Purpose: This study evaluated the feasibility of sheathless access using the combination of a 4-F catheter and a triaxial system for transcatheter arterial chemoembolization (TACE).

Materials and Methods: A total of 35 of 53 patients were selected to undergo TACE of hepatocellular carcinoma (HCC) using a triaxial system that included a 4-F shepherd hook catheter, a 2.7-2.9-F high-flow microcatheter, and a 1.7-1.9-F microcatheter without using a sheath introducer. Feasibility was defined as successful completion of the procedure without using another microcatheter or switching to another system. The duration of manual compression after catheter removal was set to 10 minutes. Two hours and 1 hour of bed rest after the procedure were prescribed for 24 and 11 patients, respectively.

Results: TACE using a triaxial system without a sheath introducer was feasible in 34/35 cases (97%). A small amount of bleeding around the catheter at the puncture site was observed during the procedure in 3 cases. No other hemorrhagic complications were observed 5 days after the procedure.

Conclusion: Sheathless arterial access using the combination of a 4-F catheter and a triaxial system for TACE of HCC was shown to be both feasible and safe. Additionally, using the triaxial system resulted in hemostasis within 1-2 hours of bed rest after catheter removal.

A 73-year-old woman presented with hemorrhagic shock resulting from a hepatocellular carcinoma (HCC) rupture. A hemothorax caused by diaphragmatic injury was identified from radiofrequency ablation performed 3 years prior. Contrast-enhanced computed tomography showed the HCC rupture (a 41 mm diameter tumor was seen in liver segment I, as well as contrast medium that had extravasated around the tumor), a right diaphragmatic hernia, and right pleural effusion. Celiac angiography showed extravasation of contrast medium from a tumor vessel. Transcatheter arterial embolization was performed. However, she died of liver failure 10 days later.

In recent years, percutaneous endovascular intervention has become the primary treatment for pediatric post-liver transplantation portal vein stenosis. This procedure is usually performed using a transhepatic approach. Herein, we report the transsplenic endovascular management of a 3-year-old girl with post-liver transplantation, late-onset portal vein occlusion, which occurred after repeated percutaneous transhepatic angioplasty procedures. Transhepatic access was precluded by thrombosis, and we considered an ileocecal approach too invasive; therefore, we performed a portal vein recanalization by puncturing a collector branch of the splenic vein, dilating the portal vein thrombotic stenosis using a balloon, and inserting a self-expanding stent. The majority of percutaneous procedures for portal vein stenosis in children are transhepatic; however, our case demonstrates that transsplenic stent insertion is possible, and should be considered when the transhepatic approach is precluded.

Most pancreaticoduodenal artery aneurysms involve celiac trunk stenosis or occlusion. Few cases have been related to superior mesenteric artery (SMA) stenosis, and none of these was treated with SMA angioplasty before transcatheter arterial embolization (TAE) or operative resection of the aneurysm. We treated a 79-year-old woman with incidentally detected inferior pancreaticoduodenal artery aneurysms, presumably secondary to SMA stenosis. Abdominal angiography indicated that TAE of the aneurysms would disturb collateral flow and cause SMA ischemia, so SMA angioplasty was performed before TAE of the aneurysms. Arteriography of the SMA six days after angioplasty revealed partial thrombosis in the giant aneurysm. The smaller aneurysm was then embolized to occlude collateral flow, which facilitated further thrombosis of the giant aneurysm without recurrence.

We report two cases of acute arterial hemorrhage successfully treated by transarterial embolization, using the triaxial system and n-butyl-2-cyanoacrylate (NBCA). Case 1 is a 78-year-old man with a large hematoma in the rectus abdominis muscle. Case 2 is a 63-year-old man with massive jejunal bleeding and shock. In both cases, severe coagulopathy was present, and safe embolization with NBCA was necessary. In the triaxial system, which consists of a 1.9-French (F) microcatheter, a 2.7-F high-flow microcatheter, and a 4-F catheter, the high-flow microcatheter introduced through the 4-F catheter usually acts as supporting catheter to advance the 1.9-F microcatheter distally. In our cases, the high-flow microcatheter was also useful for the prevention of NBCA reflux into an untargeted artery, and thus, safe embolization could be performed.

Background If only proximal embolization or ligation is performed for an internal iliac artery aneurysm (IIAA), transcatheter arterial embolization is sometimes difficult due to complex collateral circulation. A new method of direct percutaneous n-butyl-2-cyanoacrylate (NBCA) sac embolization (b-DNSE) under balloon arterial occlusion for re-intervention of an IIAA after proximal ligation is presented.

Methods The patient was placed in the supine position under local anesthesia. A 20-cm-long, 20G-PTCD needle was advanced to the aneurysmal sac using fluoroscopy. A 5F, 11-cm sheath was inserted via the left common femoral artery, and a Selecon MP catheter was advanced to the left limb. Sacography showed the sac with only the iliolumbar artery as the involved branch. Then, the left limb was balloon-occluded, and the sac was more widely visualized with the appearance of the superior gluteal artery and the obturator artery on sacography. Sac embolization using 10 ml of 50% NBCA diluted with lipiodol was performed under balloon arterial occlusion, and the needle was removed. Completion arteriography showed good Lipiodol distribution without a residual sac or involved branches. No obvious complications were seen, and the procedure was completed.

Results The patient was discharged 2 days after the procedure. At 6-month follow-up, contrast-enhanced computed tomography showed no sac enhancement without Lipiodol washout and no expansion of the excluded aneurysm.

Conclusion b-DNSE for re-intervention of an IIA aneurysm is feasible when embolization of all involved branches proves difficult. We intend to further investigate this technique.

Selective catheterization of some branch arteries may occasionally be impossible, especially small branches arising from a large parent artery or the aorta with an acute angle at the orifice. A catheter with a large side hole or cleft is a useful device for selecting such branch arteries. This catheter can be made easily during the procedure from a conventional angiographic catheter as individual anatomy requires, and a microcatheter-guidewire system can be advanced into the desired branch artery through the side hole or cleft.