Central venous access is frequently used in various situations, including total parenteral nutrition, measuring central venous pressure, administration of vasoactive drugs, and continuous infusion of anticancer agents. Therefore, this is one of the most basic procedures that must be performed certainly and safely to carry out the standard treatment in any field. On the other hand, there have been a few reports of some complications associated with this procedure. Recently, image-guided puncture has become the standard of this procedure, and interventional radiologists perform it in many hospitals. Good practice of central venous access is an essential procedure for interventional radiologists. To maintain the pride of our profession, we should learn all kinds of techniques so to be able to complete this procedure in any situation.

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Superior vena cava syndrome (SVCS) is a distressing manifestation of benign or malignant disease obstructing the superior vena cava (SVC). Almost all cases of SVC are caused by obstruction of SVC due to advanced unresectable malignant tumors such as lung cancer and mediastinal tumor. The stent placement for the obstructed portion is very effective to release immediately the obstruction of SVC and play an important role as palliative therapy to obtain an improved QOL. This paper reports the indications, procedure, therapeutic results and complications of stent therapy for SVC based on our experiences of 74 cases.

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Inferior vena cava filter placement is an effective method to prevent recurrence of pulmonary thromboembolism. The indications of vena cava filter placement are still unclear, and so we need to examine validity in every individual case. We describe herein the variety, indications, methods and complications of inferior vena cava filter placement.

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Acute massive pulmonary thromboembolism is a life-threatening condition with a high mortality rate due to acute right ventricular failure and cardiogenic shock. Anticoagulation is the most traditional treatment for pulmonary thromboembolism, but may not be sufficient for massive thromboemboli. Systemic thrombolytic therapy and surgical embolectomy are the usual therapeutic options in this situation. Catheter directed thrombolysis and catheter embolectomy are now available to treat the most severe cases of massive pulmonary thromboembolism. There currently are 3 categories of catheter-tip embolectomy for removing or fragmenting pulmonary thromboemboli: (1) aspiration thrombectomy, (2) fragmentation, and (3) rheolytic thrombectomy. The success of these techniques depends on a thorough understanding of the mechanism of each devices and familiarity with the relevant catheterization techniques. Although no controlled clinical trials are available, data from cohort studies indicate that the clinical outcomes after surgical and catheter embolectomy may be comparable. We hereby present a review of currently available equipment and techniques, and describe our work with hybrid treatment using a combination of mechanical fragmentation, local fibrinolysis and clot aspiration.

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Budd-Chiari syndrome is a rare condition, which is thought to affect a couple of hundred patients in Japan per year. It is defined as portal hypertension owing to occlusion or stenosis of main hepatic vein or IVC intrahepatic portion. We will discuss this entity and write about our recent case. Budd-Chiari syndrome is divided into three categories: hepatic type, IVC type, or mixed type. The main strategy to treat this condition used to be medical management, or making shunts. But, recently TIPS, PTA, and transplantations are available. Among them IVR is coming to be the procedure of choice. Therefore we have to know about this condition.

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Pelvic congestion syndrome with an incompetent ovarian vein is a condition that in some particular patients carries significant morbidity. While incompetent and dilated ovarian vein is a common finding in routine CT and MR imaging, ovarian venography remains the "gold standard" for evaluation. Percutaneous transcatheter embolization offers a minimally invasive, safe, and effective treatment for pelvic congestion syndrome. Bilateral embolization, if necessary, using a sclerosing agent and coils has been shown to be associated with better results. Radiologists should be aware of the clinical manifestations of the pelvic congestion syndrome so that appropriate patients will be referred for the treatment.
Another subject is spermatic varicocele causing swelling and pain of the scrotum that may be associated with sperm abnormalities causing male infertility. Transcatheter embolization is a safe and effective treatment with a low recurrence rate. As a treatment for infertility, however, careful patient selection is mandatory because only patients with abnormal sperm parameters will benefit from treatment.

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Primary aldosteronism has an estimated prevalence of 5-10% of all patients with hypertension. Aldostrone producing adenoma or unilateral hyperplasia is usually treated with unilateral laparoscopic adrenalectomy. Adrenal venous sampling is the standard reference for determining the indication of adrenalectomy. In this article, we describe the indications and technical procedure of adrenal venous sampling, and discuss the interpretation of the obtained results.

