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CIRSE 2016

Barcelona, Spain

September 10-14

CIRSE 2016
ABSTRACTS &
AUTHOR INDEX

S37 PART 1:

S143 PART 2:
S187 PART 3:
S347 PART 4:

Special Sessions
Special Session Controversies
Fundamental Courses
Honorary Lectures
Hot Topic Lectures
CIRSE Meets Lectures
Free Papers
Posters
Author Index

Online Publication Number:

10.1007/s00270-016-1405-3

Cardiovascular and Interventional Radiological Society of Europe

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Abstract Book

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CIRSE 2016

Barcelona, Spain

September 10-14

CIRSE 2016
PART 1

Abstracts of
Special Sessions
Special Session Controversies
Fundamental Courses
Honorary Lectures
Hot Topic Lectures
CIRSE Meets Lectures
sorted by presentation
numbers

Cardiovascular and Interventional Radiological Society of Europe

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CIRSE

Fundamental Course
Patient assessment before endovascular therapy

Abstract Book

101.2
Imaging and procedure planning
D.K.Tsetis
Unit of Vascular and Interventional Radiology, University Hospital
Heraklion, Iraklion, Greece

101.1
Protocols and pathways
R.Uberoi
Interventional Radiology, John Radcliffe Hospital, Oxford, United
Kingdom
Learning Objectives
1. Basic protocols for patient referral and use of leaflets
2. Basic protocols for patient assessment
3. Basic protocol for patient follow-up
Interventional radiology is an integral part of many areas of modern hospital medicine, with increasing involvement in supporting
and often replacing traditional surgical and medical management
of patients. Pathways for appropriate referral should be established
in all centers carrying out interventional radiology for both elective
and emergency patients so that patients are optimally managed
with minimal delays in treatment. This requires engagement with
colleagues from across a range of specialties to produce protocols
from the patients presentation to completion of the patient treatment episode. In some instance this may be direct referral from the
primary care physician and treatment by and IR specialist who takes
complete responsibility for the patients care during the treatment
episode or shared care with other clinical specialists. Patients treatments should be discussed at a formalised multi-disciplinary team
meeting where the most appropriate management strategy can be
formulated.
Following the decision to treat, there should be a standardised
proforma which allows the patients and staff to be clear as to how
the patient will be treated, where the patient will be treated, what
patient preparation will be required prior to the procedure, including management of the patient drugs, consent, the procedure itself,
sedation and analgesia during the procedure, how and into whos
care the patient will be discharged following treatment, any follow-up protocols and who will assume overall responsibility for that
treatment.
To help in this process, staff and patients should be engaged in
helping design the protocols and pathways. These should include
patient information leaflets which can be sent out well in advance of
the procedure to allow understanding of the procedure and risks so
that a better informed consent can be undertaken. There should be
checklists for staff to utilise on the patients arrival and discharge to
ensure that the patient and staff are well prepared to minimise the
risk during and following completion of the procedure. This should
also include the CIRSE checklist immediately prior to commencing
the procedure itself. There should be regular audit of these practices
for continued learning and to improve /modify practices as well as
updating protocols/pathways where necessary.
Conclusion: Interventional radiology specialists have a duty to
ensure that all procedures are carried out appropriately, efficiently
and safely. To aid in this, all units should have clearly written protocols and pathways accessible to staff and patients.
References
1. The Provision of Interventional Radiology Services in Europe:
CIRSE Recommendations. Tsetis D, Uberoi R, Fanelli F, Roberston
I, Krokidis M, van Delden O, Radeleff B, Mller-Hlsbeck S,
Szerbo-Trojanowska M, Lee M, Morgan R, Brountzos E, Belli AM.
Cardiovasc Intervent Radiol. 2016 Apr;39(4):500-6. doi: 10.1007/
s00270-016-1299-0. Epub 2016 Feb 9.

Learning Objectives
1. Appropriate imaging assessment and review to plan cases
2. Planning cases
Digital subtraction angiography (DSA) has been considered for
many years the gold standard for imaging and procedural planning
before endovascular therapy. However, DSA is an invasive technique
associated with significant local and systemic complications, including hematomas, arterial damage, systemic anaphylaxis, and renal
failure. Less invasive imaging modalities, such as computed tomography angiography (CTA), magnetic resonance angiography (MRA),
and duplex ultrasound arterial mapping, offer an alternative to DSA.
Today, most interventionists will rely on CTA or MRA to assess aortic
morphology, evaluate access artery patency and locate side branch
orifices in patients with thoracic and abdominal endovascular aortic repair (EVAR and TEVAR). Recent developments in cross-sectional
imaging, including advanced image postprocessing, multi-modality
image fusion, and new contrast agents, have resulted in improved
spatial resolution for preoperative planning. Advanced reconstruction algorithms, like dynamic CTA and MRA, provide valuable information on dynamic changes in aneurysm morphology that might
have an important impact on endograft selection. Prior to endovascular treatment manufacture of anatomically accurate, patientspecific, small-caliber arterial models is feasible using data from a
patients CT scan, free open-source software, and low-cost internet
3D printing services.
Magnetic resonance angiography (MRA) provides noninvasive visualization of vascular pathology, without harmful radiation. This is
important for planning an endovascular intervention and helps to
evaluate the efficiency and effectiveness of the treatment. MRA with
conventional extracellular contrast agents relies on accurate contrast bolus timing, limiting the imaging window to first-pass arterial
phase. The recently introduced blood pool contrast agent, gadofosveset trisodium, reversibly binds to human serum albumin, resulting in increased T1 relaxivity and prolonged intravascular retention time, permitting both first-pass and steady-state phase highresolution imaging. High-quality MRA serves, amongst others, as
a detailed roadmap for the endovascular treatment of aortoiliac
occlusive disease, inferior vena cava thrombus, pelvic congestion
syndrome, and lower extremity arteriovenous malformation.
Duplex ultrasound arterial mapping represents a minimally invasive,
economically proficient modality for roadmapping procedural outcome in endovascular revascularization in patients with critical limb
ischemia. It allows for high patient turnover with procedural and
clinical success without compromising hemodynamic outcome. This
modality is superior to other available modalities as the sole preoperative imaging tool in a successful limb salvage program.
References
1. Ghatwary TM, Patterson BO, Karthikesalingam A, Hinchliffe RJ,
Loftus IM, Morgan R, et al. A systematic review of protocols for
the three-dimensional morphologic assessment of abdominal
aortic aneurysms using computed tomographic angiography.
Cardiovasc Intervent Radiol. 2013; 36: 14e24.
2. Katsamouris A, Giannoukas A, Tsetis D, Kostas T, Petinarakis I,
Gourtsoyiannis N. Can ultrasound replace arteriography in the
management of chronic arterial occlusive disease of the lower
limb? Eur J Vasc Endovasc Surg. 2001; 21: 155-9.
3. Menke J, Larsen J. Meta-analysis: Accuracy of contrast-enhanced
magnetic resonance angiography for assessing steno-occlusions
in peripheral arterial disease. Ann Intern Med. 2010; 153: 325-34.

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101.3
Patient preparation
M.ern
Department of Radiology, University Hospital, Olomouc, Czech
Republic
Learning Objectives
1. Dealing with patient factors i.e. drugs, hydration, diabetes,
bloods, etc.
2. Liason with clinical colleagues and wards
Patient preparation before endovascular procedures plays an
important role in preventing complications.
Normal coagulation parameters (INR 1.5, aPTT up to 1.5 times
the normal value, platelets 75.10 ml) are required before vascular
procedures to avoid hemorrhagic complications.
It is important to assess patients medications (drugs) before intervention with individual consideration. The basic recommendation
for warfarin (Coumadin) is to discontinue it 5 days before intervention, to monitor of INR after 2 days, and, if INR decreases below 2,
to eventually start treatment with LMWH. The recommendation for
new oral anticoagulants (NOAC) (dabigatran, rivaroxaban, and
apixaban) is to stop taking them at least 24 hours before intervention. High-risk patients (e.g., patients with bronchial asthma, polyvalent allergy, or previous allergic reaction to iodine contrast) should
be prepared, before iodine contrast administration, by corticosteroids (prednisone 40 mg 12-18 hours and 20 mg 6-9 hours before
the procedure) to prevent allergic reaction. Metformin should be
discontinued 2 days before to 2 days after intervention (with iodinated contrast agent) especially in patients with abnormal renal function (because of risk of lactic acidosis). Antithyroid drugs (thiamazole, 3 days before and continue for 2 weeks after administration
of contrast agents) are recommended to prevent thyrotoxicosis
in high-risk patients. Regular medication (cardiotonic drugs and
drugs for hypertension and asthma) is administered before the procedure. Acetylsalicylic acid (aspirin, 45-100 mg) is administered 1
day before and life-long after PTA. Dual antiplatelet therapy (aspirin 100 mg/day, clopidogrel 75 mg/day) is recommended 3-7 days
prior to carotid artery stenting to 3 months after the procedure.
Patients with type I diabetes mellitus are scheduled for a procedure in the morning; they take half the dose of insulin and receive
slow intravenous infusion of glucose (at least 5 g of glucose per
hour).
Patients must have fasted or reduced the intake of fluids to a clear
liquid (100 ml/hour) for 4 hours prior to the planned procedure. The
recommendation for elective procedures requiring general anesthesia, or sedation/analgesia, is to abstain from intake of clear liquids at
least 2 hours and of solid foods 6 h before a procedure. Adequate
hydration is the basis of prevention of contrast-induced nephropathy (CIN). It is recommended to increase oral fluid intake 24 hours
before and after the procedure or to administer 0.9% NaCl solution
intravenously with a rate of 1-2 ml/kg/h for at least 4 hours before
and 24 hours after the procedure.
Liaison with clinical colleagues and wards is essential to prevent
complications and to achieve good clinical results.
References
1. American Society of Anesthesiologists Committee.
Practice guidelines for preoperative fasting and the use
of pharmacologic agents to reduce the risk of pulmonary
aspiration: application to healthy patients undergoing elective
procedures: an updated report by the American Society of
Anesthesiologists Committee on Standards and Practice
Parameters. Anesthesiology. 2011;114(3):495-511.
2. Andreucci M, Solomon R, Tasanarong A. Side effects of
radiographic contrast media: pathogenesis, risk factors, and
prevention. Biomed Res Int. 2014;2014:1-6.

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3. Enomoto Y, Yoshimura S. Antiplatelet therapy for carotid artery

stenting. Interv Neurol. 2013;1(3-4):151-63.
4. Goergen SK, Rumbold G, Compton G, Harris C. Systematic review
of current guidelines, and their evidence base, on risk of lactic
acidosis after administration of contrast medium for patients
receiving metformin. Radiology. 2010;254(1):261-9.
5. Smith I, Kranke P, Murat I, et al. Perioperative fasting in
adults and children: guidelines from the European Society of
Anaesthesiology. Eur J Anaesthesiol. 2011;28(8):556-69.
6. Taslakian B, Sebaaly MG, Al-Kutoubi A. Patient evaluation and
preparation in vascular and interventional radiology: what
every interventional radiologist should know (Part 1: patient
assessment and laboratory tests). Cardiovasc Intervent Radiol.
2015 Oct 22. [Epub ahead of print]
6. Taslakian B, Sebaaly MG, Al-Kutoubi A. Patient Evaluation and
preparation in vascular and interventional radiology: what
every interventional radiologist should know (Part 2: patient
preparation and medications). Cardiovasc Intervent Radiol.
2016;39(4):489-99.
7. Vison A, Tonello D, Zalunardo B, et al. Antithrombotic
treatment before and after peripheral artery percutaneous
angioplasty. Blood Transfus. 2009;7(1):18-23.

101.4
Consultation and consent
B.Gonalves, P.Lopes, M.J.Sousa
Servio de Radiologia de Interveno, Instituto Portugues de Oncologia
- FG, Porto, Portugal
Learning Objectives
1. How to ensure informed patient consent
2. Use of patient leaflets
CONSULTATION
In the new era of interventional radiology (IR) as a subspecialty of
radiology, the interventional radiologist has gained his space and
has been allowed to establish a completely new relation with his
patient. With the increasing number of IR techniques, we also have
seen an increasing number of consultation requests from the medical and surgical specialties. Several procedures changed from
inpatient to outpatient basis. Clinical evaluation and patient care
became mandatory before and after the procedures.
A structured consultation before an interventional procedure
should be based in a problem-oriented medical record. A concept
developed by Lawrence Weed in the early 1970s who wrote the first
SOAP note under this methodology. S indicates subjective data
obtained from your patient symptoms; O indicates objective data
obtained by observation, patient signs, physical examination, blood
tests, diagnostic imaging studies (US, Doppler-US, CT, MR, PET), and
previous interventions or surgeries; A designates patient assessment, a summary of all the significant data, patient condition, your
conclusions, new data that becomes available, and the relevant
medical diagnoses; and P indicates the plan for your patient, i.e.,
the proposed treatment or further diagnostic studies. A chart or a
scheme might be done to better organize your problem-oriented
medical record.
A SOAP note gives the IR a structured, rigorous, and objective way
to communicate with others, avoiding unscientific medical terminology. Using SOAP, you can easily assess patient morbidities that are
relevant before an endovascular treatment that may interfere with
patients main diagnosis, in order to treat or avoid a possible complication during your procedure.
Medical conditions such as diabetes, high blood pressure, heart disease, smoking history, peripheral vascular disease, cancer, previous procedures, and others are very important since they may interfere in the choice of the vascular access or the proposed treatment.

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Symptoms grading classifications like Fontaine or Rutherford in

peripheral artery disease can be easily assessed to determine the
indication for a proposed treatment.
INFORMED CONSENT
Informed consent must be asked and be provided according the
good medical practice or the guidelines for a specific intervention.
A standard of care must be informed; the potential benefits have to
be explained, but potential complications should also be given. The
IC should be written and signed by the patient himself. Leaflets or
schemes may also be given to better explain and illustrate the following procedure. Finally, local country legislation has always to be
respected.

Special Session
Thyroid ablation
102.1
Treatment of benign nodules: thermal ablation vs. surgery
F.Stacul
Dept. of Radiology, Maggiore Hospital, Trieste, Italy
Learning Objectives
1. To learn about indications for thermal ablation in benign
nodules
2. To learn about devices and techniques for thermal ablation in
benign nodules
3. To understand the results and the complication rates of ablation
Benign thyroid nodules are a common occurrence whose only remedy, in case of symptoms, has always been surgery until the advent
of new techniques, such as radiofrequency ablation (RFA). This presentation aims at evaluating RFA efficacy, tolerability, and costs and
comparing them to hemithyroidectomy for the treatment of benign
thyroid nodules.
A total of 136 patients who underwent RFA were retrospectively
compared to 74 patients who were surgically treated, either in a
standard inpatient or in a short-stay surgical regimen. RFA was performed in a single session and reduced nodular volume by 72% after
12 months. It was an effective method for treating nodule-related
clinical problems, but it was not as effective as surgery for the treatment of hot nodules. Hyperthyroidism was completely resolved only
in 40% of patients.
RFA and surgery were both safe, although RFA had fewer complications (RFA complications included 2 cases of transient voice change,
1 case of late-onset painless thyroiditis with transient thyrotoxicosis,
and 1 case of skin burn; and surgical complications included 4 cases
of transient hypocalcemia, 6 cases of unilateral transient nerve palsy,
and 2 cases of wound complications). Post-procedural pain was rare
after RFA. Surgery was also well tolerated, but post-operative pain
was scored significantly higher. RFA costed 1661.50 (the needle
cost was the most relevant component), surgery costed 4556.30,
and short-stay surgery costed 4139.40 per patient (operating theater and hospitalization costs were the most relevant components).
RFA, however, did not allow for any pathologic analysis of the nodules, which, in 6 patients who had undergone surgery (8%), revealed
that the nodules harbored malignant cells. Therefore, it would be
sensible to continue the monitoring of the ablated nodules at least
yearly for 5 years.
Additionally, it is important to note that one RFA session does not
affect subsequent thyroid surgery: 3 patients who had undergone
RFA were successfully operated on later without intraoperative
problems.
In conclusion, this comparative study suggests that RFA represents
an effective alternative to surgery, which is more expensive and
occasionally unnecessary, for the treatment of benign thyroid nodules causing local symptoms or cosmetic concerns.

Abstract Book
References
1. J.H. Baek, J.H. Lee, J.Y. Sung et al, Complications encountered
in the treatment of benign thyroid nodules with US-guided
radiofrequency ablation: a multicenter study. Radiology,
262(1):335-342, 2012.
2. J.H. Baek, J.H. Lee, R. Valcavi et al, Thermal ablation for benign
thyroid nodules: radiofrequency and laser. Korean Journal of
Radiology, 12(5):525-540, 2011.
3. S. Bernardi, C. Dobrigna, B. Fabris et al, Radiofrequency ablation
compared to surgery for the treatment of benign thyroid
nodules. International Journal of Endocrinology, Article ID
934595, 10 pages, 2014.
4. C. Dobrigna, S. Bernardi, B. Fabris et al, Surgical and
pathological changes after radiofrequency ablation of thyroid
nodules. International Journal of Endocrinology, Article ID
576576, 8 pages, 2015.
5. H.K. Lim, J.H. Lee, E.J. Ha et al, Radiofrequency ablation of
benign non-functioning thyroid nodules: 4-year follow-up
results for 111 patients. European Radiology, 23(4):1044-1049,
2013.
6. D.G. Na, J.H. Lee, S.L. Jung et al, Radiofrequency ablation
of benign thyroid nodules and recurrent thyroid cancers:
consensus statement and recommendations. Korean Journal of
Radiology, 13(2):117-125, 2012.
7. J.H. Shin, J.H. Baek, E.J. Ha, and J.H.Lee, Radiofrequency
ablation of thyroid nodules: basic principles and clinical
application. International Journal of Endocrinology, Article ID
919650, 7 pages, 2012.

102.2
The role of thermal ablation in malignant thyroid disease
J.H.Baek
Radiology, Asan Medical Center, Seoul, Korea
Learning Objectives
1. To learn about indications for thermal ablation in malignant
thyroid disease
2. To learn about devices and techniques for thermal ablation in
malignant thyroid disease
3. To understand the results and the complication rates of ablation
Papillary thyroid carcinoma (PTC) is the most common subtype (>
80% of all thyroid cancers) of thyroid malignancy with good prognosis and a low mortality rate (1). Although patients with PTC show
an excellent outcome, the tumor recurrence in the neck ranged from
20% to 59% according to their risk. The standard treatment strategy
for recurrent patients is surgery followed by radioactive iodine therapy and thyroid hormone therapy. When surgery is not available,
radioactive iodine therapy, radiation therapy, and chemotherapy
are therapeutic options. Although surgery is the standard treatment,
complications can be increased because distortion of neck anatomy
by scar tissue formation, especially in patients with repeated neck
dissections. For these patients, ultrasound US-guided treatments
have been used as an alternative such as ethanol ablation (EA) (2-6),
radiofrequency ablation (RFA) (7-11) and laser ablation (LA) (1214). The goal of this review is to evaluate the role of US-guided RFA
based on the scientific evidence available and an expert opinion for
managing recurrent thyroid cancers.
1. Indications
Recommendations by Korean Society of Thyroid Radiology (15) suggest that RFA can be used in patients at high surgical risk and in
patients who refuse to undergo repeated surgery. Recently Italian
opinion statement proposed similar indications for recurrent thyroid
cancers (16): patients with recurrent thyroid cancers (operation bed
and lymph nodes) at high surgical risk. Before RFA, tumor recurrence
should be confirmed by US-guided fine needle aspiration cytology
and/or measurement of the washout thyroglobulin concentration.

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Treatment strategies of US-guided treatment for recurrent thyroid cancers are not well established; however, two treatment strategies have been suggested: complete versus conservative treatment. Complete treatment defines as treatment of any visible recurrent cancers on US. The purpose of the treatment is to improve any
symptomatic and cosmetic problems caused by recurrent tumors.
To achieve complete ablation of recurrent tumors visible on US, several studies have suggested that nonsurgical treatment be restricted
to patients with three or less recurrent thyroid cancers in the neck
and no metastatic tumors beyond the neck at the time of treatment
(2, 7, 11, 17). Conservative treatment has been applied to treat large
recurrent cancers that cause cosmetic and/or symptomatic problems, such as discomfort, pain, dysphagia, hoarseness, and dyspnea
by involving critical structures in the neck or other area (18).
2. Devices
Two types of electrodes have been used for thyroid RFA; these are
straight internally cooled and multi-tined expandable electrode (1925). Recently the straight internally cooled electrode is a mainstay of
thyroid RFA (26). Our thyroid RFA team has been used straight type
internally cooled electrode, which was developed for liver RFA. This
type electrode is easy to move and more suitable for Moving Shot
Technique; however the electrode for liver RFA is long (15cm) and
thick (17-gauge). Therefore we developed a modified straight internally cooled electrode, which is short in shaft length (7 cm) to permit
easy control because thyroid gland is a superficial organ, thin (1819gauge) to minimize injury to the normal thyroid gland (22). Thin
electrode, especially 19-gauge, can also easily penetrate small metastatic tumors through the surgical scar (7, 11). And we can use active
tips of various sizes (0.5 cm, 0.7 cm or 1 cm). The size of the electrode
is chosen according to the tumor size and status of surrounding danger structures. An electrode with a small active tip, especially 0.5cm,
is effective for the treatment of small recurrent tumors or tumors
that are close to critical structures (27).
3. Techniques
The patient is placed in the supine position with the neck extended.
Two grounding pads are attached to both thighs. Regarding the use
of anesthesia, 12% lidocaine is used in most centers without premedication (7, 11, 17). Lidocaine a simple and effective pain control
method and applied to the puncture site and soft tissue around the
recurrent tumor. However Monchik et al. (28) have reported the use
of intravenous drugs, a combination of fentanyl citrate (100400
mcg) and midazolam (14mg), as a possible treatment.
To prevent unnecessary scar formation the skin is not incised, and to
prevent serious hemorrhage the vessels along the approach route
should be carefully evaluated. The nerves in the lateral aspect of the
neck should also be carefully evaluated. If a metastatic tumor is adjacent to the nerve, the hydrodissection technique is useful for preventing thermal injury. A 5% dextrose solution should be carefully
injected between the nerve and the tumor (7, 11, 17). The movingshot technique has been used to treat benign thyroid nodules and
recurrent thyroid cancers (11, 15, 29). Before starting ablation, the
targeted tumor should be divided into multiple conceptual ablation units and RFA performed unit by unit by moving the electrode
tip. These conceptual units are smaller at the periphery of the tumor
and the portions adjacent to the critical structures (e.g., nerve, trachea, and esophagus) and are larger in the central, safe portion of
the tumor. For small tumors, however, the electrode should be fixed
to the center of the tumor and not be moved during the procedure.
Initially, the electrode tip is positioned in the deepest and most
remote conceptual unit of the tumor to enable easy monitoring of
the electrode tip without the disturbance caused by microbubbles.
Ablation is started using 10-15W of power in the 0.5cm, 20-30W in
the 0.7cm and 40-50W in 1 cm active tip. If a transient hyperechoic
zone does not form at the electrode tip within 510 s, the RF power
can be increased in 510W increments up to 3080W. If the patient

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cannot tolerate pain during ablation, lidocaine injection around the

tumor can be used to relieve pain. During the follow-up period, the
indications for repeated RFA include the presence of power Doppler
signals or enhancing portion in CT scan despite a reduction in tumor
size (3, 4, 7, 11), tumor volume reduction less than 50% (6), and the
presence of residual tumor tissue on fine-needle aspiration cytology
(3, 6, 8).
4. Clinical outcomes
During the follow-up period efficacy is evaluated by the reduction
in the tumor volume [(initial volume final volume) x 100/initial volume] (25), the therapeutic success rate (volume reduction >50%)
(30), complete disappearance of the treated tumor, the serum thyroglobulin concentration, tumor perfusion, and changes in the echogenicity of the treated tumor (15). Following RFA, several investigators have reported a mean volume reduction of 5698% (7, 17, 18,
31), complete disappearance of 2594% of tumors (7, 8, 17, 28, 32),
therapeutic success rates of 75 97% (7, 8, 11, 28), improvement of
symptoms in 64% of patients (18), and a decrease in the serum thyroglobulin concentration in the majority of patients (7, 8, 18, 28).
However, long-term follow-up data have not been published.
The meta-analysis including nine articles including 189 patients
(male: 54 and female: 135) with 255 tumor lesions, who underwent
US-guided RFA beyond the mean 6 months of follow-up. The results
showed that tumor volume, largest diameter and serum thyroglobulin level were decreased. Recently meta-analysis compared the efficacy and safety of RFA and EA. The first study concluded that both
RFA and EA are acceptable management tools for locally recurrent
thyroid cancers in terms of efficacy and safety. However the mean
number of RFA sessions was <1.3 in 83.3% (5/6 RFA studies), and the
number of EA sessions was more than two in 75% (3/4 EA studies)
(33).
5. Complications
Following RFA, various complications have been reported, including discomfort, pain, neck swelling, skin burn, and changes in voice
(7-9, 11, 17, 18, 28, 31, 32, 34). The most common complications are
discomfort and pain in the neck. The majority of patients complain
of discomfort and pain during ablation. Pain sometimes radiates to
the teeth, jaw, head, and chest, but is usually resolved within several minutes to hours following the procedure. To relieve pain during ablation, the ablation power is reduced or stopped and/or local
anesthesia is administered deep into the tumor or surrounding tissue (5, 6, 35). During RFA, heat propagation to surrounding tissue is a
main cause of pain, but during EA, pain is most likely related to localized leakage of the injected ethanol into the surrounding soft tissue.
Pain does not disturb the RFA in most patients.
Serious complications are induced by damage of nerve or esophagus (36-40). To prevent serious complications, the operators should
be aware of the anatomy of the neck and always trace the electrode
tip during the procedure using ultrasound.
6. Conclusion
RFA is a possible alternative for the treatment of recurrent thyroid cancers in patients at high risk of surgery or those who refuse
repeated surgeries. It is slightly superior to ethanol ablation in terms
of efficacy, mean number of treatment sessions required, and the
extent of the ablation zone. However, RFA demonstrates a higher
tendency and severity of voice complications than ethanol ablation
for the treatment of central neck lesions. To minimize these complications, the operators should be aware of the various possible complications that could present as well as the preventive techniques
that are available.
References
1. Haugen BRM, Alexander EK, Bible KC, Doherty G, Mandel
SJ, Nikiforov YE, et al. 2015 American Thyroid Association
Management Guidelines for Adult Patients with Thyroid Nodules
and Differentiated Thyroid Cancer. Thyroid 2016;26:1-133.

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2. Hay ID, Lee RA, Davidge-Pitts C, Reading CC, Charboneau

JW. Long-term outcome of ultrasound-guided percutaneous
ethanol ablation of selected recurrent neck nodal metastases
in 25 patients with TNM stages III or IVA papillary thyroid
carcinoma previously treated by surgery and 131I therapy.
Surgery 2013;154:1448-1454; discussion 1454-1445.
3. Heilo A, Sigstad E, Fagerlid KH, Haskjold OI, Grholt KK, Berner
A, et al. Efficacy of Ultrasound-Guided Percutaneous Ethanol
Injection Treatment in Patients with a Limited Number of
Metastatic Cervical Lymph Nodes from Papillary Thyroid
Carcinoma. J Clin Endocrinol Metab 2011;96:2750-2755.
4. Kim BM, Kim MJ, Kim EK, Park SI, Park CS, Chung WY. Controlling
recurrent papillary thyroid carcinoma in the neck by
ultrasonography-guided percutaneous ethanol injection. Eur
Radiol 2008;18:835-842.
5. Lewis BD, Hay ID, Charboneau JW, McIver B, Reading CC,
Goellner JR. Percutaneous ethanol injection for treatment
of cervical lymph node metastases in patients with papillary
thyroid carcinoma. Am J Roentgenol 2002;178:699-704.
6. Lim CY, Yun JS, Lee J, Nam KH, Chung WY, Park CS. Percutaneous
ethanol injection therapy for locally recurrent papillary thyroid
carcinoma. Thyroid 2007;17:347-350.
7. Baek JH, Kim YS, Sung JY, Choi H, Lee JH. Locoregional control
of metastatic well-differentiated thyroid cancer by ultrasoundguided radiofrequency ablation. AJR Am J Roentgenol
2011;197:W331-336.
8. Dupuy DE, Monchik JM, Decrea C, Pisharodi L. Radiofrequency
ablation of regional recurrence from well-differentiated thyroid
malignancy. Surgery 2001;130:971-977.
9. Guenette JP, Monchik JM, Dupuy DE. Image-guided ablation
of postsurgical locoregional recurrence of biopsy-proven
well-differentiated thyroid carcinoma. J Vasc Interv Radiol
2013;24:672-679.
10. Kim JH, Yoo WS, Park YJ, Park DJ, Yun TJ, Choi SH, et al. Efficacy
and Safety of Radiofrequency Ablation for Treatment of Locally
Recurrent Thyroid Cancers Smaller than 2 cm. Radiology
2015;276:909-918.
11. Lim HK, Baek JH, Lee JH, Kim WB, Kim TY, Shong YK, et al.
Efficacy and safety of radiofrequency ablation for treating
locoregional recurrence from papillary thyroid cancer. Eur Radiol
2015;25:163-170.
12. Mauri G, Cova L, Ierace T, Baroli A, Di Mauro E, Pacella CM, et
al. Treatment of Metastatic Lymph Nodes in the Neck from
Papillary Thyroid Carcinoma with Percutaneous Laser Ablation.
Cardiovasc Intervent Radiol 2016.
13. Mauri G, Cova L, Tondolo T, Ierace T, Baroli A, Di Mauro E, et al.
Percutaneous laser ablation of metastatic lymph nodes in the
neck from papillary thyroid carcinoma: preliminary results. J Clin
Endocrinol Metab 2013;98:E1203-1207.
14. Papini E, Bizzarri G, Bianchini A, Valle D, Misischi I, Guglielmi R, et
al. Percutaneous ultrasound-guided laser ablation is effective for
treating selected nodal metastases in papillary thyroid cancer. J
Clin Endocrinol Metab 2013;98:E92-97.
15. Na DG, Lee JH, Jung SL, Kim JH, Sung JY, Shin JH, et al.
Radiofrequency ablation of benign thyroid nodules and
recurrent thyroid cancers: consensus statement and
recommendations. Korean J Radiol 2012;13:117-125.
16. Garberoglio R, Aliberti C, Appetecchia M, Attard M, Boccuzzi
G, Boraso F, et al. Radiofrequency ablation for thyroid nodules:
which indications? The first Italian opinion statement. J
Ultrasound 2015;18:423-430.
17. Lee SJ, Jung SL, Kim BS, Ahn KJ, Choi HS, Lim DJ, et al.
Radiofrequency ablation to treat loco-regional recurrence
of well-differentiated thyroid carcinoma. Korean J Radiol
2014;15:817-826.

Abstract Book
18. Park KW, Shin JH, Han BK, Ko EY, Chung JH. Inoperable
symptomatic recurrent thyroid cancers: preliminary result of
radiofrequency ablation. Ann Surg Oncol 2011;18:2564-2568.
19. Deandrea M, Limone P, Basso E, Mormile A, Ragazzoni F, Gamarra
E, et al. US-guided percutaneous radiofrequency thermal
ablation for the treatment of solid benign hyperfunctioning or
compressive thyroid nodules. Ultrasound Med Biol 2008;34:784791.
20. Baek JH, Jeong HJ, Kim YS, Kwak MS, Lee D. Radiofrequency
ablation for an autonomously functioning thyroid nodule.
Thyroid 2008;18:675-676.
21. Baek JH, Kim YS, Lee D, Huh JY, Lee JH. Benign predominantly
solid thyroid nodules: prospective study of efficacy of
sonographically guided radiofrequency ablation versus control
condition. AJR Am J Roentgenol 2010;194:1137-1142.
22. Baek JH, Moon WJ, Kim YS, Lee JH, Lee D. Radiofrequency
ablation for the treatment of autonomously functioning thyroid
nodules. World J Surg 2009;33:1971-1977.
23. Lee JH, Kim YS, Lee D, Choi H, Yoo H, Baek JH. Radiofrequency
ablation (RFA) of benign thyroid nodules in patients with
incompletely resolved clinical problems after ethanol ablation
(EA). World J Surg 2010;34:1488-1493.
24. Spiezia S, Garberoglio R, Milone F, Ramundo V, Caiazzo C, Assanti
AP, et al. Thyroid nodules and related symptoms are stably
controlled two years after radiofrequency thermal ablation.
Thyroid 2009;19:219-225.
25. Jeong WK, Baek JH, Rhim H, Kim YS, Kwak MS, Jeong HJ, et al.
Radiofrequency ablation of benign thyroid nodules: safety and
imaging follow-up in 236 patients. Eur Radiol 2008;18:1244-1250.
26. Gharib H, Hegedus L, Pacella CM, Baek JH, Papini E. Clinical
review: Nonsurgical, image-guided, minimally invasive therapy
for thyroid nodules. J Clin Endocrinol Metab 2013;98:3949-3957.
27. Baek JH, Kim YS, Sung JY, Choi H, Lee JH. Locoregional Control
of Metastatic Well Differentiated Thyroid Cancer in the Neck
by Ultrasonography-guided Radiofrequency Ablation AJR Am J
Roentgenol 2011;in press.
28. Monchik JM, Donatini G, Iannuccilli J, Dupuy DE. Radiofrequency
ablation and percutaneous ethanol injection treatment
for recurrent local and distant well-differentiated thyroid
carcinoma. Ann Surg 2006;244:296-304.
29. Ha EJ, Baek JH, Lee JH. Moving-shot versus fixed electrode
techniques for radiofrequency ablation: comparison in an
ex-vivo bovine liver tissue model. Korean J Radiol 2014;15:836843.
30. Sung JY, Baek JH, Kim YS, Jeong HJ, Kwak MS, Lee D, et al.
One-step ethanol ablation of viscous cystic thyroid nodules. AJR
Am J Roentgenol 2008;191:1730-1733.
31. Kim JH, Yoo WS, Park YJ, Park do J, Yun TJ, Choi SH, et al. Efficacy
and Safety of Radiofrequency Ablation for Treatment of Locally
Recurrent Thyroid Cancers Smaller than 2 cm. Radiology
2015;276:909-918.
32. Wang L, Ge M, Xu D, Chen L, Qian C, Shi K, et al.
Ultrasonography-guided percutaneous radiofrequency ablation
for cervical lymph node metastasis from thyroid carcinoma. J
Cancer Res Ther 2014;10 Suppl:C144-149.
33. Suh CH, Baek JH, Choi YJ, Lee JH. Efficacy and Safety of
Radiofrequency and Ethanol Ablation for Treating Locally
Recurrent Thyroid Cancer: A Systematic Review and
Meta-Analysis. Thyroid 2016;26:420-428.
34. Long B, Li L, Yao L, Chen S, Yi H, Ye X, et al. Combined use of
radioiodine therapy and radiofrequency ablation in treating
postsurgical thyroid remnant of differentiated thyroid
carcinoma. J Cancer Res Ther 2015;11 Suppl:C244-247.
35. Ha EJ, Baek JH, Lee JH. The efficacy and complications of
radiofrequency ablation of thyroid nodules. Curr Opin Endocrinol
Diabetes Obes 2011;18:310-314.

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36. Ha EJ, Baek JH, Lee JH, Kim JK, Shong YK. Clinical significance
of vagus nerve variation in radiofrequency ablation of thyroid
nodules. Eur Radiol 2011;21:2151-2157.
37. Ha EJ, Lee JH, Lim HK, Bae Kim W, Baek JH. Identification
of continuity of transected nerve on sonography after
neck dissection: direct sign of traumatic neuroma. Thyroid
2011;21:1385-1387.
38. Hong MJ, Baek JH, Kim DY, Ha EJ, Choi WJ, Choi YJ, et al. Spinal
Accessory Nerve: Ultrasound Findings and Correlations with
Neck Lymph Node Levels. Ultraschall Med 2014.
39. Shin JE, Baek JH, Ha EJ, Choi YJ, Choi WJ, Lee JH. Ultrasound
Features of Middle Cervical Sympathetic Ganglion. Clin J Pain
2015;31:909-913.
40. Ha EJ, Baek JH, Lee JH. Ultrasonography-Based Thyroidal and
Perithyroidal Anatomy and Its Clinical Significance. Korean J
Radiol 2015;16:749-766.

102.3
HIFU for benign nodules
R.Kovatcheva
Department of Thyroid and Metabolic Bone Disorders, Medical
University of Sofia, University Hospital of Endocrinology, Sofia, Bulgaria
Learning Objectives
1. To learn about indications for HIFU in thyroid disease
2. To learn about patient selection and technique of HIFU
3. To understand the results and the complication of HIFU
Learning Objectives: Principals, indications, patient selection,
effectiveness, and side effects of ultrasound (US)-guided high-intensity focused ultrasound (HIFU) treatment of benign thyroid nodules.
Background: Thyroid nodules can be detected by US with a prevalence of 1967%, but less than 10% of them are malignant. About
1/3 of the benign thyroid nodules show continuous growth with
symptoms of compression or cosmetic concerns. Surgery is still the
main therapeutic strategy, although it carries a 210% risk of complications as hypocalcaemia, transient or permanent recurrent laryngeal nerve palsy, bleeding, postoperative infection. US-guided
HIFU is a new, non-invasive thermo-ablative method, developed to
reduce thyroid nodule size. Our aim was to show the long-term efficacy and safety of a single and repeated US-guided HIFU treatment
of benign solid thyroid nodules.
Procedure details: The HIFU ablation was performed with a realtime US-guided HIFU system (EchoPulse, Theraclion, France), a
mobile unit consisting of a corpus with energy generator, an articulated arm with a treatment head, a cooling system, and a touch
screen interface for procedure planning and follow-up. The treatment head incorporated both the imaging transducer and the HIFU
transducer for delivering energy to the target. The treatable area
was 528 mm from the skin, and the intended size of the HIFU ablation unit was 9 mm in length and 1.82.5 mm in orthogonal dimensions. The safety of the adjacent structures was ensured by using a
laser-based movement detector that enabled immediate power
interruption in case a patient moved or swallowed. The planned
treatment volume and the vulnerable structures (carotid artery, trachea, and skin) were outlined by the physician on a touch-screen
interface on two axes. On the basis of this information, the device
software defined the treatment units and safety margins. The procedure consisted of HIFU repeated pulses for ablation of the whole targeted tissue. Skin integrity was secured by means of a cooling system. The complete procedure duration consisted of time for installation, positioning, planning, and treatment. Treatment duration
included time for sonication (4 seconds per ablation unit) that varied with treatment volume, time for cooling (1530 seconds), which
depended on the energy level and the nodule distance from the
skin, and time for repositioning.

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Clinical findings: 20 euthyroid patients (mean age, 44.5 years)

with benign solitary or dominant thyroid nodule were treated with
US-guided HIFU, under conscious sedation. Twelve patients (group
1) received one treatment and 8 patients (group 2) received second
treatment after 3-month follow-up. Nodule volume was established
at baseline, 3 and 12 months after the final treatment. Thyroid function was assessed at baseline and 12 months after the final treatment. Adverse events during and after the HIFU procedure were
evaluated. Pain associated with the treatment was subjectively rated
by using a 010 cm visual analog scale. Written informed consent
was acquired from all patients.
The mean energy applied per nodule volume did not significantly
differ between group 1 and 2 (3.51.4 kJ/mL and 4.11.6 kJ/mL,
respectively). Starting from 5.042.82 ml (group 1) and 4.832.93
ml (group 2), the mean volume decreased significantly at 12-month
follow-up (2.35 2.44 ml, p=0.003, and 2.63 1.85 ml, p=0.017,
respectively) with a maximal volume reduction of 95.4% and 66%,
respectively. The mean volume reduction did not differ significantly
between group 1 and 2 (55.7% 27.2 and 50%21, respectively).
In all treated patients, the mean TSH was significantly higher 12
months after the final treatment (2.26 1.08 mIU/L compared with
1.70.97 mIU/L before HIFU, p=0.013), but still within normal ranges.
After the first treatment transient subcutaneous oedema and mild
skin redness were observed in 2 patients and after the second treatment, one patient developed Horner syndrome, which resolved 6
months later.
Conclusion: The effect of one and two consecutive HIFU treatments in solid benign thyroid nodules is comparable. The method
is safe and well tolerated by the patients, with rare and transient
side effects. Although TSH slightly increases after HIFU ablation, the
long-term thyroid function remains normal.
References
1. Frates MC, Benson CG, Charboneau JW, et al. Management
of thyroid nodules detected at US: Society of Radiologists in
Ultrasound Consensus Conference Statement. Radiology 2005;
237:794800.
2. Erdogan MF, Gursoy A, Erdogan G. Natural course of benign
thyroid nodules in a moderately iodine-deficient area. Clin
Endocrinol (Oxf) 2006;65(6):767771.
3. Bergenfelz A, Jansson S, Kristoffersson A, et al. Complications
to thyroid surgery: results as reported in a database from a
multicenter audit comprising 3,660 patients. Langenbecks Arch
Surg 2008;393(5):667673.
4. Esnault O, Franc B, Chapelon JY. Localized ablation of thyroid
tissue by high-intensity focused ultrasound: improvement of
noninvasive tissue necrosis methods. Thyroid 2009;19(10):1085
1091.
5. Esnault O, Franc B, Menegaux F, et al. High intensity focused
ultrasound ablation of thyroid nodules: first human feasibility
study. Thyroid 2011;21(9):965973.
6. Zhou YF. High intensity focused ultrasound in clinical tumor
ablation. World J Clin Oncol 2011;2(1):827.
7. Gharib H, Hegeds L, Pacella CM, Baek JH, Papini E. Clinical
review: Nonsurgical, image-guided, minimally invasive therapy
for thyroid nodules. J Clin Endocrinol Metab 2013;98(10):3949
3957.
8. Kovatcheva RD, Vlahov JD, Stoinov JI, Ivanova RS, Shinkov AD.
High-intensity focused ultrasound [HIFU] a feasible option for
the treatment of benign thyroid nodules. 37th Annual Meeting
of ETA, 7-11 September 2013, Leiden, The Netherlands. Eur
Thyroid J, 2013, 2(suppl 1): 183.
9. Kovatcheva R, Vlahov JD, Stoinov JI, Lacoste F, Zaletel K.
US-guided high-intensity focused ultrasound ablation of
non-functioning benign thyroid nodules three months of
follow-up. 38th Annual Meeting of ETA, 6-10 September 2014,
Santiago de Compostela, Spain. Eur Thyroid J, 2014,3(suppl 1):
177.

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10. Kovatcheva R, Vlahov J, Stoinov J, Lacoste F, Ortuno C,

Zaletel K. US-guided high-intensity focused ultrasound as
a promising non-invasive method for treatment of primary
hyperparathyroidism. European Radiology, 2014, 24(9): 2052.
11. Kovatcheva RD, Vlahov JD, Stoinov JI, Zaletel K. Benign Solid
Thyroid Nodules: US-guided High-Intensity Focused Ultrasound
Ablation-Initial Clinical Outcomes. Radiology, 2015, 276(2):597
605.
12. Kovatcheva R, Vlahov J, Stoinov J, Zaletel K. Long-term results
of US-guided high-intensity focused ultrasound treatment
of benign thyroid nodules. XVII European Congress of
Endocrinology, 16-20 May 2015, Dublin, Ireland. Endocrine
Abstracts, 2015, 37, GP.25.01.
13. Kovatcheva R, Vlahov JD, Stoinov JI, Zaletel K. The Effect of
One and Two Sessions of US-guided High-Intensity Focused
Ultrasound (HIFU) Treatment on Thyroid Nodule Volume and
Thyroid Function. XV International Thyroid Congress, 18-23
October 2015, Orlando, USA. Thyroid, 2015, 25(Suppl 1): A-176
177.

102.4
Irreversible electroporation: what is the advantage?
M.R.Meijerink
Radiology and Nuclear Medicine, VUMC, Amsterdam, Netherlands
Learning Objectives
1. To learn about principles and indications of IRE
2. To learn about advantages over other ablation techniques
3. To understand the technique and results of IRE
No abstract available.

Special Session
Intraprocedural radiation dose management
103.1
Occupational dosimetry in the interventional laboratory: dose
limits and risk estimation
G.Bartal
Radiology, Meir MC, Kfar-Saba, Israel
Learning Objectives
1. To learn about the potential risks of occupational radiation
exposure
2. To learn about the dose limits for different organs and
acceptable dose
3. To learn how to estimate the risks
As more evidence is emerging from recent publications on the dangers of occupational radiation exposure in Image (Fluoroscopy)
guided interventions there is a clear need to recognize the risks, to
learn about staff dose limits and the ways to reduce the possible
damage to a Minimum.
Recent publications confirm the alarming incidence and variety of
occupational-related illnesses of medical staff working in the interventional laboratory (1, 2, 3).
International Commission on Radiation Protection (ICRP) issued a
new recommendation for the occupational dose limit to the lens
of the eye based on the new threshold for lens effects and the suggested equivalent dose limit for the lens of the eye was reduced
from 150mSv year-1 (ICRP 2013 Proceedings) to 20mSv year-1, averaged over a 5-year period, with no years dose exceeding 50mSv
(ICRP, 2012). Last International and European BSS (Basic Safety
Standards) comprises new limit (European Commission, 2012; IAEA,
2014) for the medical staff (1).

Abstract Book
Relatively high exposure doses have been reported for both extremities (2) and the eye lens (3, 4) of the Interventional Radiologists (IRs)
that in some cases, exceed the personal dose limits. Moreover, new
controlled data suggest lower or even no dose threshold for radiation-induced eye lens injuries. These data are under consideration
by the ICRP and may lead to the re-evaluation of the existing dose
limit (1).
There is no acceptable dose definition or recommendation for
the personnel, as it depends on the specific applications and is different for public, workers and patients. There are dose limits for
the personnel, which are not applicable to the medical exposure of
patients.
Noticeably, new dose thresholds, particularly the 0.5 Gy threshold for the lens of the eye, affect occupational protection for operators and other staff, which is principally important for fluoroscopically guided procedures (1, 6). Regrettably, not all operators protect
their eyes or their brain sufficiently during interventions. After several years of work without proper protection, cumulative absorbed
doses to the lens can exceed 0.5 Gy [ RELID (Retrospective Evaluation
of Lens Injuries and Dose) (see: https://rpop.iaea.org/rpop/rpop/content/news/relid-cataract-study.htm)].
During most of the IAEA surveys of radiation-related lens opacities
in interventionalists and staff, 4050% of the professionals involved
in interventional cardiology procedures who volunteered to be
examined had posterior subcapsular lens opacities (2, 3, 4). Only 10%
of the members of the control groups had such opacities. Important
to note that most of the observed lens opacities were in interventionists who had worked for several years without any eye protection. The dose rate to the operator can exceed 10 mSv h-1 when the
high-dose fluoroscopy mode is used and 50 mSv h-1 during cine
acquisition. The highest dose rate was recorded at the Left Anterior
Oblique (LAO 90) projection, which corresponds to the lateral projection when the operator is standing at the tube side (4, 5).
Many medical specialties outside the imaging departments (e.g. vascular surgery, urology, orthopaedics, gastroenterology, anaesthetics and pain management) are starting to use or increase their use
of fluoroscopically guided procedures in surgical theatres without
the radiation protection tools available in standard interventional
laboratories (ICRP, 2010). Such a practice may result in occupational
doses for these physicians that are higher than the typical values
recorded in interventional radiology and cardiology services, where
protection tools are used regularly (6).
Lack of compliance with the regular use of personal dosimetry has
been a problem for many years in many countries (5, 7). This is one
of the reasons for the shortage of an accurate occupational dose
data (and reliable radiation risk estimations) in different professional
groups. One of the methods of estimating staff doses is working on
Monte Carlo calculations and detection of staff location in the catheterisation laboratory to calculate approximately staff doses during clinical procedures through the use of radiographic and geometric data. Another method that was recently published is use of
a realistic approach to estimate lens doses in interventional cardiology when personal dosimeters are not used regularly. The authors
concluded that for around 2000 diagnostic, PCI, and valvular procedures, when the median scatter dose value per procedure at the
C-arm was 0.78, 1.07, and 1.45 mSv, respectively (4). Lens doses are
approximately 5060% of these values when radiation protection
tools are not used. For all of these procedures, the ratio between the
scatter dose at the C-arm and the kerma-area product was 10.311.3
mSv(Gy cm2)-1 (6). Several medical societies including CIRSE and SIR
have published or endorsed documents on occupational protection
that are also expected to improve staff radiation safety (7). New ethical issues are emerging in situations where reducing patient dose
involves increasing staff doses and vice versa. Occupational radiological protection is still a challenge in several clinical situations.
ICRP has included specific recommendations and advice for occupational protection in most of its publications in recent years (ICRP,
2000, 2007 a,b,c, 2009, 2010, 2013 a,b).

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Operator dose (incident air kerma) at the typical working position is around 1/1000 of incident air kerma at the patients skin, so
the instantaneous dose rate to an unprotected operator may reach
approximately 5mGymin-1.
Newer active personal dosimeters display occupational dose rates in
real time inside the interventional fluoroscopy suite, and allow subsequent detailed analyses of staff and patient doses by recording
dose at very short intervals. This data on implementation of the real
time active personnel dosimetry permit the development of new
optimisation strategies to improve occupational protection (7, 9).
References
1. E. Vano, D.L. Miller, L. Dauer. 2013. Implications in medical
imaging of the new ICRP thresholds for tissue reactions. ICRP
2013 Proceedings.
2. Ciraj-Bjelac O., Rehani M., Minamoto A., et al., 2012. Radiationinduced eye lens changes and risk for cataract in interventional
cardiology. Cardiology. 123, 168171.
3. Chodick, G. et al. (2008). Risk of cataract after exposure to low
doses of ionizing radiation: a 20-year prospective cohort study
among US radiologic technologists. Am. J. Epidemiol. 168,
620631.
4. Lie, . ., Paulsen, G. U. and Whni, T., 2008. Assessment
of effective dose and dose to the lens of the eye for the
international cardiologist. Radiat. Prot. Dosim. 132(3), 313318.
5. Vano, E., Gonzalez, L., Fernandez, J. M., Prieto, C. and Guibelalde,
E., 2006. Influence of patient thickness and operation modes
on occupational and patient radiation doses in interventional
cardiology. Radiat. Prot. Dosim. 118, 325330.
6. M. G. Andreassi et al., 2016. Occupational Health Risks in Cardiac
Catheterization Laboratory Workers Circ Cardiovasc Interv., 9,
pp. 1-8.
7. Bartal G., Vano E., Paulo G., et al., 2014. Management of patient
and staff radiation dose in interventional radiology: current
concepts. Cardiovasc. Intervent. Radiol. 37, 289298.
8. Vano E., Fernandez JM, Sanchez R.M., et al., 2013. Realistic
approach to estimate lens doses and cataract radiation risk in
cardiology when personal dosimeters have not been regularly
used. Health Phys. 105, 330339. ICRP 2013 Proceedings.
9. Sanchez R., Vano E., Fernandez J.M., et al., 2010. Staff radiation
doses in a real-time display inside the angiography room.
Cardiovasc. Intervent. Radiol. 33, 12101214.

103.2
Radiation protection tools: shielding and personal protective
devices
N.Rathmann
Institute of Clinical Radiology and Nuclear Medicine, University Medical
Center Mannheim, Medical Faculty Mannheim Heidelberg University,
Mannheim, Germany
Learning Objectives
1. To learn about shielding in the interventional laboratory
2. To learn about various protective tools for the operator
3. To learn how to best protect the operator and the personnel
during interventional procedures
Who will benefit from this information?
Radiologists and technical staff.
What needs to be taken into consideration in terms of radiation
protection tools?
Over the last decade, modern flat-panel (FP) C-arm cone-beam CT
(CBCT) systems have been increasingly installed in newest fashion angiography suites, offering different angulations and settings
like C-arm CT and at the same time providing conventional fluoroscopy and angiography. With the new available motion space, different aspects of radiation protection gain importance since established X-ray shielding devices might not be practical and sufficient

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[1, 2]. Additionally, not all aspects of radiation protection can be

directly transferred from one device for interventional guidance to
another as CBCT systems have a different X-ray beam geometry and
hence, scatter radiation behavior when compared to multidetector
CT (MDCT) [1].
Since radiation exposure to the patient does not equal to that to
the medical staff [3], display of this information does not necessarily lead to an exposure reduction of the staff. Moreover, continuing
advances in the use of 3D and in future maybe even 4D intervention
guidance will make radiation protection for patients and the medical staff more challenging in the near.
Examples of how these issues have been addressed:
A multitude of parameters can be optimized in order to reduce the
overall radiation exposure. The interventional radiologist (IR) can
directly influence some parameters and other parameters are not
adaptable due to inherent technical prerequisites of the system.
Well-accepted principles remain the basis of radiation protection
for the patient and the medical staff using angiography devices and
MDCT. The well-known ALARA principle does not just refer to the
duration of X-ray use but in general to the optimization of radiation
protection [4]. In general, it should be the primary goal to reduce
scatter radiation in order to reduce overall radiation exposure. To
only use imaging for the necessary moment would be one option.
If the use of an X-ray device is indicated, assistance of the integrated computer system helps by achieving this aim. For using all
the offered possibilities of the devices, IR has to be well acquainted
with the device and the software itself. Latest imaging devices offer
automatic dose adjustment by modulating tube voltage and tube
current dependent on the patients thickness, resulting in a lower
radiation exposure to the patient and decreased scatter radiation.
Functions like last-image hold, the reference-image function, and
simulated road mapping are tools, allowing the operator to reduce
exposure time that further reduces the pulse rate from continuous
imaging to 7.5 images/s and results in a 90% dose reduction [5].
Respecting the inverse square law remains the backbone in terms of
radiation protection factoring into many aspects. It could be shown
that state-of-the-art MDCT is associated with less radiation exposure
to the medical staff compared to older generation CT scanners. One
explanation is that with increasing number of slice systems, the isocenter is located at a larger distance to the gantry opening [6]. Since
most of the scatter radiation causing exposure to the IR is produced
on the side of the X-ray-source, angulation of a multi-axis angiography device will result in an increased radiation exposure to the IR if
the IR is located on the side of the X-ray source. Thus, the IR should
always be at a distance from the X-ray source. Keeping the table at
a low position also allows the IR be at a distance from the source of
scatter radiation, i.e., the patient [5, 7].
Radiation protection garment with 0.5-mm lead equivalent reduces
the radiation exposure by 90% [5]. Wearing lead glasses in order to
avoid radio-induced cataract either through acute or chronic radiation exposure should be mandatory not just because of the revision
of the eye lens threshold to 0.5 Gray (Gy) by the ICRP [1, 8]. Also, sterile protective gloves are available for reducing radiation exposure
by 15%30%. However, the automatic dose adjustment of the X-ray
device might bear its risk when wearing sterile protective gloves.
Though one should always avoid direct exposure to the X-ray beam,
sterile protective gloves would cause the system to increase the
dose to obtain a sufficient signal-to-noise ratio ultimately resulting
in an increased overall radiation exposure [9].
X-rays move straight in vacuum being part of the electromagnetic
spectrum and photons [5]. Hence, any protection device absorbing
the X-rays would cast a shadow with reduced radiation exposure.
Using lead glass and lead curtains for shielding close to the source
of scatter radiation would significantly reduce radiation exposure to
the medical staff if taking cover behind it: a shield with 1.0- to 1.5mm lead-equivalent thickness nearly completely absorbs X-rays [9].
In this context, a colleague who cannot take any more cover would
also be a possible X-ray shield.

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In future, the use of navigation systems may help to reduce radiation exposure to the medical staff to close to zero. They could allow
the IR to leave the room during application of radiation and to only
enter the room when needle manipulation or controlling of the navigation system is necessary [2].
Taking home message:
Well-accepted principles such as ALARA and inverse square law
remain the backbones of radiation protection.
Always try to use installed radiation shielding devices instead of
always wearing radiation protection garments.
Be familiar with the software settings of the X-ray devices to always
use the lowest dose settings offering sufficient image quality (e.g.,
low frame rate, less magnification).
Replace old X-ray devices.
References
1. Icrp, Rehani MM, Gupta R, et al. Radiological Protection in Cone
Beam Computed Tomography (CBCT). ICRP Publication 129. Ann
ICRP 2015; 44:9-127.
2. Rathmann N, Kostrzewa M, Kara K, et al. Radiation exposure
of the interventional radiologist during percutaneous biopsy
using a multiaxis interventional C-arm CT system with 3D laser
guidance: a phantom study. Br J Radiol 2015; 88:20150151.
3. Hausler U, Czarwinski R, Brix G. Radiation exposure of medical
staff from interventional x-ray procedures: a multicentre study.
Eur Radiol 2009; 19:2000-8.
4. The 2007 Recommendations of the International Commission
on Radiological Protection. ICRP publication 103. Ann ICRP 2007;
37:1-332.
5. Hertault A, Maurel B, Midulla M, et al. Editors Choice Minimizing Radiation Exposure During Endovascular
Procedures: Basic Knowledge, Literature Review, and Reporting
Standards. Eur J Vasc Endovasc Surg 2015; 50:21-36.
6. Rathmann N, Haeusler U, Diezler P, et al. Evaluation of radiation
exposure of medical staff during CT-guided interventions. J Am
Coll Radiol 2015; 12:82-9.
7. Haqqani OP, Agarwal PK, Halin NM, Iafrati MD. Minimizing
radiation exposure to the vascular surgeon. J Vasc Surg 2012;
55:799-805.
8. Brown KR, Rzucidlo E. Acute and chronic radiation injury. J Vasc
Surg 2011; 53:15S-21S.
9. Schueler BA. Operator shielding: how and why. Tech Vasc Interv
Radiol 2010; 13:167-71.

103.3
Real-time dosimetry in IR
L.Tselikas
Interventional Radiology, IGR, Villejuif, France
Learning Objectives
1. To learn about conventional dosimetry
2. To learn what real-time dosimetry is currently on the market
3. To learn the influence of the real-time dosimetry during an
interventional procedure
No abstract available.

Abstract Book

103.4
Patient dose reduction technologies
W.Jaschke
Department of Radiology, Medical University Innsbruck, Innsbruck,
Austria
Learning Objectives
1. To understand the radiation risk to the patient during
interventional oncological procedures
2. To learn how to estimate and calculate the patient dose
3. To learn how to reduce the patient dose
Radiation induced tissue injuries were a common problem during
the pioneering days of radiology. Due to improved technical equipment for diagnostic radiology and training of professionals in radiation protection, tissue injuries disappeared completely in later
years. However, the by the introduction of CT perfusion measurements and fluoroscopy-guided interventions, this nearly forgotten
problem recurred. Since the early nineties, an increasing number of
radiation-induced tissue injuries were reported. A vast majority of
these injuries are related to interventional procedures or CT perfusion measurements. Also, threshold values for exposures of the eye
lens and circulatory system were drastically reduced in 2011. This
all together increased the awareness of radiation protection issues
among the public authorities and the radiology community.
In order to reduce the risk for patients (deterministic and stochastic effects of radiation), operators have to be aware of the radiation
dose involved in interventional procedures. However, to date, there
is no tool which allows for a rapid and easily available measurement
of radiation dose to the patient. Skin dose can be rather easily measured by real-time dosimetry. However, positioning of the dosimeter
in the field of view interferes with the procedures. The assessment
of the dose to critical organs is even more difficult since dose calculations depend on the geometry of the patient, the geometry and
Location of the irradiated field of view (which changes during the
procedure), and other parameters.
Modern imaging systems provide exposure data in the form of a
radiation dose structured report (RDSR). However, dose estimates
of skin or critical organs cannot be easily calculated from this data.
Surrogate markers include DLP and CTDI for CT and cumulative air
kerma (CK), respectively, at the interventional reference point (IRP)
for fluoroscopy. These values are standardized parameters to evaluate the radiation output. They are useful tools to compare different
equipment, protocols, and procedures, but do not represent dose to
the patient. Nevertheless, they help to define critical dose limits during interventional procedures. A substantial radiation exposure has
to be assumed if the following thresholds are reached or exceeded:
a peak skin dose of 3 Gy, a cumulative air kerma at RP 5 Gy, air kerma
area product of 500 Gycm2 or fluoro time of 60 min. Finally, measuring patient dose or dose parameter is not justified in all patients.
Reducing patient dose may be achieved by lowering dose to nontarget organs (shielding) by using techniques for reducing dose during fluoroscopy and imaging (optimizing equipment parameters)
and by implementing dose reduction strategies.
Non-target organs (eye, gonads, and thyroid) can be efficiently protected by using flexible shields or specially designed protection
devices.
Optimizing equipment parameters includes simple measures like
maximizing the distance between the patient and X-ray tube and
minimizing the distance between the image detector and patient.
Introducing low-dose fluoroscopy options using low entrance dose
and low frame rates help reduce patient dose. Operators should be
encouraged to use shutters and avoid zooming and angled views.
Equipment manufactures provide several tools to reduce patient
dose. These should be carefully evaluated and introduced in standard protocols. Individualization of protocols to operators should be
avoided; rather, easily understandable low-dose protocols should

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be offered to all operators. New techniques such as automatic dose
reduction in areas outside the field of interest of the operator or
detectors requiring lower entrance dose will provide additional possibilities for dose reduction in near future.
The most efficient way to reduce patient dose is to imply an institutional dose management/reduction system (DMS or DRS). A DRS
utilizes all technical and procedure-related possibilities of lowering
patient dose. A structured DRS requires a periodical reassessment
of the efficiency of lowering doses to patients and a continuous surveillance of exposure rates. In addition, DRS implies planning a procedure before starting the intervention and selection of the optimal
strategy to reach the endpoint of the procedure.
Finally, most procedures do not imply a relevant radiation risk
for the patient. This is especially true for old patients and patients
with a life-threatening disease. Standard radiation protection measures and a well-planned and conducted interventional procedure
are sufficient to eliminate the risk of radiation. However, high-dose
procedures such as abdominal or pelvic embolization, implantation of fenestrated aortic stent grafts, cardiac interventions, or TIPSS
include a definitive radiation risk. Special attention has to be paid
to patients with multiple procedures/imaging studies. Careful dose
monitoring over time has to be a part of DRS.

Special Session
Prostate embolisation
104.1
Patient selection
D.Abt
Klinik fr Urologie, Kantonsspital St. Gallen, St. Gallen, Switzerland
Learning Objectives
1. To learn how to select patients for BPH treatment
2. To learn about pre-treatment imaging requirements and
urologic assessment
3. To describe other non-endovascular options, including medical
and surgical treatments currently available
Definitions and background
Lower urinary tract symptoms (LUTS) are common in adult men
and increase with age. LUTS can be divided into storage, voiding
and post-micturition symptoms and can, besides other causes, be
caused by benign prostatic obstruction (BPO), which is often associated with benign prostatic enlargement (BPE) resulting from the histologic condition of benign prostatic hyperplasia (BPH).1
With the Guidelines on the Management of Non-neurogenic Male
LUTS, incl. Benign Prostatic Obstruction (BPO) by the European
Association of Urology (EAU), an excellent overview on the topic is
available. Based on structured literature searches, they provide a
summary with special attention on the existing level of evidence (LE)
and are supplemented by a grade of recommendation (GR) assessed
by expert panels.2
Differential diagnosis
Besides BPO, many other disorders can cause LUTS. Thus, detrusor
overactivity, nocturnal polyuria, detrusor underactivity, neurogenic
bladder dysfunction, urinary tract infections, foreign bodies, prostatitis, urethral strictures, bladder tumours, distal ureteral stones and
others have to be excluded using appropriate diagnostics. 3
Assessment of patients
For this purpose, a variety of examinations are available [e.g. medical
history, symptom score questionnaires, frequency volume charts,
physical examination (including digital rectal examination), urinalysis, PSA, assessment of renal function, measurement of post void
residual, uroflowmetry, imaging of upper urinary tract and prostate,
urethrocystoscopy and urodynamic investigations]. However, there

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is no generally valid examination algorithm, and type and extent of

investigations should be based on the patients symptoms, risk factors and the planned treatment. 2
Watchful waiting
If LUTS are caused by BPO, watchful waiting is appropriate in men
with mild symptoms. Lifestyle advice should always be offered
before or concurrent with treatment. 4
Medical treatment
Medical therapy is usually the first-line treatment. There is a high
level of evidence for the use of 1-blockers, 5-reductase inhibitors,
PDE-5-inhibitors and antimuscarinics. Besides the leading symptoms, prostate size and progression risk have to be considered when
the type of medical treatment is determined. Different combinations of the drugs described above have been investigated and can
provide additional treatment effects. 2
Surgical treatment
If symptoms persist or progress despite medication or if critical clinical findings (i.e. recurrent urinary retention, urinary tract infections,
renal impairment due to BPO, high amounts of post-void residual
urine, bladder stones or big diverticula) are present, surgical treatment options have to be taken into consideration. More invasive
treatment methods usually provide a better outcome regarding
functional micturition parameters. However, patients preference,
risk situation, anticoagulation and prostate size have to be considered to find the ideal treatment modality. 2
Thus, for patients not suitable for anesthesia, transurethral microwave therapy (TUMT), transurethral needle ablation (TUNA) and
prostatic stents are available; however, these options provide only
limited treatment effects.
Transurethral laser vaporisation represents the treatment of choice if
anesthesia is possible, but anticoagulation cannot be stopped.
In low-risk patients without a need for anticoagulation, the choice
of treatment should mainly be based on the prostate size. While
transurethral incision of the prostate (TUIP) represents the current
standard for prostates <30 ml, transurethral resection of the prostate (TURP) still constitutes the gold standard for prostate volumes
between 30 and 80 ml. Open prostatectomy and holmium laser enucleation of the prostate (HoLEP) are the first-choice treatment for
prostates >80 ml.2
Currently, there is low evidence (LE: 3) for prostatic artery embolisation (PAE) as a treatment option for BPO. Poor quality of the studies performed so far, questionable sustainability of the method and
uncertainty about the ideal prostate volume have been described
as limiting factors and prospective randomised trials seem to be
mandatory.5
Conclusion
Diagnosis of BPO, exclusion of potential differential diagnoses
and treatment of BPO are often challenging. As no universal treatment option exists, the treatment has to be adjusted depending on
patients preference, results of the urological assessment and the
course of disease. Prostate size and patients risk have to be considered for the choice of surgical treatment. PAE still has to be considered experimental and should be performed within well-designed
clinical trials.
References
1. Abrams P, Cardozo L, Fall M, et al. The standardisation of
terminology of lower urinary tract function: report from the
Standardisation Sub-committee of the International Continence
Society. Neurourol Urodyn 2002;21(2):167-78.
2. S. Gravas (chair), A. Bachmann, A. Descazeaud, et al. Guidelines
on the Management of Non-Neurogenic Male Lower Urinary
Tract Symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO).
European Association of Urology 2014. https://uroweb.org/
guideline/treatment-of-non-neurogenic-male-luts/.

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3. Gratzke C, Bachmann A, Descazeaud A, et al. EAU Guidelines

on the assessment of non-neurogenic male lower urinary tract
symptoms including benign prostatic obstruction. Eur Urol
2015;67(6):1099-109.
4. Wasson JH, Reda DJ, Bruskewitz RC, et al. A comparison of
transurethral surgery with watchful waiting for moderate
symptoms of benign prostatic hyperplasia. The Veterans Affairs
Cooperative Study Group on Transurethral Resection of the
Prostate. New Engl J Med 1995;332(2):75-9.
5. Schreuder SM, Scholtens AE, Reekers JA, et al. The role of
prostatic arterial embolization in patients with benign prostatic
hyperplasia: a systematic review. Cardiovasc Intervent Radiol
2014;37(5):1198-219.

104.2
Anatomical variants
F.C.Carnevale
Interventional Radiology, University of Sao Paulo Medical School, Sao
Paulo, Brazil
Learning Objectives
1. To learn the basic arterial anatomy and pre-procedural imaging
2. To learn about the anatomical variants that can be encountered
3. To learn how to overcome anatomical difficulties and techniques
for super-selective embolisation
Prostate artery embolization (PAE) is a new treatment option for
LUTS related to BPH [1]. For several reasons PAE can be a technically
challenging procedure. Anatomical features are especially important in this scenario, since identifying and catheterizing target arterial branches are the most technically challenging and time-consuming steps. Although several previous reports have described
male pelvic vascular anatomy and its frequent variations [2-4], interventional radiologists still lack a simple model that could facilitate
recognition of target branches. Pelvic computed tomographic angiography and digital subtraction angiography have been used for
prostate vascular anatomy identification.
Not recognizing prostatic branches during the initial digital subtraction angiography of the internal iliac artery (IIA) can lead to unnecessary catheterization of multiple vessels, which increases procedure time, use of iodinated contrast medium and radiation exposure. Moreover, embolization of non-target arteries (ie, bladder, rectal and penile branches) can result in major complications such as
organ ischemia [5,6].
Recently, Assis et al. have proposed the University of Sao Paulo (USP)
classification for the arteries feeding the prostate. They were able to
identify the most frequent patterns of the origins of the IVA and it
was classified into 5 subtypes, in order of their cranial-caudal position (upper to lower branches). These included type I: IVA originating from the anterior division of the IIA, from a common trunk with
the superior vesical artery; type II: IVA originating from the anterior
division of the IIA, inferior to the superior vesical artery (SVA) origin;
type III: IVA originating from the obturator artery; type IV: IVA originating from the internal pudendal artery; and type V: less common
origins of the IVA, including from an accessory internal pudendal
artery, the IIA anterior division trifurcation or quadrifurcation, the
inferior epigastric artery, the posterior division of the IIA, or from the
distal segment of internal pudendal artery. Double vascularization
was defined as cases in which the prostatic branches feeding the
central gland and peripheral zone had independent origins in one
pelvic side. Table 1 summarizes anatomical findings.
Two hundred eighty six pelvic sides (n = 286) were analyzed, and 267
(93.3%) were classified into I-IV types. Among them, the most common origin was the type IV (n = 89, 31.1%), followed by type I (n =
82, 28.7%), type III (n = 54, 18.9%), and type II (n = 42, 14.7%), respectively. Type V anatomy was seen in 16 cases (5.6%). Among type V,
the most common origin of the IVA was from the accessory internal

Abstract Book
pudendal artery (n = 6, 2.1%; Figure 2a), followed by the IIA anterior
division trifurcation (n = 5, 1.8%; Figure 2b). Origins from the inferior epigastric artery, the posterior division of the IIA, the distal segment of the internal pudendal artery, a quadrifurcation of the anterior division of IIA and proximal third of the inferior gluteal artery
were seen one time each (0.35%). In the remaining 3 cases, no IVA or
prostatic branches were seen during angiography (1.0%), likely due
to atherosclerosis. Among type IV origins, in 39 cases (43.8%) a rectal
branch was identified from a common trunk with the IVA, and some
of these required selective embolization with coils. Double vascularization was seen in 23 cases (8.0%), and a single origin of prostatic
branches was observed in the other 263 cases (92.0%).
Even in instances of less common origins (Type V), the IVA and the
prostatic branches were frequently recognized as originating from
the accessory pudendal artery and from the IIA anterior division trifurcation (2.1% and 1.8% of total cases, respectively). Other direct
origins from the posterior division of the IIA and from the inferior
epigastric were rare (0.35% each), and possibly related to neovascularization due to atherosclerotic occlusion of original arteries. This
occurred primarily in elderly patients for whom prior MRI revealed
central gland asymmetry, related to atherosclerotic auto-occlusion
of parent arteries. In such cases, prostatic vascularization can be significantly harder to identify.
Origin of the IVA from the internal pudendal artery (type IV) was
the most common pattern observed in our cohort and has important implications for the PAE procedure. Although catheterization is
usually simple due to a favorable angle, in a considerable number
of cases (n = 39, 43.8%) there was a rectal branch associated, usually adjacent or off a common trunk with a prostatic branch vascularizing the apex and peripheral zone. In cadaveric and radiological
studies, the middle rectal artery was present in up to 56.7% of the
pelvic sides, and usually originated from the IPA [7-8]. In such cases,
embolisation must be performed with caution, as rectal bleeding and ischemic rectitis with ulcers after PAE have been previously
described [5,9]. Coiling the rectal component may be necessary to
avoid reflux of the embolic agent that would otherwise result in
non-target embolization. Another option, when possible, is advancing the microcatheter far beyond the rectal branchs origin, so reflux
would be less likely to occur. When the IVA has a short trunk, with or
without associated rectal branches, care must be taken since reflux
to the IPA itself can lead to penile/corpus cavernosa ischemia. As an
anatomic consideration, we also observed that in the type IV pattern
the inferior gluteal artery originated from the posterior division of
the IIA in 40.5% of cases (36 of 89). This resulted in a very short anterior division, extending from the IIA bifurcation to the origin of the
SVA, and then continuing on as the IPA itself.
The IVA and prostatic arteries originating from the anterior division
of the IIA (type II) and from the obturator artery (type III) are less frequently associated with clinically significant non-target embolizations in our groups experience, although this needs further confirmation. In type II patterns, the long extension of the IVA trunk
results in less reflux, while in type III patterns, even in instances of
short trunks, if there is reflux, it tends to migrate to pelvic bone and
muscular structures, with minor clinical relevance. Nevertheless,
care must always be taken in order to avoid reflux to undesired
structures, especially in small vessels where antegrade flow can be
blocked by the presence of the microcatheter. Vasodilators may be
useful in this scenario, in cases of spasm, or to improve antegrade
flow, although they can also open pelvic arterial anastomoses.
Type I patterns are frequently difficult to catheterize. The common
trunk of the superior and inferior vesical arteries is usually short
and sometimes cranially oriented, followed by a caudal and lateral oriented curve. In these cases, microcatheterization is difficult or impossible, especially if there are atherosclerotic changes or
a large anterior IIA division. In such cases, a wider secondary curve
in the microguidewire (Cobra-C2 or double-angled shapes) may
facilitate catheterization. Sometimes it is necessary to progress the

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microcatheter into the common trunk in order to get enough support to access the IVA. Use of Roberts (RUC) catheter (Cook Medical,
Bloomington, IN) and curved-tip microcatheters can also help to
direct the microwire into the IVA.
As a rule, the central area of the prostate gland is fed by the superior or antero-medial pedicle (central gland branch), and the inferior or postero-medial pedicle supplies the capsule and apex (capsular branch). This is supported by cadaveric and angiographic studies
[4,10]. In our study, these two branches had a common origin in the
vast majority of the cases (92.0%), with only 8.0% having independent and separate origins. Because the superior or antero-medial
arterial pedicle vascularizes the BPH nodules localized in the central, periurethral and transitional zones, it is the main artery to be
embolised during PAE. Although the capsular branch predominantly
vascularizes the peripheral zone and the prostatic apex, we have
seen with cone-beam CT that it can also send small arterial feeders
to the central gland.
Garcia-Monaco et al [10], in a study involving dissection of 18 male
pelves, confirmed the presence of small anastomoses between both
prostatic branches. In a recent study by Frenk et al. [11] prostate volume reduction was correlated with the degree of prostate ischemia.
For these reasons we suggest that embolization of both central
gland and capsular branches may be necessary in order to achieve
optimal prostate ischemia, although this should be further investigated by specific studies.
We believe that understanding the normal prostate vascularization
and anatomic variations is important to standardize the PAE technique, and to avoid non-target embolization or injury to other vessels due to unnecessary manipulation of catheters and wires, especially in elderly patients with comorbidities. We propose this classification as a simple method to identify and classify the patterns of the
origin of the IVA and the prostatic arteries, increasing overall confidence during PAE.
Thorough knowledge of male pelvic anatomy is of paramount
importance to achieve the best clinical outcomes, minimize complications and learning curve effects, and reduce procedure times
and radiation exposure. Evaluation of anatomical patterns in a systematic fashion, following a standard classification, can help to make
PAE a more effective and safe procedure.
Table 1. Angiographic anatomical classification in 286 pelvic sides.
Classification
Incidence Anatomic description
Type I
28.7%
IVA originating from anterior division
of IIA, in a common trunk with SVA
Type II
14.7%
IVA originating from anterior division
of IIA, inferior to SVA
Type III
18.9%
IVA originating from obturator artery
Type IV
31.1%
IVA originating from IPA
Type V (others) 5.6%
Less common origins
References
1. Carnevale FC, Antunes AA, da Motta Leal Filho JM, de Oliveira
Cerri LM, Baroni RH, Marcelino AS, et al. Prostatic artery
embolization as a primary treatment for benign prostatic
hyperplasia: preliminary results in two patients. Cardiovasc
Intervent Radiol. 2010;33:355-61.
2. Bilhim T, Casal D, Furtado A, Pais D, Oneill JEG, Pisco JM.
Branching patterns of the male internal iliac artery: imaging
findings. Surg Radiol Anat, 2010, DOI 10.1007/s00276-010-0716-3.
3. Bilhim T, Pereira JA, Fernandes L, Tinto HR, Pisco JM.
Angiographic anatomy of the male pelvic arteries. AJR 2014;
203:373-82.
4. Bilhim T, Pisco JM, Pinheiro LC, Furtado A, Casal D, Duarte M,
et al. Prostatic arterial supply: Anatomic and imaging findings
relevant for selective arterial embolization. J Vasc Interv Radiol
2012; 23:1403-15.

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5. Assis AM, Rodrigues VCP, Yoshinaga EM, Antunes AA, Harward

SH, Srougi M, et al. Prostatic artery embolization (PAE) for
treatment of benign prostatic hyperplasia in patients with
prostates exceeding 90g: A prospective single center study.
Journal of Vasc Interv Radiol, 2014; 2015 Jan;26:87-93.
6. Schreuder SM, Scholtens AE, Reekers JA, Bipat S. The role of
prostatic arterial embolization in patients with benign prostatic
hyperplasia: a systematic review. Cardiovasc Intervent Radiol.
2014; 37:1198-219.
7. DiDio LJ, Diaz-Franco C, Schemainda R, Bezerra AJ. Morphology
of the middle rectal arteries. A study of 30 cadaveric dissections.
Surg Radiol Anat 1986; 8:229-36.
8. Bilhim T, Pereira JA, Tinto HR, Fernandes L, Duarte M, ONeill JE,
et al. Middle rectal artery: myth or reality? Retrospective study
with CT angiography and digital subtraction angiography. Surg
Radiol Anat 2013; 35:517-22.
9. Moreira AM, Marques CF, Antunes AA, Nahas CS, de Gregorio
Ariza MA, Carnevale FC. Transient ischemic rectitis as a potential
complication after prostatic artery embolization: case report
and review of the literature. Cardiovasc Intervent Radiol. 2013;
36:1690-4.
10. Garcia-Monaco R, Garategui L, Kizilevski N, Peralta O, Rodriguez
P, Palacios-Jaraquemada J. Human cadaveric specimen study
of the prostatic arterial anatomy: Implications for arterial
embolization. J Vasc Interv Radiol 2014; 25:315-22.
11. Frenk NE, Baroni RH, Carnevale FC, Gonalves OM, Antunes
AA, Srougi M, Cerri GG. MRI findings after prostatic artery
embolization for treatment of benign hyperplasia. AJR Am J
Roentgenol. 2014 Oct;203(4):813-21. doi: 10.2214/AJR.13.11692.

104.3
CBCT-guided embolisation
H.Kobeiter
Department of Radiology, Henri Mondor Hospital, Crteil, France
Learning Objectives
1. To learn how to perform pre-procedural imaging that may
influence difficult cases
2. To describe the use of CBCT during the procedure to overcome
challenging cases
3. To describe pros and cons of CBCT-guided PAE
Prostatic arterial embolization (PAE) is a new option to treat benign
prostatic hyperplasia (BPH). This technique has shown promising
results by improving clinical symptoms and inducing prostate volume reduction (1-6). Identification of the prostatic arteries (PA) is
the key to allowing selective catheterization before embolization.
Prostatic arterial anatomy is complex and variant (7, 8). 2D digital
subtraction angiography (DSA) is the main imaging modality used
for PAE. It provides excellent visualization of pelvic vessels, but its
low sensitivity for soft-tissue contrast and two-dimensional projection nature makes it difficult to fully elucidate the complex prostatic
vascular anatomy and definitively identify the prostatic arterial supply. Cone-beam computed tomography (CBCT) provides volumetric tomographic images using an angiographic unit equipped with
a flat panel detector. CBCT has gained acceptance as a routine imaging technique in interventional radiology. During PAE, CBCT can be
used to localize the prostate, identify PA and their anatomical variants, and consequently, improve safety and feasibility of selective
embolization. However, its routine use may be limited by the time
necessary to review the volumetric datasets to accurately depict the
PA and potential extra-prostatic supply. A method to quickly identify candidate PA may unlock the clinical information provided by
CBCT images.
All patients in our experience underwent a CBCT (arterial phase)
after single injection of 24 mL of iodinated contrast at a rate of 2mL/s
using a power injection through a catheter located in the main trunk

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of both internal iliac arteries (IIA) sequentially. The arterial CBCT was
acquired 4 seconds after the start of injection. For each CBCT scan,
480 projection images (60 frames/s) were acquired during an 8 seconds acquisition time covering a 180 clockwise rotation at 30/s
(field of view: 25 x 25 x 19 cm; matrix size: 384 x 384 x 296, pixel binning: 4 x 4, isotropic resolution: 0.6 mm). Three-dimensional visualization was obtained on a dedicated workstation (Xtravision, Philips
Healthcare). Than we have used an automatic vessel detection software: PAs for each side were identified using a vessel-tracking prototype software (EmboGuide software, Philips Healthcare). The final
vessel centerlines were used during three-dimensional roadmap
as graphical overlay on live fluoroscopy together with a volumetric
rendering of the arterial CBCT to guide micro-catheter positioning.
Movements of the C-arm, flat detector, and table are automatically
tracked and compensated.
A key step for a successful PAE is the identification of PAs. Extraprostatic supply of the PA must be detected before PAE to avoid
non-target embolization (bladder, penis, seminal vesicles, and rectum) and local complications (ischemic rectitis, ischemia of the bladder wall). Correct identification of PA using 2D DSA may be challenging and time consuming. Bagla et al. reported on the potential utility of CBCT during the PAE procedure and showed . CBCT was feasible, potential non-target embolization was identified and could be
corrected in 46% of cases using CBCT information in 46% of cases. In
this study, CBCT was only performed selectively to confirm correctness of the target artery, which was selected using multiple 2D DSA
prior to CBCT acquisition. Our study (Chiaradia et al) evaluates a software that automatically detects the PAs using non-selective dualphase CBCT. Vessel-tracking software was able to identify anatomical variants and collateral supply in atheroma patients.
In conclusion, CBCT with automatic software-detection of PA allows
identification of the PA during PAE. It may reduce procedure time
but more studies are needed.
References
1. Gao YA, Huang Y, Zhang R, et al. Benign prostatic hyperplasia:
prostatic arterial embolization versus transurethral resection of
the prostate-a prospective, randomized, and controlled clinical
trial. Radiology. 2014;270:920-928.
2. Bagla S, Martin CP, van Breda A, et al. Early results from a United
States trial of prostatic artery embolization in the treatment of
benign prostatic hyperplasia. J Vasc Interv Radiol. 2014;25:47-52.
3. Pisco JM, Pinheiro LC, Bilhim T, Duarte M, Mendes JR, Oliveira
AG. Prostatic arterial embolization to treat benign prostatic
hyperplasia. J Vasc Interv Radiol. 2011;22:11-19.
4. Pisco J, Campos Pinheiro L, Bilhim T, et al. Prostatic arterial
embolization for benign prostatic hyperplasia: short- and
intermediate-term results. Radiology. 2013;266:668-677.
5. Golzarian J, Antunes AA, Bilhim T, et al. Prostatic artery
embolization to treat lower urinary tract symptoms related
to benign prostatic hyperplasia and bleeding in patients with
prostate cancer: proceedings from a multidisciplinary research
consensus panel. J Vasc Interv Radiol. 2014;25:665-674.
6. Bilhim T, Pisco JM, Rio Tinto H, et al. Prostatic arterial supply:
anatomic and imaging findings relevant for selective arterial
embolization. J Vasc Interv Radiol. 2012;23:1403-1415.
7. Bilhim T, Pisco JM, Furtado A, et al. Prostatic arterial supply:
demonstration by multirow detector angio CT and catheter
angiography. Eur Radiol. 2011;21:1119-1126.
8. Bagla S, Rholl KS, Sterling KM, et al. Utility of cone-beam CT
imaging in prostatic artery embolization. J Vasc Interv Radiol.
2013;24:1603-1607.
9. Chiaradia M, Radaelli A, Campeggi A, Bouanane M, De La
Taille A, Kobeiter H. Automatic three-dimensional detection of
prostatic arteries using cone-beam CT during prostatic arterial
embolization. J Vasc Interv Radiol. 2015;26:413-417.

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104.4
Evidence
M. Grosso, S. Bongiovanni, I. Baralis, F. Pedrazzini, D. Sortino,
A.Balderi
Radiology, Santa Croce e Carle Hospital, Cuneo, Italy
Learning Objectives
1. To learn about the results of current relevant trials
2. To outline the outcomes of non-endovascular techniques and
PAE
3. To become familiar with the evidence regarding outcomes
Benign prostatic hyperplasia (BPH) is the most frequent cause of
lower urinary tract symptoms (LUTS) in the aging male. Autopsy
studies indicated that no men younger than 30 years old had evidence of BPH and the prevalence rises with aging, at 88% in men in
their 80s and nearly 100% in the ninth decade, supporting a urologic
dogma that all men will have BPH if they live long enough.
Patients with mild LUTS are generally treated with watchful waiting or lifestyle modification. Medical treatment is usually the firstline option and is indicated for patients with moderate LUTS. The
two main categories of medications for management of BPH are
-blockers and 5-reductase inhibitors. Patients with a refractory
disease or complications because of medical treatment are considered for surgical therapy.
Instead transurethral resection of the prostate (TURP) is the goldstandard surgical treatment. It is effective, with IPSS (international
prostate symptom score) reduced on average by 70% even though
it is related to a higher rate of complications with increased gland
size >80 ml. The most important side effect of this treatment is retrograde ejaculation (70-86%); other complications are bleeding requiring blood transfusion (2.5-7.2%), TUR syndrome (3.4-4.7%), erectile
dysfunction (6.5%), urinary incontinence (0.7-1.4%), and urethral stenosis (3.8-4%). Open prostatectomy is the procedure of choice for
prostates larger than 80-100 cm3, but it is an invasive surgical procedure with concomitant morbidity and extended hospitalization.
Several other less invasive therapies have been popularized in the
past two decades, including photoselective vaporization of the
prostate, transurethral needle ablation, transurethral microwave
therapy, and holmium laser enucleation of the prostate. Despite
of promising results of laser enucleation, the learning curve is very
protracted.
Prostatic artery embolization (PAE) as an emerging interventional
technique to treat LUTS secondary to BPH (LUTS/BPH) has recently
gained in popularity worldwide.
The therapeutic potential of PAE in the management of symptomatic BPH was first described by DeMeritt et al. in 2000. The authors
treated a spontaneous prostatic bleeding in patients with BPH and
during the follow-up they noted shrinkage of the enlarged prostate
and a relief of symptoms.
However, this milestone clinical report did not attract much academic attention until 2008, when Sun et al. first published an animal experimental study that confirmed the technical feasibility and
safety of PAE for the treatment of symptomatic BPH.
Since then there have principally been two authors, Prof. Carnevale
from Sao Paulo, Brazil, and Prof. Pisco from Lisbon, Portugal, who
have obtained the preliminary results of PAE.
In 2009 and 2011, Carnevale et al. reported the preliminary results
and midterm follow-up in two patients treated with PAE. Both
patients reported a significant improvement in IPSS and QoL
(Quality of Life) scores at 18 months. However the first large series
was described by Pisco et al in 2013, they performed PAE in 89
patients with LUTS associated with BPH using 200-m nonspherical polyvinyl alcohol particles. An average decrease in IPSS score, an
increased in QoL score, a mean PV (Prostate Volume) reduction were
detected after a 7,9 months follow-up, with only one mayor complication consisting in a necrosis of the bladder inferior wall.

