A case of retained placenta increta successfully treated via uterine arterial embolization using N-butyl 2-cyanoacrylate.

A 29-year-old woman with placenta increta with hemorrhage underwent uterine artery embolization using 12.5% NBCA (N-butyl 2-cyanoacrylate) diluted with iodized oil (Lipiodol). Complete resolution of placenta increta without performing curettage was obtained. The uterus returned to its normal shape, with restored endometrium, junctional zone, and myometrium. Menstruation resumed after 3 months. In cases of retained placenta due to placenta accreta, and even those with placenta increta, uterine artery embolization using NBCA is a useful treatment.

Percutaneous vertebroplasty for vertebral compression fractures with intravertebral cleft: cement injection under vacuum aspiration.

PURPOSE: To evaluate the efficacy of cement injection under vacuum aspiration (CIVAS) of cleft contents in percutaneous vertebroplasty for osteoporotic vertebral compression fractures with an intravertebral cleft. MATERIALS AND METHODS: From April 2008 to October 2010, vertebroplasty for single-level osteoporotic vertebral compression fractures with clefts was performed in 34 patients (seven women, 27 men; mean age, 77 y) with CIVAS and in 41 patients (three women, 38 men; mean age, 77 y) by conventional injection (control group). In this retrospective study, the cement volume, cement ratio, visual analog scale (VAS) pain score, and incidences of leakage, new vertebral compression fracture, and nonhealing were compared between groups. Vertebral height changes in the CIVAS group were also evaluated. RESULTS: There were significant decreases in VAS scores in both groups (P < .001). There were no significant differences in complications between groups (cement leakage, P = .70; new vertebral compression fracture, P = .17; nonhealing, P = .086). Vertebral height was significantly decreased by vacuum aspiration and increased by cement injection (P < .001). The mean cement volume was significantly higher (P = .0057) in the CIVAS group (4.87 mL) than in the control group (3.58 mL). Cement filling was achieved more sufficiently in the CIVAS group (P = .014). CONCLUSIONS: The CIVAS method is feasible and appears to improve cleft filling in the treatment of single-level vertebral compression fractures with a cleft, compared with conventional cement injection.

[Oncology IVR--application to palliative medicine].

Oncology IVR is a minimum invasive and locoregional treatment by newly developed interventional techniques consisting of transarterial chemoembolization (TACE), radiofrequency ablation, cryoablation and percutaneous bone plasty (PBP), etc. These treatment methods are considered to be effective to rapid tumor reduction and palliation. The redistributed subclavian arterial infusion chemotherapy via an implanted catheter-port system which was newly developed by authors would be effective for local recurrence of breast cancer. The combination therapy of these interventional techniques can offer new treatment strategies for an improvement of patient's quality of life and more effective palliative medicine.

Risk factors for perioperative venous thromboembolism: A retrospective study in Japanese women with gynecologic diseases.

BACKGROUND: Patients with gynecologic cancer have a high risk of venous thromboembolism (VTE) like patients with other cancers. However, there is little information on risk factors for VTE during gynecologic surgery and no uniform preventive strategy. Our objectives were to identify risk factors for perioperative VTE in gynecologic patients and establish methods for prevention. METHODS: We analyzed 1,232 patients who underwent surgery at the Department of Obstetrics and Gynecology of St. Marianna University School of Medicine between January 2005 and June 2008. We investigated (1) risk factors for preoperative VTE, (2) use of an inferior vena cava (IVC) filter, and (3) risk factors for postoperative VTE. RESULTS: There were 39 confirmed cases of perioperative VTE (3.17%), including 25 patients with preoperative VTE and 14 with postoperative VTE. Thirty-two patients had cancer and seven patients had benign diseases. Twenty-two of the 32 cancer patients (68.7%) had preoperative VTE, while postoperative VTE occurred in 10 cancer patients. Multivariate analysis indicated that ovarian cancer, tumor diameter ≥10 cm, and previous of VTE were independent risk factors for preoperative VTE. Among ovarian cancer patients, multivariate analysis showed that an age ≥50 years, the presence of heart disease, clear cell adenocarcinoma, and tumor diameter ≥20 cm were independent risk factors for preoperative VTE. The factors significantly related to preoperative VTE in patients with benign disease included previous VTE, age ≥55 years, tumor diameter ≥20 cm, and a history of allergic-immunologic disease. Thirteen of the 25 patients (52%) with preoperative VTE had an IVC filter inserted preoperatively. Postoperative screening (interview and D-dimer measurement) revealed VTE in 14/1,232 patients (1.14%). Multivariate analysis indicated that cancer surgery, a history of allergic-immunologic disease, and blood transfusion ≥2,000 ml were independent risk factors for postoperative VTE. CONCLUSIONS: Perioperative VTE is often fatal and preventive measures should be taken in the gynecologic field, especially when patients have the risk factors identified in this study. Since VTE is often present before surgery, preoperative screening is important and use of an IVC filter should be considered.

