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the local suppression rate and survival rate, are reported to The protocol used for the three-dimensional rotating image
have improved compared with previous results. [1-3] was as follows: detector, 30 cm × 38 cm × 154 µm; FOV,
LR 22.5 cm × AP 22.5 cm × HF 18 cm; matrix, 1,024 ×
Previously, endovascular intervention mainly employed 1,024; projection, 30 projection/s for 5 s, rotation 200°;
conventional cut-film angiography; however, the dosage, 1.2 µ Gy/pulse; contrast agent, iopamidol solution
usage of digital subtraction angiography (DSA) and (150 mg I/mL) (Iopamiron 150; Bayer; Osaka, Japan); infusion
the interventional radiology features (IVR)-CT system, rate and duration, 1-2.5 mL/s, 8 s; and delay time, 3 s. Both
combining conventional angiography with CT, has now upper limbs were raised, and imaging was performed with
become more prevalent. The IVR-CT system can obtain the patients holding their breath. The data obtained were
tomographic images when performing IVR, providing much transferred to an X-Leonard workstation (Siemens) and
useful additional information. CT hepatic arteriography and maximum intensity projection (MIP), volume-rendering
CT arterioportography are recognized as techniques with (VR), and MPR (axial, coronal, and sagittal thickness, 3 mm)
the highest detection rates in HCC diagnosis. However, images were generated.
[4-7]
because the IVR-CT system obtains information from two
separate X-ray imaging devices (DSA and CT equipments), Endovascular intervention (TACE)
difficulties are often experienced while correlating the two First, a 3F or 4F sheath was inserted by the percutaneous
sets of data obtained from the two devices. approach from the groin into the femoral artery, and
two-dimensional DSA imaging of the celiac and superior
Angiography devices equipped with a flat panel detector- mesenteric arteries was performed using diagnostic
based cone-beam CT (CBCT) imaging system can provide catheters. Next, a two-dimensional DSA image of the
three-dimensional and tomographic images on a single hepatic artery (any one of the common, proper or replaced
X-ray device through rotational CBCT imaging in addition to hepatic arteries) was obtained, and maintaining the catheter
a conventional two-dimensional DSA image. Furthermore, in the same location, CBCT three-dimensional rotating
because of no change in the conventional angiography imaging was performed. As mentioned above, the CBCT
equipment, no additional space is required for the IVR-CT volume data were processed in the workstation. Using this
system. [8,9] information, we performed superselective catheterization
of the subsegmental branches of the hepatic artery. After
We hypothesized that a three-dimensional understanding of confirming tumor staining on the two-dimensional DSA
hepatic artery anatomy and multiple planar reconstruction image, a suspension of the chemotherapeutic agent
(MPR) images obtained from arbitrary cross-section epirubicin (farmorubicin, 10-40 mg; Kyowa Hakko, Tokyo,
may contribute to nodule detection and feeding artery Japan) and iodized oil (lipiodol, 1-6 mL; Andre Guerbet,
identification by combining CBCT imaging with conventional Aulnay-sous-Bois, France) was infused arterially. Embolization
DSA imaging in endovascular intervention for HCC. In was performed using a gelatin sponge (Gelpart, 1-10 mg;
this study, we retrospectively examined the HCC nodule Nippon Kayaku/Astellas, Tokyo, Japan) in patients with
detection and feeding artery identification capabilities of preserved hepatic function (Child-Pugh classification A). In
CBCT imaging. addition, for diagnostic purposes, small amounts of iodized
oil were introduced into the subsegmental arterial branches,
METHODS including those supplying the densely stained tumors. After
two weeks of treatment, CT imaging was performed to
Subjects confirm the presence or absence of iodized oil deposition.
The subjects were 24 patients (12 males and 12 females)
from our facility with clinically suspected HCC who Evaluation
underwent TACE using CBCT in addition to conventional HCC was defined as vascular enhancement on DSA imaging
digital subtraction angiography (DSA). The trial period was after superselective catheterization and nodular deposition
from October 2006 to January 2008. The patients were of Lipiodol on CT imaging after treatment. Retrospectively,
aged between 52 and 84 years (average age, 71.2 years). All the study coordinator (Y.U.) reviewed all DSA, CBCT and CT
patients had underlying chronic hepatitis or cirrhosis. In all imaging after treatment and recorded the size and location
cases, a dynamic study using multi-row detector computed of each HCC on a subsegmental basis. The gold standard
tomography (MDCT; Aquilion-16 or Aquilion-64; Toshiba, of a feeding artery was also based on tumor staining on
Tokyo, Japan) was conducted within one month before DSA imaging after superselective catheterization. First,
TACE. All patients were clinically diagnosed with HCC by two radiologists engaged in interventional radiology
dynamic CT and/or the elevation of tumor markers. (M.H. and D.K.) evaluated the presence of HCC on DSA
from a common, proper or replaced hepatic artery with or
Imaging device without CBCT in a consensus fashion. When a focal vascular
The angiography equipment used in endovascular intervention enhancement was seen, they diagnosed it as HCC. Next,
was AXIOM Artis dBA (Siemens). In addition to conventional the identification of a feeding artery was also attempted in
two-dimensional DSA imaging, rotation of the detector with subsegmental branch unit. A feeding artery was defined as a
the C-arm helped in three-dimensional rotational imaging. vessel continuing with tumor stain and visualized separately
232 Hepatoma Research | Volume 2 | August 25, 2016