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The only randomized trial comparing TURP and PAE has been published in Radiology in march 2014 by Yuan-an Gaos Chinese group
(1); surgical treatment showed superior improvement at one and 3
months but at 6 and 12 months follow-up the results of both groups
are similar regarding IPPS, QoL, peak urinary flow and postvoiding residual volume. Clinical failure of PAE was 9,4% and there were
more frequent complication associated (post-embolization syndrome 11,1% and 25,9% of acute urinary retention).
Bagla et al. have reported the first US experience (2); 20 patients
have been treated with up to six months results: clinical success was
obtained in 19/20; there were no minor or major complications.
Registers in Italy and US are now ongoing; in Southampton UK
a multidisciplinary register comparing PAE and TURP has been
launched with over 50 patients recruited in PAE arm and 25 in the
TURP one.
Since May 2012, in our Interventional Radiology Department (3) were
treated 35 patients with LUTS in BPH, refractory to medical therapy.
The indication for treatment was given by a team made up of urologist and interventional radiologists. Patients enrolled were ineligible or refusing traditional surgical endoscopic treatment. PAE was
technically successful in 96,7% of cases, without any complications.
All the eleven patients with indwelling catheter before the procedure removed it from one to four weeks after PAE. We achieved a
statistically significant volume reduction, IPSS reduction, and QoL
improvement.
Pisco et al. in CIRSE 2015 have obtained long-term results of PAE in
240 patients: technical success 233 patients (97.1%), 72.1% of clinical
success at the time of discharge, and 70% long-term improvement;
in this paper, a major complication (bladder wall ischemia treated by
surgery) was described.
One of the latest studies proposed by Pisco et al., in 2016 (4), evaluates the efficacy of PAE in patients with a high prostate volume > 100
cm3. The treatment was performed in 152 patients, with a technical
success in 149. Instead, 33 cases resulted in a clinical failure (23.6%),
of which 23 in the short term (< 6 months) and the remaining 10 in
the medium-term. Cumulative clinical success rates were 90%, ending in 72.4% from 18 until 66 months. Hence, PAE provides sustained
short-, medium-, long-term control for LUTS in patients with prostate volume > 100 cm3.
To improve the results of PAE Carnevale has developed the
PErFecTED technique (Proximal Embolization First Then Embolize
Distal) with promising outcomes (5). He has prospectively randomized 30 patients to receive TURP or original PAE compared them to a
cohort of patients treated with PErFecTED PAE. TURP and PErFecTED
PAE both resulted in significantly lower IPSS than oPAE but were not
significantly different from one another. Therefore, TURP and PAE
are both safe and effective treatments. TURP and PErFecTED PAE
yield similar symptom improvement, but TURP is associated with
both better urodynamic results and more adverse events.
Also, in case of recurrence of symptoms after PAE, prostatic artery
re-embolization has been proposed by Costa et al. at CIRSE 2015; 30
patients were re-embolized with PVA particles with 93.72% of technical success, at 6 months follow-up. 80% of clinical success was
reached with an IPSS mean decrease of 31%.
In conclusion, PAE is a minimally invasive procedure performed
under local anaesthesia, feature that makes it suitable to old patients
with comorbidity. The treatment is indicated in patients with either
small or large prostates. This technique has many positive sides such
as absence of retrograde ejaculation, impotence, and urethral stenosis. Furthermore, the typical contraindications of TURP like heart
disease, metallic implant or penile prosthesis, several urethral stenosis, artificial sphincter and elevated ASA score are not restrictions
for PAE. Even if PAE seems to be really safe some complications have
been underlined by Schreuder et al. in a recent systematic review (6).
They described as mayor complication important pain due to bladder ischemia (0.57%), acute urinary retention (2.97%) and cases of
rectum, anus, or corpus cavernosum ischemia. They found out also

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few minor complications like hematoma on puncture site (3.68%),

hematuria (8.36%), hematospermia (5.38%), urinary tract infection
(9,49%), prostatitis, and balanitis (1.42%). In spite of complications,
89% of patients were discharged on the day of the procedure and
the remaining 11% the day after.
After all, evidence demonstrates that PAE is safe and effective, with
a low complication rate, and in accordance with the latest studies, it
can also be repeated in the same patients.
References
1. Gao Y-A, Huang Y, Zhang R, et al. Benign Prostatic Hyperplasia:
Prostatic Arterial Embolization versus Transurethral Resection
of the Prostate-A Prospective, Randomized, and Controlled
Clinical Trial. Radiology. 2014;270(3):920-928. doi:10.1148/
radiol.13122803.
2. Bagla S, Smirniotopoulos JB, Orlando JC, van Breda A, Vadlamudi
V. Comparative Analysis of Prostate Volume as a Predictor of
Outcome in Prostate Artery Embolization. J Vasc Interv Radiol.
2015;26(12):1832-1838. doi:10.1016/j.jvir.2015.08.018.
3. Grosso M, Antonietti A, Balderi A, Pedrazzini F, Sortino D,
Bongiovanni S. Prostatic artery embolization in benign prostatic
hyperplasia: monocentric experience in 30 patients. Journal
of Vascular and Interventional Radiology. 2016;27(3):S283.
doi:10.1016/j.jvir.2015.12.718.
4. Pisco J, Bilhim T, Pinheiro LC, Fernandes L, Pereira J, Costa NV,
Duarte M, Oliveira AG. Prostate Embolization as an Alternative to
Open Surgery in Patients with Large Prostate and Moderate to
Severe Lower Urinary Tract Symptoms. J Vasc Interv Radiol. 2016
Mar 25. pii: S1051-0443(16)00159-7. doi: 10.1016/j.jvir.2016.01.138.
[Epub ahead of print].
5. Carnevale FC, Iscaife A, Yoshinaga EM, Moreira AM, Antunes AA,
Srougi M. Transurethral Resection of the Prostate (TURP) Versus
Original and PErFecTED Prostate Artery Embolization (PAE) Due
to Benign Prostatic Hyperplasia (BPH): Preliminary Results of a
Single Center, Prospective, Urodynamic-Controlled Analysis.
Cardiovasc Intervent Radiol. 2016;39(1):44-52. doi:10.1007/
s00270-015-1202-4.
6. Schreuder SM, Scholtens AE, Reekers JA, Bipat S. The Role of
Prostatic Arterial Embolization in Patients with Benign Prostatic
Hyperplasia: A Systematic Review Cardiovasc Intervent Radiol.
2014;37(5):1198-1219. doi:10.1007/s00270-014-0948-4.

Special Session
Safe and effective practice in interventional
oncology
202.1
Safety in interventional radiology: the essential steps
M.J.Lee
Radiology, Beaumont Hospital, Dublin, Ireland
Learning Objectives
1. To understand the factors that affect safety in interventional
radiology
2. To learn the value of safety check lists
3. To understand how clinical considerations affect complications
in interventional radiology
No abstract available.

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Abstract Book

202.2

202.4

Registries and trials in interventional oncology: how its

evidence base is being established

The CIRSE Quality Assurance framework for interventional

oncology: an essential tool for effective cancer care

P.L.Pereira
Dept of Radiology, Minimally Invasive Therapies and Nuclearmedicine,
SLK-Clinics GmbH, Ruprecht-Karls-University Heidelberg, Heilbronn,
Germany

L.M.Kenny
Cancer Care Services, Royal Brisbane and Womens Hospital, Brisbane,
QLD, Australia

Learning Objectives
1. To learn the difference between registries and comparative trials
2. To understand the contribution of registries to assessing
outcomes in interventional radiology
3. To understand the importance of creating an evidence base in
interventional radiology
Medicine, at some instances more than other fields, undergoes a
constant development process, making guidelines and standard
operative procedures an important tool for the medical community.
This is especially true in oncology, a discipline in which multidisciplinarity and combined therapies are essential for optimized patient
care and better outcome. Principles of clinical guidelines should be
based on current scientific evidences, with participants coming from
different medical societies, and by default on the consensus of medical experts; these are also called good clinical practices.
Moreover, high-quality guidelines are necessary not only for a structured knowledge transfer but also for finding their place in the structure of the health system, becoming more and more a reference for
discussions with reimbursement institutes and insurance companies. Finally, evidence-based guidelines serve as a basis to define
quality indicators that will be used for the certification process of
comprehensive cancer centers as well as for creating and updating
disease management programs for all medical practitioners.
If one refers to the number of papers, lectures, and conferences
focused on interventional radiology, we are forced to admit that
interventional oncology is occupying a large part of interventional
radiology. The major reason for this is that over the last 30 years,
interventional oncology has not only developed effective palliative
monotherapies such as transarterial chemoembolization and radioembolization for hepatic tumors but also achieved curative treatments by treating selected patients presenting with kidney, liver, or
lung cancer with thermal ablation.
Nevertheless, international recommendations of expert societies
do not seem to recognize the real value of interventional oncology.
Thus, the role of interventional oncology is accepted and has been
established almost only for the treatment of patients presenting
with HCC without cirrhosis and in some palliative clinical situations.

Fundamental Course
Venous stenting
203.1

202.3

Recanalisation of deep venous obstructions: current status

A curriculum for interventional oncology: why is it necessary

and what will it teach?
A.Gangi
Interventional Radiology, University Hospital of Strasbourg, Strasbourg,
France
Learning Objectives
1. To understand why a curriculum for interventional oncology is
necessary
2. To become familiar with the content of the interventional
oncology curriculum
3. To understand how the interventional oncology curriculum will
fit in to the overall curriculum for interventional radiology
No abstract available.

Learning Objectives
1. To understand the need for a quality assurance (QA) framework
in interventional oncology
2. To learn how the QA framework was created
3. To learn the essential elements of the QA framework
In acknowledgement of the overwhelming importance of standards
of practice and their ultimate incorporation into a quality assurance program, CIRSE has developed a set of practice standards for
Interventional Oncology. The framework is based on the Australian
and New Zealand Radiation Oncology Practice Standards and they
follow the entire care pathway for patients undergoing interventional cancer procedures.
They will support safe quality care for patients and will also act as a
basis on which interventional oncologists can work with facilities to
improve the infrastructure and processes required for their teams to
practise effectively.
There are 14 Standards, broadly divided into three areas and each
follows a standard format:
Facility management (7 standards)
Treatment planning and delivery (3 standards)
Safety and quality management (4 standards)
There is a consistent format for each Standard, as follows:
i Each Standard refers to a corresponding goal or outcome.
ii Criteria describe the key processes required to attain that goal.
iii A commentary provides information which outlines how a criterion applies in everyday practice.
iv The required evidence that documents the records that the facility should be able to provide to demonstrate compliance with
the Standards.
These draft Standards will be piloted in a number of interventional
oncology units during the second half of 2016. Upon completion,
CIRSE will incorporate the Standards into a quality assurance and
credentialing program.

R.deGraaf
Radiology, Maastricht University Medical Centre, Maastricht,
Netherlands
Learning Objectives
1. To learn about current evidence in deep venous interventions
2. To learn about challenges in deep venous obstructions
3. To learn about differences of congenital and post thrombotic
interventions
Deep venous obstruction is a relatively prevalent condition caused
by post-thrombotic vein damage or extraluminal venous compression or a combination of the two. Post-thrombotic syndrome (PTS)
develops in up to 50% of patients in the months or years following
a deep venous thrombosis (DVT). Pathophysiology of PTS is based
on vein wall stiffening, intraluminal scarification and valvular damage, all associated with the local inflammatory response following

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an acute DVT. Non-thrombotic iliac vein lesions (NIVL) are usually caused by an overriding artery (e.g. May-Thurner), alternatively
by any two pelvic structures wedging the iliac vein. In some cases,
additional wall or luminal fibrosis might be found, caused by a prolonged aggravation of the vein. Both conditions impede venous
outflow of the lower extremity and are linked to symptoms associated with chronic venous disease. Since the pioneering clinical experience from Neglen, Raju and others in the early 90s, endovascular
treatment of deep venous obstruction has been taking a giant leap
forward. It has been shown that high technical success is achievable and patency rates are at least as good as from its surgical predecessor. Moreover, clinically, patients improve significantly after
recanalization of the obstructed iliofemoral and caval veins. In the
last two decades, a number of publications report on patency rates
after stenting for chronic iliofemoral obstructions. Overall, NIVL
show higher patency rates than chronic post-thrombotic lesions.
For example, May-Thurner syndrome patients have the best outcome, with primary patency ranging between 90 and 95% and secondary patency between 95 and 99% after 3 years. For patients with
post-thrombotic obstruction, primary and secondary patency rates
are strikingly lower, at 55-65% and 76-93%, respectively, at 3 years.
The wide variation in patency rates might be dependent on multiple aspects, e.g. patient selection, imaging, anticoagulation regimens and implanted stents. There is no consensus on which patient
benefits most from a specific treatment strategy, e.g. endovascular, hybrid or open surgery. Furthermore, stent design might pose
a very important variable in long-term patency. However, no comparable studies have been performed and no single stent design is
deemed superior. Finally, post-intervention anticoagulation management is not uniform across medical centres around the world.
Some may even advocate antiplatelet therapy, although data to support this strategy in venous disease are circumstantial. The nearest
challenge will be to identify a common approach in the treatment
of deep venous obstruction by appraisal of the current data, moving
towards international guidelines.
References
1. Neglen P, Hollis KC, Olivier J, Raju S. Stenting of the venous
outflow in chronic venous disease: long-term stent-related
outcome, clinical, and hemodynamic result. Journal of vascular
surgery. 2007;46(5):979-90.
2. Kahn SR, Shrier I, Julian JA, Ducruet T, Arsenault L, Miron MJ,
et al. Determinants and time course of the postthrombotic
syndrome after acute deep venous thrombosis. Annals of
internal medicine. 2008;149(10):698-707.
3. de Wolf MA, de Graaf R, Kurstjens RL, Penninx S, Jalaie H, Wittens
CH. Short-term clinical experience with a dedicated venous
nitinol stent: initial results with the sinus-venous stent. European
journal of vascular and endovascular surgery: the official journal
of the European Society for Vascular Surgery. 2015.
4. Seager MJ, Busuttil A, Dharmarajah B, Davies AH. Editors Choice
- A systematic review of endovenous stenting in chronic venous
disease secondary to iliac vein obstruction. European journal
of vascular and endovascular surgery : the official journal of the
European Society for Vascular Surgery. 2016;51(1):100-20.
5. Vogel D, Comerota AJ, Al-Jabouri M, Assi ZI. Common femoral
endovenectomy with iliocaval endoluminal recanalization
improves symptoms and quality of life in patients with
postthrombotic iliofemoral obstruction. Journal of vascular
surgery. 2012;55(1):129-35.

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203.2
Decision-making in deep venous interventions: from imaging
to follow-up
L.Oguzkurt
Radiology, Koc University Hospital, Istanbul, Turkey
Learning Objectives
1. To learn about clinical presentation of deep venous obstructions
and how to improve outcomes through intervention
2. To learn about different imaging techniques: US, CT, MR
3. To learn about decision-making: when to perform intervention,
and when to re-intervene
Data from contemporary prospective studies estimates that 20% to
50% of patients with deep venous thrombosis (DVT) will develop
postthrombotic syndrome (PTS), and 5% to 10% of them will have
severe symptoms (1,2). Although not certain, proximally extensive
DVT, prior ipsilateral DVT, persistent venous symptoms 1 month
after DVT, obesity, and older age appear to be the risk factors. The
best treatment for PTS is prevention of DVT. Those who develop PTS
will experience one or more of the following: aching pain, heaviness, swelling, cramps, difficulty walking, edema, and skin changes
including venous ulcers in the affected limb (2,3).
The diagnosis of the disease is clinical. However, imaging is important to confirm the presence of previous DVT and to depict diameter and extension of the involved veins, collaterals, and underlying
congenital or acquired obstructions. Ultrasonography is not as helpful in chronic cases as in acute DVT. Computed tomography venography has superseded catheter venography as a diagnostic method
for the assessment of acute or chronic DVT. Magnetic resonance
venography may be helpful, and conventional venography is usually
obtained only during the endovascular treatment.
Endovascular treatment is suggested in selected patients with
extensive acute proximal DVT who have good functional status and
life expectancy > 1 year and low risk of bleeding (4). CIRSE standards
of practice guidelines suggest that patients with CEAP clinical class 3
to 6 and chronic venous outflow obstructions should be considered
for interventional therapy. Clinical scoring systems offer objective
measures for indication of recanalization. The CEAP classification
and Villalta scores are the most important and accepted measures
to decide who to intervene and to follow-up to see the clinical outcome of the intervention. Preliminary studies demonstrated good
clinical outcome for endovascular treatment with stent placement
in resolving or decreasing the severity of postthrombotic symptoms and signs (3,6). To date, no methodologically rigorous, comparative trials have addressed whether this therapy improves the clinical manifestations of PTS. All patients are anticoagulated before,
during, and after the procedure. Compressive stockings are recommended for at least 3 to 6 months after the procedure.
Endovascular recanalization of venous occlusion in postthrombotic
syndrome is promising for these chronically ill patients. However,
much is unknown, and we need more and good evidence in the
near future.
References
1. Delis KT, Bountouroglou D, Mansfield AO. Venous claudication
in iliofemoral thrombosis: long-term effects on venous
hemodynamics, clinical status, and quality of life. Ann Surg
2004;239(1):118-126.
2. Vedantham S. Valvular dysfunction and venous obstruction in
the post-thrombotic syndrome. Thromb Res 2009;123(suppl
4):S62-S65.
3. Neglen P, Hollis KC, Olivier J, Raju S. Stenting of the venous
outflow in chronic venous disease: long-term stent-related
outcome, clinical, and hemodynamic result. J Vasc Surg
2007;46(5):979-990.

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CIRSE

4. Kearon C, Kahn SR, Agnelli G, Goldhaber S, Raskob GE, Comerota

AJ. Antithrombotic therapy for venous thromboembolic disease:
American College of Chest Physicians Evidence-Based Clinical
Practice Guidelines (8th ed). Chest 2008;133(6 suppl):454S-545S.
5. Mahnken A, Thomson K, de Haan M, OSullivan J. CIRSE
standards of practice guidelines on iliocaval stenting. Cardiovasc
Intervent Radiol 2014;37:889-897.
6. Raju S, Owen Jr S, Neglen P. The clinical impact of iliac venous
stents in the management of chronic venous insufficiency. J Vasc
Surg 2002;35(1):8-15.

203.3
Technical aspects of deep venous interventions, tips and tricks
G.J.OSullivan
Interventional Radiology, U.C.H. Galway, Galway, Ireland
Learning Objectives
1. To learn about different interventional techniques
2. To learn about different interventional material
3. To learn about current evidence on different techniques
The first speaker, Dr. de Graaf, has already discussed recanalization
of deep venous obstructions. The second speaker, Dr. Oguzkurt,
has discussed decision making in deep venous interventions: from
imaging to follow-up. We will therefore concentrate on the practical
nuts and bolts of how to do it.
For the purpose of this 13-minute lecture, we will concentrate on the
IVC and ilio-femoral veins.
I am also assuming this is for chronic disease rather than acute iliofemoral deep vein thrombosis.
The following aspects will be discussed:
Anatomy/imaging techniques
Which access point; why choose one over another?
Which wires?
Support catheters?
RF wires?
When you should stop?
In 13 minutes, it is unrealistic to cover it all; but hopefully, this will
give you some pointers.
References
1. Knipp BS, Ferguson E, Williams DM, Dasika NJ, Cwikiel W, Henke
PK, Wakeeld TW (2007) Factors associated with outcome after
interventional treatment of symptomatic iliac vein compression
syndrome. J Vasc Surg 46:743749.
2. Raju S, Tackett P Jr, Neglen P (2009) Reinterventions for
nonocclusive iliofemoral venous stent malfunctions. J Vasc Surg
49:511518.
3. Kurklinsky AK, Bjarnason H, Friese JL, Wysokinski WE, McBane
RD, Misselt A, Moller SM, Gloviczki P (2012) Outcomes of
venoplasty with stent placement for chronic thrombosis of the
iliac and femoral veins: single-center experience. J Vasc Interv
Radiol 23:10091015.
4. Raju S, Neglen P (2009) Percutaneous recanalization of total
occlusions of the iliac vein. J Vasc Surg 50:360368.
5. Wahlgren CM, Wahlberg E, Olofsson P (2010) Endovascular
treatment in postthrombotic syndrome. Vasc Endovascular Surg
44:356360.
6. Raju S, Hollis K, Neglen P (2006) Obstructive lesions of the
inferior vena cava: clinical features and endovenous treatment. J
Vasc Surg 44:820827.
7. Ye K, Lu X, Li W, Huang Y, Huang X, Lu M, Jiang M (2012)
Long-term outcomes of stent placement for symptomatic
nonthrombotic iliac vein compression lesions in chronic venous
disease. J Vasc Interv Radiol 23:497502.

Abstract Book
8. te Riele WW, Overtoom TT, van den Berg JC, van de Pavoordt
ED, de Vries JP (2006) Endovascular recanalization of chronic
long-segment occlusions of the inferior vena cava: midterm
results. J Endovasc Ther 13:249253.
9. Neglen P, Hollis KC, Olivier J, Raju S (2007) Stenting of the venous
outow in chronic venous disease: long-term stent related
outcome, clinical, and hemodynamic result. J Vasc Surg 46:
979990.
10. Hartung O, Loundou AD, Barthelemy P, Arnoux D, Bou M,
Alimi YS (2009) Endovascular management of chronic disabling
ilio-caval obstructive lesions: long-term results. Eur J Vasc
Endovasc Surg 38:118124.
11. Hartung O (2011) Results of stenting for postthrombotic venous
obstructive lesions. Perspect Vasc Surg Endovasc Ther 23:255
260.
12. Titus JM, Moise MA, Bena J, Lyden SP, Clair DG (2011) Iliofemoral
stenting for venous occlusive disease. J Vasc Surg 53:706712.
13. Hartung O, Lugli M, Nicolini P, Bou M, Maleti O, Alimi YS (2010)
Stenting for iliac veins post-thrombotic obstructive lesions:
results of a multicentric retrospective study. J Vasc Surg 51:790.
14. Holper P, Kotelis D, Attigah N, Hyhlik-Drr A, Bckler D
(2010) Long-term results after surgical thrombectomy and
simultaneous stenting for symptomatic iliofemoral venous
thrombosis. Eur J Vasc Endovasc Surg 39:349355.
15. Nayak L, Hildebolt CF, Vedantham S (2012) Postthrombotic
syndrome: feasibility of a strategy of imaging-guided
endovascular intervention. J Vasc Interv Radiol 23:11651173.
16. Alhadad A, Klbel T, Herbst A, Holst J, Alhadad H, Gottster
A (2011) Iliocaval vein stenting: Long term survey of
postthrombotic symptoms and working capacity. J Thromb
Thrombolysis 31:211216.
17. Broholm R, Panduro JL, Baekgaard N (2010) Catheter-directed
thrombolysis in the treatment of iliofemoral venous thrombosis.
A review. Int Angiol 29:292302.
18. Hartung O, Otero A, Bou M, Decaridi G, Barthelemy P, Juhan C,
Alimi YS (2005) Mid-term results of endovascular treatment for
symptomatic chronic nonmalignant iliocaval venous occlusive
disease. J Vasc Surg 42:11381144.
19. Neglen P, Raju S (2000) Balloon dilation and stenting of chronic
iliac vein obstruction: technical aspects and early clinical
outcome. J Endovasc Ther 7:7991.

203.4
Prevention of PTS, eliminating the cause of DVT
J.A.Vos
Interventional Radiology, St. Antonius Hospital, Nieuwegein,
Netherlands
Learning Objectives
1. To learn about the pathophysiology on PTS
2. To learn about the different treatment options
3. To learn about prevention of DVT and PTS
Introduction
Deep venous thrombosis (DVT) of the lower extremity is a relatively
common condition, with an estimated annual incidence of about
0.52 per 1000 individuals. Post-thrombotic syndrome (PTS) is a
clinical condition that occurs in 20%60% of individuals in the first
2 years after being diagnosed with DVT. The clinical symptoms are
pain, heaviness, itching and/or swelling of the affected limb combined with varicose veins and skin discoloration and ulcers in severe
cases. From a personal standpoint, it may lead to a loss in the quality of life (QoL). From the perspective of the society, it may lead to
the loss of productivity in those employed and leads to significant
healthcare costs. The healthcare costs associated with PTS have
been estimated to exceed $200 million per annum in USA.

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Risk factors
Several risk factors have been shown to be associated with the
development of PTS in the settings of DVT:
Body mass index > 30
Proximal location of thrombosis (iliofemoral)
Non-compliance with anticoagulation medication
Non-compliance with elastic compression therapy
Recurrent thrombosis
Several known risk factors for DVT have been implicated to increase
the likelihood of developing PTS after DVT by some authors, but
these factors have not been corroborated by other studies:
Age > 65 years
Hormonal replacement therapy
Pregnancy
Recent surgery
Plaster cast
Coagulation disorders
Prevention of PTS
The key for preventing PTS is of course preventing DVT. This means
adequate prophylaxis for risk groups (major surgery, immobilisation, prolonged hospital admission, ICU treatment, patients suffering from coagulopathies, etc.).
If a patient does develop DVT, adequate treatment should be initiated. In case anticoagulation therapy is required, good patient compliance is mandatory. In case of swelling of the leg, compression
bandages should be used initially to reduce the chance of PTS. These
bandages should be worn 24 h/day. After the immediate swelling
has subsided, elastic compression stockings can reduce the chances
of recurrence and of developing PTS. These can be worn only during
the daytime. Obese patients should be strictly advised, and if possible aided, to lose weight as this significantly decreases the chances
of developing PTS.
Finally and most importantly, for interventional radiologists, increasing evidence suggests that revascularisation can improve initial
symptoms and decrease the likelihood of developing PTS in patients
with femoral and especially iliac thrombosis.

Special Session
Special indications and their outcome for UFE
204.1
Fertility
A.-M.Belli
Dept. of Radiology, St. Georges Hospital, London, United Kingdom
Learning Objectives
1. To learn about the possible role of UFE to increase fertility
2. To learn about specific technical considerations in this patient
population
3. To learn about the evidence for UFE and fertility
Current evidence confirms that uterine artery embolisation
improves quality of life and is a safe, efficacious and cost-effective
treatment for symptomatic fibroids.
However, the current data is insufficient to provide strong evidence
of its place in women desiring fertility. Uterine fibroids are implicated as a cause of subfertility even if the uterine cavity hysteroscopically appears normal. Despite this, many women with large
fibroids conceive without difficulty.
There is case series evidence to suggest that there is no adverse
impact on fertility when uterine artery embolisation has been performed in the management of women with postpartum haemorrhage. However, women presenting for treatment with symptomatic fibroids tend to be older and to have completed their families,
making comparison with surgical procedures such as myomectomy
difficult.

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A systematic review of the literature in 2013, compared the cumulative pregnancy rate following UAE with the age adjusted rate in
the general population (mean age 36 years) and concluded that the
68% rate was comparable. A review from 2010, however, highlighted
higher spontaneous abortion and postpartum haemorrhage rates in
the UAE population compared with the non-UAE fibroid controls.
Whether UFE can be used to increase fertility is an interesting question and may depend on the position and size of the fibroids and
how this may impact fertility. The evidence for a beneficial effect
of myomectomy is also weak. The myomectomy literature reports
pregnancy rates between 8% and 46%, whilst the pregnancy rates
after UAE range from 8% to 47%.
It is acknowledged that UAE may transiently occlude arterial flow
to the ovary, but despite this, the incidence of clinically apparent
injury to ovarian reserve is low with most women who experience
amenorrhoea being over 45 years of age. The technique of embolisation could theoretically have an effect. It is possible that aiming
for stasis may increase the risk of occlusion of the ovarian arteries,
but there is no evidence to support this theory. Furthermore, there
is no evidence to support other strategies such as coil embolisation
of the ovarian artery to prevent retrograde flow of embolic particles
through large utero-ovarian anastamoses or the protective effect of
upsizing embolic particles.
All studies conclude that further research is needed in this area.

204.2
Large and subserosal fibroids
P.M.Crowe
Radiology Department, Birmingham Heartlands Hospital, Birmingham,
United Kingdom
Learning Objectives
1. To learn about the caveats for UFE for large and subserosal
fibroids
2. To learn about specific technical considerations in this patient
population
3. To learn about outcome differences compared to other types of
fibroid
Uterine artery embolisation is now a well-established treatment for
symptomatic uterine fibroids and one of the most common questions posed by referrers is what is the maximum size of a treatable fibroid?. Published guidelines do not include specific size criteria (1,2). There is no strict definition of a large fibroid, but an arbitrary size of 10 cm diameter has been used by several authors for
the purpose of data analysis. Large fibroids may be single or multiple or may be conglomerate fibroid masses that have commenced
as smaller fibroids and have merged over time. Fibroids occur in various locations and subserosal fibroids are those which extend to the
serosal surface and may protrude outside it as exophytic or pedunculated fibroids.
The pre-embolisation workup of larger fibroids is similar to that of
any fibroid. MRI scanning with contrast enhancement gives the
necessary anatomical and perfusion information required, and at
the very least, patients should undergo ultrasound with colour
Doppler to assess fibroid vascularity. Large fibroids may have grown
very slowly for a number of years, and despite the large size, many
patients suffer little through significant bulk or pressure symptoms.
In such patients, embolisation may still be considered, despite relatively little perfusion if the dominant clinical complaint is of menorrhagia. Taking a good clinical history is essential in deciding whether
or not to proceed with the embolisation of larger fibroids and more
importantly in offering the patient guidance as to the likely outcome to help them choose between embolisation, surgery or other
options. If bulk and pressure symptoms dominate, a more vascular
fibroid is likely to show a greater degree of shrinkage post-embolisation. Embolisation is often recommended in patients who have had

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multiple previous surgical procedures due to scarring and possible

adhesions from a previous open surgery.
The procedure of embolisation of larger fibroids is essentially the
same as that of embolisation of smaller ones and may in fact be
technically more straightforward as the uterine arteries tend to be
more hypertrophied and easier to super-selectively catheterise.
Earlier upsizing of particles may be considered, and for very vascular large fibroids, gel foam may be used in addition. Apparent perfusion defects in a fibroid on injection of contrast through the uterine
artery should raise suspicion of a secondary source of arterial supply,
such as the ovarian artery, and this is particularly the case with large
broad-ligament fibroids.
Embolisation of large fibroids, particularly pedunculated fundal
fibroids, may be performed as a planned sequential or combined
procedure with pre-embolisation to devascularise the large pedunculated fibroid and to treat any smaller fibroids in the body of the
uterus and be followed by a planned myomectomy procedure to
physically remove the pedunculated fibroid without the need of
further surgical exploration to resect the smaller fibroids as these
are adequately treated by embolisation (3). The surgery following
embolisation is usually performed during the same hospital admission or may be delayed for several months with a final decision on
myomectomy surgery made after the initial follow-up scan postembolisation. Multidisciplinary working with a gynaecologist, ideally within a fibroid clinic setting, ensures that all potential treatment options and combinations are considered and treatment is tailored to the individual patients situation and priorities.
Despite early concerns about potential complications of treating large fibroids, several published series have now reported the
embolisation of large fibroids to be safe and to show no higher risk
of significant clinical complications than those shown by the embolisation of smaller fibroids (4,5,6). The volume of embolic agent used
has also not been shown to correlate with an increased complication risk (6). UFE should be offered as a viable treatment option to
women with large-volume fibroids who do not wish to consider
open surgery or for whom surgery poses specific risks, including patients on anticoagulant therapy, multiple previous myomectomies or those with anaesthetic risk factors such as morbid obesity. As with any fibroid embolisation procedure, the patient should
be properly counselled and consented by the operator, and in this
patient group, greater emphasis is placed on improvement in clinical symptoms as an outcome measure rather than purely objective
infarction or percentage volume reduction analyses.
References
1. Van Overhagen H, Reekers JA (2015) CIRSE standards of practice
guidelines - Uterine artery embolization for symptomatic
leiomyomata. Cardiovasc Interv Radiol 38:536-542.
2. Royal College of Obstetricians & Gynaecologists and The Royal
College of Radiologists (2013) Clinical Recommendations on the
use of uterine artery embolisation (UAE) in the management of
fibroids (Third edition).
3. Paxton BE, Lee JM, Kim HS (2006) Treatment of intrauterine and
large subserosal leiomyomata with sequential uterine artery
embolisation and myomectomy. J Vasc Interv Radiol 17:19471950.
4. Berczi V, Valcseva E, Kozics D, et al (2015) Safety and
effectiveness of UFE in fibroids larger than 10cm. Cardiovasc
Interv Radiol 38:1152-1156.
5. Smeets AJ, Nijenhuis RJ, van Rooij WJ, et al (2010) Uterine artery
embolization in patients with large fibroid burden: long-term
clinical and MR follow-up. Cardiovasc Interv Radiol 33:943-948.
6. Parthipun AA, Taylor J, Manyonda I, Belli AM (2010) Does size
matter? Analysis of the effect of large fibroids and uterine
volumes on complication rates of uterine artery embolisation.
Cardiovasc Interv Radiol 33:955.

Abstract Book

204.3
Adenomyosis
P.N.M.Lohle
Radiology, St. Elisabeth Hospital, Tilburg, Netherlands
Learning Objectives
1. To learn about typical clinical presentation of adenomyosis
2. To learn about specific technical considerations in this patient
population
3. To learn about outcome differences compared to fibroid
patients
Adenomyosis is a benign invasion of the endometrium into the myometrium that results in a diffusely enlarged uterus that microscopically exhibits ectopic non-neoplastic endometrial glands and stroma
surrounded by the hypertrophic and hyperplastic myometrium.
Symptomatology
The clinical diagnosis is challenging as its presenting symptoms
overlap with those of common uterine disorders such as fibroids of
the uterus. Adenomyosis is often underdiagnosed and is responsible for symptoms such as heavy menstrual bleeding and pain, with
or without bulk related symptoms and fertility issues, in premenopausal women. The reported occurrence of adenomyosis significantly varies. The prevalence of adenomyosis in tissues obtained
from hysterectomy is reported between 8.8% and 31%. With broad
criteria for the diagnosis of adenomyosis, a prevalence as high as
70% in women between 40 and 50 years of age is suggested. Among
women with clinical manifestations of adenomyosis, about one fifth
are aged under 40 years, but the vast majority are aged between 40
and 50 years.
Imaging
Magnetic resonance imaging (MRI) is particularly useful both in
doubtful transvaginal ultrasound (TVUS) cases and in providing a
complete evaluation of the disease with its panoramic views. With
T2-weighted images and contrast enhanced T1-weighted MRI, the
thickness of the junction zone can reliably be measured; a thickness
over 12 mm is considered diagnostic for adenomyosis. The presence of foci of high signal intensity within the myometrium constitutes an additional, but not a mandatory, criterion. MRI is a reliable
modality for diagnosing adenomyosis, with a sensitivity varying in
the literature between 78% and 88% a specificity between 67% and
100%. MRI can categorize adenomyosis as focal or diffuse and can
be repeated in time to evaluate the effect of treatment. Three different groups of uterine adenomyosis are easily identified with MRI: 1)
pure adenomyosis, 2) adenomyosis with fibroid predominance, and
3) uterine fibroids with adenomyosis predominance. Adenomyosis
may be subdivided into diffuse and focal. Focal adenomyosis is
also known as adenomyoma. From personal experience, around
80% of these women may have adenomyosis mixed with fibroids,
15% pure diffuse adenomyosis, and 5% pure focal adenomyosis
(adenomyoma).
Medical treatment
Medical treatment of adenomyosis ranges from local treatment with
the release of medications by an intrauterine device (IUD) to systemically administered treatment. IUD-released progestogens are used
to reduce heavy menstrual bleedings in women with adenomyosis.
Medications available for systemic administration include gonadotropin-releasing hormone (GnRH) agonists.
Surgical management
Excision or enucleation is usually the preferred surgical approach
for focal adenomyosis, but the type of treatment is heavily dependent on the type of lesion and the extent of myometrial involvement. Hysterectomy is usually indicated as a definitive treatment.
Rates of complication after hysterectomy range between 1.5% and
29.3%. Recovery time is reported to range between 6 and 8 weeks,
and healthcare-related expenses and lost time at work render hysterectomy an option associated with high costs.

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CIRSE 2016
UAE
In 1995, Ravina published the first report on women treated by uterine artery embolization (UAE) for symptomatic uterine fibroids.
UAE has emerged as an effective therapy in the treatment of uterine fibroids. The clinical success rate of UAE for uterine fibroids with
respect to symptomatic improvement of associated menorrhagia
and pelvic pain ranges from 85%95% to 80%90%. Based on the
similarity of symptoms caused by uterine fibroids and adenomyosis and the positive results after UAE for fibroids, this interventional
procedure has been investigated as a possible option to treat adenomyosis. Successful infarction of symptomatic fibroids with UAE
may also be achievable in women suffering from focal or diffuse
adenomyosis with or without fibroids. Although the first results of
UAE for adenomyosis were disappointing, later studies showed substantial clinical improvement in majority of treated women with
adenomyosis. Similar to UAE in fibroids, the targeted embolization with occlusion of uterine artery vessel branches with embolic
material will induce cessation of arterial blood flow to the adenomatous tissue. Intentional infarction will eventually result in complete
or partial elimination of adenomyotic foci and subsequently relieve
symptoms.
The UAE catheterization technique for symptomatic adenomyosis is no different from the technique for symptomatic fibroids.
Embolization is performed by using a particulate embolic agent. The
currently available data do not seem to indicate a preferred embolic
agent for use in women with symptomatic adenomyosis. Although
in part based on speculation, deep penetration with the embolic
agents seems to be needed for optimal infarction of areas with adenomyosis. Calibrated microspheres are able to selectively occlude
the tiny arterial branches of the adenomatous tissue deep in the
uterine stroma and thus create adequate tissue infarction.
Results of UAE in adenomyosis
A complete and detailed meta-analysis on UAE for the treatment of
adenomyosis is published, including 15 studies with a total of 511
patients published between 1999 and 2010 (Popovic et al. J Vasc
Interv Radiol 2011;22:901-9). Clinical improvement of bleeding, pain,
and bulk-related symptoms were reported by three quarters of
included women. The median follow-up was 26.9 months.
As a result of published data, the Dutch have already embraced UAE
for adenomyosis in the Official Nationale Guideline for heavy menstrual bleeding (HMB). Dutch gynecologists and interventionalists
have created a flow chart with state-of-art therapy for HMB, including adenomyosis. Gynecologists are obliged to discuss and offer
patients UAE for adenomyosis in daily practice.
Despite the acceptance of the embolization treatment for adenomyosis, the Dutch believe that there remains a need for more solid
sound data. Therefore, Dutch gynaecologists and interventionalists have started the worlds first adenomyosis RCT (QUESTA), following the Scottish REST and Dutch EMMY randomized controlled
trial (RCT) for uterine fibroids. With 12 participating Dutch hospitals,
the primary objective of this RCT is to evaluate the effect of UAE on
the quality of life compared to hysterectomy in women with symptomatic adenomyosis. This study is an unblinded RCT, with pre-interventional and follow-up MRI, which will provide us Level 1 evidence.
Secondary objectives are failure rate, complications, additional therapy, patient satisfaction, imaging, and cost effectiveness. Power
analysis calculated that 96 patients were needed for this trial with
an intervention distribution: embolisation versus hysterectomy ratio
of 2:1. We hope to be able to more specifically determine the place
of UAE for adenomyosis with the QUESTA RCT providing us Level 1
evidence.
Conclusion
During the last decade, the UAE technique has undergone several
refinements and extended its application beyond the embolization of fibroids. Now, patients with pure adenomyosis or adenomyosis with fibroids are also potential candidates for UAE. Clinical and
symptomatic improvements have been reported by many studies

SS/FC/HL/HTS/CM

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regarding UAE for adenomyosis. Short-term outcomes for pure adenomyosis and adenomyosis with fibroids range from 83% to 93%.
In the long term, patients report significant improvement in 65%
of pure adenomyosis and in 82% of adenomyosis with fibroids. UAE
has minimal side effects, seems cost effective, and preserves fertility. Therefore, UAE is an attractive treatment option and a valuable
alternative to hysterectomy.
Based on the current available Level 2 evidence and awaiting the
QUESTA final Level 1 results, UAE seems to be an attractive and useful treatment option. Therefore, it seems unjustified to withhold
UAE for symptomatic adenomyosis.
References
1. Lohle PN, De Vries J, Klazen CA, Boekkooi PF, Vervest HA, Smeets
AJ, Lampmann LE, Kroencke TJ. Uterine artery embolization for
symptomatic adenomyosis with or without uterine leiomyomas
with the use of calibrated tris-acryl gelatin microspheres:
midterm clinical and MR imaging follow-up. J Vasc Interv Radiol.
2007 Jul;18(7):835-41.
2. Jha RC, Takahama J, Imaoka I, Korangy SJ, Spies JB, Cooper
C, Ascher SM. Adenomyosis: MRI of the uterus treated with
uterine artery embolization. AJR Am J Roentgenol. 2003
Sep;181(3):851-6.
3. Pelage JP, Jacob D, Fazel A, Namur J, Laurent A, Rymer R,
Le Dref O. Midterm results of uterine artery embolization for
symptomatic adenomyosis: initial experience. Radiology. 2005
Mar;234(3):948-53.
4. Froeling V, Scheurig-Muenkler C, Hamm B, Kroencke TJ. Uterine
artery embolization to treat uterine adenomyosis with or
without uterine leiomyomata: results of symptom control
and health-related quality of life 40 months after treatment.
Cardiovasc Intervent Radiol. 2012 Jun;35(3):523-9.
5. Smeets AJ, Nijenhuis RJ, Boekkooi PF, Vervest HA, van Rooij WJ,
Lohle PN. Long-term follow-up of uterine artery embolization
for symptomatic adenomyosis. Cardiovasc Intervent Radiol. 2012
Aug;35(4):815-9.
6. Nijenhuis RJ, Smeets AJ, Morpurgo M, Boekkooi PF, Reuwer PJ,
Smink M, van Rooij WJ, Lohle PN. Uterine artery embolisation
for symptomatic adenomyosis with polyzene F-coated hydrogel
microspheres: three-year clinical follow-up using UFS-QoL
questionnaire. Cardiovasc Intervent Radiol. 2015 Feb;38(1):65-71.
7. Popovic M, Puchner S, Berzaczy D, Lammer J, Bucek RA. Uterine
artery embolization for the treatment of adenomyosis: a review.
J Vasc Interv Radiol. 2011 Jul;22(7):901-9; quiz 909.
8. Levgur M. Therapeutic options for adenomyosis: a review. Arch
Gynecol Obstet. 2007 Jul;276(1):1-15.

204.4
Post-menopausal UFE
J.B.Spies
Radiology, MedStar Georgetown University Hospital, Washington, DC,
United States of America
Learning Objectives
1. To learn which patients would possibly qualify for
post-menopausal UFE
2. To learn about specific technical considerations in this patient
population
3. To learn about ways not to miss a sarcoma
A vast majority of uterine fibroid embolization (UFE) procedures are
performed in pre-menopausal women. In most studies, about 80%
90% of women present with heavy menstrual bleeding, commonly
in association with other bulk-related symptoms. In the FIBROID
Registry, 85% of women presented with heavy menstrual bleeding
(1). It is very infrequent; therefore, the procedure is considered in
post-menopausal women.

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Abstract Book

Having said that, there are post-menopausal women who present

with symptoms such as pressure, abdominal wall distortion, and urinary symptoms. Therefore, UFE may be indicated in selected menopausal patients. However, there are several important cautions that
must be emphasized.
First, post-menopausal bleeding is nearly never caused by fibroids.
Menopause is defined as 12 months of amenorrhea after the final
menstrual cycle (2). Vaginal bleeding that occurs after that must be
carefully assessed. At a minimum, endometrial biopsy and transvaginal sonography should be performed, and in many cases, hysteroscopy may be indicated. Endometrial abnormalities such as polyps, hyperplasia, and endometrial cancer are much more common
causes of post-menopausal bleeding and must be excluded. Even in
the circumstance where another cause is not found, it still is rare that
fibroids are the cause.
There is limited study on the outcomes of embolization for bulkrelated symptoms, but in one published study to date (3), clinical
success was achieved in 22 of 24 women (92%), with relief of symptoms and imaging outcomes comparable to those achieved in premenopausal women.
UFE for treating bulk-related symptoms in post-menopausal women
can be effective in properly selected patients but requires special
care in pre-procedure evaluation.
References
1. Worthington-Kirsch R, Spies J, Myers E, et al. The Fibroid Registry
for Outcomes Data (FIBROID) for uterine artery embolization:
short term outcomes. Obstet and Gynec. 2005;106:52-9.
2. Soules M, Sherman S, Parrott E, et al. Exective summary:
stages of reproductive aging workshop (STRAW). Fertil Steril.
2001;76:875-8.
3. Chrisman HB, Minocha J, Ryu RK, et al. Uterine artery
embolization: a treatment option for symptomatic fibroids in
postmenopausal women. J Vasc Interv Radiol. 2007;18:451-4.

be sonographically visualized. Invasive angiography allows a better

evaluation of the central veins and delineation of the complete vascular tree. In addition, diagnosis and treatment can be performed in
one angiographic session. Therefore, angiography is recommended
only for patients with expected subsequent interventions.
Today, sectional imaging techniques are used as secondary diagnostic methods. Computed tomography (CT) is also suitable for visualizing central veins and the complete vascular tree in case of inconsistent sonographic findings. Gadolinium-enhanced MRI is not recommended to visualize dialysis access complications because of the
potential risk of gadolinium-associated nephrogenic systemic fibrosis in dialysis patients.
Here we review the current clinical and diagnostic methods in
dialysis access insufficiency by addressing the following learning
objectives:
to learn about clinical parameters to assess the dialysis access
function
to learn about the pathophysiology of stenosis development
to learn about different imaging methods to assess the fistula
function
References
1. Kamper L, Faizy TD, Haage P. Diagnosis and treatment of
insufficient dialysis vascular access. Rofo. 2015; 187: 360-71.
2. Kamper L, Frahnert M, Grebe SO, Haage P. Radiological
assessment of vascular access in haemodialysis patients. J Vasc
Access. 2014; 15 Suppl 7: S33-7.

Special Session
Dialysis access

Learning Objectives
1. To learn about different types of stent grafts available for AV
fistulas
2. When and how to use stentgrafts in AV fistulas
3. What is the current evidence on using stent grafts in AV fistulas

303.1

303.2
Current status of stent grafts
Z.J.Haskal
Vascular & Interventional Radiology, University of Virginia,
Charlottesville, VA, United States of America

No abstract available.

Clinical assessment and imaging for failing fistulas

L.Kamper
Diagnostic and Interventional Radiology, HELIOS Klinikum Wuppertal,
Wuppertal, Germany
Learning Objectives
1. To learn about different clinical parameters to assess fistula
function
2. To learn about different imaging methods to assess fistula
function
3. To learn about pathophysiology of stenosis development
Proper dialysis access function is required for efficient dialysis. The
most common complications in dysfunctional access are stenosis of
the anastomosis and the dialysis access vessels as well as thrombosis and steal syndrome. Thrombotic complications typically occur as
a result of stenosis. Moreover, dialysis patients often develop central
venous stenoses as a reaction to wall trauma associated with previous dialysis catheters and as a result of the arterialized blood flow in
venous circulation.
Dialysis access insufficiency is ideally diagnosed and treated in the
framework of interdisciplinary cooperation between nephrologists,
vascular surgeons, and interventional radiologists. Proper clinical
examination is still the basis for the assessment of dialysis access
dysfunction. In addition, there is a wide variety of diagnostic and
minimally invasive modalities available.
Duplex sonography is the method of choice for imaging insufficient dialysis access. However, central venous vessels cannot always

303.3
Current status on drug-eluting devices in dialysis access
M.Das
Department of Radiology, Maastricht University Medical Center,
Maastricht, Netherlands
Learning Objectives
1. To learn about different types of drug-eluting devices available
for AV fistulas
2. When and how to use drug-eluting devices in AV fistulas
3. What is the current evidence on using drug-eluting devices in
AV fistulas
Dialysis access fistulas and grafts are lifesaving in patients with renal
insufficiency and failure. Number of patients requiring hemodialysis
has continued to increase over the last decades and is expected to
increase further in future, making interventional radiology an integral part of this lifesaving procedure. Arteriovenous fistulas (AVF)
or arteriovenous grafts [AVG; usually made of polytetrafluoroethylene (PTFE)] are surgically placed and need to maintain a blood flow
of at least 400500 ml/min in order to allow proper hemodialysis
function. Problems occur due to the unphysiological blood pressure, which induces wall stress to the venous vessel wall; this further induces tangential and shear wall stress, which consecutively
may lead to the development of stenosis, resulting in reduced blood
flow.

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CIRSE 2016
In patients with suspected stenosis, percutaneous balloon angioplasty (PTA) usually is the first method of choice, although primary patency rate after 6 months can be <50%. Stenting should
be avoided in the first place as long as possible as stenting does
not show an increase in the patency rate. Different types of interventions have shown various success rates, including placing of
stent grafts and using cutting balloons or primarily high pressure balloons. None of these have currently shown high enough
patency rates to be recommended as an alternative for PTA. Drugeluting balloons (DEB) and drug-eluting stents (DES) have successfully been implemented in the treatment of coronary artery disease. Using drugs like paclitaxel and everolimus, which are coated
to the balloon, should help reduce the reactions taking place in the
vessel wall. These drugs belong to the group of cytotoxic agents
(paclitaxel) or immunosuppressants (sirolimus) and aim at reducing
the build-up of neointima. The challenge is to bring enough of the
agent to the vessel wall at the location of the stenosis and to have
enough bioactive drugs at the place over some period of time. In
DEB, the drug is usually put into a polymer matrix, which degrades
when the material comes into contact with the vessel wall. Initial
studies using DEB in comparison to primary treatment with standard
balloon angioplasty showed reduced restenosis rates of 12% in comparison with 28% in peripheral artery disease. In dialysis fistula, evidence is less available but current results are encouraging. Katsanos
et al. performed a prospective randomized trial comparing DEB and
standard PTA in AVF and AVG using paclitaxel-coated balloons and
showed a primary patency rate of 70% versus 25%.
These initial results are very promising; however, large (ideally, prospective randomized multicenter) trials are lacking. Thus, further
research is mandatory. This presentation will give a more in-depth
understanding and knowledge on the current technique and give a
detailed overview about current and ongoing studies on drug-eluting technique in dialysis access treatment.
References
1. Portugaller RH, Kalmar PI, Deutschmann H. The eternal tale of
dialysis access vessels and restenosis: are drug-eluting balloons
the solution? J Vasc Access. 2014;15:439-47.
2. Aruny JE, Lewis AL, Caedella JF, et al. Quality improvement for
percutaneous management of the thrombosed or dysfunctional
dialysis access. J Vasc Interv Radiol. 2003;14:S247-S53.
3. Haskal ZJ, Trerotola S, Dolmatch B, et al. Stent graft versus
balloon angioplasty for failing dialysis-access grafts. N Engl J
Med. 2010;262:494-503.
4. Axel DI, Kunert W, Goeggelmann C, et al. Paclitaxel inhibits
arterial smooth muscle cell proliferation and migration in vitro
and in vivo using local drug delivery. Circulation. 1997;96:636-45.
5. Roy-Chaudhury P, Sukhatme VP, Cheung AK. Hemodialysis
vascular access dysfunction: a cellular and molecular viewpoint.
J Am Soc Nephrol. 2006;17:1112-7.
6. Tepe G, Zeller T, Albrecht T, et al. Local delivery of paclitaxel to
inhibit restenosis during angioplasty of the leg. N Engl J Med.
2008;358:689-99.
7. Werk M, Langner S, Reinkensmeier B, et al. Inhibition of
restenosis in femoropopliteal arteries: paclitaxel-coated versus
uncoated balloon: femoral paclitaxel randomized pilot trial.
Circulation. 2008;118:1358-65.
8. Werk M, Albrecht T, Meyer DR, et al. Paclitaxel-coated balloons
reduce restenosis after femoro-popliteal angioplasty: evidence
from the randomized PACIFIER trial. Circ Cardiovasc Interv.
2012;5:831-40.
9. Katsanos K, Karnabatidis D, Kitrou P, et al. Paclitaxel-coated
balloon angioplasty vs. plain balloon dilation for the treatment
of failing dialysis access: 6-month interim results from a
prospective randomized controlled trial. J Endovasc Ther.
2012;19:263-72.

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303.4
Treatment of chronic central venous obstructions
J.H.Peregrin
Diagnostic and Interventional Radiology, IKEM, Prague, Czech Republic
Learning Objectives
1. To learn about the special challenge of central venous
obstructions
2. Tips and tricks on how to treat central venous obstructions
3. What is the current evidence on treatment of central venous
obstructions
Central venous stenosis or obstruction (CVD), defined as >50% stenosis in the jugular, subclavian or axillary veins, can cause significant
complications in the long-term clinical management of haemodialysis (HD) patients. Its incidence is reported to range from 25% to 40%
(1, 2). It is caused by the development of venous intimal hyperplasia.
CVD is particularly more common in patients with a history of the
central venous catheter placement, especially after repeated cannulations or a long duration of catheter use (3, 4, 5). Transvenous leads
for pacemakers and defibrillators and PICCs are associated with a
higher risk of CVD development as well (6). However, there are haemodialysis patients with idiopathic CVD development (7). CVD can
be asymptomatic and unrecognised and become clinically apparent
in the presence of increased venous return caused by dialysis fistula
or graft placement (5, 8).
The optimal approach to CVD is prevention. If central vein cannulation is necessary, the right internal jugular vein approach is preferred as the subclavian veins or left jugular vein are associated with
higher risk of CVD development (3, 9, 10).
Endovascular interventions are considered as the primary treatment
option for haemodialysis patients with CVD. They include angioplasty (PTA), bare metal stent (BMS) placement or covered stent
placement (stent grafts). The Kidney Disease Outcomes Quality
Initiave (K/DOQI) guidelines recommend PTA (with or without stent
placement) as the method of choice for CVD (11). Thus, the treatment of symptomatic CVD starts with balloon dilatation. PTA is an
effective treatment for venous stenosis or occlusions but results in
endothelial injury, including smooth cell damage, and it may result
in the development of neointimal hyperplasia (12). This is the reason
why PTA has a high success rate in preserving the access function,
but it has long-term patency rates requiring repeated interventions
(13). Self-expandable metal stents are used when PTA fails (usually
due to elastic venous recoil) or in recurrent stenosis, but the longterm patency is also limited (9, 13, 14). In recent literature, use of covered stents has shown promise: technical success remains high and
the primary and assisted patency rates seem to be significantly better than those using BMS (14, 15).
References
1. Lumsden AB, MacDonald MJ, Isiklar H, Martin LG, Kikeri D,
Harker LA, Allen RC. Central venous stenosis in the hemodialysis
patient: incidence and efficacy of endovascular treatment.
Cardiovasc Surg. 1997 Oct;5(5):504-9.
2. Glanz S, Gordon DH, Lipkowitz GS, Butt KM, Hong J, Sclafani SJ.
Axillary and subclavian vein stenosis: percutaneous angioplasty.
Radiology. 1988 Aug;168(2):371-3.
3. Hernndez D, Daz F, Rufino M, Lorenzo V, Prez T, Rodrguez A,
De Bonis E, Losada M, Gonzlez-Posada JM, Torres A. Subclavian
vascular access stenosis in dialysis patients: natural history and
risk factors. J Am Soc Nephrol. 1998 Aug;9(8):1507-10.
4. Trerotola SO, Kothari S, Sammarco TE, Chittams JL. Central
venous stenosis is more often symptomatic in hemodialysis
patients with grafts compared with fistulas. J Vasc Interv Radiol.
2015 Feb;26(2):240-6.
5. Modabber M, Kundu S. Central venous disease in hemodialysis
patients: an update. Cardiovasc Intervent Radiol. 2013
Aug;36(4):898-903.

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6. Dhamija RK, Tan H, Philbin E, Mathew RO, Sidhu MS, Wang J,

Saour B, Haqqie SS, Beathard G, Yevzlin AS, Salman L, Boden
WE, Siskin G, Asif A. Subcutaneous implantable cardioverter
defibrillator for dialysis patients: a strategy to reduce central vein
stenoses and infections. Am J Kidney Dis. 2015 Jul;66(1):154-8.
7. Kotoda A, Akimoto T, Kato M, Kanazawa H, Nakata M, Sugase
T, Ogura M, Ito C, Sugimoto H, Muto S, Kusano E. Central
venous stenosis among hemodialysis patients is often not
associated with previous central venous catheters. ASAIO J. 2011
Sep-Oct;57(5):439-43.
8. Collin G, Jones RG, Willis AP. Central venous obstruction in the
thorax. Clin Radiol. 2015 Jun;70(6):654-60.
9. Agarwal AK, Haddad NJ, Khabiri H. How should symptomatic
central vein stenosis be managed in hemodialysis patients?
Semin Dial. 2014 May-Jun;27(3):278-81.
10. Schillinger F, Schillinger D, Montagnac R, Milcent T. Post
catheterisation vein stenosis in haemodialysis: comparative
angiographic study of 50 subclavian and 50 internal jugular
accesses. Nephrol Dial Transplant. 1991;6(10):722-4.
11. III. NKF-K/DOQI Clinical Practice Guidelines for Vascular Access:
update 2000. Am J Kidney Dis. 2001 Jan;37(1 Suppl 1):S137-81.
12. Lee T. Novel paradigms for dialysis vascular access: downstream
vascular biology--is there a final common pathway? Clin J Am
Soc Nephrol. 2013 Dec;8(12):2194-201.
13. Bakken AM, Protack CD, Saad WE, Lee DE, Waldman DL, Davies
MG. Long-term outcomes of primary angioplasty and primary
stenting of central venous stenosis in hemodialysis patients. J
Vasc Surg. 2007 Apr;45(4):776-83.
14. Jones RG, Willis AP, Jones C, McCafferty IJ, Riley PL. Long-term
results of stent-graft placement to treat central venous stenosis
and occlusion in hemodialysis patients with arteriovenous
fistulas. J Vasc Interv Radiol. 2011 Sep;22(9):1240-5.
15. Anaya-Ayala JE, Smolock CJ, Colvard BD, Naoum JJ, Bismuth J,
Lumsden AB, Davies MG, Peden EK. Efficacy of covered stent
placement for central venous occlusive disease in hemodialysis
patients. J Vasc Surg. 2011 Sep;54(3):754-9.

Special Session
Embolisation for lower GI bleeding
304.1
Patient preparation and imaging
J.Urbano
Vascular & Interventional Radiology, Jimnez Daz Foundation
University Hospital, Madrid, Spain
Learning Objectives
1. To define clinical presentation of acute and chronic LGIB
2. To learn the different imaging modalities available for
assessment
3. To learn when to embolise a LGIB
Gastrointestinal bleeding (GIB) is clinically and anatomically classified into upper GIB (UGIB) and lower GIB (LGIB) with different diagnostic and therapeutic approaches. UGIB source is the oesophagus, stomach or duodenum. When the bleeding source is distal to
the ligament of Treitz, it is considered as LGIB. In general, acute UGIB
causes haematemesis and LGIB causes melena or rectal bleeding.
When bleeding is massive and GI transit is very fast, UGIB can also
produce melena. Bleeding can also be acute or chronic. The main
clinical sign of chronic bleeding is anaemia and requires medical,
and sometimes surgical, management.
This session is focused on acute GIB and the role of IR.
UGI endoscopy provides accurate diagnosis, aids in estimating prognosis and allows therapeutic intervention. Vascular and

Abstract Book
interventional radiology (VIR) may be required for bleeding unresponsive to endoscopic intervention. Drug therapy depends on the
cause of bleeding. Intravenous proton-pump inhibitors should be
used in patients with high-risk ulcers. Terlipressin, B-blockers and
broad-spectrum antibiotics should be used following a variceal
haemorrhage. Hospitals admitting patients with acute UGIB need to
provide out of hours endoscopy and VIR for all patients.
Acute non-variceal UGIB is diagnosed and treated by endoscopy,
and in most of the cases, no other imaging techniques are required.
About 5% of the UGIB cases cannot be fixed by endoscopic techniques. The patients with active bleeding refractory to endoscopic treatment and those who have had prior surgery, preventing endoscopic access, should undergo angiography and VIR treatment. Currently, surgery is only considered when VIR is not possible
or fails. When the cause of UGIB is not peptic and pancreatitis, iatrogenic, MalloryWaiss, aortoenteric fistula or post-surgical bleeding is suspected and an abdominal MDCT scan has to be performed
together with endoscopy to obtain a complete assessment before
embolisation.
Variceal acute UGIB due to portal HT has a different diagnostic
and therapeutic approach. Endoscopy is again the corner stone of
both diagnosis and treatment. However, in these patients, hepatic
Doppler US and an MDCT abdominal scan are always necessary to
assess portal permeability, portal flow, portosystemic shunts and
ascites, rule out HCC and know the anatomic hepatic vein location
wherein TIPS may be required.
In most cases of LGIB, bleeding from the colon and rectum, resulting
from benign pathology, is self-limiting and requires no specific therapy. Endoscopy will be the main diagnostic test in case of chronic
LGIB. When acute LGIB produces a large amount of blood inside the
colon, endoscopic assessment and treatment is not possible or has
failed. Because in this setting endoscopy is not useful and does not
reach the small bowel, MDCT is used as the main imaging technique
in the diagnosis of active haemorrhage if the clinical condition of the
patient allows.
MDCT angiography with arterial phase and portal-venous phase
could act as an accurate screening method for the detection and
localisation of active LGIB and it is more sensitive than digital subtraction angiography. Active bleeding is seen on CT as a contrast
extravasation into the bowel lumen that typically changes and
increases from the arterial to the portal phase. Oral contrast should
be avoided if non-contrast and delayed phases acquisitions are
optional. CT angiography provides valuable information that can
be used to guide mesenteric catheterisation and embolisation if a
bleeding source is localised.
The current role of angiography as a diagnostic tool is limited for
cases with negative MDCT but clinical and endoscopic evidence of
GI bleeding. However, when bleeding site is not clear, highly superselective DSA of the suspected bleeding artery is more sensitive
than MDCT in detecting active haemorrhage.
Patient preparation
Resuscitation efforts and correction of coagulopathy before and
during angiographic procedure
Haemodynamic parameters and clotting screen [activated partial
thromboplastin time (APTT), prothrombin time (PT) and platelets],
previous surgical or endoscopic treatments, anticoagulation with
warfarin, aspirin use, smoking history and excess alcohol use have to
be checked by VIR before GIB embolisation.
Administer antiperistaltic agents before the procedure.
Foley catheter
Avoid use of radiodense contrast agents in the GI tract. Oral contrast
can obscure detection of vascular contrast extravasation.
Preprocedural review
Review all diagnostic imaging findings and surgical history.
Review endoscopic findings with the gastroenterologist; clips can
help both angiographic and surgical target treatments.

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Collateral as well as primary blood supply must be evaluated and
addressed; be aware of the patients surgical history and its potential
impact on the vascular supply.
Discuss treatment plans before starting the procedure, including the
possibility of empiric embolisation (embolisation of the vessel even
though there is no angiographically demonstrable sign of bleeding;
this is usually based on endoscopic diagnosis or surgical history).
When to embolise
Although GI active bleeding on a CT is important in the decision
making, it is not enough and embolisation should not be indicated
only because an MDCT is positive. Embolisation is only possible
when the bleeding site is focal. The patients haemodynamic stability is a primary determinant. The following parameters can serve as
thresholds for the indication of embolisation in GIB:
Requirement for blood transfusion, 20% decrease in haematocrit
Persistent or recurrent bleeding after 24 h of stability
Four units packed red blood cells (RBCs) transfused in less than
24 h
Systolic blood pressure less than 100 mm Hg
Heart rate greater than 100 beats per minute
It is important to use these parameters as a guide rather than absolute trigger points. They need to be considered in conjunction with
each individuals overall clinical condition and comorbidities.
References
1. Nanavati SM. What if endoscopic hemostasis fails? Alternative
treatment strategies: interventional radiology. Gastroenterol
Clin North Am 2014; 43: 73952.
2. Ierardi AM, Urbano J, De Marchi G, Micieli C, Duka E, Iacobellis F,
Fontana F, Carrafiello G. New advances in lower gastrointestinal
bleeding management with embolotherapy. Br J Radiol 2016; 89:
20150934.
3. Schenker MP, Majdalany BS, Funaki BS, Yucel EK, Baum RA, Burke
CT, Foley WD, Koss SA, Lorenz JM, Mansour MA, Millward SF,
Nemcek AA Jr, Ray CE Jr. ACR Appropriateness Criteria on upper
gastrointestinal bleeding. J Am Coll Radiol 2010; 7: 84553.
4. ACR Appropriateness Criteria: Radiologic Management of
Lower Gastrointestinal Tract Bleeding. ttps://acsearch.acr.org/
docs/69457/Narrative.
5. Artigas JM, Mart M, Soto JA, Esteban H, Pinilla I, Guilln E.
Multidetector CT angiography for acute gastrointestinal
bleeding: technique and findings. Radiographics 2013; 33:
145370.

304.2
Optimal angiographic techniques
M.D.Darcy
Interventional Radiology, Washington University School of Medicine in
St Louis, St. Louis, MO, United States of America
Learning Objectives
1. To learn how to optimise the diagnosis of the bleeding site
(including CO2)
2. To learn how crucial a flawless technique is for a good outcome
3. To learn if there is a role for empiric embolisation in LGIB
Arteriography is known to be less sensitive for detecting lower gastrointestinal bleeding than either CTA or tagged RBC scans, which
are used to screen for active bleeding. Thus, a negative arteriogram after a positive CTA or scan is a frequent occurrence. Careful
attention to the angiographic technique can increase the chances
of detecting the bleeding. For increasing the angiographic yield,
the right patients should be selected for angiography. Studies
have shown that a patient who is clinically stable is far more likely
to have a negative arteriogram than a patient who is tachycardic or
hypotensive.
Once the decision to perform an arteriogram is made, careful evaluation of the clinical history as well as the results of endoscopy or

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screening imaging will enable to concentrate the efforts in the

appropriate vascular distribution. Knowledge of a suspected location of bleeding not only provides information on which artery to
inject first but also provides guidance for more super-selective catheterizations and angiography. It is important to be aware of collateral supply, particularly in watershed areas, and ensure that all the
vessels that may be responsible for the bleeding are injected. An
example would be transverse colon bleeding due to the inferior
mesenteric artery (IMA) if the proximal superior mesenteric artery
(SMA) is stenotic. In addition, it is important to be aware of pertinent
anatomic variants such as middle colic supply arising from a dorsal
pancreatic branch off the splenic artery.
Several technical factors are critical for the optimal angiographic
technique. Imaging the entire distribution of the vessel being
injected is important. For example, a common error of this type may
be missing low rectal bleeding by failing to center low enough during an IMA arteriogram. Adequate contrast injection rate and volume are necessary to avoid poor opacification of an area of extravasation. Studies should be conducted in both the subtracted and
non-subtracted mode to distinguish subtle bleeding from areas of
misregistration artefacts. These artefacts can also be minimized by
the use of glucagon to paralyze the bowel.
If the bleed has been relatively well localized by endoscopy or prior
imaging and no bleeding is identified during injection of the visceral
artery trunk, subselective injections should be given in the region
of interest. This leads to better concentration of contrast in the area
of extravasation. Carbon dioxide (CO2) has been reported to aid in
the demonstration of bleeding when liquid contrast angiography
fails to show any extravasation. This is postulated to work because
of the lower viscosity of CO2, allowing it to more readily leak out of
a small breach in the blood vessel. However, one study (1) indicated
that CO2 angiography was actually less sensitive than iodinated
contrast angiography. Given that GI bleeding is often intermittent,
repeat injections in the suspected territory after having studied all
the other visceral vessels will sometimes reveal the bleeding despite
an initial negative arteriogram.
In cases of multiple negative studies but persistent bleeding, some
researchers have advocated provocative angiography. The rationale is that stimulating the patient to bleed allows the diagnosis to
be made, which in turn allows treatment that should eliminate continued bleeding. Thus, temporary stimulation of bleeding leads to
an overall reduction or termination of blood loss. Various protocols
have been used, including anticoagulation, vasodilator infusion,
thrombolytic infusion, and combinations of these drugs. Rosch et
al. first described provocative angiography for GI bleeding in 1982
(2). Later, in 1988, they reported 21 cases of provocative angiography and showed that their ability to demonstrate extravasation
increased from 32% (in those who only underwent standard angiography) to 69% (3). The largest contemporary series was reported by
Kim et al. (4). Their protocol involved systemic anticoagulation with
heparin, followed by selective infusion of vasodilators and t-PA, into
the area suspected to be the source of bleeding. Of 36 provocative
angiograms in 34 patients, angiographically visible extravasation
was observed in 31%. This allowed them to embolize the lesion in 10
of these 11 patients, and hemorrhagic complications did not result
from the provocative maneuvers in any patient. While the benefit of
provocative angiography is sometimes debated, there have been no
reported cases of provocative angiography causing hemodynamic
instability or uncontrollable hemorrhage.
When no bleeding can be identified, the suspected vascular bed
can sometimes be empirically embolized. Empiric embolization has
been used for many years in the upper GI tract, although its value
has been debated. Sometimes referred to as blind embolization,
empiric embolization is actually most often guided by prior endoscopic findings. Sometimes, endoscopy may point to a general
region such as the gastric fundus or duodenum, prompting embolization of the left gastric or gastroduodenal artery, respectively.

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However, endoscopic localization may be very precise as the situation when endoscopic clips were placed on a visible vessel or bleeding ulcer. Here, the specific vessel supplying the bleeding pathology
can be precisely targeted for embolization.
Some studies (5, 6) have shown comparable rebleeding rates,
regardless of whether embolization was performed empirically or
to manage demonstrable extravasation. However, a larger study (7)
has suggested that the value of empiric embolization depends on
which vascular bed this is applied to. For gastric hemorrhage, it was
shown that the rate of hemostasis 30 days post-embolization was
67% when embolization was performed to treat an angiographic
abnormality in comparison with the rate of 42% after empiric embolization. However, for duodenal bleeding, hemostasis 30 days after
angiography was equivalent (60% vs. 58%) for patients undergoing empiric embolization and those undergoing embolization for
arterial hemorrhage observed at angiography. Moreover, the rate
of hemostasis was significantly worse (33%) for those patients who
underwent a diagnostic arteriogram but were not embolized.
In addition to endoscopic guidance, modern CTA angiography can
sometimes define the specific arterial branch that is the source of
bleeding. This has allowed empiric embolization to be extended to
the lower GI tract. Feld et al. (8) described successful super-selective
embolization of a sigmoid colon artery, despite a negative arteriogram. The anatomy depicted by CTA perfectly matched the catheter arteriogram; therefore, it was possible to know which vessel was
the source of bleeding, despite not visualizing extravasation during
the arteriogram.
References
1. Sandhu C, Buckenham TM, Belli AM. Using CO2-enhanced
arteriography to investigate acute gastrointestinal hemorrhage.
AJR Am J Roentgenol. 1999;173(5):1399-401.
2. Rosch J, Keller FS, Wawrukiewicz AS, Krippaehne WW, Dotter
CT. Pharmacoangiography in the diagnosis of recurrent massive
lower gastrointestinal bleeding. Radiology. 1982;145(3):615-9.
3. Rosch J, Kozak B, Keller FS. Interventional Diagnostic
Angiography in Acute Lower-Gastrointestinal Bleeding.
Seminars Intervent Radiol. 1988;5:10-8.
4. Kim CY, Suhocki PV, Miller MJ, Jr., Khan M, Janus G, Smith TP.
Provocative mesenteric angiography for lower gastrointestinal
hemorrhage: results from a single-institution study. J Vasc Interv
Radiol. 2010;21(4):477-83.
5. Yap FY, Omene BO, Patel MN, Yohannan T, Minocha J, Knuttinen
MG, et al. Transcatheter embolotherapy for gastrointestinal
bleeding: a single center review of safety, efficacy, and clinical
outcomes. Dig Dis Sci. 2013;58(7):1976-84.
6. Dixon S, Chan V, Shrivastava V, Anthony S, Uberoi R, Bratby M. Is
there a role for empiric gastroduodenal artery embolization in
the management of patients with active upper GI hemorrhage?
Cardiovasc Intervent Radiol. 2013;36(4):970-7.
7. Arrayeh E, Fidelman N, Gordon RL, LaBerge JM, Kerlan RK,
Jr., Klimov A, et al. Transcatheter arterial embolization for
upper gastrointestinal nonvariceal hemorrhage: is empiric
embolization warranted? Cardiovasc Intervent Radiol.
2012;35(6):1346-54.
8. Feld RS, Zink S, Posteraro A. Empiric embolization of a
diverticular bleed with CT angiographic mapping: enlarging the
therapeutic window of transcatheter arterial intervention. J Vasc
Interv Radiol. 2010;21(4):593-5.

Abstract Book

304.3
The role of liquid agents
R.Loffroy
Department of Vascular and Interventional Radiology, FranoisMitterrand University Hospital, Dijon, France
Learning Objectives
1. When and how to use liquid embolics in LGIB
2. Pros and cons of using liquids in LGIB
3. Results and complications of liquid embolics in LGIB
Embolization is currently proposed as the first step in the treatment
of severe, acute, and life-threatening lower gastrointestinal bleeding (LGIB) in cases where the endoscopic approach is not possible or
not useful. The efficacy of embolization depends on a combination
of bleeding site occlusion and clot forming. The main concern with
embolic materials is rebleeding and the risk of secondary bowel
ischemia. There are no guidelines for the choice of embolic material used, and the final decision is specific to each case. However, liquid embolic materials, including N-butyl cyanoacrylate glues (NBCA)
and gelling solutions (Onyx, ethylene vinyl alcohol copolymer; Ev3
Endovascular, Inc. Plymouth, MN) have gained acceptance.
NBCA is an effective, rapid, and safe embolic material, which may be
lifesaving in emergent situations. NBCA has several advantages. It
allows for rapid and permanent embolization due to its fast polymerization when it comes in contact with blood. A single injection
may provide complete hemostasis through simultaneous embolization of collateral vessels connected to the bleeding focus. It is useful in patients with coagulopathy as the vessel occlusion is independent of the coagulation process. NBCA glue has other favorable characteristics that make it an effective embolization agent.
First, NBCA has a low viscosity that allows for injection through small
caliber catheters. Furthermore, the polymerization and injection
rates of NBCA can be adjusted to allow for very distal occlusion to
the tip of the microcatheter. During the procedure, NBCA is mixed
with iodized oil in ratios varying from 1:1 to 1:3 and the microcatheter must be flushed with 5% dextrose solution prior to injection to
prevent the premature polymerization of NBCA within the catheter.
Injection is stopped when extravasation of the mixture occurs from
the bleeding site or when an underlying pseudoaneurysm is completely opacified. In general, coils are preferred for embolization of
pseudoaneurysm as they allow precise placement. However, it is
often difficult to selectively place the catheter close to and beyond
the pseudoaneurysm in small or tortuous vessels. Furthermore,
when there are multiple efferent arteries from the pseudoaneurysm
or when multiple collaterals from adjacent arteries feed the aneurysm, embolization with coils may be time consuming and technically difficult. Although catheterization may be possible, it may be
difficult to deliver the coils because of the tortuosity of the vessels.
At such instances, NBCA can be a good choice due to its low viscosity. Embolization with NBCA glue is technically more challenging than embolization with microcoils and requires specific training
and expertise. Indeed, relatively few interventional radiologists are
experienced in this technique. However, the potential complications
of NBCA glue injection, including catheter entrapment, abscess formation, and uncertain control of vascular penetration with nontarget embolization, can be avoided in well-trained hands. In our experience, the following steps can help ensure a successful NBCA embolization procedure: (i) use of a strong supporting catheter to facilitate ease of microcatheter navigation, (ii) awareness of the complex
vascular anatomy and use of road mapping, (iii) deep wedging of the
microcatheter beyond the margin of the colon to prevent excessive
embolization of the vasa recta, (iv) use of contrast imaging to double-check catheter position with respect to the point of bleeding
before NBCA injection, (v) use of the appropriate ratio of lipiodol to
NBCA, (vi) use of a single column injection technique under continuous fluoroscopic monitoring (with an injection volume as small as

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possible to avoid reflux), and (vii) rapid removal of the catheter after
glue injection. Only two glues are currently and officially available
in the market worldwide for endovascular use: Glubran2 (GEM) and
Trufill (Cordis); these glues have a European Conformity marking and
U.S. Food and Drug Administration approval, respectively. Histoacryl
(B. Braun), which has been used in many previous series, is normally
not allowed for endovascular procedures because of the absence of
European Conformity marking or U.S. Food and Drug Administration
approval. Its use is considered off-label in such a setting. In addition,
Histoacryl polymerizes faster and provides higher exothermic reaction (90C) than other glues, resulting in more challenges associated
with its use and the development of more inflammation and histotoxicity. High clinical success rates with the use of glue are reported
in the literature (85%96%), suggesting that this embolic agent has
gained acceptance. Recurrent bleeding ranges from 4% to 15%).
On the other hand, selective arterial embolization with Onyx is a
very interesting and promising treatment option for lower GI bleeding. Onyx seems to provide controlled embolization due to slow
polymerization that enables deep penetration with less risk of catheter gluing due to its non-adhesive nature. The main disadvantage of
Onyx is its relatively high cost compared with other embolic agents.
The 6% concentration of ethylene-vinyl alcohol copolymer (Onyx18)
is mostly used to ensure more fluidity and to permit greater penetration in the thin vasa recta. This property is particularly useful in tortuous or rigid vessels, where it is occasionally impossible to deploy
microcoils as selectively as would be desirable. This liquid embolic
material can also be delivered through a 0.010-inch microcatheter,
which may be useful in small or spastic vessels. Onyx produces a
plug in the eroded artery and simultaneously blocks the primary site
of bleeding. The slow real-time injection under fluoroscopic guidance provides greater control over the distribution of the embolization agent, avoiding nontargeted embolization. Because this product is non adhesive and its solidification time is long, the microcatheter is not entrapped, even though its tip is surrounded by the Onyx.
Distal migration of Onyx is rare because of its adhesive nature and
slow, controlled real-time injection; however, retrograde reflux into
a nontargeted vessel is possible if the injection technique is incorrect and if it is performed at a greater velocity than recommended.
Another disadvantage is that if the operator does not have enough
experience with the use of Onyx, the time, radiation dose, and complexity of the procedure may be excessively increased. Some authors
have reported severe vasospasm in cases of rapid injection. This is
especially important during the early stages of the embolization
procedure when the dimethyl sulfoxide (DMSO) is being replaced by
Onyx in the catheter dead space. Therefore, the first 1 mL of embolic
agent must be injected very slowly. DMSO is volatile and is excreted
via respiration and sweat. This has a typical smell, unlike that of diabetic ketoacidosis, and may last for a few days. The patient and ward
staff should be warned to expect this. In addition, chemical irritation caused by DMSO is usually painful. It is advisable to start stirring Onyx as soon as it is suspected that its use may be necessary. If
microcatheter repositioning is needed when Onyx is being used for
embolization, the microcatheter will no longer accept a microguide
when it is filled with Onyx, and a new microcatheter will be required.
Another drawback is that Onyx creates streak artifacts that hinder
future multi-detector CT evaluation; however, in cases of LGIB, this
problem is minor because of the small amount of Onyx employed.
Free flow is necessary for particles or cyanoacrylate embolization;
however, Onyx works equally well with or without flow, and this is
an advantage in cases where vasospasm is present. Recently, Onyx
has exhibited nice results in terms of LGIB control, with a clinical success rate that approaches 100% and no major complications or procedure-related deaths. The 30-day rebleeding rate is reported to be
about 10%.
All advantages and drawbacks of liquid embolic materials for the
treatment of LGIB will be presented in detail in this review.

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References
1. Loffroy R, Rao P, Ota S, De Lin M, Kwak BK, Geschwind JF.
Embolization of acute nonvariceal upper gastrointestinal
hemorrhage resistant to endoscopic treatment: results and
predictors of recurrent bleeding. Cardiovasc Intervent Radiol
2010;33(6):1088-100.
2. Hur S, Jae HJ, Lee M, Kim HC, Chung JW. Safety and efficacy of
transcatheter arterial embolization for lower gastrointestinal
bleeding: a single-center experience with 112 patients. J Vasc
Interv Radiol 2014;25(1):10-9.
3. Yata S, Ihaya T, Kaminou T, Hashimoto M, Ohuchi Y, Umekita Y,
Ogawa T. Transcatheter arterial embolization of acute arterial
bleeding in the upper and lower gastrointestinal tract with
N-butyl-2-cyanoacrylate. J Vasc Interv Radiol 2013;24(3):422-31.
4. Huang CC, Lee CW, Hsiao JK, Leung PC, Liu KL, Tsang YM, Liu HM.
N-butyl cyanoacrylate embolization as the primary treatment
of acute hemodynamically unstable lower gastrointestinal
hemorrhage. J Vasc Interv Radiol 2011;22(11):1594-9.
5. Frodsham A, Berkmen T, Ananian C, Fung A. Initial
experience using N-butyl cyanoacrylate for embolization
of lower gastrointestinal hemorrhage. J Vasc Interv Radiol
2009;20(10):1312-9.
6. Loffroy R. Which Acrylic Glue Should Be Used for Transcatheter
Arterial Embolization of Acute Gastrointestinal Tract Bleeding?
AJR Am J Roentgenol 2015;205(4):W465.
7. Loffroy R. Transcatheter arterial embolization for
gastroduodenal ulcer bleeding: the use of cyanoacrylate glue
has gained acceptance. Acta Radiol 2014;55(3):325-6.
8. Kolber MK, Shukla PA, Kumar A, Silberzweig JE. Ethylene vinyl
alcohol copolymer (onyx) embolization for acute hemorrhage: a
systematic review of peripheral applications. J Vasc Interv Radiol
2015;26(6):809-15.
9. Urbano J, Manuel Cabrera J, Franco A, Alonso-Burgos A.
Selective arterial embolization with ethylene-vinyl alcohol
copolymer for control of massive lower gastrointestinal
bleeding: feasibility and initial experience. J Vasc Interv Radiol
2014;25(6):839-46.
10. Lenhart M, Paetzel C, Sackmann M, Schneider H, Jung EM,
Schreyer AG, Feuerbach S, Zorger N. Superselective arterial
embolisation with a liquid polyvinyl alcohol copolymer in
patients with acute gastrointestinal haemorrhage. Eur Radiol
2010;20(8):1994-9.

304.4
The role of particles
B.S.Funaki
Radiology, University of Chicago, Chicago, IL, United States of America
Learning Objectives
1. When and how to use particles in LGIB
2. Pros and cons of using particles in LGIB
3. Results and complications of particles in LGIB
Because microcoils are both effective and forgiving, they are the
authors primary embolic for treatment of non-variceal lower gastrointestinal hemorrhage. However, particles have been reported to be
equally effective and continue to be the agents of choice in some
centers. Interventional radiologists who use particles argue that
particles flow along the path of least resistance toward the bleeding vessel. Additionally, at least theoretically, particles may be superior to microcoils in patients with coagulopathies as they can result
in a more complete vessel occlusion. Particles are preferable over
microcoils for tumoral hemorrhage or in some cases where vasospasm precludes distal catheterization. Compared with microcoils,
the drawbacks of particles include the inability to directly visualize
particles and the lack of any effective means to mollify non-target

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embolization due to particles, if it inadvertently occurs. There is a

lack of consensus regarding the ideal particle size. Some advocate
smaller particles (150250 m), while others use larger particles
(>250 m) owing to the higher risk of infarction with smaller sizes.
References
1. Funaki B. Microcatheter embolization of lower gastrointestinal
hemorrhage: an old idea whose time has come. Cardiovasc
Intervent Radiol. 2004; 27:591-9.
2. Bandi R, Shetty PC, Sharma RP, Burke TH, Burke MW, Kastan D.
Superselective arterial embolization for the treatment of lower
gastrointestinal hemorrhage. J Vasc Interv Radiol. 2001; 12:1399405.
3. Tanveer-Ul-Haq, Idris M, Salam B, Akhtar W, Jamil Y. Comparison
of microcoils and polyvinyl alcohol particles in selective
microcatheter angioembolization of non variceal acute
gastrointestinal hemorrhage. Pak J Med Sci. 2015; 31:751-6.

Fundamental Course
Thermal liver ablation
901.1
HCC: patient selection
T.deBare
Department of Radiology, Gustave Roussy Cancer Campus, Villejuif,
France
Learning Objectives
1. To learn how to optimise imaging for HCC staging
2. To understand the selection criteria for thermal ablation in HCC
according to the BCLC staging scheme
3. To understand prognostic factors limiting the outcome for
thermal ablation of HCC
According to, local ablation with radiofrequency is considered the
standard of care for patients with BCLC early or very early stage HCC
not suitable for surgery.
The best efficacy is reported for thermal ablation are in very early
stage HCC (single <2-cm tumor) where ablation and resection
achieve complete responses in more than 90% of cases with good
long-term outcome. Whether radiofrequency ablation (RFA) should
replace surgery in such patients is debated in Europe, but a portion
of such patients receive ablation due to treatment stage migration
concept.
According to Asia Pacific consensus recommendations, in HCC
below 3 cm, even resectable tumors are candidates for ablation.
Location of the disease is of course a key parameter in the decision
to ablate or resect.
RFA alone results in a 5-year overall survival of 76% when used
in patients classified as resectable according to EASL/EORTC
guidelines.
Thermal ablation can be applied to larger tumors, but due to the
decrease in efficacy for local tumor control, when a tumor above 3
cm has to be targeted with thermal ablation, the combination of RFA
and TACE has an added benefit in OS versus RFA alone.
References
1. European Association for the Study of the Liver; European
Organisation for Research and Treatment of Cancer. EASL- EORTC
clinical practice guidelines: management of hepatocellular
carcinoma. J Hepatol 2012;56:908-943.
2. Peng ZW, Zhang YJ, Chen MS, Xu L, Liang HH, Lin XJ et al.
Radiofrequency ablation with or without transcatheter
arterial chemoembolization in the treatment of hepatocellular
carcinoma: a prospective randomized trial. J Clin Oncol
2012;31:426-432.

Abstract Book

901.2
HCC: ablation techniques
T.Bilhim
Interventional Radiology, Hepatobiliary-Pancreatic and
Transplantation Center, CHLC, Lisbon, Portugal
Learning Objectives
1. To understand indications, contraindications and device
selection for thermal ablation in HCC
2. To learn how to avoid and manage complications in thermal
ablation of HCC
3. To understand the outcomes after thermal ablation in HCC in
comparison to resection
Treatment for early stage HCC should be discussed within multidisciplinary teams, and all available curative options including surgical resection, liver transplantation, and image-guided ablation (as
sole treatment or as bridge to transplant) should be considered.
Candidates should have tumor staging with triple-phase CT or MR
of the liver showing either a single tumor < 5 cm or up to three nodules < 3 cm each.
Prothrombin time ratio < 50% and platelet count < 50,000/L should
be corrected. ECOG performance status 2; ChildPugh class C; diffuse/infiltrative tumors; vascular invasion; and distant disease are
considered contraindications. Aspirin/clopidogrel should be withheld at least 5 days before.
Radiofrequency ablation (RFA) is considered the standard technique; however, microwave ablation (MWA) is increasingly being
used because it produces larger ablation zones, with less susceptibility to heat-sink effect and lower ablation sessions and times
needed, allowing for simultaneous ablations of multiple nodules.
Irreversible electroporation (IRE) is a nonthermal technology with
promising data for central tumors near main bile ducts or blood vessels. Percutaneous ethanol injection (PEI) remains a viable option
for small (< 2 cm) HCC tumors unsuitable for thermal ablation. Other
less frequently used devices are cryoablation, laser ablation and
high-intensity focused ultrasound. A 0.51-cm-thick ablative margin
should be produced all around the tumor.
Lesions near the liver surface, especially near the colon, pose higher
risks of complications. Hydrodissection can be used to separate
the colon from the ablation area. Central lesions and those near
the gallbladder are at higher risk of biliary tract injury. Lesions near
hepatic vessels are prone to heat-sink effect. Potential complications
(2.2%11%) include post-ablation syndrome (pain, nausea, vomiting), bile duct injury, intraperitoneal bleeding, hepatic abscess, skin
burns, tumor seeding along the needle track, portal vein thrombosis, sepsis, hepatic failure, and colon perforation. Antibiotic coverage, correct patient and device selection, proper planning and
image guidance, and tract ablation can help mitigate most of these
complications.
Compared to PEI, RFA offers a survival benefit, especially for tumors
larger than 2 cm, with higher adverse events rate (4.1% versus 2.7%).
RFA leads to 5-year survival rates of 51%76%. Compared to RFA,
MWA may lead to better outcomes with lower operative times, especially in larger tumors. Comparisons between RFA and resection
have been conflicting, with some randomized trials demonstrating no difference and others favoring resection at the cost of higher
morbidity. Tumor size and location should be considered when
choosing different treatment options.
References
1. European Association for the Study of the Liver. European
Organisation for Research and Treatment of Cancer. EASL-EORTC
clinical practice guidelines: management of hepatocellular
carcinoma. J Hepatol 2012; 56(4): 908943.

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2. Gervais DA, Goldberg SN, Brown DB, Soulen MC, Millward
SF, Rajan DK. Society of Interventional Radiology position
statement on percutaneous radiofrequency ablation for the
treatment of liver tumors. J Vasc Interv Radiol 2009; 20(7) Suppl:
S342S347.
3. Crocetti L, de Baere T, Lencioni R. Quality improvement
guidelines for radiofrequency ablation of liver tumours.
Cardiovasc Intervent Radiol 2010; 33(1): 1117.
4. Livraghi T, Solbiati L, Meloni MF, Gazelle GS, Halpern EF,
Goldberg SN. Treatment of focal liver tumors with percutaneous
radio-frequency ablation: complications encountered in a
multicenter study. Radiology 2003; 226(2): 441451.
5. Shiina S, Teratani T, Obi S et al. A randomized controlled trial
of radiofrequency ablation with ethanol injection for small
hepatocellular carcinoma. Gastroenterology 2005; 129(1):
122130.
6. Lencioni R, Cioni D, Crocetti L et al. Early-stage hepatocellular
carcinoma in patients with cirrhosis: long-term results of
percutaneous image-guided radiofrequency ablation.
Radiology 2005; 234(3): 961967.
7. Orlando A, Leandro G, Olivo M, Andriulli A, Cottone M.
Radiofrequency thermal ablation vs. percutaneous ethanol
injection for small hepatocellular carcinoma in cirrhosis:
meta-analysis of randomized controlled trials. Am J
Gastroenterol 2009; 104(2): 514524.
8. Cho YK, Kim JK, Kim MY, Rhim H, Han JK. Systematic review of
randomized trials for hepatocellular carcinoma treated with
percutaneous ablation therapies. Hepatology 2009; 49 (2):
453459.
9. Lu DS, Yu NC, Raman SS et al. Radiofrequency ablation of
hepatocellular carcinoma: treatment success as defined by
histologic examination of the explanted liver. Radiology 2005;
234(3): 954960.
10. Groeschl RT, Pilgrim CH, Hanna EM et al. Microwave ablation for
hepatic malignancies: a multiinstitutional analysis. Ann Surg
2014; 259(6): 11951200.
11. Cannon R, Ellis S, Hayes D, Narayanan G, Martin RC. Safety
and early efficacy of irreversible electroporation for hepatic
tumors in proximity to vital structures. J Surg Oncol 2013; 107(5):
544549.
12. Sche er HJ, Nielsen K, de Jong MC et al. Irreversible
electroporation for nonthermal tumor ablation in the clinical
setting: a systematic review of safety and e cacy. J Vasc Interv
Radiol 2014; 25(7): 9971011.
13. Dunne RM, Shyn PB, Sung JC et al. Percutaneous treatment
of hepatocellular carcinoma in patients with cirrhosis: a
comparison of the safety of cryoablation and radiofrequency
ablation. Eur J Radiol 2014; 83(4): 632638.
14. Wang JH, Wang CC, Hung CH, Chen CL, Lu SN. Survival
comparison between surgical resection and radiofrequency
ablation for patients in BCLC very early/early stage
hepatocellular carcinoma. J Hepatol. 2012; 56(2): 412218.
15. Tohme S, Geller DA, Cardinal JS, et al. Radiofrequency ablation
compared to resection in early-stage hepatocellular carcinoma.
HPB (Oxford). 2013; 15(3): 210217.
16. Jiang L, Yan L, Wen T, et al. Comparison of outcomes of hepatic
resection and radiofrequency ablation for hepatocellular
carcinoma patients with multifocal tumors meeting the
Barcelona-clinic liver cancer stage a classification. J Am Coll
Surg. 2015; 221(5): 951961.
17. Liu PH, Hsu CY, Lee YH, et al. When to perform surgical resection
or radiofrequency ablation for early hepatocellular carcinoma?:
a nomogram-guided treatment strategy. Medicine (Baltimore).
2015; 94(43): e1808.