Percutaneous vertebroplasty performed by the isocenter puncture method.

PURPOSE: The aim of this study was to clarify the usefulness of the isocenter puncture (ISOP) method. MATERIALS AND METHODS: We investigated 73 vertebral bodies that had undergone percutaneous vertebroplasty (PVP) by the ISOP method, 118 vertebral bodies that had undergone the puncture simulation method, and 33 vertebral bodies that had undergone the conventional method. The items to be examined included the success rate (SR) of the median puncture of the vertebral body and the procedure time. The puncture accuracy and fluoroscopy time were also measured for the ISOP method. RESULTS: The SR was significantly higher and the procedure time significantly shorter when using the ISOP method rather than the conventional method. However, no significant differences were observed between the ISOP method and the puncture simulation method. The errors between the puncture needle tip and the puncture target point in the ISOP method were an average of 1.52, 2.08, and 1.87 mm in each of the horizontal, ventrodorsal, and craniocaudal directions. The fluoroscopy time when operating on one vertebral body was an average of 5.8 min. CONCLUSION: The ISOP method is considered to be a useful approach while also reducing the puncture time and the fluoroscopy time.

Cost-Effectiveness Analysis of Percutaneous Vertebroplasty for Osteoporotic Compression Fractures.

STUDY DESIGN: Single-center, single-arm, prospective time-series study. OBJECTIVE: To assess the cost-effectiveness and improvement in quality of life (QOL) of percutaneous vertebroplasty (PVP). SUMMARY OF BACKGROUND DATA: PVP is known to relieve back pain and increase QOL for osteoporotic compression fractures. However, the economic value of PVP has never been evaluated in Japan where universal health care system is adopted. METHODS: We prospectively followed up 163 patients with acute vertebral osteoporotic compression fractures, 44 males aged 76.4±6.0 years and 119 females aged 76.8±7.1 years, who underwent PVP. To measure health-related QOL and pain during 52 weeks observation, we used the European Quality of Life-5 Dimensions (EQ-5D), the Rolland-Morris Disability Questionnaire (RMD), the 8-item Short-Form health survey (SF-8), and visual analogue scale (VAS). Quality-adjusted life years (QALY) were calculated using the change of health utility of EQ-5D. The direct medical cost was calculated by accounting system of the hospital and Japanese health insurance system. Cost-effectiveness was analyzed using incremental cost-effectiveness ratio (ICER): Δ medical cost/Δ QALY. RESULTS: After PVP, improvement in EQ-5D, RMD, SF-8, and VAS scores were observed. The gain of QALY until 52 weeks was 0.162. The estimated lifetime gain of QALY reached 1.421. The direct medical cost for PVP was ¥286,740 (about 3061 US dollars). Cost-effectiveness analysis using ICER showed that lifetime medical cost for a gain of 1 QALY was ¥201,748 (about 2154 US dollars). Correlations between changes in EQ-5D scores and other parameters such as RMD, SF-8, and VAS were observed during most of the study period, which might support the reliability and applicability to measure health utilities by EQ-5D for osteoporotic compression fractures in Japan as well. CONCLUSIONS: PVP may improve QOL and ameliorate pain for acute osteoporotic compression fractures and be cost-effective in Japan.

Unilateral transpedicular percutaneous vertebroplasty using puncture simulation.

PURPOSE: The aim of this study was to improve the accuracy of puncture to the median vertebral body using the unilateral transpedicular approach on percutaneous vertebroplasty (PVP). We have developed and evaluated a simple puncture simulation method based on the puncture angle determined by preoperative computed tomography (CT). MATERIAL AND METHODS: Two groups were evaluated. The first (group A) comprised 23 patients (34 vertebral bodies) who had undergone PVP without preoperative puncture simulation before May 2004, and the second group (group B) comprised 24 patients (39 vertebral bodies) who had undergone preoperative puncture simulation and PVP after May 2004. CT in the prone position was performed, and the puncture angle on CT (PAC) via the vertebral arch pedicle targeting the anterior one-third median site of the vertebral body was determined. Puncture was performed by targeting the isocenter established on a fluoroscopic monitor based on the PAC. Determinations were made of the success rate (SR) of the median puncture of the vertebral body, the effect of treatment using the visual analogue score, and the overall procedural time between groups A and B. RESULTS: The SR was 56% (19/34 vertebral bodies) in group A, and 97% (37/38 vertebral bodies), including only one vertebral body in which it was difficult to perform the unilateral approach on CT images, in group B, with the difference being significant by Student's t-test (P < 0.001). Among patients with available follow-up data, the unipedicular and bipedicular approaches achieved adequate pain relief with mean decreases in pain severity of 5.1 +/- 2.6 and 5.9 +/- 2.8, respectively. No significant differences in the treatment effect between the two groups was observed (P = 0.811). The overall procedure time per puncture was shorten for the simulation group (36.0 min) than for group A (73.1 min), as shown by regression analysis. CONCLUSION: The preoperative PAC determination for PVP under fluoroscopy increased the completion rate of PVP by the unilateral transpedicular approach. This method should be accepted from the viewpoint of burden reduction on patients and surgeons.

