of incarcerated umbilical hernia after the

abscess cavity through percutaneous transhepatic route. A 71

Denver peritoneovenous shunt operation. A 50-year-old man

year-old woman was admitted to our hospital with high fever

has suffered from cirrhosis of the liver caused by viral hepatitis

and fatigue. She had past history of operation right breast

C for 10 years, and intractable ascites for 1 year. So, he has

carcinoma and left renal carcinoma. Abdominal CT revealed

undergone treatment of ascites several times. Furthermore,

abscesses in left lobe of the liver. Percutaneous drainage was

he had an umbilical hernia, but it has been possible to

performed on next day. However drainage and antibiotic

reduce manually. Recently, it became difficult to control the

therapy, symptom and abscess were not improved much after

ascites, and the Denver peritoneovenous shunt operation was

2 week of drainage. During tract dilatation for exchange of

considered. The operation was performed successfully, and the

larger French size of drainage tube, soft tip of steal guide wire

ascites decreased. However, 10 days later, the umbilical hernia

was fractured and fallen in liver abscess cavity.

developed. It was difficult to repair manually, and the hernia

After 2 week of the accident, we tried to remove the fractured

seemed to be incarcerated on CT. So, surgery for the umbilical

guide wire through percutaneous transhepatic route. At first,

hernia was performed. The incarcerated small intestine was

the two 0.035-inch gidewires were placed through the same

not necrotic, so excision of the herniated intestine was not

drainage tube, then drainage catheter was removed. 6-French

performed. However, his condition became worse gradually,

vascular sheath was advanced over one of the 0.035-inch wire

and he died 2 days after the surgery. The Candida albicans

into the abscess cavity. We inserted endoscopic forceps into

was found from his ascites and his blood, so the cause of his

the 6-Fr vascular sheath and successfully removed a cut guide

death was suspected to be septic shock following peritonitis. We

wire under fluoroscopic guide. Finally, a new pigtail drainage

have experienced a rare complication of incarcerated umbilical

catheter was advanced over another guidewire. After retrieval

hernia after the Denver peritoneovenous shunt operation.

of the fractured guide wire and additional drainage, the

We think avoidance of the Denver shunt operation should be

patient became afebrile, and CT demonstrated that abscess

considered for patients who has a history of hernia.

was healed.

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prostate cancer and cryoablation could be technically feasible.

Department of Radiology, Nagoya City University Graduate

School of Medical Sciences, JPN

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Hemostasis by balloon occlusion for a

pseudoaneurysm of the popliteal artery
after total knee replacement
Kazushi Suzuki, Masashi Shimohira, Takuya Hashizume,
Kengo Ohta, Kenichiro Kurosaka, Yuta Shibamoto

Multiple arterial embolizations in a subject

with pseudoaneurysm after pancreaticoduodenectomy
Ryota Nishio1, Toru Saguchi2, Kazuhiro Saito2,
Mitsuru Ookubo1, Yoshiko Takahashi1, Shingo Inoue1,
Kiyoshi Koizumi1, Kiminori Takano3, Yuta Abe3,
Motohide Shimazu3, Koichi Tokuue2
1

Department of Radiology, Tokyo Medical University Hachioji

Medical Center, JPN
2
Department of Radiology, Tokyo Medical University
Hospital, JPN
3
Department of Surgery, Tokyo Medical University Hachioji
Medical Center, JPN

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Percutaneous reconstruction of
pancreatico-jejunal anastomosis: A case
report

Stent placement for pulmonary artery

anastomotic stenosis soon after livingdonor lobar lung trasplantation

Yoshiaki Watanabe1, Takashi Omura2,

Hirotsugu Nakai1, Toshiya Shibata1, Minoru Yabuta1,

Toyomichi Shibata1, Hiroyoshi Isoda1, Kaori Togashi1,
Junichi Tazaki2, Fengshi Chen3

Yasuhiro Takemoto , Makoto Furuse

1

Department of Radiology, Higashiyamato General Hospital,

JPN

Department of Surgery, Higashiyamato General Hospital,

JPN

Department of Radiology, Kyoto University, JPN

Department of Cardiovascular Medicine, Kyoto University,
JPN

Department of Thoracic Surgery, Kyoto University, JPN

A-78-year-old woman was admitted to undergo total knee

A 6 7 - y e a r- o l d m a n d i a g n o s e d w i t h p a n c r e a t i c h e a d

Purpose: Dysfuction of pancreatico-jejunal anastomosis following

We report a case of stent placement for a kink in the pulmonary

replacement for left knee osteoarthritis. After surgery,

carcinoma invading the superior mesenteric artery and vein,

pylorus-preserving pancreaticoduodenectomy is a rare complication,

artery (PA) anastomosis soon after living-donor lobar lung

swelling of the left lower limb occurred, and contrast-enhanced

underwent pancreatico-duodenectomy(PD) after neoadjuvant

but is critical. This dysfunction usually results in formation of

transplantation (LDLLT).

CT revealed acute occlusion of the popliteal artery. Thus,

chemoradiotherapy.

anticoagulant therapy was performed. Three weeks later,

In clinical course and surgical procedures, The subject had

a pseudoaneurysm at the left knee was found at enhanced

a small amount of bloody discharge through a drain tube on

CT, but it was difficult to identify the artery from which

postoperative day (POD) 18, and CT showed a pseudoaneurysm

the pseudoaneurysm developed, due to a severe artifact.

in the middle colic artery cross-section. Hemostasis was induced

So, ultrasound-guided compression was attempted at first.

for the lesion by coil packing using balloon-assisted neck plasty.