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18. Fu C, Liu N, Deng Q, Li X, Ma K, Bie P. Radiofrequency ablation

vs. surgical resection on the treatment of patients with small
hepatocellular carcinoma: a system review and meta-analysis of
five randomized controlled trials. Hepatogastroenterology. 2014;
61(134): 17221729.
19. Wang Y, Luo Q, Li Y, Deng S, Wei S, Li X. Radiofrequency ablation
versus hepatic resection for small hepatocellular carcinomas: a
meta-analysis of randomized and nonrandomized controlled
trials. PLoS One. 2014; 9(1): e84484.
20. Wang Y, Luo Q, Li Y, Deng S, Li X, Wei S. A systematic assessment
of the quality of systematic reviews/meta-analyses in
radiofrequency ablation versus hepatic resection for small
hepatocellular carcinoma. J Evid Based Med. 2014; 7(2): 103120.
21. Chinnaratha MA, Chuang MY, Fraser RJ, Woodman RJ, Wigg
AJ. Percutaneous thermal ablation for primary hepatocellular
carcinoma: A systematic review and meta-analysis.
J Gastroenterol Hepatol. 2016; 31(2): 294301.
22. Wang ZL, Liang P, Dong BW, Yu XL, Yu de J. Prognostic factors
and recurrence of small hepatocellular carcinoma after hepatic
resection or microwave ablation: a retrospective study.
J Gastrointest Surg. 2008; 12(2): 327337.
23. Clinical Interventional Oncology - Expert Consult. Stephen T Kee,
MD, David C Madoff, MD and Ravi Murthy, MD, FACP. Saunders.
24. Interventional Oncology (Practical Guides in Interventional
Radiology). Suvranu Ganguli, Ripal. T. Gandhi, Salomo Faintuch.
Thieme.
25. Chinnaratha MA, Chuang MY, Fraser RJ, Woodman RJ, Wigg
AJ. Percutaneous thermal ablation for primary hepatocellular
carcinoma: A systematic review and meta-analysis.
J Gastroenterol Hepatol. 2016; 31(2): 294301.
26. Weis S, Franke A, Mssner J, Jakobsen JC, Schoppmeyer K.
Radiofrequency (thermal) ablation versus no intervention or
other interventions for hepatocellular carcinoma. Cochrane
Database Syst Rev. 2013; 12: CD003046.

901.3
Colorectal metastases: patient selection
W.Prevoo
Radiology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek
Hospital, Amsterdam, Netherlands
Learning Objectives
1. To understand oncological selection criteria for local ablation in
CRC metastases
2. To learn about the optimised staging techniques for CRC
metastases
3. To understand prognostic factors limiting the outcome for
thermal ablation of CRC metastases
Colorectal liver metastases (CRLM) occur in 50% of patients with
colorectal cancer. Only a minority (10%25%) can be treated by surgical resection. Although reviews and meta-analysis have not provided clear recommendations for the clinical application of thermal
ablation in CRLM, minimally invasive image-guided thermal ablation
is an accepted treatment tool to improve patient survival in unresectable oligometastatic CRLM. Patients with limited hepatic and
pulmonary colorectal metastatic disease may also qualify for percutaneous treatment if extrahepatic disease is deemed curable.
Laparoscopically and percutaneously image-guided thermal ablation is performed in open procedures in combination with surgical
resection. To achieve the best outcome for the patient, secure selection is mandatory.
Furthermore, standardised patient selection and treatment procedures may contribute towards thermal ablation becoming a solid
and valuable treatment option for patients with CRLM at some stage
in their disease.

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Patient selection and treatment options depend on certain recommendations that will be discussed during presentation:
1. ASA and Fong Clinical Risk Score (CRS)
2. Patient choice
3. Combination of surgical resection and intraoperative ablation
4. (Neo)adjuvant Chemotherapy, SIRT
5. Tumour size, number, volume and location
6. Optimal ablation technology
7. Optimal peri-procedural imaging, guidance and monitoring
8. Follow-up
9. Test-of-time approach
10. Role of MDT
To date, only one RCT has been performed (CLOCC trial). Despite the
long-term results presented last year (ASCO 2015) that showed an
indisputable survival benefit using RFA plus chemo over that using
chemo alone (8-year OS 36% vs. 8%), a new RCT is very difficult to
perform because of the vested interests of surgeons and oncologists, evolving technologies and strategies. Also, difficulties in randomisation and crossover are difficulties in design.
Future design of RCTs, however, should focus on a non-inferiority
study comparing thermal ablation and hepatic resection in patients
with at least one resectable and ablatable CRLM (3cm) and no or
limited extrahepatic disease. Primary endpoint: OS. Secondary endpoints: DFS, procedural morbidity and mortality, hospital stay, QoL
and costbenefit analysis.
Thermal ablation is a widely, but not completely, accepted treatment option for patients with CRLM. Well-selected patients who will
benefit most of ablation treatment with good results will contribute
to convince other oncology disciplines to accept thermal ablation as
part of management of patients with unresectable CRLM.
References
1. Adson MA. Resection of liver metastases--when is it worthwhile?
World J Surg. 1987 Aug;11(4):511-20.
2. van Amerongen MJ, van der Stok EP, Ftterer JJ, Jenniskens SF,
Moelker A, Grnhagen DJ, Verhoef C, de Wilt JH. Short term and
long term results of patients with colorectal liver metastases
undergoing surgery with or without radiofrequency ablation.
Eur J Surg Oncol. 2016 Apr;42(4):523-30.
3. Hompes D, Prevoo W, Ruers T. Radiofrequency ablation as a
treatment tool for liver metastases of colorectal origin. Cancer
Imaging. 2011 Mar;11:23-30.
4. Livraghi T, Solbiati L, Meloni F, Ierace T, Goldberg SN, Gazelle
GS. Percutaneous radiofrequency ablation of liver metastases in
potential candidates for resection: the test-of-time approach.
Cancer. 2003 Jun;97(12):3027-35.
5. Gillams A, Goldberg N, Ahmed M, Bale R, Breen D, Callstrom
M, Chen MH, Choi BI, de Baere T, Dupuy D, Gangi A, Gervais D,
Helmberger T, Jung EM, Lee F, Lencioni R, Liang P, Livraghi T, Lu
D, Meloni F, Pereira P, Piscaglia F, Rhim H, Salem R, Sofocleous
C, Solomon SB, Soulen M, Tanaka M, Vogl T, Wood B, Solbiati L.
Thermal ablation of colorectal liver metastases: a position paper
by an international panel of ablation experts, The Interventional
Oncology Sans Frontires meeting 2013. Eur Radiol. 2015
Dec;25(12):3438-54.
6. Solbiati L, Ahmed M, Cova L, Ierace T, Brioschi M, Goldberg SN.
Small liver colorectal metastases treated with percutaneous
radiofrequency ablation: local response rate and long-term
survival with up to 10-year follow-up. Radiology. 2012
Dec;265(3):958-68.
7. Tanis E, Nordlinger B, Mauer M, Sorbye H, van Coevorden F,
Gruenberger T, Schlag PM, Punt CJ, Ledermann J, Ruers TJ. Local
recurrence rates after radiofrequency ablation or resection
of colorectal liver metastases. Analysis of the European
Organisation for Research and Treatment of Cancer #40004 and
#40983. Eur J Cancer. 2014 Mar;50(5):912-9.

Abstract Book

901.4
Colorectal metastases: ablation techniques
R.Bale
Interventional Oncology - Microinvasive Therapy (SIP) Clinic of
Radiology, Medical University Innsbruck, Innsbruck, Austria
Learning Objectives
1. To understand indications, contraindications and device selction
for thermal ablation in CRC metastases
2. To learn how to avoid and manage complications in thermal
ablation of CRC metastases
3. To understand the outcome after thermal ablation of CRC liver
metastases in comparison to resection
Indications and contraindications for thermal ablation of colorectal
liver metastases (CRLM):
Thermal ablation of CRLM is recommended for a tumour size of <3
cm (maximum <5 cm) and 13 lesions (maximum <10). In tumours
close to large blood vessels, careful follow-up is recommended and
repeat treatment may be necessary (1). It is key to three dimensionally achieve an appropriate safety margin of at least 1 cm. Therefore,
intraoperative assessment of the ablation zone, ideally by fusion of
the contrast-enhanced pre- and post-ablation imaging, is required.
The size of lesion that can be successfully treated within one session
depends on the ablation technique (RFA, MW, IRE and single-needle
vs. multi-needle), the guidance technique (conventional US/CT and
guidance vs. sononavigation/stereotaxy/robotic) and operator experience. If the short axis of the ablation zone is 2.5 cm, only lesions up
to 0.5 cm can be treated safely with a single probe position. If larger
tumors are treated with the same device, multiple overlapping ablation zones are required. Using stereotactic multiprobe RFA, even
tumors >10 cm can be safely treated (2).
How to avoid and manage complications:
Major complications of thermal ablation include bile duct injury,
organ injury and bleeding. Tumors located next to major bile ducts
may be avoided or treated by high-flow biliary cooling via nasobiliary tubes or other non-thermal interventional oncology techniques. In tumors located <1 cm to vulnerable structures, displacement from the ablation zone (e.g. using hydro or gas dissection) is
required. A contrast-enhanced imaging immediately after ablation is
recommended in order to exclude organ injury and bleeding. In the
case of arterial extravasation, immediate transarterial embolisation
should be performed.
Outcome after thermal ablation of CRC liver metastases in comparison with that after resection:
Liver resection is still associated with high mortality (up to 5%) and
major morbidity (25%30%) (3). Percutaneous ablation is much less
invasive than resection with major complication rates below 2.5% in
experienced centers (4). Based on the evaluation of 15 studies, each
of them reporting at least a 3-year survival data in a minimum of 50
patients (1), the mean 3-year survival from the date of first thermal
ablation was 50% (37%77%) and the mean 5-year survival was 31%
(17%51%) in a total of 1613 patients. When ablation was applied
to patients with potentially resectable disease, the 5-year survival
increased to 50%, which is comparable to the survival after liver
resection.
References
1. Gillams A, Goldberg N, Ahmed M et al. (2015) Thermal ablation of
colorectal liver metastases: a position paper by an international
panel of ablation experts, the interventional oncology sans
frontires meeting 2013. Eur Radiol: 343854.
2. Bale R, Widmann G, Schullian P, Haidu M, Pall G, Klaus A, Weiss
H, Biebl M, Margreiter R (2012) Percutaneous stereotactic
radiofrequency ablation of colorectal liver metastases. Eur
Radiol: 9307.

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3. Knudsen AR, Kannerup AS, Mortensen FV, Nielsen DT (2009)
Radiofrequency ablation of colorectal liver metastases
downstaged by chemotherapy. Acta Radiol: 71621.
4. Solbiati L, Ahmed M, Cova L, Ierace T, Brioschi M, Goldberg
SN (2012) Small liver colorectal metastases treated with
percutaneous radiofrequency ablation: local response rate and
long-term survival with up to 10-year follow-up. Radiology:
95868.

Special Session
Biopsy: new developments
902.1
Preprocedural work-up including coagulation
M.C.Burgmans
Department of Radiology, Leiden University Medical Center, Leiden,
Netherlands
Learning Objectives
1. To learn about optimal patient assessment prior to biopsy,
including patient education
2. To learn about the appropriate use of safety check lists prior to
biopsy
3. To learn about coagulation requirements prior to biopsy,
including management of the new generation anticoagulant
drugs
Percutaneous image-guided biopsies are associated with low morbidity and mortality rates. Therefore, in the minds of both doctors and patients, biopsies are generally considered to be straightforward, low-risk procedures. Nevertheless, serious complications
such as bleeding, organ perforation and even death may occur.
Care should be taken to ensure that indications are appropriate
and precautions have been taken to avoid complications. Also, sufficient pre-procedural patient information should be provided to
ensure that patients are well aware of the indications and risks of the
procedure.
The indication for a percutaneous biopsy is often determined by
the referring physician, not infrequently without the consultation
of an interventional radiologist. Nevertheless, the interventional
radiologist holds (shared) responsibility over the appropriateness
of the indication. Effective communication between the interventional radiologist and referring physician is essential, especially if the
responsibility to provide patient information and obtain informed
consent is delegated to the team of the referring physician. The
operator must verify that the indication, risks and alternatives are
discussed, documented in the patient records and informed consent has been obtained in accordance to applicable legislation. The
threshold for discussing a procedure on the phone or in a multidisciplinary meeting should be low in cases that are not considered to be
straightforward.
Patient consultation by the interventional radiologist prior to the
procedure offers the best guarantee that patient information is accurate and specific and informed consent is valid (1). Such consultation
should ideally occur at a time and place remote to the biopsy procedure as this will provide time to the patient for thinking about the
provided information and to the doctor for anticipating peri-procedural difficulties such as the patients inability to maintain a certain position or high anxiety (1). Outpatient consultation is best performed in a dedicated interventional clinic, but telephonic consultation may be more practical in non-complex cases. Inpatients are
best assessed during a bedside visit in the days preceding the procedure. A patients understanding of the procedure may be improved
by providing patient information folders and a hospital website with
written and/or visual information about the biopsy procedure.

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Prior to the biopsy procedure, the interventional radiology team

should review the indication, medical history of the patient, all pertinent imaging and laboratory tests, patient instructions to fasten and
stop medication and the order of specific materials, anaesthesiology support or non-standard post-procedural care. This review process is best performed using a checklist, such as the CIRSE IR Patient
Safety Checklist (2). The checklist ensures a rigorous and complete
pre-procedural work-up and can also be used to document that
precautions have been taken to prevent complications. The use of
such a checklist has been proven to reduce errors in surgical as well
as interventional radiology procedures (3). The checklist can also
be used to perform a check just prior to the start of the procedure
(sign-in) and at the end of the procedure (sign-out).
Routine pre-procedural laboratory tests are not required as this has
been proven to be of little value (4). Rather, selective testing should
be performed based on the proposed procedure and age and risk
factors such as comorbidity or use of anticoagulants. Pre-procedural
assessment of the coagulation profile is required in patients if a
patient receives anticoagulation therapy or has known or suspected
risk factors for bleeding (e.g. liver disease, renal failure, thrombocytopenia and disseminated intravascular coagulation). Other laboratory tests may only be mandated in specific cases, i.e. when intravenous administration of iodinated contrast is considered to visualise
vital structures during a CT-guided biopsy.
Stratification of patients into different risk categories may aid in
determining as to how to manage different coagulation parameters
(5). Generally, three different risk categories are recognised: low risk
(i.e. biopsy of a superficial lesion), moderate risk (i.e. biopsy of a retroperitoneal lymph node) and high risk (i.e. renal biopsy). What is
regarded as an acceptable threshold for coagulation parameters in
each category may vary in different institutions, but many hospital
protocols will not differ much from the following recommendations.
It is recommended to correct the international normalised ratio (INR)
to 2.0 in low-risk procedures and to 1.5 in moderate and high-risk
procedures. The threshold for partial thromboplastin time (aPTT) is
1.5 x control for moderate and high-risk procedures. The platelet
count should be corrected when 50,000/mm3 for all categories. It is
important to note that the platelet count reflects the number of circulating platelets but not the platelet function.
In elective cases, withholding warfarin with or without administration of vitamin K is used to correct abnormal INR values. In patients
in whom obtaining a biopsy specimen is more urgent, correction
can be performed using fresh frozen plasma (FFP). aPTT can be corrected by withholding (unfractionated) heparin before the procedure and/or administration of FFP. A low platelet count may be corrected by transfusion of platelet concentrates. The use of aspirin,
clopidogrel or dipyridamole is not an absolute contraindication to
a percutaneous biopsy, but cessation of such platelet-aggregation
inhibitors may be required in high-risk procedures and in patients
using multiple anticoagulant drugs. The half-life of these plateletaggregation inhibitors is relatively long, and therefore, medication
should be stopped at least 5 days before the procedure.
Over recent years, there is an increasing use of so-called newer oral
anti-coagulant drugs (NOADs). The mechanism of action of NOADs is
different from that of coumarin derivatives, which inhibits the activity of the vitamin K-dependent coagulation factors (II, VII, IX and X).
Dabigatran is a direct thrombin inhibitor, and rivaroxaban and apixaban are factor Xa inhibitors. Compared to coumarin derivatives,
NOADs offer the advantages of a wider therapeutic window, no
requirement for monitoring, a lower risk of intracranial bleeding and
stable anticoagulation with little drug and dietary interactions. The
main disadvantage of NOADs is the lack of a known reversal agent.
The half-life of NOADs is relatively short and stopping of medication 48 hours prior to the biopsy procedure is generally sufficient. In
exceptional cases where performing the biopsy is urgent, the procedure should be delayed for at least 12 hours.

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References
1. Lutjeboer J et al. Impact on patient safety and satisfaction
of implementation of an outpatient clinic in interventional
radiology (IPSIPOLI-Study): a quasi-experimental prospective
study. Cardiovasc Intervent Radiol. 2015;38(3):543-51.
2. Lee MJ. Patient safety in interventional radiology: a CIRSE IR
checklist. Cardiovasc Intervent Radiol. 2012;35(2):244-6.
3. Koetser IC et al. A checklist to improve patient safety in
interventional radiology. Cardiovasc Intervent Radiol.
2013;36(2):312-9.
4. Smetana GW et al. The case against routine preoperative
laboratory testing. Med Clin N Am. 2003;87(1):7-40.
5. Patel IJ et al. Consensus guidelines for periprocedural
management of coagulation status and hemostasis risk in
percutanoues image-guided interventions. J Vasc Interv Radiol.
2012;23(6):727-36.

902.2
Optimal biopsy
C.J.Zech
Klinik fr Radiologie und Nuklearmedizin, University Hospital Basel,
Basel, Switzerland
Learning Objectives
1. To learn about different needle types including FNA, histology
needles and co-axial technique
2. To learn about the number of specimens required and
appropriate management of collected specimens
3. To learn about when to do FNA and when to do histology
Percutaneous image-guided biopsies are a frequently used tool to
acquire biological specimens. For the analysis of biopsy specimens,
aspiration specimens for cytological and core biopsies for histopathological work-ups have to be distinguished.
In fine-needle aspiration biopsies (FNAB), usually, thin hollow 18or 20-G needles are used to puncture the lesion or fluid, and then
sampling is done via the aspiration of single cells from a soft tissue lesion or via aspiration of body fluids like ascites or pleural effusion. This method has been evaluated for various body regions, and
in the literature, very high diagnostic accuracy has been described.
The evaluation of cytological specimens needs a deep experience in
the cytopathological lab and surely may vary from center to center.
Moreover, the aspiration of solid lesions may often result in insufficient material. Therefore, many publications with superb results of
FNAB have the cytological lab directly adjacent to the biopsy room,
and the sampling is repeated until a valid specimen is obtained. This
setting for sure may result in an extremely high accuracy paired with
minimal biopsy trauma as compared to core biopsies. A special form
of aspiration biopsies are bone biopsies, wherein a cone-shaped
large bore (>14 G) hollow needle is driven into an osseous lesion and
then withdrawn by slight aspiration. Afterwards, the specimen can
be pushed out reversely from the tip and a large bone core can be
harvested.
In cutting-type core biopsies, a tissue core is harvested with special manual, semi-automatic or automatic biopsy system. To achieve
this, usually, a slightly larger diameter of the needle system is
required (16- or 18-G core biopsy systems). However, with this the
amount of material that is harvested is also higher. Core biopsies are
usually used for soft tissue masses. The cores are fixated in formalin and embedded and stained for histopathological analysis. The
success of the biopsy cannot be immediately evaluated because the
aforementioned procedural steps take some hours. Therefore, many
physicians decide to sample at least two macroscopically good quality cores. On core biopsies, architectural tissue changes can also
be diagnosed. There are different core biopsy systems available. In
daily routine, a lot of biopsies are sampled with side-notch type core
biopsy systems, and end-notch type and vacuum-type core biopsy
systems are used for specific settings.

Abstract Book
For both FNAB and core biopsies the coaxial technique is recommended. For this, a larger bore (e.g. 17 G) outer needle is directly
placed in front of the lesion. Next, a slightly thinner biopsy needle
(e.g. 18 G) is passed through the outer needle and it allows obtaining
multiple biopsies with only one puncture. This will not only reduce
discomfort and procedure time for the patient but also reduce complications like bleeding or pneumothorax (for lung biopsies) and the
risk of needle tract seeding because the biopsy needle ideally only
comes into contact with the potentially malignant lesions and is
later withdrawn through the outer needle.
A general rule pertaining to when to perform FNAB or core biopsies
is not available. FNAB will have fewer complications because of the
smaller needle size and because of the lack of the traumatic mechanism of core sampling. A large study investigating factors for complications showed that needle size and the type of biopsies (aspiration vs. core) had an influence on the bleeding complications [1].
On the other hand, as mentioned before, a full histological diagnosis and ample material for special staining is only available with core
biopsies. Also, if there is no experienced cytopathologist available,
FNAB will not reach the high accuracy as published.
For the appropriate management of the collected specimens, a
good collaboration between the IR physician and the lab is needed.
The required management of the specimen with regard to the container, fixating or hydrating fluids and shipping has to be lined-up
upfront. Moreover, the communication with regard to the clinical
diagnosis, exact location of the sampling point and required special
staining has to be accurately done.
With all these considerations taken into account, percutaneous
image-guided biopsies will be fast, reliable and safe and, thus, a
valuable tool for physicians to obtain biological specimens.
References
1. Mueller et al. Percutaneous ultrasonographically guided liver
punctures: an analysis of 1961 patients over a period of ten years
BMC Gastroenterology 2012, 12:173.

902.3
New techniques in biopsies
L.Tselikas
Interventional Radiology, IGR, Villejuif, France
Learning Objectives
1. To learn about new image-guided techniques for biopsy
2. To learn about applications of fusion imaging to improve biopsy
3. To learn about applications of navigation guidance for biopsy
No abstract available.

902.4
Tricky biopsies
J.Kettenbach
Institute of Medical Radiology, Diagnostic, Intervention, University
Hospital St. Plten/Karl Landsteiner University of Health Science,
St. Plten, Austria
Learning Objectives
1. To learn about alternative routes and approaches for difficult
biopsies
2. To learn tricks and tips for difficult biopsies
3. To learn how to minimise complications when performing
difficult biopsies
Alternative routes and approaches for difficult biopsies:
Patient positioning, use of imaging hardware, alternative access
routes, and procedural techniques can be used to overcome an
obstacle that prevents biopsy of a lesion because of its location or its
inaccessibility due to surrounding organs.

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1) Patient Positioning:
In general, patient positioning should be chosen based on the location of the lesion, size of the lesion, and the patients ability to tolerate positioning.
For lung biopsies, the prone position is preferred because the posterior ribs move less than the anterior ribs; the posterior intercostal spaces are wider than the anterior intercostal spaces; and prone
positioning prevents the patient from visualizing the needle during
the procedure, which may decrease anxiety. The oblique and decubitus positions are less desirable because they are not as stable,
but they can be utilized if necessary for lateral subpleural lesions.
The important factors in choosing an access route include avoiding chest wall vessels such as subclavian, internal mammary, intercostal, and intrapulmonary vessels. It is also important to minimize
pleural transgression by performing a single pleural puncture and
avoiding fissures if possible. Large bullae should also be avoided.
If biopsy is being performed for a lesion of mixed CT attenuation,
biopsy should be targeted toward the solid component of the nodule or mass. Similarly, if there is central necrosis, biopsy should be
directed at the wall of the lesion. Winokur et al and others recommended that subpleural lesions should not be targeted directly, but
a path transgressing some normal lung parenchyma should be chosen. Subpleural nodules are often pushed away by the biopsy needle or trocar, and thus a direct path may result in multiple pleural
punctures. Furthermore, a coaxial technique is often preferred in
order to decrease the number of pleural punctures. However, other
studies showed no difference in complication rates of pneumothorax and pulmonary hemorrhage in cases using an outer cannula
compared with those using a single-pass needle.
Following removal of the needles, it is advantageous to place the
patient in a position with the biopsy side down. Talking, moving,
and coughing should be discouraged to minimize increases in intrathoracic pressure that could result in a pneumothorax.
For a biopsy in the upper abdomen, it can be helpful to place the
patient ipsilateral side down during the procedure. Thus, the dependent lung becomes deflated, which decreases the risk of transgressing the lung, thus reducing the risk of pneumothorax and empyema.
It can also cause a lesion to move into a more dependent position
away from the midline and make it more amenable to percutaneous
access. Changing the position of the patient may also move mobile
structures, such as bowel, revealing a suitable approach for percutaneous access.
2) Selection of Imaging Hardware:
Ultrasound (US) allows real-time imaging and multiplanar monitoring of the course of biopsy needles as they transverse tissue planes
along the path to the abscess or lesion. However, US needs an experienced user; puncture needles attached to a guiding tool, a navigation device, or a robot may facilitate precise needle placement.
Computed tomography (CT) allows accurate visualization of all
kind of tissues, including bone and air-filled areas. For biopsies on
deep-seated lesions, in fatty liver disease, or the presence of adjacent bowel or bone may make sonographic guidance difficult, CT
guidance is highly recommended. Using CT fluoroscopy and angled
gantry are useful tools for difficult CT-guided biopsies. Compared
with conventional CT, CT fluoroscopy is faster and requires fewer
needle passes, resulting in up to 27% shorter procedure times in
lung biopsies. CT fluoroscopy has also been associated with fewer
complications compared with conventional CT, predominantly due
to shorter procedure times and fewer needles passes resulting into a
lower pneumothorax rate. However, CT fluoroscopy results in significantly increased radiation doses to both the patient and the radiologist, which may limit its widespread adoption. The amount of radiation doses, however, can be minimized by using the quick check
method of CT fluoroscopy, most commonly used today.
Magnetic resonance tomography (MRT) may be used in lesion
that requires a significant lesion-to-tissue contrast to be visualized such as brain tumors, breast, liver tumors, prostate, and soft

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tissue sarcomas. MR-guided biopsies require dedicated hardware,

MR-compatible biopsy devices, and some experience handling an
MR scanner for needle visualization. As a non-ionizing radiation
technique, it may also be recommended in biopsies of children.
3) Alternative Access Routes:
(a) To vary the gantry angulation is not well known, but useful
when a proposed access route in the axial plane may cross bowel
or other vital organs. In particular, for subphrenic lesions such as an
adrenal gland tumor or a liver lesion in segment VII, VII, IV, and II, the
main difficulty in biopsy is the risk of pleural transgression, which
can result in pneumothorax, pleural effusion, or empyema. To puncture a lesion in the upper abdomen (e.g., pancreas tumor) or in the
lower abdomen (e.g., enlarged intestinal, pelvic, or retroperitoneal
lymph node) can also pose a challenge for percutaneous access due
to the central location of the lesion surrounded by the intestine and/
or the bony pelvis. Angling the gantry in a cranial or caudal direction can usually open a direct route to the lesion that avoids vital
organs. By knowing the gantry angle, the operator can easily adjust
the angle of the localizing needle.
(b) Transjugular access: the transjugular liver biopsy (TJLBx) is a
well-established, safe, effective, and well-tolerated technique to
obtain liver tissue specimens in patients with diffuse liver disease
associated with severe coagulopathies or massive ascites. Liver biopsies are necessary for diagnosing cirrhosis, acute liver failure, or viral
hepatitis, and for assessing its activity, for determining whether
there is nonalcoholic steatohepatitis (NASH), or, in fulminant hepatitis, for determining the prognosis and providing the indication
for an emergency liver transplant. At present, the main indication
for transjugular liver biopsy is diagnosis of acute alcoholic hepatitis, due to the need for specific corticosteroid treatment and the frequency of hemostatic disorders in this condition. Similarly, just after
a liver transplant, hemostatic disorders are common, so a histological examination is often necessary.
Biopsy via the venous system reduces the risks of bleeding, because
the capsule of Glisson is not perforated. Thus, a TJLBx is almost
always feasible and shows a very low rate of complications. In addition, if bleeding does occur, it returns directly into the venous system rather than into the peritoneum. Indications for transjugular
liver biopsy in general result from contraindications to percutaneous
biopsy and include a prothrombin level lower than 50 or 60% of normal values depending on local policies, a platelet count of less than
60,000/mL, abundant ascites, the need to measure the pressures
in the hepatic vein, right atria, and inferior vena cava as well as the
intraportal pressure (wedge or precapillary pressure), or an anticoagulant or antiplatelet aggregation treatment that cannot be interrupted. Some authors include other indications even if there is no
coagulation abnormality or ascites, such as previously failed percutaneous biopsy, morbid obesity, an atrophic liver, suspected amyloidosis, a cardiac liver, hemodialysis and chronic renal insufficiency,
peliosis hepatis, and hereditary hemorrhagic telangiectasia, which
all increase the risk of hemorrhage.
A TJLBx is generally contraindicated or not feasible if there is thrombosis of the right internal jugular vein. In this case, there are alternative approaches suggested by certain authors, such as via the right
external jugular vein, the left internal jugular vein, or the femoral
vein. However, these approaches are riskier than the conventional
route and should be performed by very experienced interventional
radiologists and used only as a last resort. Other contraindications
for transjugular liver biopsy include thrombosis of the hepatic veins,
hydatid cyst, cholangitis, and the absence of cooperation from the
patient.
The use of ultrasonographic guidance for percutaneous puncture
of the right internal jugular vein is recommended to decrease the
incidence of local cervical minor complications. Semi-automated
biopsy devices are very effective in obtaining optimal tissue samples
for a precise and definite histological diagnosis. The relative limitations of TJLBx are the slightly higher procedural costs as compared

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to a regular liver biopsy, the radiation dose given to the patient, the
increased procedure time by comparison with the more common
percutaneous liver biopsy, and the need of a well-trained interventional radiologist.
Although, in general, percutaneous kidney biopsy is considered
to be relatively safe, it is associated with a higher risk of complications in the patients with (1) an inability to cooperate with the procedure, (2) bleeding disorders, (3) severe hypertension, (4) a solitary
or horseshoe kidney, (5) morbid obesity, and (6) end-stage renal disease or bilaterally small kidneys.
Such high-risk biopsy candidates are encountered more frequently
due to the increasing prevalence of liver and kidney disease due to
hepatitis C, an aging population with associated comorbidity, and
the more widespread use of anticoagulant and antiplatelet drugs.
Also, the incidence of subclinical perirenal hematoma may be as
high as 57% to 85%. An open biopsy is an alternative to closed percutaneous biopsy but requires a general anesthetic with attendant
morbidity and mortality and is rarely justified. Thus, a transjugular kidney biopsy (TJKBx) offers an attractive alternative for the following reasons: first, the needle is passed through the vein wall into
the surrounding parenchyma, being directed away from the larger
blood vessels.
Therefore, any bleeding that occurs should drain directly back into
the vein, thereby limiting extravascular blood loss. If a capsular perforation occurs and is associated with significant extravasation, elective coil embolization of the biopsy tracks may be performed during the same procedure. Whereas previous studies have documented the feasibility of TJKBx using a modified Colapinto aspiration biopsy needle, the use of the Quick-core transvenous side-cut
biopsy needle system has been recently recommended. This needle
has a smaller diameter, allowing deeper placement and thus more
peripheral cortical sampling. In addition, fewer passes are required
to obtain sufficient tissue and the excessive fragmentation associated with the aspiration biopsy needle is avoided. There is, however,
a higher incidence of capsular perforation.
(d) Traversing organs: In some cases, traversing an intervening
organ such as the liver, stomach, rectum, and vagina is considered
to be safe. For instance, the stomach is most commonly traversed for
both percutaneous biopsy of pancreatic lesions and percutaneous
drainage of fluid collections associated with pancreatitis.
Occasionally even traversing the duodenum or the small intestine
can be helpful; however, smaller diameter of the biopsy needles (<19
G) may be then recommended. In any case, an underlying disease
or recent surgery must be considered when choosing a transrectal
or transvaginal route in order to avoid enterorectal and enterovaginal fistulas.
4) Procedural techniques:
The use of organ displacement with 0.9% saline solution (hydrodissection) for placement of drainage catheter can be used for percutaneous biopsy as well. Variations in this technique have previously
been described to displace structures away from renal tumors targeted for radiofrequency ablation.
Moderate sedation is preferred during percutaneous access when
crossing the pleural or the peritoneum during lung and liver biopsy.
This allows the patient to lie motionless during the procedure and
have regular respirations. Sedation can also be useful for patient
anxiety and for younger patients who often have difficulty lying
still due to pain. A balance must be reached when using sedatives
because oversedation can result in irregular respiration increasing
the difficulty of the biopsy. Intravenous midazolam and fentanyl are
most commonly used for providing sedation.
Following removal of the biopsy needle, numerous techniques have
been described in regard to sealing the biopsy tract, one of which is
creating a blood patch with autologous venous blood. Others may
use gelatin foam plugs mixed with contrast, injected through the
outer puncture cannula, in coaxial biopsies to prevent bleeding or
tumor cell seeding along the biopsy tract.

Abstract Book
Conclusion
Percutaneous image-guided biopsies are safe, effective, and widely
used to obtain tissue samples for further histologic or microbiologic
evaluation. Appropriate preprocedural planning, patient preparation, and adherence to strict procedural routine can minimize the
risks associated with biopsy.
References
1. Arellano RS, Gervais DA, Mueller PR. CT-guided drainage
of abdominal abscesses: hydrodissection to create access
routes for percutaneous drainage. AJR Am J Roentgenol.
2011;196(1):189-91.
2. Chen EA, Neeman Z, Lee FT, Kam A, Wood B. Thermal protection
with 5% dextrose solution blanket during radiofrequency
ablation. Cardiovasc Intervent Radiol. 2006;29(6):1093-109.
3. Daly B, Krebs TL, Wong-You-Cheong JJ, Wang SS. Percutaneous
abdominal and pelvic interventional procedures using CT
fluoroscopy guidance. AJR Am J Roentgenol. 1999;173(3):637-44.
4. Daren Subar, Ali Khan and Derek OReilly (2011). Complications
of Liver Biopsy, Liver Biopsy, Dr Hirokazu Takahashi (Ed.),
ISBN: 978-953-307-644-7, InTech, Available from: http://www.
intechopen.com/books/liverbiopsy/complications-of-liverbiopsy-2.
5. Dohan A, Guerrache Y, Boudiaf M, Gavini JP, Kaci R, Soyer P.
Transjugular liver biopsy: indications, technique and results.
Diagn Interv Imaging. 2014;95(1):11-5.
6. Garnon J, Ramamurthy N, Caudrelier J J, Erceg G, Breton E,
Tsoumakidou G, Rao P, Gangi A. MRI-guided percutaneous
biopsy of mediastinal masses using a large bore magnet:
technical feasibility. Cardiovasc Intervent Radiol. 2015 Nov 24.
[Epub ahead of print]
7. Gupta S, Nguyen HL, Morello FA Jr, Ahrar K, Wallace MJ, Madoff
DC, Murthy R, Hicks ME. Various approaches for CT-guided
percutaneous biopsy of deep pelvic lesions: anatomic and
technical considerations. Radiographics. 2004;24(1):175-89.
8. Hata N, Jinzaki M, Kacher D, Cormak R, Gering D, Nabavi A,
Silverman SG, DAmico AV, Kikinis R, Jolesz FA, Tempany CM.
MR imaging-guided prostate biopsy with surgical navigation
software: device validation and feasibility. Radiology.
2001;220(1):263-8.
9. Kettenbach J, Blum M, El-RaBadi K, Langenberger H, Happel B,
Berger J, Ba-Ssalamah A. [Percutaneous liver biopsy. Overview of
different techniques]. Radiologe. 2005;45(1):44-54.
10. Kettenbach J, Kacher DF, Koskinen SK, Silverman SG, Nabavi A,
Gering D, Tempany CM, Schwartz RB, Kikinis R, Black PM, Jolesz
FA. Interventional and intraoperative magnetic resonance
imaging. Annu Rev Biomed Eng. 2000;2:661-90.
11. Kettenbach J, Kronreif G. Robotic systems for percutaneous
needle-guided interventions. Minim Invasive Ther Allied
Technol. 2015;24(1):45-53.
12. Kim GR, Hur J, Lee SM, et al. CT fluoroscopy-guided lung biopsy
versus conventional CT-guided lung biopsy: a prospective
controlled study to assess radiation doses and diagnostic
performance. Eur Radiol 2011;21(2):232-9.
13. Kim KW, Kim MJ, Kim HC, Park SH, Kim SY, Park MS et al. Value of
patent track sign on doppler sonography after percutaneous
liver biopsy in detection of postbiopsy bleeding: A prospective
study in 352 patients. AJR Am J Roentgenol. 2007;189:109-16.
14. Marchetto BE, Meglin AJ, Chiricosta FM, Temo JA, Duhan JL:
Transvenous renal biopsy in an ex vivo swine kidney model:
Comparison of five devices. J Vasc Interv Radiol. 1997;8:831-4.
15. McDermott S, Levis DA, Arellano RS. Approaches to the difficult
drainage and biopsy. Semin Intervent Radiol. 2012;29(4):256-63.
16. Schmidt AJ, Kee ST, Sze DY, Daniel BL, Razavi MK, Semba
CP, Dake MD. Diagnostic yield of MR-guided liver biopsies
compared with CT- and US-guidedliver biopsies. J Vasc Interv
Radiol. 1999;10(10):1323-9.

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17. Thompson BC, Kingdon E, Johnston M, Tibballs J, Watkinson
A, Jarmulowicz M, Burns A, Sweny P, Wheeler DC. Transjugular
kidney biopsy. Am J Kidney Dis. 2004;43(4):651-62.
18. Tombesi P, Postorivo S, Catellani M, Tassinari D, Abbasciano V,
Sartori S. Percutaneous ultrasonography-guided core needle
biopsy of gastrointestinal lesions: whats its actual role in clinical
practice? A retrospective study for safety and effectiveness.
Ultraschall in der Medizin. 2011;32 Suppl 1:S62-7.
19. Winokur RS, Pua BB, Sullivan BW, Madoff DC. Percutaneous lung
biopsy: technique, efficacy, and complications. Semin Intervent
Radiol. 2013;30(2):121-7.
20. Yueh N, Halvorsen RA Jr, Letourneau JG, Crass JR. Gantry tilt
technique for CT-guided biopsy and drainage. J Comput Assist
Tomogr. 1989;13(1):182-4.

Special Session
Calcium burden and treatment solutions in
modern endovascular practice
903.1
Peripheral arterial calcification: mechanism of action,
detection, classification and clinical implications
F.Fanelli
Interventional Radiology Unit, Department of Radiological Sciences,
Sapienza - University of Rome, Rome, Italy
Learning Objectives
1. To learn how to classify calcium distribution in the peripheral
artery
2. To learn about the physiopathology of calcified peripheral
lesions
3. To learn about the new studies on the role of calcium in
peripheral arterial disease
Vascular calcification, traditionally called ossification of the arteries,
is still the topic of continued research.
Chronic kidney disease and diabetes mellitus are the main causes of
vascular calcification, which is essentially progressive accumulation
of calcium and phosphate within the arteries with mineral deposits
both in the intima and media layer of the vessel wall.
Besides the vascular bed, where calcium is responsible for the atherosclerotic disease, it can accumulate in other organs such as the
spleen, liver and kidney.
Vascular calcification is the pathologic response to toxic stimuli
involving metabolic substances and/or inflammatory cells. Similar
to the process of bone formation, there is a complex, intracellular
molecular process that includes the differentiation of macrophages
and vascular smooth muscle cells into osteoclast-like cells.
The alterations in serum calcium and phosphate levels, in concert
with the oxidative stress caused by locally generated hydrogen peroxide (H2O2), promote the differentiation of smooth muscle cells in
the vascular wall to the anosteogenic phenotype. These alterations
are also associated with a significant loss of endogenous smooth
muscle cell calcification inhibitors (e.g. matrixGlaprotein, a calciumbinding protein involved in bone formation, pyrophosphate and the
inducible inhibitor osteopontin) and circulating inhibitors such as
fetuin-A.
Vascular calcifications are divided into intimal and medial
(Monckebergs medial sclerosis). Intimal calcification is associated with atherosclerotic plaques and thought to result from modified lipid accumulation, pro-inflammatory cytokines and apoptosis within the plaque that induces osteogenic cell differentiation.
The most accredited function of intimal calcification is to isolate and
interrupt the progress of an abnormal cellular process, thereby protecting the healthy adjacent intima.

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Medial calcification is considered to be more widespread in the

lower abdominal region, associated with peripheral arterial disease
and resulting from the osteogenic differentiation of smooth muscle
cells within the medial layer of the vessel wall.
Although medial calcification is generally not linked to luminal
obstruction, the decrease in the arterial vessel of wall elasticity
and compliance can ultimately lead to atherosclerosis and reduced
perfusion.
Different non-invasive methods can be used to detect the presence
of vessel calcifications, such as CT angiography, ultrasound colour
Doppler and plain X-ray.
Obviously, none of these methods can perform accurate differentiation between intimal and medial calcification.
Intravascular ultrasound (IVUS) can be considered to be the method
of choice for calcium evaluation. Moreover, the use of virtual histology (VH, Volcano Co) facilitates the definition of the amount of calcium and its distribution.
Calcium deposition a well-known complication during endovascular procedures because it is underdiagnosed and underestimated
in angiography. It makes a vessel resistant to dilatation and subject
to recoil and embolism and is dramatically responsible for the incidence and entity of dissections. Infact, 71% of flow-limiting dissections occur within a calcified vessel because the presence of calcium
reduces the arterial wall elasticity so much that it cannot be compliant when a balloon is inflated. This problem is gained increasing
attention at present with the introduction of drug-coated balloons
(DCB) when an optimal PTA is required to reduce the number of
stents implanted. In 2008, Raman et al. reported their experience in
the evaluation and quantification of vessel calcification using multidetector CT in combination with a specific algorithm. The evaluation
of vessel calcification plays a very important role when planning an
endovascular procedure, particularly after the introduction of DCB.
Several methods have been proposed to assess and quantify vascular calcifications in the coronaries, but just a few methods are available at present for peripheral application.
Our method is based on the evaluation of the calcified portion of
the vessel using CT angiography (axial plane) and digital subtraction
angiography (DSA). The accuracy of this technique has been confirmed by IVUS.
CT allows accurate evaluation of the circumferential distribution
of calcium, while DSA is useful to assess the length of non-straight
peripheral vessels.
Another method was proposed by Rocha-Singh et al. who introduced the proposed peripheral arterial calcification scoring system
(PACSS) classification. Intimal and medial vessel wall calcifications at
the target lesion site were assessed by high-intensity fluoroscopy,
and DSA was evaluated in AP projection. Four different grades were
identified:
Grade 0: No visible calcium at the target lesion site
Grade 1: unilateral calcification < 5 cm; a) intimal calcification; b)
medical calcification; c) mixed type
Grade 2: unilateral calcification 5 cm; a) intimal calcification; b)
medical calcification; c) mixed type
Grade 3: bilateral calcification < 5 cm; a) intimal calcification; b) medical calcification; c) mixed type
Grade 4: bilateral calcification 5 cm; a) intimal calcification; b) medical calcification; c) mixed type
In the era of drug elution, calcium is still indicated as a potential barrier to optimal drug absorption after the use of DCB. In particular, circumferential distribution seems to be a strong predictor of patency
loss in comparison with longitudinal extension .All this has made primary stenting the preferred strategy in these settings. Nonetheless,
once the stent is deployed, calcium continues to pose further challenges with the risk of mal-apposition and suboptimal expansion
and increased likelihood of stent fractures.
To increase the efficacy of the endovascular technique, vessel preparation with atherectomy or debulking is very promising because

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it can improve vascular remodelling, enhance drug diffusion in the

vessel wall and promote drug effect, thereby reducing stenosis and
improving tissue perfusion with the potential beneficial effect of
increasing walking distance in claudicants, accelerating wound healing and contributing to limb salvage in CLI patients.
References
1. Kashyap VS, Pavkov ML, Bishop PD, Nassoiy SP, Eagleton MJ,
Clair DG, Ouriel K. Angiography underestimates peripheral
atherosclerosis: lumenography revisited. J Endovasc Ther.
2008;15(1):117-25.
2. Fitzgerald PJ, Ports TA, Yock PG. Contribution of localized
calcium deposits to dissection after angioplasty. An
observational study using intravascular ultrasound. Circulation.
1992;86(1):64-70.
3. Fanelli F, Cannavale A, Gazzetti M, Lucatelli P, Wlderk A, Cirelli
C, dAdamo A, Salvatori FM. Calcium burden assessment and
inpact on drug-eluting balloons in peripheral arterial disease.
Cardiovasc Intervent Radiol. 2014;37:898-907.
4. Tepe G, Beschorner U, Ruether C, Fischer I, Pfaffinger P, Noory
E, Zeller T. Drug-eluting balloon therapy for femoropopliteal
occlusive disease: predictors of outcome with a special emphasis
on calcium. J Endovasc Ther. 2015;22(5):727-33.
5. Cioppa A, Stabile E, Popusoi G, Salemme L, Cota L, Pucciarelli
A, Ambrosini V, Sorropago G, Tesorio T, Agresta A, Biamino
G, Rubino P. Combined treatment of heavy calcified femoropopliteal lesions using directional atherectomy and a paclitaxel
coated balloon: One-year single centre clinical results.
Cardiovasc Revasc Med. 2012;13(4):219-23.
6. Roberts D, Niazi K, Miller W, Krishnan P, Gammon R, Schreiber T,
Shammas NW, Clair D; DEFINITIVE Ca++ Investigators. Effective
endovascular treatment of calcified femoropopliteal disease
with directional atherectomy and distal embolic protection: final
results of the DEFINITIVE Ca++ trial. Catheter Cardiovasc Interv.
2014;84(2):236-44.
7. Fonseca A et al. Intravascular Ultrasound Assessment of the
Novel AngioSculpt Scoring Balloon Catheter for the Treatment
of Complex Coronary Lesions. J Invasive Cardiol. 2008:20:21-27.
8. Costa JR, Mintz GS, Carlier SG, et al. Nonrandomized comparison
of coronary stenting under intravascular ultrasound guidance
of direct stenting without predilatation versus conventional
predilatation with a semi-compliant balloon versus predilatation
with a new scoring balloon. Am J Cardiol. 2007;100:812-7.
9. Scheinert D, Peeters P, Bosiers M, OSullivan G, Sultan S,
Gershony G. Results of the multicenter first-in-man study of
a novel scoring balloon catheter for the treatment of infrapopliteal peripheral arterial disease. Catheter Cardiovasc Interv.
2007;70:1034-9.
10. Tepe G, Zeller T, Schnorr B, Claussen CD, Beschorner U, Brechtel
K, Scheller B, Speck U. High-grade, non-flow-limiting dissections
do not negatively impact long-term outcome after paclitaxelcoated balloon angioplasty: an additional analysis from the
THUNDER study. J Endovasc Ther. 2013;20(6):792-800.
11. Rocha-Singh KJ, Zeller T, Jaff MR. Peripheral arterial calcification:
prevalence, mechanism, detection, and clinical implications.
Catheter Cardiovasc Interv. 2014;83:E212-20.
12. Raman R, Raman D, Napel S, Rubin GD. Semiautomated
quantification of the mass and distribution of vascular
calcification with multidetector CT: method and evaluation.
Radiology 2008;247:241-50.

Abstract Book

903.2
Rotational vs. directional vs. orbital vs. photoablation: which
atherectomy for heavy calcified lesions?
U.Teichgrber
Diagnostic and Interventional Radiology, University Hospital Jena,
Jena, Germany
Learning Objectives
1. To learn the technical differences between different types of
atherectomy devices
2. To learn about the debulking technique in vessel preparation
3. To learn about new concepts of combined treatments
No abstract available.

903.3
Scoring balloons: an alternative method for vessel
preparation
E.Blessing
Abteilung Innere Medizin und Angiologie, SRH Klinikum KarlsbadLangensteinbach gGmbH, Karlsbad, Germany
Learning Objectives
1. To learn the technical aspects of scoring balloons
2. To understand the role of scoring balloons in vessel preparation
3. To learn about the role of scoring balloon in combination with
drug-coated balloons in heavily calcified peripheral lesions
Treatment of calcified femoropopliteal lesions remains challenging,
even in the era of drug-eluting balloon angioplasty. Lesion recoil
and dissections after standard angioplasty often require subsequent
stent implantation, which can also prompt negative implications
in heavily calcified lesions. Poorer patency rates in calcified lesions
despite the use of drug-eluting balloons may be due to the limited
penetration depth of the antiproliferative drug in the presence of
vascular calcium deposits.
Preparation of calcified lesions with the AngioSculpt scoring balloon may be a valuable option as either a stand-alone treatment,
followed by drug-eluting balloon angioplasty, or prior subsequent
stent deployment.
A total of 121 calcified femoropopliteal lesions were treated in 101
subsequent patients. Whether treatment was limited to scoring balloon angioplasty only (37.1%) or was followed by drug-eluting balloon inflation (32.3%) or stent deployment (30.6%) was at the discretion of the interventionalist. Patency was evaluated by duplex ultrasound or angiography after 6 and 12 months.
The overall primary patency after 12 months was 81.2% and secondary patency was 91.8%. Patency rates did not differ significantly
between the 3 treatment strategies. Surprisingly, the degree of calcification did not predict patency. High patency rates also translated
into improved clinical outcome in our cohort.
Preparation with the AngioSculpt scoring balloon offers a valuable
treatment option for calcified femoropopliteal lesions.

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903.4
Lithoplasty: last frontier in calcium modulation
A.Holden
Interventional Radiology, Auckland City Hospital, Auckland, New
Zealand
Learning Objectives
1. To learn the principles of lithoplasty
2. To learn the technical aspects of lithoplasty
3. To learn the results and the role of lithoplasty in peripheral
arterial disease
The treatment of vascular calcification remains challenging and is
associated with higher complications, stent use, and poor outcomes.
Although several strategies are available for debulking of vessels
prior to additional treatment, none of them are without tradeoffs.
We studied the Peripheral Lithoplasty Catheter System (Shockwave
Medical, Fremont CA), a lithotripsy-enhanced low-pressure balloon
catheter for calcified peripheral arterial disease (PAD).
DISRUPT PAD 2 is a prospective, multicenter, single-arm study that
enrolled 60 patients with calcified PAD. The primary safety endpoint
was absence of major adverse events at 30 days. The primary effectiveness endpoint was primary patency at 12 months, defined as
<50% restenosis. Secondary effectiveness endpoints included procedural success, defined as <50% residual stenosis with or without
adjunctive PTA therapy, in addition to patency and functional outcomes at 6 months. A subset of the enrolled cases underwent OCT
imaging pre- and post-treatment.
The mean lesion length, percent stenosis, and total occlusions
were 7.6 3.8 cm, 77 13%, and 10.0%, respectively. All lesions
had moderate (51%) or severe (49%) calcification. Lithoplasty treatment resulted in an acute procedural success of 100%, a mean residual stenosis of 24 6%, and an acute gain of 3.0 mm. There was
one major adverse event at 30 days. Minor dissections occurred in
16%, and only one stent was placed. Six-month patency and functional outcomes will be available at presentation. Additional analysis of OCT images may provide insight into changes in vascular calcium burden.
In this study, lithoplasty had a favorable safety profile, with no major
vascular complications. Acute gain was excellent without a need for
significant stent use and should lead to higher patency than traditional therapies for this difficult-to-treat patient population.

Special Session Controversy

Controversies in new fields of embolisation
904.1
Bariatric embolisation: con
P.Vorwald, M.Posada, G.Salcedo
Gastroesophageal surgery, Fundacin Jimnez Diaz, Madrid, Spain
Learning Objectives
1. To learn which patients should be avoided
2. To learn about the biggest danger
3. To learn about the evidence
Characteristics of the ideal bariatric procedure are discussed. From a
surgical point of view, the Roux-en-Y laparoscopic bypass (RYLGB) is
actually the gold standard procedure, but sleeve gastrectomy (SG) is
gaining importance.
RYLGB and SG are extensively audited in large databases.
The 30-day mortality is between 0.1% and 0.5% for both procedures;
the 1-year morbidity ranges between 14.9% for RYLGB and 10.8% for
SG and weight loss outcomes are excellent for both procedures: the
3-year median percentual excess weight loss (%EWL) was between

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60% and 46% (1, 2). The actual discussion is whether patients should
be sleeved or not; data of actual meta-analysis are provided (3, 4).
At the moment, only long-term data (>10 years follow-up) are available for RYLGB and not for SG (1).
Animal (5, 9), retrospective (6, 7, 9) and prospective human studies
(8, 9) dealing with gastric artery embolisation (GAE) converge at the
following:
very low case load
modest weight loss
non-durable weight loss effect
concerns about safety before RYLGB and SG
Future directions of GAE are discussed:
bridging of obese cirrhotic patients for liver transplantation (10)
other embolisation techniques (EMBARGO) (11)
future role for obese patients with classic contraindications for
surgery
References
1. Schachter L et al. Respiratory assessment and management in
bariatric surgery. Respirology 2012; 17: 1039-1047.
2. Coleman KJ et al. Three year weight outcomes from a bariatric
surgery registry in a large integrated healthcare system. Surg
Obes Relat Dis 2014; 10: 396-404.
3. van Rutte PWJ et al. To sleeve or NOT to sleeve in bariatric
surgery? ISRN Surg 2012; 1-5.
4. Li J et al. Laparoscopic Roux-en-Y-gastric bypass versus
laparoscopic sleeve gastrectomy to treat morbid obesity-related
comorbidities: a systematic review and meta-analysis. Obes Surg
2016; 26: 429-42.
5. Wolf M et al. Gastric embolization to treat obesity. Endovascular
Today 2014: 65-70.
6. Gunn AJ et al. A preliminary observation of weight loss following
left gastric artery embolization in humans. J Obes 2014; 1-4.
7. Anton K et al. Weight loss following left gastric artery
embolization in a human population without malignancy: a
retrospective review. J Obes Weight Loss Ther 2015; 5: 1-4.
8. Syed MI et al. Bariatric embolization: Does it carry any weight?
Applied Radiology 2016: 30-32.
9. Weiss CR et al. Bariatric embolization of the gastric arteries for
the treatment of obesity. J Vasc Interv Radiol 2015; 26: 613-624.
10. Salsamendi J et al. Minimally invasive percutaneous
endovascular therapies in the management of complications
of non alcoholic fatty liver disease (NAFLD): A case report.
Radiology Case 9: 36-43.
11. Diana M et al. Embolization of Arterial Gastric Supply in Obesity
(EMBARGO): an endovascular approach in the management of
morbid obesity: proof of the concept in the porcine model. Obes
Surg 2015; 25: 550-558.

904.2
Bariatric embolisation: pro
C.R.Weiss
The Russell H. Morgan Department of Radiology and Radiologic
Science, Johns Hopkins University School of Medicine, Baltimore, MD,
United States of America
Learning Objectives
1. To learn which patients fit best
2. To learn about the greatest potential
3. To learn about the evidence
Bariatric arterial embolization (BAE) is a new endovascular procedure developed for the treatment of obesity. This procedure has
shown great promise both in animal studies and in early human trials. In fact, current clinical trial data demonstrates that BAE is safe in
severely obese patients and that it appears to promote weight loss
with associated appetite suppression. In this presentation, we will

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review the hypothesized mechanism of action of BAE, the preclinical data, and the early clinical data. The goal of this presentation will
be to assess the potential utility of BAE in the treatment of the obese
patient.
Learning objectives:
1) Understand the metabolic function of the stomach and how bariatric surgery and bariatric embolization alter that function.
2) Understand the supporting preclinical data in favor of BAE.
3) Understand the supporting clinical data for BAE in the obese
patient.
4) Understand future directions/needs in BAE research.

904.3
Haemorrhoid embolisation: con
P.Vavra
Department of Surgical Studies, Faculty of Medicine, University of
Ostrava, Ostrava, Czech Republic
Learning Objectives
1. To learn about best standard options
2. To learn about the biggest danger
3. To learn about the current literature
Haemorrhoids are one of the most common diseases of the gastrointestinal tract (with a prevalence of 43.5%), manifested by rectal bleeding, pain and, in some cases, anaemia. These symptoms are
caused by connective tissue cushions covered by an anastomotic
plexus between the superior rectal artery and rectal veins. The initial
treatment consists of improvement of hygiene and higher dietary
fibre intake. These measures are aimed at improving the overall
state of the anorectal area and less strain during defecation, which
may lead to a complete remission in less severe cases. The employment of local analgesics or corticosteroids is usually not advisable,
even though they may alleviate some of the symptoms, but there is
the possibility of side effects, especially during prolonged therapy.
Some patients may benefit from phlebotonic (flavonoid) medication, especially when combined with higher dietary fibre intake. This
combination is more effective than increased dietary fibre intake
alone or ligation and increased fibre intake combined [1].
In more severe cases, special types of treatment, such as sclerotherapy, cryotherapy, photocoagulation (or similar procedures such
as diathermy or electrotherapy), elastic band ligation or surgery
are often necessary [1,2]. During sclerotherapy, a solution of phenol and quinine or hypertonic salt is injected into the submucosa,
causing thrombosis and sclerosis of the surrounding connective
tissue. It improves the patients status in 90% of the cases, but features a relatively high rate of post-operative complications, including pain (in up to 70%), impotence, abscess or urinary retention [4].
The most common treatment is elastic band ligation, performed
in 44% cases [3]. It can be performed in ambulatory conditions and
even though its recurrence rate is 68% in a 5-year follow-up, they
may be performed repeatedly with satisfactory results [4]. All coagulation techniques (photocoagulation, bipolar diathermy or electrotherapy) rely on coagulating the target site, forming a necrotic area,
which consequently heals with fibrosis. This method is seldom used
as it usually requires repeated applications or additional procedures.
Furthermore, it may often be followed by pain or other complications. Currently, rubber band ligation is considered the best initial
procedure.
Surgical procedures are performed in 10% of cases [5]; the Milligan
and Morgans open haemorrhoidectomy is usually conducted.
During this procedure, ligation of arterial blood supply and hemorrhoidal resection is performed. A circular stapled anopexy [5] is an
alternative invasive approach, which involves the removal of hemorrhoidal tissue by a special circular stapler, followed by a reposition of the remaining tissue. This procedure is minimally invasive as

Abstract Book
it is performed through the anus and features reduced post-operative pain and quicker recovery; however, it may also be followed
by complications, such as urine retention (0.3-22%) or rectal bleeding (4-17%) [3]. Another alternative is an elective transanal Dopplerguided hemorrhoidal artery ligation (DG-HAL), which reduces the
blood flow in the superior rectal artery, thereby reducing the symptoms [6]. The long-term efficacy of this method is reported at up to
92% by several studies.
In 1992, Galkin assumed that an embolisation could be used in the
treatment of haemorrhoids [7]. Embolisation is most frequently used
in the case of lower gastrointestinal bleeding by an interventional
radiologist; however, its role in treating haemorrhoids is still unclear.
From 1994 to 1998, two studies were published showing promising
results with very low recurrence rates [8,9] in treating haemorrhoids.
The development of this new technique, often referred to as emborrhoid, was conducted by Vidal, 2015 [2], showing satisfactory results
in patients who were not suitable for other treatments. However,
several other sources report the occurrence of post-operative complications, including significant anal pain and recurrent bleeding [10].
Unfortunately, there is currently no randomised, prospective, multicentre study, which would reliably compare the DG-HAL with the
emborrhoid technique. The latter is usually considered a better
option for patients, who underwent a proctological surgery in the
past or where no other option is feasible. It may also be helpful in
the early stages of the disease in young patients or during rare massive rectal bleeding, when the rectum is filled with blood. However,
even in these acute cases, it is usually necessary to haemodynamically stabilise the patient first [11].
The emborrhoid procedure may result in post-operative complications, including ischaemia, rebleeding, or temporary painful
oedema, which disappears within 2 weeks [2]. It is always necessary
to perform an embolisation of all arteries connected to the haemorrhoid tissue; this however possesses the danger of ischaemic complications and necrosis. These complications may result in a prolapse
of the haemorrhoid tissue, which needs to be addressed surgically.
Further research in this area is necessary to essentially evaluate the
recommended practices better. The employment of the catheterisation technique may possess the danger of causing pseudoaneurysms of femoral arteries, resulting in the possibility of life-threatening bleeding. Another disadvantage is the exposure to X-ray. The
catheterisation site may be more susceptible to infections, especially
in immunosuppressed patients. These patients would largely benefit from a semi-invasive procedure, such as a haemorrhoid ligation.
The management of hemorrhoids is similar to treating oesophageal
bleeding; it is recommended to manage the bleeding by endoscopic
band ligation or sclerotherapy. A catheterisation technique, the transjugular intrahepatic portosystemic shunt (TIPS), should only be
used for bleeding resistant to other methods of treatment [12].
The emborrhoid procedure raises several questions about the personnel dealing with this technique. Most of the aforementioned
complications require surgical treatment. Furthermore, the indication for these treatments comes from a surgeon a proctologist.
The surgeon prepares the patient for the procedure, obtains medical history, and performs the initial examination. Usually, additional
examinations are necessary, i.e. rectoscopy, anoscopy or coloscopy.
These are also performed by a proctologist. After that, the patient
would have to be transferred to a radiology department to undergo
the haemorrhoid embolisation, possibly returning to the department of surgery for treatment of incurred complications. This would
lead to unnecessary transfers of the patient and management of the
procedure. Considering the possibility of complications and problematic procedure management, the author suggests using noninvasive well-established techniques, preferably the elastic band
ligation, which presents a low probability of complications and may
be safely performed repeatedly.

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References
1. Y.-H. Ho, Tan, M., and Seow-Choen, F., Micronized purified
flavonidic fraction compared favorably with rubber band
ligation and fiber alone in the management of bleeding
hemorrhoids, Diseases of the Colon, vol. 43, no. 1, pp. 66-69,
2000, doi: 10.1007/BF02237246.
2. V. Vidal, Sapoval, M., Sielezneff, Y., De Parades, V., Tradi, F., Louis,
G., Bartoli, J. M., and Pellerin, O., Emborrhoid: A New Concept
for the Treatment of Hemorrhoids with Arterial Embolization,
CardioVascular and Interventional Radiology, vol. 38, no. 1, pp.
72-78, 2015., doi: 10.1007/s00270-014-1017-8.
3. R. Bleday, Pena, J. P., Rothenberger, D. A., Goldberg, S. M., Buls,
J. G., Louis, G., Bartoli, J. M., and Pellerin, O., Symptomatic
hemorrhoids: A New Concept for the Treatment of Hemorrhoids
with Arterial Embolization, Diseases of the Colon, vol. 35, no. 5,
pp. 477-481, 1992., doi: 10.1007/BF02049406.
4. R. D. Madoff, Fleshman, J. W., Rothenberger, D. A., Goldberg, S.
M., Buls, J. G., Louis, G., Bartoli, J. M., and Pellerin, O., American
gastroenterological association technical review on the
diagnosis and treatment of hemorrhoids, Gastroenterology,
vol. 126, no. 5, pp. 1463-1473, 2004., doi: 10.1053/j.
gastro.2004.03.008.
5. A. Longo, 6th world congress of Endoscopy Surgery. Naples:
Mundozzi Editore; 1998. Treatment of haemorrhoidal disease by
reduction of mucosa and haemorrhoidal prolapse with a circular
stapling device: A new procedure; pp. 777-784.
6. V. Vidal, Hemorrhoid Embolization: The Emborrhoid
Technique, Endovascular Today, vol. 14, no. 4, pp. 76-77, 2015.
7. E. V. Galkin, Interventional radiology of chronic hemorrhoid.,
Vestnik Rentgenologii i Radiologii, vol. 4, pp. 52-56, 1998.
8. E. V. Galkin, Iavisia, A. M., and Vdovenko, P. A., Interventional
radiology of chronic hemorrhoids complicated by hemorrhage,
Vestnik Rentgenologii i Radiologii, vol. 5, pp. 21-24, 1998.
9. E. V. Galkin, Gladkov V. V., Zakharchenko A. A., Endovascular
treatment of hemorrhoids, Abstracts of the Nevskij Radiological
Forum, pp. 51-52, 2011.
10. P. G. Tarazov, Arterial Embolization of Hemorrhoids,
CardioVascular and Interventional Radiology, vol. 38, no. 4, pp.
1055-1055, 2015, doi: 10.1007/s00270-015-1148-6.
11. M.I. Syed, Chaudhry, N., Shaikh, A., Morar, K., Mukerjee, K. and
Damallie, E., Catheter-directed middle hemorrhoidal artery
embolization for life-threatening rectal bleeding. Canadian
Journal of Gastroenterology, vol. 21, no. 2, pp. 117-123, 2007.
12. Stent insertion for bleeding oesophageal varices: NICE
interventional procedure guidance, NICE, 2016. [Online].
Available: https://www.nice.org.uk/guidance/ipg392/chapter/1guidance. [Accessed: 11 Mar. 2016].

904.4
Haemorrhoid embolisation: pro
V.Vidal
Service de Radiologie, Hpital Timone Adultes, Marseille, France
Learning Objectives
1. To learn about the appropriate embolisation technique
2. To learn about the greatest potential
3. To learn about the current literature
With a prevalence of 4%35%, haemorrhoids are the most common anorectal condition. One of the main chronic symptoms is rectal beeding. Its recurrence can alter the quality of life and, more
rarely, cause anaemia. Pain is less common, only occurring in the
event of a complication (congestive exacerbation, external haemorrhoidal thrombosis or fissures). The most common treatment
involves hygiene and dietary measures, phlebotonics and/or nonsurgical outpatient treatment (infrared photocoagulation or elastic
band ligation).

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The haemorrhoidal arteriovenous network is a normal vascular formation. There is a clear distinction between the external haemorrhoidal network below the dentate line under the skin of the anal
margin depending on the pudendal artery (branch of the inferior
rectal artery) and the internal haemorrhoidal network located in the
upper part of the anal canal
above the dentate line in the submucosal space depending on the
superior rectal artery. Haemorrhoids have a complex anatomical
structure. This vascular plexus, also known as the anal cushion, has
been described as the corpus cavernosum recti.
Surgical treatment is necessary in 10% of cases. The reference procedure is Milligan and Morgans open haemorrhoidectomy. It consists
of resecting the three haemorrhoidal cushions by ligating their arterial pedicle as high up as possible.
In order to develop a minimally invasive approach, Doppler-guided
haemorrhoidal artery ligation procedure (DG HAL) has been developed as an effective treatment method of haemorrhoids.
This technique includes identification by Doppler and ligation of the
haemorrhoidal arteries, providing a significant reduction of arterial blood flow to the haemorrhoidal cushions using a trans-anal
approach under anaesthesia. The advantage of this technique is
that it maintains the haemorrhoidal tissue in place, preserving anal
continence, with no rectal wounds (no local care), significantly less
pain, and no complications of open surgery, thereby allowing faster
recovery.
Based on the principle of this technique, the Emborrhoid technique has been developed. It includes coil embolisation of the arterial inflow from the distal branches of the inferior mesenteric artery.
Embolisations are performed using the right femoral route. The inferior mesenteric artery is catheterized using a Simmons catheter. The
superior rectal arteries are then catheterized using a microcatheter. Coils used for the embolisation are 0.018, from to 2 to 3 mm in
diameter.
The technical success of the Emborrhoid technique has been
reported to be up to 90%. The clinical success of the Emborrhoid
technique has been reported to be up to 74% to 83%, with no
complications.
There are many benefits of endovascular treatment, including complete visualisation of all the branches of SRAs and anastomoses with
middle and inferior rectal arteries. With DG-HAL, it is possible that
not all arteries are detected, which can lead to incomplete treatment, particularly if there are anastomoses. Embolisation eliminates
the risk of direct anorectal trauma. We believe that rectal bleeding
occurs when the venous haemorrhoidal pressure reaches a certain
threshold. Embolisation may significantly decrease the arterial flow,
leading to a decrease in the venous pressure below this threshold.
Furthermore, the vascularisation via the pudendal artery protects
from ischemic complications as well as probably explains the lack of
total success after embolisation because in some cases, the vascularisation of the haemorrhoidal plexus occur from the pudendal artery.
Coil embolisation of the superior rectal artery branches is an
approach that can provide safe and clinically efficient haemorrhoidal symptom reduction.
References
1. Aigner F, Bodner G, Gruber H, Conrad F, Fritsch H, Margreiter R,
et al. The vascular nature of hemorrhoids. J Gastrointest Surg Off
J Soc Surg Aliment Tract. 2006;10(7):1044-50.
2. De Parades V, Faucheron J-L. [Doppler-guided hemorrhoidal
artery ligation: the new deal of surgical treatment of
hemorrhoids]. Gastroentrologie Clin Biol. 2008;32(6-7):660-3.
3. Vidal V, Louis G, Bartoli JM, Sielezneff I. Embolization of the
hemorrhoidal arteries (the emborrhoid technique): a new
concept and challenge for interventional radiology. Diagn Interv
Imaging. 2014;95(3):307-15.
4. Vidal V, Sapoval M, Sielezneff Y, De Parades V, Tradi F, Louis G, et
al. Emborrhoid: a new concept for the treatment of hemorrhoids
with arterial embolization: the first 14 cases. Cardiovasc
Intervent Radiol. 2014; 38:72-78.

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904.5

Abstract Book

Transradial approach for visceral interventions: con

Fundamental Course
Lung ablation

A.Buecker
Klinik fr Diagnostische und Interventionelle Radiologie,
Universittsklinikum des Saarlandes, Homburg, Germany

1001.1

Learning Objectives
1. To learn about minimising bed-rest
2. To learn about the biggest danger
3. To learn about the current literature
Almost all publications dealing with pros and cons of radial artery
access are from the cardiology literature. Consequently, two major
disadvantages of arterial access are not sufficiently addressed when
considering the arterial access for peripheral or visceral artery interventions. First of all, there is the additional risk of embolism to
the brain, when a guide wire or catheter is unnecessarily moved
through the aortic arch. Larger databases dealing with coronary
angiographies consider this risk to be very low, but it might be an
underestimated complication due to publication bias. The complication rate of access site bleeding has been reported to be lower
for cardiac interventions, when using the radial access. It is unclear
if this advantage holds true also for peripheral interventions.
Furthermore, this reduction of bleeding complications is followed
by a higher number of vessel occlusions. It is usually argued by the
cardiologist that this causes no clinical symptoms and is therefore
of no consequence. However, the lack of two patent radial arteries
might be of high relevance, if the vessel is to be transplanted later in
life. Looking at the disadvantages for the interventionalist, a higher
radiation exposure for radial access compared to the standard femoral approach needs to be mentioned. Given the individual choice
to patients, they might choose the radial access more often despite
the possible long-term disadvantages due to the more comfortable
puncture and compression.

904.6
Transradial approach for visceral interventions: pro
A.Fischman
Radiology and Surgery, Mount Sinai Medical Center, New York, NY,
United States of America
Learning Objectives
1. To learn about appropriate patient selection
2. To learn about the greatest potential
3. To learn about the current literature
No abstract available.

Techniques, imaging guidance and follow-up protocols:

ten-year update
R.Cioni, L.Crocetti
Division of Interventional Radiology, Cisanello University Hospital, Pisa,
Italy
Learning Objectives
1. To learn about techniques for lung tumour ablation,
highlighting similarities and differences
2. To learn how to perfom image-guided lung ablation
3. To learn how to follow up patients after treatment, explaining
common findings after ablation and how to diagnose
persistence/recurrence of disease
Thermal ablative techniques are now being considered in the treatment of primary and secondary lung tumors. Thermal ablative techniques produce irreversible tumor tissue destruction through application of either hot or cold thermal energy. Radiofrequency ablation (RFA) was the first ablative modality to be applied in the treatment of lung tumors. During RFA, molecular friction is created when
an electrical current is delivered to tumor cells surrounding the RFA
probe tip, thus creating a rise in tissue temperature, named the Joule
effect. Tissue surrounding the electrode is heated by electrical conduction. To overcome RFA limitations, i.e., tissue charring decreasing
ablation effectiveness, small volumes of ablation and long procedural time, microwave ablation was subsequently introduced. When
microwave energy is applied to human tissue, water molecules in
the tissue adjacent to the probe tip continuously realign with the
applied field leading to an increase in local tissue temperatures.
Microwave power penetrates tissues of low electric conductivity
such as lung and charred tissue. Finally, cryoablation involves rapid
tumor cooling causing cell death at temperatures around 50C.
This occurs as a result of rapid expansion of argon released from the
ablation probe, named the JouleThompson effect, causing cooling
of the adjacent tissues. Sequential warming and cooling augments
the degree of cellular damage. The ice ball that forms during freezing is visible on computed tomography (CT), allowing the operator
to closely monitor the ablation zone.
All the above-mentioned percutaneous techniques are usually performed under CT guidance. The lesion is localized on CT scans, and
the shortest path that avoids bullae, interlobar fissures, or pulmonary vessels is chosen. Needle advancement can be performed real
time if CT fluoroscopy is used. Special attention must be placed on
verifying the correct placement of the active part of the needle with
respect to the tumor.
In the initial imaging after ablation, the treated nodule always
appears larger than the original tumor size on CT because the ablation zone encompasses a margin around the tumor. Over time, this
ablation zone should decrease in size. Residual disease or recurrence of disease may be present if there is contrast enhancement
in the ablation zone, peripheral nodular growth, or a change within
the ablation zone from ground-glass to solid opacity; increased metabolic activity centrally or in a nodular pattern at the ablation site
on PET-CT more than 3 months after ablation is also suggestive of
recurrence of disease.
References
1. Lencioni R, Crocetti L, Cioni R, et al. Response to radiofrequency
ablation of pulmonary tumours: a prospective, intention-totreat, multicentre clinical trial (the RAPTURE study). Lancet
Oncol. 2008;9(7):621-8.
2. Crocetti L, Lencioni R. Radiofrequency ablation of pulmonary
tumors. Eur J Radiol. 2010;75(1):23-7.

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3. Pereira PL, Masala S; Cardiovascular and Interventional
Radiological Society of Europe (CIRSE). Standards of practice:
guidelines for thermal ablation of primary and secondary lung
tumors. Cardiovasc Intervent Radiol. 2012;35(2):247-54.
4. Alexander ES, Dupuy DE. Lung cancer ablation: technologies
and techniques. Semin Intervent Radiol. 2013;30(2):141-50.
5. Ridge CA, Solomon SB. Percutaneous ablation of colorectal lung
metastases. J Gastrointest Oncol. 2015;6(6):685-92.

1001.2
Indications and results in NSCLC
J.Palussire1, X.Buy1, V.Catena1, F.Chomy2
1Department of Radiology, Institut Bergoni, Bordeaux, France,
2Department of Oncoloy, Institut Bergoni, Bordeaux, France
Learning Objectives
1. To learn how to select patients with NSCLC for ablation
2. To learn about the respective role of ablation and surgery in the
treatment of NSCLC
3. To learn about mid- and long-term results of ablation in the
treatment of NSCLC
For stage I non-small cell lung cancer (NSCLC), a surgical approach
associating lobectomy and lymph node resection remains the firstline treatment and the best option. However, approximately 20% of
patients are ineligible due to existing comorbidities.
Currently, treatments including stereotactic body radiotherapy
(SBRT) or percutaneous image-guided ablation, which includes
radiofrequency ablation (RFA), microwave ablation (MWA), cryoablation (Cryo), are emerging and have been delivering promising
results.
Among methods of ablation, RFA has been the most evaluated, with
a median reported rate of complete ablation of 90%, even if variability exists between publications with a range from 38% to 97% [1].
Most studies on patients with stage I NSCLC have reported lower
efficacy and a statistically lower success rate of ablation with tumors
over 2-3 cm in diameter. Incomplete local treatment was revealed
with recurrence of 10.1% at 1 year and 28% at 2 years [2].
Considering the infiltrative nature of a NSCLC, a key point is to
obtain the largest margins possible. In a pathology study after RFA
on NSCLC [3], even if the thermal lesion completely encompassed
the tumor, margins from the neoplastic lesion appeared shorter (<5
mm) in patients with incomplete ablation than in the patients with
complete ablation (8 mm on average). The ideal ablation for NSCLC
should give an ablation zone with at least an additional 810 mm of
ablation beyond the visible tumor margin in all directions [2].
When using expandable electrode, a systematic oversizing of the
ablation zone relative to the tumor volume may contribute to lower
the percentage of local recurrence (21.1% at 3 years) [4]. An electrode
diameter at least 10 mm larger than the diameter of the target tumor
is a predictor of success, with less than 10% of local recurrence [5].
In this context, the use of MWA may be advantageous, as it offers
improvement in thermal delivery compared to RFA [6]. Cryo is also
an interesting modality with the potential use of multiple probes to
build an ablation volume with sufficient margins. First results with
cryo applied to NSCLC are positive and encouraging [7].
The first publications give an overall survival with RFA of 27% at 5
years; recent publications show improved results, probably due to
better patient selection and improvement of both the technique
and the operators.
However, comparative studies are rare, and the place of each local
therapy remains to be evaluated. As all these techniques are recent,
and long-term comparative studies are warranted.
References
1. Zhu JC, Yan TD, Morris DL. A systematic review of radiofrequency
ablation for lung tumors. Ann Surg Oncol 2008;15:1765-74.

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2. Beland MD, Wasser EJ, Mayo-Smith WW, et al. Primary

non-small cell lung cancer: review of frequency, location, and
time of recurrence after radiofrequency ablation. Radiology
2010;254:301-7.
3. Ambrogi MC, Fontanini G, Cioni R, et al. Biologic effects of
radiofrequency thermal ablation on non-small cell lung cancer:
results of a pilot study. J Thorac Cardiovasc Surg 2006;131:1002-6.
4. Palussiere J, Lagarde P, Auperin A, et al. Percutaneous lung
thermal ablation of non-surgical clinical N0 non-small cell lung
cancer: results of eight years experience in 87 patients from two
centers. Cardiovasc Intervent Radiol 2015;38:160-6.
5. Ihara H, Gobara H, Hiraki T, et al. Radiofrequency ablation of
lung tumors using a multitined expandable electrode: impact of
the electrode array diameter on local tumor progression. J Vasc
Interv Radiol 2016;27:87-95.
6. Planche O, Teriitehau C, Boudabous S, et al. In vivo evaluation
of lung microwave ablation in a porcine tumor mimic model.
Cardiovasc Intervent Radiol 2013;36:221-8.
7. Yamauchi Y, Izumi Y, Hashimoto K, et al. Percutaneous
cryoablation for the treatment of medically inoperable stage I
non-small cell lung cancer. PLoS One 2012;7:e33223.

1001.3
Indications and results in colorectal cancer metastases
A.Gillams
Imaging Dept, The London Clinic, London, United Kingdom
Learning Objectives
1. To learn how to select for ablation patients with colorectal
cancer metastases in the lung
2. To learn about the respective role of ablation and surgery in the
treatment of colorectal lung metastases
3. To learn about mid- and long-term results of ablation in the
treatment of colorectal cancer lung metastases
Ablation is a very effective tool for the local control of small volume lung tumours. It is the optimal technique for bilateral or small
volume but multifocal disease. Although any metastatic deposit
can be treated, patients with colorectal metastases form the largest cohort. Results from metastasectomy suggest a survival advantage. Number, distribution and speed of development, i.e. diseasefree interval between primary resection and the development of
lung metastases, are considered when deciding whether a patient is
operable. Surgical preference is given to fit patients with fewer than
3 metachronous metastases, preferably unilateral, a longer diseasefree interval and no extra-pulmonic disease. Ablation is currently
NICE approved in inoperable patients, but this should change. Our
analysis of 122 patients who were not operable candidates but who
had small volume colorectal lung metastases showed a median survival of 41 months and a 3-year survival of 57% (1). Survival was better in patients with smaller tumours: median 51 months, 3-year 64%
for 2-cm tumours versus 31 months and 44% for 2.14-cm tumours
(p = 0.08). A history of ablated/resected liver metastases, systemic
chemotherapy or prior lung resection, total number of lung metastases ablated and uni- or bilaterality did not impact survival. Other
groups have reported 3-year survival in >55% in inoperable patients
(2). If ablation is applied to operable patients, the survival figures
improve: 5056% at 5 years (3,4).
Advantages of ablation over resection include limited impact on
lung function, short recovery times, good quality of life and the
option to repeat treatment as required when new metastatic events
occur, as is often the case. It is also more cost effective. Downsides
such as absence of histological data can be compensated for by percutaneous biopsy. The often touted palpation of the lung to detect
CT occult disease is only available at open surgery and often results
in removal of benign lesions. Further it is really only important for a

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one chance only technique such as surgery. Patients with metastatic

colorectal cancer undergo routine surveillance scanning when small
but enlarging, i.e. significant lesions, declare with a long detectiontherapeutic window.
Conclusion: There are some lesions that are very well served by ablation and others that are better served by resection. Our aim should
be to deliver the optimal treatment for the given tumour/patient at
that moment in time independent of treatment hierarchies.
References
1. Gillams A, Khan Z, Osborn P, et al. Survival after radiofrequency
ablation in 122 patients with inoperable colorectal lung
metastases. Cardiovasc Intervent Radiol. 2013 Jun;36(3):724-30.
2. Yamakado K, Inoue Y, Takao M, et al. Long-term results of
radiofrequency ablation in colorectal lung metastases: single
center experience. Oncol Rep. 2009 Oct;22(4):885-91.
3. Matsui Y, Hiraki T, Gobara H, et al. Long-term survival following
percutaneous radiofrequency ablation of colorectal lung
metastases. J Vasc Interv Radiol. 2015 Mar;26(3):303-10.
4. de Bare T, Auprin A, Deschamps F, et al. Radiofrequency
ablation is a valid treatment option for lung metastases:
experience in 566 patients with 1037 metastases. Ann Oncol.
2015 May;26(5):987-91.

1001.4
Role of SBRT and ablation
C.T.Sofocleous
Interventional Radiology, Memorial Sloan Kettering Cancer Center, New
York, NY, United States of America
Learning Objectives
1. To learn how ablation and SBRT differ in patient selection and
tumour response evaluation
2. To learn about respective results of ablation and SBRT
3. To learn how the two techniques can be combined
No abstract available.

Special Session
Intra-arterial therapies in the liver: the evidence
1004.1
Bland embolisation
G.M.Varano
Division of Interventional Radiology, European Institute of Oncology,
Milan, Italy
Learning Objectives
1. To learn how to select patients and provide appropriate patient
care
2. To learn how to combine bland embolisation with systemic
therapy
3. To learn how to evaluate current results reported in the
literature
Intra-arterial therapies are widely used nowadays in the treatment
of liver tumors, both primary and metastatic. In particular, they are
mainly used in the treatment of hepatocellular carcinomas (HCCs)
and neuroendocrine tumors (NETs). Different embolizing materials
have been used in the last years both alone or in association with
several drugs. Intra-arterial therapies are indicated for HCCs not suitable for percutaneous ablation or surgical resection, as these techniques has been demonstrated to improve survival in comparison
with best supportive care. However, it is still unclear whether results
of these intra-arterial therapies are more related to the ischemic

Abstract Book
effect of the embolization or to the local effect of delivered drugs.
Regarding HCC in particular, no evidence of superiority of transarterial chemoembolization (TACE) in comparison with embolization
alone (TAE) has been ever demonstrated, even if embolizing materials in conventional TACE were not designed to achieve the best ischemic effect, but only to temporarily stop the blood flow in order to
increase the local effect of the drug. Moreover, up to now there are
no drugs with proven good efficacy over HCC, and doxorubicin, the
most widely used agent, has been proven to determine only marginal benefits for the patients in terms of disease control and survival. Conversely, doxorubicin has been shown to determine liver
toxicity, with a potential consequent worsening of liver function,
which might be particularly relevant in cirrhotic patients. Following
the idea that the ischemic effect is the most important one in the
transarterial treatment of HCC, some materials with higher embolizing effect have been developed, and more precise superselective
embolizing technique have been adopted. In particular, the adoption of very small caliber particles that could reach smaller peripheral arteries causing permanent ischemia has been reported with
favorable results. Very recently, a prospective randomized trial
started in 2007 comparing doxorubicin-eluting microspheres with
embolization with microspheres alone was reported. In this study,
no difference in the two groups regarding adverse events, tumor
response, median progression-free survival, and overall survival was
found. This is the first strong evidence that TAE, when performed
with dedicated material and selective technique may achieve the
same results of TACE, thus challenging the real importance of adding drugs when performing trans-arterial embolization in patients
with HCC. Another interesting application of TAE is the treatment of
liver metastases from NETs. These tumors are rare malignancies originating from neural crest cells, which can produce amines or hormones, such as histamine, serotonin, adrenaline, gastrin, and somatostatin (SST); these can often contribute to the onset of symptoms.
NETs can originate in almost every anatomical part; however, most
frequently they originate in gastrointestinal tract. Almost 75% of
patients affected by GI (small bowel) and up to 85% affected by pancreatic NETs develop synchronous or metachronous liver metastasis.
In these patients, survival and disease-related symptoms are highly
affected by liver involvement. Different treatment algorithms have
been developed mainly based on tumor characteristics and extension, such as tumor grade, site of primary tumor, rate of disease progression, and functionality. In case of extended hepatic disease, TAE
represents a valid option to control both disease progression and
symptoms palliation. In this scenario, the use of intra-arterial therapies has been reported to be highly effective. Of crucial importance is multidisciplinary approach to achieve correct selection of
patients and to choose a combination with other systemic therapies. In conclusion, there is no actual evidence of superiority of TACE
over TAE in the treatment of HCC, and several authors are starting to
promote the use of bland embolization alone in order to spare the
drug-related liver toxicity. Moreover, application of TAE to patients
with liver metastases seems to offer a promising therapeutic option
in the multidisciplinary approach in patients with NETs.
References
1. Brown DB, Geschwind J-FH, Soulen MC, et al. Society
of Interventional Radiology position statement on
chemoembolization of hepatic malignancies. J Vasc Interv
Radiol 2009;20:S317-23.
2. Chlebowski RT, Brzechwa-Adjukiewicz A, Cowden A, et al.
Doxorubicin (75 mg/m2) for hepatocellular carcinoma: clinical
and pharmacokinetic results. Cancer Treat Rep 1984;68:487-91.
3. Bonomo G, Pedicini V, Monfardini L, et al. Bland embolization
in patients with unresectable hepatocellular carcinoma using
precise, tightly size-calibrated, anti-inflammatory microparticles:
first clinical experience and one-year follow-up. Cardiovasc
Intervent Radiol 2010;33:552-9.

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CIRSE 2016
4. Facciorusso A, Di Maso M, Muscatiello N Drug-eluting beads
versus conventional chemoembolization for the treatment of
unresectable hepatocellular carcinoma: A meta-analysis. Dig
Liver Dis 2016.
5. Brown KT, Do RK, Gonen M, et al. Randomized trial of hepatic
artery embolization for hepatocellular carcinoma using
doxorubicin-eluting microspheres compared with embolization
with microspheres alone. J Clin Oncol 2016.
6. Llovet J, Ducreux M, Lencioni R, et al. EASL-EORTC clinical
practice guidelines: management of hepatocellular carcinoma.
Eur J Cancer 2012;48:599-641.
7. de Baere T, Dufaux J, Roche A, et al. Circulatory alterations
induced by intra-arterial injection of iodized oil and emulsions
of iodized oil and doxorubicin: experimental study. Radiology
1995;194:165-70.
8. Jordan O, Denys A, De Baere T, Boulens N, Doelker E.
Comparative study of chemoembolization loadable beads:
in vitro drug release and physical properties of DC bead and
hepasphere loaded with doxorubicin and irinotecan. J Vasc
Interv Radiol 2010;21:1084-90.
9. Hong K, Khwaja A, Liapi E, Torbenson MS, Georgiades CS,
Geschwind JF. New intra-arterial drug delivery system for the
treatment of liver cancer: preclinical assessment in a rabbit
model of liver cancer. Clin Cancer Res 2006;12:2563-7.
10. Modlin IM, Oberg K, Chung DC, et al. Gastroenteropancreatic
neuroendocrine tumours. Lancet Oncol 2008;9:61-72.
11. Modlin IM1, Lye KD, Kidd M. A 5-decade analysis of 13,715
carcinoid tumors. Cancer 2003;97:934-59.
12. Rao PP, Pascale F, Seck A, et al. Irinotecan loaded in eluting
beads: preclinical assessment in a rabbit VX2 liver tumor model.
Cardiovasc Intervent Radiol 2012;35:1448-59.
13. Varela M, Real MI, Burrel M, et al. Chemoembolization of
hepatocellular carcinoma with drug eluting beads: efficacy and
doxorubicin pharmacokinetics. J Hepatol 2007;46:474-81.
14. Lammer J, Malagari K, Vogl T, et al. Prospective randomized
study of doxorubicin-eluting-bead embolization in the
treatment of hepatocellular carcinoma: results of the PRECISION
V study. Cardiovasc Intervent Radiol 2010;33:41-52.
15. Bhagat N, Reyes DK, Lin M, et al. Phase II study of
chemoembolization with drug-eluting beads in patients with
hepatic neuroendocrine metastases: high incidence of biliary
injury. Cardiovasc Intervent Radiol 2013;36:449-59.

1004.2
Conventional TACE
T.deBare
Department of Radiology, Gustave Roussy Cancer Campus, Villejuif,
France
Learning Objectives
1. To learn how to select patients and provide appropriate patient
care
2. To learn how to combine c-TACE with systemic therapy
3. To learn how to evaluate current results reported in the
literature
Conventional TACE using a combination of chemotherapy and lipiodol and followed by particulate embolization is the only intra-arterial therapy for HCC that is supported by randomized controlled trials and meta-analysis.
In a selected group of patients with HCC (intermediate stage according to EASL/EORTC classification), conventional TACE has demonstrated superiority to supportive care using both cis-platinum and
doxorubicin as therapeutic agents. Due to this high level of evidence
(level 1), TACE is recommended in intermediate-stage HCC with
grade 1A.

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Clinical studies published after 2002 seem to report a longer median

overall survival rate than those published until 2002. Namely, a prospective JapanKorea cooperative study including 99 patients
reported a median OS of 37 months, and the median OS was 26
months in a phase III trial including 502 patients.
There is no randomized trial demonstrating equivalence or superiority of other type of intra-arterial therapy over c-TACE in intermediate-stage HCC.
References
1. Lo CM, Ngan H, Tso WK et al. Randomized controlled trial of
transarterial lipiodol chemoembolization for unresectable
hepatocellular carcinoma. Hepatology 2002;35(5):11641171.
2. Llovet JM, Real MI, Montana X et al. Arterial embolisation or
chemoembolisation versus symptomatic treatment in patients
with unresectable hepatocellular carcinoma: a randomised
controlled trial. Lancet 2002;359(9319):17341739.
3. Llovet J, Ducreux M, Lencioni R et al. EASL-EORTC clinical
practice guidelines: management of hepatocellular carcinoma.
Eur J Cancer 2012;48(5):599641.
4. Lencioni R, de Baere T, Soulen M. Lipiodol transarterial
chemoembolization for hepatocellular carcinoma: a systematic
review of efficacy and safety data. Hepatology 2016 [epub ahead
of print].
5. de Baere T, Arai Y, Lencioni R et al. Treatment of liver tumors with
lipiodol TACE: technical recommendations from experts opinion.
Cardiovasc Intervent Radiol 2016;39:334343.

