Interventionral radiology (IVR) is one kind of less invasive surgery, but accidents and complications during the procedure cannot be completely avoided. As almost all IVR procedures in Japan, are performed without control by an anesthetist, Japanese interventionists must take responsibility for the intraprocedural control of the patient, in addition for the interventional procedure itself. Accordingly, support by nursing specialists in interventional radiology is necessary, and the nurture has been begun, just now. For the guarantee of the IVR quality, educational systems for interventionists, nursing specialists and radiographers, must be established by centralization of the interventional radiology procedures.

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Recently, the concept of "the Trinity of IVR" was introduced into IVR, and the importance of the team approach in medical care has been more and more.
Even if it is said the Trinity of IVR, it might be a pretended team approach in medical care only by doctors, nurses, and radiological technologists who gather in the angio-room, and perform the duties appropriate to their profession. But this would be far from the true team approach in medical care.
The purpose of IVR is to obtain an excellent therapeutic result in safety, in a short period of time, without adverse events and pain as much as possible. Therefore each professional considers the needs of the patient, it is important to show a maximum power to get the best IVR and care with good teamwork.
The position of the IVR nurses have been established in our country. It is needed to improve the quality of the nursing, promotion of the team approach in medical care and progress of the specialty more and more.
As a means to realize these tasks, we suggest the use of "peer review", "cockpit resource management" and "appropriate authority gradient" to perform logical IVR.

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In interventional radiology, the nurse plays an important role as a member of the medical team. However, interventional radiology nursing specialists was not in Japan. The Japanese Society of Interventional Radiology (JSIR) established a certificated system of interventional radiology nurses four years ago because it has an ideal to manage the overall process of interventional radiology. The interventional radiology nurse has many duties concerning monitoring, care, and safety of patients, and education of patients and their families, and so on. This system educates nurses to practice these duties. Now 630 nurses have this certification. After this, we must enrich the educational program for them more and more while they are certainly growing. And this system should be widely publicized since unfortunately it is not yet well recognized.

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In nine patients with descending thoracic aortic aneurysm, the segmental artery feeding the Adamkiewicz artery (AKA) was covered by stent graft. The collateral blood supply to AKA was evaluated with a MDCT.
AKAs were clearly visualized both pre- and post-stent graft in all patients by MDCT. At post-stent graft study, collateral arteries to the segmental artery feeding AKA were also visualized in all patients.
Collateral sources were internal thoracic artery (ITA)(3 patients, 33%), thoracodorsal artery (TDA)(5 patients, 56%), highest intercostal artery (HIA)(1 patient, 11%), and distal intercostal artery/lumbar artery (2 patients, 22%). They were ipsilateral to AKA in all patients. ITA, TDA and HIA branched from subclavian artery, so subclavian artery ipsilateral to AKA was very important as a collateral source to AKA.
Collateral connections were musculophrenic artery (1 patients, 11%), paravertebral anastomosis (1 patients, 11%), muscular branch anastomosis (3 cases, 33%), and intersegmental anastomosis (4 patients, 44%).

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Accumulation of Lipiodol is often improved under balloon-occluded transarterial chemoembolization (B-TACE) for hepatocellular carcinoma (HCC). To reveal the reason for this phenomenon, we measured the mean arterial pressure at the orifice of the celiac artery. We also measured it at the embolized artery before and after balloon inflation in 14 cases. Surprisingly, pulsated movement and flow of the Lipiodol droplets were seen in the distal arteries of the occluded portion in all cases. In 11 cases, the blood pressure decreased by 39mmHg or more after balloon inflation compared with that before balloon inflation, and accumulation of Lipiodol in the HCC nodule was improved. In 2 cases, the blood pressure was already decreased by 41mmHg or more before balloon inflation compared with that at the orifice of celiac artery because of the lodging of the catheter tip. In these 2 cases, the balloon was slightly inflated and accumulation of Lipiodol in the HCC nodule was also improved. In the remaining case, the blood pressure decreased only by 29mmHg after balloon inflation, and it was not improved. A hypothesis to explain this improved accumulation is as follows: the pulsated blood flow is maintained in the distal portion of balloon inflation by collateral arteries, while the arterial pressure is decreased. The Lipiodol emulsion is so viscous that it does not pass through the arterio-portal communication when the arterial pressure is decreased by balloon inflation. In contrast, it continues to flow into the tumor even when the arterial pressure is decreased because the HCC nodule is hypervascular and its flow resistance is lower.