Interventional radiology for critical hemorrhage in obstetrics: Japanese Society of Interventional Radiology (JSIR) procedural guidelines.

There has been an increasing demand for interventional radiology (IR) procedures for the treatment of severe postpartum hemorrhage (PPH) (also called critical hemorrhage in obstetrics). The Japanese Society of Interventional Radiology Guideline Committee developed the practical guidelines for IR procedures for severe PPH using evidence-based methodology. This article aimed to describe the rationale for developing these guidelines and to provide the answers for clinical questions about IR procedures consisting of current available evidence and the consensus among experts.

A new method of an axial puncture approach for draining loculated pleural effusions.

PURPOSE: The authors devised a new method of an axial puncture approach through the pulmonary apex (PA) for percutaneous catheter drainage (PCD) of loculated fluid collections extending to the PA. The purpose of this report is to introduce the new procedure. METHODS: Percutaneous catheter drainage by the axial puncture approach was performed in two patients with limited supine position and loculated pleural fluid collection in the posteromedial part of thoracic cavity. RESULTS: The procedures succeeded in two patients without difficulties while keeping them in a supine position, even if the loculated fluids exist in the posterior side of thoracic cavity. CONCLUSIONS: Percutaneous catheter drainage by the axial puncture approach is particularly effective in patients with limited supine positions and loculated pleural fluid collection in the posteromedial part of thoracic cavity.

Transcatheter arterial chemoembolization (TACE) or embolization (TAE) for symptomatic bone metastases as a palliative treatment.

PURPOSE: This study was designed to evaluate the effect of transcatheter arterial chemoembolization (TACE)/embolization (TAE) for symptomatic bone metastases especially in palliation. METHODS: Between April 2006 and December 2009, 24 bone metastatic lesions of 18 patients (8 women and 10 men; mean age, 64 years) underwent palliative TACE or TAE. A total of 40 sessions were performed, with 1-4 sessions per lesion. The primary lesions included hepatocellular carcinoma, colorectal cancer, renal cell cancer, ovarian cancer, thyroid cancer, uterine cervical cancer, and esophageal cancer. Symptomatic lesions involved thoracic spine, lumbar spine, pelvis, rib, and femur. The procedures were performed with a coaxial catheter technique to catheterize selectively target arteries. If not possible due to small branches, blood flow alteration by coil was achieved. Gelatin sponge was the initial embolic materials. As anti-cancer agents, epirubicin, fluorouracil, and mitomycin were mainly used in consideration for primary lesion and past treatment. RESULTS: Sufficient devascularization of targeted lesions was obtained in 18 of 24 (75%) lesions without any serious complication. Pain relief was obtained in 20 lesions (83%), with significantly decrease in the visual analogue scale score (P < 0.001). A relationship was found between the devascularization grade and pain relief (r = 0.49, P < 0.05). Follow-up CT images at 1 month of nine lesions (50%) revealed necrotic change in the tumors. CONCLUSIONS: Palliative TACE/TAE for symptomatic bone metastases could be a suitable treatment method because it is minimally invasive, repeatable, effective, and rapid-acting.

Clinical efficacy and value of redistributed subclavian arterial infusion chemotherapy for locally advanced breast cancer.

PURPOSE: The aim of this study was to evaluate the efficacy and safety of redistributed subclavian arterial infusion chemotherapy (RESAIC). We have focused on the local response, quality of life (QOL), and complications. We have also investigated factors that influence the local response of RESAIC. MATERIALS AND METHODS: The subjects were patients with locally advanced breast cancer whose tumors were resistant to standard systemic chemotherapy (at least more than two regimens), those who were physically unable to tolerate systemic chemotherapy, and patients with locally recurrent breast cancer. The registration period was between April 2006 and May 2009. RESULTS: A total of 24 cases in 22 patients (mean age 59.5 years, range 36-82 years) were entered in the study. The local response rate of RESAIC was 77.3% (17/22). The QOL score showed improvement on average. There were no serious complications during catheter port implantation, and there was hematological toxicity over grade 3 in 27.3% (6/22) of patients. A significant difference between responders and nonresponders was seen in patients with a replaced type tumor (on imaging, diffuse contrast enhancement was seen in whole quadrants) (P = 0.043), and the patients underwent radiotherapy (P = 0.043). CONCLUSION: RESAIC is an effective, safe treatment for locally advanced breast cancer. Because it was reviewed in only a few cases, however, large-scale studies are warranted.