1004.3
Drug-eluting beads (DEB) TACE
K.Malagari
2nd Dept. of Radiology, University of Athens Medical School, Athens,
Greece
Learning Objectives
1. To learn how to select patients and provide appropriate patient
care
2. To learn how to combine DEB-TACE with systemic therapy
3. To learn how to evaluate current results reported in the
literature
Drug-eluting beads have altered the interventional approach of
intra-arterial drug delivery. The intended purpose of embolization
is twofold: to prevent washout of the drug from the site of tumor
and to induce ischemic necrosis. Drug-eluting beads act at both levels, achieving vessel blockade and delivery of the chemotherapeutic locally for several days after embolization, while at the same time,
the diffusion of the chemotherapeutic in the systemic circulation is
negligible. In contrast to the conventional lipiodol-based chemoembolization, the drug-eluting bead chemoembolization is standardized and reproducible. Today, there are four platforms of drugeluting beads: DC Bead (Biocompatibles UK Ltd, a BTG group company), Hepasphere/Quadrasphere (Merit Medical Inc.), Tandem
(Celonova Biosciences Inc.), and LifePearl (Terumo), while there are
other radiopaque microspheres that are currently under investigation. Drug-eluting microspheres are extensively studied at a preclinical and clinical level with data of 5-year survival, and this review
focuses on this drug-eluting device in the treatment of HCC.
Efficacy studies have shown high percentage of necrosis and good
local response that is superior to conventional chemoembolization in more advanced disease (ChildPugh B, ECOG 1, recurrent or bilobar tumors). In intermediate and early stage HCC - nontreatable with curative treatments - complete response and partial
response rates range from 22.2% to 48% and 43.7% to 51%, respectively. Studies with survival as an end-point are needed, and headto-head comparisons with other drug-eluting beads are necessary.
Regarding the use of the chemotherapeutic in embolics administered for HCC, there is a debate; however, a prospective randomized

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comparison of drug-eluting beads loaded with doxorubicin and

bland beads showed that bland beads are associated with shorter
time to progression and higher local recurrences than the doxorubicin-loaded DC beads, but failed to demonstrate survival benefit due
to short-term follow-up. A recent prospective randomized trial comparing loaded and non-loaded beads revealed no significant survival benefit for the loaded beads, but the majority of the patients
included presented vascular invasion and extrahepatic disease that
are recognized factors of decreased survival regardless of treatment
offered. In another study, higher loading with doxorubicin showed
a more extensive necrosis than lower loading, evaluated histologically on surgically resected lesions. These results corroborate with
oxicogenomics that studies that revealed that loaded beads activate markers of cell death and apoptosis, while bland embolization
causes only limited cytotoxicity.
References
1. Lammer J, Malagari K, Vogl T, Pilleul F, Denys A, Watkinson A,
et al; PRECISION V Investigators. Prospective randomized study
of doxorubicin-eluting-bead embolization in the treatment
of hepatocellular carcinoma: results of the PRECISION V study.
Cardiovasc Intervent Radiol. 2010;33(1):41-52.
2. Varela M, Real MI, Burrel M, Forner A, Sala M, Brunet M, et al.
Chemoembolization of hepatocellular carcinoma with drug
eluting beads: efficacy and doxorubicin pharmacokinetics. J
Hepatol. 2007;46(3):474-81.
3. Lencioni R, de Baere T, Burrel M, Caridi JG, Lammer J, Malagari
K, et al. Transcatheter treatment of hepatocellular carcinoma
with Doxorubicin-loaded DC Bead (DEBDOX): technical
recommendations. Cardiovasc Intervent Radiol. 2012;35(5):980-5.
4. Malagari K, Pomoni M, Moschouris H, Kelekis A, Charokopakis A,
Bouma E, et al. Chemoembolization of hepatocellular carcinoma
with HepaSphere 30-60 m. Safety and efficacy study.
Cardiovasc Intervent Radiol. 2014;37(1):165-75.
5. Namur J, Citron SJ, Sellers MT, Dupuis MH, Wassef M, Manfait
M, et al. Embolization of hepatocellular carcinoma with
drug-eluting beads: doxorubicin tissue concentration and
distribution in patient liver explants. J Hepatol. 2011;55(6):1332-8.
6. Brown KT, Do RK, Gonen M, Covey AM, Getrajdman GI,
Sofocleous CT, et al. Randomized trial of hepatic artery
embolization for hepatocellular carcinoma using doxorubicineluting microspheres compared with embolization with
microspheres alone. J Clin Oncol. 2016 Feb 1. pii: JCO640821.
[Epub ahead of print].
7. Malagari K, Pomoni M, Kelekis A, Pomoni A, Dourakis S,
Spyridopoulos T, et al. Prospective randomized comparison of
chemoembolization with doxorubicin-eluting beads and bland
embolization with BeadBlock for hepatocellular carcinoma.
Cardiovasc Intervent Radiol. 2010;33(3):541-51.
8. Klass D, Owen D, Buczkowski A, Chung SW, Scudamore CH, Weiss
AA, et al. The effect of doxorubicin loading on response and
toxicity with drug-eluting embolization in resectable hepatoma:
a dose escalation study. Anticancer Res. 2014;34(7):3597-606.
9. Dreher MR, Sharma KV, Woods DL, Reddy G, Tang Y, Pritchard
WF, et al. Radiopaque drug-eluting beads for transcatheter
embolotherapy: experimental study of drug penetration and
coverage in swine. J Vasc Interv Radiol. 2012;23(2):257-64.
10. Malagari K, Pomoni M, Moschouris H, Bouma E, Koskinas J,
Stefaniotou A, et al. Chemoembolization with doxorubicineluting beads for unresectable hepatocellular carcinoma:
five-year survival analysis. Cardiovasc Intervent Radiol.
2012;35(5):1119-28.
11. Burrel M, Reig M, Forner A, Barrufet M, de Lope CR, Tremosini S,
et al. Survival of patients with hepatocellular carcinoma treated
by transarterial chemoembolisation (TACE) using drug eluting
beads. Implications for clinical practice and trial design.
J Hepatol. 2012;56(6):1330-5.

Abstract Book

1004.4
Radioembolisation (TARE)
A.Denys
Radiology and Interventional Radiology, CHUV, Lausanne, Switzerland
Learning Objectives
1. To learn how to select patients and provide appropriate patient
care
2. To learn how to combine TARE with systemic therapy
3. To learn how to evaluate current results reported in the
literature
No abstract available.

Special Session
Anaesthesia and interventional radiology: time to
face reality?
1101.1
Anaesthesia and interventional radiology: best friends or
worst enemies?
A.Gangi
Interventional Radiology, University Hospital of Strasbourg, Strasbourg,
France
Learning Objectives
1. To evaluate the impact that a systematic availability of
anaesthesia can have on IR practice
2. To learn about existing problems and possible organisational
models
3. To explore the role the IR community can have on changing the
current scenario
No abstract available.

1101.2
Which anaesthesia in percutaneous hepatobiliary procedures:
sedation
M.Bezzi1, A.Vari2
1Department of Radiological Science, University of Rome La Sapienza,
Rome, Italy, 2Department of Anesthesiology, Sapienza University
School of Medicine, Rome, Italy
Learning Objectives
1. To learn why and how percutaneous hepatobiliary procedures
should be safely performed under sedation
2. To examine the advantages of sedation over GA in the routine
clinical practice
3. To understand the clinical and economical implications of the
choice of sedation for PHP
The complexity and variety of interventional radiological procedures (IRPs) in the last decade have certainly increased. Safe and
effective sedation and analgesia are necessary to ensure optimal
procedure condition, good outcome and reduced complication
rate. Due to the increased IRP workload, anaesthesiologists are usually not available to attend all procedures, with the consequence of
interventional radiologists being more and more involved in this
procedure (1).
Healthcare cost containment and the need to reduce the number of
hospital admissions have led to a widespread use of daycare as a
cost-effective approach for IRPs. Therefore, sedation techniques are
more and more often used over general anaesthesia for IRPs.

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CIRSE 2016
Hepatobiliary procedures can be very painful and require patient
collaboration. For this reason, in the last few years, we have adopted
moderate sedation/analgesia at our institution.
Definitions
Minimal sedation (anxiolysis) is a drug-induced state during which
patients normally respond to verbal commands. Although cognitive
function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.
Moderate sedation/analgesia (previously termed conscious sedation) is a drug-induced depression of consciousness during which
patients purposefully respond to verbal commands either alone or
accompanied by light or tactile stimulation. No interventions are
required to maintain a patent airway, and spontaneous ventilation is
adequate. Cardiovascular function is usually maintained.
Deep sedation/analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but
purposefully respond following repeated or painful stimulation.
The ability to independently maintain ventilatory function may
be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate.
Cardiovascular function is usually maintained.
Anaesthesia. General anaesthesia is a drug-induced state of loss
of consciousness during which patients are not arousable even by
painful stimuli. The ability to maintain ventilatory function is compromised, requiring assistance in preserving patent airway and positive pressure ventilation. Cardiovascular functions may be impaired.
Deep sedation/analgesia and anaesthesia will be administered only
by an anaesthesiologist or a certified nurse/technician holding
appropriate clinical privileges for anaesthesia.
Clinical Scenario
Percutaneous hepatobiliary procedures (such has liver tumour ablation and percutaneous biliary drainage) can be very painful. While
pain at the percutaneous access site can be easily controlled by local
anaesthesia, that due to stimulation of the sensory neural terminations found in the periportal space and the liver capsule cannot be
controlled by local anaesthesia.
Control of intraprocedural pain is important for several reasons. First,
it allows patients to tolerate unpleasant procedures by relieving not
only pain but also fear and anxiety. Second, in children and uncooperative adults, sedation/analgesia may expedite the conduct of procedures that are not particularly uncomfortable but require that the
patient does not move. Control of pain is important for other reasons as well, particularly if the same patient is going to return to the
same interventionist for repeat procedures. Nothing will dissuade an
individual from returning for repeat procedures as much as a previous painful experience.
Patient collaboration during IRP may be needed to control the
breathing, to expose the liver and to improve the visualisation of the
liver lesion. With respect to this, patients under sedation purposefully respond to verbal commands and can cooperate with the interventional radiologist during the main phases of the procedure.
Patient Preparation
A careful preoperative evaluation (history taking, physical examination and routine lab tests) and preparation of the patient should be
performed to identify those at risk for sedation-related complications (extremes of age, significant comorbidities and/or major organ
dysfunction, history of drug/alcohol abuse, history of sleep apnea,
morbid obesity with body mass index > 35, known airway pathology, abnormal airway anatomy, uncooperative patient, planned
extremely long procedure and ASA III).
A thorough discussion of the procedure and analgesia/sedation regimen should be included during the acquisition of informed consent.
Expectations for moderate sedation should be clearly explained to
the patient (moderate anxiolysis, sedation, analgesia and possibly
amnesia). Patient and a responsible adult should also be educated
on the effects of the procedure, sedation, symptoms to report and
how to seek emergency care.

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For ambulatory patients before procedure, verify that there is a

responsible adult to accompany the patient home and document
that instructions have been given to the patient or their parent/legal
guardian, if appropriate, to avoid drinking alcohol, driving, operating heavy machinery (or other injury-prone physical activity) or
making any major decisions after the procedure for 24 hours.
Procedure
The patients should be fasting (NPO) (e.g. clear liquids for 23 hours,
light meal for 6 hours and regular meal for 8 hours). When the procedure is scheduled in the morning, the patient should be NPO after
midnight. When proper fasting has not been ensured, the procedure should be rescheduled. In case of a valid reason to perform the
procedure, the increased risks of sedation shall be weighed against
its benefits and the lightest level of effective sedation shall be
employed. An emergency procedure may require the protection of
the patients airway against aspiration (intubation) before sedation,
and the Department of Anaesthesiology must be consulted for assistance in all emergency cases.
Procedural steps:
Placement of an IV access with extension tubing and three-way
tap before positioning the patient on the table and draping.
Appropriate fluid infusion before procedure: crystalloids 12 ml/
kg/h if ejection fraction > 40%
Pre-procedural safety pause (time out as per CIRSE IR Safety
Checklist)
Use of supplemental oxygen (starting at 2 l/min on a nasal cannula)
Standard monitoring (performed by a separate practitioner other
than the interventionist, holding current BLS certification): SpO 2,
blood pressure, heart rate, ECG and verbal pain score) with recordings every 5 min
Monitoring of level of consciousness (LOC): use of bispectral index
monitoring is advisable in the adult population; alternatively, the
Ramsay sedation scale may be used
a) Anxious and agitated or restless or both
b) Cooperative, oriented and tranquil
c) Responds to commands only
d) Briskly responds to a light tactile or loud auditory stimulus
e) Sluggishly responds to a light tactile or loud auditory stimulus
f) Does not respond to a light tactile or loud auditory stimulus
Sedation/analgesia administered by a separate practitioner trained
in basic clinical pharmacology of sedative and analgesic drugs and
their antagonists and able to recognise and manage all most common adverse effects of drugs (respiratory depression, dysrhythmias, hypotension, allergic reactions, nausea and vomiting)
Current advanced life support (ALS) certification holder or anaesthesiologist available with a response time < 5 min
Medication and Peri-Procedural care
Administration of sedatives and analgesics should be titrated to
the following clinical outcomes (11-14):
SpO2 > 92% with supplemental oxygen (>2 l/min) and spontaneous, effective breathing conserved with coordinated ventilatory
efforts,
Analgesia: VAS < 3 (or PABS < 3) throughout the procedure,
Control of sympathetic reflexes: heart rate and blood pressure
value within 30% of baseline and
Reduced level of consciousness: bispectral index value 6085 with
patient cooperation maintained.
Preemptive short-acting intravenous analgesics to relieve pain
should be administered first to ensure analgesia occurs before
painful stimulus (IV or PO administration: acetaminophen 1000
milligrams, ketorolac 30 milligrams, tramadol 100 milligrams, morphine 12 milligrams, 30 min before procedure)
Short-acting sedatives should be administered to decrease anxiety
(midazolam or other benzodiazepines at dosing intervals of 13
min) (clinical administration, IV push: midazolam 0.51 milligrams,
diazepam 2.55 milligrams, lorazepam 0.52 milligrams, 15 min
before procedure)

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Major opioids should always be titrated, i.e. boluses given incrementally with sufficient time (13 min) between doses to assess
clinical effect (clinical administration IV push: fentanyl 50100
micrograms, morphine: 12 milligrams, 20 min before procedure)
Appropriate dose reduction of both sedatives and analgesics (50%)
should be applied if patient >60-year old, debilitated or chronically
ill
Appropriate dose reduction should be applied if both sedatives
and analgesics are used (decrease the opioid dosage of one third
and use 25% of starting dose of benzodiazepine as maintenance)
Supplemental oxygen should be administered as needed (nasal
cannula starting at 2 l/min, increased to maintain SpO2 > 95%)
Reversal agents must always be available whenever opioids and
benzodiazepines are used (clinical administration, IV push: naloxone 0.020.04 milligrams 2 every 12 min titrated to clinical effect
and flumazenil 0.10.2 milligrams every 12 min titrated to clinical
effect)
Post-procedural Follow-up Care
Recovery (post-procedural) care in a dedicated area should include
vital sign monitoring and nausea and pain assessment/management (VAS verbally assessed on a 010 numeric scale or PABS, give
rescue medication same as for preemptive analgesia if VAS > 3 or
PABS > 3), as done during procedure. Document vital signs, sedation score and pain scale appropriate for age every 15 min for the
first hour
Post-procedural instructions should be given to the referring physician/ward nurse (pain and PONV therapy, NPO, special procedure-related orders and lab/diagnostic follow-up orders)
For outpatient cases, a responsible adult must accompany outpatients home, write detailed discharge instructions and provide a
phone number for emergency
Conclusions
It is highly recommendable that formal training in safe sedation
and analgesia and uninterrupted attention to updated guidelines
is introduced in the IR curriculum. Knowledge of the pharmacology
of drugs used for sedation and their adverse and side effects, familiarity with sedation regimens, understanding of patient monitoring,
detection and treatment of procedure or drug-related adverse/side
effects and common complications, ventilation techniques, emergency procedures and peri-procedural patient care should be integrated in the body of knowledge for IR qualification.
Institutional standards of care for sedation/analgesia in IR should
be established, and it is possible that they may vary based on the
facility, availability of devices, type and amount of workload and
competency of personnel working in the IR suite. These standards
should be established through a cooperative relationship with the
Department of Anaesthesia.
References
1. Haslam PJ, Yap B, Mueller PR, Lee MJ. Anaesthesia practice and
clinical trends in interventional radiology: a European survey.
Cardiovasc Intervent Radiol. 2000;23:256-261.
2. Practice Guidelines for Sedation and Analgesia by
Non-Anaesthesiologists. An Updated report by the American
Society of Anaesthesiology Task Force on Sedation and
Analgesia by Non-Anaesthesiologists. Anaesthesiology
2002;96:1004-1017.
3. The Joint Commission on the Accreditation of Healthcare
Organizations (JCAHO): Comprehensive Accreditation Manual
for Hospitals. Care of patients: Anaesthesia Care Standards. 2002,
TX15-17,TX 71-79.
4. American College of Radiology-Society for Interventional
Radiology: Practice Guidelines for SedationAnalgesia. Rev. 2010; (http://www.acr.org/~/media/
F194CBB800AB43048B997A75938AB482.pdf).

Abstract Book
5. The Royal College of Radiologists. Safe Sedation, Analgesia
and Anaesthesia within the Radiology Department. 2003;
(http://www.rcr.ac.uk/publications.aspx?PageID=310&Publicat
ionID=186).
6. Working Party on Safety and Quality of Care: Guidelines for
safety and quality in anaesthesia practice in the European
Union. Eur J Anaesthesiol 2007; 24:479-482.
7. Summary of recommendations for Perioperative Fasting in
Adults and Children: Guidelines from the European Society of
Anaesthesiology. Eur J Anaesthesiol. 2011;28:556-569.
8. Practice Guidelines for Preoperative Fasting and the Use
of Pharmacologic Agents to Reduce the Risk of Pulmonary
Aspiration: Application to Healthy Patients Undergoing Elective
Procedures. An Updated Report by the American Society
of Anaesthesiologist Committee on Standards and Practice
Parameters. Anaesthesiology 2011;114:495-511.
9. 2010 American Heart Association Guidelines for
Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care Science. Circulation 2010;122:S729-S776.
10. Herr K, Coyne PJ, Key T, Manworren R, McCaffery M, Merkel S,
Pelosi-Kelly J, Wild L. American Society for Pain Management
Nursing. Pain assessment in the nonverbal patient: position
statement with clinical practice recommendations. Pain Manag
Nurs. 2006;7:44-52.
11. Martin ML, Lennox PH. Sedation and analgesia in the
interventional radiology department. J Vasc Interv Radiol.
2003;14:1119-1128.
12. Schupp CJ, Berbaum K, Berbaum M, Lang EV. Pain and anxiety
during interventional radiologic procedures: effect of patients
state anxiety at baseline and modulation by nonpharmacologic
analgesia adjuncts. J Vasc Interv Radiol. 2005;16:1585-1592.
13. Arepally A, Oechsle D, Kirkwood S, Savader SJ. Safety of
conscious sedation in interventional radiology. Cardiovasc
Intervent Radiol. 2001;24:185-190.
14. Willey J, Vargo JJ, Connor JT, Dumot JA, Conwell DL, Zuccaro
G. Quantitative assessment of psychomotor recovery after
sedation and analgesia for outpatient EGD. Gastrointest Endosc.
2002;56:810-816.

1101.3
Which anaesthesia in percutaneous hepatobiliary procedures:
general
A.H.Mahnken
Department of Diagnostic and Interventional Radiology, University
Hospital Marburg, Philipps University of Marburg, Marburg, Germany
Learning Objectives
1. To learn why and how percutaneous hepatobiliary procedures
should be safely performed under general anaesthesia
2. To examine the advantages of GA over sedation in the routine
clinical practice
3. To understand the clinical and economical implications of the
choice of general anaesthesia for PHP
Hepatobiliary covers a broad range of interventional radiology
procedures. Among these interventions, percutaneous tumor ablation, such as radiofrequency (RF) or microwave (MW) ablation, represent the most challenging procedures. In order to achieve optimal results, perfect lesion targeting is crucial. Equally important
are patient comfort in terms of pain management and exposure to
stress. The latter also is a relevant, though rarely discussed, issue for
the interventionalist. Today, anesthesia has reached its safest point
in history with an anesthesia-related mortality of 0.055/10.000 anesthetics. Considering the continuous improvement in the safety of
general anesthesia (GA), it can now as safely be applied in ambulatory or office-based services, when compared with a typical in-hospital setting.

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CIRSE 2016
So far, percutaneous ablation procedures are performed either
under local anesthesia (LA) with or without conscious sedation (CS)
or GA. There is no consensus regarding the use of one or the other,
with the choice being a matter of local preference. However, based
on an analysis of the current literature, most procedures appear to
be performed under GA. The only study directly comparing CS and
GA for percutaneous ablation focused on lung ablation. No difference in terms of feasibility, local tumor control, and complications
was found [3].
From theory, GA provides multiple advantages over LA and CS, not
only in hepatobiliary interventions. As perfect positioning of the
probe is paramount, any inadvertent patient motion needs to be
minimized. Under LA, unintended patient motion may impair precise positioning, potentially resulting in the need of multiple punctures to achieve an ideal needle position. From patient and animal data, the liver is known to move with an amplitude of 12 cm
[4]; and with spontaneous breathing, the patient not necessarily
achieves an identical breath-hold position over multiple breathing
cycles. Uncontrolled breathing and inadvertent patient movement,
sometimes even requiring repeated passage of an organs capsule,
increase the risk of abdominal injury [5]. With GA, patient immobilization and respiratory motion control, including prolonged apnea,
are safely achievable. Further improvements can be achieved by
combining GA with high-frequency jet ventilation [6]. These techniques were shown to achieve a more precise lesion targeting while
simultaneously reducing the radiation exposure to the patient and
the interventionalist [6,7].
Another major advantage of GA is better pain control. This is essential in central and subcapsular lesions, where percutaneous ablation
is usually painful and hard to control with LA and CS alone. Ablation
close to bile ducts and the gall bladder often causes acute nausea, which is also better controlled under GA. Previous research has
shown that GA helps to increase lesion size in hepatic RF ablation
due to the changes in liver perfusion [8], a factor that may contribute to complete ablation. There are even some complex procedures,
such as irreversible electroporation, where GA with full relaxation is
a mandatory prerequisite. Furthermore, GA is obviously mandatory
in incompliant patients as well as in the pediatric population.
Costs are the key disadvantage of GA in hepatobiliary interventions.
While it is well known that anesthesia costs/minute vary widely
throughout the world, ranging from few Euro cents to more than
4 [9,10], there are no data comparing cost savings due to improved
procedure safety and reduced procedure time with the additional
costs of anesthesia.
In conclusion, GA provides advantages over LA and CS in terms of
reduced procedure time and radiation exposure at the price of
potentially increased procedure costs. Although there is no data on
the socio-economic impact of these factors, GA should generously
be used in complex hepatobiliary procedures, as patient safety and
reduction in radiation exposure outweigh unknown economic risks.
References
1. Urman RD, Punwani N, Shapiro FE. Patient safety and officebased anesthesia. Curr Opin Anaesthesiol 2012; 25: 648-653.
2. Renner J, Grnewald M, Bein B. Can anaesthetic management
improve the outcome? Anasthesiol Intensivmed Notfallmed
Schmerzther 2015; 50: 314-321 [German].
3. Hoffmann RT, Jakobs TF, Lubienski A et al. Percutaneous
radiofrequency ablation of pulmonary tumors--is there a
difference between treatment under general anaesthesia and
under conscious sedation? Eur J Radiol 2006; 59: 168-174.
4. Korin HW, Ehman RL, Riederer SJ et al. Respiratory kinematics of
the upper abdominal organs: a quantitative study. Magn Reson
Med 1992; 23: 172-178.
5. Livraghi T, Solbiati L, Meloni MF et al. Treatment of focal
liver tumors with percutaneous radio-frequency ablation:
complications encountered in a multicenter study. Radiology
2003; 226: 441-451.

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6. Abderhalden S, Biro P, Hechelhammer L et al. CT-guided

navigation of percutaneous hepatic and renal radiofrequency
ablation under high-frequency jet ventilation: feasibility study. J
Vasc Interv Radiol 2011; 22: 1275-1278.
7. Denys A, Lachenal Y, Duran R et al. Use of high-frequency
jet ventilation for percutaneous tumor ablation. Cardiovasc
Intervent Radiol 2014; 37: 140-146.
8. Kettenbach J, Kstler W, Rcklinger E et al. Percutaneous salineenhanced radiofrequency ablation of unresectable hepatic
tumors: initial experience in 26 patients. AJR Am J Roentgenol
2003; 180: 1537-1545.
9. Demirel I, Ozer AB, Kilinc M et al. Comparison of anaesthetic cost
in open and laparoscopic appendectomy. Niger J Clin Pract 2014;
17: 696-700.
10. Schuster M, Standl T, Wagner JA et al. Effect of different cost
drivers on cost per anesthesia minute in different anesthesia
subspecialties. Anesthesiology 2004;101: 1435-1443.

1101.4
Propofol given by non-anaesthiologists: the Swiss GI
experience
L.T.Heuss
Klinik fr Innere Medizin, Spital Zollikerberg, Zollikerberg, Switzerland
Learning Objectives
1. To learn how to use propofol in IR procedures
2. To analyse its advantages over sedation in the routine clinical
practice
3. To learn how to manage potential complications
No abstract available.

1101.5
The CIRSE Survey on Anaesthetic Practices for Interventional
Radiology in Europe
A.Vari
Department of Anesthesiology, Sapienza University School of Medicine,
Rome, Italy
Learning Objectives
1. To learn in details the results of the CIRSE Survey on Anaesthetic
Practices for Interventional Radiology in Europe
2. To gain an insight into the most critical issues evidenced by the
survey
3. To examine possible solutions for change
The past two decades have seen an impressive expansion of the role
of interventional radiology. The number and complexity of procedures performed by interventional radiologists have increased the
demand for safe anesthetic management of patients ranging from
outpatient cases to complex, highly challenging patients who are
deemed poor candidates for more invasive traditional procedures.
As for other specialties, in a great number of centers, anesthesia providers are not uniformly available to attend IR cases; consequently,
interventional radiologists are increasingly involved in administering sedative drugs and managing complications of pharmacological sedation. The relatively limited literature available (1-6) reports
a large inter-hospital variability in practice patterns among countries and institutions, with different levels and methods of sedation being used for similar procedures. In consideration of the persisting, large variability of IR suite settings in terms of staffing and
anesthetic practices and the growing debate on sedation administered by non-anesthesiologists all over Europe, the Cardiovascular
and Interventional Radiology Society of Europe (CIRSE) has decided
to take a deeper and more specific look into the issue of anesthetic management of IR patients, to frame the potential for future

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initiatives. In this presentation, the results of this European survey are presented and discussed, with a special focus on anesthetic
periprocedural care, the demonstrated geographical differences
within Europe, and the related suggestions provided by the survey
responders.
References
1. Haslam PJ, Yap B, Mueller PR, Lee MJ. Anesthesia practice and
clinical trends in interventional radiology: a European survey.
Cardiovasc Intervent Radiol. 2000;23(4):256-61.
2. Mir FA, Ng CK, Nettey M. Anaesthesia for interventional
radiology: Time to take a lead. Eur J Anesthesiol. 2010 27;47:19.
3. Sunshine JH, Lewis RS, Bhargavan M. A portrait of interventional
radiologists in the United States. AJR Am J Roentgenol.
2005;185(5):1103-12.
4. Mueller PR, Wittenberg HK, Kaufman A, Lee MJ. Patterns of
anesthesia and nursing care for interventional radiology
procedures: a national survey. Radiology 1997;202(2):339-43.
5. Keeling AN, Reekers JA, Lee MJ. The Clinical Practice of
Interventional Radiology: A European Perspective. Cardiovasc
Intervent Radiol. 2009;32(3):406-11.
6. Trotteur G, Stockx L, Dondelinger RF. Sedation, analgesia and
anesthesia for interventional radiological procedures in adults.
Part I. Survey of interventional radiological practice in Belgium.
JBR-BTR. 2000;83(3):111-5.

Abstract Book
If IR is not the only provider of endovascular treatment of PAD and
aortic disease, it was and should be in the future the leading force in
developing new treatment concepts.
Sailing the ocean is always an adventure. In previous times, poor
navigation instruments, pirates, and stormy conditions were major
risks. Today, still the violence of wind and waves can be a great challenge. In vascular IR, the limitation of instruments and the pirate
activities of other disciplines are challenging us. However, this
should be the incentive to work on a continuous improvement of
our service.

Hot Topic Symposium

Aortic emergencies
1302.1
Death and secondary aortic rupture risk 15 years after EVAR or
open repair
R.M.Greenhalgh
Vascular Surgery Research Group, Imperial College, London, United
Kingdom
No abstract available.

Honorary Lecture
Andreas Gruentzig Lecture

1302.2

1301.1

A.Chavan, B.Schmuck, O.Eldergasch, R.P.Thomas

Institut fr Diagnostische & Interventionelle Radiologie, Klinikum
Oldenburg gGmbH, Oldenburg, Germany

Acute TEVAR for ruptured aneurysm and dissection

Vascular IR and sailing the ocean

J.Lammer
Cardiovascular and Interventional Radiology, Medical University
Vienna, Vienna, Austria
Both were pioneered by ingenious men and by chance. Dotter
observed a clinical improvement after diagnostic angiograms crossing arterial stenoses with large bore catheters. Columbus headed for
India sailing west and crossed the Atlantic Ocean. Both were important first steps but quite imperfect. The Dotter procedures caused
moderate widening of arterial stenoses; Columbus landed at the
Bahamas. Both ideas to cross the Atlantic Ocean on the way to East
Asia and to treat arteriosclerotic arterial disease by endovascular
techniques were derided as a tomfoolery. However, many further
steps of development were required. The biggest obstacles were
the lack of appropriate instruments. The sailors in the 15th century
had poor instruments for navigation and Dotter, only large-bore
catheters.
Gruentzig developed the angioplasty balloon in 1974, which was a
big step forward; in 1985, Palmaz patented his stent. Together with
Richter, he did the first iliac, renal, and TIPS stenting and with Parodi,
the first EVAR. To be fair, all these pioneers had predecessors such
as Leif Eriksson, Porstmann, Cragg, Roesch, and Volodos. In 1992,
Machan patented the coating of stents with paclitaxel. Speck developed local delivery of paclitaxel on a balloon, and Tepe published
first results of DEB in PAD. Interventional radiologists were those
who have done most pioneering works for endovascular treatment
of PAD.
Currently, POBA and bare metal stenting are replaced by new concepts. RCTs have demonstrated that DEB is superior to POBA.
Bioresorbable technologies will replace metal stents in the near
future. New drugs, drug combinations, antibodies, and gene therapy
for local delivery are on the horizon.
Since the first publication of tubegrafts in TAA by Dake in 1994 and
of bifurcated stentgrafts in AAA by Blum in 1996 in the NEJM, many
device improvements have been achieved. New concepts such as
EVAS may replace the bifurcated devices.

Ruptured aneurysms and dissections involving the ascending aorta

or the aortic arch are still a domain of open surgery (1-3). As opposed
to this, pathology involving the descending thoracic aorta is increasingly being endoluminally treated (4-8).
With the interventionalists becoming increasingly familiar with the
Perclose technique under local anesthesia, thoracic endovascular
aneurysm repair for rupture (rTEVAR) has acquired a new dimension
as the patient is spared the acute hemodynamic changes that may
be associated with performing the procedure under general anesthesia, especially as permissive hypotension has proved to effectively reduce blood loss (9). Furthermore, early institution of CSF
drainage reduces morbidity by limiting the incidence of post-procedural paraplegia (10).
As compared to open repair for ruptured descending thoracic aortic
aneurysms, rTEVAR is associated with a lower morbidity and mortality and shows equivalent late outcomes (5,11). In experienced hands,
rTEVAR has a procedural success rate of about 95%. Procedurerelated complications, including stroke and paraplegia, occur in
about 11% to 15% of the patients. The results reflect the commencement of a paradigm shift in the approach to treat this formidable
surgical challenge. Unlike the open surgical approach centered primarily around the surgical team, rTEVAR requires a cohesive team
effort that spans several disciplines. In addition, the surgical team
should be prepared to perform debranching procedures such as
carotid-subclavian or celiac artery bypass, which are not commonly
performed otherwise (12).
In ruptured type B dissections, the primary aim of entry closure is
to cut off direct blood flow to the ruptured false lumen and thus
achieve hemodynamic stability, ultimately preventing mortality and
major cardiac, cerebral, visceral, and renal complications. Trimarchi
and colleagues consider rTEVAR to be a suitable bridging procedure
to elective open repair at a later stage (13). However, this is a topic
of debate in the petticoat era, with proximal entry closure being
followed by bare metal stenting of the distal true lumen to initiate
complete aortic remodeling (14-15).

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CIRSE 2016
However, to ensure consistently good results with rTEVAR, certain
organizational requirements and infrastructures are mandatory
in a clinical setting of severe chest pain, hemorrhagic pleural effusion, and/or hemoptysis. These include a round-the-clock immediate access to a multi-slice CT, a constant 24/7 availability of an experienced endovascular team, an adequate stock of appropriate catheters, guidewires, endografts, and bare metal stents, as well as the
availability of a hybrid OR (12,13,16).
References
1. Borst HG, Heinemann MK, Stone CD (eds.) (1996): Surgical
treatment of aortic dissection. Churchill Livingstone, New York.
2. Karck M, Chavan A, Hagl C, Friedrich H, Galanski M, Haverich
A: The frozen elephant trunk technique: a new treatment for
thoracic aortic aneurysms. J Thorac Cardiovasc Surg 2003; 125:
1550-3.
3. Chavan A, Karck M, Hagl C, Winterhalter M, Baus S, Galanski
M, Haverich A: Hybrid endograft for one-step treatment of
multisegment disease of the thoracic aorta. J Vasc Interv Radiol
2005; 16: 823-9.
4. Semba CP, Kato N, Kee ST, Lee GK, Mitchell RS, Miller DC, Dake
MD: Acute rupture of the descending thoracic aorta: repair with
use of endovascular stent-grafts. J Vasc Interv Radiol 1997; 8:
337-42.
5. Patel HJ, Williams DM, Upchurch GR, Dasika NL, Deeb GM: A
comparative analysis of open and endovascular repair for the
descending thoracic aorta. J Vasc Surg 2009; 50: 1265-70.
6. Dake MD, Kato N, Mitchell RS, Semba CP, Razavi MK, Shimono T,
Hirano T, Takeda K, Yada I, Miller DC: Endovascular stent-graft
placement for the treatment of acute aortic dissection. N Engl J
Med 1999; 340: 1546-52.
7. Morgan R, Loosemore T, Belli AM: Endovascular repair of
contained rupture of the thoracic aorta. Cardiovasc Intervent
Radiol 2002; 25: 291-4.
8. Hausegger KA, Tiesenhausen K, Schedlbauer P, Oberwalder P,
Tauss J, Rigler B: Treatment of acute aortic type B dissection with
stent-grafts. Cardiovasc Intervent Radiol 2001; 24: 306-12.
9. van der Vliet JA, van Aalst DL, Schultze Kool LJ, Wever JJ,
Blankensteijn JD: Hypotensive hemostasis (permissive
hypotension) for ruptured abdominal aortic aneurysm: are we
really in control? Vascular 2007; 15: 197-200.
10. Jonker FHW, Verhagen HJM, Lin PH, Heijmen RH, Trimarchi S, Lee
WA, Moll FL, Athamneh H, Muhs BE: Outcomes of endovascular
repair of ruptured descending thoracic aortic aneurysms.
Circulation 2010; 121: 2718-23.
11. Jonker FH, Trimarchi S, Verhagen HJ, Moll FL, Sumpio BE, Muhs
BE: Meta-analysis of open versus endovascular repair for
ruptured descending thoracic aortic aneurysm. J Vasc Surg 2010;
51: 1026-32.
12. Coselli JS, Gopaldas RR: Ruptured Thoracic Aneurysms. To stent
or not to stent? Circulation 2010; 121: 2705-7.
13. Trimarchi S, Segreti S, Grassi V, Lomazzi C, de Vincentiis C,
Rampoldi V: Emergent treatment of aortic rupture in acute type
B dissection. Ann Cardiothorac Surg 2014; 3: 319-24.
14. Nienaber CA, Kische S, Zeller T, Rehders TC, Schneider H,
Lorenzen B, Bnger C, Ince H: Provisional extension to induce
complete attachment after stent-graft placement in type B
aortic dissection: the PETTICOAT concept. J Endovasc Ther 2006;
13: 738-46.
15. Melissano G, Bertoglio L, Rinaldi E, Civilini E, Tshomba Y,
Kahlberg A, Agricola E, Chiesa R: Volume changes in aortic true
and false lumen after the PETTICOAT procedure for type B
aortic dissection. J Vasc Surg 2012; 55: 641-51.
16. Willigendael EM, Cuypers PW, Teijink JA, van Sambeek MR:
Systematic approach to ruptured abdominal aortic aneurysm
in the endovascular era: intention-to-treat eEVAR protocol. J
Cardiovasc Surg 2012; 53: 77-82.

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1302.3
Traumatic rupture of the thoracic aorta
M.D.Dake
Falk Cardiovascular Research Center, Stanford University School of
Medicine, Stanford, CA, United States of America
Endovascular therapy has revolutionized the treatment of blunt
traumatic thoracic aortic injuries. With an increased access to highresolution CT scanning, more of these injuries are being diagnosed
and treated. This talk will focus on blunt aortic injury and its management, including classification and triage, timing of repair, and
current status of endovascular repair.
Blunt thoracic aortic injury typically occurs as a result of sudden
deceleration with multi-directional forces being applied to the aortic arch and descending thoracic aorta, most commonly at the site
of the ligamentum arteriosum. The severity of damage to the aorta
can vary from an intimal tear to pseudoaneurysm formation or even
aortic rupture. The frequencies of thoracic aortic rupture is 0.3% in
pedestrian injuries (n=5,838), 0.1% in high-level fall injuries (n=1,613),
and 1.4% in pelvic fractures (n=1,450).
Given the mode of injury, aortic damage is associated with multiple
other injuries; patients commonly experience long bone and pelvic
fractures, pulmonary contusions, and blunt head trauma. These injuries can complicate a traditional open aortic repair making it a very
high-risk procedure because of the need for thoracotomy and single
lung ventilation. The use of endovascular repair in these cases may
provide a safer alternative.
Since the first published clinical series of endovascular repair in 1997,
the mortality and frequency of paraplegia have markedly decreased
with endovascular repair versus those with open surgical repair. In
general, most large meta-analyses in the medical literature associate
one-third to one-half the mortality rate and one-sixth to one-fourth
the frequency of paraplegia with endovascular repair.
Technical tips and the results of clinical trials of endovascular repair
will be reviewed, including the risks and complications associated
with endograft use.
References
1. Kato N, Dake MD, Miller DC, Semba CP, Mitchell RS, Razavi MK,
Kee ST. Traumatic thoracic aortic aneurysm: treatment with
endovascular stent-grafts. RADIOLOGY 1997;205:657-662.
2. Chung J, Owen R, Turnbull R, Chyczij H, Winkelaar G, Gibney
N. Endovascular repair in traumatic thoracic aortic injuries:
comparison with open surgical repair. J VASC INTERV RADIOL
2008;19:478-486.
3. Go MR, Barbato JE, Dillavoum ED, Gupta N, Rhee RY, Makaroun
MS, Cho JS. Thoracic endovascular aortic repair for traumatic
aortic transection. J VASC SURG 2007;46:928-933.
4. Midgley PI, MacKenzie KS, Corriveau MM, Obrand DI, Abraham
CZ, Fata P, Steinmetz OK. Blunt thoracic aortic injury: a single
institution comparison of open and endovascular management.
J VASC SURG 2007;46:662-668.
5. Marcheix B, Dambrin C, Boldu JP, Arnaud C, Hollington L, Cron
C, Mugniot A, Soula P, Bennaceur M, Chabbert V, Otal P, Cerene
A, Rousseau H. Endovascular repair of traumatic rupture of the
aortic isthmus: midterm results. J THOR CARDIOVASC SURG
2006;132:1037-1042.
6. Lin PH, Bush RL, Zhou W, Peden EK, Lumsden AB. Endovascular
treatment of traumatic thoracic aortic injury -- should this be the
new standard? J VASC SURG 2006;43:A22-A29.

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1302.4
Intramural haematoma and penetrating ulcer
F.E.Vermassen
Department of Vascular Surgery, University Hospital Ghent, Ghent,
Belgium
No abstract available.

Fundamental Course
Radioembolisation
1701.1
Dose calculation for IRs
E.G.SantosMartn
Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA,
United States of America
Learning Objectives
1. To learn how to take advantage of current methods for
radioembolisation dosimetry
2. To learn how to improve dosimetry and its efficacy in
radioembolisation
3. To learn how to evaluate the data in current literature
Radioembolization dosimetry
Radioembolization (RE) with yttrium-90 (Y-90) is an established
treatment tool for primary and secondary liver tumors. Y-90 RE is
based on the administration of resin or glass microsphere containing radioisotope Y-90 into the hepatic arteries that supply the liver
tumors. Microsphere distribution varies according to the arterial
flow until the microspheres reach the arterioles in and around the
tumor, delivering high local radiation absorbed dose.
Y-90 RE comprises two different therapeutic principles: embolization and brachytherapy. The delivery of microspheres is adjusted
based on angiographic findings (embolization). The administration
of radiation with dosimetry based on the tumor and target volume
classifies this therapy as a brachytherapy procedure. The biological
tissue effects are essentially related to the radiation injury.
Y-90 properties
Y-90 is a beta emitter (beta energy 0.93 MeV) with a half-life of 2.67
days. Up to 94% of the Y-90 microsphere radiation dose can be delivered during the first 11 days following treatment. Tissue penetration
ranges between 2.5 and 11 mm. According to the Medical Internal
Radiation Dose (MIRD) principle, 1 gigabecquerel (GBq) of Y-90 uniformly distributed through 1 kg of tissue provides an absorbed dose
of approximately 50 Gy.
Platforms: Y-90 microspheres: glass microspheres (Therasphere,
BTG) and resin microspheres (SIR-spheres, Sirtex Medical). Glass
microspheres are FDA approved for unresectable HCC since 1999,
and resin microspheres are FDA approved for CRC liver metastases
since 2002.
Glass microspheres are smaller and with higher activity. They contain 2500 Bq per microsphere, and approximately 12 million microspheres are injected per patient. Resin microspheres contain 50 Bq
per microsphere, and 4060 million microspheres are injected per
patient.
Pre-treatment imaging and dosimetry
Before the RE procedure, a pre-planning arteriogram is obtained.
This allows us to identify the anatomy pertinent to the case, embolize non-target vessels close to the injection site, and define the best
place to inject a scout dose. Y-90 does not emit gamma radiation.
In order to assess the Y-90 biodistribution, pre-treatment planning
is performed with a high activity surrogate isotope. Technetium99m macroaggregated albumin (99mTc-MAA) is used for simulation,

Abstract Book
and SPECT-CT is the preferred imaging technique for the assessment
of extrahepatic activity and lung shunting. Lung shunting is due to
arteriovenous shunting within the liver (parenchyma or tumor) and
could potentially result in radiation pneumonitis after RE.
Prediction and measurement of activity distributions is the biggest
challenge of RE. Personalized predictive dosimetry will help individualize the treatment, maximizing the antitumoral effect and minimizing the toxicity.
References
1. Smits ML, Elschot M, Sze DY, Kao YH, Nijsen JF, Iagaru AH, de
Jong HW, van den Bosch MA, Lam MG. Radioembolization
dosimetry: the road ahead. Cardiovasc Intervent Radiol. 2015
Apr;38(2):261-9.
2. Braat AJ, Smits ML, Braat MJ, van den Hoven AF, Prince
JF, de Jong HW, van den Bosch MA, Lam MG. 90Y Hepatic
radioembolization: an update on current practice and recent
developments. J Nucl Med. 2015 Jul;56(7):1079-87.
3. Tong AK, Kao YH, Too CW, Chin KF, Ng DC, Chow PK. Yttrium-90
hepatic radioembolization: clinical review and current
techniques in interventional radiology and personalized
dosimetry. Br J Radiol. 2016 Jun;89(1062):20150943.
4. Rodrguez LS, Thang SP, Li H, Khor LK, Tay YS, Myint KO, Tong
AK. A descriptive analysis of remnant activity during (90)Y resin
microspheres radioembolization of hepatic tumors: technical
factors and dosimetric implications. Ann Nucl Med. 2016
Apr;30(3):255-61.
5. Garin E, Rolland Y, Laffont S, Edeline J. Clinical impact of (99m)
Tc-MAA SPECT/CT-based dosimetry in the radioembolization of
liver malignancies with (90)Y-loaded microspheres. Eur J Nucl
Med Mol Imaging. 2016 Mar;43(3):559-75.
6. Hickey R, Lewandowski RJ, Prudhomme T, Ehrenwald E, Baigorri
B, Critchfield J, Kallini J, Gabr A, Gorodetski B, Geschwind JF,
Abbott A, Shridhar R, White SB, Rilling WS, Boyer B, Kauffman
S, Kwan S, Padia SA, Gates VL, Mulcahy M, Kircher S, Nimeiri
H, Benson AB, Salem R. 90Y radioembolization of colorectal
hepatic metastases using glass microspheres: safety and survival
outcomes from a 531-patient multicenter study. J Nucl Med.
2016 May;57(5):665-71.

1701.2
Embolisation principles: preparation for radioembolisation
R.J.Lewandowski
Interventional Radiology, Northwestern University, Chicago, IL, United
States of America
Learning Objectives
1. To learn how to take advantage of embolisation in preparation
of radioembolisation
2. To learn how to select patients for embolisation in preparation
of radioembolisation
3. To learn how to use recent data to improve safety and efficacy
Patients are deemed candidates for radioembolization based on
tumor type/stage, disease burden, liver function, performance status, and ability to effectively deliver radioactive microspheres to
tumor while mitigating complications from non-target embolization. Dedicated planning angiography and macro-aggregated
albumin (MAA) injection are required to ensure appropriate treatment planning. Importantly, patients should be discussed in a multidisciplinary forum, ensuring appropriate timing/triaging of available therapies. Eligible patients need to have no contraindication to
angiography[1].
Hepatic arterial variants are common, existing in 40% of patients[2].
The primary area of consideration is the left hepatic lobe, where
extra-hepatic arteries are more commonly encountered[3]. Early
branches of the left hepatic artery include a caudate branch and
occasionally hepatic segment 4 arteries. Any other branch off the

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proximal left hepatic artery, prior to its terminal bifurcation, should
be interrogated. Arteries of interest include the right gastric artery,
falciform artery, replaced left inferior phrenic artery, and accessory
left gastric/esophageal artery. Inadvertent delivery of microspheres
to these arteries can result in significant toxicity, including gastrointestinal tract ulceration, abdominal pain/skin necrosis, and/or diaphragm injury.
Tips to identify these branches include reviewing the size/distribution of the left hepatic lobe prior to angiography, paying special
attention to the fissure for the ligamentum venosum. An artery in
this location indicates an accessory/replaced left hepatic artery from
the left gastric artery. Otherwise, any artery identified on angiography that appears to course in a location where there is not liver on
cross-sectional imaging should be interrogated[4].
All intra-hepatic arteries have the same flow dynamics. Carrying digital subtraction imaging out to the delayed venous phase will help
identify extra-hepatic perfusion; arteries with different flow dynamics/pressures tend to retain contrast, whereas the hepatic arteries
uniformly washout. These arteries may also actually increase in size
as they move towards the periphery of the liver. The delayed phase
is also helpful in assessing for a draining coronary vein, an indicator of extra-hepatic (i.e., gastric) perfusion. Cone-beam CT should
be employed to confirm appropriate tumor targeting whenever
necessary.
Macro-aggregated albumin (MAA) labeled with technetium is
injected into the hepatic arteries prior to treatment in order to simulate radioembolization. While this study may identify non-target
deposition of microspheres, its primary purpose is to estimate the
lung shunt fraction (LSF). The lung dose should be <30 Gray/treatment (or <50 Gray lifetime) for glass microspheres, or the LSF should
be <20% for resin microspheres to mitigate the occurrence of radiation pneumonitis[5].
References
1. Kennedy, A., et al., Recommendations for radioembolization
of hepatic malignancies using yttrium-90 microsphere
brachytherapy: a consensus panel report from the
radioembolization brachytherapy oncology consortium. Int J
Radiat Oncol Biol Phys, 2007. 68(1): p. 13-23.
2. Covey, A.M., et al., Variant hepatic arterial anatomy revisited:
digital subtraction angiography performed in 600 patients.
Radiology, 2002. 224(2): p. 542-7.
3. Song, S.Y., et al., Nonhepatic arteries originating from the
hepatic arteries: angiographic analysis in 250 patients. J Vasc
Interv Radiol, 2006. 17(3): p. 461-9.
4. Lewandowski, R.J., et al., Radioembolization with (90)y
microspheres: angiographic and technical considerations.
Cardiovasc Intervent Radiol, 2007. 30(4): p. 571-92.
5. Salem, R. and K.G. Thurston, Radioembolization with 90Yttrium
microspheres: a state-of-the-art brachytherapy treatment for
primary and secondary liver malignancies: part 1: technical and
methodologic considerations. J Vasc Interv Radiol, 2006. 17(8): p.
1251-78.

1701.3
Patient care: outpatient setup, special precautions
W.S.Rilling
Vascular and Interventional Radiology, Medical College of Wisconsin,
Milwaukee, WI, United States of America
Learning Objectives
1. To learn how to perform radioembolisation on out-patient
set-up
2. To learn how to take all the necessary precautions
3. To learn how to use recent data to improve safety and efficacy
Currently, there are very limited data regarding Y90 radioembolization of primary renal cell carcinoma. There is a single case report

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described in the literature. This patient had a sarcomatoid sub-type

of renal cell carcinoma with liver metastases. The patient was treated
with a conservative dose of 80 gy to the tumor, which was well tolerated. Overall imaging follow-up showed stable disease in the primary tumor with progression of distant metastases in the liver and
elsewhere.
The application of radioembolization in renal cell carcinoma may
be limited due to the fact that even very large tumors with vascular invasion are still treated with radical excision provided that the
patient can tolerate a large operation. The role of Y90 radioembolization will likely remain very limited in this disease. However, treatment of liver metastases from renal cell carcinoma shows promise and interventional techniques for treating renal cell carcinoma
metastases in a variety of locations including the skeletal system is
another area of potential benefit to these patients.

1701.4
Overview of recent trials
J.I.Bilbao
Dept. of Radiology, Clinica Universidad de Navarra, Pamplona, Spain
Learning Objectives
1. To learn about the latest RCTs (e.g. Sirflox)
2. To learn about outcome of Y-90 in different tumour entities
(HCC, colon mets and others)
3. To learn about applications of Y-90 outside the liver
Involvement of a multidisciplinary team (MDT) is essential in the
management of metastatic colorectal cancer (mCRC) and hepatocellular carcinoma (HCC).
Three previously published randomised studies (1-3) provided
the basis of our knowledge on the use of RE with Y-90 resin microspheres to treat mCRC. These studies indicated that RE has a role in
chemotherapy-refractory mCRC but also delays liver progression
and possibly improves overall survival (OS) when added to first-line
chemotherapy regimens.
A fourth controlled trial has now been reported, SIRFLOX (4), which
greatly enhances our knowledge of the use of RE with Y-90 resin
microspheres (SIR-Spheres) in combination with first-line chemotherapy for patients with liver-dominant mCRC. In SIRFLOX, patients
were recruited with non-resectable liver-only or liver-dominant
mCRC with no previous chemotherapy for advanced disease. After
screening, 530 patients were randomised to receive mFOLFOX chemotherapy ( bevacizumab) or mFOLFOX chemotherapy ( bevacizumab) + a single session of SIRT with Y-90 resin microspheres. The
primary endpoint was progression-free survival (PFS) at any site, and
there was no significant difference between the groups (median
PFS 10.7 months and 10.2 months in the SIRT group and non-SIRT
group, respectively). However and importantly, assessment of PFS in
the liver with a competing risks analysis showed that patients whose
treatment included SIRT had a 7.9-month improvement in PFS in
the liver from 12.6 to 20.5 months (p=0.002) and a 31% reduced risk
(HR=0.69) of the tumours in their liver progressing (Figure 2). Similar
liver resection rates were observed in the two arms of the study.
For HCC, ENRY provided survival data in a large population (n=325)
who had received Y-90 resin microspheres, and showed that factors
such as ECOG performance status and tumour burden influenced
survival after treatment with RE (5)
Recently, a pilot randomised trial, SIRTACE, suggested that RE
may be an alternative to TACE for patients with unresectable HCC
because a single session of SIRT with Y-90 resin microspheres had a
similar impact on ORR and HRQoL as multiple sessions of TACE (6).
RE has been available for several years; however, with the new data
emerging on this therapy option, our challenge as interventional
radiologists will no longer be the uncertainties in the literature but
to interpret the wealth of evidence in order to deliver SIRT optimally
to patients who could most benefit (7,8).

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References
1. Gray B, Van Hazel G, Hope M, et al. Randomised trial of
SIR-Spheres plus chemotherapy vs. chemotherapy alone for
treating patients with liver metastases from primary large bowel
cancer. Ann Oncol 2001;12:1711-20.
2. Van Hazel G, Blackwell A, Anderson J, et al. Randomised phase 2
trial of SIR-Spheres plus fluorouracil/leucovorin chemotherapy
versus fluorouracil/leucovorin chemotherapy alone in advanced
colorectal cancer. J Surg Oncol 2004;88:78-85.
3. Hendlisz A, Van den Eynde M, Peeters M, et al. Phase III trial
comparing protracted intravenous fluorouracil infusion alone
or with yttrium-90 resin microspheres radioembolization for
liver-limited metastatic colorectal cancer refractory to standard
chemotherapy. J Clin Oncol 2010;28:3687-94.
4. Gibbs P, Heinemann V, Sharma NK, et al. SIRFLOX: Randomized
phase III trial comparing first-line mFOLFOX6 bevacizumab
(bev) versus mFOLFOX6 + selective internal radiation therapy
(SIRT) bev in patients (pts) with metastatic colorectal cancer
(mCRC). J Clin Oncol 2015;33 (suppl.):A3502.
5. Sangro B, Carpanese L, Cianni R, et al. Survival after yttrium-90
resin microsphere radioembolization of hepatocellular
carcinoma across Barcelona clinic liver cancer stages: a European
evaluation. Hepatology 2011;54:868-78.
6. Kolligs FT, Bilbao JI, Jakobs T, et al. Pilot randomized trial of
selective internal radiation therapy vs. chemoembolization in
unresectable hepatocellular carcinoma. Liver Int 2015;35:1715-21.
7. Ricke J, Bulla K, Kolligs F, et al. Safety and toxicity of
radioembolization plus Sorafenib in advanced hepatocellular
carcinoma: analysis of the European multicentre trial SORAMIC.
Liver Int 2015;35:620-6.
8. Vilgrain V, Abdel-Rehim M, Sibert A, et al. Radioembolisation
with yttrium-90 microspheres versus sorafenib for treatment of
advanced hepatocellular carcinoma (SARAH): study protocol for
a randomised controlled trial. Trials 2014;15:474.

Special Session
Robotic interventions: which patients;
is it worth it?
1702.1
Carotid stenting
B.T.Katzen
Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami,
FL, United States of America
Learning Objectives
1. To learn which patients benefit most
2. To learn about the set-up for carotid interventions
3. To learn specific tips and tricks

Abstract Book
embolization,the specific anatomical challenges in PAE are : tortuous arteries to navigate, misdirection of pre-shaped catheters,
acutely angulation of the ostium of the prostatic artery especially
when it arise very proximally from the inferior vesical artery. This can
result in lenghty procedure and high radiation dose to operator and
patient.
Robotic intervention is mainly represented today by the Magellan
robotic catheter. A 6 F guiding catheter which can be deflected by
specific remote manipulation allows to enter the internal iliac artery
over a .35 stiff guide wire. Up to a recent period, the subsequent
manipulation of a micro catheter was manually performed in order
to catheterize the prostatic Artery, although it was already possible
to approach its ostium very close with the 6 F guiding catheter.
Recently, a specific driving mechanism has allowed robotic assisted
manipulation of the micro catheter and wire. This is based on the use
of a . 018 stiff guide wire that allowed cross-over and one step cannulaiton of the internal iliac artery followed by micro catheter insertion into the PA. This approach is a breakthrgouh despite remaining
limitations such as rigidity of the wire, inability to do control injection with enough practicality.
A new specific micro catheter from the internal R and D Hansen
team seems very promising and should be available for clinical testing very soon.
With regards to the radiation saving, a preliminary study presented
recently confirmed the interest of using remote control of catheter
system allowed by the Magellan system. In a case series of 14 cases
comprising 10 TACE Katzen showed that by allowing remote manipulation of the catheter, the physician s dose reduction could be
reduced by 92 % in TACE and 95 % in vascular interventions. More
evidence is needed to confirm these findings but it seems intuitive that remote manipulation allows the IR to step back from the
groin and will represent in the future a signifcant benefit of robotic
assisted embolization.
Overall, it appears know that the Magellan system is very reliable
and allows access to the PA in case of severely calcfified and tortuous iliacs, but that there are still more progress needed in system set
up and step by step catheterization to allow its widespread use.
Further progress will likely come also from integration of imaging
guidance (RF guidance or other) to allow reduction of fluoro time by
fusion of pre-op MR/CT images.
In conclusion, Robotic assisted embolization of the PA is definelty
a progress and furhter refinements of the available technology is
needed in order to meet the IR s need and come into current clinical practice.
References
1. Andreassi MG et al JACC Cardio vascular Intervention 2015.
2. Katzen BT et al. Presented at Charing Cross 2015.
3. Riga CV et al. Advantages and limitations of robotic
endovascular catheters for carotid artery stenting.
J Cardiovasc Surg 2012; 53 :1-4.

1702.3

No abstract available.

Fibroid embolisation
M.S.Hamady
Radiology, St Marys Hospital, London, United Kingdom

1702.2
Prostate embolisation
M.R.Sapoval, C.DelGiudice, G.Amouyal, O.Pellerin
Dept. of Cardiovascular Radiology, Hpital Europen Georges
Pompidou, Paris, France

Learning Objectives
1. To learn which patients benefit most
2. To learn about the set-up for fibroid embolisation
3. To learn specific tips and tricks

Learning Objectives
1. To learn which patients benefit most
2. To learn about the set-up for prostate interventions
3. To learn specific tips and tricks
Complex embolization procedure may require prolonged intervention time for several reasons. In the setting of prostatic artery

No abstract available.

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1702.4
Visceral arterial interventions
D.Kuhelj
Institute of Radiology, University Medical Centre, Ljubljana, Slovenia
Learning Objectives
1. To learn which patients benefit most
2. To learn about the set-up for visceral arterial interventions
3. To learn specific tips and tricks
The number and the complexity of percutaneous procedures involving visceral arteries is increasing from dilatations and stenting, grafting, embolizations and chemoembolizations, and coiling to chimneys and snorkels and fenestrated and branched stent grafts. Many
patients who were previously considered to be ineligible have
become eligible for endovascular treatment with the new tools and
approaches. Consequently, there are many issues addressing the
operators:
Access vessels, especially for larger devices, that are mainly
affected by tortuosity and calcifications that influence catheterization and the rate of periprocedural complications
Catheter stability, allowing access and implantation of different
devices
Radiation exposure to patients and operators, which is not negligible in this area, even in relatively simple interventional procedures
The amount of contrast media (CM) necessary for the procedures,
etc.
To overcome these issues, operators should be skilled during training, which lasts for years.
In complex anatomy, the navigation and maneuverability of robotic
catheter systems (RCS) are supposed to be better compared with
those of manual catheterization and RCS should therefore be safer
for patients because of the better stability of catheters and lower
amount of radiation exposure and CM.
Unfortunately, the current data, especially clinical, on the performance of RCS in the visceral arteries is limited and sometimes controversial, so it is difficult to draw solid conclusions.
Especially, during the implantation of fenestrated and branched
stent grafts, RCS are supposed to be able to reduce procedure time,
radiation dose, and number of catheter movements in order to target the desired vessel and to potentially lower the complication rate,
especially in combination with current image fusion and 3D imaging
technology in the angiosuite. Catheter stabilization with RCS offers
obvious advantage in difficult anatomies. Randomized study in animal models showed the superiority of RCS over manually performed
procedure in the visceral, renal, and contralateral iliac arteries. The
study included not only catheterization but also stent deployment
in in vivo models. Vascular lesions after the procedures were significantly more common in manually performed procedures (p < 0.01).
Overall, the study showed non-inferiority to establish manual technique in tested animals, although the conclusions were drawn from
healthy specimens and the results might be different in presence of
pathology encountered in real-life settings.
Also, the time to target vessel cannulation showed superiority of
RCS over manually performed procedure in the complex anatomies (branched and fenestrated stent grafts); cannulation of the
renal, celiac, and superior mesenteric arteries was significantly faster
with RCS. The greatest differences were in anatomically challenging vessel cannulation, with an overall time reduction of 83%. RCS
offers centerline navigation, producing minimal impact to the vessel wall and reducing the possibility of vessel damage, distal embolization, or dissection. Catheter stability is another important feature, allowing the avoidance of deep ostial cannulation (with possible damage), while obtaining a stable route for endovascular therapy, including dilatation balloons and stent delivery at desired point
without difficult curve crossing. There are some reports, including
our experience, favoring access to the visceral arteries from above

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due to easier access to the target vessel and more stable catheter
position. Stable ostial catheter position with RCS allows conventional, trans-femoral approach instead of the approach from above
that might be questionable, especially in the use of larger introducer
sheaths necessary for some complex procedures.
Technical results of RCS are often similar between highly experienced and less experienced interventional operators. This confirms
that robotic therapy is easy to use, possibly reducing the learning
time for beginners to perform complex procedures.
Radiation doses, received during abdominal vascular procedures
can be considerable, especially in long-lasting, complex procedures.
Radiation dose to the operator is reduced by the use of RCS, which
allow remote control of the system. Consequently, the radiation
dose for the staff is lower or even negligible in case of location of
the remote control outside the angiosuite. Although dose reduction
mostly affects staff, patient dose can also be reduced due to shorter
procedure times.
Aortic and iliac tortuosity, excessive calcifications, and plaques influence stent graft delivery and represent a high risk for vessel damage and distal embolization. Remote vascular access can be seriously affected by tortuosity, including visceral branches or contralateral limb cannulation, especially in the presence of a large, nonthrombosed abdominal aneurysm. Considerable iliac tortuosity
makes manual target vessel cannulation increasingly demanding,
while it was not affecting procedures, performed by RCS; functionality was unaffected by the severity of iliac tortuosity. Also, the robotic
catheters are steered in contrast to the conventional catheters that
require force and pushing, controlling the catheter tip and potentially resulting in a less traumatic impact to the vessel.
In situ stent graft fenestration has been described in animal models, offering the possibility of endovascular approach to the patients
unsuitable for conventional stent grafts, especially in emergency
conditions where branched and fenestrated devices are not readily accessible. This technique could also be beneficial in aortic dissections, when fenestration between true and false lumens should
sometimes be performed as well as for cannulation of arterial
branches in false lumen.
Promising data of in vitro and animal model-based RCS are not
always confirmed by clinical data; in a safety and feasibility study
including 15 patients and 37 vessel cannulations, during branched
and fenestrated stent graft implantations, not all vessels were cannulated by RCS in 15 minutes. Manual approach was successfully attempted in all patients, although cannulation time was longer than 30 minutes. Also, technical encounters were identified.
Catheter steering in a limited space between aortic lumen and fabric was limited, and the diameter of peripheral catheter (6 Fr) was
unsuitable for delivery of many peripheral stent grafts.
There are other issues to consider, including less contact to the
patient and less friendly environment due to additional RCS equipment, influencing patient comfort. It also offers no tactile and force
feedback information, which is very important for the operators.
Some systems try to overcome this with force sensors, allowing constant catheter-tissue measurements, although still no tactile feeling
can be simulated. Systems often use expensive and non-standard
catheters, raising costs and reducing catheter availability. The size of
RCS is limited: for visceral use, 6 Fr is larger as catheters, used during manual catheterization, while for peripheral stent graft implantation, 6 Fr is often too small, while 9 Fr might cause issues with safe
hemostasis.
The major drawback of RCS is still the price. The systems are expensive; initial reported cost of more than 600,000$ is augmented with
high maintenance costs of over 60,000$ per year, augmented with
expensive disposable catheters. Though systems decrease gradually in size, they are still large and cumbersome, limiting the use in
routine work in standard angiosuites. Set-up times for the systems
are not negligible, lasting from 5 to 15 minutes for each procedure
in laboratory and clinical settings. Still, if the rest of the procedure

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would be performed faster, there would be minimal or no practical

impact of RCS set-up time on the procedure duration.
Despite promising initial results, current clinical data show only limited benefit of RCS. Their use seems safe, and radiation dose, especially to the staff, can be significantly reduced. Further clinical studies will provide better insights and define the role of RCS in the visceral arteries. The major drawback for the wider use of RCS is the
price of the system, its maintenance, and disposable catheters.
References
1. Kuhelj D, Zdear U, Jevti V, et al. The risk for deterministic
effects in patients during endovascular aortic stentgraft
implantation. Br J Radiol 2010;83:958-63.
2. de Ruiter QMB, Moll FL, van Herwaarden JA. Current state in
tracking and robotic navigation. J Vasc Surg 2015;61:256-64.
3. Riga CV, Bicknell CD, Hamady MS, et al. Robotically-steerable
catheters and their role in the visceral artery segment. J
Cardiovasc Surg 2011;52:352-62.
4. Duran C, Lumsden AB, Bismuth J. A randomized control animal
trial demonstrating feasibility and safety of the Magellan
endovascular robotic system. Ann Vasc Surg 2014;28;470-8.
5. Riga CV, Bicknell CD, Hamady M, et al. Tortuous iliac systems--a
significant burden to conventional cannulation in the visceral
segment: is there a role for robotic catheter technology? J Vasc
Interv Radiol 2012;23:1369-75.
6. Raghu C, Louvard Y. Transradial approach for percutaneous
transluminal angioplasty and stenting in the treatment of
chronic mesenteric ischemia. Catheter Cardiovasc Interv
2004;61:450-4.
7. Cochennec F, Kobeiter H, Gohel M, et al. Feasibility and safety
of renal and visceral target vessel cannulation using robotically
steerable catheters during complex endovascular aortic
procedures. J Endovasc Ther 2015;22:187-93.
8. Antoniu GA, Riga CV, Mayer EK, et al. Clinical applications of
robotic technology in vascular and endovascular surgery. J Vasc
Surg 2011;53:493-9.

Special Session
Musculoskeletal embolisation
1703.1
Pre-operative embolisation
R.Marcello
Diagnostic and Interventional Radiology, San Filippo Neri Hospital,
Rome, Italy
Learning Objectives
1. To learn how to select patients and provide appropriate patient
care
2. To learn tips and tricks for successful pre-operative embolisation
3. To learn how to use recent data to improve safety and efficacy
Embolization of tumors has been widely practiced in medicine, particularly by interventional radiologists, and was first used for renal
cell carcinomas. One of the earliest reports of such a procedure was
in 1975 when it was employed to reduce perioperative blood loss.
The well-known target of this procedure is to decrease blood supply to hypervascular tumors and attain get pain control due to bone
metastasis and management of tumors that are unresponsive to traditional therapy. At the beginning, the embolization procedure was
involved in trauma or hemorrhage control with further quick implementation in the treatment of organ-based tumors.
Indications to transarterial embolization of primary or metastatic
musculoskeletal tumors may vary from operative blood loss to simplify definitive surgery and allow palliation and control of pain,
bleeding, and fever. Embolization may even increase tumor sensitivity to chemotherapy or radiation therapy. Musculoskeletal tumors

Abstract Book
include primary or metastatic tumors of benign or malignant etiology of the muscles, joints, and skeleton.
Bone tumors may present as fractures or in the settings of incidental findings, with pain and impairment or loss of function. Infiltration
of the periosteum and adjacent structures such as joints, neural
bundles, and compression of soft tissues lead to loss of function
and onset of pain. Trabecular fractures and complete fractures may
occur; both are currently accompanied by pain and disability. The
presence of a musculoskeletal tumor may also be noted incidentally
when investigations are carried out for different purposes.
MSK tumor management is complex and many specialties, including interventional and diagnostic radiology, orthopedic surgery,
neurosurgery and general surgery, oncology, and radiotherapy are
involved. The embolization procedure is also complex with significant risks for adjacent structures to be involved as undesired target embolization. Therefore, it is mandatory to establish the goals
of treatment, the potential side effects, and complications as well as
to make the correct selection of patients to be included in treatment
planning.
The primary aim of embolization is to stop or significantly decrease
blood supply to the tumor with subsequent necrosis and tumor lysis.
The procedure may be in the setting of a palliative cure to relieve
pain as a pre-operative measure to decrease blood loss in a clearer
operative field, to obtain a less difficult dissection, and get a more
definitive surgery and a decrease in tumor size. Reports of arterial
embolization procedure of MSK tumors prior to surgery are rare but
usefulness is reported in every case.
In some cases, embolization outcomes may be a complete tumor
necrosis to degrees of ischemia and hypovascularity. Pre-procedural
work-up is essential, particularly by means of magnetic resonance
(MR), computed tomography (CT), and ultrasound (US) in order to
identify arterial blood supply, venous drainage, extent into adjacent
tissue, and proximity of vital structures potentially sharing arterial
supply. CT angiography is particularly useful in large and complex
lesions with multiple arterial feeders when multiple treatments are
planned.
Diagnostic angiography is performed prior to embolization to
detect the tumor-feeding vessels and establish the safety of the procedure. Pre-procedural tests to ensure a safe angiography include
prothrombin time or partial thromboplastin time in patients on heparin, platelet count, and hemoglobin. Abnormal coagulation should
be corrected since particulate embolic agents such as coils and
injectable thrombogenic agents require a normal intrinsic clotting
cascade. This is particularly important in patients with active bleeding or after multiple transfusions, in whom the coagulation profile
should be corrected prior to embolization.
Particular attention must be paid when performing embolization in
the spine region to prevent non-target embolization of the spinal
arteries. In the femoral and humeral regions, the undesired embolization of the vasa nervorum of the main nerves must be avoided.
Once the feeding arteries are identified and detection of the vessels to avoid is carefully done, the vascular network to the tumor is
catheterized.
The best-choice technique is the use of a coaxial catheter system, which comprises of a large 46-Fr catheter hooking the main
artery of the region to give stability to a microcatheter (2.7 Fr or
less) advanced through the larger selective catheter. Advantages of
using a coaxial catheter system include the ability to deliver embolic
agents further from the parent vessel in order to reduce the risk of
non-target embolization likely by the selective cannulation of the
often hypertrophied feeding vessels, which are hard to engage with
the larger diagnostic catheter, preventing spasm or occlusion of target vessels that may result in a false procedure end-point.
Since the main purpose of embolization is to obtain thrombus formation and occlusion of feeding vessels to the tumor, embolizing materials must be administered through the selective catheter
placed in an artery or vein.

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The choice of an embolic agent should be made on the basis of multiple factors such as vessel caliber, collateral supply to or from adjacent normal tissue, arteriovenous shunts, and most importantly, the
operator experience.
Embolization materials may be classified as permanent or temporary
and on the basis of their physical state as particulate or liquid.
Liquid embolization materials include glue (N-butyl cyanoacrylate-NBCA-GEM S.r.l. Viareggio, Italy), absolute alcohol, Ethibloc
(Ethicon, Norderstedt, Germany), sodium tetradecyl sulfate, Onyx
(Microtherapeutics, Irvine CA, USA).
Particulate agents include embosphere (Biosphere, France), polyvinyl alcohol (PVA) particles (Contour Cook Inc. Bloomington IN, USA),
and gelfoam (Pharmacia, USA).
Embolization of bone tumors with liquid embolics leads to more
complete tumor necrosis and is advantageous when definitive treatment is desired. Ossification of tumors after embolization procedures with glue may be observed. On the other hand, liquids carry a
higher risk of non-target embolization and catheter occlusion.
Particulate agents are quite easy to handle even if an error in particle
size selection may lead to potential pulmonary embolism. PVA it is
a commonly used agent because of several desirable characteristics
such as reliable occlusion of tumor vessels. However, PVA can aggregate in catheter lumen causing occlusion.
Embosphere are PVA particles with regular and smooth surface.
They are compressible and can be delivered through small catheters.
Gelfoam is a dissolvable sponge-like material considered a temporary embolization agent with recanalization within a month of
occluded arteries.
Coils are reserved for occlusion of large and medium-sized feeding
arteries often in combination with particulate agents. They have an
important role in the emergency setting with an operator unfamiliar
with other embolics such as liquids.
The basic principle and the main goal of tumor embolization is the
occlusion of most of the capillary bed. The occlusion of the main
feeding arteries is ineffective because of the presence of many collaterals in hypervascular bone tumors. Surgery should be performed
within 3 to 5 days of embolization in order to prevent reconstitution
of tumor blood flow.
The two common complications of embolization procedures are the
undesired non-target site embolization and the well-known postembolization syndrome that presents with fever, pain at the treated
site, headache, and malaise.
References
1. Iwamoto S, Takao S, Nose H, Otomi Y, Takahashi M, Nishisho T,
Ueno J, Yasui N, Harada M. Usefulness of transcatheter arterial
embolization prior to excision of hypervascular musculoskeletal
tumors. J Med Invest. 2012;59:284288.
2. Gupta P, Gamanagatti S. Preoperative transarterial embolisation
in bone tumors. World J Radiol. 2012;4:186192.
3. Carpenter P R, Ewing J W, Cook A J, Kuster A H. Angiographic
assessment and control of potential operative hemorrhage with
pathologic fractures secondary to metastasis. Clin Orthop Relat
Res. 1977;123:68.
4. Basile A, Rand T, Lomoschitz F, et al. Trisacryl gelatin
microspheres versus polyvinyl alcohol particles in the
preoperative embolization of bone neoplasms. Cardiovasc
Intervent Radiol. 2004;27:495502.
5. Munk P L, Legiehn G M. Musculoskeletal interventional
radiology: applications to oncology. Semin Roentgenol.
2007;42:164174.
6. Rossi G, Rimondi E, Bartalena T, et al. Selective arterial
embolization of 36 aneurysmal bone cysts of the skeleton with
N-2-butyl cyanoacrylate. Skeletal Radiol. 2010;39:161167.
7. Feldman F, Casarella W J, Dick H M, Hollander B A. Selective
intra-arterial embolization of bone tumors. A useful adjunct in
the management of selected lesions. Am J Roentgenol Radium
Ther Nucl Med. 1975;123:130139.

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8. Forauer A R, Kent E, Cwikiel W, Esper P, Redman B. Selective

palliative transcatheter embolization of bony metastases from
renal cell carcinoma. Acta Oncol. 2007;46:10121018.
9. Guzman R, Dubach-Schwizer S, Heini P, et al. Preoperative
transarterial embolization of vertebral metastases. Eur Spine J.
2005;14:263268.
10. Sun S, Lang E V. Bone metastases from renal cell carcinoma:
preoperative embolization. J Vasc Interv Radiol. 1998;9:263269.
11. Chatziioannou A N, Johnson M E, Pneumaticos S G, Lawrence D
D, Carrasco C H. Preoperative embolization of bone metastases
from renal cell carcinoma. Eur Radiol. 2000;10:593596.
12. Hansch A, Neumann R, Pfeil A, et al. Embolization of an unusual
metastatic site of hepatocellular carcinoma in the humerus.
World J Gastroenterol. 2009;15:22802282.
13. Wirbel R J, Roth R, Schulte M, Kramann B, Mutschler W.
Preoperative embolization in spinal and pelvic metastases. J
Orthop Sci. 2005;10:253257.
14. Schirmer C M, Malek A M, Kwan E S, et al. Preoperative
embolization of hypervascular spinal metastases using
percutaneous direct injection with n-butyl cyanoacrylate:
technical case report. Neurosurgery. 2006;59:E431E432.
15. Mindea S A, Eddleman C S, Hage Z A, Batjer H H, Ondra S L,
Bendok B R. Endovascular embolization of a recurrent cervical
giant cell neoplasm using N-butyl 2-cyanoacrylate. J Clin
Neurosci. 2009;16:452454.
16. Brban S, Sancak T, Yildiz Y, Salik Y. Embolization of benign
and malignant bone and soft tissue tumors of the extremities.
Diagn Interv Radiol. 2007;13:164171.
17. Bandiera S, Gasbarrini A, De Iure F, Cappuccio M, Picci P,
Boriani S. Symptomatic vertebral hemangioma: the treatment
of 23 cases and a review of the literature. Chir Organi Mov.
2002;87:115.
18. Chu J P, Chen W, Li J P, et al. Clinicopathologic features and
results of transcatheter arterial chemoembolization for
osteosarcoma. Cardiovasc Intervent Radiol. 2007;30:201206.
19. Findik S, Akan H, Baris S, Atici A G, Uzun O, Erkan L.
Preoperative embolization in surgical treatment of a primary
hemangiopericytoma of the rib: a case report. J Korean Med Sci.
2005;20:316318.
20. Yamamoto A, Imai S, Kobatake M, Yamashita T, Tamada
T, Umetani K. Evaluation of tris-acryl gelatin microsphere
embolization with monochromatic X Rays: comparison with
polyvinyl alcohol particles. J Vasc Interv Radiol. 2006;17(11 Pt
1):17971802.
21. Chen Y, Yan Z, Wang J, Wang X, Cheng J, Gong G, Luo J.
Transarterial chemoembolization for pain relief in patients
with hypervascular painful metastatic spinal tumors refractory
to percutaneous vertebroplasty. J Cancer Res Clin Oncol.
2013;139:13431348.

1703.2
Palliative embolisation: alone and in combination with
ablation
R.F.Grasso, E.Faiella
Radiology, Campus Biomedico University, Rome, Italy
Learning Objectives
1. To learn how to select patients and provide appropriate patient
care
2. To learn how to select the most appropriate combination of
techniques
3. To learn how to evaluate current results reported in the
literature
Some reports have shown that ablation therapy is effective and a
safety palliative treatment for the relief of symptoms induced by
tumors (1,2). The pain is generated by increasing the intratumoral or
interstitial pressure or by releasing cytotoxic substances (3).

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The clinical case and the selection of each patient have to be discussed in a previous multidisciplinary board with the oncologist, the
radiotherapist, and the orthopedic.
In majority of the cases, the patient to be treated is affected by
a metastatic bone or soft tissue lesion and patients with limited
metastatic disease benefit from a single ablation with or without
embolization.
The reduction in pain can be obtained by means of both thermal
ablation and freezing with the use of cryoablation.
Meanwhile, especially in the case of a huge soft tissue mass, one can
reduce the vascularization of the tumor with the use of preoperative
embolization. In this case, you will obtain a bigger area of necrosis
compared to that obtained by standard ablative techniques without
preoperative embolization.
Several embolic agents can be used, including both liquid [alcohol,
N-2-butyl-cyanoacrylate, Ethibloc (Ethicon), sodium tetradecyl sulfate, and Onyx] and solid or semisolid (gelfoam, microparticles, and
coils) (4,5).
Major considerations for choosing an embolic agent are speed and
reliability of delivery, duration of occlusive effect, and preservation
of normal tissue (6).
Serial embolization provides devascularization, size reduction, calcification of margins, and pain relief.
The first goal to be obtained is the absence of complications since
these are often terminal patients and the mean target is the reduction in pain and not the cure of the pathology.
Knowing the anatomy and the course of the various nerve and their
branches is of primary importance in order to avoid complications
that can lead to an improvement in pain, which in this case is obviously related to the procedure.
Therefore, physicians must monitor the ongoing possibility of neuropathy development during ablation; when neuropathy develops,
ablation of a tumor has to be aborted.
Thermocouples have to be used in case of lesions to be ablated
close to the nerve or vital structures, always considering how to protect these anatomical district (i.e., dissection with CO 2 or glucose).
In conclusion, embolization and ablation can be performed alone or
in combination in primary bone tumors as well as metastatic lesions
in an ever-increasing number.
References
1. Dupuy DE, Liu D, Hartfeil D, Hanna L, Blume JD, Ahrar K, Lopez R,
Safran H, DiPetrillo T: Percutaneous radiofrequency ablation of
painful osseous metastases: a multicenter American College of
Radiology Imaging Network trial. Cancer 2010, 116(4):989997.
2. Callstrom MR, Dupuy DE, Solomon SB, Beres RA, Littrup PJ, Davis
KW, Paz- Fumagalli R, Hoffman C, Atwell TD, Charboneau JW,
Schmit GD, Goetz MP, Rubin J, Brown KJ, Novotny PJ, Sloan JA:
Percutaneous image-guided cryoablation of painful metastases
involving bone: Multicenter trial. Cancer 2013, 119(5):10331041.
3. Indal G, Friedman M, Locklin J, Wood BJ: Palliative
radiofrequency ablation for recurrent prostate cancer.
Cardiovasc Intervent Radiol. 2006, 29(3):482485.
4. Basile A, Rand T, Lomoschitz F, Toma C, Lupattelli T, Kettenbach
J, Lammer J. Trisacryl gelatin microspheres versus polyvinyl
alcohol particles in the preoperative embolization of bone
neoplasms. Cardiovasc Intervent Radiol. 2004, 27(5):495502.
5. Pellerin O, Medioni J, Vulser C, Dan C, Oudard S, Sapoval M.
Management of painful pelvic bone metastasis of renal cell
carcinoma using embolization, radio-frequency ablation, and
cementoplasty: a prospective evaluation of efficacy and safety.
Cardiovasc Intervent Radiol. 2014, 37(3):730736.
6. Mavrogenis AF, Rossi G, Rimondi E, Papagelopoulos PJ, Ruggieri
P. Embolization of bone tumor. Orthopaedics 2011, 34(4):303
310.

Abstract Book

1703.3
Inflammatory and degenerative disease
Y.Okuno
Radiology, Edogawa Hospital, Tokyo, Japan
Learning Objectives
1. To learn how to select patients for embolisation in the shoulder
2. To learn how to select patients for embolisation in the knee
3. To learn how to evaluate current results reported in the
literature
Musculoskeletal inflammatory and degenerative disorders, including frozen shoulder and knee osteoarthritis, are frequent and are
responsible for severe chronic pain and disability, leading to a significant socioeconomic burden.
Despite the large number of patients affected by these conditions,
the source of pain remains unclear and a significant number of
patients are resistant to conventional therapies.
Frozen shoulder is a condition of uncertain etiology that is characterized by the painful restriction of shoulder motion. It is a self-limiting disorder that resolves within 13 years, but residual pain is one of
the most important issues in its management. A study reported that
after non-surgical treatment, 27% of patients had mild or moderate pain at 1.8 years of follow-up[1], and another study reported that
35% of patients had residual pain at 7 years of follow-up[2]. When
conservative therapy is not effective, more invasive approaches are
sometimes required, including capsular distention, manipulation
under anesthesia, and arthroscopic capsular release. Nevertheless,
the optimal treatment for frozen shoulder that is resistant to traditional conservative treatments has not reached consensus.
Knee osteoarthritis is a major source of pain and disability in the
aging population. Minor symptoms can be managed with pain
relievers. Severe and end-stage osteoarthritis can be treated with
total joint arthroplasty. However, the management of moderate
arthritis resistant to non-surgical options and not severe enough to
warrant joint replacement surgery is challenging.
Studies have shown that angiogenesis may contribute to chronic
pain by enabling the growth of new unmyelinated sensory nerves
along its path[3]; these two phenomena are closely related. In fact,
histopathological studies have demonstrated the existence of
abnormal neovessels with accompanying nerve fibers in tissues
obtained during various painful conditions, including osteoarthritis[4], frozen shoulder[5], and overuse injuries such as tendinopathy
and enthesopathy[6]. In addition, angiogenesis is believed to contribute to the genesis of inflammation and especially to its maintenance, and some researchers demonstrated that the pharmacological inhibition of angiogenesis could lead to the improvement of
inflammation and pain behavior in animal experimental models[7].
With the advent of new technology and skills in the field of interventional radiology, the embolization of small abnormal neovessels
has become feasible and appears to be a potential target to treat
chronic pain in musculoskeletal conditions.
We have previously reported the results of transarterial embolotherapy in patients with refractory tendinopathy and enthesopathy[8],
frozen shoulder[9], and mild to moderate knee osteoarthritis[10]. We
named this embolic treatment using small-sized and small amounts
of embolic agents as transcatheter arterial microembolization
(TAME), and so far, we have performed this treatment for more number of patients and assessed long-term clinical results.
Patients diagnosed with frozen shoulder or mild knee osteoarthritis
are good candidates for TAME.
Frozen shoulder (adhesive capsulitis):
Fifty patients with nighttime shoulder pain, normal radiographic
appearance, and painful restriction of passive motion in 2 or more
directions were diagnosed with frozen shoulder and included in the
study.

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From the angiographic findings of our consecutive case series, 49
out of 50 patients had abnormal vessels located at the rotator interval and surrounding tissue, which is thought to be the fat triangle
under the coracoid process. Patients with prior shoulder surgery,
mental illness, and uncontrolled diabetes show weaker results and
should be excluded.
Knee osteoarthritis:
In our experience, patients with mild or minimal degenerative
changes and severe symptoms were significantly relieved by TAME.
Moreover, patients with moderate degenerative changes experienced excellent pain relief. These findings indicate that pain in
osteoarthritis does not necessarily arise from the degenerative site
or owing to cartilage loss. Angiographic findings in the previous
study showed abnormal neovessels within several periarticular tissues, including the synovium and periosteum around the medial
condyle, infrapatellar fat pad, medial meniscus base, and medial
side of the joint capsule.
Patients with severe degenerative changes (KellgrenLawrence
grade 3 or 4) show inferior response rates compared to those with
mild to moderate osteoarthritis (KellgrenLawrence grade 02).
Patients with bone marrow lesions (edema) depicted on MRI also
showed poor results. Thus, we suggest that these patients should be
excluded.
We have also noticed that local tenderness at physical examination
is a good indicator of the existence of abnormal neovessels, suggesting that embolotherapy is a suitable option.
Diagnostic imaging also contributes to patient selection. Abnormal
hypervascularization is depicted by Doppler ultrasound and MRI;
this abnormal vascularization shows a high signal intensity in fluidsensitive sequences such as short tau inversion recovery (STIR) and
fat-suppressed T2W and as an enhancement after paramagnetic
contrast agent addition (gadolinium).
Arterial access:
Radial or brachial artery is selected for shoulder procedures, and
common femoral artery is used in an ipsilateral anterograde route
when we target the knee joints. We use 3-Fr or 4-Fr catheter systems.
Diagnostic angiography:
In our previous studies, neovascularization at the painful site was
clearly depicted on digital subtraction angiography. Abnormal
neovessels were excessive and disorganized and contained arteriovenous shunts according to the findings of early venous drainage.
Embolic material:
We used two types of embolic materials: imipenem/cilastatin
sodium (IPM/CS) and calibrated microsphere. IPM/CS is an FDA
approved antibiotic, which is slightly soluble in water and when suspended in a contrast agent, forms 10- to 70-m particles that exert
an embolic effect[11]. A suspension of 0.5 g of IPM/CS in 510 mL of
iodinated contrast agent was prepared by pumping syringes for 10 s
and then injected in 0.2 mL increments until blood flow of abnormal
vessels stagnated.
We have also introduced small-sized and well-calibrated microspheres as embolic agents[10].
The endpoint of embolization is complete stasis of antegrade flow
in the abnormal feeder vessels. Being careful not to infuse too much
amount of particles to normal vasculature is important for good
pain alleviation.
Frozen shoulder:
TAME using IPM/CS was safely performed and resulted in significant
pain reduction and improvement of range of motion and shoulder
function in the short-term follow-up. Furthermore, within our case
series of 25 patients followed up during a mean time of 3 years, we
noticed that a vast majority of patients had normal painless shoulder. Short-term results (after 6 months) were comparable to those
of other invasive treatments such as arthroscopic capsular release
and manipulation under anesthesia. Long-term results were slightly
better than those of the other treatments (more patients were
free of pain and showed better recovery of the range of motion),

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suggesting that TAME does not make direct damage to shoulder capsule and does not alter the healing process. Regarding our
results, we hypothesize that TAME accelerated the healing process.
Knee osteoarthritis:
Six months after TAME, 85% of treated patients showed good
response with satisfactory decrease in pain score. These effects were
sustained over 23 years, and there was no statistical difference
in mean pain scores at 6 months and at 23 years after TAME. The
MRI assessment at 23 years after TAME in 20 patients revealed that
the patients did not show aggressive knee cartilage loss or newly
formed meniscus tear. There was no evidence of progressive degenerative change, bone marrow necrosis, or edema.
According to our experience, this unconventional and innovative interventional radiology treatment for resistant musculoskeletal pain seems promising and offers a new effective option for pain
control; it is obvious that the efficacy and safety profile of this new
application of embolization should be studied at a larger scale and
should be tested in high-quality controlled trials to evaluate the real
effectiveness of this procedure.
It is important to keep in mind that this procedure remains more
invasive than other routinely used minimally invasive treatments for
pain control and should be performed by a trained interventional
radiologist. Moreover, its added value in pain management must
be rigorously proven. Our limitations are a small number of patients
treated for a wide variety of disorders, and we do not have a control
group. To date, our work represents a solid proof of concept and a
sound basis for further studies.
References
1. Mapp PI, Walsh DA. Mechanisms and targets of angiogenesis
and nerve growth in osteoarthritis. Nat Rev Rheumatol
2012;8:390-8.
2. Walsh DA, Bonnet CS, Turner EL, et al. Angiogenesis in the
synovium amd at the osteochondral junction in osteoarthritis.
Osteoarthr Cartil 2007;15:743-51.
3. Xu Y, Bonar F, Murrell GA. Enhanced expression of neuronal
proteins in idiopathic frozen shoulder. J Shoulder Elbow Surg
2012;21:1391-7.
4. Alfredson H, Ohberg L, Forsgren S. Is vasculo-neural
ingrowth the cause of pain in chronic Achilles tendinosis?
An investigation using ultrasonography and colour Doppler,
immunohistochemistry, and diagnostic injections. Knee Surg
Sports Traumatol Arthrosc 2003;11:334-8.
5. Ashraf S, Mapp PI, Walsh DA. Contributions of angiogenesis
to inflammation, joint damage, and pain in a rat model of
osteoarthritis. Arthritis Rheum 2011;63:2700-10.
6. Okuno Y, Matsumura N, Oguro S. Transcatheter arterial
embolization using imipenem/cilastatin sodium for
tendinopathy and enthesopathy refractory to nonsurgical
management. J Vasc Interv Radiol 2013;24:787-92.
7. Okuno Y, Oguro S, Iwamoto W, et al. Short-term results of
transcatheter arterial embolization for abnormal neovessels in
patients with adhesive capsulitis: a pilot study. J Shoulder Elbow
Surg 2014;23:e199-206.
8. Okuno Y, Korchi AM, Shinjo T, et al. Transcatheter Arterial
Embolization as a Treatment for Medial Knee Pain in Patients
with Mild to Moderate Osteoarthritis. Cardiovasc Intervent
Radiol 2015;38:336-43.
9. Woodhams R, Nishimaki H, Ogasawara G, et al. Imipenem/
cilastatin sodium (IPM/CS) as an embolic agent for
transcatheter arterial embolisation: a preliminary clinical study
of gastrointestinal bleeding from neoplasms. Springerplus
2013;2:344.
10. Griggs SM, Ahn A, Green A. Idiopathic adhesive capsulitis.
A prospective functional outcome study of nonoperative
treatment. J Bone Joint Surg Am 2000;82-A:1398-407.
11. Shaffer B, Tibone JE, Kerlan RK. Frozen shoulder. A long-term
follow-up. J Bone Joint Surg Am 1992;74:738-46.

