Misako Yoshimatsu

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

BackgroundPatients 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.MethodsWe 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.ResultsThere 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.ConclusionsPerioperative 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.

Unilateral transpedicular percutaneous vertebroplasty using puncture simulation

PurposeThe 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).Materials and methodsTwo 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.ResultsThe 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 Students 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.ConclusionThe 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.

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

PurposeThe 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 methodsThe 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.ResultsA 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).ConclusionRESAIC 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.

Percutaneous vertebroplasty performed by the isocenter puncture method

PurposeThe aim of this study was to clarify the usefulness of the isocenter puncture (ISOP) method.Materials and methodsWe 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.ResultsThe 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.ConclusionThe 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): &Dgr; medical cost/&Dgr; 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.

Development of a New Support Method for Transpedicular Punctures of the Vertebral Body: The Isocenter Puncture Method

Recently, the percutaneous transpedicular puncture of vertebral body under fluoroscopic guidance using a singleplane or biplane C-arm radiographic system has gained acceptance for percutaneous vertebroplasty (PVP) and vertebral bone biopsy [1–4]. PVP is usually performed by bilateral transpedicular puncture to gain uniform distribution of the injected cement in the vertebral body. However, if the tip of the puncture needle is advanced to the midline of the vertebral body, PVP by unilateral transpedicular puncture can be achieved. The unilateral transpedicular approach has advantages over the bilateral transpedicular approach, such as reduction of procedure time, cost, and radiation exposure [5, 6]. However, advancing the needle to the midline under fluoroscopic guidance is technically difficult, as is vertebral bone biopsy of a small lesion in the vertebral body. Currently, the CT-guided approach is used for this purpose [7, 8]. To advance the puncture needle to the target in the vertebral body under fluoroscopic guidance, we developed a new puncture method called the isocenter puncture (ISOP) method using the isocenter of the C-arm radiographic system. The purpose of this paper is to describe the ISOP method and our initial clinical results. The ISOP Concept

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

AbstractThere 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 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.

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.

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.