Differences in Trocar Positioning within the Vertebral Body Using Two Different Positioning Methods: Effect on Trainee Performance.

Purpose. To evaluate the educational effect of the Japanese Society of Interventional Radiology 7th Academic Summer Seminar from a technical perspective. Materials and Methods. Nineteen trainees participated in the seminar. The seminar consisted of vertebroplasty trainings using swine with the single-plane landmark method and with the ISOcenter Puncture (ISOP) method. All trainees were advised by an instructor as they operated the instruments and punctured the vertebra. For each trainee, the accuracy in the final position of the needle tip of the initial puncture in each swine training was evaluated. Results. Error in the final position of the needle tip of ≥5 mm from the target puncture site occurred in the lateral direction in 42% (8/19) of trainees with the landmark method and 5% (1/19) with the ISOP method. No error ≥5 mm occurred in the vertical or anteroposterior directions. In terms of puncture accuracy, error in the lateral direction was significantly lower with the ISOP method than with the landmark method (2.2 ± 1.5 mm versus 5.6 ± 3.2 mm). Conclusion. This seminar was effective training for trocar placement for beginners. The puncture was more accurate with the ISOP method than with the landmark method.

Clinical application of a new indwelling catheter with a side-hole and spirally arranged shape-memory alloy for hepatic arterial infusion chemotherapy.

A new indwelling catheter, G-spiral (GSP), was developed for hepatic arterial infusion chemotherapy (HAIC) by way of an implanted catheter-port system (CPS). Here we evaluated its physical properties and the outcomes of its clinical use. The GSP vessel-fixing power and its ability to follow a guidewire were determined with a vascular in vitro model, and Student t test was used to determine statistical significance (P < 0.05). A retrospective analysis was performed to evaluate the technical success rate and to identify the clinical complications associated with radiologic CPS implantation with GSP in 65 patients with unresectable hepatic tumors. The mean vessel-fixing power of the GSP (14.4 g) significantly differed from that of a GSP with a cut shape-memory alloy (3.3 g). The mean resistance to following the guidewire displayed by the GSP (88.5 g) was significantly less than that for a 5F W-spiral (106.3 g) or 4F Cobra-type angiographic catheter (117.8 g). The CPS was placed successfully in 64 of 65 cases (98.5%). Hepatic artery occlusion was observed in one case. Occlusion, cracking, and infection of CPS were observed in one, two, and one case, respectively. The GSP is a highly useful indwelling catheter that can be used for HAIC.

Development of a new subclavian arterial infusion chemotherapy method for locally or recurrent advanced breast cancer using an implanted catheter-port system after redistribution of arterial tumor supply.

Locally or recurrent advanced breast cancers can receive arterial blood supply from various arteries, such as the internal thoracic artery (ITA), the lateral thoracic artery, and the other small arterial branches originating from the subclavian artery. Failure to catheterize and subsequent formation of collateral arterial blood supply from various arteries are some of the reasons why the response to conventional selective transarterial infusion chemotherapy is limited and variable. To overcome this problem, we developed a new subclavian arterial infusion chemotherapy method using an implanted catheter-port system after redistribution of arterial tumor blood supply by embolizing the ITA. We named this technique ("redistributed subclavian arterial infusion chemotherapy" (RESAIC)). Using RESAIC, patients can be treated on an outpatient basis for extended periods of time. Eleven patients underwent RESAIC, and the complete remission and partial response rate in 10 evaluable patients was 90%: complete remission [CR] n = 4, partial remission n = 4, stable disease n = 1, and not evaluable n = 1. Three of four patients with CR had no distant metastasis, and modified radical mastectomy was performed 1 month after conclusion of RESAIC. The resected specimens showed no residual cancer cells, and pathologically confirmed complete remission was diagnosed in each of these cases. Although temporary grade-3 myelosuppression was seen in three patients who were previously treated by systemic chemotherapy, there was no other drug-induced toxicity or procedure-related complications. RESAIC produced a better response and showed no major complications compared with other studies despite the advanced stage of the cancers.