However, due to the swelling of the left lower limb, it was even

Follow-up CT POD 26 showed a pseudoaneurysm at the

difficult to show the pseudoaneurysm. On the next day, she

gastroduodenal artery cross-section, for which hemostasis was

complained of severe pain around her knee. Rupture of the

also induced by coil packing using balloon-assisted neck plasty.

pseudoaneursym was suspected and emergency angiography

Furthermore, follow-up CT on the 46th postoperative day

was performed. A 4-Fr. SHK (shepherd hook) catheter was

detected coil migration at the cross sectional area of the middle

placed in the left femoral artery through a 4-Fr. sheath from

colic artery treated previously, and additional coil packing with

the right femoral artery. A pseudoaneursym was found at

a neck plasty technique was conducted.

the knee at angiography, but it was not shown from which

The subjects subsequent clinical course was good, and he

artery it developed, because of an artificial joint. Thus,

was being followed up after discharge from the hospital. Four

intravascular ultrasound (IVUS) was performed, and a small

months postoperatively, however, he suffered hematemesis

intractable external pancreatic fistula. Conservative management

is effective in almost 70% of the cases, however, surgical treatment
is required in cases not effective. Since the mortality and morbidity
rate of the surgical treatment is not low, minimally invasive
treatment such as endoscopical or percutaneous procedure might be
preferred. In this case report, we demonstrate a novel procedure to
reconstruct a pancreatico-jejunal anastomosis percutaneously.
Case Report: A 74-year-old woman underwent pylorus-preserving
pancreaticoduodenectomy for carcinoma of the common bile duct,
with reconstruction by a modified Childs procedure. One year
later, she was readmitted to our hospital because of formation
of pseudocyst around the pancreatico-jejunal anastomosis
demonstrated by Computed tomography (CT). CT also revealed
dehiscence of the pancreatico-jejunal anastomosis. Percutaneous
drainage of the pseudocyst was performed and fistulography from

A 64-year-old man with idiopathic pulmonary fibrosis

underwent bi-lateral LDLLT. After reperfusion, the left PA
anastomosis showed a kink and the left PA flow decreased.
But it could not be corrected completely during surgery.
Emergency angiography was performed via the right femoral
vein approximately 24 hours after reperfusion and left
pulmonary arteriogram depicted 90% stenosis at the left PA
anastomotic site. A 6mm-diameter X 18mm-long Palmatz
Genesis stent was placed at the anastomotic site, and the left
pulmonary arterial flow recovered. After the stent placement,
the patient was successfully weaned from extracorporeal
membrane oxygenation, and finally he recovered to take orally.
In conclusion, stent placement for a kink in the PA anastomosis
after LDLLT was an effective treatment.

the drainage tube demonstrated complete obstruction of the jejunal

wall anastomosis.

hole of the popliteal artery was obviously detected. So, the

and hemorrhagic shock, leading to CPA, requiring that he

pseudoaneurysm was found to arise from the popliteal artery.

be hospitalized immediately. The gastroduodenal artery

Then, balloon occlusion of the popliteal artery was performed

cross-section treated previously showed a pseudoaneurysm

to acquire hemostasis. At first, we hoped that the hemostasis

penetrating the stomach, necessitating coil isolation of the

was acquired with short time occlusion. However, even 1-hour

proper hepatic artery and common hepatic artery.

occlusion was not enough. Therefore, we decided to extend

The incidence of postoperative bleeding has been reported to

balloon occlusion until the next day (about 10 hours). Then,

be highest in PD, and we obtained similar results. Post-TAE

we confirmed that the distal site of the popliteal artery was

survival has been regarded to be high, and we succeeded in

depicted through a collateral artery at the angiography. At

TAE for hemostasis in our subject. He eventually died, however

angiography performed on the next day, the pseudoaneurysm

of hemorrhagic shock.

0.035 inch guidewire was traversed through the main pancreatic

completely disappeared. A small thrombus was found at

Embolization in postoperative bleeding and pseudoaneurysm

duct to the pseudocyst. This guidewire was captured by a snare (EN

To percutaneously reconstruct pancreatico-jejunal anastomosis,

we underwent the procedure described below. First, under
CT fluoroscopy guidance, 18 gauge PTCD needle was inserted
percutaneously into the jejunum adjacent to the pseudocyst and
then penetrated the posterior wall of the jejunum to let the needle
tip go inside the pseudocyst. Nine-French peel away sheath was
inserted into the pseudocyst traversing adjacent jejunum by this
route. Next, under CT fluoroscopy, another 18 gauge PTCD needle
was inserted percutaneously into the dilated main pancreatic duct.

the distal site of the popliteal artery, but it disappeared by

is considered useful but because post embolization survival in

Snare) through the 9 Fr sheath and pulled-through. The tip of the 7

prostaglandin E1 injection. After the procedure, the patient had

subjects in poor general condition after massive bleeding is low,

Fr pigtail catheter was placed inside the jejunum through the main

no signs of recurrence and did well during a 1.5-year follow up

postoperative bleeding and pseudoaneurysms must be detected

period.

and treated at the earliest possible opportunity.

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Department of Radiology, Nagoya City University Graduate

School of Medical Sciences, JPN

PE174

pancreatic duct and pseudocyst by the pull-through guidewire.

Conclusion: It is difficult to endoscopically treat dehiscence of
pacreatico-jejunal anastomosis following pancreaticoduodenectomy
reconstructed by Childs procedure due to the difficulty to approach
the main part of the pancreatico jejunal anastomosis endoscopically.
Our method to reconstruct pancreatico-jejunal anastomosis is a
novel treatment, which could be performed percutaneously.

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