Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) was designed to provide microscopically negative margins of the celiac artery, nerve plexus, and retroperitoneal tissue for patients with locally advanced pancreatic body cancer. We have been routinely performing the preoperative embolization of CHA for those patients scheduled for DP-CAR since August 1998, to limit the post-surgical ischemic complications of the liver, gall bladder and stomach, by maintaining the blood supply through development of collateral pathways via the superior mesenteric artery and pancreatic arcade. When performing preoperative CHA embolization, it is important to preserve the proper hepatic artery and gastroduodenal artery in order to develop the collateral pathways. It is also preferable to preserve a more than 5-mm length of the distal CHA for easier ligation at surgery. We employed several conventional embolization techniques. However, migration of embolic material from CHA occurred in several patients. From these experiences, we developed an embolization technique using two simultaneous microcatheters and interlocking detachable coils (IDCs). We call this a “dual microcatheter-dual IDC (DMDI) technique”. The DMDI technique provided an excellent high success rate than conventional technique. Recently, embolization technique using amplatzer vascular plug4 (AVP4) has become an good alternative to DMDI technique due to its excellent ease of positioning of AVP4.

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Distal pancreatectomy with en bloc celiac axis resection (DP-CAR) was now employed for locally advanced cancer of the body of the pancreas involving the common hepatic artery and/or celiac trunk. Recently, pancreaticoduodenectomy with common hepatic artery resection (PD-CHAR) is employed for locally advanced cancer of the head of the pancreas. In this operation, reconstruction of the hepatic artery is generally needed. In some cases, reconstruction of the hepatic artery is not needed due to hepatic arterial variants. Herein, we discussed the strategy for preoperative coil embolization of PD-CHAR in our institute by reporting two cases.

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Postpancreatectomy hemorrhage (PPH) is a rare but often severe complication after pancreatic resection. In consequence the incidence and mortality rates in the literature reveal a large range 3-8% and 15-60%, respectively. Treatments for PPH include laparotomy and endovascular interventions. We describe endovascular management that includes embolization and stentgraft placement. Embolization is based on the “isolation technique”, in which both the proximal and distal parts including the bleeding point are filled with embolic materials to avoid retrograde blood flow. It is minimally invasive and associated with a high success rate. Stentgraft placement is a good option for complete hemostasis and the preservation of parental artery flow.

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The prognosis of pancreatic cancer is extremely poor. Although currently systemic chemotherapy is being widely used as a standard treatment for advanced pancreatic cancer, the results are not satisfactory. A major challenge for pancreatic arterial infusion is achievement of optimal drug distribution. Most cases of pancreatic cancer required chemoinfusion via the celiac and the superior mesenteric artery. Then, alternation of pancreatic blood supply technique to convert the dual pancreatic blood supply into the single celiac arterial supply was developed. A clinical phase I/II trial of arterial infusion using this technique with 5-fluorouracil (5-FU) combined with systemic gemcitabine showed a high response rate of 68.8%. For liver metastases, TACE using irinotecan eluting microspheres (DEBIRI) is a promising therapy. Even after failure of current standard chemotherapies of FOLFIRINOX and/or gemcitabine plus nab-PTX, DEBIRI often shows a good response. Arterial infusion chemotherapy also has a role as an adjuvant therapy after pancreatic resection. A combination of hepatic arterial infusion of 5-FU and systemic gemcitabin decreased the hepatic recurrence ratio. We believe intra-arterial therapy has a high potential to become a breakthrough in a treatment of pancreatic cancer.

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Purpose: To evaluate the feasibility of percutaneous isolated pancreatic perfusion (PIPP) chemotherapy from fundamental experiments to clinical applications.
Methods: We conducted two major experiments for PIPP using 32 pigs. In the first experiment, pharmacologic, histopathologic, and chronological laboratory studies were performed to determine the optimal infusion rate. In the second experiment, 17 pigs underwent PIPP with contrast medium, and the percent enhanced volume to the whole pancreas (%eV) was quantitated at 3 infusion rates of 12, 24, and 36 mL/min by MDCT arteriography. Additional experiments underwent a revised PIPP without and with balloon occlusion of the anterior mesenteric artery (AMA), and the %eV was compared.
Results: In the first study, the optimal infusion rate of 40 mL/min was selected in terms of histopathological safety. The median pancreatic-to-systemic exposure ratios were 71.8 for C-max and 54.8 for the area under the curve. All laboratory data remained normal or returned to pretreatment levels within 1 week. In the second study, without AMA occlusion, high infusion rates significantly increased the enhancement volume. With AMA occlusion, the median %eVs were 92.8%, 95.4%, and 98.5%, respectively, significantly larger than the corresponding areas without AMA occlusion (P = 0.031).
Conclusion: PIPP is feasible and may enable either partial or complete drug delivery to the pancreas as required. Based on experimental results, we started to perform PIPP for patients with stage IV pancreatic cancer.

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Pulmonary varix is a localized dilatation of the pulmonary vein, which is rare and usually asymptomatic. On the other hand, pulmonary arteriovenous malformation (PAVM) is an abnormal shunt between a pulmonary artery and vein without any intervening capillary beds. PAVM could constitute a risk factor such as a cerebral infarction or cerebral abscess. Therefore, pulmonary varix should be distinguished from PAVM accurately. Pulmonary angiography is essential for have a high degree of usability for definitive diagnosis of the pulmonary varix.
A female in her 70s was incidentally pointed out a dilated vessel in the right lung on contrast enhanced CT. Angiogram revealed that the pulmonary artery and pulmonary vein had no shunt with each other. We diagnosed pulmonary varix and no treatment was required. Now she remains asymptomatic, and follow-up is continued annually.

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Duodenal varices are rare, but often life-threatening when ruptured. Treatments of ruptured duodenal varices have not been established, but in most cases, endoscopic injection sclerotherapy (EIS) is the first-line treatment. Interventional radiology including balloon-occluded retrograde transvenous obliteration (BRTO) has been reported as a useful therapy for duodenal varices following endoscopic therapy or natural hemostasis. Because drainage veins for duodenal varices are usually narrow and meandering, conventional BRTO tends to be difficult as an emergency therapy. Here we present a case of ruptured duodenal varices successfully treated by BRTO using a micro-balloon catheter.

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