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Purpose: The purpose of this study was to design an inexpensive system of an artery model with pulsation for training in procedures such as transcatheter arterial coil embolization or experiments. The system was made to fulfill the following requirements. (1) imitating the pulsation of the arterial blood flow, (2) minimal change of the pressure in the system after embolization, (3) feasibility of microcatheter manipulation, (4) non-visualization of artery models' wall under fluoroscopy without the use of contrast materials.
Materials and Methods: For the first requirement (1), silicone artery models with a tubing pump were provided to imitate the pulsating arterial blood flow. For (2), this system had an adjustment system for keeping the intraluminal pressure constant even when the flow in the vessel model stopped after embolization. The adjustment system controlled the intraluminal pressure by fluid level in another drainage route standing vertically besides the main artery model route. The artery model runs through a water phantom with a small amount of contrast materials not to be visualized under fluoroscopy.
Results: Intraluminal pressure was controlled in this system and was well relative to flow rates. The pressure changed minimally under the clamp test at a range of 8 to 16mmHg. The artery model was not visualized under fluoroscopy without contrast materials. This system was available for training of coil embolization using a silicone aneurysm model, though there was a minimal frictional resistance between the silicone and coils. The cost of this system was about \300,000.
Conclusions: This multipurpose vascular model system with pulsation was inexpensively made and had feasibility for training of procedures such as coil embolization.

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Malignant portal vein stenosis or occlusion can lead to portal hypertension with complications such as intestinal variceal bleeding. We report herein a patient successfully treated by transileocolic portal venous stent placement using kissing technique for malignant portal vein obstruction with associated small bowel varices. The case had liver dysfunction and anemia caused by melena. Portography showed severe stenosis of the bilateral first branches of the portal vein from recurrent hilar cholangiocarcinoma and dilated jejunal veins supplying varices as the suspected cause of intestinal bleeding. Double self-expandable metallic stents were placed in bilateral branches of the portal vein across a main portal vein using the "kissing" technique by transileocolic approach. Portography after stent placement showed relief of the portal vein stenosis and disappearance of the jejunal venous collaterals. Liver dysfunction and symptoms were improved after the procedure. Kissing stenting via an transileocolic approach is an effective option for malignant obstruction of bilateral portal vein branches.

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Ehlers-Danlos syndrome (EDS) is a disorder affecting connective tissue including joint lesions, skin and artery lesions. Patient with EDS often develop aneurysm/pseudoaneurysm. Surgical and endovascular interventions are fraught with complications and high morbidity.
We report a case of EDS type IV (also known as the arterial type or ecchymotic type) with a splenic pseudoaneurysm. Although this patient experienced vascular trauma of splenic artery during catheterization, he was successfully treated by transcatheter arterial embolization (TAE), with detachable coils obtained. Initially, endovascular interventions proved to be preferable to open surgery due to the minimum trauma in EDS type IV patient; however, upon further examination, the current mode of treatment is therapeutic plane in detail.

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We report our experience using a 3 French pigtail catheter (CX catheter-AII; Cathex; Kanagawa, Japan) for aortography. The 3 French pigtail catheter is made of nylon, and the distal portion forms a loop, 8mm in diameter, in which 12 holes are spirally punctured. The inner and outer diameters are 0.87mm and 1.17mm, respectively, while the length of the catheter can be either 70cm or 110cm. The catheter has a lumen of 0.87mm, and accepts a 0.032inch guidewire. The maximum injection pressure allowed is less than 1200 psi. The maximum injection rate is 16ml/s in the 70cm catheter and 12ml/s in the 110cm catheter. The image quality obtained with the 3 F pigtail catheter was sufficient to diagnose and complete procedures during various kinds of examinations. After angiographic procedures, the brachial or femoral artery was manually compressed for 5 minutes, and the patient was confined to bed rest with compression by a plaster cast or a cross bandage for 120 min, with no complications noted at the puncture site. The 3 F pigtail catheter is feasible and useful for aortography.

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