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1703.4
Malformations
I.J.McCafferty
Dept. of Radiology, The Queen Elizabeth Hospital Birmingham,
University Hospital Birmingham NHS Trust, Birmingham, United
Kingdom
Learning Objectives
1. To learn how to select patients and provide appropriate patient
care
2. To learn tips and tricks for successful embolisation
3. To learn how to use recent data to improve safety and efficacy
In this session on musculoskeletal embolisation: malformations, I
will cover the clinical presentation, classification, patient selection,
imaging and treatment.
Vascular malformations are a complex group of developmental
abnormalities that present significant challenges in diagnosis and
management. The clinical presentation can range from an asymptomatic birthmark to fulminant cardiac failure. The diverse nature
of symptoms associated with vascular malformations and their rarity implies that patients have often seen multiple specialists before
the correct diagnosis is made. Patients often undergo unnecessary
biopsy, surgery and in some cases imaging, which can mean that the
vascular malformation grows and can affect the outcome of further
treatment in some cases. The management of this complex group of
patients should, therefore, be undertaken within a multidisciplinary
team. The exact make-up of the multidisciplinary team depends on
the local availability and interest; however, in our experience, the
team has typically included intervention radiologists, plastic surgeons (craniofacial and peripheral), maxillofacial surgeons and dermatologists. However, other specialties, e.g. general paediatrics, ear,
nose and throat surgeons, laser specialists and vascular surgeons,
frequently receive referrals.
Vascular malformations are developmental anomalies that are a
result of arrested development at various stages of vasculogenesis
or angiogenesis. These can be localised or diffuse and are commonly
sporadic. They are present at birth, although they may not become
apparent until adolescence or adulthood. They affect males and
females equally and persist throughout the life, typically with a fluctuating course of symptoms that can be accentuated by pregnancy.
Lymphatic malformations are localised developmental abnormalities of the lymphatic system, which result in numerous thin-walled
cysts containing lymph. The cysts vary in size and typically are
divided into microcystic (cysts measuring less than 2 cm) and macrocystic (cysts measuring more than 2 cm) variants.
One of the more complex components of understanding and
managing vascular malformations is the knowledge of the current accepted terminology to describe the different entities within
the spectrum of vascular anomalies. A practical classification system that allows a simple differentiation of the subtypes of vascular
anomalies to allow implementation of the correct treatment algorithm is essential.
In 1982, Glowacki and Mulliken (1) proposed a biological classification of vascular anomalies based on clinical behavior, histology and
histochemistry. The classification was accepted by the International
Society for the Study of Vascular Anomalies (ISSVA) and was updated
at the inaugural ISSVA meeting in 1992. This classification is now
widely accepted and has helped resolve the confusion of terminology in the field of vascular anomalies. The classification was updated
at the 20th ISSVA workshop in Melbourne in April 2014. Broadly
speaking, Glowacki and Mulliken divided vascular anomalies into 2
groups: vascular tumours (underlying endothelial hyperplasia) and
vascular malformations (dysmorphogenesis and abnormal cellular
turnover). Vascular malformations are further divided into low flow

Abstract Book
(capillary, venous, lymphatic and combined) and high flow (arteriovenous malformations and arteriovenous fistula). In musculoskeletal terms, the lesions can also be subdivided using the Birmingham
classification, which helps predict the likely outcomes.
Birmingham Classification of Venous Malformations in Periphery
Type 1: Localised or Superficial
a. Without skin involvement or b. With skin involvement
Type 2: Fascia or Muscle Infiltration
a. Without skin involvement or b. With skin involvement
Type 3: Bone or Joint Involvement
a. Without skin involvement or b. With skin involvement
Type 4: Trunk and Limb Lesion (chest or abdomen)
a. Without skin involvement or b. With skin involvement
Type 5: Diffuse Whole Limb Involvement, e.g. KlippelTrenaunay
syndrome
a. Without skin involvement or b. With skin involvement
A vast majority of low-flow vascular malformations (LFVMs) can
be diagnosed by a detailed history and clinical examination; typically, one can also differentiate the majority into lymphatic and
venous subtypes. Imaging is, therefore, there to confirm the diagnosis and extent of involvement, identify rare but significant differential diagnoses and plan treatment options (conservative, percutaneous sclerotherapy or surgery). Numerous modalities exist to image
patients with LFVMs; for example, plain films may show numerous
phleboliths associated with a soft tissue mass and aid the diagnosis of a venous LFVM. Computed tomography (CT) may also show
these characteristics and demonstrate the extent of the lesion as
a hypodense or heterogeneous mass, which enhances slowly and
peripherally (LMs) and homogenously (VMs) with the presence of
intralesional fat as well as haemorrhage. However, the most useful
imaging modalities for the diagnosis and planning of treatment are
ultrasound and magnetic resonance imaging. Diagnostic angiography has no role in the management of LFVMs.
The session will concentrate on intramuscular and bone vascular
malformations from low flow to high flow elements. The importance
of distinguishing these entries will be covered and discussion will
include the imaging modalities best placed to identify and classify
these lesions and plan treatment. I will discuss the potential treatment options and agents that can be used to treat these lesions. I
will concentrate on the agents that I have the most experience with
rather than give a wide ranging description of what is available.
References
1. McCafferty I. Management of low-flow vascular malformations:
clinical presentation, classification, patient selection, imaging
and treatment. Cardiovasc Intervent Radiol. 2015;38:1082104.
2. Mulliken J, Glowacki J. Hemangiomas and vascular
malformations in infants and children: a classification based on
endothelial characteristics. Plast Reconstr Surg. 1982;69:41222.
3. Burrows P, Mason K. Percutaneous treatment of low flow
vascular malformations. J Vasc Interv Radiol. 2004;15:43145.
4. Mendonca D, McCafferty I, Nishikawa H, Lester R. Venous
malformations of the limbs: the Birmingham experience,
comparisons and classification in children. J Plast Reconstr
Aesthet Surg. 2010;63:3839.
5. McCafferty I, Jones R. Imaging and management of vascular
malformations. Clin Radiol. 2011;66:120818.
6. Muir T, Kirsten M, Fourie P, Dippenaar N, Ionescu GO.
Intralesional bleomycin injection (IBI) treatment for
haemangiomas and congenital vascular malformations. Pediatr
Surg Int. 2004;19:76673.
7. Fayad L, Hazirolan T, Bluemke D. Vascular malformations in the
extremities: emphasis on MRI features that guide treatment
options. Skeletal Radiol. 2006;35:12737.
8. Yakes WF. Endovascular management of high-flow arteriovenous
malformations. Semin Intervent Radiol. 2004;21:4958.

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Special Session
The role of IR in inflammatory pancreatic disease
1704.1
Clinical overview of pancreatitis
G.Carrafiello, A.M.Ierardi
Department of Radiology, University of Insubria, Varese, Italy
Learning Objectives
1. To learn about the clinical course, complications and outcome of
pancreatitis
2. To learn about current treatment strategies for pancreatitis
3. To learn about new developments and on-going studies in
treatment of pancreatitis
Acute pancreatitis (AP) is defined as an acute inflammatory state of
the pancreas and is conventionally categorized as either a mild or
severe disease (1).
Worldwide, the incidence of AP is increasing; this is probably related
to the increasing incidence of gallstones, obesity, and aging, which
are all well-known risk factors for AP, among the population.
Although the pathophysiology of AP is incompletely understood,
it is believed that in gallstones and alcoholic pancreatitis, a chain of
events is triggered by a temporary or permanent pancreatic duct
obstruction. Locally, this leads to the activation and release of pancreatic enzymes into the pancreatic interstitium and peripancreatic
tissues. When severe, autodigestion and necrosis occur (2).
In about 80% of cases, AP is a mild self-limiting disease characterized
by minimal local and systemic effects and an uneventful recovery.
In 15% to 20% of cases, severe AP that is accompanied by an exaggerated systemic response characterized by the release of inflammatory cytokines and other mediators develops; this is also known as
the systemic inflammatory response syndrome (SIRS) (3), which contributes to the development of multiple organ dysfunction (4).
The clinical diagnosis of AP requires 2 of the following 3 features (1):
Abdominal pain strongly suggestive of AP (epigastric pain radiating
to the back)
Serum amylase and/or lipase activity at least 3 times the upper limit
of the normal
Characteristic findings of AP on imaging with CT, the best universally
available imaging modality
If abdominal pain is strongly suggestive of AP but the serum amylase and/or lipase activity is less than 3 times the upper limit of
normal, characteristic findings of AP on a CECT or MR imaging are
required to confirm the diagnosis.
The 1992 Atlanta symposium defined AP and classified the complications of AP based on the clinical criteria (6) as acute peripancreatic
fluid collection (APFC), pancreatic necrosis, acute pseudocyst, and
chronic pancreatitis and pancreatic abscess. APFCs occur early in the
course of AP, are located in or near the pancreas and always lack a
wall of granulation or fibrous tissue. Pancreatic necrosis is defined as
a diffuse or focal area(s) of nonviable pancreatic parenchyma, which
is typically associated with peripancreatic fat necrosis. Acute pseudocyst is a collection of pancreatic juice enclosed by a wall of fibrous
or granulation tissue that arises as a consequence of AP or pancreatic trauma. Chronic pancreatitis and pancreatic abscess is defined
as a circumscribed intra-abdominal collection of pus, usually in proximity to the pancreas, containing little or no pancreatic necrosis,
which arises as a consequence of AP or pancreatic trauma.
However, as time goes on, some of the definitions in the original Atlanta classification have been proved to be confusing, especially the definition of severity. In 2012, the Atlanta classification was revised with an emphasis on persistent organ failure (7).
Multifactorial scoring systems, including Ranson et al (8) and Acute
Physiology and Chronic Health Evaluation (APACHE)-II scores (9)
have been used since the 1970s for the assessment of the severity

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of AP. Balthazar computed tomography severity index (CTSI) (10)

was developed in 1990. These predictive methods have been established as an important tool for the assessment of the severity of AP.
A new prognostic scoring system, the Bedside Index for Severity in
AP (BISAP) (11), has recently been proposed as an accurate and simple method for early identification of patients at risk of in-hospital
mortality.
The revised Atlanta classification introduces two distinct phases
of AP: first, or early, phase that occurs within the 1st week of onset
of disease and second, or late, phase that takes place after the 1st
week of onset (7). During the 1st week of AP, the pathologic conditions in and around the pancreas progress from early inflammation
with variable degrees of peripancreatic edema and ischemia to resolution or to permanent necrosis and liquefaction. In this early phase,
severity is entirely based on clinical parameters because the need
for treatment in the first phase is primarily determined by the presence or absence of organ failure caused by SIRS and much less by
morphologic findings involving the pancreas and peripancreatic
areas. Over the course of the 1st week, organ failure, usually defined
by Marshall scoring system (12), either resolves or becomes more
severe. Patients with organ failure that resolves in 48 hours are considered to have mild pancreatitis without complications and have
a mortality rate of 0% (7,13). Severe AP in the first phase is defined
as organ failure that lasts for more than 48 hours or until death (7).
It is a standard clinical practice within the first 3 days of admission
of a patient with AP to record the markers of severity (e.g., hematocrit; score from APACHE II, Ranson, or any other system; pulmonary
complications on chest radiograph, including pleural effusion; and
serum levels of C-reactive protein) (7,14). The late phase begins after
the 1st week and may extend for weeks to months and is characterized by increasing necrosis, infection, and persistent multi-organ
failure. Local complications may systemically manifest with bacteremia and sepsis when necrotic tissue becomes infected (15). The need
for treatment in this phase is determined by the presence of symptoms and/or complications of AP, and the type of treatment is based
on the imaging findings in the pancreatic and peripancreatic region
as seen on contrast-enhanced CT or MR images and by the presence
of local complications (7,14,15). Development of increasing necrosis,
persistent SIRS, and multiorgan failure cause a significant increase in
mortality. In the 1992 Atlanta classification, a distinction was made
between interstitial pancreatitis and sterile or infected necrosis. In
the revised Atlanta classification, these two types are defined in a
manner similar to the definitions for interstitial edematous pancreatitis (IEP) and acute necrotizing pancreatitis, but necrotizing pancreatitis is further subdivided into parenchymal necrosis alone, peripancreatic necrosis alone, and a combined type (peripancreatic and
parenchymal necrosis) with or without infection (7,15).
The revised Atlanta classification is also designed to aid patient
treatment through appropriate triage to intervention or conservative medical care. The severity or stage of AP dictates the type of
treatment that the patient needs (15).
IEP is usually self-limited and supportive measures alone suffice.
Most APFCs spontaneously resolve or mature into pseudocysts.
Majority of these pseudocysts spontaneously disappear over time
and do not require any treatment. About 25% become symptomatic
or infected and necessitate drainage (16).
AP can be accompanied by pancreatic parenchymal or peripancreatic collections. The acute collections are referred to as either APFCs
or as acute necrotic collections (ANCs), depending on the absence or
presence, respectively, of necrosis. IEP can be associated with APFC,
and over time, with pancreatic pseudocysts. Necrotizing pancreatitis in its three forms can be associated with ANC, and over time, with
walled-off necrosis (WON). All of these collections can be sterile or
infected (14,15).
Necrotizing pancreatitis requires close monitoring, and minimallyinvasive radiologic procedures or laparoscopic, endoscopic, or surgical techniques often are needed to improve the outcome in these
patients (15).

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No universally accepted treatment algorithm currently exists. The

approach often is dictated by the expertise of the surgeon and the
interventional radiologist. Image-guided drainage procedures have
proved to be effective alternatives to surgery, particularly early in
the course of complications from severe AP with necrosis (7,14,15).
Some of these percutaneous procedures are performed to stabilize seriously ill patients before surgery (bridge care) and others are
intended to cure (7,14,15).
Interventional radiology is also called on for ancillary procedures.
Pseudoaneurysms or active bleeding related to AP may occur.
Embolization represents the treatment of choice (15).
In conclusion, treatment planning is based on severity of pancreatitis and presence or absence of infection combined with clinical
signs. The revised Atlanta classification system (14) with CT helps
guide management and monitor the success of treatment.
References
1. Frossard JL, Steer ML, Pastor CM. Acute pancreatitis. Lancet
2008;371(9607):143152.
2. Bollen TL. Imaging of acute pancreatitis: update of the revised
Atlanta classification. Radiol Clin N Am 2012;50(3):429445.
3. Bhatia M, Wong FL, Cao Y, et al. Pathophysiology of acute
pancreatitis. Pancreatology 2005;5(2-3):132144.
4. Mofidi R, Duff MD, Wigmore SJ, et al. Association between
early systemic inflammatory response, severity of multiorgan
dysfunction and death in acute pancreatitis. Br J Surg
2006;93(6):738744.
5. Bollen TL, van Santvoort HC, Besselink MG, van Es WH, Gooszen
HG, van Leeuwen MS. Update on acute pancreatitis: ultrasound,
computed tomography, and magnetic resonance imaging
features. Semin Ultrasound CT MRI 2007;28(5):371383.
6. Bradley EL III. A clinically based classification system for acute
pancreatitis. Summary of the Inter- national Symposium on
Acute Pancreatitis, Atlanta, GA, September 11 through 13, 1992.
Arch Surg 1993;128:586590.
7. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson
CD, Sarr MG, Tsiotos GG, Vege SS. Classification of acute
pancreatitis--2012: revision of the Atlanta classification and
definitions by international consensus. Gut 2013;62:102111.
8. Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K, Localio SA.
Objective early identification of severe acute pancreatitis. Am J
Gastroenterol 1974;61:443451.
9. 9.Larvin M, McMahon MJ. APACHE-II score for assessment and
monitoring of acute pancreatitis. Lancet 1989;2:201205.
10. Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute
pancreatitis: value of CT in establishing prognosis. Radiology
1990;174:331336.
11. Singh VK, Wu BU, Bollen TL, Repas K, Maurer R, Johannes RS,
Mortele KJ, Conwell DL, Banks PA. A prospective evaluation
of the bedside index for severity in acute pancreatitis score in
assessing mortality and intermediate markers of severity in
acute pancreatitis. Am J Gastroenterol 2009;104:966971.
12. Halonen KI, Pettil V, Leppniemi AK, Kemppainen EA,
Puolakkainen PA, Haapiainen RK. Multiple organ dysfunction
associated with severe acute pancreatitis. Crit Care Med
2002;30(6):12741279.
13. Whitcomb DC. Clinical practice. Acute pancreatitis. N Engl J Med
2006;354(20):21422150.
14. Sarr MG, Banks PA, Bollen TL, et al. Revision of the Atlanta
classification of acute pancreatitis. Acute Pancreatitis
Classification Workgroup, April 2008. http://www.pancre- asclub.
com/resources/AtlantaClassification. Accessed April 8, 2011.
15. 15.Thoeni RF. The revised Atlanta classification of acute
pancreatitis: its importance for the radiologist and its effect on
treatment. Radiology 2012; 262(3):751764.
16. Johnson MD, Walsh RM, Henderson JM, et al. Surgical versus
nonsurgical management of pancreatic pseudocysts. J Clin
Gastroenterol 2009;43(6):586590.

Abstract Book

1704.2
Imaging of pancreatitis
W.Schima
Abteilung fr Diagnostische und Interventionelle Radiologie,
Vinzenzgruppe Wien, Vienna, Austria
Learning Objectives
1. To learn about imaging strategies for pancreatitis
2. To learn about imaging features in pancreatitis including
a uniform nomenclature for reporting complications of
pancreatitis
3. To learn how imaging can help predicting the need for
interventions
Acute pancreatitis is a common reason for hospitalization. Its manifestations range from transient abdominal discomfort to multiorgan failure and death. The Revised Atlanta Classification of 2012
requires the presence of at least 2 of the following 3 criteria: (1)
abdominal pain consistent with pancreatitis, (2) increase (3 fold)
in serum amylase or lipase levels, and (3) imaging findings of acute
pancreatitis. Thus, imaging diagnosis is of great importance in
equivocal cases and in suspected complications.
According to the Revised Atlanta Classification, the disease is categorized as interstitial edematous or necrotizing pancreatitis. In interstitial edematous pancreatitis, acute (non-encapsulated) peripancreatic fluid collection may occur in the early phase (<4 weeks). In the
late phase, these may resolve or evolve into pseudocysts, which are
typically homogenously hypoattenuating at CT and T2 hyperintense
on MRI. The natural history of pseudocysts depends on their size.
Approximately 40% of them will spontaneously resolve. Treatment is
indicated if patients become symptomatic or complications such as
gastric outlet obstruction, bile duct dilatation, or hemorrhage occur.
Necrotizing pancreatitis may present with either combined pancreatic and peripancreatic necrosis or pancreatic necrosis or peripancreatic necrosis alone. These acute necrotic collections in the early
phase may evolve into walled-off necrosis (WON) in the late stage
(4 weeks). A WON containing chunks of digested fat and parenchyma must not be confused with a pseudocyst containing enzymatic fluid. However, they may appear similar on CT imaging, but
US or MRI will reveal the predominantly solid nature of a WON.
Secondary infection of necrotizing pancreatitis is associated with
increased mortality. Infection of peri-/pancreatic necrosis usually
occurs in the third week after disease onset. The diagnosis of infection is difficult based on imaging. Infection is more likely if collections have broad contact with bowel. Gas within a collection is not
a sensitive sign, but it is a quite specific sign. In case of infection,
percutaneous aspiration is sought, followed by drainage in positive
cases. However, necrotic collections with large proportions of debris
require a more aggressive approach with large-bore catheters or
surgical necrosectomy.
Acute pancreatitis is a complex disease, which results in substantial
morbidity and mortality. The Revised Atlanta Classification system
introduces a new and uniform terminology for the imaging features.
Contrast-enhanced CT is the main pillar of diagnostic imaging and
image-guided therapy. MRI with MRCP has a role in characterizing
fluid collections and delineating the ductal system and its integrity.
References
1. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute
pancreatitis--2012: revision of the Atlanta classification and
definitions by international consensus. Gut 2013;62:102-111.
2. Bollen TL, Singh VK, Maurer R, et al. A comparative evaluation of
radiologic and clinical scoring systems in the early prediction of
severity in acute pancreatitis. Am J Gastroenterol 2012;107:612619.
3. Heiss P, Bruennler T, Salzberger B, et al. Severe acute pancreatitis
requiring drainage therapy: findings on computed tomography
as predictor of patient outcome. Pancreatology 2010;10:726-733.

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4. Meyrignac O, Lagarde S, Bournet B, et al. Acute pancreatitis:
Extrapancreatic necrosis volume as early predictor of severity.
Radiology 2015;276:119-128.
5. Shyu JY, Sainani NI, Sahni VA, et al. Necrotizing pancreatitis:
diagnosis, imaging, and intervention. Radiographics
2014;34:1218-1239.
6. Takahashi N, Papachristou GI, Schmit GD, et al. CT findings of
walled-off pancreatic necrosis (WOPN): differentiation from
pseudocyst and prediction of outcome after endoscopic
therapy. Eur Radiol 2008;18:2522-2529.
7. Zhao K, Adam SZ, Keswani RN, et al. Acute pancreatitis: Revised
Atlanta Classification and the role of cross-sectional imaging.
AJR Am J Roentgenol 2015;205:W32-41.

1704.3
Endoscopic treatments
J.Phillips-Hughes
Radiology, Oxford University Hospitals NHS Trust, Oxford, United
Kingdom
Learning Objectives
1. To learn about the endoscopic options in treating complications
of pancreatitis
2. To learn about patient selection for endoscopic treatments for
complications of pancreatitis
3. To learn about new developments in endoscopic treatments for
complications of pancreatitis
Endoscopic therapy is increasingly used in the treatment of selected
patients with acute and chronic inflammatory pancreatic disease.
It plays an important role in the multidisciplinary management of
conditions ranging from ERCP and sphincterotomy in acute gallstone pancreatitis to endoscopic ultrasound-guided necrosectomy
in complex advanced disease and coeliac plexus block in chronic
pain.
Indications, contraindications, and techniques of these procedures,
particularly endoscopic ultrasound-guided treatment of peripancreatic fluid collection, pseudocyst, acute necrotic collection, and
walled-off necrosis will be discussed.

1704.4
Percutaneous treatments
O.Akhan
Radiology, Hacettepe University, Ankara, Turkey
Learning Objectives
1. To learn about percutaneous options for treatment of
complications of pancreatitis
2. To learn about patient selection for percutaneous treatment of
complications of pancreatitis
3. To learn about the role of percutaneous treatment combined
with VARD in the treatment of pancreatitis
Acute pancreatitis is a potentially lethal disease associated with serious complications and a high mortality rate of up to 40%. Most of
the morbidities and mortalities are seen in patients with acute necrotizing pancreatitis as interstitial pancreatitis is the mild form of
the disease. Organ failure and infected pancreatic necrosis (IPN) are
the most important causes of mortality in acute pancreatitis (1-3).
Conservative treatment is accepted to be the best option for sterile
necrosis. However, surgical necrosectomy is the traditional choice of
treatment for IPN, which is associated with high morbidity and mortality (4,5). Some new techniques such as laparoscopic and endoscopic necrosectomy and video-assisted retroperitoneal debridement (VARD) have been developed with better results in order to
avoid the complications of open surgical necrosectomy (6-8).

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In the management of acute pancreatitis complications, the role of

interventional radiology (IR) has already increased, especially in last
decade. Its role mainly includes percutaneous drainage of peripancreatic fluid collection in IEP and percutaneous drainage of postnecrotic pancreatic fluid collection (PNPFC) and walled-off pancreatic necrosis (WOPN).
Peripancreatic fluid collections develop in 40% of cases within or
around the pancreas at the early phase of the disease (3). Although
most of APFCs resolve spontaneously, some persist beyond 4
weeks to develop pseudocysts. The presence of underlying infection is confirmed by FNA (9). Pseudocysts can cause mass effect or
become infected, which is necessary for percutaneous treatment.
Percutaneous drainage of these lesions is an easy and common procedure and simple drainage will often suffice for these collections.
The drainage catheter is inserted either under CT guidance or under
US and fluoroscopy guidance by using Seldinger or Trocar techniques (10-13).
Acute necrotizing pancreatitis is seen in up to 15% of all cases of
acute pancreatitis and can be complicated by infected necrosis and
multisystem organ failure (3,10). Management of necrotizing pancreatitis has evolved over the past two decades from more aggressive
and traditional surgical necrosectomy to more conservative relying on minimally invasive percutaneous and endoscopic necrosectomies. This change was prompted by higher mortality in patients
who underwent early surgical necrosectomy compared to patients
who underwent delayed surgical necrosectomy, i.e., more than
28 days following the onset of symptoms (14-16). More than one
large-bore catheters measuring up to 30 F are used to evacuate all
the necrotic debris. The catheters are irrigated using sterile normal
saline (up to 1.5 L) on daily basis. The clinical success of percutaneous necrosectomy is between 20% and 64% (17,18).
The revised Atlanta classification is a better tool to classify fluid collections and necrosis as it gives a chance for better discussion on
the treatment options. Therefore, successful management can be
achieved by a multidisciplinary approach in order to decide for the
best treatment option.
References
1. Whitcomb DC. Clinical practice. Acute pancreatitis. N Engl J Med
2006;354:2142-50.
2. Petrov MS, Shanbhag S, Chakraborty M, et al. Organ failure
and infection of pancreatic necrosis as determinants of
mortality in patients with acute pancreatitis. Gastroenterology
2010;139:813-20.
3. Banks PA, Bollen TL, Dervenis C, et al. Classification of acute
pancreatitis2012: revision of the Atlanta classification and
definitions by international consensus. Gut 2013;62:102-11.
4. Uhl W, Warshaw A, Imrie C, et al. International association of
pancreatology. IAP guidelines for the surgical management of
acute pancreatitis. Pancreatology 2002;2:565-73.
5. Connor S, Alexakis N, Raraty MG, et al. Early and late
complications after pancreatic necrosectomy. Surgery
2005;137:499-505.
6. Voermans RP, Veldkamp MC, Rauws EA, et al. Endoscopic
transmural debridement of symptomatic organized pancreatic
necrosis (with videos). Gastrointest Endosc 2007;66:909-16.
7. Bucher P, Pugin F, Morel P. Minimally invasive necrosectomy for
infected necrotizing pancreatitis. Pancreas 2008;36:113-9.
8. van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up
approach or open necrosectomy for necrotizing pancreatitis. N
Engl J Med 2010;362:1491-502.
9. Paye F, Rotman N, Radier C, Nouira R, Fagniez PL. Percutaneous
aspiration for bacteriological studies in patients with necrotizing
pancreatitis. Br J Surg 1998;85:755-9.
10. Theoni RF. The revised Atlanta classification of acute pancreatitis:
its importance for the radiologist and its effect on treatment.
Radiology 2012;262:751-64.

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11. Bruennler T, Langgartner J, Lang S, et al. Outcome of patients

with acute, necrotizing pancreatitis requiring drainage does
drainage size matter? World J Gastroenterol 2008;14:725-30.
12. Chalmers AG. The role of imaging in acute pancreatitis. Eur J
Gastroenterol Hepatol 1997;9:106-16.
13. Shankar S, van Sonnenberg E, Silverman SG, Tuncali K, Banks PA.
Imaging and percutaneous management of acute complicated
pancreatitis. Cardiovasc Intervent Radiol 2004;27:567-80.
14. Dupuis CS, Baptista V, Whalen G, et al. diagnosis and
management of acute pancreatitis and its complications.
Gastrointest Interv 2013; 2:36-46.
15. Mier J, Leon EL, Castillo A, Robledo F, Blanco R. Early versus late
necrosectomy in severe necrotizing pancreatitis. Am J Surg
1997;173:71-5.
16. Rodriguez JR, Razo AO, Targarona J, et al. Debridement and
closed packing of sterile or infected necrotizing pancreatitis:
insights into indications and outcomes in 167 patients. Ann Surg
2008;247:294-9.
17. Baudin G, Chassang M, Gelsi E, et al. CT-guided percutaneous
catheter drainage of acute infectious necrotizing pancreatitis:
assessment of effectiveness and safety. Am J Roentgenol
2012;199:192-9.
18. Freeny PC, Hauptmann E, Althaus SJ, Traverso LW, Sinanan
M. Percutaneous CT-guided catheter drainage of infected
acute necrotizing pancreatitis: techniques and results. Am J
Roentgenol 1998;170:969-75.

Special Session
Alternative arterial access
1802.1
Direct SFA access
F.Wolf
Division of Cardiovascular and Interventional Radiology, Medical
University of Vienna, Department of Biomedical Imaging and ImageGuided Therapy, Vienna, Austria
Learning Objectives
1. To learn how to perform direct SFA puncture
2. To learn about the advantages
3. To learn about complications
The number of arterial endovascular procedures is still increasing, and technically, there are almost no more limits to treat arterial
occulsions and stenoses. On the other hand, patients get more and
more complex because of multiple comorbidities and in many cases
due to being overweight. With an increasing number of patients, it
is not possible to gain regular arterial acces using the common femoral artery as the standard puncture site in an antegrade or retrograde way. There are different alternative access ways such as transbrachial, transpopliteal, or transpedal.
Another possibility to gain antegrade or retrograde access is to
puncture the superficial femoral artery.
This presentation will show how to use the superficial femoral artery
as a safe access route and how to avoid complications. Moreover, different ways to occlude the vessel will be presented in addition to
recent literature dealing with this alternative arterial access.
References
1. Gutzeit A, Schoch E, Reischauer C, Hergan K, Jenelten R,
Binkert CA. Comparison of a 21G micropuncture needle and
a regular 19G access needle for antegrade arterial access into
the superficial femoral artery. Cardiovasc Intervent Radiol. 2014
Apr;37(2):343-7. doi: 10.1007/s00270-013-0669-0. Epub 2013 Jul
10.

Abstract Book
2. Gutzeit A, van Schie B, Schoch E, Hergan K, Graf N, Binkert
CA. Feasibility and safety of vascular closure devices in an
antegrade approach to either the common femoral artery or
the superficial femoral artery. Cardiovasc Intervent Radiol. 2012
Oct;35(5):1036-40. Epub 2012 Aug 3.
3. Kweon M, Bhamidipaty V, Holden A, Hill AA. Antegrade
superficial femoral artery versus common femoral artery
punctures for infrainguinal occlusive disease. J Vasc Interv
Radiol. 2012 Sep;23(9):1160-4. doi: 10.1016/j.jvir.2012.06.006.
Epub 2012 Jul 24.

1802.2
Retrograde access of the lower limb
P.E.Huppert
Radiology, Neuroradiology and Nuclear Medicine, Klinikum Darmstadt,
Darmstadt, Germany
Learning Objectives
1. To learn how to perform retrograde puncture
2. To learn about the advantages
3. To learn about complications
Depending on the lesion length, lesion location, and calcification
grade, transfemoral antegrade guidewire recanalization of chronic
total occlusions of BTK arteries fails in up to 50% of cases. Retrograde
access may improve the technical success rate in these patients.
Retrograde access to BTK arteries includes techniques using percutaneous puncture of pedal and crural arteries as well as loop techniques via communicating arteries. Because of a short distance,
the dorsal pedal artery and distal posterior tibial artery are most
often used for percutaneous retrograde access. Appropriate material (small vessel kit), high-quality fluoroscopy with angulation, and
assistance by a second person for contrast injection via inguinal
sheath improve technical success.
Percutaneous access to crural arteries at proximal segments is more
difficult but possible. Access to metatarsal arteries is possible too
but seldom needed.
After retrograde insertion of a short 34-F introducer into pedal or
crural arteries, the retrograde guidewire passage of arterial occlusion is the next step. If successful, the guidewire is directed into a
diagnostic catheter or snared and pulled out via inguinal sheath. If
complete the retrograde guidewire passage is impossible recanalization from antegrade and retrograde access is performed using
balloon catheters until passage of guidewire in one direction via
communicating dissections succeeds.
Loop techniques are useful if antegrade access via crural arteries and
communicating arteries like perforators, collaterals, and plantar arch
facilitates reaching the lesion from below and passing an obstruction retrograde. Low profile devices and i.a. application of vasodilators are mandatory to obviate damage to small arteries during
passage.
Only small case series have been published concerning these techniques, reporting high technical success rate and low complication
rate.
References
1. Huppert P (2012) Rekanalisation von Unterschenkelarterien. In:
Debus S, Gross-Fengels W (Hrsg) Operative und interventionelle
Gefmedizin Springer, Heidelberg.
2. Met R, van Lienden KP, Koelemay MJ. Subintimal angioplasty
for peripheral arterial occlusive disease: A systematic review.
Cardiovasc Intervent Radiol 2008;31:687-97.
3. Botti CF, Ansel GM, Silver MJ. Percutaneous retrograde tibial
access in limb salvage. J Endovasc Ther 2003;10:614-8.
4. Spinosa DJ, Harthun NL, Bissonette EA. Subintimal arterial
flossing with antegrade-retrograde intervention (SAFARI) for
subintimal recanalization to treat chronic critical limb ischemia. J
Vasc Interv Radiol 2005;16:37-44.

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5. Fusaro M, Tashani A, Mollichelli N. Retrograde pedal artery
access for below-the-knee percutaneous revascularisation. J
Cardiovasc Med 2007;8:216-8.
6. Gandini R, Pipitone V, Stefanini M. The Safari technique to
perform difficult subintimal infragenicular vessels. Cardiovasc
Intervent Radiol 2007;30:469-73.
7. Montero-Baker M, Schmidt A, Brunlich S. Retrograde approach
for complex popliteal and tibioperoneal occlusions. J Endovasc
Ther 2008;15:594-604.
8. Fusaro M, Agostoni P, Biondi-Zoccai G. Trans-Collateral
angioplasty for a challenging chronic total occlusion oft he tibial
vessels: A novel approach to percutaneous revascularization
in critical lower limb ischemia. Catheter Cardiovasc Interv
2008;71:268-72.
9. Manzi M, Fusaro M, Ceccacci T. Clinical results of below-the
knee intervention using pedal-plantar loop technique for
the revascularization of foot arteries. J Cardiovasc Surg
2009;50:331-7.
10. Palena LM, Manzi M. Extreme below-the knee interventions:
Retrograde transmetatarsal or transplantar arch access for foot
salvage in challenging cases of critical limb ischemia. J Endovasc
Ther 2012;19:805-11.
11. Gandini R, Uccioli L, Spinelli A. Alternative techniques for
treatment of complex below-the knee arterial occlusions
in diabetic patients with critical limb ischemia. Cardiovasc
Intervent Radiol 2013;36:75-83.
12. Rusza Z, Nemes B, Bansaghi Z. Transpedal access after failed
anterograde recanalization of complex below-the-knee and
femoropopliteal occlusions in critical limb ischemia. Catheter
Cardiovasc Intervent 2014;83:997-1007.
13. Palena LM, Brocco E, Manzi M. The clinical utility of belowthe-ankle angioplasty using transmetatarsal artery access
in complex cases of CLI. Catheter Cardiovasc Intervent
2014;83:123-9.
14. Bazan HA, Le L, Donovan M. Retrograde pedal access for
patients with critical limb ischemia. J Vasc Surg 2014;60:375-82.
15. Werner M, Piorkowski M, Schmidt A. Techniques and outcome
of retrograde crural artery revascularization. J Cardiovasc Surg
2013;54:151-8.

1802.3
Radial access
C.A.Binkert
Interventional Radiology, Kantonsspital Winterthur, Winterthur,
Switzerland
Learning Objectives
1. To learn how to perform radial puncture
2. To learn about the advantages
3. To learn about complications
Within the last decade, there was a significant shift in cardiology
from the femoral artery to the radial approach for coronary artery
interventions. This change was supported by favorable procedural
outcomes and a low complication rate at the radial access site by
several randomized trials from cardiology literature (RIFLE, RIVAL).
Recently, the first retrospective interventional radiology study was
published by Posham et al. They reported the results of 1531 consecutive transradial cases, mostly visceral interventions (n = 1169), some
uterine fibroid embolizations (n = 116), and a few peripheral interventions (n = 43). The technical success rate was high (98.2%) with
a very low complication rate (2.51%: one pseudoaneurysm, one seizure, and 13 hematomas).
Technical considerations:
In order to avoid an ischemic hand complication at the access site,
it is important that even an occlusion of the radial artery should not
harm the hand. Therefore, the Barbeau test should be performed

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before using the radial approach. With the Barbeau test, the ulnar
supply to the hand is tested by monitoring the pulse waveform of
the thumb with oximetry, while compressing the radial artery. If the
pulse waveform is flat without a recovery over time (type D), the
radial approach should not be used. In order to avoid violating the
arterial wall, the outer diameter of the sheath should be smaller than
the radial diameter. Typically, a diameter less than 2 mm is considered unsuitable for access when using a 5-F sheath.
Heparin should be used in all cases to minimize the risk of thrombosis. Additionally, vasodilators should be given to avoid spasm
around the sheath. A typical radial cocktail consists of 3000 units
of heparin, 200 ug of nitroglycerin, and 2.5 mg of verapamil. In all
cases, hydrophilic sheath should be used for easy removal.
Room setup:
Most angiographic suites are setup for retrograde femoral access
for right-handed interventionalists. For radial artery access, different
room setups have been suggested.
Left arm access from across the table: the advantage of this access is
that the room organization does not have to be changed, but without long arms, it can be difficult to reach over the table. In addition,
the patients arm across the lower abdomen can obstruct the X-ray
beam, making it unsuitable for the pelvis.
Left arm access by standing on the other side of the table: this
approach is very suitable for left-handed interventionalists, but
quite cumbersome for right-handed ones. Therefore, an alternative
is to place the left arm on a board away from the table. In this setup,
the interventionalist can stand between the patients body and the
arm. In my experience, this position, although facilitates the easy
handling of wires and catheters by a right-handed person, is uncomfortable because one feels trapped and there is the danger of getting more radiation than necessary because of the vicinity to the
X-ray beam.
A right arm radial approach is my preferred access because there is
no need to alter the room setup and the patient can keep the arm
comfortably alongside the body. A minor disadvantage is the 1015
cm longer distance to the abdomen or pelvis.
Challenges of radial approach:
Nearly, all equipment today in IR is designed for femoral access.
Besides longer shafts, there should be easier exchanges for radial
work. Therefore, rapid exchange should be introduced for more
procedures and possibly even dedicated instruments for a radial
approach.
While clinically noticeable complications are rare, a recent study
from Rotterdam looked at more subtle changes of the radial artery
with Duplex. They found 55.8% pseudoaneurysms, 53.2% lumen
compromise, and 2.6% occlusions at 30 days. Further studies with
Duplex should be performed to learn about these asymptomatic
findings.
Every change in daily practice is somewhat disruptive and therefore initially, more time consuming. But the radial approach is worthwhile to look into for patient comfort (immediate ambulation,
shorter recovery), for potential cost saving, for true outpatient interventions without the need for a recovery bed, and for possible easier
access to steep angled origins of visceral arteries.
References
1. Romagnoli et al (RIFLE). J Am Coll Cardiol 2012;60:24819.
2. Metha et al (RIVAL). J Am Coll Cardiol 2012;60:24909.
3. Posham et al. J Vasc Interv Radiol 2016;27:15966.
4. Barbeau et al. Am Heart J 2004;147:48993.
5. Costa et al (Rotterdam radial access). Circ Cardiovasc Interv
2016;9:e003129.

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1802.4
Subclavian access
G.Puippe
Diagnostic and Interventional Radiology, University Hospital, Zurich,
Switzerland
Learning Objectives
1. To learn how to gain subclavian access
2. To learn about the advantages
3. To learn about complications
Endovascular treatment of pararenal abdominal aortic aneurysms
(PAAAs) and/or thoracoabdominal aortic aneurysms (TAAAs) with
chimney endografts usually requires a large-sized arterial access
at the upper extremity. Other procedures such as transarterial aortic valve implantation may also need arterial access at the upper
extremity in case of aortoiliac occlusive disease or extensive pelvic vessel tortuosity [1, 2]. The trend toward totally percutaneous
aneurysm repair and the results from the PEVAR trial [3] triggered
the interest for large-sized percutaneous arterial accesses at the
upper extremity. Requirements for an ideal large-sized percutaneous upper extremity access are as follows. First, an adequate vessel
diameter allowing for hosting large-sized sheaths, while preserving
the antegrade flow to the brachial and cerebral vascular territories
to avoid dissections, thrombosis, and ischemia. Second, the artery
should be superficial and readily accessible under sonographic guidance without passing sensitive structures. Third, if attempting a total
percutaneous approach, closing of vessel access site must be warranted and different closure strategies should be at hand. The subclavian artery in the lateral infraclavicular fossa fulfills most of the
requirements as it is usually of an adequate size and rarely heavily
calcified. Moreover, its course is rather superficial and almost always
visible with ultrasound even in obese patients. Closure of access site
can be performed by suture-mediated closure devices or as a bailout procedure by stent-graft implantation by either a transfemoral
or transbrachial route.
All patients who are planned for upper extremity access should have
cross-sectional imaging of the aortic arch and the proximal arch vessel origins. Patients with mural thrombus or plaques in the arch or
at the vessel origins are at increased risk for stroke and/or peripheral embolization with a reported incidence of 3%10% [4]. In these
patients, guidewire passages and sheath exchanges should be
reduced to a minimum in order to not mobilize plaques or thrombotic material. Therefore, the use of a preclosing technique with
Perclose-AT is questionable in these patients.
Technique for percutaneous subclavian artery access with
Perclose-AT preclosing: The subclavian artery in the lateral infraclavicular fossa is visualized in a longitudinal axis with a linear ultrasound probe. Pressure on the ultrasound probe should be minimized to keep the subclavian vein always visible. Local anesthesia is
recommended as it reduces local vasospasms. Under sonographic
guidance, the subclavian artery is punctured with an 18-G cannula.
The needle path should be at a 45-degree angle to the skin. The
needle tip must be visualized all the time to avoid inadvertent puncture of the pleural cavity or lung. Passing the subclavian vein must
be avoided in any case. A needle tract through the pectoralis muscle should be minimized, if possible, as it may impede the advancement and deployment of the Perclose-AT system. After successful
puncture, a 0.035 guidewire is inserted and the needle is removed.
Perclose-AT preclosing is performed in a standard fashion, as known
from the percutaneous femoral artery accesses, and a 89-F sheath
is inserted. The large-sized sheath should only be advanced over a
stiff guidewire to avoid dissections and/or perforations.
At the end of the procedure, a guidewire should be left in place.
The sheath can be removed, and the loose preknotted sutures can
be tightened with a knot pusher. A guidewire should always be
left in place until complete hemostasis is guaranteed. In case of

Abstract Book
insufficient hemostasis, several bailout procedures are possible.
The first attempt should be a postclosing procedure with another
Perclose-AT, which can be inserted and deployed over the existing
guidewire. If one or two postclosing maneuvers failed to provide
hemostasis, a sheath can be reinserted to stop bleeding. According
to our experience in these circumstances, a stent graft is needed to
seal the access site. The stent graft can be delivered either through a
transfemoral or a transbrachial route. The latter is reserved to cases
in which the subclavian artery is no more accessible from the femoral artery. Having a femoral sheath still in place allows for snaring
the subclavian artery guidewire and establishing a through-andthrough guidewire. Over this, the stent graft can be delivered until
the subclavian artery. At this point, the through-and-through guidewire has to be removed. Through the stent graft delivery catheters,
the brachial artery can be reached with a stiff guidewire. The stent
graft can then be positioned and exactly deployed at the access site.
Completion angiography can be performed through the stent-graft
delivery catheter. Sealing by the transbrachial route is feasible but
remains problematic due to the following reasons. First, another
access has to be established, and depending on the stent-graft size,
another large-sized sheath has to be introduced, which can again
cause closure problems at the access site.
In summary, percutaneous ultrasound-guided access to the subclavian artery with preclosing offers an alternative for large-sized upper
extremity access in patients undergoing endovascular aneurysm
repair.
References
1. Schofer N, Deuschl F, Conradi L, Lubos E, Schirmer J,
Reichenspurner H, Blankenberg S, Treede H, Schafer U.
Preferential short cut or alternative route: the transaxillary
access for transcatheter aortic valve implantation. J Thorac Dis
2015; 7: 1543-7.
2. Laflamme M, Mazine A, Demers P, Lamarche Y, Ibrahim R, Asgar
A, Cartier R. Transcatheter aortic valve implantation by the left
axillary approach: a single-center experience. Ann Thorac Surg
2014; 97: 1549-54.
3. Nelson PR, Kracjer Z, Kansal N, Rao V, Bianchi C, Hashemi H,
Jones P, Bacharach JM. A multicenter, randomized, controlled
trial of totally percutaneous access versus open femoral
exposure for endovascular aortic aneurysm repair (the PEVAR
trial). J Vasc Surg 2014; 59: 1181-93.
4. Knowles M, Nation DA, Timaran DE, Gomez LF, Baig MS,
Valentine RJ, Timaran CH. Upper extremity access for
fenestrated endovascular aortic aneurysm repair is not
associated with increased morbidity. J Vasc Surg 2015; 61: 80-7.

Fundamental Course
Liquid embolic agents
1803.1
Overview of liquid embolic agents
M.Kcher
Department of Radiology, University Hospital Olomouc, Olomouc,
Czech Republic
Learning Objectives
1. To learn about different types of liquid embolic materials
2. To learn about indications and technique of the use of liquids in
embolisation
3. To learn about results and complication of their use in general
Unlike solid embolic materials, liquid agents can, on the basis of their
physical properties, fill homogeneously target vascular areas. Liquid
embolic materials include adhesive agents, non-adhesive agents,
and sclerosing (cytotoxic) agents. Individual groups differ in physical
properties, such as viscosity, rapidity of solidification, and visibility

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on fluoroscopy. Based on these properties and the morphology of
vascular lesion intended for embolization, suitable embolic agent
should be selected. Depending on the morphology and localization
of vascular lesion, transarterial, transvenous, percutaneous, or combined approach is required.
Acrylates are adhesive embolic materials that rapidly solidify on
contact with ionic fluids such as blood or saline. When mixed with
oil-based contrast agent, acrylates become visible under fluoroscopy and alter the rapidity of solidification. More peripheral level
of embolization is achieved with increasing ratio of oil-based contrast agent to glue along with prolongation of embolization time.
Although acrylates are considered as permanent embolic agents,
recanalization may occur.
Non-adhesive agents are based on ethylene vinyl alcohol copolymer (EVOH) dissolved in dimethyl sulfoxide (DMSO) and suspended
micronized tantalum powder to provide contrast for visualization
under fluoroscopy. They are most commonly used in treatment of
brain AVMs. These agents provide a more controlled delivery compared with adhesive ones, but due to high viscosity, penetration of
small vessels is difficult. Non-adhesive agents are based on ethylene vinyl alcohol copolymer and are also considered as permanent
embolic agents, but recanalization is possible, as well.
Sclerosing agents induce endothelial cell damage with thrombosis
and finally fibrosis of vascular lesion. It is based on denaturation of
blood proteins, dehydration and hyperhydration of endothelial cells,
precipitation of protoplasm, and denudation of vessel wall. Absolute
ethanol is the most effective and popular. Due to very low viscosity,
ethanol provides very good penetration of small vessels. It has the
lowest percentage of recurrence and low cost but experience are
needed to avoid complication risks.
Embolization by liquid agents is used in a wide variety of clinical situations, such as acute hemorrhage of varying etiology, tumor embolization, vascular malformations occlusion, and endoleak after EVAR.
Because indications for use of each type of liquid embolization
agents overlap with some degree, the material we are familiar with
should be preferred.

1803.2
When and how to use glue
H.J.Jae
Radiology, Seoul National University Hospital, Seoul, Korea
Learning Objectives
1. To learn specific techniques of embolisation with glue
2. To learn about indications and techniques for the use of acrylic
glue
3. To learn about possible complications and pitfalls of glue
embolisation
Transcatheter arterial embolization (TAE) has been widely used to
control active bleeding of various causes and TAE is generally preferred over surgery, especially in high-risk patients. Various embolic
materials have been used for embolization and more commonly
used agents are pieces of gelatin sponge, coils, and polyvinyl alcohol particles. However, many interventional radiologists are still
reluctant to use liquid embolic materials such as n-butyl cyanoacrylate (NBCA), mainly because of concerns about complicated ischemic injury and unfamiliarity with them.
NBCA has several advantages over other embolic materials. It allows
rapid and permanent embolization with quick polymerization when
contacted with blood. Complete hemostasis can be achieved by single injection with simultaneous embolization of the collateral vessels connected to the bleeding point, which can cause backbleeding or rebleeding. NBCA is also useful in patients with coagulopathy because it does not depend on coagulation for its therapeutic
effect. Serious complications, such as bowel ischemia or innocent
vessel embolization, can be minimized with adequate indication

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and careful procedures by trained interventional radiologists. Thus,

NBCA can be an alternative embolic material, which is effective,
rapid, and safe in transcatheter embolization of active bleeding, and
it may be lifesaving in emergency situations, especially when the
patients have a coagulopathy.
In this presentation, we are going to deal with adequate indications,
technical tips, and clinical outcomes of glue (NBCA) embolization.
References
1. Transcatheter embolotherapy with N-butyl cyanoacrylate for
ectopic varices. Choi JW, Kim HC, Jae HJ, Jung HS, Hur S, Lee M,
Chung JW. Cardiovasc Intervent Radiol. 2015;38:344-51.
2. Transcatheter arterial embolization of nonvariceal upper
gastrointestinal bleeding with N-butyl cyanoacrylate. Jae
HJ, Chung JW, Jung AY, Lee W, Park JH. Korean J Radiol.
2007;8:48-56.
3. Bronchial artery embolization to control hemoptysis:
comparison of N-butyl-2-cyanoacrylate and polyvinyl alcohol
particles. Woo S, Yoon CJ, Chung JW, Kang SG, Jae HJ, Kim HC,
Seong NJ, Kim YJ, Woo YN. Radiology. 2013;269:594-602.
4. Transcatheter arterial embolization of intramuscular active
hemorrhage with N-butyl cyanoacrylate. Yoo DH, Jae HJ,
Kim HC, Chung JW, Park JH. Cardiovasc Intervent Radiol.
2012;35:292-8.
5. Guidelines for the use of NBCA in vascular embolization devised
by the Committee of Practice Guidelines of the Japanese
Society of Interventional Radiology (CGJSIR), 2012 edition.
Takeuchi Y, Morishita H, Sato Y, Hamaguchi S, Sakamoto N,
Tokue H, Yonemitsu T, Murakami K, Fujiwara H, Sofue K, Abe
T, Higashihara H, Nakajima Y, Sato M; Committee of Practice
Guidelines of the Japanese Society of Interventional Radiology.
Jpn J Radiol. 2014;32:500-17.
6. Experimental study on acute ischemic small bowel changes
induced by superselective embolization of superior mesenteric
artery branches with N-butyl cyanoacrylate. Jae HJ, Chung JW,
Kim HC, So YH, Lim HG, Lee W, Kim BK, Park JH. J Vasc Interv
Radiol. 2008;19:755-63.
7. Safety and efficacy of transcatheter arterial embolization for
lower gastrointestinal bleeding: a single-center experience with
112 patients. Hur S, Jae HJ, Lee M, Kim HC, Chung JW. J Vasc
Interv Radiol. 2014;25:10-9.
8. Postpartum hemorrhage from extravasation or
pseudoaneurysm: efficacy of transcatheter arterial embolization
using N-butyl cyanoacrylate and comparison with gelatin
sponge particle. Park KJ, Shin JH, Yoon HK, Gwon DI, Ko GY, Sung
KB. J Vasc Interv Radiol. 2015;26:154-61.
9. N-butyl cyanoacrylate embolization for control of acute arterial
hemorrhage. Kish JW, Katz MD, Marx MV, Harrell DS, Hanks SE. J
Vasc Interv Radiol. 2004;15:689-95.
10. The use of cyanoacrylate adhesives in peripheral embolization.
Pollak JS, White RI Jr. J Vasc Interv Radiol. 2001;12:907-13.
11. Experimental studies on new liquid embolization mixtures
(histoacryl-lipiodol, histoacryl-panthopaque). Stoesslein F,
Ditscherlein G, Romaniuk PA. Cardiovasc Intervent Radiol.
1982;5:264-67.
12. Transcatheter arterial embolization of arterial esophageal
bleeding with the use of N-butyl cyanoacrylate. Park JH, Kim HC,
Chung JW, Jae HJ, Park JH. Korean J Radiol. 2009;10:361-5.
13. Instant selective arterial occlusion with isobutyl 2-cyanoacrylate.
Dotter CT, Goldman ML, Rosch J. Radiology. 1975;114:227-30.
14. N-butyl cyanoacrylate glue embolization of splenic artery
aneurysm. Kim BS, Do HM, Razavi M. J Vasc Interv Radiol.
2004;15:91-4.
15. Transcatheter arterial embolization of ruptured
pseudoaneurysms with coils and n-butyl cyanoacrylate.
Yamakado K, Nakatsuka A, Tanaka N, Takano K, Matsumura K,
Takeda K. J Vasc Interv Radiol. 2000;11:66-72.

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1803.3
When and how to use sclerosants
W.A.Wohlgemuth
Institut fr Rntgendiagnostik, Universittsklinikum Regensburg,
Regensburg, Germany
Learning Objectives
1. To review the most frequently used sclerosants
2. To learn about technique of sclerotherapy
3. To review complications and pitfalls of sclerosing therapy
The main indication for sclerosant use is slow-flow vascular malformations, in particular venous malformations and lymphatic malformations. As opposed to embolic agents, they are delivered via a
transarterial route using a direct image-guided puncture into the
lesion.
The most commonly used agents for venous malformations are polidocanol (=aethoxysklerol) or sodium tetradecyl sulphate (STS) and
pure ethanol. In lymphatic malformations, picibanil (=OK-432) and
bleomycin are common. The specific properties, effects, complications, and indications are discussed.
When using these agents, a test injection of the contrast medium
under fluoroscopy guidance is mandatory to estimate the injection
volume, exclude communicating drainage veins, and identify the
punctured part of the lesion.
Postinterventional treatment includes LMWH anticoagulation and
compression therapy.

1803.4
When and how to use ethylene vinyl alcohol
K.Zelek
Department of Radiology, Jessenius Faculty of Medicine and University
Hospital, Martin, Slovak Republic
Learning Objectives
1. To learn about characteristics of ethylene vinyl alcohol
2. To learn about indications for use
3. To learn about injection technique and limitations of use of
EVOH
Characteristics
Ethylene vinyl alcohol (EVOH) copolymer is a non-adhesive liquid embolic agent dissolved in dimethyl sulfoxide (DMSO) and suspended in micronized tantalum powder to provide contrast for visualization under fluoroscopy. It solidifies gradually from the periphery in towards the centre. It is not carried by the blood flow, but
conversely is displaced by pressure applied by the operator to the
syringe.
The main advantage of EVOH is its ability to penetrate deeply into
the vasculature and into different compartments of the lesion,
which can lead to complete and permanent occlusion.
Indication for use
According to literature, the main indications include the following:
Arteriovenous malformations
Arteriovenous fistulas (including dural fistula and carotid-cavernous
fistula)
Hypervascular tumours (e.g. meningioma, paraganglioma, juvenile nasopharyngeal angiofibroma, hemangiopericytoma, choroid
plexus papilloma and angiomyolipoma)
Aneurysms and pseudoaneurysms
Bleeding (e.g. after traumatic vessel injury and pancreatitis, gastrointestinal and haemoptysis)
Endoleaks
Injection technique
EVOH can be injected via a microcatheter (detachable tip microcatheter is usually preferred) or a dual-lumen balloon-occlusion catheter,

Abstract Book
as well as percutaneously via a needle. Higher concentration of
EVOH is recommended for embolizing higher fistulous components.
This liquid embolic system allows a slow controlled injection, the
capacity to stop and start the injection, cohesive deposition and
delivery and performance of control angiography during embolic
injection. One of the specific methods for using EVOH involves waiting for the reflux to settle (a few minutes) and then restarting the
injection. Beyond this time, the distal tip of the catheter can no longer reflux and passes anterogradely into the territory which is to
be embolized. Using the plug-and-push technique, it is possible to
apply EVOH against the direction of blood flow. An injection rate of
0.16 mL/min and not exceeding a 0.3 mL/min injection rate is recommended by the producer.
Aspiration of EVOH at the end of injection or injection of DMSO at
the end of embolization prevents non-target embolization EVOH.
Limitations
This embolic material is not indicated for use with premature
infants, small children, pregnant women and individuals with significant liver function impairment. It must be shaken for several minutes prior to use. Special DMSO compatible catheters are required.
DMSO is toxic to endothelium and causes pain. The toxicity of the
DMSO solvent should also be taken into account. The maximum
dose of 200 mg/kg of DMSO must not be exceeded.
During long injection of EVOH, the microcatheter distal tip can glue.
Bipolar devices should be used with caution for surgical resection of
embolized lesions.
References
1. Belloni E, Bodini FC, Cella A, Michieletti E, Scagnelli P.
Embolization of a congenital uterine arteriovenous
malformation using a liquid embolizing agent (Onyx). Research
2014;1:698. http://dx.doi.org/10.13070/rs.en.1.698.
2. Crowley RW, Ducruet AF, Kalani MY, Kim LJ, Albuquerque FC,
McDougall CG. Neurological morbidity and mortality associated
with the endovascular treatment of cerebral arteriovenous
malformations before and during the Onyx era. J Neurosurg.
2015 Jun;122(6):1492-7. doi: 10.3171/2015.2.JNS131368.
3. Ding D, Starke RM, Evans AJ, Liu KC. Direct transcranial puncture
for Onyx embolization of a cerebellar hemangioblastoma. J Clin
Neurosci. 2014 Jun;21(6):1040-3. doi: 10.1016/j.jocn.2013.08.028.
4. Elsenousi A, Aletich VA, Alaraj A. Neurological outcomes and
cure rates of embolization of brain arteriovenous malformations
with n-butyl cyanoacrylate or Onyx: a meta-analysis.
J Neurointerv Surg. 2016 Mar;8(3):265-72. doi: 10.1136/
neurintsurg-2014-011427.
5. Hayes SB, Johnson JN, Most Z, Elhammady MS, Yavagal D,
Aziz-Sultan MA. Transarterial embolization of intractable
nasal and oropharyngeal hemorrhage using liquid embolic
agents. J Neurointerv Surg. 2015 Jul;7(7):537-41. doi: 10.1136/
neurintsurg-2014-011101.
6. Henrikson O, Roos H, Falkenberg M. Ethylene vinyl alcohol
copolymer (Onyx) to seal type 1 endoleak. A new technique.
Vascular. 2011 Apr;19(2):77-81. doi: 10.1258/vasc.2010.oa0257.
7. Hrer T, Toivola A, Larzon T. Embolization with Onyx in
iatrogenic bleeding of the gluteal region. Innovations (Phila).
2011 Jul;6(4):267-70. doi: 10.1097/IMI.0b013e31822afbe9.
8. Jadhav AP, Pryor JC, Nogueira RG. Onyx embolization for the
endovascular treatment of infectious and traumatic aneurysms
involving the cranial and cerebral vasculature. J Neurointerv
Surg. 2013 Nov;5(6):562-5. doi: 10.1136/neurintsurg-2012-010460.
9. Keeling AN, McGrath FP, Lee MJ. Interventional radiology in the
diagnosis, management, and follow-up of pseudoaneurysms.
Cardiovasc Intervent Radiol. 2009 Jan;32(1):2-18. doi: 10.1007/
s00270-008-9440-3.

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10. Kim B, Jeon P, Kim K, Kim S, Kim H, Byun HS, Jo KI. Predictive
Factors for Response of Intracranial Dural Arteriovenous Fistulas
to Transarterial Onyx Embolization: Angiographic Subgroup
Analysis of Treatment Outcomes. World Neurosurg. 2015 Nov 6.
doi: 10.1016/j.wneu.2015.10.052.
11. Koer N, Hanmolu H, Batur , Kandemirli SG, Kzlkl O,
Sanus Z, z B, Ilak C, Kaynar MY. Preliminary experience
with precipitating hydrophobic injectable liquid in brain
arteriovenous malformations. Diagn Interv Radiol. 2016
Mar-Apr;22(2):184-9. doi: 10.5152/dir.2015.15283.
12. Kolber MK, Shukla PA, Kumar A, Silberzweig JE. Ethylene vinyl
alcohol copolymer (onyx) embolization for acute hemorrhage:
a systematic review of peripheral applications. J Vasc Interv
Radiol. 2015 Jun;26(6):809-15. doi: 10.1016/j.jvir.2015.02.025.
13. Ladner TR, He L, Lakomkin N, Davis BJ, Cheng JS, Devin CJ,
Mocco J. Minimizing bleeding complications in spinal tumor
surgery with preoperative Onyx embolization via dual-lumen
balloon catheter. J Neurointerv Surg. 2016 Feb;8(2):210-5. doi:
10.1136/neurintsurg-2014-011505.
14. Lin YC, Juan YH, Mhuircheartaigh JN, Sheng TW, Saboo SS,
Wong HF, Wu JS. Surgically challenging pulmonary and hepatic
vascular malformations treated with Onyx application. Vasa.
2014 Sep;43(5):390-4. doi: 10.1024/0301-1526/a000376.
15. Lopes DK, Moftakhar R, Straus D, Munich SA, Chaus F,
Kaszuba MC. Arteriovenous malformation embocure
score: AVMES. J Neurointerv Surg. 2015 Jun 15. doi: 10.1136/
neurintsurg-2015-011779.
16. Lutz J, Holtmannsptter M, Flatz W, Meier-Bender A, Berghaus
A, Brckmann H, Zengel P. Preoperative embolization to
improve the surgical management and outcome of juvenile
nasopharyngeal angiofibroma (JNA) in a single center: 10-year
experience. Clin Neuroradiol. 2015 Jan 29. [Epub ahead of print]
17. zkan N, Kreitschmann-Andermahr I, Goerike SL, Wrede KH,
Kleist B, Stein KP, Gembruch O, Sandalcioglu IE, Wanke I, Sure
U. Single center experience with treatment of spinal dural
arteriovenous fistulas. Neurosurg Rev. 2015 Oct;38(4):683-92. doi:
10.1007/s10143-015-0645-z.
18. Rahme R, Grande A, Jimenez L, Abruzzo TA, Ringer AJ. Predicting
parent vessel patency and treatment durability: a proposed
grading scheme for the immediate angiographic results
following Onyx HD-500 embolization of intracranial aneurysms.
J Neurointerv Surg. 2014 Dec;6(10):754-60. doi: 10.1136/
neurintsurg-2013-010943.
19. Rangel-Castilla L, Barber SM, Klucznik R, Diaz O. Mid and long
term outcomes of dural arteriovenous fistula endovascular
management with Onyx Experience of a single tertiary
center. J Neurointerv Surg. 2014 Oct;6(8):607-13. doi: 10.1136/
neurintsurg-2013-010894.
20. Rangel-Castilla L, Shah AH, Klucznik RP, Diaz OM. Preoperative
Onyx embolization of hypervascular head, neck, and spinal
tumors: experience with 100 consecutive cases from a single
tertiary center. J Neurointerv Surg. 2014 Jan;6(1):51-6. doi:
10.1136/neurintsurg-2012-010542.
21. Regine R, Palmieri F, De Siero M, Rescigno A, Sica V, Cantarela
R, Villari V. Embolization of traumatic and non-traumatic
peripheral vascular lesions with Onyx. Interv Med Appl Sci. 2015
Mar;7(1):22-9. doi: 10.1556/IMAS.6.2014.003.
22. Saeed Kilani M, Izaaryene J, Cohen F, Varoquaux A, Gaubert
JY, Louis G, Jacquier A, Bartoli JM, Moulin G, Vidal V. Ethylene
vinyl alcohol copolymer (Onyx) in peripheral interventional
radiology: indications, advantages and limitations. Diagn Interv
Imaging. 2015 Apr;96(4):319-26. doi: 10.1016/j.diii.2014.11.030.
23. Singh G, Lopes DK, Jolly N. Neuro-endovascular embolic agent
for treatment of a renal arteriovenous fistula. AIMS Medical
Science, 3(1): 96-102. doi: 10.3934/medsci.2016.1.96.

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24. Urbano J, Manuel Cabrera J, Franco A, Alonso-Burgos A.

Selective arterial embolization with ethylene-vinyl alcohol
copolymer for control of massive lower gastrointestinal
bleeding: feasibility and initial experience. J Vasc Interv Radiol.
2014 Jun;25(6):839-46. doi: 10.1016/j.jvir.2014.02.024.
25. Wendel M, Beheshti M, Yousaf M, Erdem E. Transcatheter arterial
emboiation of a uterine artery pseudoaneurysm with Onyx
following D&C for uterine bleeding. Radiology Case Reports.
(Online) 2013;8:630. doi: 10.2484/rcr.v8i2.630.
26. Wohlgemuth WA1, Mller-Wille R, Teusch VI, Dudeck O,
Cahill AM, Alomari AI, Uller W. The retrograde transvenous
push-through method: a novel treatment of peripheral
arteriovenous malformations with dominant venous outflow.
Cardiovasc Intervent Radiol. 2015 Jun;38(3):623-31. doi: 10.1007/
s00270-015-1063-x.
27. Zelek K, ink I, Jank J, Laca L, Talapkov R. Bleeding in acute
pancreatitis treated by transcatheter arterial embolization
with ethylene-vinyl alcohol copolymer (Onyx). Vasa. 2012
Sep;41(5):380-2. doi: 10.1024/0301-1526/a000226.
28. Zelek K, Sopilko I, vihra J, Kliment J. Successful embolization
of a renal artery pseudoaneurysm with arteriovenous fistula and
extravasations using Onyx after partial nephrectomy for renal
cell carcinoma. Cardiovasc Intervent Radiol. 2009 Jan;32(1):163-5.
doi: 10.1007/s00270-008-9332-6.

Special Session
How to handle the radiation risk
1901.1
Radiation Dose Structured Report (RDSR) of fluoroscopyguided interventions: do we get what we want?
G.Bartal
Radiology, Meir MC, Kfar-Saba, Israel
Learning Objectives
1. To clarify basic principles and real life applications of DICOM
dose data and dose reporting in fluoroscopy-guided
interventions
2. To provide practical, user-friendly tools for the implementation
of the RDSR in fluoroscopy-guided interventions
3. To present the use of the RDSR for optimising of patient dose
during complex fluoroscopy-guided procedures
Referring physicians prefer structured reports for radiologic examinations over conventional narrative reports as they perceive that
structured reports provide improved clarity. However, the added
value of structured reports over narrative reports has not been
objectively demonstrated (1). Patient outcomes are clearly affected
by the quality of radiologic reports, thereby necessitating an
improvement in the reporting practices (2, 3). Each Department creates a library of clear and consistent report templates. Structured
reporting gradually becomes a routine in our daily practice as radiologists and as interventionists.
Dose reporting, especially radiation dose structure reporting
(RDSR), is a completely different issue. It can be reliable in CT, but it
is unavailable or unutilized in most of the fluoroscopy-guided interventions (FGIs). Special attention is paid to tracking radiation dose in
the past few years, but the data need to be stored in a standardized
way to allow analysis.
When working on this topic, another possible title that comes to
mind is Radiation Dose Structured Reporting in FluoroscopyGuided Interventions for dummies.
Unfortunately, FGI specialists (intervention radiologists, intervention cardiologists, and other users of fluoroscopy) in general are
less aware of patient exposure and pay most of their attention
to the procedure itself. Dose measurement and interpretation in

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C-arm fluoroscopy is complex and still debatable. Therefore, dose

recording and interpretation in FGIs is usually ignored or simply
unreported.
Lets have a quick look on what is RDSR and how it works. DICOM
can save information about how a specific study was produced. Prior
to RDSRs release in 2005, there was no standard way to separate
radiation exposure data from the image data (4). Accessing and storing dose data also required a lot of storage space because the information was attached to the images.
Image acquisition and processing comprises lots of complex processes; for example, in image duplication, the exposure data also is
duplicated; this could result in overestimation of the radiation dose.
Also, if images, such as fluoroscopic images, were rejected due to
technical issues or patient motion or not recorded, those radiation
exposures were not saved. RDSR addressed these shortcomings.
If the image is rejected and deleted, that header will not exist anymore, but RDSR will take the exposure into account. In addition, if
there was a radiation event that did not generate an image, there
was no image header with dose information, but a radiation dose
structured report was generated (5).
Variety of rapidly changing methodologies and models can be used
to estimate patient dose. As soon as the estimation of the radiation
dose absorbed by a patient is completed, storing and transferring
the method used, parameters involved, and resulting dose estimate
in a standard format is required. It is taken for granted that the optimal location for information related to the dosimetric method used
and the estimated patient radiation dose transferring this data to a
Dose Information Reporter, a performer (in the IHE) that may or may
not be combined with a RIS, a PACS, or may be a standalone system.
Contemporary pilot projects indicate that multiple factors can
degrade accurate and reliable capture of dose indicators for FGI.
Currently, the data is captured by manually entering radiation metrics into the radiology report. This could occur by dictating or typing
the values into the report. Compliance has to be audited monthly by
pulling all FGI reports from a randomly selected workday. There is
a need for counting reports as well as counting the all FGI reports
for specific workday. Reliability of manual data entry is questionable
and compliance will vary between the persons involved. Manual
RDSR has many limitations, and there is a clear need to digitize this
laborious and complex process. Such techniques are already available and will be gradually implemented in our practice.
For automatic reading, three methods can be used to capture data
in computer-readable formats:
1. Fluoroscopy units send DICOM structured reports to an
institutional archive.
2. Radiographers enter dose indicators in a local database such as
the Radiology Information System (RIS).
3. Utilization of the dedicated software to collect electronic and
analog data on radiation exposure from fluoroscopy units and
the PACS and store this data in a radiation dose database.
Agreement should be periodically audited by determining the number of FGI procedure records that include all metrics with the number of FGI procedures performed, post-intervention data collection,
and data analysis. As detailed above, manual data entry should be
avoided, when possible, as time limits will clearly impact and limit
manual dose calculation and reporting. Moreover, lack of training
also degrades performance.
Manual or better automatic RDSR should become an institutional
routine and part of the post-procedural audits. Currently, one of
the main problems with automatic RDSR is that only the newest fluoroscopic systems support the DICOM SR standard. Older fluoroscopes may not be able to report reference point air kerma (RaK) or
kerma area product (KaP). While IR services should track their overall compliance, they can also separately chart compliance in the specific rooms that support RaK and KaP. The goal is to create processes
that reliably achieve 100% compliance and the final target would be
equipment upgrades (6).

Abstract Book
Although periodic audits of analog and manual systems might meet
the requirements in the short run, radiology departments in general and IR services in particular are encouraged to invest in automated/electronic systems capable of continually monitoring system
performance.
It is extremely important to be familiar with your equipment and the
typical radiation doses incurred during routine studies. One of the
well-known problems is that the standard manufacturer default settings often deliver a higher radiation dose as their goal is to deliver
the best possible image quality; however, we should use diagnostic
image quality.
DICOM can also save information about how a particular study was
conducted. Increasing attention has been paid to tracking radiation
dose in the past few years, but the data need to be stored in a standardized way so that they can be analyzed (6).
Before the release of RDSR in 2005, there was no standard way to
separate radiation exposure data from the image data. Accessing
and storing dose data also required a lot of storage space because
the information was attached to the images (5, 6).
Physicians performing FGI are responsible to educate themselves on
radiation safety and ways to reduce unnecessary radiation exposure
(7). This should be considered part of the procedure and is as important as the other technical components of the case. There is a clear
need for changing our behavior in order to comply with the ALARA
principle. RDSR is one of the tools that will ensure such a change.
References
1. Schwartz LH, Panicek DM, Berk AR, Li Y, Hricak H. Improving
communication of diagnostic radiology findings through
structured reporting. Radiology 2011;260(1):174181.
2. Krupinski EA, Hall ET, Jaw S, Reiner B, Siegel E. Influence of
radiology report format on reading time and comprehension. J
Digit Imaging 2012;25(1):6369.
3. Brook O. et al. Structured reporting of multiphasic CT for
pancreatic cancer: potential effect on staging and surgical
planning. Radiology 2015;274(2):464472.
4. Supplement 191: Patient Radiation Dose SR (PRDSR) Digital
Imaging and Communications in Medicine (DICOM) Supplement
191: Patient Radiation Dose Reporting (P-RDSR).
5. Beta E, Parikh AS, Street M, Duncan JR. Capture and analysis
of data from image-guided procedures. J Vasc Interv Radiol
2009;20(6):769781.
6. Duncan JR, Currie S. Assessing Physician Performance (Chapter
19). In: Abujudeh H, Bruno MA, eds. Quality and Safety in
Radiology: Oxford University Press; 2012. Available at: http://
global.oup.com/academic/product/quality-and-safety-inradiology-9780199735754;jsessionid=5B7A0A1CDB31A99791F30
6EC9129F9D5?cc=us&lang=en&#. Accessed October 1, 2014.
7. Heilmaier CH et al. Improving patient safety: implementing dose
monitoring software in fluoroscopically guided interventions. J
Vasc Interv Radiol 2015;26(11):16991709.

1901.2
How to identify high-risk procedures for operators
R.W.R.Loose
Institute for Radiology, Hospital Nuremberg-North, Nuremberg,
Germany
Learning Objectives
1. To identify the interventional procedures most likely to expose
staff to higher risks
2. To highlight the importance of technical measures to be taken
to minimise the risks of occupational exposure
3. To demonstrate how training and personal behaviour can
reduce risks of occupational exposure
With only few exceptions, all measures for reducing the patient
dose in interventional procedures also enable the reduction of

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occupational exposures. The main factors of occupational exposures are the frequency of procedures performed by an individual
interventionist, the complexity and duration of procedures, the distance between operators and the radiation field, all technical shielding measures against scattered radiation, and the level of training.
It is possible for most interventionists to keep their annual occupational dose below 10 mSv and typically within a range of 24 mSv
or less [1]. However, individual occupational doses may exceed these
values. In addition, there is a wide variation in occupational doses
for the same type of procedure, indicating that training is an important issue in radiation protection.
Many technical shielding measures are well established and simple
for operating monoplane C-arm fluoroscopic systems. The complexity of sufficient shielding increases with biplane systems in neuroradiology and cardiology. Special challenges arise from robot C-arm
systems in hybrid operating rooms, with up to 10 and more staff
members being around a patient in procedures performed by vascular or cardiac surgeons.
In 36 European countries, the frequency of interventions guided by
fluoroscopy ranges from 0.03% to 2.74%, with an average of 0.6% for
all x-ray procedures. Interventional cardiology procedures have an
average frequency of 4.2 per 1000 individuals. In terms of collective
doses, interventional radiology contributes from 0.001 to 0.34 mSv/
year, corresponding to 0.4%28.7% of the total x-ray collective doses
[2].
In cardiology, high dose rates to staff arise from procedures in interventional electrophysiology, transcatheter aortic valve replacement
(TAVR), and mitral valve repair [3].
In vascular surgery, fluoroscopically guided placement of endovascular stent grafts to treat aortic aneurysms in the chest and abdomen has increased dramatically [4].
In radiology and neuroradiology, typical procedures with significant
staff exposure and increasing frequency are cerebral coiling of aneurysms, embolization of AVMs, (TACE), and radioembolization (SIRT)
of the liver.
An approach to identify high-risk procedures for operators could be
to identify staff members with high occupational doses. If these persons wear electronic online dosimeters to measure exposures of the
body and/or eye lens or extremities, the dose contribution of each
procedure and even partial steps of a procedure can be identified. As
the next step, solutions for individual dose reduction, such as additional personal or system-mounted protection devices, less-interventional procedures, or specific training, should be considered.
References
1. Tsapaki, V., Kottou, S., Vano, E., Komppa, T., Padovani, R.,
Dowling, A., Molfetas, M., Neofotistou, V., 2004. Occupational
dose constraints in interventional cardiology procedures: the
DIMOND approach. Phys. Med. Biol. 49, 997-1005.
2. European Commission, Medical Radiation Exposure of the
European Population Radiation Protection No. 180, 2015.
3. Sauren, L.D., van Garsse, L., van Ommen, V., Kemerink, G.J., 2011.
Occupational radiation dose during transcatheter aortic valve
implantation. Cathet. Cardiov. Interv. 78, 770-776.
4. Scali, S.T., Goodney, P.P., Walsh, D.B., Travis, L.L., Nolan, B.W.,
Goodman, D.C., Lucas, F.L., Stone, D.H., 2011. National trends and
regional variation of open and endovascular repair of thoracic
and thoracoabdominal aneurysms in contemporary practice. J.
Vasc.Surg. 53, 1499-1505.

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1901.3
How to identify high-risk procedures for patients
G.Paulo
Medical Imaging & Radiotherapy, Instituto Politcnico de Coimbra,
ESTESC-Coimbra Health School, Coimbra, Portugal
Learning Objectives
1. To identify the interventional procedures most likely to expose
the patient to higher risks
2. To highlight the importance of technical measures to be taken
to minimise the risks to the patient and optimise the procedure
3. To create awareness of the importance of clear and
comprehensive communication with the patient regarding the
risks and benefits of interventional procedure
Fluoroscopy-guided procedures (FGPs) play an essential role in
modern medicine and are used in the diagnosis, treatment, and palliation of numerous medical and surgical conditions, instead of more
invasive procedures involving the known risks of general anesthesia and surgery, thereby contributing to a more efficient and better
patient experience and delivering higher health care outcome and
quality of life.
However, several literature references indicate that some FGPs are
performed by health professionals who do not make the best use of
the technological equipment features and who are not sufficiently
trained in radiation protection.
There is an evident lack of teamwork and guidelines on how to plan,
perform, and monitor FGPs, particularly in those in which high doses
are expected to be delivered to patients.
In general, patients are not being counselled about the radiation
risks, prior to, during, or after FGP and are normally discharged with
no information about the dose received and the possibility of skin
injuries.
FGPs should always be performed considering a three-dimensional
action approach: pre-procedure, intra-procedure, and post-procedure actions.
Using this approach and specific methodological actions, it is possible to reduce the risk of FGP.
It is of crucial importance, before performing FGP, to identify highrisk patients such as those who have a systemic disease and/or who
are overweight. Patients who are expected and clinically justified
to undergo high-dose FGP should be adequately evaluated before
the procedure in order to characterize their exposure history, clinical
condition, skin damage, and other relevant information, allowing to
prepare and adapt the best exposure conditions for optimized FGP.
References
1. Establishing an Interventional Radiology Patient Radiation
Safety Program, Steele J et al, Radiographics, 2011.
2. Fluoroscopically Guided Interventional Procedures: A review
of Radiation Effects on Patients Skin and Hair, Balter S et al,
Radiology, 2010.
3. ICRP, 2000. Avoidance of Radiation Injuries from Medical
Interventional Procedures, ICRP Publication 85. Ann. ICRP 30 (2).
4. Patient Dose Optimization in Fluoroscopy Guided Interventional
Procedures, IAEA-TECDOC-1641, 2010.
5. Reducing Radiation Risks for Patients and Staff, NIH Publication
n 05-5286, 2005.
6. Severe Skin Reactions from Interventional Fluoroscopy: Case
Report and Review of the Literature, Wagner et al, Radiology,
1999.

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1901.4
Diagnostic reference levels (DRLs) help or hindrance?
E.Vano
Radiology, Complutense University, Madrid, Spain
Learning Objectives
1. To identify the role of diagnostic reference levels (DRLs) in the
optimisation of interventional procedures
2. To recognise the impact of the X-ray system settings and the
procedure complexity in patient dose values
3. To suggest corrective actions when patient doses are higher
than the DRLs
The intrinsic difficulty of interventional radiology procedures often
implies the use of long fluoroscopy times and a significant number
of acquired images. This can entail significant radiation risk to the
patients. Moreover, many patients undergo more than one procedure. If the dose rate in fluoroscopy or the dose per acquired image
at the entrance of the patient (or at the entrance of a phantom) is too
high, some corrective actions could be required. Thus, information
would be an important aspect to audit the working conditions of a
specific X-ray system in catheterisation laboratories. The used imaging protocols and complexity of the procedures are also key aspects
to know if patient radiation doses used during interventional procedures are in the range of the standard good practice or may be too
high and some corrective actions may be required. Dose limitation
is not recommended for medical exposures. The clinical outcome
shall be the priority, but the use of the appropriate radiation dose is
a key aspect of any quality programme in interventional radiology.
Diagnostic reference levels (DRLs) have been introduced to help on
this issue.
Concept of diagnostic reference level (DRL)
The International Commission on Radiological Protection (ICRP)
defines DRL as a tool used to aid in the optimisation of protection in
the medical exposure of patients for diagnostic and interventional
procedures.
A DRL value is a selected level of a radiation dose quantity for typical examinations for groups of standard-sized patients. It is used
in medical imaging with ionising radiation to indicate whether in
routine conditions, the patient dose from a specified procedure
is unusually high or low for that procedure. DRLs do not apply to
individual patients. They are derived from an arbitrary value (3 rd
quartile) in a distribution of values locally obtained and nationally
collected.
Radiation metrics used for DRLs should be appropriate to the imaging modality being evaluated, should assess the amount of ionising
radiation applied to perform a medical imaging task and should easily be measured or determined (e.g. air kerma-area product [KAP] for
fluoroscopy-guided procedures). The quantity or quantities selected
are those that are readily available for each type of medical imaging
modality and medical imaging task.
The process to set and update DRLs should be both flexible and
dynamic. Flexibility is necessary for procedures where few data are
available (e.g. interventional procedures in paediatric patients) or
where data are available from only one or a few centres. A dynamic
process is necessary to allow initial DRLs to be derived from these
data while waiting for a wider survey to be conducted.
Paediatrics requires special considerations. The amount of administered radiation for examinations of children can vary tremendously
due to the great variation in patient size and weight. Appropriate
weight bands (generally with 10-kg intervals) are recommended
for establishing paediatric DRLs and should be promoted for
paediatrics.
Requirements of the European directive on diagnostic reference levels
The new European Directive 2013/59/Euratom strengthens and
expands the previous requirements regarding DRLs. Member

Abstract Book
states of the European Union shall ensure the establishment, regular review and use of DRLs for radiodiagnostic examinations with
regard to the recommended European diagnostic reference levels
where available and where appropriate for interventional radiology
procedures and the availability of guidance for this purpose.
DRLs are defined in the directive as dose levels in medical radiodiagnostic or interventional radiology practices or in the case of
radiopharmaceuticals, levels of activity, for typical examinations for
groups of standard-sized patients or standard phantoms for broadly
defined types of equipment.
The directive also underlines the need for appropriate local reviews
whenever DRLs are consistently exceeded and requires that the corresponding corrective action is taken without undue delay.
Quantities used to set DRLs in interventional radiology
For interventional radiology, several DRL quantities may be used
(if available): KAP, cumulative air kerma at the patient entrance reference point, fluoroscopy time and the number of radiographic
images (e.g. cine images in cardiology and digital subtraction angiography images in vascular procedures).
Cone-beam CT (CBCT) has become a routine part of some interventional fluoroscopy procedures. Optimisation of this portion of the
procedure has therefore become important. Recording the doserelated quantities for the CBCT portion of interventional procedures,
when this information is available, may be helpful in the optimisation of this portion of interventional procedures.
Complexity of the procedures
For interventional procedures, the amount of radiation applied to
the patient depends largely on the type of procedure and on procedural complexity. Procedural complexity may vary for different
clinical indications for the same procedure requiring different levels of radiation doses. Thus, complexity of the procedure should
be considered in setting DRLs and a multiplying factor for the DRL
value (e.g. 2 or 3) may be appropriate for more complex cases of a
procedure.
Patient dose audits
In the past, patient dosimetry in IR was performed with a small sample of procedures to calculate mean or median values of different
dosimetric quantities as part of the clinical audit and to compare
with DRLs. With the introduction of digital systems, it is easy to collect and archive dosimetric and demographic data from the imaging
procedures, either separately or together with the images, as part
of the Digital Imaging and Communication in Medicine (DICOM)
headers or in other DICOM services such as the Modality Performed
Procedure Step (MPPS) and the Radiation Dose Structured Report
(RDSR). The advantages of these DICOM services include the ability to process data from all procedures instead of only a small sample, automation of the process and the inclusion of other data from
the procedures (e.g. C-arm angulations and distances) in addition
to dosimetric parameters. In addition, this automatic collection of a
complete data set will provide information necessary to help determine whether a patient should be included in the follow-up protocol for potential skin injuries.
Optimisation in interventional radiology
The application of DRLs is not sufficient by itself for the optimisation
of protection. Optimisation is generally concerned with maintaining the quality of the diagnostic information provided by the examination commensurate with the medical purpose, while at the same
time, seeking to reduce patient exposures to radiation to a level as
low as reasonably achievable. Image quality or more generally, the
diagnostic information provided by the examination (including the
effects of post-processing) must also be evaluated.
Compliance with DRLs does not by itself indicate that the procedure is performed at an optimised level with regard to the amount
of radiation used. The ICRP recognises that additional improvement
can often be obtained by using the median value (the 50th percentile) of the distribution of values of dose-related quantities used to
set the national DRLs.

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The ICRP recommends setting DRLs based on surveys of the DRL
quantities for procedures performed on an appropriate sample of
patients. The use of phantoms is considered not sufficient in most
cases as when phantoms are used, the effects of operator performance are not taken into account.
The numerical values of DRLs are advisory. However, an authorised
body may require the implementation of the DRL concept.
Median values of the DRL quantity for medical imaging procedures
for a specific X-ray room or for a radiology department or other facility should be compared with DRL values to identify whether the
data for the location are substantially higher or lower than those
that might be anticipated. DRL is considered to be exceeded when
the median value of the DRL quantity for a representative sample
of standard-sized patients at a facility is greater than the local or
national DRL value.
Corrective actions when local values exceed DRLs
If a DRL value for any procedure is exceeded, an investigation
should be undertaken without undue delay to determine possible
reasons and a corrective action plan should be implemented and
documented.
The investigation should include review of equipment performance, the settings used and the examination protocols. The factors most likely to be involved are survey methodology, equipment
performance, procedure protocol, operator skill and procedure
complexity.
The first priority should be the evaluation in the dose settings of
the X-ray units involved. Phantom entrance doses for low, medium
and high fluoroscopy modes and digital subtraction angiography
(DSA) acquisitions should be measured and compared with similar
X-ray units. Calibration factor of the transmission ionisation chamber should also be verified. Collaboration among medical physicists,
radiologists and service engineers will help to optimise the use of
X-ray systems in interventional radiology practice.
Update of DRLs
National DRLs should be revised at regular intervals of 35 years
or more frequently when substantial changes in technology, new
imaging protocols or improved post-processing of images become
available.
Since national DRLs require large surveys, which can require substantial effort to perform and analyse, they are not always as responsive to changes in technology. Where it is apparent that further optimisation is being locally achieved, Local DRLs based on surveys
within that limited area might be introduced to further assist the
optimisation process.
Some current mistakes interpreting DRLs
DRLs are a supplement to professional judgement and do not provide a dividing line between good and bad medical practice.
DRLs are not intended to be used for individual patients or as trigger
(alert or alarm) levels for individual patients or individual examinations. DRL values are not limits.
Effective dose is not an appropriate quantity for use as a DRL.
Effective dose is not a measurable quantity and is not a good indicator of the amount of ionising radiation used to perform a medical
imaging task. Its use could introduce extraneous factors not needed
and not pertinent for the purpose of DRLs.
References
1. Bartal, G., Vano, E., Paulo, G., Miller, D.L., 2014. Management
of patient and staff radiation dose in interventional radiology:
current concepts. Cardiovasc Intervent Radiol. 37:289-98.
2. European Council Directive 2013/59/Euratom on basic safety
standards for protection against the dangers arising from
exposure to ionising radiation and repealing Directives 89/618/
Euratom, 90/641/Euratom, 96/29/Euratom, 97/43/Euratom and
2003/122/Euratom. 2014.OJ of the EU. L13; 57:1-73.
3. European Society of Radiology (ESR), 2015. Summary of the
European Directive 2013/59/Euratom: essentials for health
professionals in radiology. Insights Imaging. 6:411-7.

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4. Fernandez-Soto, J.M., Ten, J.I., Sanchez, R.M., Espana, M., Pifarre,

X., Vano, E., 2015. Benefits of an automatic patient dose registry
system for interventional radiology and cardiology at five
hospitals of the Madrid area. Radiat Prot Dosim. 165:53-6.
5. IAEA, 2009. Establishing guidance levels in x ray guided medical
interventional procedures: A pilot study. Safety Reports Series
No. 59. International Atomic Energy Agency, Vienna.
6. ICRP, 2001. International Commission on Radiological Protection.
Diagnostic reference levels in medical imaging: Review and
additional advice. ICRP Supporting Guidance 2. Ann. ICRP 31(4).
7. ICRP, 2007. The 2007 Recommendations of the International
Commission on Radiological Protection. ICRP publication 103.
Ann. ICRP 37(24).
8. ICRP, 2009. Education and training in radiological protection for
diagnostic and interventional procedures. ICRP Publication 113.
Ann. ICRP 39(5).
9. Miller, D.L., Balter, S., Cole, P.E., et al., 2003. Radiation doses in
interventional radiology procedures: The RAD-IR study Part II:
skin dose. J Vasc Interv Radiol. 14:977-90.
10. Miller, D.L., Kwon, D., Bonavia, G.H., 2009. Reference levels for
patient radiation doses in interventional radiology: proposed
initial values for U.S. practice. Radiology. 253:753-64.
11. NCRP, 2010. Radiation dose management for fluoroscopically
guided interventional medical procedures. NCRP Report
No. 168. National Council on Radiation Protection and
Measurements, Bethesda, MD.
12. Vano, E., Gonzalez, L., 2001. Approaches to establishing
reference levels in interventional radiology. Radiat Prot Dosim.
94:109-12.
13. Vano, E., Sanchez, R., Fernandez, J.M., et al., 2009. Importance
of dose settings in the x-ray systems used for interventional
radiology: a national survey. Cardiovasc Intervent Radiol.
32:121-6.
14. Vano, E., Sanchez, R., Fernandez, J.M., et al. 2009. Patient
dose reference levels for interventional radiology: a national
approach. Cardiovasc Intervent Radiol. 32:19-24.