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Pelvic congestion syndrome (PCS) is a cause of chronic pelvic pain related to the presence of varicose veins surrounding the uterus and ovaries. Although it has been demonstrated that embolization of the ovarian vein for PCS is effective, experience is still limited in Japan. We report a case with PCS successfully treated by transcatheter embolosclerotherapy using ethanol and coils. In this case, imaging studies showed abnormally dilated left ovarian and pelvic veins with a reversed flow of the left ovarian vein. Diagnosis of PCS was based on the presence of these radiological findings, and the absence of clinical findings of other pathologic conditions (e.g. PID, endometriosis, AVM and nuts cracker phenomenon). Endovascular treatment included transcatheter ethanol injection into the left ovarian plexus and coil embolizations of the left ovarian vein. The procedure was successful and we observed marked improvement of her symptoms within a week. There has been no recurrence for 3 years.

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Arteriovenous malformation (AVM) of the tongue is a rare developmental lesion in the head and neck vascular anomaly. We report a case of tongue AVM with intractable bleeding. With conventional and "scatter" techniques, N-butyl-cyanoacrylate (NBCA)-Lipiodol mixture was selectively injected into the feeding lingual arteries without complications. "Scatter" technique is a new method to continuously deliver NBCA on the flow as small particles from the proximal portion of the feeding artery to small fistulas. No bleeding was observed during the 29-month follow-up. Since minor bleeding occurred 30 months after the initial embolization, re-embolization using NBCA was performed. Her bleeding has not recurred after the second embolization. For treatment of tongue AVM, transarterial embolization with NBCA appears to be a safe and effective method.

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A man in the 7th decade complaining of melena was admitted to our hospital. Emergency gastroduodenoscopy demonstrated massive hemorrhage from a parapapillary diverticulum. Endoscopic treatment failed to achieve hemostasis, and the patient received emergency angiography. CT arteriography via the right branch of the posterior superior pancreaticoduodenal artery (PSPDA) revealed contrast medium leakage in the parapapillary diverticulum, which could not be detected by digital subtraction angiography (DSA). Superselective transcatheter arterial embolization (TAE) of the branch using N-butyl cyanoacrylate achieved hemostasis. However, hemorrhage recurred on the next day. DSA showed an extravasation from the left branch of the PSPDA, which was embolized with microcoils continuously. The patient was discharged 13 days after the 2nd TAE procedure without recurrent hemorrhage. In conclusion, TAE is a valuable treatment for acute massive hemorrhage from parapapillary diverticulum when endoscopic treatment is difficult.

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In this study, we report a case of hemobilia caused by a pseudoaneurysm in the common bile duct (CBD), which was treated using transcatheter arterial embolization. The patient was a woman in her 70s; she had CBD stones and had undergone endoscopic retrograde biliary drainage. The drainage tube had to be repeatedly changed because of obstruction. The patient developed anemia, and hemobilia occurred with progression of the anemia. On performing emergency arteriography, a saccular aneurysm was detected in the posterior superior pancreaticoduodenal artery (PSPDA); the aneurysm protruded into the CBD lumen and caused extravasation of the contrast medium into the bile duct. The patient was successfully treated using transcatheter arterial embolization therapy with metallic coils. Hemobilia caused by a pseudoaneurysm in the PSPDA is a rare condition. Our results indicate that transcatheter arterial embolization therapy with metallic coils is a useful treatment option for this condition.

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Heparin-induced thrombocytopenia (HIT) is a potentially fatal complication when heparin is used for treatment. We encountered a man in his 60's with HIT diagnosed after placement of a port-catheter system for hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma. Heparin had been used to prevent occlusion of the venous line and the indwelling catheter. In general, an indwelling catheter containing heparin should be removed after the patient is diagnosed as having HIT. However, in this case, after cessation of the heparin flush alone, the thrombocytopenia recovered immediately. Thus, removal of the port-catheter system was unnecessary.

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