Hot Topic Symposium

Paradigm shift: acute ischaemic stroke
2102.1
Treatment of acute ischaemic stroke: what is the future role of
intravenous thrombolysis?
H.Mattle
Neurology, Inselspital, University of Bern, Bern, Switzerland
Several randomised controlled trials (RCTs) in acute ischaemic stroke
(NINDS A+B, ECASS I-III, ATLANTIS A+B, EPITHET and IST-3) have
used intravenous recombinant tissue plasminogen activator (iv tPA)
(Emberson J et al., Lancet. 2014;384:1929-35). Iv tPA enhances the
chances of favourable outcomes despite a slightly increased risk of
symptomatic intracranial haemorrhage, when given up to 5 hours
after stroke onset. The earlier was iv tPA given, the bigger were the
proportional benefits, despite stroke severity and patients age.
Mechanical thrombectomy using stent retrievers was introduced
later. MR CLEAN was the first among the several RCTs (ESCAPE,
REVASCAT, SWIFT PRIME and EXTEND IA) that proved the benefit of
iv tPA followed by mechanical thrombectomy in stroke caused by
large vessel occlusions in the anterior circulation, i.e. ICA or proximal MCA (M1, M2) occlusions (Goyal M et al., Lancet. 2016 Feb 18). In
basilar artery occlusion, there is still equipose whether mechanical
thrombectomy after iv tPA is superior to tPA alone. The BASICS trial
addresses this question. According to the patient data meta-analysis, there was no heterogeneity of treatment effect across any of the
prespecified variables: age, sex, NIHSS, site of intracranial occlusion,

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intravenous alteplase received or ineligible, ASPECTS, time from

onset to randomisation and presence of tandem cervical carotid
occlusion. However, adjusted cORs for treatment were not significant for patients younger than 50 years, patients with low ASPECTS
or low NIHSS scores and patients with an M2 segment thrombus.
Stroke patients with a low NIHSS are more likely to have a small
vessel occlusion that is located peripherally to the large vessels
(Heldner MR et al., Stroke. 2013;44:1153-1157). When patients with
0-4 NIHSS scores are treated with iv tPA, they have a chance that is
9.8% greater compared to placebo to reach mRS 0-1 at 90 days. The
corresponding values for NIHSS 5-10 are 4.7%, NIHSS 11-15 are 3.2%,
NIHSS 16-21 are 3.4% and NIHSS 22 are 4.5%. This indicates that
patients with low NIHSS scores and thus mostly peripheral occlusions are likely to benefit more from iv tPA than patients with higher
NIHSS scores. Patients with higher NIHSS scores and thus mostly
large vessel occlusions are the target group for mechanical thrombectomy. Patients with low NIHSS scores are likely to have peripheral occlusions that stent retrievers cannot reach. They will probably
always remain the target group for iv tPA.
References
1. Emberson J, Lees KR, Lyden P, Blackwell L, Albers G, Bluhmki E,
Brott T, Cohen G, Davis S, Donnan G, Grotta J, Howard G, Kaste
M, Koga M, von Kummer R, Lansberg M, Lindley RI, Murray G,
Olivot JM, Parsons M, Tilley B, Toni D, Toyoda K, Wahlgren N,
Wardlaw J, Whiteley W, del Zoppo GJ, Baigent C, Sandercock
P, Hacke W; Stroke Thrombolysis Trialists Collaborative Group.
Effect of treatment delay, age, and stroke severity on the
effects of intravenous thrombolysis with alteplase for acute
ischaemic stroke: a meta-analysis of individual patient data from
randomised trials. Lancet. 2014;384:1929-35.
2. Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ,
Demchuk AM, Dvalos A, Majoie CB, van der Lugt A, de Miquel
MA, Donnan GA, Roos YB, Bonafe A, Jahan R, Diener HC, van den
Berg LA, Levy EI, Berkhemer OA, Pereira VM, Rempel J, Milln
M, Davis SM, Roy D, Thornton J, Romn LS, Rib M, Beumer D,
Stouch B, Brown S, Campbell BC, van Oostenbrugge RJ, Saver
JL, Hill MD, Jovin TG; HERMES collaborators. Endovascular
thrombectomy after large-vessel ischaemic stroke: a
meta-analysis of individual patient data from five randomised
trials. Lancet. 2016 Feb 18, epub.
3. Heldner MR, Zubler C, Mattle HP, Schroth G, Weck A, Mono ML,
Gralla J, Jung S, El-Koussy M, Ldi R, Yan X, Arnold M, Ozdoba C,
Mordasini P, Fischer U. National Institutes of Health stroke scale
score and vessel occlusion in 2152 patients with acute ischemic
stroke. Stroke. 2013;44:1153-7.

2102.2
Selection of patients for mechanical thrombectomy: what is
the role for advanced imaging?
T.Engelhorn
Neuroradiologische Abteilung, Universittsklinikum Erlangen,
Erlangen, Germany
Management of acute ischemic stroke is rapidly developing. The
current approach to patient selection for mechanical stroke reperfusion therapies is based on the time from stroke symptom onset
and imaging-derived existence of a major vessel occlusion such as
the ICA, the BA, or the proximal MCA. This approach is reasonable
in the first 6 h after stroke onset when substantial salvageable tissue probably exists in the majority of patients. However, it neglects
the variable collateral physiology that exists between individual
patients and probably plays a critical role beyond this time window. Recent data could prove that interventional stroke treatment
provides superior clinical outcome when compared with intravenous thrombolytic therapy only. Besides the neurological deficit

Abstract Book
(NIH stroke scale score 10), brain imaging is of major importance.
The goals of imaging evaluation for acute stroke are to establish a
diagnosis as early as possible in order to obtain accurate information about intracranial (collateral) vasculature and brain perfusion
to select the appropriate therapy. At least brain CT imaging ideally
multimodal MRI using perfusion and diffusion imaging and various
types of cerebral angiography should be available 24/7 with priority to stroke patients. Based on recent data, alternative approaches
using the ASPECT score, absolute lesion volumes of the core infarct
and of the surrounding region of hypoperfusion appear promising,
but require further validation. This presentation will summarize the
impact of recent studies on imaging-guided patient selection for
mechanical treatment in acute stroke.

2102.3
Organisation of future stroke care: who should treat and who
should be responsible for the patients?
P.A.Brouwer
Neurointervention, Karolinska Hospital, Stockholm, Sweden
In 2013, three ischemic stroke trials focusing on endovascular therapy and showing negative results were presented at the same conference in Honolulu. At this time, the day was considered to be the
doomsday for intra-arterial stroke therapy.
However, in October 2014, the MR CLEAN trial was presented, which
showed highly significant benefit of the intra-arterial stroke treatment compared to intravenous lytics only. In the wake of this trial,
multiple other trials showed similar results and were published in
the NEJM.
The fact that the stroke trials were positive was a mere reflection of
the fact that people that were trained to perform thrombectomy,
as part of their normal professional neurointerventional workload,
could have a positive effect on patient outcome.
One problem with new techniques is that many doctors see a reason to step into that particular area and provide the treatment. It
is often forgotten that the treatments are highly specialized and
that knowledge of the end-organ as well as technical skills as well as
experience are necessary to ensure a safe treatment. In the case of
intra-arterial ischemic stroke treatment, this is all the more true since
it can be considered an operative procedure in which there is a difference in who will perform the treatment, in contrast to i.v thrombolysis where the nurse can inject it just as easily as the professor (or
sometimes maybe even better).
A second problem is that all neurointerventions are regarded
as sexy, since there is no room for mistakes. Sexy specialties are
attractive to outsiders until they encounter their first foreseeable
complication.
A third problem is that many of our untrained colleagues consider
themselves skilled enough to do this. There is a name for this: the
Dunning-Kruger effect.
Doctors that are unskilled and unaware are a serious threat to the
patient but also to the technique itself. If, suddenly, all unskilled (but
unaware) doctors would perform intra-arterial thrombectomies, the
technique will have to be abandoned because of too many complications and therefore not living up to the trial effects in the real-life
situation. We have seen this before.
Obviously, there are many reasons to say I need to do it, but there is
hardly ever an altruistic reason; it is only an excuse for an untrained
physician. Ask yourself whether you really wanted to go there once
you have your first avoidable complication. Provided that you are
honest enough to admit that it was avoidable....
References
1. Training Guidelines for Endovascular Ischemic Stroke
Intervention: An international multi-society consensus document. J
NeuroIntervent Surg doi:10.1136/neurintsurg-2016-012316.

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Fundamental Course
Basic acute ischaemic stroke intervention
2501.1
Overview of treatment options: neurologists view
E.M.Arsava
Department of Neurology, Hacettepe University, Faculty of Medicine,
Ankara, Turkey
Learning Objectives
1. To learn where we stand in acute stroke treatment algorithms
2. To learn the neurologists reaction to major paradigm shift
secondary to the current evidence in acute stroke
3. To understand the neurologists view: when not to use IA
treatment
Treatment algorithms in the acute stroke setting are primarily tailored according to the time elapsed from symptom onset to admission. In patients presenting within 4.5 hours of symptom onset, systemic thrombolysis by intravenous recombinant tissue plasminogen
activator (rtPA) is the approved treatment of choice, unless there is
a contraindication to the therapy [1-4]. Despite its proven efficacy,
a significant number of patients cannot be treated with intravenous
rtPA in the real world setting either due to the narrow therapeutic
time window or contraindications to treatment [5]. Furthermore, the
effectiveness of intravenous thrombolysis is poor in patients with
proximal arterial occlusions [6].
Intra-arterial thrombolysis, either by pharmacological agents or
mechanical devices, is considered as an attractive therapeutic
option in such patients. Despite the positive results of the PROACT-II
trial, which compared intra-arterial prourokinase plus heparin with
heparin alone in ischemic stroke patients admitted within 6 hours
of symptom onset [7], the treatment was never approved by central
regulatory agencies for use in proximal occlusions. Contrary to the
slow and unyielding progress in the field of intra-arterial thrombolytics, the developments in the field of mechanical devices were more
fruitful. Some of these mechanical devices, including the MERCI
Retriever, Penumbra system, Solitaire revascularization device, and
Trevo stent retriever, based on their success and swiftness in recanalization of proximal cerebral occlusions (up to >80% recanalization rate), obtained investigational device exemption approval from
regulatory agencies for use in patients with acute ischemic stroke
[8, 9]. However, as the data primarily relied on observational registries and did not come from randomized controlled trials, the issue
of whether mechanical thrombectomy is efficacious in improving
clinical outcome when compared to the best medical treatment
(including intravenous thrombolysis) was unresolved, until recently.
Recently published trials demonstrated a significant increase in the
proportion of patients with favorable clinical outcome undergoing endovascular recanalization in comparison to the group receiving best medical treatment [10-14]. As majority of the patients in the
endovascular groups of these studies have also received intravenous
thrombolysis, the guidelines strongly suggest not withholding intravenous rtPA in treatment eligible patients admitted within 4.5 hours
of symptom onset. Regardless of their combination with intravenous
rtPA, the current evidence emphasizes the use of stent retrievers for
endovascular therapies in acute ischemic stroke patients with proximal occlusions where groin puncture can be attained within 6 hours
of symptom onset.
References
1. Tissue plasminogen activator for acute ischemic stroke. The
National Institute of Neurological Disorders and Stroke rt-PA
Stroke Study Group. N Engl J Med. 1995;333(24):1581-7.

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2. Saver JL. Number needed to treat estimates incorporating

effects over the entire range of clinical outcomes: novel
derivation method and application to thrombolytic therapy for
acute stroke. Arch Neurol. 2004;61(7):1066-70.
3. Hacke W, Donnan G, Fieschi C, et al.; ATLANTIS Trials
Investigators; ECASS Trials Investigators; NINDS rt-PA Study
Group Investigators. Association of outcome with early stroke
treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA
stroke trials. Lancet. 2004;363(9411):768-74.
4. Hacke W, Kaste M, Bluhmki E, et al.; ECASS Investigators.
Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic
stroke. N Engl J Med. 2008;359(13):1317-29.
5. Lloyd-Jones D, Adams R, Carnethon M, et al; American
Heart Association Statistics Committee and Stroke Statistics
Subcommittee. Heart disease and stroke statistics--2009
update: a report from the American Heart Association Statistics
Committee and Stroke Statistics Subcommittee. Circulation
2009;119:e21-e181.
6. Mori E, Yoneda Y, Tabuchi M, et al. Intravenous recombinant
tissue plasminogen activator in acute carotid artery territory
stroke. Neurology. 1992;42(5):976-82.
7. Furlan A, Higashida R, Wechsler L, et al. Intra-arterial
prourokinase for acute ischemic stroke. The PROACT II study:
a randomized controlled trial. Prolyse in Acute Cerebral
Thromboembolism. JAMA. 1999;282(21):2003-11.
8. Saver JL, Jahan R, Levy EI, et al. Solitaire flow restoration device
versus the Merci Retriever in patients with acute ischaemic
stroke (SWIFT): a randomised, parallel-group, non-inferiority
trial. Lancet. 2012;380(9849):1241-9.
9. Nogueira RG, Lutsep HL, Gupta R, et al. Trevo versus Merci
retrievers for thrombectomy revascularisation of large vessel
occlusions in acute ischaemic stroke (TREVO 2): a randomised
trial. Lancet. 2012;380(9849):1231-40.
10. Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial
of intraarterial treatment for acute ischemic stroke. N Engl J Med.
2015;372(1):11-20.
11. Campbell BC, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy
for ischemic stroke with perfusion-imaging selection. N Engl J
Med. 2015;372(11):1009-18.
12. Goyal M, Demchuk AM, Menon BK, et al. Randomized
assessment of rapid endovascular treatment of ischemic stroke.
N Engl J Med. 2015;372(11):1019-30.
13. Saver JL, Goyal M, Bonafe A, et al. Stent-retriever thrombectomy
after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med.
2015;372(24):2285-95.
14. Jovin TG, Chamorro A, Cobo E, et al. Thrombectomy within 8
hours after symptom onset in ischemic stroke. N Engl J Med.
2015;372(24):2296-306.

2501.2
Patient selection: optimal timing and imaging
J.Weber
Institute of Radiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
Learning Objectives
1. To learn how to select patients based on imaging parameters
2. To understand how to select proper treatment in different
clinical settings
3. To learn how to optimise the time for acute stroke treatment
Since the first prospective multicenter studies dealing with acute
ischemic stroke (AIS) treatment based on intravenous fibrinolysis (NINDS, ECASS) were published in the mid-nineties, development of new strategies, including endovascular efforts, have led
to tremendous improvements with respect to stroke patients outcome and survival rate. Former endovascular studies showed a tendency toward a treatment benefit but failed to show superiority to

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non-invasive management. However, several recent trials confirmed

the efficacy and safety of endovascular and/or intravenous treatment for selected patient groups. From the beginning, imaging
played a central role in patient selection. More than that, it became
clear early, due to the first statistically non-significant results in these
trials, that patient selection based on clinical and imaging evaluations is the major key for the successful treatment of AIS.
Besides the more or less arbitrary time window, modern imaging
tools like diffusion- and perfusion-weighted (DWI, PWI) magnetic
resonance imaging (MRI) as well as computed tomography (CT)
complemented by CT angiography (CTA) and perfusion (CTP) are
crucial in identifying the infarct core and the tissue at risk; this is the
goal of all therapeutic interventions. This mismatch concept now is
accepted as the essential information to select adequate treatment
for different patient groups.
However, due to the available trial data, the time window still is considered as an evidence-based hard threshold in many stroke-treating hospitals worldwide. Undisputed human beings are variable,
and many (patho-) physiological factors determine a potential treatment success in this diversity. Modern and now well-established
imaging tools have the potential to provide this necessary information. Although CT is a highly sensitive imaging technique in detecting ischemia-induced cellular edema, well-trained and experienced
radiologists are required for accurate diagnosis. CTA and CTP add
valuable data in assessing the site of vessel occlusion and the pathophysiological state of the brain tissue. The development of DWI
marked a milestone in AIS imaging, and easy, highly sensitive, and
very early detection of brain ischemia became a cakewalk. In combination with PWI, the infarction mismatch can be estimated. Former
restricted availability of these techniques is a thing of the past these
days in well-developed countries.
This session will focus on the contemporary state-of-the-art imaging
applied in AIS and how to derive the essential information in a reasonable time to achieve optimal patient selection for whatever is the
best suited treatment.

2501.3
Current techniques in IA stroke intervention

Abstract Book
for patients with an acute ischaemic stroke caused by a large vessel
occlusion of the anterior intracranial circulation.(1-5) These results
caused a revolutionary change in stroke treatment since the introduction of intravenous therapy with thrombolytics more than 20
years before. The different trials used different inclusion criteria and
showed differences in outcome.
In this lecture, a short history of acute stroke treatment trials, including the 2015 RCTs, will be given. Differences between the 2015 trials will be addressed, and new studies with subgroup analyses and
pooled data from these studies will be presented.(6) Implications,
including benchmarks and guidelines, of the results of these trials
and substudies will be discussed.
References
1. Berkhemer OA, Fransen PS, Beumer D, van den Berg LA, Lingsma
HF, Yoo AJ, et al. A randomized trial of intraarterial treatment for
acute ischemic stroke. The New England journal of medicine.
2015;372(1):11-20.
2. Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton
J, et al. Randomized assessment of rapid endovascular treatment
of ischemic stroke. The New England journal of medicine.
2015;372(11):1019-30.
3. Campbell BC, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L,
Yassi N, et al. Endovascular therapy for ischemic stroke with
perfusion-imaging selection. The New England journal of
medicine. 2015;372(11):1009-18.
4. Jovin TG, Chamorro A, Cobo E, de Miquel MA, Molina CA, Rovira
A, et al. Thrombectomy within 8 hours after symptom onset
in ischemic stroke. The New England journal of medicine.
2015;372(24):2296-306.
5. Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM,
et al. Stent-retriever thrombectomy after intravenous t-PA vs.
t-PA alone in stroke. The New England journal of medicine.
2015;372(24):2285-95.
6. Goyal M, Menon BK, van Zwam WH, Dippel DW, Mitchell PJ,
Demchuk AM, et al. Endovascular thrombectomy after largevessel ischaemic stroke: a meta-analysis of individual patient
data from five randomised trials. Lancet. 2016.

Special Session
Treatment options for pancreatic cancer

I.Q.Grunwald
Neuroscience and Vascular Simulation, Faculty of Medical Science,
Anglia Ruskin University, Southend-on-Sea, United Kingdom
Learning Objectives
1. To learn how to select access devices for acute stroke treatment
2. To learn different thrombectomy and suction techniques
3. To understand how to select a certain technique to optimise the
treatment

2502.1
Expanding surgery of locally advanced pancreatic cancer
P.Bachellier
Chirurgie Gnrale, Hpatique, Endocrinienne et Transplantation, Les
Hpitaux Universitaires de Strasbourg, Strasbourg, France

No abstract available.

2501.4
Trials update
W.H.vanZwam
Dept. of Radiology, Maastricht University Medical Centre, Maastricht,
Netherlands
Learning Objectives
1. To understand the latest stroke trials results
2. To understand the impact of recent trials on acute stroke
management
3. To learn how to optimise acute stroke treatment in light of
different trial results
In 2015, five randomised controlled trials were published and three
more were presented at international stroke conferences, all reporting a clear benefit of endovascular treatment over standard care

Learning Objectives
1. To know the indications and technique for expanding surgery of
locally advanced pancreatic cancer
2. To understand the results and complications
3. To learn about current evidence and future trends
To evaluate the short- and mid-term outcomes of 100 consecutive
pancreatectomies with simultaneous arterial resection (AR) performed over a 25-year period.
Pancreatic malignancies invading arterial vessels have been considered for long as a contraindication to resection because of poor
prognosis and prohibitively high postoperative mortality reported
by previous historical studies.
A large prospective single-center database of patients who underwent pancreatic resection between January 1990 and June 2015 was
used to identify patients with simultaneous AR. During a preliminary
period (period A) of 15 years (before 2010), only 31 patients underwent pancreatectomy with AR. According to the promising results
of this preliminary group, 69 additional pancreatectomies with AR

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were performed from 2010 to 2015 (period B). Patient characteristics,
improvement of the procedure, and post-operative outcomes were
compared across the two periods.
There were 42 pancreaticoduodenectomies, 17 total pancreatectomies, and 41 distal pancreatectomies performed. The overall mortality and morbidity were 7% and 44%, respectively. Sixty-nine
patients received preoperative chemotherapy, 87 simultaneous
venous resection, and 83 arterial reconstructions (with 17 multiple
arterial reconstructions). The rate of venous and arterial wall pathologic invasion was 72% and 65%, respectively. The use of neoadjuvant chemotherapy (p<0.001), the number of arterial reconstruction
(p=0.010), and the presence of portal hypertension (p=0.0006) significantly increased from period A to period B, while the mortality
(p=0.32) and morbidity (p=0.89) remained comparable. Subgroup
analysis of patients with pancreatic adenocarcinomas (n=95) found
an overall survival of 61%, 27%, and 17% at 1, 2, and 3 years, respectively, which was not different over the two periods with eight
patients surviving for more than 3 years.
In the largest series reported to date, pancreatic resection combined
with en bloc arterial resection showed an acceptable postoperative morbidity and mortality despite increased technical complexity.
Occasional long-term survival can be observed in selected patients
treated by efficient neoadjuvant chemotherapy.

2502.2
Transarterial therapy
T.Tanaka
Radiology, Nara Medical University, Kashihara, Japan
Learning Objectives
1. To know the indications and technique for transarterial therapy
in pancreatic cancer
2. To understand the results and complications
3. To learn about current evidence and future trends
Pancreatic cancer is the fourth leading cause of cancer death in the
world. The prognosis is extremely poor with a 5-year survival rate of
around 5%. Less than 20% of cases are resectable. Systemic chemotherapy using gemcitabine has been widely used as a standard therapy for unresectable pancreatic cancer. However, the response rate
of gemcitabine monotherapy was only 5% and the median survival
time was about 6 months. For more than a decade, there had been
little progression in the treatment of pancreatic cancer. Numerous
randomized clinical trials using new cytotoxic agents or molecular targeting drugs had failed to demonstrate significant improvement compared with that demonstrated using gemcitabine alone.
A large-scale trial comparing gemcitabine alone with gemcitabine
combined with erlotinib found a small but statistically significant
difference in the overall survival time (5.91 versus 6.24 months).
This result has caused heated discussions regarding the cost effectiveness of the treatment of pancreatic cancer. The addition of erlotinib increases the cost by $16,613 retail for the 6-month treatment
period. Recently, FOLFIRINOX and gemcitabine combined with
nab-PTX showed a greater survival improvement compared with
that shown by gemcitabine alone. However, severe adverse events
of not only hematological toxicity but also fatigue and neuropathy
frequently occurred. Therefore, to improve a therapeutic outcome
without severe toxicities, the development of a novel therapeutic
strategy is required.
Intra-arterial therapy is one of the expected therapies for chemoresistant cancer patients. Several published literatures on intra-arterial
therapy have demonstrated interesting and promising results. The
response rates of 30% to 80% and the median survival times of 9 to
22 months have been reported. When we conduct intra-arterial chemoinfusion for pancreatic cancer, we must consider the drug distribution. In 2004, we reported the drug distribution in advanced

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pancreatic cancer evaluated by CT during arterial injection of contrast material using the hybrid CT and angiography system [1]. Our
results indicated that both the pancreatic head and the body cancer
required chemoinfusion from the celiac and the superior mesenteric
arteries. Based on this result, in 2007, we conducted a clinical study,
in which 5-FU was infused from both the celiac and superior mesenteric arteries and concurrently extra-beam radiotherapy was delivered [2]. This chemoradiotherapy using the dual arterial infusion
technique achieved a high response rate of 70% and median survival
time of 11 months. However, the side effects of diarrhea and hypoalbuminemia occurred due to the chemoinfusion into the superior
mesenteric artery. Then, in 2009, we developed a new technique to
convert the dual pancreatic blood supply into a single one from the
celiac artery [3]. With the embolization of the pancreatic branches
that arise from the superior mesenteric artery, the whole tumor was
supplied by the celiac artery alone in the selected patients. Using
this technique, in 2012, we conducted a phase I/II study of intraarterial 5-FU combined with full-dose systemic gemcitabine [4]. In
phase I, we assessed the recommended dosage of intra-arterial 5-FU
with the dose escalation study. In phase II, we evaluated the tumor
response, the survival duration, and the adverse events. The recommended dose of intra-arterial 5-FU was determined as 1000 mg/m2.
The high response rate of 68.8% was achieved without severe toxicity. The progression-free survival was 6 months and overall survival
was 9.8 months for the patient with liver metastasis. The outstanding high tumor response of intra-arterial 5-FU can be explained by
the pharmacokinetic study. In an animal study using pig, the AUC
of 5-FU in the pancreatic head was around 2.5 times higher in the
intra-arterial superior mesenteric balloon occlusion group than in
the intra-venous group and in the intra-arterial without occlusion
group [5]. Intra-arterial therapy could be effective for a neoadjuvant
setting prior to surgery or radiotherapy because of the high possibility of tumor size reduction [6].
Postoperative hepatic recurrence is frequently seen in 30% to 60%
of clinical cases and in 80% to 90% of autopsy cases. Hepatic recurrence often occurs within a short period after surgery and usually
induces short survival after recurrence. Previous randomized control trials showed the hepatic recurrence rates of 36% in CONKO001 study and 30% in JSAP-02 study after standard adjuvant chemotherapy using gemcitabine. To prevent hepatic recurrence, we
developed novel adjuvant strategy using intra-arterial 5-FU infusion combined with systemic gemcitabine [7]. In our study, overall
hepatic recurrence rate was only 13%. The 2-year survival rate was
75% in our study and 48% in CONKO-001 study. After pancreatic surgery, catheter placement is difficult in some cases due to tortuous
and stenotic celiac and/or hepatic arteries. To overcome the difficulty, we used the coaxial indwelling catheter system [8]. Regarding
the safety of arterial infusion chemotherapy after pancreaticoduodenectomy (PD), we have to carefully evaluate the possibility of biliary complications. We reported that the ratio of complications was
only 6.5% by hepatic arterial hemoinfusion after PD [9].
TACE using irinotecan-eluting beads is also effective for liver metastases from pancreatic cancer. The results of a multicenter registry
showed that the response rate was 80% and overall survival was 9.3
months after the refraction of standard chemotherapy. We have also
experienced several cases in which DEBIRI was effective for multiple
liver metastases from pancreatic cancer.
In conclusion, intra-arterial therapy has a high potential to become
the breakthrough in the treatment of pancreatic cancer.
References
1. Tanaka T, Sakaguchi H, Anai H, Yamamoto K, Morimoto K,
Nishiofuku H, Kichikawa K. Catheter position for adequate
intra-arterial chemotherapy for advanced pancreatic cancer:
evaluation with CT during arterial injection of contrast material.
J Vasc Interv Radiol 2004, 15:1089-1097.

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2. Tanaka T, Sakaguchi H, Anai H, Yamamoto K, Morimoto K,

Tamamoto T, Kichikawa K. Arterial infusion of 5-fluorouracil
combined with concurrent radiotherapy for unresectable
pancreatic cancer: results from a pilot study. Am J Roentgenol
2007, 189:421-428.
3. Tanaka T, Sakaguchi H, Sho M, Yamamoto K, Nishiofuku H,
Nakajima Y, Kichikawa K. A novel interventional radiology
technique for arterial infusion chemotherapy against advanced
pancreatic cancer. Am J Roentgenol 2009, 192:168-187.
4. Tanaka T, Sho M, Nishiofuku H, Sakaguchi H, Inaba Y, Nakajima
Y, Kichikaiwa K. Unresectable pancreatic cancer: arterial
embolization to achieve a single blood supply for intraarterial
infusion of 5-Fluorouracil and full-dose IV gemcitabine. Am J
Roentgenol 2012, 198:1445-1452.
5. Tanaka T, Yamamoto K, Sho M, Nishiofuku H, Inoue M,
Sueyoshi S, Anai H, Sakaguchi H, Nakajima Y, Kichikawa K.
Pharmacokinetic evaluation of pancreatic arterial infusion
chemotherapy after unification of the blood supply in an animal
model. J Vasc Interv Radiol 2010, 21:116-121.
6. Tanaka T, Nishiofuku H, Tamamoto T, Sho M, Anai H, Sueyoshi
S, Sakaguchi H, Hasegawa M, Nakajima Y, Kichikawa K. Intraarterial chemoinfusion prior to chemoradiotherapy with
full-dose systemic gemcitabine for management of locally
advanced pancreatic cancer. Anticancer Res 2011, 31:3909-3912.
7. Sho M, Tanaka T, Yamada T, Nomi T, Akahori T, Doh J, Yamato
I, Hokuto D, Nishiofuku H, Marugami N, Kanehiro H, Kichikawa
K, Nakajima Y. Novel postoperative adjuvant strategy prevents
early hepatic recurrence after resection of pancreatic cancer. J
Hepatobiliary Pancreat Sci 2011, 18:235-239.
8. Hashimoto A, Tanaka T, Sho M, Nishiofuku H, Masada T, Sato
T, Marugami N, Anai H, Sakaguchi H, Kanno M, Tamamoto T,
Hasegawa M, Nakajima Y, Kichikawa K. Adjuvant hepatic arterial
infusion chemotherapy after resection for pancreatic cancer
using coaxial catheter-port system compared with conventional
system. CVIR in press.
9. Hashimoto A, Nishiofuku H, Tanaka T, Sho M, Anai H, Nakajima
Y, Kichikawa K. Safety and optimal management of hepatic
arterial infusion chemotherapy after pancreatectomy for
pancreatobiliary cancer. Am J Roentgenol 2012, 198:923-930.

2502.3
RFA and IRE
K.P.vanLienden
Dep. of Interventional Radiology, Academic Medical Center,
Amsterdam, Netherlands
Learning Objectives
1. To know the indications and technique for RFA and IRE in
pancreatic cancer
2. To understand the results and complications
3. To learn about current evidence and future trends
No abstract available.

Abstract Book

2502.4
HIFU
F.Orsi
Division of Interventional Radiology, IEO Istituto Europeo di Oncologia,
Milan, Italy
Learning Objectives
1. To know the indications and technique for for HIFU in pancreatic
cancer
2. To understand the results and complications
3. To learn about current evidence and future trends
Pancreatic cancer is considered as one of the main big killers in
oncology, with still a very poor prognosis both in patients ameanable to resection (6% 5-year survival rate, which has not substantially improved in the last 40 years) and of course in those with
more advanced stage disease. The median survival ranges from
4.5 months for stage IV to 24.1 months for stage I. More than 50%
of patients are diagnosed with an advanced stage of pancreatic disease. Radiotherapy and chemotherapy are the primary common
therapies for unresectable pancreatic cancer, but they are both only
palliative options, limited to relieving symptoms, improving quality
of life, and prolonging survival. In the last few years, HIFU has been
proposed as an option for palliative treatment of pancreatic tumors
in the advanced stage. Focused ultrasound has the potential to offer
a noninvasive ablative technique for palliation in patients with
pancreatic cancer. Guided by imaging (usually ultrasound due to
the feature of providing real-time images), a high-intensity acoustic beam is focused on the cancer. This beam heats and destroys
the cancerous tissue without damaging the nearby tissues or structures. Multiple preclinical and non-randomized clinical series have
been published, reporting more than 3500 patients already treated
worldwide with HIFU therapy, with the aim of assessing the safety
and efficacy of this procedure. Substantial tumor-related pain reduction was achieved in most cases after HIFU treatment, and few significant side effects were observed. Moreover, some studies reported
an increased effect on survival when chemotherapy was provided in combination with HIFU. The mechanical rather than thermal destruction of tumor tissue is advocated as the main cause of
the increased stimulation of the immune system; this is reported by
some authors. As a potentially noninvasive technique that does not
rely on ionizing radiation, focused ultrasound may offer the following benefits:
Shorter recovery time.
More precise targeting of tumor and metastases, resulting in lower
risk of complications.
Repeated procedural performance.
However, not all patients will be suitable for HIFU treatment because
of the bowel blocking the pathway of the beam. There is also potential for damage to non-targeted tissues such as the skin.
Indications, techniques, pros, and cons will be described.

Special Session
The patients perspective in PAD
2503.1
Patient-reported outcome measurements (PROMS)
M.J.W.Koelemay
Vascular Surgery, Academic Medical Center, Amsterdam, Netherlands
Patient-reported outcome measures
Patient-reported outcomes (PROs) are measurements of any aspect
of a patients health status that comes directly from the patient,
without interpretation of the patients responses by a physician
or anyone else. Patient-reported outcome measures (PROMS) are

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questionnaires that are used to assess PROs. PROMS aim to capture
the subjective (health-related) quality of life or functional status
experienced by an individual patient.
The aim of treating patients with peripheral arterial disease is to
improve their pain-free walking distance and subsequently their
health-related quality of life (HQol) and functional status. Yet, it has
been recognized that the correlation between PROMS and more
traditional hard endpoints such as anklebrachial index (ABI) and
walking distance on a treadmill is only poor to moderate. Since it
is the expectations of the patients treated for PAD that need to be
met, it is obvious that PROMS should be the main endpoint in the
evaluation of treatment success.
Available PROMS
Both generic and disease-specific PROMS have been used in
research in patients with IC. Generic PROMS offer the possibility of
comparing patients with IC to patients with other diseases. However,
the use of generic instruments has several problems. First, as generic
PROMS were designed for a general population, they are likely to
include items that are irrelevant to the patients under study, which
creates the opportunity for inaccurate responses. Second, generic
instruments are likely to miss issues that are particularly relevant to a
specific disease. Disease-specific instruments have been developed
for a well-defined patient population, and if well done, are based on
qualitative interviews with patients and experts in the field. Thus,
they are likely to encompass only items that are relevant and meaningful to the population under study. There are many disease-specific PROMS for patients with PAD, including the CLAUS, intermittent
claudication questionnaire (ICQ), PAQ, PADQol, VascuQol for recording HQol, and the EACH-Q/WELCH walking impairment questionnaire (WIQ) to assess the functional status.
The issues that will be addressed in this talk will comprise a validation of PROMS, determination of the minimally important difference,
and practical problems when introducing PROMS as routine evaluation of or indicators for the quality of care.

2503.2
Shared decision making
D.T.Ubbink
Department of Surgery, Academic Medical Center, Amsterdam,
Netherlands
The patients right to complete information
Medical treatments, however effective, always entail the risk of
undesired complications or side effects. This is particularly poignant in vascular surgical patients who may undergo (repeated)
endovascular or vascular surgical interventions. Both the disorder to be treated and the intervention to be performed can be
life-threatening.
Therefore, it is an ethical duty to inform such patients in detail about
their odds of expected desired, but also the possible undesired outcomes and complications (Legemate 2015), especially when new
interventional techniques are introduced.
Apart from communication about available evidence regarding
treatment options, the patients preference needs to be elicited to
make sure the physicians advice matches the patients preference
(Mulley 2012).
The patients right to vote
Shared decision-making (SDM) invokes the bidirectional communication between physicians and patients required to involve the
patients preference in the eventual treatment choice. Physicians
should provide information about the patients disorder, the possible treatment options and their pros and cons. Patients in turn
should inform their physician about their preferences regarding
these options.
SDM is considered as an essential part of evidence-based medicine,
as it helps determine whether the available evidence on the possible

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benefits and harms of treatment options match the patients characteristics and preferences.
Particularly in vascular surgery, several conditions (such as abdominal aortic aneurysm (AAA), peripheral arterial disease (PAD), and thoracic outlet syndrome) seem particularly suitable for SDM, because
multiple treatment options are available with similar effectiveness.
Even if there are any differences in effectiveness from a medical
point of view, the purported effect should be in agreement with the
patients preferences. Also, the quality and quantity of life should be
weighed against each other in every patient.
Current practice
Regarding the information physicians provide their vascular patients
with, there is room for improvement (Knops 2010). Furthermore,
SDM is not (yet) being practiced widely in vascular surgery (Santema
2016). This is in part due to the fact that physicians have not been
taught during their medical education how to practice SDM. At the
same time, most vascular patients are not aware of the fact they can
play a role in the decision-making process, while others are cognitively not capable.
Tools to support SDM
To foster SDM during the physician-patient encounter when treatment decisions are made, awareness among stakeholders and training of physicians as to SDM are prerequisites. Although applying
SDM may take more time initially, it may save time eventually and
cause better patient compliance and satisfaction. To support the
SDM process, several tools are available or are being developed for
an increasing number of (vascular) disorders.
Patient decision aids are interactive, digital, or paper-based tools
that inform patients about their disorder, the feasible treatment
options, their pros and cons, a questionnaire to check their understanding of this information, and another questionnaire to elicit
their preferences regarding the treatment options explained. This
helps patients to be better prepared for their next contact with their
physician and to express their preferences in the decision-making
conversation.
High-level evidence shows these decision aids are helpful to
increase the patients knowledge, reduce their decisional conflict,
and promote SDM (Stacey 2014). Besides, patients who have been
involved in the decision-making process by means of decision aids
tend to choose less invasive treatments (Knops 2013). Thus, SDM
may even save costs (Oshima Lee 2013).
Option grids are one-page summaries of the questions patients frequently ask regarding the treatment options and the answers to
each of these options, based on best available evidence. Such tools
can be used during the physician-patient encounter to facilitate the
SDM process. More and more of these option grids are being developed (www.optiongrid.org).
Currently, in our center, we have developed decision aids and option
grids for patients with an abdominal aneurysm (comparing endovascular repair vs. open surgery vs. watchful waiting) (Ubbink 2008),
symptomatic carotid stenosis (endarterectomy vs. carotid stenting
vs. medication), claudication (supervised exercise training vs. angioplasty), and varicosis.
SDM is here to stay
Patients increasingly want, and have the right, to be involved in decision-making about their health issues. In chronic disorders like arteriosclerotic disease, the responsibility for the patients health and for
treating the disorder can be shared with the patient.
Let us therefore, as physicians in the realm of vascular disorders, be
willing and prepared to apply SDM whenever possible to improve
the quality of care we provide.
References
(In alphabetical order)
1. Knops AM, Ubbink DT, Legemate DA, de Haes JC, Goossens A.
Information communicated with patients in decision making
about their abdominal aortic aneurysm. Eur J Vasc Endovasc
Surg. 2010 Jun;39(6):708-13.

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2. Knops AM, Legemate DA, Goossens A, Bossuyt PM, Ubbink

DT. Decision aids for patients facing a surgical treatment
decision: a systematic review and meta-analysis. Ann Surg. 2013
May;257(5):860-6.
3. Legemate DA, Koelemay MJ, Ubbink DT. Number unnecessarily
treated in relation to harm: a concept physicians and patients
need to understand. Ann Surg. 2015 Dec 21. [Epub ahead of
print]
4. Mulley AG, Trimble C, Elwyn G. Stop the silent misdiagnosis:
patients preferences matter. BMJ. 2012 Nov;345:e6572.
5. Oshima Lee E, Emanuel EJ. Shared decision making to improve
care and reduce costs. N Engl J Med. 2013 Jan;368(1):6-8.
6. Santema TB, Stubenrouch FE, Koelemay MJ, Vahl AC, Vermeulen
CF, Visser MJ, Ubbink DT. Shared decision making in vascular
surgery: an exploratory study. Eur J Vasc Endovasc Surg. 2016
Apr;51(4):587-93.
7. Stacey D, Lgar F, Col NF, Bennett CL, Barry MJ, Eden KB,
Holmes-Rovner M, Llewellyn-Thomas H, Lyddiatt A, Thomson
R, Trevena L, Wu JH. Decision aids for people facing health
treatment or screening decisions. Cochrane Database Syst Rev.
2014 Jan;1:CD001431.
8. Ubbink DT, Hageman MG, Legemate DA. Shared decisionmaking in surgery. Surg Technol Int. 2015 May;26:31-6.
9. Ubbink DT, Knops AM, Molenaar S, Goossens A. Design and
development of a decision aid to enhance shared decision
making by patients with an asymptomatic abdominal aortic
aneurysm. Patient Prefer Adherence. 2008 Feb;2:315-22.

2503.3
Supervised exercise training first: pro/con
J.A.Reekers
Department of Radiology, Academic Medical Centre, Amsterdam,
Netherlands
Learning Objectives
1. To learn about supervised exercise treatment
2. To understand the economics of SET
Intermittent claudication is a lifestyle-limiting disease. The etiology is atherosclerosis, which is a progressive systemic disease. The
outcome that matters to the patient is improvement of the walking distance. However, this improvement should be matched to
the expected lifetime, which is in most claudication patients on an
average 20 years. PTA gives an immediate relief of complaints with
an increase in walking distance. However, the patency for short
lesions is around 85% at 12 months and no more than 60% for longer lesions. Although the results for longer lesions, as reported in
recently published studies on drug-eluting stents and drug-eluting
balloons in the SFA, suggest better results, the published data only
show better patency and TLR but no clinical improvement. For clinical outcome, there is no improvement compared to standard PTA.
In the randomized studies comparing supervised exercise training
(SET) with PTA, the outcome for the endpoint walking improvement
is equal. Also, a recently published meta-analysis showed no difference at 12 months. So, if both treatments have the same outcome,
there is no reason to primarily choose the more expensive one, i.e.,
PTA. About 20% of patients, however, have no benefit at 6 months
from SE. For this subgroup, a secondary PTA could be considered
at 6 months. So, the treatment pathway for claudicants should be
to start with SET for all and perform a secondary PTA for the nonresponders at 6 months.

Abstract Book

2503.4
Primary PTA first: pro/con
A.Buecker
Clinic of Diagnostic and Interventional Radiology, UKS, Homburg,
Germany
Structured walking exercise is mentioned in S3 guidelines as basic
treatment for patients suffering from peripheral arterial disease.
Nonetheless, the physiological mechanism of walking exercise for
the improvement of maximum walking distance has not been established. If local ischemia is responsible for building of new collaterals, it is not understandable as to why arm training affects the maximum walking distance as well. Furthermore, the definition of structured walking training is unclear. Individual training times and cycles
per week differ from one study to the next. The need for further
supervised training followed by the initial training phase is unclear
as well. Additionally, despite an increase in the maximum walking
distance, no improvement of quality of life is achieved by walking
exercise. Patient compliance is another major problem of structured
exercise training. However, even before walking, training can begin;
a high number of patients were excluded from studies due to principle inabilities in performing walking exercises. The CLEVER study
directly compared walking exercise and stenting. The maximum
walking distance was defined as the primary endpoint. Regarding
this, walking exercise was superior to stenting, but looking at secondary endpoints like pain-free walking distance and quality of
life, stenting proved to be superior. Besides walking distance, exercise training is known to reduce cardiovascular events; therefore, all
patients should be encouraged to perform (walking) exercise regularly before and/or after interventional treatment of peripheral arterial disease.

Special Session
Bone ablation: current evidence and future
frontiers
2504.1
Benign tumours
D.K.Filippiadis, A.D.Kelekis
2nd Radiology Department, University General Hospital ATTIKON,
Athens, Greece
Learning Objectives
1. To learn how to treat benign MSK tumours
2. To learn how to use different ablation techniques for benign
MSK tumours
3. To learn how to use data to improve safety and efficacy
The true incidence of benign bone tumors is unknown since the
vast majority of these lesions are asymptomatic and go undetected
unless are incidentally illustrated in imaging studies. The pathologic
substrate of these lesions includes developmental aberrancies, reactive changes, or localized neoplastic processes, whilst the activity
ranges from latency to aggressive lesions. Benign bone tumors are
more common in younger patients and when symptomatic present
with a variety of symptoms including pain and mobility restriction.
These tumors can be classified into the following:
Tumors of osteoid matrix derived from bone and cartilage progenitor cells of the embryonal mesenchyma including enostosis, osteoma, osteoid osteoma and osteoblastoma
Tumors of chondroid matrix are cartilage-forming tumors including osteochondroma, enchondroma, juxtacortical chondroma,
chondroblastoma and chondromyxoid fibroma

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Tumors forming or arising from fibrous tissue including fibroxanthoma, fibrous dysplasia, osteofibrous dysplasia and desmoplastic
fibroma
Tumors associated with Langerhans cell histiocytosis
Tumors with a fatty matrix including lipoma
Tumors with a vascular matrix including hemangioma, glomus
tumor and lymphangioma
Tumors of unknown origin including giant cell tumor, aneurismal
bone cyst, simple bone cyst
Evolution in imaging technology as well as in instrumentation has
provided the ground necessary for flourishing of percutaneous minimally invasive ablative techniques for the treatment of benign bone
tumors. Percutaneous ablation in the musculoskeletal system can be
classified as:
Chemical (ie injection of ethanol, acetic acid)
Thermal [radiofrequency ablation (RFA), coblation/plasma energy
ablation, laser ablation, microwave ablation (MWA), cryoablation]
Irreversible electroporation (IRE)
MR-guided HIFU (High Intensity Focus Ultrasound which totally
lacks any invasive character)
In the vast majority of benign tumors the aim of ablation is curative
and the Interventional Radiologist should be aware of the tumor
histology, the patients general condition, and the degree of bone
destruction degree which will be relevant to the potential need
for consolidation. Specifically for consolidation the choice of the
injected material depends on the lesion location, extent of ablation
zone and upon the age of the patient with pyrophosphate cements
being used in younger individuals.
As far as percutaneous techniques are concerned, ablation session
in musculoskeletal system should be performed under extensive
local sterility measures, prophylactic antibiotics and anesthesiologic
control. A trocar is either hammered or drilled through the intact
bone; once inside the lesion coaxially a bone biopsy needle can be
inserted for sampling. The trocar provides access to the lesion and
the ablation device of choice can be inserted. Always keep in mind
that the trocar must be removed away from the expected ablation
zone in order to avoid conduction which will transmit heat or ice
from the lesion to the surface, with resultant skin and soft tissues
burns or frostbites. Extra care should be taken for the surrounding
nerve structures which are sensitive to heat or cold. Heating at 45C
has been proven neurotoxic to spinal cord and peripheral nerves;
similarly temperatures at -20C can cause temporary neuropraxia
with permanent neurologic damage occurring at -40C. Protective
measures include:
passive thermal protection techniques (thermocouples for temperature monitoring, intra-operative neurological monitoring systems such as neurodiagnostic EEG, EMG and evoked potential electrodes and accessories)
active thermal protection techniques (skin protection, hydrodissection, CO2 or air insulation)
Potential complications of ablation for benign bone tumors include
iatrogenic damage to the surrounding nerve root or tissues due to
electrode placement, heat effect and size of bone necrosis.
Osteoid osteoma is a benign inflammatory bone tumor encompassing 2-3% of all bone tumors and 10% of benign bone tumors;
it is most common in males < 25 years of age with patients typically
complaining of pain that worsens at night and is promptly relieved
by salicylates. The tumor was first reported by Jaffe in 1953; osteoid
osteoma is composed of the nidus which is bone at various maturity stages surrounded by highly vascular connective tissue stroma.
Depending on the location and axial imaging findings, osteoid osteoma can be classified into subperiosteal, intracortical, endosteal
or intramedullary and intra-articular with the latter being the least
common type and refers to lesions located within or near a joint. In
the literature there are scarce studies with limited patient number
reporting disappearance of the pain post conservative therapy even
if the imaging findings remain with no change however, the long

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term use of NSAIDs can result in potential complications and additionally there is a chance of muscular atrophy and bone deformity in
ages<5 years.
The application of radiofrequency ablation (RFA) was introduced
in clinical practice by Rosenthal in 1992 performing a percutaneous approach for the treatment of osteoid osteoma. Nowadays thermal ablation of osteoid osteoma constitutes a first line therapy.
Numerous studies upon all ablation techniques, others with lesser
and others with higher numbers of patients report high pain reduction rates (up to 96%) and low recurrence rates (~7% at 2 years).
Comparing percutaneous ablation to the traditional surgical techniques for osteoid osteoma (wide excision removing a bone block,
marginal resection of the entire nidus, curettage or high speed burr
techniques) favors percutaneous approach in terms of minimum
trauma, minimum functional restriction and significantly lower cost.
Apart from osteoid osteoma, percutaneous ablation can be used
for the treatment of various other benign tumors including osteoblastoma (<3cm in diameter), chondroblastoma, chondromyxoid
fibroma, intracortical chondroma, aneurysmal bone cyst, eosinophilic granuloma and cystic hydroma. State of the art reviews report
that essentially any small well defined lesion at imaging can be
treated with RF ablation. In aggressive benign osseous tumors with
extensive destruction eg aneurysmal bone cyst percutaneous ablation can be combined to other minimally invasive techniques such
as trans-arterial embolization (prior to ablation for blood flow reduction and lesion necrosis) or cement augmentation (post ablation for
structural support). It is obvious that the young age of these patients
promotes the use of bone-forming biologic cements over classic
PMMA.
Recent studies upon cryoablation report promising preliminary
results in the treatment of extrabdominal desmoids tumors and
Mortons neuromas. Percutaneous approach for soft tissue tumors
seems to achieve local tumor control and pain reduction and at the
same time is governed by reduced complications rate and post-therapeutic convalescence rate.
In conclusion, nowadays in our therapeutic armamentarium plenty
of ablation techniques can be used for the treatment of symptomatic benign bone tumors. Proper patient and technique selection,
high level equipment specifications and appropriate training constitute the major pillars for ensuring success (both technical and clinical) and avoiding complications.
References
1. Brown DB (2011) Musculoskeletal ablation. In: Hong K and
Georgiades CS (eds) Percutaneous tumor ablation. Strategies
and Techniques. Thieme.137-152.
2. Gangi A, Tsoumakidou G, Buy X, Quoix E (2010) Quality
improvement guidelines for bone tumour management.
Cardiovasc Intervent Radiol 33(4): 706-13. doi: 10.1007/s00270009-9738-9.
3. Kelekis AD, Somon T, Yilmaz H, Bize P, Brountzos EN, Lovblad K,
Ruefenacht D, Martin JB (2005) Interventional spine procedures.
Eur J Radiol 55(3):362-83. PMID:16129245.
4. Gangi A, Buy X (2010) Percutaneous bone tumor management.
Semin Intervent Radiol 27(2): 124-36. doi: 10.1055/s-00301253511.
5. Rosenthal D, Callstrom MR (2012) Critical review and state of
the art in interventional oncology: benign and metastatic
disease involving bone. Radiology 262(3): 765-80. doi: 10.1148/
radiol.11101384.
6. Kurup AN, Callstrom MR (2010) Image-guided percutaneous
ablation of bone and soft tissue tumors. Semin Intervent Radiol
27(3): 276-84. doi: 10.1055/s-0030-1261786.
7. Tsoumakidou G, Garnon J, Ramamurthy N, Buy X, Gangi A (2013)
Interest of Electrostimulation of Peripheral Motor Nerves during
Percutaneous Thermal Ablation. Cardiovasc Intervent Radiol
36(6): 1624-8. doi: 10.1007/s00270-013-0641-z.

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8. Rosenthal DI, Springfield DS, Gebhardt MC, Rosenberg AE,

Mankin HJ. (1995) Osteoid osteoma: percutaneous radiofrequency ablation. Radiology 197(2): 451-4. PMID:7480692.
9. Basile A, Failla G, Reforgiato A, Scavone G, Mundo E, Messina
M, Caltabiano G, Arena F, Ricceri V, Scavone A, Masala S
(2013) The use of microwaves ablation in the treatment of
epiphyseal osteoid osteomas. Cardiovasc Intervent Radiol 30
PMID:23989501.
10. Gangi A, Alizadeh H, Wong L, Buy X, Dietemann JL, Roy C (2007)
Osteoid osteoma: percutaneous laser ablation and follow-up in
114 patients. Radiology 242(1): 293-301. PMID:17090708.
11. Mahnken AH, Bruners P, Delbrck H, Gnther RW. (2011)
Radiofrequency ablation of osteoid osteoma: initial experience
with a new monopolar ablation device. Cardiovasc Intervent
Radiol; 34(3): 579-84. doi: 10.1007/s00270-010-9891-1.
12. Mylona S, Patsoura S, Galani P, Karapostolakis G, Pomoni A,
Thanos L (2010) Osteoid osteomas in common and in technically
challenging locations treated with computed tomographyguided percutaneous radiofrequency ablation. Skeletal Radiol
39(5): 443-9. doi: 10.1007/s00256-009-0859-7.
13. Napoli A, Mastantuono M, Cavallo Marincola B, Anzidei M,
Zaccagna F, Moreschini O, Passariello R, Catalano C (2013)
Osteoid osteoma: MR-guided focused ultrasound for entirely
noninvasive treatment. Radiology 267(2): 514-21. doi: 10.1148/
radiol.13120873.
14. Lanza E, Thouvenin Y, Viala P, Sconfienza LM, Poretti D,
Cornalba G, Sardanelli F, Cyteval C. Osteoid Osteoma Treated
by Percutaneous Thermal Ablation: When Do We Fail? A
Systematic Review and Guidelines for Future Reporting.
Cardiovasc Intervent Radiol. 2013 Dec 13. [Epub ahead of print].
PMID:24337349.
15. Maurer MH, Gebauer B, Wieners G, De Bucourt M, Renz DM,
Hamm B, Streitparth F (2012) Treatment of osteoid osteoma
using CT-guided radiofrequency ablation versus MR-guided
laser ablation: a cost comparison. Eur J Radiol 81(11): e1002-6.
doi: 10.1016/j.ejrad.2012.07.010.
16. Ramnath RR, Rosenthal DI, Cates J, Gebhardt M, Quinn RH (2002)
Intracortical chondroma simulating osteoid osteoma treated by
radiofrequency. Skeletal Radiol 31(10): 597-602. PMID:12324830.
17. Corby RR, Stacy GS, Peabody TD, Dixon LB (2008)
Radiofrequency ablation of solitary eosinophilic granuloma of
bone. AJR 190(6): 1492-4 doi: 10.2214/AJR.07.3415.
18. Cable BB, Mair EA (2001) Radiofrequency ablation of
lymphangiomatous macroglossia. Laryngoscope 111(10):
1859-61. PMID:11801958.
19. Tutton S, Olson E, King D, Shaker JL (2012) Successful treatment
of tumor-induced osteomalacia with CT-guided percutaneous
ethanol and cryoablation. J Clin Endocrinol Metab. 97(10):3421-5.
doi: 10.1210/jc.2012-1719.
20. Becce F, Richarme D, Letovanec I, Gilgien W, Theumann N (2012)
Percutaneous radiofrequency ablation of primary intraosseous
spinal glomus tumor. Skeletal Radiol. 41(4):467-72. doi: 10.1007/
s00256-011-1308-y.
21. Welch BT, Welch TJ (2011) Percutaneous ablation of benign bone
tumors. Tech Vasc Interv Radiol. 14(3):118-23. doi: 10.1053/j.
tvir.2011.02.003.
22. Dupuy DE, Hong R, Oliver B, Goldberg SN (2000) Radiofrequency
ablation of spinal tumors: temperature distribution in the spinal
canal. AJR 175(5):1263-6. PMID:11044019.
23. Froese G, Das RM, Dunscombe PB (1991) The sensitivity of the
thoracolumbar spinal cord of the mouse to hyperthermia. Radiat
Res 125:173180. PMID:1996375.
24. Letcher FS, Goldring S (1968) The effect of radiofrequency
current and heat on peripheral nerve action potential in the cat.
J Neurosurg 29: 42-7. PMID:5674091.

Abstract Book
25. Adachi A, Kaminou T, Ogawa T, Kawai T, Takaki Y, Sugiura
K, Ohuchi Y, Hashimoto M (2008) Heat distribution in the
spinal canal during radiofrequency ablation for vertebral
lesions: study in swine. Radiology 247(2):374-80. doi: 10.1148/
radiol.2472070808.
26. Nakatsuka A, Yamakado K, Maeda M, Yasuda M, Akeboshi M,
Takaki H, Hamada A, Takeda K (2004) Radiofrequency ablation
combined with bone cement injection for the treatment of bone
malignancies. J Vasc Interv Radiol 15(7): 707-12.PMID:15231884.
27. Diehn FE, Neeman Z, Hvizda JL et al (2003) Remote thermometry
to avoid complications in radiofrequency ablation. J Vasc Interv
Radiol 14: 1569-76. PMID:14654495
28. Buy X, Tok CH, Szwarc D, Bierry G, Gangi A (2009) Thermal
protection during percutaneous thermal ablation procedures:
interest of carbon dioxide dissection and temperature
monitoring. Cardiovasc Intervent Radiol 32(3): 529-34. doi:
10.1007/s00270-009-9524-8.
29. Filippiadis DK, Tutton S, Kelekis A (2014) Percutaneous bone
lesion ablation. Radiol Med 119(7): 462-9.
30. Filippiadis DK, Tutton S, Mazioti A, Kelekis A (2014) Percutaneous
image-guided ablation of bone and soft tissue tumours: a
review of available techniques and protective measures. Insights
Imaging 5(3): 339-46.

2504.2
Ablation of MSK oligometastatic disease
M.R.Callstrom
Department of Radiology, Mayo Clinic, Rochester, MN, United States of
America
Learning Objectives
1. To learn how to treat and manage MSK oligometastatic disease
2. To learn how to categorise MSK oligometastatic disease
3. To learn how to use data to improve safety and efficacy
No abstract available.

2504.3
Palliative therapies in malignant tumours
G. Koch, R.L. Cazzato, G. Tsoumakidou, J. Caudrelier, J. Garnon,
A.Gangi
Interventional Radiology, University Hospital of Strasbourg, Strasbourg,
France
Learning Objectives
1. To learn how to use different IR techniques in the palliative
setting
2. To learn how to take advantage of radiotherapy in the palliative
setting
3. To learn how to use data to improve safety and efficacy
Most bone metastases develop in patients with breast, prostate,
lung, thyroid, and kidney cancers. Most lesions are located in the
spine, pelvis, and proximal part of the extremities. In 75% of cases,
these lesions cause skeletal-related events (SREs) that are characterized by pain, pathological fractures, loss of limb function, and nerve
compression. The goal of palliative treatment is not to radically
destroy the tumor but to alleviate pain and prevent SREs (especially
fractures).
Radiotherapy is the gold standard treatment for symptomatic bone
metastasis, but this technique has some limitations: its effects are
slow and limited in time as the median time to response is 3 weeks
and the median time to progression is about 6 months. Moreover,
one third of the patients do not respond to radiotherapy treatment
(1). Thus, interventional radiology (IR) has a place in palliative care.

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IR palliative treatment can be achieved with consolidative techniques (cementoplasty or screw fixation) or with ablative techniques, such as radio frequency ablation (RFA), microwave ablation
(MWA), cryoablation, and high-intensity focused ultrasound (HIFU).
A combination of ablative and consolidative techniques is recommended when an osteolytic lesion with extra-osseous component is treated or for large volumes of ablation in tumors involving
weight-bearing bones to prevent the risk of secondary fractures. For
hypervascular metastasis (e.g., kidney or thyroid cancers), intra-arterial embolization might be an option combined to percutaneous
techniques.
Cementoplasty consists of percutaneous injection of polymethylmethacrylate cement (PMMA) and provides pain relief and
bone strengthening in patients with malignant bone tumors (2).
Cementoplasty is indicated for patients with osteolytic tumors
(metastasis, multiple myeloma, and lymphoma) located to the vertebral body, acetabulum, femoral condyles, talus, and calcaneus, causing local pain, disability, and high risk of compression fracture (3,4).
Cementoplasty does not stop tumor growth; thus, it should not be
considered as a radical treatment. PMMA is highly resistant to compression forces but susceptible to torsion forces. Thus, cement injection should not be used in long diaphysis, as it does not provide
bone strengthening, with possible fracture of the cement rod.
Screw fixation should be considered for the treatment of nondisplaced pathologic or bone insufficient fractures or in cases of
impending fractures (i.e., osteolytic lesions weakening the bone);
such technique can be applied when both compression and torsion forces are involved. Screw fixation might be used in bones of
the pelvic ring (including the femoral neck and the sacrum) or shoulder girdle.
Percutaneous ablation using RFA is produced by alteration of the
electric current at the tip of an electrode, causing local ionic agitation and subsequent frictional heating. According to the size of the
lesion and the generator used, different protocols are applied. The
best guidance modality is CT, with or without fluoroscopy. The electrodes can be placed either directly inside the lesion or through a
coaxial system. For sclerotic bone lesions a system of coaxial drill
needle can be applied to penetrate the target lesion. Bone RFA is
painful and requires regional block or general anesthesia. The difficulty of treating bone tumors with RFA lies in the thermal protection
of vulnerable surrounding structures (particularly nerve roots) (5).
When using RFA for pain palliation, significant (>50%) and rapid pain
relief (during the first 24 hours to 1 week post-treatment) is achieved
in 70-95% of cases, with substantial decrease of the consumption of
analgesic drugs (6). Though recurrence of pain may occur (due to the
advanced disease), the vast majority of patients remain pain free at
the ablated area.
Cryoablation relies on the application of extreme cold aiming to
destroy cells, by causing both direct cellular and vascular injury.
The procedure is carried out by means of thin probes (17 gauge)
and exploits the Joule-Thomson effect of gases in order to achieve
rapid cooling at low temperatures (-100C) of the surrounding tissue. The basic principles of cryosurgery for tumors are fast cooling
of the tissue to a lethal temperature, slow thawing, and repetition
of the freezing-thawing cycle. Percutaneous cryoablation proved
to be a safe and effective for pain management due to metastatic
disease involving bone and soft tissues. Regarding bone metastasis, cryoablation is not influenced by tissue impedance and thus, it
is efficient for both osteolytic and sclerotic tumors. Similar to bone
RFA, the procedure is performed under sedation or general anesthesia (though cryoablation appears to be less painful than RFA) (7). In
most centers, cryoablation is performed under CT or MR guidance
(with MR-compatible cryoprobes). The distance between probes
should be 2 cm. With cryoablation the ablation zone (namely iceball) is clearly seen as a hypodense (on CT) or a signal-void area
(on MRI), while the boundaries between the frozen and non-frozen

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areas are well defined and depicted with high contrast. Cryoablation
has the advantage of synergic and simultaneous activation of many
probes (up to 25) in order to treat large lesions. Pain palliation in
malignant painful bone tumors is achieved in >70% of cases, with
substantial decrease in the use of pain killers and improvement of
the quality of life (8). The main advantages of cryoablation over RFA
are that the former is less painful thus, requiring less intra and postprocedural analgesia, and that the area of ablation is clearly visualized with cryoablation, which is not the case with RFA.
MWA utilizes dielectric hysteresis produced by a percutaneously
applied electromagnetic field (900-2500 MHz) to produce heat
energy. Interstitial antennas are used to couple energy from the generator power source to the tissue. In contrast to RFA, MW antennas
are capable of propagating through and effectively heating many
types of tissue, without being influenced by the tissue dielectric
properties. According to the size of the lesion, one or more antennas
are inserted and may be activated simultaneously. The best image
guidance modality for MWA is CT (with or without fluoroscopy). No
MR-compatible generators-antennas are available at the moment.
MW antennas can be placed either directly inside the lesion or
through coaxial systems. Compared to RFA, MWA can produce larger
areas of ablation in less time; moreover, it is not influenced by tissue impedance and is less susceptible to heat sink effects. As MWA
is a rather new technique, no long-term results exist at the moment.
HIFU uses convergent high-intensity ultrasound to induce focalized
tissue destruction by rapid increase of local temperature. To treat
localized painful bone metastases, HIFU has been used in combination with MR guidance under conscious sedation (9). This technique
demonstrated good pain relief at 1 and 3 months follow-up, with
decrease in the use of analgesic drugs. At the 3-month CT follow-up,
up to 56% of osteolytic lesions showed an increased bone density,
suggesting a potential consolidative role of HIFU. However, further
studies are needed to confirm this aspect.
When hypervascular lesions are treated, ablative techniques, especially cryoablation and RFA, may be faced with the cold or heat sink
effect. Pre-ablative intra-arterial embolization of the tumor may
increase the effect of thermal ablation.
References
1. Steenland E, et al. The effect of a single fraction compared to
multiple fractions on painful bone metastases: a global analysis
of the Dutch Bone Metastasis Study. Radiother Oncol, 1999. 52:
p. 101-9.
2. Gangi A, et al., Interventional radiologic procedures with CT
guidance in cancer pain management. Radiographics, 1966. 16:
p. 1289-304.
3. Gangi A, et al., Percutaneous vertebroplasty: indications,
technique and results. Radiographics, 2003. 2003(23:e10).
4. Gangi A and Buy X, Percutaneous bone tumor management.
Semin Interventi Radiol, 2010. 27(2): p. 124-36.
5. Callstrom MR, et al., Painful metastases involving bone:
feasibility of percutaneous CT- and US-guided radio-frequency
ablation. Radiology 2002. 224: p. 87-97.
6. Callstrom MR and Charboneau JW, Image-guided Palliation of
Painful Metastases Using Percutaneous Ablation. . Tech Vasc
Interventional Rad 2007. 10: p. 120-131.
7. Thacker PG, et al., Palliation of painful metastatic disease
involving bone with imaging-guided treatment: comparison of
patients immediate response to radiofrequency ablation and
cryoablation. AJR Am J Roentgenol, 2011. 197(2): p. 510-5.
8. Callstrom MR, et al., Painful metastases involving bone:
percutaneous image-guided cryoablation-prospective trial
interim analysis. Radiology, 2006. 241(2): p. 572-80.
9. Gianfelice D, et al., Palliative treatment of painful bone
metastases with MR imaging-guided focused ultrasound.
Radiology. 2008;249(1):355-63.

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2504.4
HIFU: therapeutic and palliative applications
A.Napoli, C.Palla
Department of Radiological Sciences, University of Rome La Sapienza,
Rome, Italy
Learning Objectives
1. To learn how to use HIFU in the therapeutic setting
2. To learn how to use HIFU in the palliative setting
3. To learn how to use data to improve safety and efficacy
Bone is frequently involved in advanced neoplastic disease, representing the third most common organ to which cancer metastasizes
(1). The incidence of bone metastases has recently increased since
the improvement in life expectancy in neoplastic patients, especially in those affected by prostate or breast cancer (2). In addition
to chemotherapy, useful to control the systemic disease progression, supplementary independent local therapy on bone metastases may be required in order to prevent skeletal complications and
preserve the quality of life (1,3). Pain is the most common symptom of bone metastases, with 50%70% of patients suffering from
severe pain. Patient with painful bone metastases usually undergo
palliative treatments, including localized therapies (radiation and
surgery), systemic therapies (chemotherapy, hormonal and radiopharmaceutical therapies, bisphosphonates), and analgesics (opioids and nonsteroidal anti-inflammatory drugs). In order to significantly reduce side effects of the conventional treatments and provide additional therapeutic options, several new treatment modalities have been introduced in the last decades, including radiofrequency, laser, microwaves, and cryoablation. The current noninvasive standard for local pain palliation is represented by External
Beam Radiotherapy (EBRT), not always providing a complete and
durable symptom relief: pain persistence is reported in 20%30%
of patients (4,5) and pain recurrence occurs in up to 25% of patients
following treatment (6). Magnetic resonance-guided focused ultrasound (MRgFUS) has been clinically approved in the European Union
for the palliative treatment of bone metastases (7-9). The MRgFUS
technique combines the realtime thermal monitoring capabilities
of MRI with the heat generating properties of focused ultrasound
waves. This approach is usually conducted in an outpatient setting
and does not require ionizing radiation, allowing the treatment to
be repeated, in case of symptom recurrence or new tumor appearance. The major advantages of MRgFUS include highly accurate
three-dimensional treatment planning using MR guidance, realtime
monitoring of thermal damage in the target zone using MR thermometry, continuous temperature mapping of treated tissue (10),
and immediate post treatment assessment of therapy. An additional
advantage of MRgFUS over other ablative techniques is the totally
noninvasive nature of the focused ultrasound intervention. During
treatment, realtime multislice MR thermometry is used to evaluate temperature rising within the target tissue. Based on this feedback, portions of the periosteum and/or tumor that were not fully
ablated may be retreated. This realtime MR feedback also enables
the physician to overcome misregistration due to respiratory or bulk
patient movement (11-13). In general, focused ultrasound system
produces acoustic energy generated by a piezoelectric transducer
that operates at frequencies of 200 kHz4 MHz. Using high energy
levels, the interaction between focused ultrasound beams and biologic tissues produces a rise in cell temperature within the treated
volume of tissue. The increased cell temperature leads to coagulative necrosis at a thermal range of 6585C, depending on the tissue absorption coefficient (14,15). In order to obtain a greater and
more rapid temperature elevation, each sonication is usually limited
to focal volumes of 0.25 mm, with a substantially negligible effect
on the surrounding tissue. Sonication lasting, moreover, is limited
to only few seconds, thereby reducing the potentially detrimental
effects of perfusion and blood flow on energy distribution (16,17).

Abstract Book
The concentration of acoustic energy on the intact surface of cortical bone produces a rapid temperature increase that mediates critical thermal damage to the adjacent periosteum, which is the most
innervated component of mature bone tissue. Such thermal ablation has been shown to be an extremely effective approach for
pain management (18,19). MRgFUS ablation is useful to treat painful bone lesions from metastatic disease in patients with known history of malignancy, as shown by clinical or imaging examinations.
In particular, MRgFUS ablation is indicated in patients who are considered radiation failures, including patients who received radiation without adequate symptom relief, those who can no longer
undergo ERBT for safety reasons, and those who refuse other therapeutic options. In our department, we evaluated the safety and efficacy of MRgFUS treatment in pain palliation of lesions from different
known primary tumors. We enrolled patients who had exhausted
EBRT as well as patients not previously treated with EBRT for target metastases; our study demonstrated that MRgFUS can be effectively applied as primary noninvasive technique for pain palliation
related to bone metastases (20). Clinical data include evaluation of
visual analog pain score (VAS), changes in the drug schedule and
improvements in the quality of life. The VAS is an 11 point pain scale
that ranges between 0 (absence of pain) and 10 (the worst pain ever
experienced). The absorption rate of ultrasound by the cortical bone
is up to 50 times higher than other biological tissues, thereby allowing only a minimal fraction of the applied energy to penetrate across
the cortex (16,17). For this reason, high intensity focused ultrasound
was not considered useful for the ablation of lesions deeply localized within the bone marrow, thereby limiting its application to pain
palliation in superficial lesions (13) for a long time. Recently, it has
been demonstrated that while both high acoustic absorption and
low thermal conductivity of the cortical bone limit the diffusion of
the conventional focused ultrasound energy to the cortex surface,
the use of treatment protocols with modulated treatment parameters may achieve heating effect at therapeutic level deeper into
the bone marrow (21). The modulation of treatment parameters for
tumor control relies on system tuning to increase acoustic energy
levels and sonication duration and to decrease the frequency, allowing heating beyond the cortex (22-24). In fact, a lower frequency is
associated with a deeper penetration. Therefore, this technique
also shows a potential role in achieving local tumor control, allowing remineralization of the trabecular bone or reducing the lesion
size (25). In our department, lesion changes were evaluated according to MD Anderson (MDA) criteria in order to investigate treatment
efficacy in terms of local tumor control (20). The degree of lesion
necrosis produced by high intensity focused ultrasound is quantified as non-perfused volume (NPV), defined as the volume of neoplastic lesion enhancing at baseline that did not show any contrast
uptake after treatment. The use of NPV parameter can represent an
added value in the evaluation of treated area and should be analyzed in association with MDA criteria. Moreover, NPV can be considered as the immediate predictor of tumor necrosis and thus of treatment efficacy; this parameter might play an important role in future
patient management, thereby avoiding persistence with a potentially ineffective treatment and consequences such as toxic effects,
morbidity, accelerated tumor growth, delay in potentially effective
treatment and unnecessary expense. In conclusion, MRgFUS ablation is an extremely promising alternative therapy for successful
palliation of bone metastases and demonstrates a potential important role in tumor control, because of the bony structure remodeling
induced by thermo-related coagulative necrosis.
References
1. Selvaggi G, Scagliotti GV. Management of bone metastases in
cancer: a review. Crit Rev Oncol Hematol 200556:365378.
2. Kurup AN, Callstrom MR. Ablation of skeletal metastases: current
status. J Vasc Interv Radiol 201021:S242S250.
3. Mundy GR. Metastasis to bone: causes, consequences and
therapeutic opportunities. Nat Rev Cancer 20022:584593.

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4. Hartsell WF, Scott CB, Bruner DW, et al. Randomized trial of short
versus long course radiotherapy for palliation of painful bone
metastases. J Natl Cancer Inst 200597:798804.
5. Goetz MP, Callstrom MR, Charboneau JW, et al. Percutaneous
image guided radiofrequency ablation of painful metastases
involving bone: a multicenter study. J Clin Oncol 200422:300
306.
6. Saarto T, Janes R, Tenhunen M, Kouri M. Palliative radiotherapy
in the treatment of skeletal metastases. Eur J Pain 20026:323
330.
7. Liberman B, Gianfelice D, Inbar Y, et al. Pain palliation in patients
with bone metastases using MRguided focused ultrasound
surgery: a multicenter study. Ann Surg Oncol 200916:140146.
8. Catane R, Beck A, Inbar Y, et al. MRguided focused ultrasound
surgery (MRgFUS) for the palliation of pain in patients with
bone metastases: preliminary clinical experience. Ann Oncol
200718:163167.
9. Jolesz FA, McDannold N. Current status and future potential of
MRIguided focused ultrasound surgery. J Magn Reson Imaging
200827(2):391399.
10. Gianfelice D, Gupta C, Kucharczyk W, Bret P, Havill D, Clemons M.
Palliative treatment of painful bone metastases with MR imaging
guided focused ultrasound. Radiology 2008249:355363.
11. Rieke V, Vigen KK, Sommer G, Daniel BL, Pauly JM, Butts K.
Referenceless PRF shift thermometry. Magn Reson Med
200451:12231231.
12. Arora D, Cooley D, Perry T, Skliar M, Roemer RB. Direct thermal
dose control of constrained focused ultrasound treatments:
phantom and in vivo evaluation. Phys Med Biol 200550:1919
1935.
13. Orsi F, Arnone P, Chen W, Zhang L. High intensity focused
ultrasound ablation: a new therapeutic option for solid tumors. J
Cancer Res Ther 20106:414420.
14. Simon CJ, Dupuy DE, MayoSmith WW. Microwave ablation:
principles and applications. Radiographics 200525:S69S83.
15. Sapareto SA, Dewey WC. Thermal dose determination in cancer
therapy. Int J Radiat Oncol Biol Phys 198410:787800.
16. Jolesz FA, Hynynen K. Magnetic resonance image guided
focused ultrasound surgery. Cancer J 20028:S100S112.
17. Jolesz FA. MRIguided focused ultrasound surgery. Annu Rev
Med 200960:417430.
18. Gianfelice D, Gupta C, Kucharczyk W, et al. Palliative treatment
of painful bone metastases with MR imagingguided focused
ultrasound. Radiology 2008249:355363.
19. Liberman B, Gianfelice D, Inbar Y, et al. Pain palliation in patients
with bone metastases using MRguided focused ultrasound
surgery: a multicenter study. Ann Surg Oncol 200916:140146.
20. Napoli A, Anzidei M, Cavallo Marincola B, et al. Primary pain
palliation and local tumor control in bone metastases treated
with magnetic resonance guided focused ultrasound. Invest
Radiol 201348:351358.
21. Chen W, Zhu H, Zhang L, et al. Primary bone malignancy:
effective treatment with high intensity Focused ultrasound
ablation. Radiology 2010255:967978.
22. Chen WZ, Wu F, Zhu H, et al. High intensity focused ultrasound
in the treatment of experimental malignant bone tumor. Chin J
Ultrasonography 200110:313315.
23. Chen WZ, Wu F, Zhu H, et al. Preliminary study on high intensity
focused ultrasonic treatment of osteosarcoma. Chin J Clin Oncol
200128:489491.
24. Chen W, Wang Z, Wu F, et al. High intensity focused ultrasound
in the treatment of primary malignant bone tumor [in Chinese].
Zhonghua Zhong Liu Za Zhi 200224:612615.
25. Napoli A, Anzidei M, Cavallo Marincola B, et al. MR imaging
guided focused ultrasound for treatment of bone metastasis.
Radiographics 201333:15551568.

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Special Session
How to improve acute stroke management:
present and future
2601.1
How to improve patient selection for mechanical
thrombectomy or IV thrombolysis
C.P.Stracke1, H.Nordmeyer2, R.Chapot3
1Klinik fr Neuroradiologie, Diagnostische und Interventionelle
Radiologie, Kinderradiologie, Neurochirurgie und Sportmedizin,
Alfried Krupp Krankenhaus, Essen, Germany, 2Neuroradiology, Alfried
Krupp Krankenhaus, Essen, Germany, 3Klinik fr Radiologie und
Neuroradiologie, Alfried Krupp Krankenhaus, Essen, Germany
Learning Objectives
1. To review imaging in acute stroke of anterior and posterior
circulation
2. To learn about the current role and limitations of prognostic
scales
3. To learn about future trends in patient selection for
endovascular therapy of ischaemic stroke
Mechanical thrombectomy with stent retrievers showed high clinical efficacy in stroke treatment in recent 6 randomised clinical trials.
The rate of good clinical outcome (mRs < 2) in patients with large
intracranial vessel occlusion ranges from 33% (MR CLEAN trial) to
71% (EXTEND-IA trial). Beside technical aspects and the critical timeline of stroke treatment, the patient selection for thrombectomy is
important.
Surprisingly, patient age and time window have less influence on the
clinical outcome than historically expected. Other parameters such
as collateralisation scores or the ASPECT score have to be considered. Subgroups of patients with intracranial stenosis seem to have
poorer prognosis.
The impact of iv-TPA in large vessel occlusion on the clinical outcome seems to be very small in combination with thrombectomy
and will be the focus of upcoming RCTs.
References
1. Weber R, Nordmeyer H, Hadisurya J, Heddier M, Stauder M, Stracke
P, Berger K, Chapot R. Comparison of outcome and interventional
complication rate in patients with acute stroke treated with mechanical thrombectomy with and without bridging thrombolysis. J
Neurointerv Surg. 2016 Feb 22.

2601.2
Role of access/support devices to improve IA acute stroke
treatment
K.A.Hausegger
Radiology, General Hospital Klagenfurt, Klagenfurt, Austria
Learning Objectives
1. To review guiding catheters and technical tricks in IA access in
acute ischaemic stroke
2. To learn about usefulness of temporary balloon occlusion during
clot removal
3. To learn about possible complications due to IA access
The prerequisite for a successful mechanical thrombectomy (MTE) in
patients with acute ischemic stroke is a stable access to the affected
vascular territory, which is one of the common and internal carotid
arteries in case of anterior and one of the vertebral arteries in case
of posterior circulation strokes. If possible, the aortic arch configuration and above all the condition of the supra-aortic vessels (carotid
and/or vertebral arteries) should be evaluated in the preinterventional CT angiogram.

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The configuration of the aortic arch (type 13) determines how easy
or difficult the cannulation of the access vessel is. Especially, a type 3
aortic arch configuration may cause difficulties. For type 1 and 2 aortic arch configurations, catheters with a multi-purpose configuration
are typically used; for type 3 aortic arch configuration, a sidewinder
II catheter (i.e., Simons II) is preferred for probing the carotid arteries. After successful probing of the access vessel, a reinforced sheath
is typically placed in the proximal portion of the access vessel over
an extra stiff exchange wire (Amplatz wire). Some operators primarily use a sheath with a configurated dilatator. Alternatively, a guiding
catheter may be used; however, these catheters provide less support
compared to a reinforced sheath.
In rare cases, where a standard approach from the groin is not possible due to extensive vascular tortuosity and/or unfortunate aortic
arch anatomy, a transbrachial access may be chosen as an alternative. Side selection depends on individual situation. MTE after direct
puncture of the common carotid artery has also been described as a
very rare access route.
Selection of sheath or guiding catheter diameter depends on the
dimension of the access vessels. There is a clear tendency toward
larger diameters. Whenever possible, we prefer to place a 8-F sheath
into the proximal segment of the internal carotid artery (ICA) in anterior circulation strokes and use 6-F systems in posterior fossa strokes
due to the smaller caliber of the vertebral arteries.
With the further development of big-bore intermediate catheters (i.e., 5- or 6-F inner diameter), which have been made extremely
flexible, many operators use triaxial systems now. The intermediate
catheter is introduced via the sheath, which is placed in the access
vessel together with a coaxial 0,018 to 0.027 microcatheter of a
0.014 guidewire. Using this assembly, direct thromboaspiration via
the intermediate catheter, which has been navigated up the thromboembolic occlusion, can be performed, with simultaneous aspiration from the large sheath.
It has been shown in in vitro and clinical studies that the usage of
distal balloon occlusion catheters is an effective tool to reduce the
rate of distal embolization to new (so far, unaffected) vascular territories. Balloon catheters measuring 8- and 9-F are available. So far,
it has not been proven scientifically as to whether the technique
where a large sheath is used in combination with direct aspiration
or the routine usage of distal balloon occlusion catheters is more
effective in the prevention of distal embolization events during MTE.
However, it has become obvious that flow modification with simple
MTE using a stent retriever is not at all associated with a higher rate
of distal embolization.
The complication rate of MTE in patients with acute ischemic stroke
ranges from 5% to 11%. In majority of the studies where complications are reported, the focus is put on the intracranial bleeding
events.
Complications due to the vascular access occur in about 5% of the
patients in the form of vessel dissections and/or vascular spasms.
Vascular spasm, typically occurring in the extracranial segment
of the ICA, is self-limiting in most patients and rarely needs specific treatment. If the spasm is long lasting and severely flow limiting despite the removal of the (guiding) catheter of sheath, intraarterial application of nimopitine is effective in most cases within 510
minutes. In such rare cases, we intraarterially infuse a mixture of 15
mg nimopitine in 500 ml NaCl quickly over 15 minutes. However, we
clearly mention that this is an off-label application of nimopitine.
Dissections may be guidewire and/or catheter induced. In addition,
a dissection may be caused by the balloon of a balloon occlusion
catheter. This may be due to overinflation and mechanical manipulation during the MTE procedure. In most cases, the dissection is more
a cosmetic than a clinical problem. However, in case of flow-limiting
dissection, insertion of a stent may be necessary for flow restoration.

Abstract Book
References
1. Behme D, Gondecki L, Fiethen S, Kowoll A, Mpotsaris A, Weber
W. Complications of mechanical thrombectomy for acute
ischemic stroke-a retrospective single-center study of 176
consecutive cases. Neuroradiology. 2014 Jun;56(6):467-76.
2. Chueh JY, Puri AS, Wakhloo AK, Gounis MJ. Risk of distal
embolization with stent retriever thrombectomy and ADAPT. J
Neurointerv Surg. 2016 Feb;8(2):197-202.
3. Chueh JY, Khn AL, Puri AS, Wilson SD, Wakhloo AK, Gounis MJ.
Reduction in distal emboli with proximal flow control during
mechanical thrombectomy: a quantitative in vitro study. Stroke.
2013 May;44(5):1396-401.

2601.3
Direct recanalisation with or without stent retrievers
I.Q.Grunwald
Neuroscience and Vascular Simulation, Faculty of Medical Science,
Anglia Ruskin University, Chelmsford, United Kingdom
Learning Objectives
1. To learn about basic principles of recanalisation in intracranial
arteries
2. To review various types of stent-retrievers
3. To compare stent-retrieval technique with aspiration
No abstract available.

2601.4
Clots: how to best manage a complex problem
T.Andersson
Neuroradiology, Karolinska Sjukhuset, Stockholm, Sweden
Learning Objectives
1. To review pathological types of the thrombi relevant to
mechanical thrombectomy
2. To learn about CT density and the possibility to retrieve the clot
3. To learn about possible changes of IVTL on clot affecting its
mobility during mechanical thrombectomy
Recently, five randomized control studies showed superiority of
intra-arterial treatment (IAT) added to intravenous thrombolysis
(IVT) over stand-alone IVT in patients suffering from a large artery
stroke in the anterior circulation1-5. In these studies, however, the
revascularization rate varied from 59% to 88%, which means that
obviously a substantial proportion of patients, between approximately 15% and 40%, did not become revascularized. This is mainly
due to technical reasons. Access problems may to some extent be
the explanation but only for a relatively small proportion of patients,
as most of the times, it is possible to access the embolic obstruction.
Instead, clot properties may be the determining factor. A thromboembolus contains many different substances, but one very important factor seems to be the content of fibrin. A mature, fibrinrich clot is firm, tough, and sticky and therefore much less likely
to deform. With this follows the obvious risk of being difficult to
remove with conventional stent retrievers or with aspiration alone.
In contrast, clots rich in red blood cells are soft, friable, and slippery,
which means that they may be easier to remove; instead, they are
more prone to embolization in the same or in a previously unaffected territory. And even if we finally manage to achieve revascularization, the actual procedure would take too long, and the patient
may develop a definite infarct with a concomitant bad outcome.
Here, again, clot properties become important. Ideally, it should
be possible to remove the majority of clots with 12 attempts and
the total time of the procedure, from groin puncture to revascularization, should not take more than 1530 minutes. With efficient

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devices and a good technique, including flow-arrest utilizing a balloon guide catheter, and adequate device positioning, this is definitely achievable. In the future, we will probably see more research
into this important field of clot properties and their relation to procedural technique to further increase the yield of our thrombectomy
efforts.
References
1. Berkhemer OA et al, A randomized trial of intraarterial treatment
for acute ischemic stroke. N Engl J Med. 2015;372:11-20.
2. Goyal M et al, Randomized assessment of rapid endovascular
treatment of ischemic stroke. N Engl J Med. 2015;372:1019-1030.
3. Campbell BC et al, Endovascular therapy for ischemic stroke with
perfusion-imaging selection. N Engl J Med. 2015;372:1009-1018.
4. Saver JL et al, Stent-retriever thrombectomy after intravenous
t-PA vs t-PA alone in stroke. N Engl J Med. 2015;372:2285-2295.
5. Jovin TG et al, Thrombectomy within 8 hours after symptom
onset in ischemic stroke. N Engl J Med. 2015;372:2296-2306.

Fundamental Course
Drug-eluting technologies
2603.1
The science behind drug-eluting balloon technology
R.Virmani
CV Path Institute, Inc., Gaithersburg, MD, United States of America
Learning Objectives
1. To learn how DEBs deliver drugs into the vessel wall
2. To learn how coating techniques of DEBs influence the final drug
concentration in the vessel wall
3. To learn how coating techniques of DEBs effect peripheral
embolisations of drug particles
Atherosclerosis is the primary cause of peripheral artery disease
(PAD), which continues to increase in the United States and Europe
and affects more than 27 million people. The symptoms of PAD vary
widely from mild claudication to critical limb ischemia (CLI) with
gangrene and limb loss, which is associated with high morbidity,
especially in the elderly. Historically, treatment strategies for PAD
have involved medical therapy and open surgical bypass procedures. Over the last decade, endovascular treatment, including percutaneous transluminal angioplasty, stenting (with or without drug),
stent grafts, and atherectomy, has become the standard of care.
However, the treatment is complicated by the fact that the superficial femoral artery (SFA) is one of the longest and most dynamically
active vessels in the body, undergoing torsion, compression, flexion, and extension relative to hip and knee motion. The lower limb
vessels are also susceptible to atherosclerosis because of low shear
stress and spiral flow, which is most evident in the long segment of
the lesser curvature of the SFA.
Endovascular interventions are currently the first-line strategy for
treatment, as recommended by the TransAtlantic Inter-Society
Consensus for type A and B lesions. More recently, drug-coated
balloons (DCBs) are now considered novel alternatives to stenting,
as they provide the same antiproliferative drug without the need
of permanent stent placement. The benefit of DCBs over stenting includes rapid delivery of the drug, which is more diffusely distributed on the luminal surface without a polymer carrier or a rigid
metallic frame, avoiding the aforementioned unfavorable foreign
body response that can contribute to in-stent restenosis.
To date, paclitaxel is the most commonly used drug for DCB technology, because it has high lipophilic physiochemical properties,
allowing passive absorption through the cell membrane and a sustained effect within the treated vessel wall. Drug delivery through
adherence to the vessel wall is facilitated by carrier excipients, a revolutionary discovery that has led to the success of DCB technology.

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Another potential advantage of DCBs is the more uniform deliverability of drug to the vessel wall relative to drug-eluting stents.
However, the downstream effects in skeletal muscle following DCB
usage present one of the major concerns, which may help distinguish the available balloon technologies on the market. Clinicians
should understand the advantages and disadvantages of the various products before selecting an appropriate DCB for their patients.

2603.2
Clinical studies on drug-eluting balloons
A.Cannavale1, M.Santoni2, M.Gazzetti3, F.Fanelli4
1Department of Radiology, East Kent Hospitals University NHS
Foundation Trust, Canterbury, United Kingdom, 2Department of
Radiological Sciences, Sapienza University of Rome, Rome, Italy,
3Department of Surgery Pietro Valdoni, Sapienza University of
Rome, Rome, Italy, 4Interventional Radiology Unit, Department of
Radiological Sciences, Sapienza University of Rome, Rome, Italy
Learning Objectives
1. To learn about existing data of RCT
2. To learn about the influence of different drug-coating
technologies on clinical data
3. To learn about ongoing clinical studies
Following the initial impressive results reported in the literature, several operators started using drug-coated balloons (DCBs) in their
daily practice. Nowadays, several mid-/long-term studies and RCTs
are being conducted, particularly on the use of DCB in the femoropopliteal segment. Among the available studies, it is worth considering only those validated by an independent core lab and published
in peer reviewed journals to limit/avoid individual measurements,
specificities, diversities, and potential bias.
According to the widely accepted hierarchy of evidence, the
most reliable studies on DCB are the following: THUNDER RCT
(Paccocath-B. Braun), ADVANCE PTX (Advance 18 PTX-Cook),
BIOLUX-I (Paseo 18-Biotronik), ILLUMENATE (Stellarex-Spectranetics),
IN.PACT SFA (IN.PACT Admiral-Medtronic), and LEVANT (LutonixBard). These are the only studies for which the 6-month LLL data
have been assessed by an independent core lab. Notably, BIOLUX-I
has reported 1-year primary patency (PP) data in a peer-reviewed
publication without an independent core lab adjudication.
From analysis of these studies, the 6-month LLL was found to be
lower in DCB than standard angioplasty (i.e., THUNDER DCB; 0.4 mm
vs. 1.7 mm, p<0.001), although only ADVANCE PTX reported no significant difference between the two techniques (0.9 mm vs. 1.3 mm,
p=0.12).
Freedom from clinically driven target lesion revascularization
(CD-TLR) was 91.3% at 12 months (IN.PACT Global Clinical Study), and
PP ranged from 89.5% to 65.2% at 1 year (LEVANT 2 RCT); these values were always superior to those of the control group.
After 2 years of follow-up, PP was 80.3% for Stellarex, 78.9 % for
IN.PACT Admiral, and 53.7% for Lutonix balloons.
TLR has been reported to be between 8.7% (IN.PACT Global Study)
and 12.3% (LEVANT 2): the lowest 1-year TLR was 2.9%, which was
reported in the IN.PACT SFA cohort.
Interesting results have been reported by subgroup analysis of long
lesions (>15 cm) and in-stent restenosis series from the IN.PACT
Global study.
Even in long lesions (49.5% of occlusions), the 12-month CD-TLR
remains high at 83.2% and PP is even higher at 91.1%. The primary patency is 88.7% in de novo ISR and 7.3% in CD-TLR at 1 year.
Notably, higher risk of thrombosis is observed in the long-lesion
group, accounting for 3.7% at 1 year in comparison with 1.4% in the
global study.
Finally, current evidence outlines the excellent performance of DCBs
at the 1-year follow-up even in the treatment of complex lesions;
however, longer term core lab-proven results are warranted.

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References
1. Katsanos K, Tepe G, Tsetis D, Fanelli F. Standards of practice
for superficial femoral and popliteal artery angioplasty and
stenting. Cardiovasc Intervent Radiol. 2014 Jun;37(3):592-603.
2. Fanelli F, Cannavale A. Drug-coated balloons and drug-eluting
stents: clinical effectiveness revisited. J Cardiovasc Surg (Torino).
2014 Oct;55(5):625.
3. Cortese B, Granada JF, Scheller B, Schneider PA, Tepe G,
Scheinert D, Garcia L, Stabile E, Alfonso F, Ansel G, Zeller T.
Drug-coated balloon treatment for lower extremity vascular
disease intervention: an international positioning document. Eur
Heart J. 2015 May.
4. Marques L, Hopf-Jensen S, Mller-Hlsbeck S. Drug-coated
balloons: what is the evidence? J Cardiovasc Surg (Torino). 2016
Feb;57(1):12-7.

2603.3
Drug-eluting stents new developments and established data
S.Mller-Hlsbeck
Diagnostic and interventional Radiology & Neuroradiology, Ev.-Luth.
Diakonissenanstalt zu Flensburg, Flensburg, Germany
Learning Objectives
1. To learn about different coating technologies
2. To learn about existing RCT data
3. To learn about ongoing clinical studies
New stent designs are intended to improve outcomes following
femoropopliteal artery treatment for peripheral arterial disease.
Long-term patency following bare metal stenting (BMS) is encouraging but remains unsatisfactory, with reported 1-year primary
patency up to 80%.1-6 Target lesion revascularization (TLR) rates for
BMS also show room for improvement, with 1-year rates around 13%
in clinical trials. 2-6
Current approache to preventing restenosis is applying an antirestenotic agent, such as paclitaxel, to the vessel wall by a drug-coated
balloon or a drug-eluting stent (DES). The use of a paclitaxel-coated
stent has been shown to improve patency over BMS in TASCII A and
B femoropopliteal lesions.7 Paclitaxel, which arrests the cell cycle in
the G2/M phase, interrupts arterial smooth muscle cell proliferation
and migration, as well as extracellular matrix formation. 8
The technology behind drug elution will be explained with reference to different coating technologies by using current RCT data
using paclitaxel as the main drug. The latest RCT data from ZilverPTX
and MAJESTIC studies will be presented in the context of ongoing
clinical studies dealing with DES technology.
References
1. Schillinger M, Sabeti S, Loewe C, et al. Balloon angioplasty versus
implantation of nitinol stents in the superficial femoral artery. N
Engl J Med. 2006;354:1879-1888.
2. Krankenberg H, Schluter M, Steinkamp HJ, et al. Nitinol stent
implantation versus percutaneous transluminal angioplasty
in superficial femoral artery lesions up to 10 cm in length: the
femoral artery stenting trial (FAST). Circulation. 2007;116:285-292.
3. Bosiers M, Deloose K, Callaert J, et al. 4-French-compatible
endovascular material is safe and effective in the treatment of
femoropopliteal occlusive disease: results of the 4-EVER trial. J
Endovasc Ther. 2013;20:746-756.
4. Laird JR, Katzen BT, Scheinert D, et al. Nitinol stent implantation
vs. balloon angioplasty for lesions in the superficial femoral
and proximal popliteal arteries of patients with claudication:
three-year follow-up from the RESILIENT randomized trial. J
Endovasc Ther. 2012;19:1-9.
5. Laird JR, Jain A, Zeller T, et al. Nitinol stent implantation in the
superficial femoral artery and proximal popliteal artery: twelvemonth results from the Complete SE multicenter trial. J Endovasc
Ther. 2014;21:202-212.

Abstract Book

6. Bosiers M, Torsello G, Gissler HM, et al. Nitinol stent implantation

in long superficial femoral artery lesions: 12-month results of the
DURABILITY I study. J Endovasc Ther. 2009;16:261-269.
7. Dake MD, Ansel GM, Jaff MR, et al. Sustained safety and
effectiveness of paclitaxel-eluting stents for femoropopliteal
lesions: 2-year follow-up from the Zilver PTX randomized and
single-arm clinical studies. J Am Coll Cardiol. 2013;61:2417-2427.
8. Wiskirchen J, Schober W, Schart N, et al. The effects of
paclitaxel on the three phases of restenosis: smooth muscle cell
proliferation, migration, and matrix formation: an in vitro study.
Invest Radiol. 2004;39:565-571.

2603.4
Drug-eluting balloons for AV fistulas
A.Massmann
Diagnostic and Interventional Radiology, Saarland University Medical
Center, Homburg, Germany
Learning Objectives
1. To learn how paclitaxel might effect the venous vessel wall
2. To learn about existing data
3. To learn about ongoing clinical studies
Failing arterio-venous hemodialysis access has to be firmly examined at the following typical levels:
arterio-venous anastomosis stenosis,
immature or degenerating shunt vein,
venous anastomosis after graft implantation, and
central vein stenosis.
In case of relevant pathologies, treatment should achieve sufficient flow along the complete course of the arterio-venous fistula. Percutaneous transluminal plain balloon angioplasty (PTA) for
hemodialysis access stenoses results only in poor patency. Drugcoated balloon angioplasty (DCB) using antiproliferative agents, e.g.,
paclitaxel, may prevent or delay neointimal hyperplasia. However,
DCB fails to overcome elastic recoil of the venous vessel wall similar to PTA.
The aim of the presentation is to review the pathophysiology of failing hemodialysis access and the treatment concept of DCB.
Following issues have to be discussed:
risks associated with the drug-coated balloon technique in the
venous system.
evidence of DCB to improve
patency and
overall clinical outcome.
Several clinical studies have shown promising results for DCB in the
treatment of failing native arterio-venous fistulas and PTFE grafts.
Efficacy of DCB in hemodialysis access is presented by recent randomized controlled trials comparing DCB with PTA. Despite the
reported favorable results, it has to be taken into account that until
now only small-scale studies with very limited numbers of patients
have been conducted.
Finally, cost-effectiveness of DCB compared to the established treatment options has yet to be proven.
References
1. Katsanos et al. Paclitaxel-coated vs. plain balloon dilation for
failing dialysis access. J Endovasc Ther. 2012.
2. Kitrou et al. Drug-eluting versus plain balloon angioplasty for
failing dialysis access. Eur J Radiol. 2015.
3. Lai et al. Paclitaxel-coated balloon improves target lesion
restenosis of autogenous radiocephalic fistulas. J Vasc Interv
Radiol. 2014.
4. Massmann et al. Paclitaxel-coated balloon angioplasty
for symptomatic central vein restenosis in patients with
hemodialysis fistulas. J Endovasc Ther. 2015.

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CIRSE 2016

Special Session
Vertebroplasty: new evidence
2604.1

SS/FC/HL/HTS/CM

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2604.2
Update on VERTOS IV
P.N.M.Lohle1, C.E.Firanescu1, J.deVries2
1Radiology, St. Elisabeth Hospital, Tilburg, Netherlands, 2Medical
Psychology, University of Tilburg, Tilburg, Netherlands

Impact of sham-controlled trials on referral patterns

K.F.Layton
Department of Radiology, Baylor University Medical Center, Dallas, TX,
United States of America
Learning Objectives
1. To learn about randomised studies in vertebral augmentation
2. To understand the influence of the randomised studies on
clinical practice
3. To learn about the influence of these studies on the
reimbursement of the augmentation procedures
There is a continued debate regarding the value of vertebroplasty
following the publication of the blinded vertebroplasty versus
sham procedure trials in 2009. These studies, infamously known
as the Kallmes and Buchbinder trials, included the Investigational
Vertebroplasty Efficacy and Safety Trial (INVEST) and A Randomized
Trial of Vertebroplasty for Painful Osteoporotic Vertebral Fractures.
We questioned whether the referring physicians at the two academic medical centers were aware of the trial results and wondered if this awareness prompted a change in their preferred treatment of osteoporotic fractures. Using an e-mail survey, questions were distributed to the physicians within the Mayo Clinic and
Baylor Health Care System (BHCS). Of the 1390 surveys sent, 194
(14%) were answered. Results showed that 92 of 158 respondents
(58%) reported familiarity with INVEST; 66 of 92 (72%) claimed that
INVEST changed their understanding of vertebroplasty efficacy; and
64 of 92 (70%) reported that INVEST diminished their enthusiasm to
refer patients for vertebroplasty. However, 105 of 159 respondents
(66%) felt vertebroplasty was an effective procedure in appropriate
patients. Mayo Clinic physicians were more likely than BHCS physicians to be aware of INVEST (73% vs 67%, P < 0.0001), to respond that
INVEST changed their understanding of the appropriate treatment
for osteoporotic compression fractures (79% vs 57%, P = 0.026), to
view vertebroplasty less favorably (45% vs 21%, P = 0.005), and to
treat osteoporotic compression fractures with medical therapy/pain
management alone (73% vs 48%, P = 0.003). INVEST changed the
referring physicians opinion of the role of vertebroplasty and diminished their willingness to refer osteoporotic compression fracture
patients for a vertebroplasty procedure. Interestingly, the impact
varied significantly by location.
References
1. Kallmes DF, Comstock BA, Heagerty PJ, Turner JA, Wilson
DJ,Diamond TH, Edwards R, Gray LA, Stout L, Owen S,
Hollingworth W,Ghdoke B, Annesley-Williams DJ, Ralston SH,
Jarvik JG. A randomizedtrial of vertebroplasty for osteoporotic
spinal fractures. N Engl J Med 2009;361(6):569579.
2. Buchbinder R, Osborne RH, Ebeling PR, Wark JD, Mitchell P,
Wriedt C, Graves S, Staples MP, Murphy B. A randomized trial of
vertebroplasty for painful osteoporotic vertebral fractures. N
Engl J Med 2009;361(6):557568.
3. Lindsey SS, Kallmes DF, Opatowsky MJ, Broyles EA, Layton KF.
Impact of sham-controlled vertebroplasty trials on referral
patterns at two academic medical centers. Proc (Bayl Univ Med
Cent) 2013;26(2):103105.

Learning Objectives
1. To learn about the inclusion criteria of the Vertos IV
2. To learn about the results of Vertos IV
3. To learn about the conclusion of this study
Osteoporotic fractures are becoming an increasing health concern
because of the growing elderly population. Patients with osteoporosis commonly fracture their vertebrae, proximal femur, distal radius,
or proximal humerus. The most common site is the vertebral body
(1,2). A vertebral compression fracture (VCF) is associated with an
increased incidence of mortality and morbidity, which results in a
reduced health status and reduction in quality of life (3). Only about
one third of new VCFs come to medical attention, suggesting most
VCFs are asymptomatic (4). The standard therapy to treat a symptomatic osteoporotic vertebral compression fracture (SOVCT) is conservative therapy, including bed rest, analgesics, physiotherapy,
osteoporosis medication, and sometimes bracing. Apart from conservative therapy, minimal invasive techniques, such as percutaneous vertebroplasty (PV), are offered to these patients with a SOVCT.
With regard to PV, retro- and prospective studies have reported clinical results with an average pain relief of 87% and improvement of
function both on the short and the long term (5,6,7). The unblinded
randomized controlled trial (VERTOS 2), comparing PV versus conservative therapy, confirmed significant better pain relief with Level
of evidence 1b of PV at acceptable costs as well as reduction of secondary VCFs and reduction of further vertebral height loss in the
PV arm as opposed to the conservative arm (8). In contrast, two placebo-controlled randomized trials (e.g. INVEST), comparing PV versus the sham procedure (placebo), reported no benefit of PV over
placebo with Level of evidence 1a (9,10). Since both placebo controlled trials from Buchbinder and Kallmes were published in 2009,
a worldwide controversy (11,12) has started between proponents
and opponents. The value of these publications on PV were sometimes heavily criticized, with statements like; both studies are mixing
apples with pears by merging acute, sub-acute, and chronic VCFs.
Physical examination was not performed in all patients and there
was no control group without intervention. Bone edema on MRI
was not used as a consistent inclusion criterion prior to the intervention and follow-up was limited to about 1-6 months. It makes these
two placebo studies difficult to interpret clinically, because the best
treatment option for patients with a VCF remains unclear for the clinician in his daily practice.
As opposed to the two placebo-controlled trials, VERTOS 2 used
strict inclusion criteria: a proven VCF on spine X-ray, local back pain
6 weeks, local back pain VAS score >5, VCF with bone edema on
MRI, proven osteoporosis and patient older than 50 years. VERTOS 2
provides data, representing clinical daily practice and applicable for
patients suffering from local back pain due to an osteoporotic VCF.
VERTOS 2 concludes that in a selected subgroup of patients with an
acute osteoporotic VCF and ongoing pain, PV is effective and safe.
Pain relief after PV is immediate, sustained during one year and was
significantly better compared to conservative therapy, at acceptable
costs. VERTOS 2 is a more pragmatic study, which provides the clinician with direct applicable information on how to best treat the
patient.
Since the publications of the two placebo controlled trials and its
effect on Health Insurance Companies (no reimbursement anymore)
the number of PV treatments for osteoporotic VCFs has decreased
significantly. However, interventional radiologists continue to treat
patients with osteoporotic VCFs with PV. Apparently, the results

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published by Buchbinder and Kallmes are not convincing enough.

Referring physicians and patients still ask for PV, which provides significant local back pain relief in almost all cases.
In order to make a contribution to the discussions, two groups
of physicians decided to conduct similar placebo controlled randomized trials (two sham RCTs; VERTOS 4 in The Netherlands and
VAPOUR in Australia) to obtain Level of Evidence 1a and compare the
results with the published data from Buchbinder and Kallmes. The
primary objective of VERTOS 4 is to compare pain relief during 1
year after PV versus the sham intervention in patients with an acute
osteoporotic VCF using the strict inclusion criteria from VERTOS 2
i.e.; local back pain 6 weeks with a VAS score >5, an osteoporotic
VCF on X-ray and bone edema on MRI. Secondary objectives are
quality of life and function and secondary VCFs during 1 year follow up. VERTOS 4 is a well-designed well-executed randomized
sham controlled multicenter trial comparable with the studies by
Buchbinder and Kallmes, but with more strict inclusion criteria like
the VERTOS 2.
In the VERTOS 4 trial, we aimed to clarify the controversial role of PV
in pain treatment of acute osteoporotic VCFs. Today we have completed the VERTOS 4 study with 180 patients enrolled. Patients were
randomly allocated to PV or the sham procedure using computer
randomization codes with a block size of five. Masking was applied
for the participating patients, internists, and outcome assessors. In
both groups, local infiltration with 5cc 1% lidocaine corresponding
to each pedicle was used for the skin and the subcutaneous tissue
that overlies the pedicles followed by infiltration with 5-cc 0.25%
bupivacaine into the periosteum of each pedicle under fluoroscopy.
In both groups, 11- and 13-Gauge bone biopsy needles were placed
at the fracture level, transpedicular till into the vertebral body for
the PV procedure or just against the periosteum for the sham procedure. The polymethylmethacrylate bone cement (PMMA, VertaPlex)
was infused under continuous lateral fluoroscopy into the vertebral body in the PV group while the sham group received no
cement while simulating with verbal and physical cues its administration. The patients from the PV group received a CT scan in order
to determine cement distribution and eventual local cement leakage while the sham group received a CT scannogram while simulating a full scan. Patients were assessed at baseline and at 1 day,
1 week, 1 month, 3 months, 6 months, and 1 year after the procedure. At the intake and during follow-up pain scores were determined and pain medication was checked. The primary outcome was
pain relief at 12 months, measured with a VAS score ranging from 0
(no pain) to 10 (worst pain ever). Clinically significant pain relief was
defined as a decrease of 3 points in the VAS score from baseline. The
secondary outcomes were quality of life measured with the Quality
of Life Questionnaire of the European Foundation for Osteoporosis
(QUALEFFO), and physical function measured with the modified
Roland Morris Disability (RMD) questionnaire at 1 week, 1, 3, 6, and
12 months. Complications and adverse events were recorded. To
identify new VCFs during follow-up, thoracic, and lumbar spine
X-rays were carried out at baseline and at 3, 6, and 12 months.
Treatment of any new VCF was according to the initial assigned protocol and no cross-over was allowed during the 1-year follow-up.
On the assumption of a 25% difference in significant pain relief
and 20% withdrawals, 90 patients were needed in each group
(alpha=0.05 and beta=0.20). SPSS was used for analysis. We compared proportions of adverse events, drugs, and baseline fractures
using X2. P values are two- sided. Differences in mean VAS score
between baseline and 1 day, 1 week, 1 month, 3 months, 6 months,
and 1 year were assessed with the paired t test. We used analysis of
variance for repeated measures to examine pain relief, quality of life,
and physical function over time. Missing data for QUALEFFO and
RMD scores were imputed with linear interpolation and last observation carried forward. Imputation of missing data increased the
power but did not affect the results. Significant pain relief over time
was analyzed with KaplanMeier survival analysis.

Abstract Book

The VERTOS 4 study is a RCT designed to assess pain relief after PV

compared to a sham intervention in patients with an acute osteoporotic VCF selected on strict inclusion criteria. The analyzed data with
pain relief after treatment during long term follow up (12 months)
will be discussed during the lecture.
References
1. Cummings SR, Melton LJ. Epidemiology and outcomes of
osteoporotic fractures. Lancet. 2002;359(9319):1761-7.
2. Melton LJ, III, Lane AW, Cooper C, et al. Prevalence and incidence
of vertebral deformities. Osteoporos Int 1993;3(3):113-9.
3. Hasserius R, Karlsson MK, Jonsson B, et al. Long-term morbidity
and mortality after a clinically diagnosed vertebral fracture in
the elderly--a 12- and 22-year follow-up of 257 patients. Calcif
Tissue Int 2005;76(4):235-42.
4. Black DM, Cummings SR, Karpf DB, et al. Randomised trial of
effect of alendronate on risk of fracture in women with existing
vertebral fractures. Fracture Intervention Trial Research Group.
Lancet 1996 Dec 7;348(9041):1535-41.
5. Galibert P, Deramond H, et al. Preliminary note on the treatment
of vertebral angioma by percutaneous acrylic vertebroplasty.
Neurochirurgie. 1987;33(2):166-8.
6. Hulme PA, Krebs J, et al. Vertebroplasty and kyphoplasty: a
systematic review of 69 clinical studies. Spine 2006.
7. Eck JC, Comparison of vertebroplasty and balloon kyphoplasty
for treatment of vertebral compression fractures: a
meta-analysis of the literature. Spine J 2007.
8. Klazen C, Lohle PN, et al. Vertos 2 trial. Lancet
2010;376(9746):1085-92.
9. Kallmes D, et al. A randomized trial of vertebroplasty. N Engl J
Med 2009;361(6):569-579.
10. Buchbinder R, et al. A randomized trial of vertebroplasty. N Engl
J Med 2009;361(6):557-568.
11. Clark W, Goh AC. Vertebroplasty for acute osteoporotic spinal
fractures-best evidence? J Vasc Interv Radiol. 2010;21(9):1330-3.
12. Gangi A, Clark WA. Have recent vertebroplasty trials changed
the indications for vertebroplasty? Cardiovasc Intervent Radiol.
2010;33(4):677-80.

2604.3
Update on the VAPOR study
W.A.Clark
Interventional Radiology, St George Private Hospital, Ramsgate, NSW,
Australia
Learning Objectives
1. To learn about the inclusion criteria of the VAPOR study
2. To learn about the results of VAPOR study
3. To learn about the conclusion of this study
A randomized trial of Vertebroplasty for Acute Painful Osteoporotic
fractURes (VAPOUR Trial)
Clark W, Bird P, Gonski P, Diamond T, Smerdely P, Schlaphoff G,
McNeil P, Bryant C, Barnes E, Gebski V.
Aims: To evaluate the efficacy and safety of vertebroplasty in
acute painful osteoporotic fractures which are less than 6 weeks in
duration.
Methods: This is a randomized, blinded, parallel group, placebo controlled trial of vertebroplasty for acute fractures less than 6 weeks
duration. Patients were randomized one to one between vertebroplasty and a simulated vertebroplasty (or placebo procedure). The
randomization service, trial advice and data analysis was provided
by independent biostatisticians at the National Health and Medical
Research Council (NHMRC) Clinical Trials Centre at the University
of Sydney. The data collection was performed by Optimus Clinical
research, an independent clinical research company. The data collection researchers and the patients remained blinded for the duration of the trial.

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CIRSE 2016

The trial methodology was similar to the placebo trials of vertebroplasty published in 20091,2 but with the following changes in patient
selection:
1. Fracture duration less than 6 weeks (rather than <12 months)
2. MRI or SPECT-CT required for enrolment (rather than radiograph
alone)
3. Inpatients included (excluded in previous blinded trials)
4. Pain score at least 7/10 (rather than 3/10 in one and not stated in
the other).
The vertebroplasty technique aimed for a maximal vertebral body
fill of PMMA, achieving PMMA distribution from the superior to the
inferior end plate of vertebral body, medial cortex of pedicle to
medial cortex of contralateral pedicle and from anterior cortex to
posterior third of vertebral body.
The primary outcome measure was Numerical Rating Scale (NRS)
patient rated pain at 14 days post intervention. Rather than a mean
population pain or disability score as the primary outcome (as in
previous blinded trials), we nominated a clinically desirable endpoint as the primary outcome the proportion of patients who had
a pain score of less than 4 out of 10 at 14 days. We hypothesised that
there would be a higher proportion of patients in the vertebroplasty
group with NRS pain less than 4 out of 10 at 14 days. Other secondary outcome measures recorded at time points 3 days, 14 days, 28
days, 3 months and 6 months were NRS pain, Roland-Morris Low
Back Pain and Disability Questionnaire (RDQ) scores, The Quality
of Life Questionnaire of the European Foundation for Osteoporosis
(QUALEFFO), European Quality of Life - 5 Dimensions, and analgesic
consumption. Change in the percentage vertebral body height loss
from baseline to 6 months was calculated from measurements on
erect calibrated radiographs at these two times.
Effectiveness analyses were by intention-to-treat principle.
Proportions were compared using a two-sided chi-squared test.
Changes in quality of life measures (pain/ functional disability
scores) analysed using t-tests enabling comparisons with published
studies. All comparisons were two-sided with a significance level of
5% considered as being statistically significant.
Results: Between November2011 and December 2014, 120 subjects
were enrolled (61 vertebroplasty group and 59 placebo group) Mean
age was 80 years, proportion of females was 73% and proportion of
hospital inpatients at time of enrolment was 59%. Average duration
of fracture at time of intervention was 2.6 weeks. 79% of patients
had fracture duration less than 3 weeks. There were no significant
group differences in reported baseline measurements. Mean (+/-SD)
PMMA injected volume per bone was 7.5+/-2.8 cc.
The proportion of patients achieving an NRS <4 at 14 days was 44%
in the vertebroplasty group and 21% in the control group (between
group difference 23 percentage points, 95% confidence interval
6 to 39, p=0.01). The advantage in this outcome in the vertebroplasty group remained similar throughout the trial from 3 days to 6
months. Mean reductions in NRS pain from baseline was greater in
the vertebroplasty group at all time points. Mean reduction in RDQ
from baseline favoured vertebroplasty at 1, 3 and 6 months. There
was a trend toward lower mean QUALEFFO (better outcome) and
higher mean EQ-5D (better outcome) in the vertebroplasty group
compared to the placebo group at all time, but the differences were
modest.
The mean loss of vertebral body height loss in the acute fracture was
similar (46% and 47% respectively) at baseline in each group. At 6
months the height loss percentage was 27% in the vertebroplasty
group and 63% in the control group.
Two patients in the vertebroplasty group had serious adverse
events, although neither related directly to the vertebroplasty procedure. One had a respiratory arrest after intravenous sedation was
administered prior to the procedure commencing. She was resuscitated and underwent trial procedure two days later without incident. One patient suffered a humeral fracture in a paretic arm during
transfer onto the radiology table in the IR suite.

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Two patients in the placebo group developed clinical spinal cord

compression due to interval collapse and fracture retropulsion of
the vertebral body in the 4 weeks following enrolment. One had
successful surgical decompression and fusion and the other developed irreversible paraplegia.
Conclusion: For patients with painful osteoporotic vertebral fractures less than 6 weeks duration in whom the pain and disability is
poorly controlled, the outcome from vertebroplasty is superior to a
placebo in reducing pain and back pain related disability. There is
also augmentation of vertebral height in the fractured bone when
the intervention is performed early.
References
1. Kallmes DF, Comstock BA, Heagerty PJ, et al. A randomized trial
of vertebroplasty for osteoporotic spinal fractures. N Engl J Med
2009;361:56979.
2. Buchbinder R, Osborne RH, Ebeling PR, et al. A randomized trial
of vertebroplasty for painful osteoporotic vertebral fractures. N
Engl J Med 2009;361:55768.

2604.4
Review of comparative studies: vertebroplasty vs.
augmentation techniques
F.RuizSantiago
Radiology Department, Hospital of Traumatology, Granada, Spain
Learning Objectives
1. To learn about the publications comparing different
augmentation techniques
2. To learn about the results of the comparatives studies
3. To learn about the best indications for each technique
The aim of this lecture is to review the current literature on vertebral
augmentation techniques, mainly vertebroplasty and kyphoplasty,
in order to compare their effectiveness to treat pain and improve
functional outcome from vertebral fractures secondary to osteoporosis and tumor conditions.
A systematic review of the literature was performed to determine
the level of evidence supporting percutaneous augmentation techniques for the treatment of vertebral fractures.
PubMed search sequence submitted was the following: (Vertebroplasty [MeSH] OR Kyphoplasty [MeSH] OR
Vertebroplasty [title/abstract] OR Kyphoplasty [title/abstract])
AND (English [lang]) AND Publication Date from 2000 to current.
A total of 2265 articles met these search criteria. Case reports,
technical notes, and animal or laboratory studies were discarded.
Selected articles were classified across 5 levels of evidence (1: highquality randomized trial, 2: lesser quality randomized control trial or
prospective comparative study, 3: case-control study, 4: case series,
and 5: expert opinion).
Grades of recommendations were also assigned according to the
evidence: Grade A, good evidence (level 1 studies with consistent
findings); Grade B, fair evidence (level 2 or 3 studies with consistent
findings); Grade C, poor quality evidence (level 4 studies); or Grade
D, insufficient or conflicting evidence (level 5 studies, or inconclusive
findings).
Based on this extensive literature review and the reported evidence
about augmentation techniques, an algorithm guiding towards the
most appropriate choice of treatment of vertebral fractures is presented, although many questions still remain unanswered.

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CIRSE meets
CIRSE meets EAU

Abstract Book

2701.2
Surgical and medical therapy for benign prostate hyperplasia
S.A.Gravas
Department of Urology, University Hospital of Larissa, Larissa, Greece

2701.1
Explanation of LUTS to interventional radiologists
S.A.Gravas
Department of Urology, University Hospital of Larissa, Larissa, Greece
Lower urinary tract symptoms (LUTS) represent one of the most
common clinical complaints in men over 45 years of age, and the
symptoms increase with age. LUTS are divided into storage (urinary
daytime frequency, nocturia, urinary urgency, and incontinence),
voiding (urinary hesitancy, slow stream, straining, splitting or spraying, intermittent stream, and terminal dribbling), and post-micturition (feeling of incomplete emptying and post-micturition dribbling) symptoms [1]. LUTS of any type (voiding and storage or postmicturition) are characterized by a dynamic pattern of progression,
with some patients complaining of gradually evolving symptoms,
while others reporting improvement or even complete remission of
LUTS.
In men, LUTS have been historically attributed to bladder outlet
obstruction (BOO) as a result of benign prostatic obstruction (BPO),
which is often associated with benign prostatic enlargement (BPE)
resulting from the histological condition of benign prostatic hyperplasia (BPH).
However, it has to be noted that BPE/BPH is not the only cause of
LUTS as several other urological and non-urological conditions have
been proved to be involved in LUTS pathogenetic pathways. Various
types of bladder dysfunctions may also be involved in the pathogenesis of LUTS, which are urodynamically manifested as detrusor
overactivity, low bladder capacity, or detrusor underactivity. In addition, other conditions inside or outside the lower urinary tract may
cause LUTS, including bladder stones, bladder tumours, distal ureteral stones, foreign body, neurological diseases, nocturnal polyuria,
prostatitis, urinary incontinence, urethral strictures, and urinary tract
infections.
Because of the high prevalence of BPE in elderly men and the multifactorial pathogenesis of LUTS, an accurate assessment of symptomatic men aged older than 40 years is critical to provide evidencebased care to them. Clinical assessment of patients with LUTS has
two main objectives: the first objective is to make the differential
diagnosis between the potential causes of male LUTS and the second objective is to define the clinical profile of men with LUTS in
order to provide the best care. The assessment should be able to
allocate patients for watchful waiting and medical or surgical treatment and to identify men at risk of progression [2].
The multifactorial view of the aetiology of LUTS has been adopted
by the European Association of Urology (EAU) guidelines, and a
broader approach to the management of men suffering from LUTS
has been introduced.
References
1. Abrams P, Cardozo L, Fall M, et al. The standardisation of
terminology in lower urinary tract function: report from the
standardisation sub-committee of the International Continence
Society. Urology. 2003;61(1):37-49.
2. Gravas S, Bach T, Bachmann A, et al. EAU Guidelines
Management of Non-Neurogenic Male Lower Urinary Tract
Symptoms (LUTS), incl. Benign Prostatic Obstruction (BPO).
http://uroweb.org/guideline/treatment-of-non-neurogenicmale-luts (assessed March 2016).

Men with lower urinary tract symptoms (LUTS) who are bothered by
their symptoms need medical treatment or surgical intervention. All
men with LUTS should be formally assessed prior to any allocation
of treatment in order to establish symptom severity and define their
clinical profile.
The first choice of therapy is behavioral modification with or without medical treatment. Medical treatment includes a1-blockers,
5a-reductase inhibitors, antimuscarinics, phosphodiesterase type
5 inhibitors, 3-agonists, combination treatments, and vasopressin
analogs. The choice of treatment depends on the type and severity
of symptoms, baseline findings, ability of the treatment to change
the assessed findings, treatment preferences of the individual
patient, as well as expectations to be met in terms of speed of onset,
efficacy, side effects, quality of life, and disease progression [1].
Surgical treatment is required when patients have experienced
recurrent or refractory urinary retention, overflow incontinence,
recurrent urinary tract infection, bladder stones or diverticula, treatment-resistant macroscopic hematuria due to benign prostatic
hyperplasia/benign prostatic enlargement, or dilatation of the upper
urinary tract due to benign prostatic obstruction (BPO) with or without renal insufficiency (absolute operation indications). In addition,
surgery is usually required when patients have not obtained adequate relief from LUTS using medical treatments or they do not want
medical therapy (relative operation indications) [1].
The current surgical modalities include transurethral resection of
the prostate, open surgery, different lasers, transurethral microwave therapy, transurethral needle ablation, stents, and prostatic
urethral lift. Interestingly, new minimally invasive techniques have
been introduced and challenge the established surgical modalities.
However, robust long-term data are needed to evaluate the efficacy of surgical treatments for BPO and a new technique by definition implies a lack of long-term data. The choice of the surgical technique depends on prostate size, comorbidities of the patient, ability to be anesthetized, patients preferences, willingness to accept
surgery-associated specific side effects, availability of the surgical
armamentarium, and experience of the surgeon with these surgical
techniques [1].
The European Association of Urology (EAU) guidelines on male LUTS
provide a realistic and practical approach to the contemporary management of men with LUTS on the basis of the best available data.
Algorithms have been developed to assist the selection of the right
treatment for the right patient.
References
1. Gravas S, Bach T, Bachmann A, et al. EAU Guidelines Management
of Non-Neurogenic Male Lower Urinary Tract Symptoms (LUTS), incl.
Benign Prostatic Obstruction (BPO). http://uroweb.org/guideline/
treatment-of-non-neurogenic-male-luts (accessed March 2016).

2701.3
For which patient PAE is most feasible (the radiologists view)
N.Hacking
Department of Clinical Radiology, University Hospitals Southampton,
Southampton, United Kingdom
No abstract available.

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2701.4
For which patient PAE is most feasible (the urologists view)
A.Stenzl
University Department of Urology, University Hospital of Tuebingen,
Tuebingen, Germany
It is assumed that 40%50% of men aged 5160 years develop prostate enlargement (the prostate on average weighs 20 g in normal
men aged 2030 years). With increasing age, over 80% of men aged
over 80 years will develop prostatic enlargement.
Common treatment starts with medical treatment, and majority
of the men needing medical treatment will later on need interventional treatment. The most common interventional treatment to
reduce prostatic enlargement is transurethral resection of the prostate (TURP). Alternatives are laser or electrocautery ablation, intraprostatic injections, radiofrequency therapy, aquablation, histotripsy, Uro-Lift compression clips, and various forms of prostatic
stenting. Prostatic artery embolisation (PAE) starting in 2010 has the
advantage that especially in larger size prostates a reduction of the
size of the prostate is achieved without general anesthesia.
Although PAE most probably will not be able to replace medical
therapy, it can definitely be an option in patients who need interventional therapy but have contraindications against general
anesthesia.
Standard prostatic enlargement in patients with no or minimal
comorbidities might be eligible for unilateral or bilateral PAE if the
size of the prostate may lead to foreseeable side-effects or complications with regular TURP or other common forms of interventional
treatment. This may be the case in patients with a prostate volume
above 60100 ml where many urologists switch their indication from
TURP to transvesical enucleation. Some forms of coagulation disorders or an obligatory intake of aspirin.
Another mandatory indication for PAE may be prostate-related macrohematuria. Recent small series have shown that good results may
again be achieved without general anesthesia. Furthermore, there
are anatomical variations or previous surgery to the genital tract,
which may make PAE the preferable option to reduce lower tract
symptoms due to prostatic enlargement.
Since PAE will need a well-trained interventional radiologist, this
treatment may be reduced to larger and/or specialized centers. With
a large amount of patients suffering from lower urinary tract symptoms due to prostatic enlargement, especially with an aging population, PAE may have to be reduced to certain indications, which have
to be outlined in current or upcoming (randomized) studies.

Special Session
Portal hypertension
2703.1
TIPS in children
O.Renc
Radiology, University Hospital Hradec Krlov and Charles University in
Prague Faculty of Medicine in Hradec Krlov, Hradec Krlov, Czech
Republic
Learning Objectives
1. To learn about specific indications for TIPS in children
2. To learn about differences in TIPS technique in children vs.
adults
3. To review results of TIPS in child populations
Despite the wide experience with transjugular intrahepatic portosystemic shunt (TIPS) creation in adults, there is still lack of information, especially the absence of randomized controlled trials, on
performing this procedure in the pediatric population. Therefore,

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studies evaluating treatment options for complications of portal

hypertension in adults usually serve as the basis for empiric therapy
in children (1, 2). On the other hand, there are some retrospective
studies that prove the efficiency of TIPS in pediatric patients (3, 4, 5).
In both adult and pediatric populations, the most common indications for TIPS creation are variceal bleeding and ascites refractory to
medical and endoscopic therapy (6, 7). In adult patients, the leading
etiology of portal hypertension is ethylic liver cirrhosis; among children, the most common cause is liver cirrhosis due to biliary atresia, cystic fibrosis, or hepatic fibrosis, leading to intrahepatic portal hypertension, and BuddChiari syndrome, veno-occlusive disease, or cardiac disease, leading to posthepatic portal hypertension (8). Furthermore, prehepatic type of portal hypertension based
on obstruction of portal vein due to umbilical vein instrumentation, infection, or trauma is more frequent in the pediatric population than in adults, but the treatment of this type of portal hypertension with TIPS is ineffective, and if needed, surgical shunting
has to be performed (1, 2, 9). TIPS creation is contraindicated in
case of liver insufficiency, significant coagulopathy, or pre-existing
encephalopathy.
In general, TIPS creation in children is considered as a temporary and
technically demanding procedure (10). This is especially because of
smaller liver dimensions, tiny vascular structures, presence of periportal fibrosis and possible anatomic variants, or a presence of liver
transplant (6, 11). Another problem is the absence of TIPS-dedicated
set of instruments for children on the market, therefore adult systems are usually used in children as well (10). Also, the TIPS technique is commonly the same as that used in the adult population.
The most difficult step of procedure, the puncture of the portal vein,
is performed under ultrasound control by some authors to reduce
the radiation dose. Concerning the shunt diameter, 810-mm ePTFE
covered-stents are preferred because of their long-term patency (4,
5, 12). The final dilatation of the shunt is recommended to be performed by an 8-mm balloon catheter to reduce the risk of encephalopathy, and only if portosystemic gradient is still 12 mm Hg and
more after such dilatation, a 10-mm balloon should be used. In very
young children of age < 2 years, only 6-mm dilatation is preferred (4,
5). Possible complications during and after TIPS procedure include
the risk of bleeding, development of encephalopathy, and TIPS
dysfunction.
After the procedure regular controls based on clinical and laboratory tests and ultrasound examination of the shunt are needed to
prevent the reoccurrence of signs of portal hypertension the common scheme is the first examination till 48 hours after the procedure, before patients hospital discharge, then every 3 months during the first year after TIPS creation and every 6 months later on (4,
5, 10).
Between 1993 and 2015, a total of 21 children (10 boys, 11 girls) in
aged 318 years (mean 13 years) and weighting 1266 kg (mean 45
kg) were treated by TIPS placement in our institution. Etiology of
portal hypertension was BuddChiari syndrome in 6 patients, cystic fibrosis in 5 patients, and autoimmune hepatitis in 2 patients.
The other children suffered from liver cirrhosis due to congenital -1 antitrypsin deficiency, congenital liver fibrosis, liver cirrhosis
after hepatitis B, liver cirrhosis with congenital cardiac defect, liver
damage as a result of long-term parenteral nutrition after skin burning, septic thrombosis of the portal vein, Wilsons disease, and hepatopulmonary syndrome. Indication for TIPS creation was variceal
bleeding in 14 patients (67%) and ascites refractory to treatment in 7
patients (33%). All procedures were performed under general anesthesia or analgosedation using TIPS-dedicated instrumentarium.
The shunt was reinforced with an uncovered stent in 12 cases; in 8
patients, we used covered stents. Portosystemic collateral embolization was performed in 9 patients.
The technical success rate was 95%, achieving an average portosystemic gradient decrease from 18.2 mm to 9.2 mm Hg. No patient
died during the procedure, and portal vein laceration as major

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complication occurred once, which was treated by stent-graft placement. The follow-up time was 7 days146 months (mean 55 months).
During this period, a total of 34 TIPS revisions in 10 patients were
performed, which on average corresponds to 2.7 procedures per
patient in the uncovered stent sub-group and to 0.25 procedures
per patient in the covered stent subgroup. During 7 days29 months
(mean 14 months) after the procedure, 5 children underwent liver
transplant; and during 1196 months (mean 50 months) after the
procedure, 6 patients died.
To conclude, TIPS placement in pediatric patients plays an important
role in solution of the undesired consequences of portal hypertension and can serve both as a short-term bridge during the risk period
prior to liver transplantation and as a long-term solution for chronic
liver disease (1, 10). When creating the shunt itself, covered stents
should be used preferentially in children.
References
1. Rosenthal P. When should we perform TIPS in children? JPGN
2012; 54: 577.
2. Mileti E, Rosenthal P. Management of portal hypertension in
children. Curr Gastroenterol Rep 2011; 13: 1016.
3. Mermuys K, Maleux G, Heye S et al. Use of the Viatorr expanded
polytetrafluorethylene -covered stent-graft for transjugular
intrahepatic portosystemic shunt creation in children: Initial
clinical experience. Cardiovasc Intervent Radiol 2008; 31:
192196.
4. Zurera LJ, Espejo JJ, Canis M et al. Transjugular intrahepatic
portosystemic shunting with covered stents in children. A
preliminary study of safety and patency. Radiologa 2014; 56:
339345.
5. Zurera LJ, Espejo JJ, Lombardo S et al. Safety and efficacy
of expanded polytertafluorethylene-covered transjugular
intrahepatic portosystemic shunts in children with acute or
recurring upper gastrointestinal bleeding. Pediatr Radiol 2015;
45: 422429.
6. Huppert PE, Astfalk W, Brambs HJ et al.Transjugular intrahepatic
portosystemic shunt in children. Initial clinical experiences and
literature review. RoFo 1998; 168: 595603.
7. Hackworth CA, Leef JA, Rosenblum JD et al. Transjugular
intrahepatic portosystemic shunt creation in children: Initial
clinical experience. Radiology 1998; 206: 109114.
8. Pozler O, Krajina A, Vanicek H et al. Transjugular intrahepatic
portosystemic shunt in five children with cystic fibrosis:
Long-term results. Hepato-Gastroenerology 2003; 50: 11111114.
9. Scholz S, Sharif K. Surgery for portal hypertension in children.
Curr Gastroenterol Rep 2011; 13: 279285.
10. Di Giorgio A, Agazzi R, Alberti D et al. Feasibility and efficacy of
transjugular intrahepatic portosystemic shunt (TIPS) in children.
JPGN 2012; 54: 594600.
11. Heyman MB, La Berge JM, Somberg KA et al. Transjugular
intrahepatic portosystemic shunts (TIPS) in children. J Pediatr
1997; 131: 914919.
12. Bureau C, Garcia-Pagan JC, Otal P et al. Improved clinical
outcome using polytetrafluorethylene-coated stents for TIPS:
Results of a randomised study. Gastroenterology 2004; 126:
469475.

Abstract Book

2703.2
Therapy options for gastric varices
J.A.Kaufman
Dotter Interventional Institute, Oregon Health & Science University
Hospital, Portland, OR, United States of America
Learning Objectives
1. To learn about differences between gastric varices and varices in
other location
2. To learn possible techniques for gastric varices embolisation
3. To review results of gastric variceal haemorrhage control with
TIPS and embolisation and compare them with BRTO
No abstract available.

2703.3
TIPS in portal and hepatic vein thrombosis
S.Punamiya
Diagnostic Radiology, Tan Tock Seng Hospital, Singapore, Singapore
Learning Objectives
1. To review current indications for TIPS in hepatic and/or portal
vein thrombosis
2. To learn about additional techniques in these settings
3. To review results of TIPS in patients with the hepatic vein
thrombosis, and acute or chronic thrombosis of the portal vein
Portal vein thrombosis (PVT) and Budd-Chiari syndrome (BCS) are
caused by thrombotic obstruction of the extrahepatic portal veins
and the hepatic venous outflow, respectively, usually producing significant symptoms of portal hypertension. Several heterogenous
prothrombotic disorders in combination with local triggering factors have been implicated in causing this thrombosis. Medical management, including anticoagulation, forms the backbone in treating both disorders; radiological and surgical intervention being
reserved for refractory and severely symptomatic cases. Amongst
these, TIPS has traditionally been considered a relative contraindication, as technical challenges produced by the occluded veins
often resulted in procedural failure. However, the past decade has
witnessed better procedural and clinical success rates, and consequently, TIPS is being increasingly offered to treat complications of
portal hypertension in this group of patients.
A. Portal vein thrombosis
The aim of treatment in PVT is to reverse or prevent progression of PVT and to treat complications of portal hypertension.
Anticoagulation results in recanalisation of acute PVT in majority of
patients and minimises serious complications like bowel ischemia
and development of varices, provided it is initiated early. Most often,
however, patients with PVT manifest at a chronic stage where anticoagulation cannot reverse complications like variceal bleeding,
symptomatic portal biliopathy and hypersplenism. Variceal bleeding
in such cases is managed in standard fashion, using vasoconstrictors, antibiotics and endoscopic treatment. TIPS can be offered in
these patients if the bleeding is not controlled or if it recurs despite
conventional therapy.
PVT occurs in up to 26% of patients with liver cirrhosis, and in this
setting it has been proposed that an occlusive PVT potentially
changes the natural history of liver cirrhosis as it increases the incidence of variceal bleeding and decreases the patients survival.
Conceptually, TIPS would benefit these patients by not only resolving the portal hypertension, but also improving transplant outcomes as it allows for a more physiological and durable end-to-end
anastomosis.
Technique of TIPS in PVT
TIPS is challenging in the presence of PVT due to difficulty encountered during portal vein access. The procedure is essentially done in

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2 steps. In the first step, the portal vein is recanalised using a transjugular, transhepatic, transplenic or transmesenteric approach.
Once the portal vein is recanalised, the TIPS is completed in routine
fashion from jugular venous access
For initial portal vein recanalisation, the portal vein can be
approached from various routes:
Transjugular access: The technique is similar to TIPS, wherein a liver
access needle is advanced across the liver parenchyma into a patent
peripheral portal venous branch from the jugular puncture. Once in
the peripheral branch, a curved angiographic catheter and hydrophilic wire are then advanced and manipulated across the portal
vein occlusion.
Transhepatic access: Here, a peripheral portal venous radicle is
accessed percutaneously using US or fluoroscopy, following which
an angiographic catheter and hydrophilic wire is manipulated across
the occluded portal vein.
Transsplenic access: In this method, a splenic hilar vein is accessed
percutaneously and catheter advanced to reach the portal vein
occlusion and cross it retrogradely.
Transmesenteric access: A mini-laparotomy is performed in the angiography suite to expose an ileal loop. A sheath is then placed within
the ileal vein, through which the angiographic catheter and wire are
advanced through the occluded portal vein.
Once access into the portal vein is gained, the occluded segment can
be recanalised using a variety of techniques, depending on the age
of the thrombus. An acute portal vein thrombus can be effectively
removed by thrombolysis, thromboaspiration, and/or mechanical
thrombectomy. Alternatively, the thrombus can be trawled into the
intrahepatic portal venous radicles using a Fogarty thrombectomy
catheter. Any residual flow limiting thrombus that is refractory to
these therapies is generally dilated or stented. A chronic portal vein
occlusion is treated with angioplasty and/or stenting with either
bare or covered stents.
TIPS is generally inserted after the portal vein is recanalised. This is
fairly straightforward if the initial access to the portal vein is transjugular, as the recanalisation and TIPS creation would be over the
same wire access. However, if the initial access is from any approach
other than jugular, the conversion to TIPS requires a portal vein target for the TIPS needle. This can be achieved by positioning a snare
or an inflated balloon in the recanalised portal vein or by guiding
the needle toward the top of end the portal vein stent. Once the
portal vein entry is successful, the TIPS is placed in standard fashion.
Results of TIPS in PVT
TIPS can be successfully inserted in portal vein thrombosis in almost
99.5% of patients when thrombosis is partial. The success rates drop
to 79% when the portal vein is completely occluded, and dip further
to 63% when the occlusion is chronic, suggested by presence of a
portal cavernoma.
A successful TIPS reduces the incidence of variceal rebleeding significantly. A 1- and 5-year cumulative variceal rebleeding rate of 10%
and 28% is noted in patients of PVT that had a TIPS inserted, versus
43% and 100% for patients that did not succeed in getting a TIPS.
Also, the short-term survival with TIPS is excellent (the 1- and 2-year
cumulative survival rates are 80-89% and 72-81%), and the longterm prognosis in these patients appears to be higher than general
patients with decompensated cirrhosis.
B. Budd-Chiari syndrome
Hepatic venous outflow obstruction causes an increase in hepatic
sinusoidal pressure that leads to a cascade of events, beginning with
hepatocellular congestion, necrosis and finally cirrhosis. Depending
on extent of venous involvement, speed of occlusion, and degree
of venous collateralisation, manifestation can vary markedly, ranging from asymptomatic disease to fulminant liver failure. Majority of
patients present with abdominal pain, ascites, hepatosplenomegaly, dilated abdominal wall veins, leg oedema and near normal liver
function despite overt portal hypertension.

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Anticoagulation and, if possible, treatment of underlying disorders

(e.g. myeloproliferative disease, paroxysmal nocturnal hemoglobinuria) form the cornerstone of therapy in BCS, and should be initiated
as early as possible in the disease. Anticoagulation alone will succeed in controlling liver disease in 10% of patients.
Next, whenever possible, recanalisation of the hepatic venous outflow by angioplasty and stenting should be attempted, as it is a low
risk procedure that decongests the liver while maintaining physiological blood flow. TIPS is recommended in symptomatic patients
with BCS when (a) the hepatic vein occlusive segment is long, (b)
there is failure to recanalise the hepatic veins, or (c) there is no clinical benefit from hepatic vein recanalisation.
Technique of TIPS in BCS
The procedure of TIPS requires few technical modifications. Since
the hepatic veins are occluded, parenchymal puncture is initiated
either from a stump of the hepatic vein or directly from the retrohepatic IVC, usually about 2-6 cm distance from the right atrium. To
aid penetration through the IVC wall, a left sided jugular approach is
preferred by some, as is the use of a coaxial 21G fine needle. Either
maneuver embeds the needle in the caval wall and prevents it from
sliding down the IVC.
Once the caval wall is penetrated, the needle is advanced through
the liver parenchyma toward the hepatic hilum. With each throw of
the needle into the liver parenchyma, entry into the portal vein is
best confirmed by injection of contrast (PTC-style) rather than aspiration of blood, as blood is invariably aspirated from the congested
liver or from small intra-hepatic venous collaterals. Longer and more
frequent throws of the needle should be anticipated, as the liver is
enlarged; most parenchymal tracts from the IVC to the portal vein
extend over 7-10 cm in length. The liver is also much softer and congested. This feature, along with the longer tracts and frequent needle passes, potentially increases the risk of intraperitoneal hemorrhage, intrahepatic hematomas or pseudoaneurysms. Utilisation of
a fine needle and aids to target the portal vein can reduce this risk.
Results of TIPS in BCS
TIPS has become the preferred form of treatment when medical
therapy has failed, as it provides improvement in clinical symptoms
and liver function and arrests progression of liver fibrosis. One of the
largest multi-centre study on TIPS in BCS revealed technical success
in over 90%, and a 1- and 10-year transplant-free survival of 88%
and 69%, respectively. Although TIPS-related complications are not
infrequent, procedural mortality is rare. Patients with BCS are known
to have a high incidence of TIPS dysfunction from intimal hyperplasia and thrombotic occlusion, requiring frequent re-interventions
to maintain its patency. Covered stents have improved the patency
rates significantly, with 6- and 12-month patency rates of 100% and
85.7%, respectively, compared to 16.7% and 0% for bare stents;
hence, its use is strongly recommended in BCS.
References
1. Bittencourt PL, Couto CA, Ribeiro DD. Portal vein thrombosis
and Budd-Chiari syndrome. Clin Liver Dis 2009;13:127-44.
2. Hollingshead M, Burke CT, Mauro MA, Weetis SM, Dixon RG,
Jaugus PF. Transcatheter thrombolytic therapy for acute
mesenteric and portal vein thrombosis. J Vasc Interv Radiol
2005;16:651-61.
3. Uflacker R. Applications of percutaneous mechanical
thrombectomy in transjugular intrahepatic portosystemic
shunt and portal vein thrombosis. Tech Vasc Interv Radiol
2003;61:59-69.
4. Chait Y, Condat B, Cazals-Hatem D, et al. Relevance of the criteria
commonly used to diagnose myeloproliferative disorders
in patients with splanchnic vein thrombosis. Br J Haematol
2005;129:553-60.
5. de Franchis R. Revising consensus in portal hypertension:
Report of the Baveno V consensus workshop on methodology
of diagnosis and therapy in portal hypertension. J Hepatol
2010;53:762-8.

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6. Qi X, Bai M, Yang Z et al: Occlusive portal vein thrombosis as

a new marker of decompensated cirrhosis. Med Hypotheses,
2011;76:522-26.
7. Englesbe MJ, Kubus J, Muhammad W et al: Portal vein
thrombosis and survival in patients with cirrhosis. Liver Transpl,
2010;16:83-90.
8. Qi X, Han G, Fan D: The preferable treatment for cirrhotic portal
vein thrombosis: anticoagulation or transjugular intrahepatic
portosystemic shunt? Hepatology, 2010;51:713-14.
9. Habib A, Desai K, Hickey R, et al. Portal vein recanalisation
- transjugular intrahepatic portosystemic shunt using the
transsplenic approach to achieve transplant candidacy in
patients with chronic portal vein thrombosis. J Vasc Interv Radiol
2015;26:499-506.
10. Perarnau JM, Baju A, Dalteroche L, Viquier J, Ayoub J. Feasibility
and long-term evolution of TIPS in cirrhotic patients with portal
thrombosis. Eur J Gastroenterol Hepatol 2010;22:1093-8.
11. Luca A, Miraglia R, Caruso S, et al. Short- and long-term effects of
the transjugular intrahepatic portosystemic shunt on portal vein
thrombosis in patients with cirrhosis. Gut 2011;60:846-52.
12. Plessier A, Sibert A, Consigny Y, et al. Aiming at minimal
invasiveness as a therapeutic strategy for Budd-Chiari syndrome.
Hepatology 2006;44:1308-16.
13. Zhang CQ, Fu LN, Xu L, et al. Long-term effect of stent
placement in 115 patients with Budd-Chiari syndrome. World J
Gastroenterol 2003;9:2587-91.
14. Eapen CE, Velissaris D, Heydtmann M, Gunson B, Olliff S, Elias
E. Favourable medium term outcome following hepatic vein
recanalization and/or transjugular intrahepatic portosystemic
shunt for Budd Chiari syndrome. Gut 2006; 55:878-84.
15. Camargo AM, Teixeira GG, Ortale JR. Anatomy of the ostia venae
hepaticae and the retrohepatic segment of the inferior vena
cava. J Anat 1996;188:59-64.
16. Perell A, Garca-Pagn JC, Gilabert R, et al. TIPS is a useful
long-term derivative therapy for patients with Budd-Chiari
syndrome uncontrolled by medical therapy. Hepatology
2002;35(1):132-9.
17. Garca-Pagn JC, Heydtmann M, Raffa S, et al. TIPS for
Budd-Chiari syndrome: long-term results and prognostic factors
in 124 patients. Gastroenterology 2008;135:808-15.
18. Gandini R, Konda D, Simonetti G. Transjugular intrahepatic
portosystemic shunt patency and clinical outcome in patients
with Budd-Chiari syndrome: covered versus uncovered stents.
Radiology. 2006;241(1):298-305.
19. Turnes J, Garcia-Pagan JC, Gonzalez M, et al. Portal
hypertension-related complications after acute portal vein
thrombosis: impact of early anticoagulation. Clin Gastroenterol
Hepatol 2008;6:1412-7.

2703.4
Management of procedural complications and encephalopathy
G.Maleux
Department of Radiology, University Hospitals Leuven, Leuven, Belgium
Learning Objectives
1. To review basic procedural complications of TIPS
2. To learn how to avoid and treat them
3. To learn how to prevent and manage post-TIPS encephalopathy
Complications related to transjugular intrahepatic portosystemic
shunt (TIPS) procedures include local procedure-related and systemic complications, occurring early or late after TIPS procedure.
Local procedure-related complications include, but are not limited
to, puncture-related symptoms, including inadvertent carotid artery
puncture with subsequent neck hematoma or stroke and pneumothorax. These potential complications can be avoided when using

Abstract Book
ultrasound guidance to assure vascular access. Catheterization of
the inferior vena cava and right hepatic vein can be associated with
cardiac arrhythmias.
Creation of the shunt tract in between the right hepatic vein and the
right proximal portal vein is the most challenging part of the TIPS
procedure and may be associated with inadvertent puncture of the
hepatic artery or perforation of the liver capsule, which may occur
more in patients with a small, atrophic liver associated with refractory ascites. Although these mistarget punctures are asymptomatic
in the large majority of cases, it might be associated with peritoneal
bleeding.
Planning the length of the stent-graft should be performed with use
of a graduated pigtail catheter, and the stent-graft should be placed
up to the confluence of the hepatic vein with the IVC. If the stentgraft is too short, late restenosis of the TIPS tract may occur 46
months after the initial TIPS procedure (7).
Early or late systemic TIPS-related complications include, but are not
limited to, hepatic encephalopathy (3,6), acute liver failure (5,9), and
infectious complications (4), especially when the TIPS stent-graft is
also infected. Both TIPS-induced hepatic encephalopathy and acute
liver failure can be managed by interventional techniques, including
TIPS shunt reduction or occlusion using a variety of techniques like
hourglass-shaped stent-graft (2), parallel technique (1), and plugocclusion, if liver transplantation is not available or contraindicated.
If the TIPS stent-graft is infected, antibiotic treatment will temporarily help, and here too, liver transplantation is the only curative treatment option (8).
References
1. Maleux G, Heye S, Verslype C, Nevens F. Management of
transjugular intrahepatic shunt induced refractory hepatic
encephalopathy with the parallel technique: results of a clinical
follow-up study. J Vasc Intervent Radiol 2007; 18: 986-92.
2. Maleux G, Verslype C, Heye S, Wilms G, Marchal G, Nevens
F. Endovascular shunt reduction in the management
of transjugular portosystemic shunt-induced hepatic
encephalopathy: preliminary experience with reduction stents
and stent-grafts. Am J Roentgenol 2007; 188: 659-64.
3. Pereira K, Carrion A, Martin P, Vanheesan K, Salsamendi J,
Doshi M, Yrizarry J. Current diagnosis and management of
post-transjugular intrahepatic portosystemic shunt refractory
hepatic encephalopathy. Liver Int 2015; 35: 2487-94.
4. Mizrahi M, Adar T, Shouval D, Bloom A, Shibolet O. Endotipsitispersistent infection of transjugular intrahepatic portosystemic
shunt: pathogenesis, clinical features and management. Liver Int
2010; 30: 175-83.
5. De Keyzer B, W. Laleman , A. Laenen , S. Heye, C. Verslype, S Van
der Merwe, Nevens F, Maleux G. Percutaneous shunt reduction
for the management of TIPS-induced acute liver failure: a
follow-up study. Ann Hepatol 2016 [in press].
6. Madoff D, Wallace M, Ahrar K, Saxon R. TIPS-related hepatic
encepahalopathy: management options with novel
endovascular techniques. Radiographics 2004; 24: 21-36.
7. Cejna M, Peck-Radosavljevic M, Thurnher S, Hittmair K,
Schoder M, Lammer J. Creation of transjugular intrahepatic
portosystemic shunts with stent-grafts: initial experiences with
a polytetraethylene-covered nitinol endoprosthesis. Radiology
2001; 221: 437-46.
8. Mortier L, Stockmans G, Maleux G, Heye S, Aerts R, Monbaliu D,
Darius T, Pirenne J, Meersseman P, George C, Van Steenbergen
W, Cassiman D, Verslype C, Nevens F, Laleman W. Repetitive
episodes of cryptogenic septicaemia in a patient with cirrhosis: a
case of heavy metal. Acta Gastroenterol Belg 2011; 74: 82-7.
9. Luca A, Miraglia R, Maruzzelli L, DAmico M, Tuzzolino F. Early
liver failure after transjugular intrahepatic portosytemic shunt
in patients with cirrhosis with model for end-stage liver disease
score of 12 or less : Incidence, outcome and prognostic factors.
Radiology, 2016.

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CIRSE 2016

Special Session
Interventional radiology: taking care of your own
patient
2704.1
How to set up your own clinical department
B.Gonalves, P.Lopes, M.J.Sousa
Servio de Radiologia de Interveno, Instituto Portugues de Oncologia
- FG, Porto, Portugal
Learning Objectives
1. To learn how to persuade decision-makers
2. To learn pre-clinical strategies to create an independent IR
department
3. To learn how to create a proper marketing strategy and a
dedicated staff structure
With the development of interventional radiology (IR) as a subspecialty of radiology, there are many questions that you can ask: Does
IR need a proper space to grow? Can you have your own management independent from radiology? Is it easy to allocate resources?
How can you persuade your hospital administration? Other questions can be placed but you need to remember that you have to
manage and justify your own budget.
First of all, you have to establish very well-defined objectives to
present to your decision-makers. Probably, they already know your
skills, your differences, and your opinions in the clinical advisory
boards. They know that IR has high direct costs (due to medical
devices) and uses a heavy technology, but you to have to emphasize
that in the end you are saving hospital stays and hospital admissions
and avoiding complications by using safe, guided procedures. In the
end, IR gets the best image among medical and surgical specialties.
A proper IR department of course demands a proper team. With this
change decision making process is very fast, can have proper patient
beds, begin a really clinical standard of care, and give a quick answer
for patient needs. You may also reduce the need of night procedures and give your colleagues a very quick answer during the day.
Workflow is always controlled by you.
From a patients point of view, you can really be seen like a clinician.
You can set up your proper marketing strategy. You can be seen as
a minimal invasive or a micro invasive surgeon. In other words, you
also be seen as a very effective physician who performs quick and
safe techniques. With the power of decision, IRs can cover all the
pathways of the clinical process and make interventions throughout
the body.

2704.2
Infrastructural requirement for day-case procedures
M.R. Sapoval, C. Del Giudice, G. Amouyal, O. Clment, N. Billot,
P.LeJeune, O.Pellerin
Dept. of Cardiovascular Radiology, Hpital Europen Georges
Pompidou, Paris, France
Learning Objectives
1. To learn how to set up your facility
2. To learn how to manage the administrative infrastructure
(patient flow, patient scheduling)
3. To learn how to establish a safety and effectiveness workflow
according to different IR procedures
Interventional Radiologists as a clinican together with his/her team,
are always highly concerned by the need to providing the best care
at the lowest cost with a highest level of confort and safety for the
patients and staff.

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Optimisation of the work-flow in Interventional Radiology is a key

issue in most health care institutions in Europe and world-wide.
Hospital and health authorities as well as private payers are engaged
toward a reduction of hospital beds, mainly driven by the need to
reduce health care cost .
Since many years, outpatient care, (day-case surgery, office based
surgery are other names for the same setting) have been developped consiting in offering simple surgical procedure without any
overnight admission. This system is highly developped in the US
where the situation is driven by a common need of phyisicians and
patients to reduce cost because they are both direct stake holders.
In countries where the cost are not directly impacting to patients
and Physicians revenue, this system is pushed by payers and is less
developped but there is clearly today an important push of all stake
holders toward this new organization of IR delivered health care.
In addition to economical considerations, it is common sense that a
patient in good general health will always prefer to go back home
and avoid one night in the hospital.
Moreover, the situation of IR which is specifically suffering from
shortage of admission privilege has pushed several teams to
develop outpatient care for the following interventions since several
years in different countries.
UFE and PAE,
Venous work,
Hemodialysis fistula maintenance,
Peripheral angioplasty in claudicants
Diagnostic neuro angiography
MSK intervention and more.
It is very important to consider before to embark in a project of daycase procedures
that the shorter the hospital stay the better the organization, scheduling, patient preparation and follow up should be organized. This
represents a significant effort when aiming at creating this activity
but also on a daily basis. The Hospital administration should then
recognize that by doing so the IR team takes over a significant burden of work and should be apropriately supported for this. In no
circumstances should the creation of such a Service be considered
without increase in manpower and surface for the department or IR.
The optimal organisation should cover all of the following features.
Housing and facilities :
Proper pre-procedure evaluation space including office to see
patient with the appropriate privacy
Adequate and flexible recovery space
Dedicated space for secretaries and scheduling
Staffing
Ambulatory IR requires more ressources than regular work.
Appropriate staffing including nurses and technicans, clerks, secretaries, Interventional Radiologists, dedicated managers are all
required to ensure appropriate care and administrative management.
Pre intervention Patient work-flow
Each patients should be seen in clinic prior to intervention to ensure
that all criteria are met.
Dedicated nurses can participate in this pre op screening provided it
is limited to simple interventions (Ports and Piccs)
Optimal Electronic patient record should be available to ensure that
all information are recorded and stored from the pre intervention
work up to the intervention and discharge.
Patient discharge
List of criteria that must be met before discharge including warning
signs of complications,
Mechanism for changing plans and having the patients stay overnight (the barrier to staying overnight should be low, so patients are
not sent home inappropriately)
Protocol (SOP) describing how to manage simple common
occurrences

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Appropiate documentation to inform the patient on how/when to

take any prescribed medications.
Early post operative follow up
There must be a 24 hours contact phone number and a mechanism
in the emergency department for evaluation and re-admission.
Call should be made to every patient the next day to ensure no
issues-. This should include a standard checklist that is covered in
the call.
In conclusion, day case intervention represents a significant progress
in IR based health care delivery. Because of the minimally invasive
nature of IR, it is obvious that our specialty should make all efforts
to support these inittiative. A Common effors of Scientific Societies
should be encouraged to support guidelines and SOP for all centers
considerign this a good opportunity and willing to embark in this
kind of ambitious projects.
References
1. Quels niveaux denvironnements techniques pour la ralisation
dactes interventionnels en ambulatoire ? rapport HAS 2010
www.has-sante.fr.
2. Liu H et al. Outpatient Day-care Neuroangiography and
Neurointervention of Unruptured Intracranial Aneurysms.
Neurointervention. 2016 Mar;11(1):37-41 ; 2016.
3. Abboud S The Radiologist Will See You Now: Patients
Perceptions of an Outpatient Interventional Clinic. Curr Probl
Diagn Radiol. 2016 Mar-Apr;45(2):137-8.
4. Manchikanti L. Ambulatory surgery centers and interventional
techniques: a look at long-term survival. Pain Physician. 2011
Mar-Apr;14(2):E177-215.
5. Garnier M et al. Management of anesthetic emergencies
and complications outside the operating room. Curr Opin
Anaesthesiol. 2014 Aug;27(4):437-41.
6. Lutjeboer J et al Impact on Patient Safety and Satisfaction
of Implementation of an Outpatient Clinic in Interventional
Radiology (IPSIPOLI-Study): A Quasi-Experimental Prospective
Study. Cardiovasc Intervent Radiol. 2015 Jun;38(3):543-51.

2704.3
Patient before and aftercare
R.Patel
Interventional Radiology, John Radcliffe Hospital, Oxford, United
Kingdom
Learning Objectives
1. To learn the main remarks in patient consultation before an IR
procedure
2. To learn how to prevent clinical complications (pain, contrast
media effects, etc.)
3. To learn how to deal with progressive pain, post-embolisation
syndrome, renal function impairment, etc.
No abstract available.

Abstract Book

2704.4
Economic case for in- and outpatient procedures
J.P.Schaefer
Diagnostic Radiology, University Hospital Schleswig-Holstein Campus
Kiel, Kiel, Germany
Learning Objectives
1. To learn how to make a cost-effectiveness analysis of different IR
procedures
2. To learn about strategies to improve IR procedures on an
out-patient basis
3. To learn how to maximise the cost-effectiveness of in-patient
procedures
Interventional radiology (IR) has been playing the key role in developing the continuously growing field of minimally-invasive therapy.
In clinical competition, interventional radiologists have to maintain
both quality and quantity; however, quality and quantity interdepend as a matter of course. When utilising different high-tech imaging tools and a large variety of IR equipment for multiple minimally
invasive procedures, interventional radiologists have to focus on the
cost effectiveness. As majority of the interventional therapies are
usually performed on an inpatient basis, minimally-invasive therapy, especially when provided under local anesthesia, is suited for
outpatients by nature. If numerous IR procedures may be performed
either as inpatient procedures or as outpatient procedures, different
variables such as 1) infrastructural aspects, 2) staff resources, 3) medical equipment and treatment protocol and 4) reimbursement have
to be taken into account. These variables interact, and in terms of
the economic aspect, affect the cost effectiveness in IR units.
Infrastructural aspects of both the hospital and the IR department
influence the inpatient and outpatient procedures. With an interdisciplinary approach by the referring clinical colleagues, specific standard operating procedures for interventional radiologists should be
set up to determine the inpatient and outpatient procedures. A crucial point for IR units is whether there is an own ward. This offers the
largest room for handling IR procedures on an inpatient and/or outpatient basis.
Staff resources in the IR unit and on a potential own ward affect the
workflow, the quality and quantity of IR procedures and the handling of patients as inpatients or outpatients. A well-defined team of
interventional radiologists, skilled nurses and technicians and doctors assistants is a basic prerequisite for organising IR units.
By choosing the adequate IR equipment and treatment protocol,
interventional radiologists directly affect and alter the invasiveness
of IR procedures, and thus modify the procedure towards inpatients
or outpatients. Focusing on absolutely minimal invasiveness combined with adequate but low anesthesia, interventional radiologists
may perform IR procedures with a hospital stay as short as possible.
Reimbursement is country and healthcare system specific. In DRG
systems, there is a great variety of what IR procedures might be performed as inpatient or outpatient procedures.
As mentioned before, the variables interact and affect the cost effectiveness in IR units. The variables may be modified and adjusted in
terms of improving the cost effectiveness.

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CIRSE 2016

Honorary Lecture
Josef Roesch Lecture
2901.1
The IR evolution in oncology: tools, treatments, guidelines
T.deBare
Dept. of Interventional Radiology, Institut Gustave Roussy, Villejuif,
France
No abstract available.

Hot Topic Symposium

Paradigm shift: liver colorectal metastases
2902.1
The paradigm is shifting the new ESMO guidelines for CRC
and more
E.VanCutsem
Gastroenterology/Digestive Oncology, Leuven Cancer Institute, Clinical
Digestive Oncology, Leuven, Belgium
No abstract available.

2902.2
The IO toolbox (efficacy of IO tools)
P.L.Pereira
Dept of Radiology, Minimally Invasive Therapies and Nuclearmedicine,
SLK-Clinics GmbH, Ruprecht-Karls-University Heidelberg, Heilbronn,
Germany
The most common cause of hepatic metastases in adults is colorectal cancer (CRC). It is expected that approximately 20% of patients
with CRC will also simultaneously suffer from liver metastases.
Approximately 60% of patients develop liver metastases at some
point in the course of a malignant disease. Patients with non-resectable or -abatable liver-predominant disease often die owing to progressive liver decompensation. Modalities of liver-targeted therapies other than the systemic therapies as well as an interdisciplinary approach may have a direct impact on patient survival by delaying hepatic decompensation. These liver-targeted therapies include
thermal ablation, intraarterial chemoembolization, and radioembolization. Future studies could include nanotechnology and stimulation of immune effects of local therapies.

2902.3
Interdisciplinarity in MDT boards proposal(s) for smart
treatment pathways
A.Adam
Radiology, 1st Floor Lambeth Wing, St. Thomas Hospital, London,
United Kingdom
Multidisciplinary teams are the standard of care in oncology, and
interventional radiologists need to be an integral part of these
teams. Decisions about patient management and patient pathways are often taken at multidisciplinary meetings. Oncologists, surgeons, gastroenterologists and other specialists are present at multidisciplinary meetings. Radiologists are usually involved in the presentation of images, but interventional radiologist are often not
included and thus do not take an active part in the decision-making
process. This needs to change.

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Cancers are getting smaller. Modern imaging can show tumours

that are 5 mm in size, and soon lesions of even smaller size will be
detectable. Small-volume and paucilesional solid organ disease will
increasingly fall within the scope of image-guided therapy.
Randomised studies in interventional radiology face significant challenges, including changing chemotherapy regimens, cross over
between treatment arms and difficulties with randomisation.
Professor Michael Rawlings, who was the chairman of the National
Institute for Clinical Excellence in 2008, said in his Harveian
Oration: randomised controlled trials are not always appropriate.
Randomised comparisons between surgery and thermal ablation in
patients with colorectal liver metastasis have been tried and abandoned because of lack of recruitment. Perhaps it is time to accept
that such studies will never be conducted, and if they are, they may
not be valid comparisons.
Large-scale and good-quality registries will help us in our decisionmaking. We should make sure that interventional radiologists are
represented in multidisciplinary teams in their capacity is interventionists and not as imagers. Also, when they are there, they should
take an active part in decision-making, taking into consideration
procedures suggested by the panel of experts in consensus.
Specialists from various disciplines should discuss each case in detail
and decisions should be based on the available expertise. This may
be intellectually less satisfying and a cause of frustration to those
unfamiliar with the complexities and difficulties of the practical disciplines such as interventional oncology but are more likely to serve
the best interests of patients.
The quality assurance system for interventional oncology developed
by CIRSE will make a significant contribution in this area by ensuring
that all aspects of care and delivered at a high standard.
Evolving technologies are a fact of life interventional oncology.
There are no smart procedures that can be used in every case; there
are only smart doctors and smart patients appropriately advised by
them.

Special Session
IR options for colon cancer at different stages
3201.1
Colonic stenting
T.Sabharwal
Department of Radiology, Guys and St. Thomas Hospital, London,
United Kingdom
Learning Objectives
1. To understand typical indications and contra-indications for
colonic stenting
2. To learn about the placement technique for colonic stents
3. To learn about the outcome of IR colonic stenting in comparison
to endoscopic techniques
Colonic stenting is now well recognised as a standard of care for alleviating bowel obstruction in palliative patients or as a staging process for curative surgery. In this talk, I will discuss the indications,
technique, complications and results.

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3201.2
Radioembolisation
T.K.Helmberger
Institut fr Diagnostische und Interventionelle Radiologie und
Nuklearmedizin, Klinikum Bogenhausen, Munich, Germany
Learning Objectives
1. To understand the rationale of why radioembolisation could fit
into current therapy regimens
2. To learn about indications and contra-indications for
radioembolisation
3. To understand outcome parameters of radioembolisation in
metastatic CRC
No abstract available.

3201.3
TACE with DEBIRI
P.E.Huppert
Radiology, Neuroradiology and Nuclear Medicine, Klinikum Darmstadt,
Darmstadt, Germany
Learning Objectives
1. To understand the rationale for DEB-TACE in metastatic CRC
2. To learn about indications and contra-indications for DEB-TACE
3. To understand outcome parameters of DEB-TACE in comparison
to other ablation techniques in metastatic CRC
Patients with liver metastases from colorectal cancer have a poor
prognosis. Fewer than 25% are candidates for curative resection or
percutaneous ablation, and of those who do undergo one of these
procedures, 70% suffer from relapse within 3 years [1]. Systemic firstline 5-fluorouracil (5-FU)-based treatment in combination with irinotecan or oxaliplatin and monoclonal antibodies offers a response
rate (RR) of 31%62%, median progression-free survival (PFS) of 6.9
10.6 months, and median overall survival (OS) of 1421.5 months
[2-5]. However, in patients refractory to these treatments, secondor third-line systemic treatments are far less effective with an RR of
4%21% and median PFS of 2.54.8 months [6-8].
Despite several advantages of catheter-based treatments of liver
tumors noted during the last decade, today, there is no clear evidence that transarterial chemoembolization (TACE) improves OS
and PFS in patients with colorectal liver metastases when compared
to systemic treatment (ST) or best supportive care. However, local
response and conversion to resectability due to these treatments
has been shown, and this will probably be beneficial in salvaging
patients.
Since 1998, several trials evaluated conventional TACE in patients
with metastases refractory to ST. In majority of these studies, a combination of cisplatin, doxorubicin, and mitomycin with particles of
polyvinyl alcohol (PVA) or collagen for embolization had been used
but with varying protocols. Reported objective RR of 2%63%, PFS
of 38 months, and OS of 8.614.3 months [9-13] demonstrated that
outcome after TACE appears to be highly variable.
Drug-eluting microspheres provide controlled drug release to
tumors, reduce systemic drug side effects, and improve reproducibility of TACE. Irinotecan is a potent drug for the treatment of
colorectal cancer liver metastases with high total body clearance
and high liver extraction rate, which are favorable for transarterial
liver treatments.
Because of serious postembolization syndrome, including intense
abdominal pain, temporary arterial hypertension, and flushing after
TACE using irinotecan-eluting microparticles (IE-TACE), an effective
protocol for pain management is mandatory.
For clinical use, different types of microparticles are available today;
these particles are capable of loading irinotecan. IE-TACE has been

Abstract Book
evaluated in 6 retrospective studies and in one RCT comprising 215
patients [14-20]. If patients had undergone pretreatment with ST,
local tumor control (no progression) was 40%86%; however, PFS
and OS were limited to 48.1 months and 5.413.3 months, respectively, after first IE-TACE. Using irinotecan-loaded microparticles
during TACE, nearly complete devascularization of colorectal liver
metastases can be obtained in a substantial proportion of cases. In
our study [18] using irinotecan-loaded HepaSphere microspheres
at 3 months, complete absence of tumor enhancement during CT
was seen in 7 of 29 patients and necrosis comprising 50% of tumor
volume was seen in 14 of 29 patients.
In patients with liver metastases, there is no standard in terms
of selective versus non-selective application of drugs, embolics,
and microspheres. For treatment of colorectal cancer metastases
using irinotecan-loaded DC beads, lobar injections were reported
involving both lobes by sequential sessions with a time interval of
38 weeks. Taking into account the disseminated nature of metastatic disease, lobar treatment during TACE seems to be mandatory.
However, if pretreatment imaging shows a dominant large tumor
involvement of a limited number of liver segments, transcatheter
treatment offers the potential to enhance the treatment intensity
by selective segmental injections prior to lobar injections. This technique of regional boosting TACE was performed in 30 of 74 treatment sessions in our study and was well tolerated without increase
in side effects [18].
IE-TACE is a treatment option for patients with failure of one or more
lines of standard palliative ST. Clinical results of these treatments
are still limited and offer the chance of prolongation of PFS by 48
months, depending on hepatic tumor load, performance status, and
extrahepatic tumor spread. Advantages of IE-TACE are a high level of
standardization and a low grade of complexity.
References
1. Pwint et al. Semin Oncol 2010;37:149-59.
2. Saltz et al. N Engl J Med 2000;343:905-14.
3. Goldberg et al. J Clin Oncol 2004;22:23-30.
4. Colucci et al. J Clin Oncol 2005;23:4866-75.
5. Chen et al. J Clin Oncol 2006;24:3354-60.
6. Hurwitz et al. N Engl J Med 2004;350:2335-42.
7. Rothenberg et al. J Clin Oncol 2003;21:2059-69.
8. Park et al. Jpn J Clin Oncol 205;35:531-5.
9. Tellez et al. Cancer 1998;82:1250-9.
10. Leichman et al. Cancer 1999;86:775-81.
11. Hong et al. J Vasc Interv Radiol 2009;20:360-7.
12. Vogl et al. Radiology 2009;250:281-9.
13. Albert et al. Cancer 2011;117:343-52.
14. Fiorentini et al. In vivo 2007;21:1085-92.
15. Martin et al. Ann Surg Oncol 2011;18:192-8.
16. Fiorentini et al. Anticancer Res 2012;32:3-11.
17. Narayanan et al. Anticancer Res 2013;33:2077-83.
18. Huppert et al. Cardiovasc Intervent Radiol 2014;37:154-64.
19. Stutz et al. Gastroenterol Res Pract 2015;2015:715102.
20. Iezzi et al. Cardiovasc Intervent Radiol 2015;Mar 24 epub.

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3201.4

3202.4

Multimodality treatment concept

Factors affecting filter retrieval

T.Ruers
Department of Surgery, The Netherlands Cancer Institute - Antoni Van
Leeuwenhoek Ziekenhuis, Amsterdam, Netherlands

O.Pellerin
Radiologie Interventionnelle, Hpital Europen Georges Pompidou,
Paris, France

Learning Objectives
1. To understand the concept of multimodality treatment in
metastatic CRC
2. To learn about the varying indications and contra-indications for
various treatment options in changing stages of disease
3. To learn about the long-term outcomes of multimodality
treatment regimens in light of the CLOCC trial

Learning Objectives
1. Techniques for removal
2. Patient and filter factors affecting removal
Despite the potential adverse effects of long-dwelling retrievable filters, including caval perforation, strut fracture, occlusion, and migration, there is an increasing interest in filter retrieval. Here, we aim to
expose the factors that limit filter retrieval.
Basically, low levels of limits can be recognized.
The first limiting factor comprises the patient and the physician
themselves. Filter retrieval rates have traditionally been variable
and overall low across institutions and in different patient populations, ranging from 3.7% to 58.9%. It has been demonstrated that a
specific IR clinical setting focusing on IVC filter patient care can dramatically increase patient education and referral to filter extraction. However, some sociological factors such as age, ethnicity, and
financial barriers affect the patient referral to IR clinics and need to
be accounted in patient management. A closer follow-up in order
to obtain optimal IVCF retrieval rates is mandatory in this specific
population.
The second limiting factor is the filter itself. Results need to be analyzed between short- and long-dwelling retrievals.
The 3-month success rate of filter removal (92%) has clearly been
demonstrated in the PREPIC II randomized control trial with the ALN
filter. The failure was strongly associated with filter adherence to the
vena cava and filter tilt of >15.
The CIRSE registry reports the same features (92%) for a mean
implantation dwelling time of 90 days across filter types. The main
reason of filter removal failure were filter thrombus (31% of failures),
filter tilt and inability to grasp the filter hook (21%), leg endothelialization preventing filter dislodgement (32%), access route thrombosis (2%), and a major complication (2%).
Those two publications point out a very low rate of removal of the
major complication (0.03%) mainly due to jugular vein puncture.
Over 3 months, despite broad cohort analysis, filter retrieval failure
seems to be associated with prolonged filter dwelling time and filter
type used. The recurrent causes of failure reported by the authors
are the incorporation of the filter legs in the IVC wall (47%), the filter hook embedded in the IVC wall (13%), and filter tilt of >15 (13%).
Iqbal et al reported, at the 2009 SIR meeting, a cohort of 60 patients
treated with the intention to remove a significant difference in the
filter dwelling time between successful and failed retrievals (mean
filter dwelling times of the successful and failed retrievals were 76
and 176 days, respectively). Among the attempted retrievals, 6/23
(26%) of Tulip filters, 6/17 (35%) of Optease filters, 1/6 (16%) of Celect
filters, and 2/12 (16%) of Recovery filters were not retrieved.
To overcome the filter removal failure, some techniques have been
developed. The use of additional device is usually proposed. For tilt,
authors proposed basic methods such as pigtail or balloon manipulation placed between the vena cava wall and filter to reduce the
tilt. Endothelialization can be removed with caution. The risk of vena
cava wall damage is high. The correct understanding of the endothelialization point is mandatory before proceeding to any maneuvers. Guidewire in a loop shape can advance around the endothelialization zone, and by a back and forth movement, the bond could be
removed. Excimer laser can efficiently assist the removal procedure
by cutting the endothelial bridge. The use of C-arm CBCT or IVUS is
helpful to orient the device.
The filter removal is needed in many patients because the filters
are associated with morbidity/mortality. An IR clinic that follows up
patients in a proactive manner is mandatory to remove the filter at

No abstract available.

Special Session
IVC filters: reassessing the evidence
3202.1
Current status in the USA
J.A.Kaufman
Dotter Interventional Institute, Oregon Health & Science University
Hospital, Portland, OR, United States of America
Learning Objectives
1. The current usage of IVC filters in the USA
2. Current indications/contra-indications
3. Removal rates of filters
No abstract available.

3202.2
Current status in Europe
G.J.Robinson
Dept of Radiology, Hull Royal Infirmary, Hull, United Kingdom
Learning Objectives
1. The current usage of IVC filters in Europe
2. Current indications/contra-indications
3. Removal rates of filters
No abstract available.

3202.3
Post-procedural patient care
S.D.Qanadli
Radiology and Interventional Radiology, Centre Hospitalier
Universitaire Vaudois, Lausanne, Switzerland
Learning Objectives
1. What to do after placing a filter i.e. follow-up, anticoagulation
2. Indications and planning for removal
3. Anticoagulation management
No abstract available.

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the earliest. The retrieval of adherent IVC filters implanted for up

to 35 years is feasible; however, these techniques need to be performed by experts.
References
1. Smith SC, Shanks C, Guy G, Yang X, Dowell JD. Social and
Demographic Factors Influencing Inferior Vena Cava Filter
Retrieval at a Single Institution in the United States. Cardiovasc
Intervent Radiol. 2015 Oct;38(5):1186-91.
2. Charlton-Ouw KM, Leake SS, Sola CN, Sandhu HK, Albarado
R, Holcomb JB, Miller CC 3rd, Safi HJ, Azizzadeh A. Technical
and financial feasibility of an inferior vena cava filter retrieval
program at a level one trauma center. Ann Vasc Surg. 2015
Jan;29(1):84-9.
3. Minocha J, Idakoji I, Riaz A, Karp J, Gupta R, Chrisman HB, Salem
R, Ryu RK, Lewandowski RJ. Improving inferior vena cava filter
retrieval rates: impact of a dedicated inferior vena cava filter
clinic. J Vasc Interv Radiol. 2010 Dec;21(12):1847-51.
4. Gasparis AP, Spentzouris G, Meisner RJ, Elitharp D, Labropoulos
N, Tassiopoulos A. Improving retrieval rates of temporary inferior
vena cava filters. J Vasc Surg. 2011 Dec;54(6 Suppl):34S-8S.e1.
5. Siracuse JJ, Al Bazroon A, Gill HL, Meltzer AJ, Schneider DB,
Parrack I, Jones DW, Connolly PH. Risk factors of nonretrieval
of retrievable inferior vena cava filters. Ann Vasc Surg. 2015
Feb;29(2):318-21.
6. Kalina M, Bartley M, Cipolle M, Tinkoff G, Stevenson S, Fulda G.
Improved removal rates for retrievable inferior vena cava filters
with the use of a filter registry. Am Surg. 2012 Jan;78(1):94-7.
7. Lee MJ, Valenti D, de Gregorio MA, Minocha J, Rimon U,
Pellerin O. The CIRSE Retrievable IVC Filter Registry: Retrieval
Success Rates in Practice. Cardiovasc Intervent Radiol. 2015
Dec;38(6):1502-7.
8. Mismetti P, Laporte S, Pellerin O, Ennezat PV, Couturaud F, Elias
A, Falvo N, Meneveau N, Quere I, Roy PM, Sanchez O, Schmidt
J, Seinturier C, Sevestre MA, Beregi JP, Tardy B, Lacroix P, Presles
E, Leizorovicz A, Decousus H, Barral FG, Meyer G; PREPIC2
Study Group. Effect of a retrievable inferior vena cava filter plus
anticoagulation vs anticoagulation alone on risk of recurrent
pulmonary embolism: a randomized clinical trial. JAMA. 2015
Apr;313(16):1627-35.
9. Pellerin O, di Primio M, Sanchez O, Meyer G, Sapoval M.
Successful retrieval of 29 ALN inferior vena cava filters at a
mean of 25.6 months after placement. J Vasc Interv Radiol. 2013
Feb;24(2):284-8.
10. Iliescu B, Haskal ZJ. Advanced techniques for removal of
retrievable inferior vena cava filters. Cardiovasc Intervent Radiol.
2012 Aug;35(4):741-50.
11. Ahmed O, Kuo WT. Laser-assisted venous thrombectomy for
treatment of recurrent in-stent restenosis and superior vena
cava syndrome. J Vasc Interv Radiol. 2016 Apr;27(4):603-6.
12. Kuo WT, Odegaard JI, Rosenberg JK, Hofmann LV. Excimer
laser-assisted removal of embedded inferior vena cava filters:
a single-center prospective study. Circ Cardiovasc Interv. 2013
Oct;6(5):560-6.
13. Kuo WT, Robertson SW, Odegaard JI, Hofmann LV. Complex
retrieval of fractured, embedded, and penetrating inferior vena
cava filters: a prospective study with histologic and electron
microscopic analysis. J Vasc Interv Radiol. 2013 May;24(5):622-30.
e1; quiz 631.

Abstract Book

Special Session
HCC: controversial issues (beyond guidelines)
3301.1
Is radiofrequency ablation still the standard of care?
R.Lencioni
Interventional Oncology Research, University of Miami Miller School
of Medicine, Sylvester Comprehensive Cancer Center, Miami, FL, United
States of America
Learning Objectives
1. To understand the current status of radiofrequency ablation in
the treatment of HCC
2. To learn about treatment modalities challenging radiofrequency
and their outcome
3. To understand the potential impact of treatment modalities
beyond radiofrequency ablation for standardised treatment
regimens
The use of RFA for the treatment of early-stage HCC is supported
by a large amount of data and robust clinical evidence. Five randomized controlled trials have compared RFA with PEI for the treatment of early-stage HCC. These investigations consistently showed
that RFA has a higher anticancer effect than PEI, leading to a better
local control of the disease. In addition, three independent metaanalyses have confirmed that in comparison with treatment with
PEI, that with RFA offers a survival benefit, particularly for tumors
larger than 2 cm. Caution, however, is needed when interpreting and generalizing these results, particularly in the light of studies that suggest a non-negligible rate of incomplete histopathological response after RFA. In fact, the ability of RFA to achieve complete
tumor eradication appears to depend on the tumor size and location. Is RFA still the best technique for tumor ablation? Several novel
technologies, including thermal and non-thermal methods, have
recently attracted attention because they appear to be able to overcome some specific limitations of RFA. MWA, in particular, is emerging as a valuable alternative to RFA and seems to have the potential to improve the rate of complete ablation achieved with RFA in
tumors larger than 23 cm, multiple tumors, or tumors in a perivascular location. IRE is promising for the treatment of small tumors
located in the vicinity of the bile duct and blood vessels. More data
are needed to define the potential of other energy-based ablation
technologies such as cryoablation in the specific field of treatment
of liver tumors. Advances in ablation systems and devices are highly
warranted. However, progress in imaging guidance and monitoring
is also a key to success. To be able to compete with surgical resection, image-guided ablation needs to be able to offer more accurate prediction of the outcome of the procedure in each patient.
Variability in outcomes needs to be minimized by careful treatment
planning. Moreover, the outcome of the ablation procedure needs
to be carefully documented by providing sound evidence that an
A0 treatment has been achieved.
References
1. Lencioni R, de Baere T, Martin RC, Nutting CW, Narayanan
G. Image-guided ablation of malignant liver tumors:
recommendations for clinical validation of novel thermal and
non-thermal technologies - a western perspective. Liver Cancer
2015;4:208-214.
2. Breen DJ, Lencioni R. Image-guided ablation of primary liver and
renal tumours. Nat Rev Clin Oncol 2015;12:175-186.

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3301.2
What is the role of combined treatments?
R.Iezzi
Department of Bioimaging and Radiological Sciences - Institute of
Radiology, A. Gemelli Hospital - Catholic University, Rome, Italy
Learning Objectives
1. To understand the challenge in treatment of borderline case and
how to identify cases suitable for treatment
2. To understand the rationale for combining various ablative
techniques
3. To learn about the outcome of combined treatments
According to the BCLC staging system, the early stage includes
patients with a single large hepatocellular carcinoma (HCC) of > 3
cm in diameter and the intermediate stage includes many patients
with very different presentations of HCC. Indeed, patients with 4
small HCC nodules, multinodular unilobar or bilobar disease, and
well-compensated liver function are all classified as intermediate
stage.
The principal purpose of research in this field should be to increase
the rate of patients who are suitable for non-surgical curative treatment and, consequently, to reduce indications for palliation alone.
In this scenario, the purpose should be to expand the indication for
radiofrequency ablation (RFA), which is a curative treatment for nodules smaller than 3 cm, by increasing its effectiveness in the treatment of single larger HCC nodules and for use during the intermediate stage. To this end, in recent years, a combination of intervention
therapies has been widely applied in the treatment of HCC.
One such combined strategy is based on the combination of the
percutaneous approaches such as RFA and intra-arterial locoregional approaches such as transarterial chemoembolization (TACE).
Several types of evidences have supported the feasibility and benefit of combined therapy, despite some studies reporting conflicting
results and outcomes. The aim of this presentation will be to explain
the technical aspects of different combined treatments and to comprehensively analyze and compare the clinical efficacy and safety of
this combined treatment option and monotherapy, either TACE or
RFA alone, in order to provide clinicians with an unbiased opinion
and valuable information.
Several studies have evaluated a multimodal approach even if it is
not clear as to which is the best combination of these two procedures. The first and more common option is represented by TACE,
followed by RFA. TACE can reduce the cooling effect of hepatic
blood flow by decreasing the hepatic arterial flow and increasing the
necrotizing effect of RFA at the tumor level. Furthermore, the edematous change in the tumor tissue induced by ischemia and inflammation after TACE is expected to enlarge the area of tumor necrosis
during RFA treatment, thereby increasing the ablation safety margin and reducing local recurrence. The second option is to perform
RFA, followed by TACE. Instead of using only lethal heating, which is
obtained with RFA, you can actually try to obtain a sustained anticancer effect from the sublethal heating created in the large area
surrounding the heating zone. In this area, we have a number of
phenomena, including increased blood flow, increased vascular
permeability, and effects on multiple cell targets. TACE performed
after RFA could increase its therapeutic effect, acting on the large
zones of sublethal heating obtained during RFA application in tissues surrounding the electrode. In detail, the chemotherapy drug
should be concentrated on a relatively small volume of residual viable neoplastic tissue characterized by reduced cell resistance to the
drug due to previous exposure to sublethal heating. Furthermore,
the delivery of a chemotherapy drug could be enhanced by the
reactive hyperemia induced by RFA application. The last option,
described in our previously published paper, could be to perform

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a single-step combination therapy, applying RFA to the lesion during balloon occlusion of the hepatic artery supplying the tumor,
thereby enhancing the thermal damage, followed by selective TACE
to enhance the cytotoxic injury. In detail, balloon occlusion of the
tumor arterial supply increases the area of coagulation necrosis
(ablation zone size) obtained with RFA, reducing arterial blood flow
and minimizing heat loss, as already shown previously. A demonstration of the superiority of one approach over the other is not possible because of the lack of randomized comparative studies.
Furthermore, the time-interval option strategy will also be discussed because to date, there has been no clear consensus about
it for balancing local therapeutic efficacy and safety. A longer time
interval between the two treatments may preserve liver function
because sufficient time is allowed for hepatic functional recovery.
However, this extended time prolongs the hospital stay required
or may increase the number of patient admissions to the hospital.
Conversely, a short interval can lead to better local efficacy because
of the more synergistic effect of the combination of TACE and RFA,
even if it may increase the potential risk of liver function injury,
mainly in cirrhotic patients with mild to moderate liver dysfunction.
In our opinion, only using a single-step combined approach makes
it possible to obtain and amplify the synergistic effects of RFA and
TACE. This approach entails further relevant advantages such as the
reduction of hospitalization days, decrease in patient discomforts,
and saving of cost because of the performance of both procedures
in the same session.
Based on a literature review and our experience, combined treatment seems to be a safe and effective option in the treatment of
patients with early/intermediate HCC when surgical resection is not
feasible; furthermore, this approach provides better results than RFA
and TACE alone for the treatment of large HCC, which is defined as
HCC > 3 cm in diameter. It can also expand the indication for RFA to
previously contraindicated complex cases, with an increased risk of
thermal ablation related complications due to tumor location or to
complex patients with high bleeding risk.
Finally, potential future techniques and applications based on the
use of new devices, such as microwave needle ablation (MWA), or
the use of antiangiogenic drugs to reduce recurrence tumor will be
highlighted.
The knowledge of technical aspects as well as the evaluation of
inclusion as well as exclusion criteria could enhance the clinical role
of these new therapeutic options to increase the rate of patients
suitable for curative treatment, reducing indications for palliation
alone.
References
1. European Association For The Study Of The Liver; European
Organisation For Research And Treatment Of Cancer.
EASL EORTC clinical practice guidelines: management of
hepatocellular carcinoma. J Hepatol 2012; 56: 908-943.
2. Wang W, Shi J, Xie WF. Transarterial chemoembolization
in combination with percutaneous ablation therapy in
unresectable hepatocellular carcinoma: a meta-analysis. Liver Int
2010; 30: 741-749.
3. Ni JY, Liu SS, Xu LF, Sun HL, Chen YT. Meta-analysis of
radiofrequency ablation in combination with transarterial
chemoembolization for hepatocellular carcinoma. World J
Gastroenterol 2013; 19: 3872-3882.
4. Liu Z, Gao F, Yang G, Singh S, Lu M, Zhang T, Zhong Z, Zhang
F, Tang R. Combination of radiofrequency ablation with
transarterial chemoembolization for hepatocellular carcinoma:
an up-todate meta-analysis. Tumour Biol 2014; 35: 7407-7413.
5. Iezzi R, Pompili M, Posa A, Coppola G, Gasbarrini A, Bonomo
L. Combined locoregional treatment of patients with
hepatocellular carcinoma: State of the art. World J Gastroenterol.
2016 Feb 14; 22: 1935-1942.

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3301.3
Ready to include radioembolisation in guidelines?
P.L.Pereira
Dept of Radiology, Minimally Invasive Therapies and Nuclearmedicine,
SLK-Clinics GmbH Heilbronn, Ruprecht-Karls-University Heidelberg,
Heilbronn, Germany
Learning Objectives
1. To learn about the representation of radioembolisation in
current guidelines
2. To understand the indications and contraindications of
radioembolisation in HCC
3. To learn about current results of radioembolisation in HCC and
the potential impact for comprehensive therapeutical regimens
Hepatocellular carcinoma (HCC) is the 6 th most common malignancy
diagnosed worldwide, and its late diagnosis limits the number of
curative treatments. Its incidence is still rising, mainly because of the
increasing numbers of hepatitis B (HBV) and C virus (HCV) infections
and the restricted use of vaccine politic in some countries. A large
number of therapy algorithms have been published worldwide;
however, only the NCCN Guidelines Version 1.2016 includes radioembolisation (1). During the previous years, yttrium-90 (90Y) radioembolisation has matured into a recognised treatment option for
colorectal liver metastases and has demonstrated a clear palliative
role by inducing necrosis and delaying progression in patients with
intermediate HCC. Comparative studies with the established conventional transarterial chemoembolisation are mostly retrospective
or have been performed with historical patient series. At the same
time, new technologies of chemoembolisation with the so-called
drug-eluted beads have shown their superiority over conventional
TACE, thereby increasing the confusion pertaining to whether TACE
or radioembolisation is the best option for patients with HCC in a
palliative situation.
References
http://www.nccn.org/professionals/physician_gls/f_guidelines.asp

3301.4
How to manage patients after stage migration
M.Burrel
Vascular Interventional Unit, Hospital Clnic Barcelona, Barcelona,
Spain
Learning Objectives
1. To understand how stage migration might change the
treatment regimen
2. To learn about the criteria for stage migration and their potential
impact on therapy
3. To learn about typical scenarios of stage migration and the
outcome of adjusted therapy regimens
Recent advancements have improved the management of patients
with liver cancer. Results of studies have provided information on
how to stage and decide the optimal treatment option for each
patient with an adequate balance between risks and benefits. The
Barcelona Clinic Liver Cancer (BCLC) staging and treatment strategy
has been widely endorsed for this purpose. However, the BCLC is
not a rigid system, and the concepts of treatable progression and
treatment stage migration are commonly applied.
In oncology, progression after systemic treatment is seen as treatment failure, and a common parameter to describe treatment efficacy is time to progression (TTP). However, in locorregional treatment, after previous achievement of objective response, progression (due to either regrowth of initially treated tumors or appearance of a new intrahepatic nodule) may be successfully treated
and the disease may be kept under control. Hence, it is clear that
the term progression had to be refined and the novel concept of
untreatable progression is justified.

Abstract Book
Even options for early-stage HCC that aim to provide complete
response and achieve long-term disease-free survival (surgery, ablation) are frequently hampered by tumor recurrence. At this point,
treatment may be initiated with the same approach or transition to
an option for a more advanced stage. Thus, all or some of the effective therapeutic options may be sequentially applied. Furthermore,
the refined evaluation of a patient may indicate that the therapeutic
option that would appear in the BCLC model as the first option to be
considered is not safe or feasible to be applied. Hence, the selected
option would be that corresponding to a different evolutionary
stage. This phenomenon is known as treatment stage migration.
One typical scenario of treatment stage migration is a BCLC A
patient treated with ablation who presents with recurrence not suitable for further ablation; TACE may be considered despite being at
stage A. Another typical situation is a BCLC B patient who presents
with untreatable progression, which will therefore be considered for
sorafenib.
All these comments are relevant because one of the most controversial issues in patients with HCC is when to start and when to stop a
specific treatment.

Special Session
Pharmacomechanical thrombolysis for acute DVT
3302.1
Patient selection and peri-interventional management
S.Vedantham
Mallinckrodt Institute of Radiology, Washington University School of
Medicine, St. Louis, MO, United States of America
Learning Objectives
1. Which clinical and imaging features are favourable for venous
DVT treatment
2. Optimising patient factors for safe thrombectomy/lysis
The treatment of deep vein thrombosis (DVT) has significantly
advanced in recent years. However, despite the use of standard
anticoagulant therapy and elastic compression stockings, DVT frequently recurs and often leads to permanent sequelae from the
development of the post-thrombotic syndrome (PTS) (1,2). Catheterbased techniques have been used in the management of DVT for
many years with the hope of enhancing PTS prevention and have
evolved to include the combined use of thrombolytic drugs with
mechanical thrombectomy devices: a hybrid technique called
pharmacomechanical catheter-directed thrombolysis (PCDT) (3).
However, there currently exist no completed multicenter randomized controlled trials (RCTs) that have evaluated the outcomes
associated with contemporary PCDT. Acute Venous Thrombosis:
Thrombus Removal with Adjunctive Catheter-directed Thrombolysis
(ATTRACT) Study is a NIH-sponsored, phase III, multicenter RCT evaluating long-term outcomes in 692 patients with acute proximal DVT
who were randomized to receive PCDT + standard therapy or standard therapy alone (4). This trials results are expected in early 2017.
Until ATTRACT and other RCTs are completed, it behooves the physician to place strong emphasis upon minimizing the risks of these
procedures via careful patient selection and peri-procedural management (5).
PTS develops in approximately 40% of patients within 2 years of a
symptomatic first-episode DVT and is relatively mild in more than
half of the cases (1). However, patients with proximal DVT develop
PTS in perhaps 50% of cases, and PTS rates in patients with iliofemoral DVT (defined as DVT involving the iliac and/or common femoral vein, with or without other involved veins) appear to exceed
50%. With iliofemoral DVT, the occurrences of recurrent VTE and
PTS with greater degrees of severity and life impact are also much
more frequent; severely impacted patients may experience severe

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short-distance venous claudication, skin changes, stasis dermatitis,
and/or venous ulceration, which exert a major negative impact on
the health-related quality of life (QOL) (1,6,7). In contrast, patients
with asymptomatic DVT or isolated calf DVT rarely develop PTS (8).
For these reasons, the anatomic extent of DVT plays a significant role
in determining the appropriateness of PCDT. Irrespective of whether
PCDT is used, clinicians should consider iliofemoral DVT as a highrisk condition for adverse long-term outcomes (9).
Currently, the most commonly used (but off-label) fibrinolytic drug
for DVT in the United States is recombinant tissue plasminogen activator (rt-PA, Genentech, South San Francisco, CA). The drug is continuously and directly infused into the thrombus at a low dose (a
typical rt-PA dose is 0.01 mg/kg/h, not to exceed 1.0 mg/h) (4,5,10).
During this time, the patient typically receives an intravenous infusion of unfractionated heparin at subtherapeutic levels. Hematocrit,
PTT, platelet count, and in some centers fibrinogen level are
obtained every 612 h, and in most centers, the patient is closely
monitored in an intensive care or stepdown unit. If active bleeding
occurs or if laboratory parameters depart from the expected ranges
(e.g., PTT > 100 s, fibrinogen < 100 mg/dl), the drug infusion is temporarily or permanently discontinued. Patients are venographically
re-studied at 624-h intervals. Major bleeds are estimated to occur
in 2%4% of patients receiving PCDT, with intracranial bleeds in
about 0.5% (5).
A strong preponderance of the available (mostly low quality) evidence favors the use of PCDT in DVT patients with a) clinically severe
manifestations of DVT, including phlegmasia cerulea dolens, acute
IVC thrombosis, or rapid thrombus extension, despite anticoagulation or b) anatomically extensive DVT that includes the common
femoral vein and/or iliac vein since this degree of involvement portends a much higher risk of recurrent DVT and PTS (10). At present, a
highly individualized approach to patient selection is recommended
(5,9). Major additional factors that impact the decision process
include symptom duration; the patients bleeding risk profile, lifeexpectancy, and anticipated activity level; and his/her willingness to
undergo a minimally-invasive catheter-based procedure.
Successful thrombolysis of acute DVT is most likely to be achieved
in patients with recently-formed thrombus, as evidenced by DVT
symptom duration of less than 1014 days (11). The best group of
patients is those with acute iliofemoral DVT. Patients with a symptom duration of 1428 days also usually experience significant
thrombolysis, but such patients often require adjunctive iliac vein
stent placement to restore complete venous patency with acceptable flow.
Patients with short life expectancy, those who do not ambulate,
and those with factors predisposing them to bleeding complications (e.g., recent surgery, trauma, or obstetrical delivery; intracranial lesions; and severe thrombocytopenia) are poor candidates as
are three additional subsets of patients: 1) patients with chronic DVT
(>28 days) limited to the femoropopliteal segment since thrombolytic therapy tends to be ineffective for them (12), 2) patients with
isolated calf vein DVT since they tend to be less symptomatic and to
develop PTS less frequently, and 3) patients with asymptomatic DVT
since they rarely develop PTS (8).
Most importantly, all patients in whom PCDT is planned must
undergo a rigorous clinical assessment to evaluate their risk of procedure-related complications, especially bleeding (5). A low threshold should be applied to exclude patients from therapy; this includes
many patients with recent surgery, trauma, or lesions in critical locations (e.g., brain metastases or stroke). Patients who are very elderly
(i.e., above 7075 years of age) are also probably at increased risk for
bleeding. Unfortunately, this will result in the exclusion of more than
half of the patients who might have been otherwise eligible for therapy. However, this level of rigor is absolutely necessary to maintain
appropriate patient safety.

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References
1. Kahn SR, Shrier I, Julian JA, et al. Determinants and time course
of the post-thrombotic syndrome after acute deep venous
thrombosis. Ann Intern Med 2008; 149:698-707.
2. Kahn SR, Shapiro S, Wells PS, et al. SOX trial investigators.
Compression stockings to prevent post-thrombotic syndrome: a
randomized placebo-controlled trial. Lancet 2014; 383:880-888.
3. Vedantham S, Vesely TM, Sicard GA, et al. Pharmacomechanical
thrombolysis and early stent placement for iliofemoral deep
vein thrombosis. J Vasc Interv Radiol 2004; 15:565-574.
4. Vedantham S, Goldhaber SZ, Kahn SR, et al. A multicenter
randomized trial to evaluate pharmacomechanical catheterdirected thrombolysis for the prevention of postthrombotic
syndrome in patients with proximal deep vein thrombosis. Am
Heart J 2013; 165:523-553.
5. Vedantham S, Sista AK, Klein SJ, et al. Quality improvement
guidelines for the treatment of lower-extremity deep vein
thrombosis with use of endovascular thrombus removal. J Vasc
Interv Radiol 2014; 25:1317-1325.
6. Douketis JD, Crowther MA, Foster GA, Ginsberg JS. Does the
location of thrombosis determine the risk of disease recurrence
in patients with proximal deep vein thrombosis? Am J Med 2001;
110:515-519.
7. Kahn SR, Shbaklo H, Lamping DL, et al. Determinants of healthrelated quality of life during the 2 years following deep vein
thrombosis. J Thromb Haemost 2008; 6:1105-1112.
8. Ginsberg JS, Hirsh J, Julian J, et al. Prevention and treatment of
postphlebitic syndrome: results of a 3-part study. Arch Intern
Med 2001; 161:2105-2109.
9. Jaff MR, McMurtry MS, Archer SL, et al. Management of massive
and submassive pulmonary embolism, iliofemoral deep
vein thrombosis, and chronic thromboembolic pulmonary
hypertension: a scientific statement from the American Heart
Association. Circulation 2011; 123:1788-1830.
10. Enden T, Haig Y, Klow N, et al. CaVenT Study Group. Long-term
outcomes after additional catheter-directed thrombolysis versus
standard treatment for acute iliofemoral deep vein thrombosis
(the CaVenT study): a randomised controlled trial. Lancet 2012;
379:31-38.
11. Mewissen WM, Seabrook GR, Meissner MH, et al. Catheterdirected thrombolysis for lower extremity deep venous
thrombosis: report of a national multicenter registry. Radiology
1999; 211:39-49.

3302.2
Thrombo-aspiration
R.Uberoi
Interventional Radiology, John Radcliffe Hospital, Oxford, United
Kingdom
Learning Objectives
1. Patient selection
2. Technique for thrombo-aspiration
3. Current evidence and outcomes
Deep vein thrombosis affects around 2%5% of the population at
some point in their lives with an incidence of 60180/100,000. The
mainstay of deep vein thrombosis has remained simple anticoagulation with low-molecular-weight heparin followed by oral anticoagulation and compression stocking to prevent acute pulmonary emboli, clot propagation, recurrence and post thrombotic syndrome for many years. However, this often results in incomplete
clot clearance in >50% of patients, significant valve damage and a
high incidence of post-thrombotic syndrome of up to 95%, particularly for ileofemoral thrombosis. Rapid clearance of thrombus can
help preserve valve function and potentially reduce the incidence
of post-thrombotic syndrome. Systemic lysis has been utilised;

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however, it can result in high incidence of bleeding complications,

including stroke. To minimise this, various endovascular techniques
are now available, including catheter thrombus aspiration, catheter-directed thrombolysis, mechanical thrombectomy and a combination of these therapies. Regardless of the endovascular techniques used, catheter-directed aspiration is often utilised as a part
of the techniques to achieve near complete clot clearance, and in
a few studies, it has been exclusively used to treat the thrombus
burden using 8/9-F guiding catheters or 9/10-F sheaths. Potential
advantages include the rapid speed of clot clearance, simplicity of
the technique, low cost and reduced risk of haemorrhagic complications. The technique was initially described in a small cohort of
patients with phlegmasia and good clinical success. Subsequently,
Kwon showed that catheter aspiration alone could be used to successfully clear thrombus in a small cohort of 27 patients with acute
limb deep vein thrombosis without lytic therapy and with a technical and clinical success of 89%. More recently, Ouzkurt used
thrombus aspiration as the primary method of clot clearance in 139
patients with acute and subacute ileofemoral deep vein thrombosis, with only 27% requiring additional catheter-directed thrombolysis. There was >95% clot clearance in >66%, 50%95% in >30% and
<50% in <4% of patients. As a consequence, 53% of patients could
be discharged on the same day. Complications were low: 12% minor
and 4% major with 3 patients with pulmonary emboli. Primary and
secondary patency rates were 77%, 74% and 72% and 93%, 78% and
78% at 1, 3 and 5 years, respectively. Zhu also has recently confirmed
the effectiveness of catheter aspiration alone in a smaller cohort of
26 patients with complete clot clearance in 24 patients in a single
session and a procedure time of 67 minutes. Two patients required
additional catheter-directed lysis. There was complete relief of
symptoms in 96% with primary and secondary patency rates of 96%
and 100%, respectively, at 12 months. Hospital stay ranged from 2 to
4 days. Disadvantages of the technique are the requirement of large
size catheters and sheaths, blood loss during the procedure and
potential dislodgement of the thrombus, resulting in pulmonary
emboli. In the study by Ouzkurt, only three patients had a significant pulmonary embolus with selective use of IVC filters, which were
placed in only 6% of patients. Venoplasty and stenting are an integral part of the technique, particularly in the presence of the May
Thurner syndrome.
Mechanical aspiration is feasible, safe and effective in a vast majority
of patients with a high technical and clinical success and low complications. This technique could reduce procedure complexity and
time and result in an early discharge, thereby reducing the cost of
the procedures. A small number of patients, however, will require
additional catheter-directed thrombolysis.
References
1. Nordstrom M, Linblad B, Bergqvist D, Kjellstrom T. A prospective
study of the incidence of deep vein-thrombosis within a defined
urban population. J Intern Med. 1992; 232:155-160.
2. Browse NL, Burnand KG, Lea Thomas M. Deep vein thrombosis:
pathology, diagnosis and treatment. In: Browse NL, Burnand
KG, Irvine AT, Wilson NM editor(s). Diseases of the veins. 2nd 3,
Edition. London: Edward Arnold, 1999:443-474.
4. Plate G, Ohlin P, Eklof B. Pulmonary embolism in the acute
ileofemoral thrombosis. Br J Surg. 1985; 72:912-915.
5. Breddin HK, Hach-Wunderle V, Nakov R, et al. Effects of a
low-molecular-weight heparin on thrombus regression and
recurrent thromboembolism in patients with deep-vein
thrombosis. N Engl J Med. 2001; 344:626-631.
6. Labas P, Ohradka B, Vladimir J, et al. The home treatment of
deep vein thrombosis with low molecular weight heparin,
forced mobilization and compression. Int Angiol. 2000; 19:303307.
7. Comerota AJ, Aldridge SC. Thrombolytic therapy for deep
venous thrombosis: a clinical review. Can J Surg. 1993; 36:359364.

Abstract Book
8. Oguzkurt L, Ozkan U, Demirturk OS, Gur S. Endovascular
treatment of phlegmasia cerulea dolens with impending venous
gangrene: manual aspiration thrombectomy as the first-line
thrombus removal method. Cardiovasc Intervent Radiol 2011;
34:1214-1221.
9. Kwon SH, Oh JH, Seo TS, et al. Percutaneous aspiration
thrombectomy for the treatment of acute lower extremity deep
vein thrombosis: is thrombolysis needed? Clin Radiol 2009;
64:484-490.
10. Ouzkurt L, Ozkan U, Gm B, et al. Percutaneous aspiration
thrombectomy in the treatment of lower extremity
thromboembolic occlusions. Diagn Interv Radiol 2010; 16:79-83.
11. Ouzkurt L, Ozkan U, Glcan O, et al. Endovascular treatment
of acute and subacute iliofemoral deep venous thrombosis by
using manual aspiration thrombectomy: long-term results of 139
patients in a single center. Diagn Interv Radiol 2012; 18:410-416.
12. Zhu QH, Zhou CY, Chen Y, et al. Percutaneous manual aspiration
thrombectomy followed by stenting for iliac vein compression
syndrome with secondary acute isolated iliofemoral deep vein
thrombosis: a prospective study of single-session endovascular
protocol. Eur J Vasc Endovasc Surg 2014; 47:68-74.

3302.3
Thrombolysis
M.Roek
Department of Radiology, Motol University Hospital, Prague, Czech
Republic
Learning Objectives
1. Currently available agents
2. Techniques for thrombolysis
3. Current evidence and outcomes
Deep venous thrombosis (DVT) is a serious and potentially lifethreatening disease. It is one of the most common disorders of the
circulatory system. DVT often results in acute and chronic complications such as pulmonary embolism, phlegmasia cerulea dolens, and
the post-thrombotic syndrome (PTS). Early diagnosis and aggressive
treatment, especially in young and otherwise healthy patients, are
important.
The standard of treatment remains anticoagulation. Patients
enrolled into aggressive treatment must have symptomatic acute
iliofemoral deep venous thrombosis (14 days) or phlegmasia. Use
of thrombolysis or clot-dissolving drugs could reduce the long-term
complications of PTS in the affected leg (1) and potentially preserve
the valvular function (2).
Thrombolytic drugs are a very important factor in the treatment of
DVT. At present, recombinant tissue plasminogen activator (rt-PA)
is probably the most commonly used drug for catheter-directed
thrombolysis (CDT). Other agents that may be used include urokinase (UK), reteplase (RPA), and tenecteplase (TNK). However, the
optimal dosage of a thrombolytic agent is still controversial.
Interventional thrombolytic techniques of thrombus removal
include CDT and pulse-spray technique (PST). CDT is an imageguided technique involving infusion of thrombolytic agents
through a multi-side hole infusion catheter or wire directly placed
into a venous thrombus through a remote puncture site (3), usually
followed by aspiration. PST increases penetration of the thrombus
by using a combination of mechanical and pharmacologic thrombolysis using a multi-side hole catheter. This technique reduces the
lysis time.
Contraindications to thrombolytic therapy include active internal bleeding; recent cerebrovascular accident or intracranial surgery, trauma, or tumor; recent serious gastrointestinal bleeding;
major trauma or surgery within 10 days; severe uncontrolled hypertension; pregnancy; endocarditis; intracardiac thrombus; known
right-to-left shunt; coagulopathy, thrombocytopenia, or absolute

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contraindications to anticoagulation; suspected septic thrombus;
and allergy to thrombolytic agents (3,4). Although most contraindications can be identified on routine clinical assessment, some (5)
have suggested brain imaging before thrombolysis in patients with
malignancies known to metastasize to the central nervous system.
Evidence-based recommendations are based on a systematic
review and meta-analysis of the relevant literature, supplemented
when necessary by less rigorous data. Recommendations are
made according to the Grading of Recommendations, Assessment,
Development, and Evaluation (GRADE) methodology, incorporating
the strength of the recommendation (strong: 1; weak: 2) and an evaluation of the level of evidence (A to C) (6).
On the basis of the best evidence currently available, authors recommend against routine use of the term proximal venous thrombosis in favor of more precise characterization of thrombi as involving the iliofemoral or femoropopliteal venous segments (Grade
1A). They further suggest the use of early thrombus removal strategies in ambulatory patients with good functional capacity and a
first episode of iliofemoral DVT of <14 days in duration (Grade 2C)
and strongly recommend their use in patients with limb-threatening ischemia due to iliofemoral venous outflow obstruction (Grade
1A). They suggest pharmacomechanical strategies over catheterdirected pharmacologic thrombolysis alone if resources are available and that surgical thrombectomy be considered if thrombolytic
therapy is contraindicated (Grade 2C) (6).
Compared with standard anticoagulant therapy, catheter-directed
pharmacologic thrombolytic therapy is associated with significant
reductions in the risks of the PTS (relative risk [RR], 0.19; 95% confidence interval [CI], 0.070.48), venous reflux (RR, 0.21; 95% CI, 0.09
0.53), and venous obstruction (RR, 0.35; 95% CI, 0.170.34) (7). These
results are consistent with a previous systematic review (8), which
included less efficient systemic and locoregional techniques, demonstrating a significant reduction in PTS (RR, 0.66; 95% CI, 0.470.94)
with thrombolytic treatment. According to this review, one case of
PTS would be prevented for every five patients treated with thrombolytic therapy. The short-term hemodynamic results of one additional randomized clinical trial in which catheter-directed pharmacologic thrombolysis was compared with standard anticoagulation has been published since the most recent systematic review
(9). Among 103 randomized patients, 6-month patency was significantly better in those who received catheter-directed pharmacologic thrombolysis (64.0% vs. 35.8%; P = 0.004), whereas the incidence of femoral vein reflux was similar (60.0% vs. 66.0%; P = 0.53).
The review results based on 17 controlled trials that randomized
a total of 1103 people with acute DVT (within 21 days of onset of
symptoms) to receive thrombolysis or anticoagulant treatment were
considered. Complete clot lysis occurred significantly more often in
the treatment group at early follow-up (risk ratio [RR], 4.91; 95% CI,
1.6614.53; P = 0.004) and at intermediate follow-up (RR, 2.37; 95%
CI, 1.483.80; P = 0.0004). Significantly less PTS occurred in those
receiving thrombolysis (RR, 0.64; 95% CI, 0.520.79; P < 0.0001).
Those receiving thrombolysis had significantly more bleeding complications (RR, 2.23; 95% CI, 1.413.52; P = 0.0006) (1).
The most definitive study, the ATTRACT trial (10), has recently completed patient enrollment. The ATTRACT trial is an NIH-funded study
of 692 patients with acute DVT of 2-week duration or less, randomized to conventional anticoagulation or anticoagulation plus a catheter-based strategy of thrombus removal. At entry, patients were
stratified by location of thrombus, either ileofemoral DVT or femoropopliteal DVT. The primary outcome is PTS at 2 years. The ATTRACT
trial will produce the largest dataset to date and will give important information regarding onset and severity of PTS, quality of life,
recurrent DVT, costbenefit analysis, and much more (2).
Thrombolysis increases the patency of veins and reduces the incidence of PTS following proximal DVT. Strict eligibility criteria are
necessary to reduce the risk of bleeding complications, and this limits the applicability of the treatment.

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References
1. Watson, L., Broderick, C., Armon, M.P. Thrombolysis for acute
deep vein thrombosis. Cochrane Database Syst Rev. 2014; 23: 1.
2. Comerota, A.J. Catheter-directed thrombolysis for iliofemoral
deep vein thrombosis: helpful or hurtful? Expert Rev Hematol.
2015; 8: 131133.
3. Mewissen, M.W., Seabrook, G.R., Meissner, M.H., Cynamon, J.,
Labropoulos, N., Haughton, S.H. Catheter-directed thrombolysis
for lower extremity deep venous thrombosis: report of a
national multicenter registry. Radiology. 1999; 211: 3949.
4. Vedantham, S., Thorpe, P.E., Cardella, J.F., Grassi, C.J., Patel, N.H.,
Ferral, H., Hofmann, L.V., Janne dOthe, B.M., Antonaci, V.P.,
Brountzos, E.N., Brown, D.B. Quality improvement guidelines for
the treatment of lower extremity deep vein thrombosis with use
of endovascular thrombus removal. J Vasc Interv Radiol. 2006;
17: 435447.
5. Vedantham, S., Thorpe, P.E., Cardella, J.F., Grassi, C.J., Patel,
N.H., Ferral, H., Hofmann, L.V., dOthe, B.M.J., Antonaci, V.P.,
Brountzos, E.N., Brown, D.B. Quality improvement guidelines for
the treatment of lower extremity deep vein thrombosis with use
of endovascular thrombus removal. J Vasc Interv Radiol. 2009;
20: S227S239.
6. Meissner, M.H., Gloviczki, P., Comerota, A.J., Dalsing, M.C., Eklof,
B.G., Gillespie, D.L., Lohr, J.M., McLafferty, R.B., Murad, M.H.,
Padberg, F., Pappas, P., Raffetto, J.D., Wakefield, T.W., Society
for Vascular Surgery, American Venous Forum. Early thrombus
removal strategies for acute deep venous thrombosis: clinical
practice guidelines of the Society for Vascular Surgery and the
American Venous Forum. J Vasc Surg. 2012; 55: 14491462.
7. Casey, E.T., Murad, M.H., Zumaeta-Garcia, M., Elamin M.B., Shi,
Q., Erwin, P.J., Montori, V.M., Gloviczki, P., Meissner, M. Treatment
of acute iliofemoral deep vein thrombosis. J Vasc Surg. 2012; 55:
14631473.
8. Watson, L.I., Armon, M.P. Thrombolysis for acute deep vein
thrombosis. Cochrane Database Syst Rev. 2004; CD002783.
9. Enden, T., Klw, N.E., Sandvik, L., Slagsvold, C.E., Ghanima,
W., Hafsahl, G., Holme, P.A., Holmen, L.O., Njaastad, A.M.,
Sandbaek, G., Sandset, P.M. Catheter-directed thrombolysis vs.
anticoagulant therapy alone in deep vein thrombosis: results of
an open randomized, controlled trial reporting on short-term
patency. J Thromb Haemost. 2009; 7: 12681275.
10. Comerota, A.J. The ATTRACT trial: rationale for early intervention
for iliofemoral DVT. Perspect Vasc Surg Endovasc Ther. 2009; 21:
221224.

3302.4
Mechanical thrombectomy
R.A.Lookstein
Interventional Radiology, Mount Sinai Medical Center, New York, NY,
United States of America
Learning Objectives
1. Mechanical devices
2. Techniques for mechanical thrombectomy
3. Current evidence and outcomes
No abstract available.

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Barcelona, Spain

September 10-14

CIRSE 2016
PART 2

Abstracts of
Free Papers
(oral communications)
sorted by presentation
numbers

Cardiovascular and Interventional Radiological Society of Europe

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Abstract Book

Free Paper Session

Dialysis intervention

Conclusion: The modified lyse-and-wait technique is a safe and

effective declotting procedure, which allows planning of challenging angioplasty maneuvers during regular working hours.

606.1

606.3

Does technical success of angioplasty in dysfunctional

hemodialysis accesses correlate with access patency?

Long-term local thrombolysis using rtPA for acute thrombosed

hemodialysis access

D.K.Rajan1, A.Sidhu2
1Medical Imaging, University Health Network, Toronto, ON, Canada,
2Radiology, Providence Hospital, Southfield, MI, United States of

S.Regus1, W.Lang1, M.Heinz2, M.Uder2, A.Schmid2

1Vascular Surgery, University Hospital, Erlangen, Germany, 2Radiology
Department, University Hospital Erlangen, Erlangen, Germany

America
Purpose: To study if 30% residual stenosis post-angioplasty (PTA)
correlates with primary access circuit patency and if any variables
predict technical success.
Material and methods: A prospective observational study performed between January 2009 and December 2012, wherein 76
patients underwent 154 PTA events in 56 prosthetic grafts (AVG) and
98 autogenous fistulas (AVF). Data collected included the following:
patient age, gender, lesion location and laterality, access type and
location, number of prior interventions, and transonic flow rates
pre- and post-intervention. Impact of technical outcome on access
patency was assessed. Univariate logistic regression was used to
assess impact of variables on technical success with significant factors assessed with a multiple variable model.
Results: Technical success of PTA in AVFs and AVGs was 79.6% and
76.7%, respectively. Technical failures of PTA were associated with
an increased risk of patency loss among circuits with AVFs (p<0.05),
but not with AVGs (p=0.7). In AVFs, primary access patency between
technical successes and failures at 3 and 6 months were 74.4% vs
61.9% (p=0.3) and 53.8% vs 23.8% (p<0.05), respectively. In AVGs,
primary access patency between technical successes and failures
at 3 and 6 months were 72.1% vs 53.9% (p=0.5) and 33.6% vs 38.5%
(p=0.8), respectively. Transonic flow rates did not significantly differ
among technically successful or failed outcomes at 1 or 3 months.
Conclusion: Technical failures of PTA had a significant impact on
access patency among AVFs with a trend toward poorer access
patency within AVGs.

606.2
Time-extended lyse-and-wait technique for thrombosed
hemodialysis access
S.Regus1, W.Lang1, M.Heinz2, M.Uder2, A.Schmid2
1Vascular Surgery, University Hospital, Erlangen, Germany, 2Radiology
Department, University Hospital Erlangen, Erlangen, Germany
Purpose: We describe our single-center experience in performing a modified lyse-and-wait technique characterized by the timeextended recombinant tissue plasminogen activator (rtPA) local
exposure time.
Material and methods: From February 2009 to April 2014, 84
patients presented with 152 acute hemodialysis access thrombosis.
They proceeded to local thrombolysis, including a single shot application of rtPA, local reaction time up to several hours, and finally
percutaneous stenosis treatment. Success rates, major adverse
events, and need for temporary catheter placements (TCP) were retrospectively analyzed.
Results: The local thrombolysis time after single shot infiltration was
18.6 hours (range 240). Mean rtPA dosage was 2.7 1.2 mg (range
19). The overall success rate was 89.5%, and the major complication rate was 3.3%, whereas TCP was necessary in 12.5% patients. PP/
SP at 1, 3, 6, 12, 18, and 24 months was 86% 3%/95% 2%, 68%
4%/92% 2%, 43% 4%/90% 2%, 28% 4%/82% 3%, 12%
3%/82% 3%, and 7% 2%/63% 4%, respectively.

Purpose: Local thrombolysis is commonly used to declot acutely

thrombosed hemodialysis access with an exposure time of recombinant-tissue plasminogen activator (rtPA), i.e., about 15 to 150 minutes. We applied different reaction times, and the aim of this study
was to compare a long (3 hours and more) (LTT) and short (less than
3 hours) (STT) thrombolysis treatment.
Material and methods: We retrospectively analyzed electronic
files of 86 interventional declotting procedures (28 STT and 58 LTT).
Special interests were the lysis time (LT) from rtPA infiltration to first
fistulography, the intervention time (IT) from first fistulography to
the end of angioplasty maneuvers, the procedure time (PT) from
rtPA infiltration until end of angioplasty, and the need for temporary
catheter placement.
Results: IT was reduced after LTT (63.3 9.3 minutes) in contrast to
STT (106.7 24.7 minutes) (p < 0.001), whereas PT was longer after
LTT (993.8 430.4 minutes) (p < 0.001). The mean rtPA dosage was
3.9 1.1 mg (range 26) in STT and 2.2 0.7 mg (range 14) in LTT (p
< 0.001). The success rate was 86.0% after STT and 89.7% for LTT (p
= 0.722), while the major complication rate was 28.6% after STT and
3.4% after LTT (p = 0.002).
Conclusion: LTT is a safe and successful declotting procedure for
acute thrombosed hemodialysis access. Despite the long time interval of up to 25 hours until the access was punctable for dialysis,
there was no increased risk of temporary catheter placement.

606.4
Creation of a percutaneous arteriovenous fistula (pAVF) for
hemodialysis access
C.G.Radosa1, N.Weiss2, T.Hofmockel1, J.C.Radosa3, M.Laniado1,
C.Gatzweiler4, R.-T.Hoffmann1
1Inst. u. Pk. f. Radiologische Diagnostik, Medizinische Fakultt
Carl-Gustav-Carus, TU Dresden, Dresden, Germany, 2Medizinische
Klinik und Poliklinik III, Medizinische Fakultt Carl-Gustav-Carus,
TU Dresden, Dresden, Germany, 3Klinik fr Frauenheilkunde,
Geburtshilfe und Reproduktionsmedizin, Universittsklinikum des
Saarlandes und Medizinische Fakultt der Universitt des Saarlandes,
Homburg, Germany, 4Klinik und Poliklinik fr Viszeral-, Thorax- und
Gefchirurgie, Medizinische Fakultt Carl-Gustav-Carus, TU Dresden,
Dresden, Germany
Purpose: Standard for vascular access of hemodialyis is the surgical
creation of a radiocephalic fistula. If not suitable, a brachiocephalic
or -basilic fistula may be created, which, however, is associated with
a higher complication rate. Recently, an endovascular approach for
ulnarulnar fistula creation (EndoAVF) had been developed, which
may be an alternative to surgical upper arm dialysis fistula. We
aimed to study the feasibility, technical success, early complications,
and outcome of this novel treatment option.
Material and methods: Six patients requiring hemodialyis access
unsuitable for surgical radiocephalic fistula creation were treated
with EndoAVF. Patients were included after a pretherapeutic ultrasound showing patent brachial and ulnar arteries and veins of adequate size, perforating veins between deep and superficial veins in

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the cubital area, and no ipsilateral central venous stenosis. A multidisciplinary vascular board confirmed the indication for EndoAVF.
Results: Endovascular treatment of all patients was possible under
a combination of local anesthesia and i.v. conscious sedation.
Technical success of EndoAVF was 100%. Mean duration of intervention was 62 min (+/-15) and decreased over time from 80 minutes to
40 minutes. There were no intra- or postoperative complications.
Ultrasound 1 day after the intervention showed a flow volume over
the fistula of 892 ml/min (+/-220). In one patient, hemodialysis was
already started without problems.
Conclusion: EndoAVF seems to be feasible and safe for the creation
of arteriovenous fistula, showing fast maturation. Larger sample
sizes and longer follow-ups are needed to prove the comparability
to surgical dialysis access creation.

606.5
Endexo: superb technology for hemodialysis catheter? data
analysis from pre-clinical trials
E.W.Lee1, K.LeBlanc2, S.Kee1
1Division of Interventional Radiology, Department of Radiology, UCLA
Medical Center, Los Angeles, CA, United States of America, 2R&D,
AngioDynamics Inc, Latham, NY, United States of America
Purpose: To evaluate and analyze the pre-clinical datat regarding the efficacy of the Endexo technology-based dialysis catheter
(BioFlo DuraMax) in achieving improved thrombo-resistance and
hemodynamic profile.
Material and methods: Pre-clinical testing included the following
methods1: ex vivo bovine loop model (n=20), in vivo simulated dialysis ovine model (n=16) and computational dialysis transonic recirculation test model (n=20). Four main characteristics of hemodialysis catheters were investigated: (1) thrombo-resistance, (2) material/tissue adherence (MTA), (3) recirculation rate (RR) and (4) in-dialysis pressure (IDP). Outcomes of BioFlo catheters were compared
with those of two non-Endexo dialysis catheters (DuraMax and
Palindrome). Independent analysis and interpretation of the data
were performed by EWL/SK, and the experimental data are recorded
with AngioDynamics Inc.
Results: In thrombo-resistance tests, Bioflo had significantly higher
thrombo-resistance than non-coated or heparin-coated Palindrome
catheter (96% vs. 84.6 and 83.5%, p<0.001). Comparing MTAs, the
proximal and mid-catheter MTAs were not different. However,
improved MTA was noted in the catheter tip region of BioFlo than
that of Palindrome (p<0.03). In terms of RR, BioFlo demonstrated
a significantly improved forward RR (0%) than Palindrome (2.5%,
p<0.0001). However, with regard to reverse RR, BioFlo had a higher
RR than Palindrome (12.2% vs. 1.0%, p<0.0001). Lastly, with regard
to IDP, BioFlo demonstrated significantly better IDP in all flow
rates (200, 300 and 400 mL/min) in forward and reverse dialysis
(p<0.0001).
Conclusion: The Endexo technology-based dialysis catheter
appears to be superior in thrombo-resistance, forward recirculation rate and in-dialysis pressure compared with the non-Endexo
catheters tested. Future clinical research will seek to validate these
findings.

SS/FC/HL/HTS/CM
Free Papers

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606.6
Novel use of a pneumatic compression device for haemostasis
of haemodialysis fistula access catheterisation sites
D.T.Ryan, M.K.OReilly, G.Sugrue, C.Farrelly
Department of Radiology, Mater Misericordiae University Hospital,
Dublin, Ireland
Purpose: Transradial pneumatic compression devices can be used
to achieve haemostasis following radial artery puncture. This article
describes a novel technique for acquiring haemostasis of arteriovenous haemodialysis fistula access sites without the need for suture
placement using one such compression device.
Material and methods: A retrospective review of fistulograms
with or without angioplasty/thrombectomy in a single institution
was performed. Twenty procedures performed on 12 patients who
underwent percutaneous intervention of failing or thrombosed
arteriovenous fistulas showed 27 puncture sites. Haemostasis was
achieved using a pneumatic compression device at all access sites.
Procedure details, including size of access sheath, heparin administration and complications, were recorded.
Results: Two diagnostic fistulograms, 14 fistulograms and angioplasties and 4 thrombectomies were performed via access sheaths
with an average size of 6 Fr (SD = 1.12). IV unfractionated heparin was
administered in 11 of 20 procedures. Haemostasis was achieved in
26 of 27 access sites following 15 to 20 minutes of compression using
the pneumatic compression device. One case experienced limited
bleeding from an inflow access site and was successfully treated
with reinflation of the device for a further 5 minutes. No other complication was recorded.
Conclusion: Haemostasis of arteriovenous haemodialysis fistula
access sites can be safely and effectively achieved using a pneumatic
compression device. This is a technically simple, safe and sutureless
technique for acquiring haemostasis after fistula access intervention.

Free Paper Session

Biliary intervention
607.1
Percutaneous transhepatic biliary drainage (PTBD) for
obstructive jaundice: right or left approach? external or
internal/external drain?
S.H.Hyon, J.Montagne, L.Boccalatte, M.E.Fratantoni, C.Abuawad,
V.M.Cano, P.Huespe, E.deSantibanes, J.Pekolj
Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
Purpose: Obstructive jaundice, either benign or malignant, mandates the reduction of bilirubin as the first step to further treatment.
PTBD is highly effective, and usually, a left, internal/external drain is
preferred (lower pain, no pleural insult, physiologic, further stenting,
biopsy). Here we analysed the impact of left or right as well as external or internal/external PTBD on bilirubin decrease.
Material and methods: In total, 122 patients with obstructive
hyperbilirubinemia (benign or malignant) undergoing PTBD were
divided into four groups: left-internal/external (L-INTEXT); left-external (L-EXT); right-internal/external (R-INTEXT); and right-external
(R-EXT). The total bilirubin (mg/dL) was determined at pre-drainage (D0), day 1 (D1), day-7 (D7), day-14 (D14) and treatment end (DE)
(occurring at stent placement, balloon dilation, drain exchange, surgery or death). Patients requiring more than one drain or a specific
type of drain were excluded. Data were expressed as median (range).
The ANOVA test was used for multiple comparisons between and
within groups. p<0.05 was considered significant.
Results: Bilirubin levels for L-INTEXT (n=32), L-EXT (n=44), R-INTEXT
(n=16) and R-EXT (n=30) were as follows: at D0, 10.5 (5.119.3), 12.5

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(2.219.6), 7.3 (2.317.4) and 10.9 (2.318.9); D1, 7.5 (3.616.1), 11.3
(1.917.4), 6.35 (2.212.8) and 8.9 (1.415.7); D7, 5.7 (3.311.6), 5.5 (1.6
12.0), 4.5 (110.2) and 6.5 (1.412.2); D14, 5.2 (1.78.7), 3.7 (1.38.5),
1.9 (0.84.1) and 6.2 (1.49.6) and DE, 4.7 (1.311.2), 3.4 (1.310.1), 1.0
(0.62.3) and 3.8 (1.18.3). No difference was observed between or
within groups, all reaching bilirubin levels of <5mg/dL at treatment
end, with no specific morbidity attributable to the side or type of
drain.
Conclusion: After PTBD, either a left or a right approach with an
external or internal/external drain is equally effective for decreasing
cholestatic hyperbilirubinaemia.

607.2
Bacterial isolates from biliary cultures obtained during
percutaneous biliary intervention: a multicentre review. Are
we prescribing the right antibiotics?
P.S.Najran1, F.Babatola2, J.Bell1, D.Mullan1, H.-U.Laasch1
1Radiology, The Christie Hospital NHS Foundation Trust, Manchester,
United Kingdom, 2Radiology, University Hospital North Staffordshire,
Stoke, United Kingdom
Purpose: A multicentre retrospective review of the most common
pathogens isolated from biliary cultures in patients undergoing percutaneous transhepatic intervention, and to assess antibiotic sensitivity, ensuring an optimal prophylactic antibiotic regime.
Material and methods: All percutaneous transhepatic interventions performed over a 2-year period in two separate centres were
reviewed retrospectively. Those wherein no biliary culture was
obtained were excluded. Analysis of the culture results, including
pathogens grown and antibiotic sensitivity, was performed.
Results: A total of 71 patients were included in the analysis, 58
from centre one and 13 from centre two. No pathogens were grown
in 22.2% of cultures (n=16). Among the positive cultures (n=55),
Enterococci and Pseudomonas were the most common pathogens
grown in 52.7% of cases (n=29). Vancomycin was the most sensitive antimicrobial demonstrating sensitivity in 25.4% (n=14) of positive cultures. Ciprofloxacin demonstrated a high sensitivity in 20%
(n=11) of positive cultures. Gentamycin was the fourth most sensitive antimicrobial demonstrating sensitivity in 16.4% (n=9) of positive cultures. Co-amoxiclav also demonstrated a high sensitivity in
25.4% (n=14) of positive cultures; however, there was a high number
of resistive organisms grown in 36.4% (n=20) of the samples demonstrating resistance to the antimicrobial.
Conclusion: In centre one, Gentamycin is administered prophylactically, whereas in centre two, Co-amoxiclav is the antimicrobial of
choice. This study has shown the choice of antimicrobial is variable
and ineffective; as a result a review of local protocol is required. With
no specific guidelines, the choice of an antimicrobial is dependant
on the knowledge of the likely pathogens and procedure-specific
infection risk. However, this study demonstrates not only variability
in but also the ineffective use of antibiotics.

607.3

Abstract Book
performed. It included patient factors such as the underlying primary disease, previous liver procedures, and clinical success. The
location and type of bile leak (anastomotic or non-anastomotic) and
the characteristics of the interventional procedure (number of prosthesis used, location, technical success, and patency) were evaluated. Major and minor complications were determined.
Results: Fourteen patients (11 men and 3 women) were included.
Mean follow-up was 375.5 days (range 151920 days). Bile leakage
occurred after surgery in 12 patients. One patient showed arteriobiliary fistula during the follow-up. In another patient the bile leakage
was secondary to bile duct rupture post-ERCP. A total of 23 SEMCS
were placed: 21 Fluency prosthesis (Bard) and 2 Wallflex prosthesis (Boston Scientific, Mass). Total technical success was achieved in
78.6% (n=11) patients, partial in 14.3% (n=2) patients, and the procedure was unsuccessful in 7.2% (n=1) patients. Clinical success was
achieved in 13 of 14 patients. The average primary patency of the
SEMCS was 331 days (range 151920 days). Nine patients did not
present any complications. In 4 patients, few complications were
detected.
Conclusion: Percutaneous placement of SEMCS is a safe and effective method in the treatment of benign bile leakage, with high initial
success rate and few complications.

607.4
Biodegradable biliary stents: a single-center experience in the
treatment of benign biliary strictures
Q.OrdiiCamprubi, I.Diez-Miranda, M.PerezLafuente,
C.Gonzalez-Junyent, D.HernandezMorales, C.Parra-Farias,
X.Merino-Casabiel, A.SegarraMedrano
Interventional Radiology, Hospital Universitari Vall DHebron,
Barcelona, Spain
Purpose: Benign biliary strictures represent a complication of surgical procedures that may determine an obstruction to bile flow, with
consequent stasis, infection and liver damage. The aim of the study
was to assess the efficacy and outcome of patients treated with percutaneous biliary stents for benign stenosis refractory to bilioplasty.
Material and methods: Over 18 months, between August 2014
and December 2015, 20 patients (6 women and 14 men; aged 282
years) with recurrent cholangitis owing to postsurgical biliary stenosis (12 of them post-transplant strictures) underwent percutaneous implantation of polydoxanne stent (22 stents). Technical success, outcome and complications were analysed during the followup period (mean 11.2 months).
Results: The stent was successfully deployed in 21 cases; one of the
stents was broken during balloon expansion. No immediate major
or minor complications occurred. During the follow-up, two episodes of transient cholangitis as well as an hepatic abscess and restenosis of the stricture were reported.
Conclusion: Percutaneous placement of biodegradable stent is a
new option in the treatment of benign biliary strictures; the technique is safe, effective, and avoids repeated invasive procedures. It
also highlights the good results in pediatric patients.

Treatment of benign bile leaks by placing transparietohepatic

self-expanding metal covered stents
M.Pramo1, P.Garca-Barqun1, M.Carrillo2, M.Millor1, I.Vivas1,
J.I.Bilbao1
1Radiology, Clnica Universidad de Navarra, Pamplona, Spain,
2Radiologia, Hospital Morales Meseguer, Murcia, Spain
Purpose: To analyze the experience when using percutaneous selfexpanding metal covered stents (SEMCS) in patients with benign
bile leakage.
Material and methods: A retrospective review of SEMCS placed in
the biliary tract between October 2008 and September 2015 was

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607.5
Irreversible electroporation with endoluminal balloon catheter
in perihilar region: preliminary results
T.Andraina1, J.Pnek1, D.ervinka2, I.Svobodova3, M.J.Arbet1,
J.Husty1, V.Vlek1
1Department of Radiology, University Hospital Brno, Masaryk
University, Brno, Czech Republic, 2The Faculty of Electrical Engineering
and Communication, Brno University of Technology, Brno, Czech
Republic, 3First Department of Pathological Anatomy, St. Annes
University Hospital, Masaryk University, Brno, Czech Republic
Purpose: To evaluate the safety and efficacy of endoluminal irreversible electroporation (IRE) in biliary tract performed with a balloon catheter in the perihilar region.
Material and methods: Endoluminal IRE of the common bile
duct was performed in 5 domestic swine using a balloon catheter
inserted during laparotomy. IRE catheter consists of 3 electrodes
with the length of 1 cm, attached around an inflatable balloon at
120 degrees. IRE was performed with parameters of 50-90 pulses of
1500-2000V delivered between each couple of electrodes. All swine
models were slaughtered 3 days after the procedure. Imaging study
using MRI and histopathologic follow-up was performed.
Results: The balloon insertion and IRE procedure was successful in
all porcine models. All animals survived for the designated period of
3 days. Periablation edema in hepatoduodenal ligament and adjacent liver tissue measured on postprocedural MRI ranged from 13 to
40 mm in maximum diameter, 2, 5-18, 7 ml in volumetric assessment.
No thrombosis of the portal vein was detected on MRI on days 0 and
3. The elastic membranes of the portal vein were preserved, while
endothelial cells were destroyed on histopathologic evaluation. The
volume of measured edema increased with energy delivered, in settings with 90 pulses and 2000 V (approx. 2560 V/cm), perforation
of common bile duct and hematoma of hepatoduodenal ligament
developed in two animals with the highest energy setting (2000 V,
90 pulses).
Conclusion: This preliminary study of endoluminal IRE on porcine
models demonstrates the feasibility of non-thermal ablation in the
perihilar region with a balloon catheter. Higher energy delivered
is associated with larger ablation zones but also with higher risk of
postprocedural complications.

607.6
Liver tract closure for transhepatic percutaneous interventions: presentation of the first-in-man case and initial
evaluation of the HEP-plug device
F.Sakhinia, R.Peck
Vascular Radiology, Sheffield Vascular Institute, Sheffield, United
Kingdom
Purpose: Increasing amounts of percutaneous transhepatic interventions are being performed worldwide with often serious complications, including haemorrhage and high mortality rates. Dale et
al. have shown a significant decrease in haemorrhagic complications
following dedicated liver tract closure. We present the first-in-man
case and initial clinical evaluation of the HEP-plug transhepatic tract
closure device.
Material and methods: A prospective registry was maintained for
all patients undergoing HEP-plug insertion, including the first-inman case undergoing PTC and stent insertion. Comparison was
made with previously published cohort of patients in the same institution between October 2010 and November 2012 who had no liver
tract embolisation (n=101) and off label tract embolisation using
Hunter biopsy pledgets (n=92). Mean blood Hb, haemorrhagic complications and blood transfusions following PTC were established in
all groups.

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Results: There were a total of 24 patients who underwent PTC and

stent insertion utilising 26 HEP plugs. We had a 4% technical failure
rate for deployment. There were no blood transfusions or haemorrhagic complications in the HEP-plug cohort. Comparison with the
historic cohorts revealed an improvement in the haemorrhagic complication rates (p=0.027, chi square test). Mean Hb drop was significantly improved compared to the no embolisation group (p=0.017),
and was similar compared to the Hunter group (0.1).
Conclusion: Liver tract embolisation following transhepatic procedures prevents haemorrhagic complications. The HEP-plug device is
the first dedicated liver tract closure system with an easy, simple and
intuitive mechanism for deployment. As this is a prospective ongoing registry, details of future cases will be presented at the time of
the conference.

Free Paper Session

Experimental work in IR
705.1
Large degradable starch microspheres to induce tissue
necrosis after transarterial embolization of the kidney
C.M.Sommer1, T.Mokry1, T.L.Gockner2, T.D.Do1, C.Schlett1,
P.Flechsig1, D.Gnutzmann1, B.A.Radeleff1, U.Stampfl1, P.L.Pereira3,
H.U.Kauczor4, S.Macher-Gppinger5
1Diagnostic and Interventional Radiology, University Hospital
Heidelberg, Heidelberg, Germany, 2Diagnostic and Interventional
Radiology, University Hospital Mainz, Mainz, Germany, 3Dept of
Radiology, Minimally Invasive Therapies and Nuclearmedicine,
SLK-Clinics GmbH, Ruprecht-Karls-University Heidelberg, Heilbronn,
Germany, 4Department of Radiology, German Cancer Research Centre,
Heidelberg, Germany, 5Pathology, University Hospital Mainz, Mainz,
Germany
Purpose: To analyze tissue necrosis induced by large degradable
starch microspheres after the transarterial embolization of the
kidney.
Material and methods: In eight pigs, the right kidney was embolized by applying four different types of embolic materials according
to a specific study protocol (for e.g., by applying a 2.8 F microcatheter and an embolic material volume of 0.5 ml): EmboSphere500-700,
EmboSphere700-900, L1, and HeiL2 (each used in n=2 kidneys).
L1and L2were prototypes (PharmaCept; Berlin, Germany) and comprised starch microspheres with a diameter of 800 m, but different crosslinking characteristics designed to induce tissue necrosis and embolic material resorption. Angiography was performed
before and immediately after embolization. One week later, angiography was repeated, and the animals were sacrificed. Study endpoints included tissue necrosis and embolic material resorption
determined by applying angiography and/or histopathology.
Results: All animals were treated using the study protocol without technical failures or complications. Angiography directly after
embolization identified the occlusion of segmental, interlobar,
arcuate and interlobular arteries for all study groups. Angiography
a week after embolization identified some recannalization for
EmboSphere500-700 and EmboSphere700-900 and significant
recannalization for L1and L2. Histopathology identified the following rates of tissue necrosis: 15%-22% for EmboSphere500-700, 42%48% for EmboSphere700-900, 36%-46% for L1, and 8%-15% for L2.
For EmboSphere500-700 and EmboSphere700-900, intact embolic
material in segmental and interlobar was observed. For L1 and L2,
only residual embolic material in arcuate arteries was detected.
Conclusion: Large degradable starch microspheres are able to
induce significant tissue necrosis and resorb almost completely
within a week after the transarterial embolization of the kidney.

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705.2
Development of an atrophyhypertrophy animal model after
partial liver radioembolization
M.Pramo1, J.I.Bilbao1, E.SantaMara2, A.Benito1,
M.Rodrguez-Fraile1, M.Iarrairaegui1
1Radiology, Clnica Universidad de Navarra, Pamplona, Spain,
2CIBERehd, Pamplona, Spain
Purpose: To develop liver damage and atrophyhypertrophy (A/H)
animal models after lobar RE.
Material and methods: Increasing amounts of resin microspheres
loaded with yttrium-90 (Sirtex Medical, Sydney) were delivered to
the 3-cranial lobes of 3-kg New Zealand female rabbits after portal
vein catheterization via superior mesenteric vein during laparotomy.
An attempt to use the intraarterial route failed. Injected activities of
0.3, 0.6, and 1.2 GBq aimed to deliver doses of radiation of 200, 400,
and 800 Gy, respectively, to the cranial lobes. Body weight and liver
function tests were obtained after RE, liver volumes were measured
before RE and at sacrifice based on a CT scan, and liver weight was
recorded at sacrifice.
Results: Sparing of the caudal lobe was confirmed in 4 animals using
decayed, fluorine18-labeled microspheres based on a micro-PET
scan. No A/H was observed in 5 animals. Five animals that received
1.2 GBq died after RE before CT. Five animals that received 0.6 GBq
developed weight loss by week 2, and A/H (median increase in caudal lobe volume 35%) was observed. Four animals that received 0.3
GBq showed mild weight loss and A/H (median increase in caudal
lobe volume 300%). Gastric ulcers were observed in 4/5 animals of
the 0.6 GBq group and 0/4 animals of the 0.3 GBq group.
Conclusion: Selective portal vein injection of 0.3 GBq of microspheres loaded with yttrium-90 to the cranial lobes of rabbits consistently induces liver damage and A/H that resembles the observations in humans. Although A/H was observed in animals of the 0.6
GBq group, severe complications were detected.

705.3
In vivo realtime interventional MR elastography (MRE) and
thermometry (MRT) during percutaneous thermal ablation of
liver: a proof of concept
P.P.Rao1, N.Corbin1, J.Vappou2, B.Elodie1, B.Wach1,
M.DeMathelin1, A.Gangi2
1Division of Robotics and Department of Interventional Radiology,
ICube Laboratory and University Hospital of Strasbourg, Strasbourg,
France, 2Interventional Radiology, University Hospital of Strasbourg,
Strasbourg, France
Purpose: To demonstrate the feasibility of monitoring thermal ablations realtime in vivo using interventional MRE and MRT.
Material and methods: Percutaneous laser ablations were performed on two male swine livers under general anesthesia and
MR guidance. Laser ablation was performed using a DIOMED25
laser device with 4 simultaneously firing non-cooled fibres and a
2-cm active tip at 12 watts of power over 10 minutes. Ablation was
monitored using realtime MRE and MRT under respiratory gating.
Mechanical waves were generated using a vibrating needle driver. A
fast and interactive spoiled gradient-echo MRE pulse sequence was
used. Elasticity maps were reconstructed realtime using an online
local frequency estimation (LFE)-based algorithm. MRE parameters
were excitation frequency 60 Hz, encoding frequency 90 Hz, acquisition matrix 102128, GRAPPA 2, motion-encoding gradient amplitude 20 mT/m, TE/TR 9.34/16.67 ms, flip angle 13, motion encoded
through slice, and one slice orthogonal to the needle MRE driver.
Acquisition was performed for 2.76 s per respiratory cycle corresponding to two MRE images.

Abstract Book
Results: An increase in the shear modulus was observed in regions
corresponding to ablation zones, from baseline of 2 Kpa4 Kpa (SD
+/-5%), and a rise of temperature to 60 was measured with MRT in
these zones. The change in the shear modulus was sustained in the
post ablation period with a fall in temperature once the ablation was
stopped. Surgical specimens confirmed the findings.
Conclusion: In vivo interventional MRE and MRT are safe and feasible and accurately depict tissue changes realtime during ablation.

705.4
A novel radiopaque and colored PEG microsphere for
embolization and chemoembolization
E.Servais1, L.Moine2, A.Beilvert1, L.Bdouet1, D.Labarre2,
A.Laurent3
1R&D, Occlugel, Jouy-en-Josas, France, 2LabEx LERMIT, CNRS UMR 8612,
Institut Galien Paris-Sud, Chtenay-Malabry, France, 3Interventional
Neuroradiology, APHP Hopital Lariboisire, Paris, France
Purpose: PEG hydrogels are commonly used as biocompatible
implants. Our objective was to synthesize microspheres from a nonresorbable hydrogel of PEG combined with various co-monomers to
control softness, drug loadability, and X-ray detectability.
Material and methods: A PEG hydrogel was used as a hydrophilic
matrix in which we grafted covalently a coloring monomer and an
iodinated monomer. Beads of different size ranges (1001200 m)
were synthesized by an emulsion process and sieved before sterilization by autoclaving. Beads deliverability was assessed in various
catheters (ID 490, 560, 700 m). Beads in agarose gels were imaged
using CBCT (Discovery 730 GE), and their radiopacity was compared to different contrast medium solutions. Cellular toxicity was
analyzed during 1 week of co-culture with L929 cell line fibroblasts
according to ISO/EN 10993-5 standard.
Results: Obtained colored radiopaque beads (100300, 500700,
700900, and 900 m) were not altered by autoclaving. Beads (containing 85% of water) were suspended in contrast medium/saline
mixture and were easily delivered through catheters (30% compressibility), with no aggregates, shape deformation, or breakage.
Beads were visible by X-ray and micro-CT imaging. Cell culture for 1
week showed an absence of cytotoxicity. Doxorubicin loading (37.5
mg/mL) on 100300-m beads was achieved in 30 min. The drug
release was gradual (20% in 1 h) and sustained during several days
(50% at day 7).
Conclusion: Soft, purple-colored, and radiopaque beads of various
size ranges were successfully made from PEG hydrogel. They were
injectable, X-ray detectable, loadable, and devoid of cytotoxicity.

705.5
First in vivo evaluation of the tissue-engineered BioStent
S.Ichihashi1, L.Rongen1, A.H.Mahnken2, T.Schmitz-Rode1,
P.Mela1, S.Jockenhoevel1
1Applied Medical Engineering, Helmholtz Institute, RWTH Aachen
University, Aachen, Germany, 2Department of Diagnostic and
Interventional Radiology, University Hospital Marburg, Philipps
University of Marburg, Marburg, Germany
Purpose: Despite a widespread use of endovascular treatment for
atherosclerotic diseases, in-stent restenosis and thrombosis remain
serious complications. We hypothesized that a stent covered with
a viable engineered tissue lined with a complete endothelial layer
should overcome in-stent restenosis by preventing ingrowth of
smooth muscle cells (SMCs) and thrombosis by providing a hemocompatible luminal surface. Based on this assumption, we developed the BioStent concept. In this first animal study, we implanted
the BioStent in the ovine carotid artery and evaluated its patency
and remodelling process.

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Material and methods: BioStents were fabricated by embedding
warp-knitted self-expanding nitinol stents within a thin fibrin layer
containing vascular SMCs. They were cultivated in a bioreactor for
two weeks under pulsatile flow and physiological pressure conditions, subsequently endothelialized and cultivated for another
week. Five BioStents were implanted for three months in the carotid
artery of adult sheep from which the SMCs and ECs had been isolated. The primary patency rate was evaluated by ultrasonography
every two weeks and angiography before explantation.
Results: Four of the five BioStents remained patent until explantation. Histology and immunohistochemistry of the explanted stents
showed tissue remodelling, with the fibrin matrix being replaced
by neotissue mainly consisting of collagen. A complete endothelial
layer was present on the luminal surface.
Conclusion: The viable BioStents demonstrated a favorable biological and functional performance. However, the failure case shows
the need for improvement of the technical stent-component with
regard to a better shaping of the terminal struts and thus their continuity with the arterial wall.

705.6
Systemic hypotension following intravenous administration
of non-ionic contrast medium during computed tomographyguided interventions: a randomized, placebo-controlled,
double-blinded phase IV clinical trial
G.Widmann1, R.Bale1, H.Ulmer2, D.Putzer1, P.Schullian1,
F.Wiedermann3, W.Lederer3
1Department of Radiology, Medical University of Innsbruck, Innsbruck,
Austria, 2Department of Medical Statistics, Informatics and Health
Economics, Medical University of Innsbruck, Innsbruck, Austria,
3Department of Anaesthesiology, Medical University of Innsbruck,
Innsbruck, Austria
Purpose: Use of intravenous contrast medium (CM) during computed tomography (CT) imaging may perturb tissue microcirculation and may even cause ischemia resulting from diminished arterial
blood pressure. The objectives of this controlled, double-blinded,
prospective, randomized phase IV clinical trial were to compare isoosmolar (IOCM) to low-osmolar non-ionic contrast medium (LOCM)
in their effects on systemic blood pressure in patients undergoing
CT-guided radiofrequency ablation of liver tumors.
Material and methods: Forty consecutive patients were randomly
assigned to either administration of LOCM (iopromide) or IOCM
(iodixanol) for the planning and post-interventional CT. As a placebo, normal saline solution (NSS) was administered during the
native needle control CT. Changes in systemic blood pressure, heart
rate, and peripheral oxygen saturation before and after intravenous
administration of either IOCM or LOCM and potential differences to
NSS were calculated. Per-hour urine output after IOCM and LOCM
was recorded. Analysis of variance for repeated measurements
together with t-testing and/or non-parametric testing was applied
for significance testing of the study endpoints ( = 0.05).
Results: Administration of CM resulted in dynamic changes of blood
pressures. LOCM resulted in systemic hypotension with mean systolic/diastolic drops of 31/26 mmHg. In contrast, IOCM only produced minimal mean changes for the lowest values of 2/0 mmHg,
similar to 3/2 mmHg after NSS. Compared with IOCM, LOCM showed
a significantly higher increase in heart rate and a 2-fold higher perhour urine output.
Conclusion: In contrast to LOCM, IOCM does not produce systemic
hypotension and may be recommended for patients in whom systemic hypotension may pose a clinical risk.

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All about veins
706.1
Clinical outcomes following percutaneous cyanoacrylate
embolisation (using VenaSeal) in treating venous disease of
the legs
K.James, S.Porcherot, S.Ray
Vascular Surgery, Kingston Hospital, Kingston, United Kingdom
Purpose: Embolisation of the saphenous vein using a cyanoacrylate
(VenaSeal) is a non-thermal endovenous technique for treating varicose veins. In this study, we examined the merits of this new procedure with particular reference to an established thermal treatment.
Material and methods: Cyanoacrylate (CA) was used to treat 51
patients (61 saphenous veins) with symptomatic venous disease,
and the treatment was compared to a cohort of 50 patients undergoing thermal radiofrequency ablation (RFA) with anaesthetic infiltration. Specific indications for CA included proximity of the treatment zone to nerve or skin, bleeding tendency, inability to wear
stockings, anaesthetic sensitivity and needle phobia. Pain scores
and procedure duration were compared, and the CA group had
duplex assessment after 6 months.
Results: Twenty one (40%) patients in the CA group had contraindications to thermal treatment, whilst 30 requested the procedure. The CA procedures took longer to perform than RFA (median
48 min vs. 34 min, p<0.01) but intra-operative pain scores were less
(p<0.01). Following CA, the venous clinical severity score improved
by a median of 3 (p<0.01), and only one patient required further
intervention. Fifty nine (97%) of the 61 saphenous veins treated by
CA remained successfully embolised 6 months later. The 2 veins with
residual reflux had a diameter in excess of 10 mm compared to a
group median of 7 mm.
Conclusion: Embolisation by CA is an effective method for treating
varicose veins. It takes longer to perform than radiofrequency but is
less painful. In total, 40% of our cohort were more suitable for CA
than thermal RFA, but veins with a larger diameter may require a
higher dose to achieve optimal closure.

706.2
Novel biomatrix sclerofoam compared to endovenous laser:
initial results and 1-year follow-up
J.C.Ragg
Interventional Radiology, Angioclinic Vein Centers, Berlin, Germany
Purpose: Common sclerofoams frequently fail in large veins. A novel
viscous microfoam using a biomatrix based on denatured autologous blood with an in vitro half life of >60 min and fast disintegration within flowing blood was evaluated in the GSV using a safety
setting to prevent foam migration via the junction.
Material and methods: In total, 120 patients (78 females, 42 males,
3281 years) with GSV insufficiency, 624 mm (mean: 10.3 mm),
were randomized to (A) a combination of endovenous laser (EVL 810
nm, ball tip; junction + segment below, length 320 cm) and a novel
biomatrix sclerofoam (BSF) using 1% aethoxysklerol for the adjacent
GSV segment (2835 cm, n = 60) or (B) EVL alone, treated segment
length 3855 cm (n = 60). BSF was deployed in case of proven proximal closure during catheter withdrawal. Follow-up examinations
were performed after 2 weeks and 2, 6, and 12 months.
Results: Initial vein occlusion was observed in all cases (120/120).
There were no adverse events, in particular, no thoracic or cerebral
symptoms in patients receiving BSF. The patterns of echogenicity
were similar in both groups. Vein regression was the same for EVL

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and BSF (+/5%). During 1-year follow-up, the thigh-to-knee segments showed reperfusion in 5/60 cases (8.33%) after BSF and in
6/60 cases (10%) after EVL alone.
Conclusion: Apart from the GSV junction segment, BSF seems to
provide a similar quality of vein occlusion, like gold standard EVL.
BSF is more convenient because no tumescence is required.

706.3
Adrenal venous sampling in primary aldosteronism:
comparison of contralateral suppression index and
multinomial regression modelling to detect lateralization
of aldosterone hypersecretion when the right adrenal vein
sampling is missing
F.Perrault1, G.Soulez1, M.Chagnon2, P.Gilbert1, M.-F.Giroux3,
P.Perreault1, L.Bouchard1, V.L.Oliva3, I.Bourdeau4, A.Lacroix4,
E.Therasse1
1Dept. Radiology, Radio-oncology and Nuclear Medicine, University
of Montreal, Montreal, QC, Canada, 2Mathematics and Statistics,
University of Montreal, Montreal, QC, Canada, 3Radiology, CHUMNotre Dame, University of Montral, Montreal, QC, Canada, 4Dept. of
Medicine, University of Montreal, Montreal, QC, Canada
Purpose: To compare multinomial regression modelling (MRM) and
contralateral suppression index (CSI) accuracy to detect the lateralization of aldosterone secretion (LAS) when the right adrenal vein
sampling (AVS) is missing.
Material and methods: All consecutive AVS from December 1989
to September 2015 were included. Non selective AVS and AVS with
missing data were excluded. Cortisol and aldosterone levels were
measured from the adrenal and left iliac veins before (basal) and
after intravenous cosyntropin injection. Reference standards for LAS
were an adrenal vein aldosterone/cortisol ratio (A/C)>2 the opposite
side for basal AVS and >4 after cosyntropin. LAS detection accuracy
was assessed with receiver operating characteristic (ROC) curves
and sensitivities were compared with a specificity set at 95%.
Results: AVSs of 174/197 (88%) patients (53 women, 121 men; mean
age 53 years) met the inclusion/exclusion criteria. MRM and CSI areas
under the ROC curves (AUC) were 0.931 and 0.923, respectively, for
right LAS (p=0.21) and 0.922 and 0.895, respectively, for left LAS
(p=0.020) for basal AVS. After cosyntropin, MRM and CSI AUC were
0.964 and 0.958, respectively, for right LAS (p=0.66) and 0.955 and
0.875 for left LAS, respectively (p<0.001). Sensitivities of MRM and
CSI were both 75% (p=1.00) for right LAS and 55.7% and 42.9%,
respectively, for left LAS (p=0.004) for basal AVS. After cosyntropin,
sensitivities of MRM and CSI were 73.3% and 68.9%, respectively, for
right LAS (p=0.73) and 72.6% and 32.3%, respectively, for left LAS
(p<0,001).
Conclusion: MRM has a better accuracy than CSI to detect LAS when
right AVS is missing.

706.4
Results from VIVO-EU, a prospective study of the Zilver Vena
venous stent in the treatment of symptomatic iliofemoral
venous outflow obstruction: on behalf of the VIVO-EU
investigators
G.J.OSullivan1, J.A.McCann-Brown2
1Interventional Radiology, U.C.H. Galway, Galway, Ireland,
2Incorporated, Cook Research, West Lafayette, IN, United States of
America

Abstract Book
symptomatic iliofemoral venous outflow obstruction. Among the
enrolled patients affected by deep vein thrombosis (DVT), 50%
(11/22) had chronic DVT, 41% (9/22) had acute DVT, and 9% (2/22)
had acute on chronic DVT. Depending on their underlying medical
condition, patients were able to undergo thrombolysis, thrombectomy, and/or IVC filter placement prior to stent placement. Patient
follow-up was conducted at 12 months and included ultrasound
examination. Study assessments included procedure success measures, adverse events, clinical symptoms of venous insufficiency, and
reinterventions. Final follow-up is anticipated in August 2016.
Results: Treated lesions were predominantly on the left side (n=33
patients; 94.3%). Based on site-reported data, stent placement
resulted in a greater than two-fold diameter improvement immediately postprocedure. Major adverse events reported to date include
one patient with a symptomatic pulmonary embolism 1 day postprocedure and one patient with a clinically-driven reintervention
for occlusion of the study lesion 155 days postprocedure. Based on
available data, clinical symptoms improved after stent placement, as
measured by VDS, CIVIQ, and VCSS.
Conclusion: The VIVO-EU study is currently completing follow-up,
with the goal of evaluating the Zilver Vena venous stent in patients
with symptomatic iliofemoral venous outflow obstruction. Data to
date has demonstrated a low complication rate and clinical improvement following stent placement.

706.5
Alginate-foam-combined dressing application in hemostasis
after central venous catheter insertion in the intervention
room
S.-Y.Chun, J.H.Shin
Radiology, Asan Medical Center, Seoul, Korea
Purpose: To evaluate the effectiveness of oozing-reducing dressing
in decreasing infection rates in patients undergoing central venous
catheter (CVC) placement in the intervention room.
Material and methods: From May 2014 to October 2015, 50 patients
(mean age: 54.2 years) who underwent liver transplantation and CVC
placement were randomly assigned into the test group (20 patients)
and the control group (30 patients) according to the dressing materials. As alginate has an innate hemostatic property and foam inflates
to exert compression when it absorbs water, they were combined
and used for the test group. Conventional gauze of the same size
was used for dressing in the control group. Immediately after CVC
placement, dressing was performed in both groups. When blood
oozed out of the CVC insertion site or the dressing was removed, the
dressing was changed. The first dressing change time, CVC placement period, and insertion site infection were investigated.
Results: The mean time interval between the initial dressing and
the first dressing change was 32.05 hours in the test (AlginateFoam
dressing) group and 21.35 hours in the control group. The result
showed that the changing frequency in the test group was obviously lesser than that in the control group. CVC-related local infection occurred in 1 patient in the test group and 3 in the control
group.
Conclusion: Alginatefoam dressing is an effective way to prevent
bleeding and reduce CVC-related infections by avoiding the need
for frequent dressing. Thus, it seems that the re-intervention rate
due to CVC-related infection may be decreased using the alginatefoam dressing.

Purpose: To evaluate the performance of the Zilver Vena venous

stent in the treatment of symptomatic iliofemoral venous outflow
obstruction.
Material and methods: This prospective, multicenter study
enrolled 35 patients (77% female; mean age of 4516 years) with

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706.6
Variables associated with reduced radiation exposure, cost,
and technical difficulty of IVC filter placement and retrieval
M.Neill, H.W.Charles, S.Kovacs, E.Aaltonen, A.R.Deipolyi
Radiology, Division of Vascular and Interventional Radiology, NYU
Langone Medical Center, New York, NY, United States of America
Purpose: Delineate sources of increased radiation during, cost of,
and difficult retrieval after IVC filter (IVCF) placement.
Material and methods: All 299 IVCFs (8/201312/2014) were identified by PACS search, 252 placed in a fluoroscopy suite (FS) and 47
in the operating room (OR), and reviewed for radiation exposure,
fluoroscopy time, filter type, and angulation. Filter removals were
assessed for the number of retrieval devices needed and fluoroscopy time.
Results: Multiple linear regressions revealed that jugular versus femoral access and filter type had no impact on radiation exposure.
However, filters placed in the OR entailed more radiation than in the
FS (156.3 vs 71.4 mGy; p=0.001), longer fluoroscopy time (6.1 vs 2.8
min; p<0.0001), and resulted in greater filter angulation (4.8 vs 2.6;
p<0.0001). Filter angulation was primarily dependent on the filter
type (p=0.02), with the Venatech and Denali filters associated with
decreased angulation (2.2 and 2.4, respectively), and the Option,
Celect, and Meridian filters associated with greater angulation (4.2,
4.6, 4.7, respectively). There was a 32% retrieval rate. Filter angulation, but not filter type or filtration duration, independently predicted cases requiring more >1 retrieval device (p=0.0008) and >30
min fluoroscopy time (p=0.02). Cost savings for IVCF placement in
the FS versus OR were estimated at $444.50/case.
Conclusion: Increased radiation and cost were associated with
placement in the OR, compared to the FS. Filter angulation was the
primary determinant of difficulty in removing filters, while angulation was determined by filter type. Performing IVCF placement
in the FS using specific filters may reduce radiation and cost, while
enabling subsequent ease of retrieval.

Free Paper Session

Prostate embolisation and IRE
707.1
Prostatic artery embolisation for benign prostatic hyperplasia:
anatomical factors affecting the procedure performance
A.Cannavale1, B.Maher2, T.J.Bryant2, M.Santoni3, N.Hacking2
1Department of Radiology, East Kent Hospitals University NHS
Foundation Trust, Canterbury, United Kingdom, 2Department of
Clinical Radiology, University Hospitals Southampton, Southampton,
United Kingdom, 3Department of Radiological Sciences, Sapienza
University of Rome, Rome, Italy
Purpose: To investigate any procedural/anatomical factors that may
affect the technical outcome of prostatic artery embolisation (PAE).
Material and methods: We performed a retrospective review of
55 patients (110 pelvic sides) who underwent PAE from June 2012
to December 2014. All selected patients underwent complete urological assessment. The following characteristics, detected on CTA,
were recorded on a diagrammatic template: prostate volume, grade
of vascular ectasia, calcification (mild, moderate and severe), presence of common gluteal trunk (CGT), gluteal-pudendal trunk (GPT),
replaced obturator artery (rOb) and number of prostatic arteries
(PrA), including origin, degree of origin/proximal tract PrA tortuosity and presence of connections with nearby visceral arteries. Uni/
multivariate analysis was used to relate the anatomical factors with
the technical success, procedure time, fluoroscopy time and radiation dose.

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Results: According to the univariate/multivariate analysis, severe

arterial ectasia and calcified atheroma did not affect technical success (p=0.5). Calcified atheroma hindered the cannulation of the left
PrA in 12.5% cases. The presence of CGT, GPT or rOb did not prove to
be a significant adverse anatomical factor. Presence of the tortuous
pattern of PrA demonstrated a reduced technical success of 84.7%
(7/46 sides failed) compared with the presence of the straight pattern of PrA (7/46 sides failed, technical success 84.7% vs. 3/64 sides
failed, 95.3%; p=0.058). Procedure and fluoroscopy time was signficantly higher in tortuous PrA. Anastomotic vessels did not affect the
technical success (p=0.921) but increased the use of Dyna-CT.
Conclusion: Anatomical factors that can affect the perfomance of
the procedure include severe aortoiliac atherosclerotic disease, tortuous PrA and presence of anastomotic vessels.

707.2
Clinical results after prostatic artery embolization (PAE): a
single-center study of 68 patients
G.Amouyal1, O.Pellerin2, N.Thiounn3, C.DelGiudice4, C.Dan2,
M.R.Sapoval5
1Interventional Radiology, Hpitaux de Paris, Hpital Europen
Georges Pompidou, Paris, France, 2Interventional Radiology, Hpital
Europen Georges Pompidou, Paris, France, 3Service dUrologie, Hpital
Europen Georges Pompidou, Paris, France, 4Vascular and Oncological
Interventional Radiology, Hpital Europen Georges Pompidou,
Universit Paris Descartes, Paris, France, 5Dept. of Cardiovascular
Radiology, Hpital Europen Georges Pompidou, Paris, France
Purpose: To report the clinical results of 68 consecutive patients
treated by PAE for symptomatic BPH using the PErFecTED technique.
Material and methods: This is a monocentric experience of 68 consecutive patients (mean age 64 years) with lower urinary tract symptoms (LUTS) or acute urinary retention (AUR) due to BPH, treated by
PAE between 12/2013 and 11/2015.
Inclusion criteria: male patients with IPSS>8 and/or QoL>3 or AUR
with failure of Foley catheter retrieval, referred for PAE because of
refusal or contraindication to surgery.
Exclusion criteria: prostate volume<40 mL, LUTS not related to BPH,
urinary infection, complicated BPH, prostate cancer.
We used the PErFecTED technique with hyper-selective flowdirected injection of diluted 300500 m Embosphere (Merit medical) into the prostatic artery.
Technical success: defined as at least unilateral embolization.
Clinical success: defined according to IPSS (25% or 8-point
decrease) and/or QoL (<4 or 1-point reduction) and/or Qmax (>7.5
mL/sec or 25%) or Foley retrieval.
Results: Technical success: 100% (68/68). Overall clinical success:
81% (55/68); 13 patients showed no clinical benefit at 12 months, and
6/7 patients had Foley retrieval at day 15.
IPPS (pre versus post); QoL and prostatic volume were 177.6 vs,
76.4 (p<0.001), 5.71.4 vs. 2.41.7 (p<0.001) and 9037 vs. 6326 mL
(p<0.001). The mean Q max was 9.74.5 (pre) vs. 16.17.1 (post) mL/
sec (p= 0.003).
No retrograde ejaculation or erectile dysfunction was observed, and
there was no case of vesical or rectal necrosis.
Conclusion: PAE is a safe and efficient treatment for LUTS and AUR
due to BPH.

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707.3
First experiences of prostatic artery embolization for large,
benign prostatic hyperplasia ahead of a randomized controlled
trial
A.Massmann1, M.Saar2, G.K.Schneider1, M.Stckle2, S.Siemer2,
C.Niklas2, A.Buecker1
1Diagnostic & Interventional Radiology, Saarland University Medical
Center, Homburg, Germany, 2Urology, Saarland University Medical
Center, Homburg, Germany
Purpose: To evaluate prostatic artery embolization (PAE) for large,
benign prostatic hyperplasia (BPH).
Material and methods: Eight patients [mean age 75.86.4 (range
6888) years] with symptomatic BPH and prostate volume (PV) >80
ml refractory to oral medication (n=2; 25%) or urinary retention (n=6;
75%) were scheduled for PAE. Pre- and post-procedural International
Prostate Symptom Score (IPSS), quality-of-life (QoL), uroflow (Qmax),
post-void residual volume (PVRV), prostate-specific antigen (PSA), PV
by transrectal ultrasound (TRUS), and contrast-enhanced dynamic
MRI were obtained. Selective embolization was performed with a
2-French micro-catheter and calibrated 100 m microspheres until
stasis was achieved in the prostatic artery. Procedure-associated
adverse events were recorded.
Results: PAE was performed in all patients (bilateral n=6; unilateral n=2). Procedure- and fluoroscopy times were 15892 and 8121
min, respectively. Further, 8032 ml of iodinated contrast agent was
used without impacting renal function. In 4 (50%) patients, protective selective coil-embolization was necessary to avoid penile/perineal non-target embolization. After 1 month, urinary retention completely resolved in all 6 afflicted patients. After 3 months, all patients
showed markedly improved target values: PV 14849 to 9236
ml (-456%) (p=0.0218); PSA 10.15.2 to 5.23.1 ng/ml (-5925%)
(p=0.0227); PVRV 192108 to 6744 ml; IPSS 258 to 113; QoL 51
to 11; Qmax 81 to 145 ml/s. Lack of perfusion with subsequent
necrosis in >50% of the prostate predicted clinically successful
embolization. No PAE-related complications occurred.
Conclusion: PAE proved to be beneficial as a safe and effective treatment for large BPH. Promising results are validated in an ongoing
prospective, randomized controlled trial (PIEMONTE study; www.
germanctr.de #31052015) comparing PAE and urologic transvesical
adenomectomy.

707.4
Prostate cancer treatment with irreversible electroporation
(IRE): efficacy and safety in 300 patients over 5 years
M.Stehling1, N.Klein1, E.Guenther1, S.Zapf1, R.ElIdrissi1,
B.Rubinsky2
1Prostate Center, Institut fr bildgebende Diagnostik, Offenbach am
Main, Germany, 2Department of Mechanical Engineering, University of
California Berkeley, Berkeley, CA, United States of America
Purpose: Irreversible electroporation (IRE) is a novel tissue ablation
modality which selectively destroys cells whilst preserving non-cellular tissue. It has low toxicity on critical anatomical structures and
may thus be an ideal therapy for prostate cancer (PCa), since it has
the potential to avoid side effects of surgical/radiation treatment of
PCa such as impotence, incontinence and rectal damage. IRE may be
suitable for the treatment of recurrent and advanced PCa.
Material and methods: Three hundred patients with T1T4 and
recurrent PCa were treated with IRE within 5 years. All treatments
were based on mp-MRI, while in 136 patients, additional transperineal 3D biopsy was performed. Treatment was under general anaesthesia and deep muscle relaxation. Probe placement was by means
of transrectal ultrasound guidance. All patients had follow-up MRI
24 hours post-treatment and further follow-up was by MRI and PSA
testing at 3, 6 and 12 months and then annually.

Abstract Book
Results: Initial ablation of cancerous tissue was successful in all
patients. We report recurrent disease in 5% of all cases during follow-up. No life-threatening and 4 medically significant adverse
events occurred. Potency was transiently reduced in 15.2% and persistently reduced in 8.4% of surveyed patients. Continence was preserved in all cases.
Conclusion: Treatment of PCa with IRE is efficacious and safe. We
report an impotence rate of 15% and zero incontinence. IRE is suitable for PCa recurrences after any previous treatment. MRI is a powerful tool for diagnosis and follow-up, but should be combined
with 3D biopsy for optimal treatment planning. IRE has potential to
become the new standard of care in the treatment of PCa.

707.5
UK-ROPE: preliminary findings
S.Modi1, T.J.Bryant1, A.F.Ray2, N.Hacking1
1Department of Clinical Radiology, University Hospitals Southampton,
Southampton, United Kingdom, 2Cedar/Department of Engineering,
Cardiff University, Cardiff, United Kingdom
Purpose: The UK-Registry of Prostate Embolisation (ROPE) is a study
to analyse data collected in a register on the efficacy and safety of
prostate artery embolisation (PAE) for lower urinary tract symptoms
(LUTS) secondary to benign prostatic enlargement. We aim to present the preliminary findings of UK-ROPE.
Material and methods: Data on all consecutive patients receiving PAE, transurethral resection of prostate (TURP) or holmium
laser prostatectomy (HoLEP) in sites taking part in the study over 19
months (July 2014February 2016) was reviewed from the Dendrite
online database.
Results: To date, 316 patients have been recruited in the study,
out of which 216 (68%) have received PAE. Recruitment of surgical patients has been slower with 87 (28%) having undergone
TURP; of which 47 (54%) underwent monopolar TURP and 40 (46%)
underwent bipolar TURP. Thirteen (4%) patients were treated with
HoLEP. Patients were treated across 17 UK sites. The age range of
the patients was 4686 years (67.67.6). Prostate volume range was
38330 ml (101 56) and was measured by CT (51%), MRI (39%), TRUS
(8%) and US (2%). All patients had symptomatic outflow obstruction
with reduced Qmax 231 (10.4 8.8). Baseline International Prostate
Symptom Scores (IPSS) range was 535 (21.2 6.9). Patients undergoing PAE had minor procedural complications, including local dissection in 4 (1.9%) and groin haematoma in 4 (1.9%). Major complications included penile ulcer in 2 (1%), which resolved after 46 weeks.
Conclusion: Recruitment for UK-ROPE has taken longer than
expected, but we are now close to the completion of the study.
Initial data relating to complications of PAE appear satisfactory with
no longstanding major complications. We await the efficacy data in
the next few months.

707.6
Prostatic artery embolization (PAE) in patients with
spinal injury to reduce the prostatic volume and facilitate
intermittent catheterization: a new indication?
A.G.Rampoldi1, F.Barbosa1, S.Secco2, C.Migliorisi1, R.Vercelli1,
M.Solcia1, A.Galfano2, A.Bocciardi2, M.Spinelli3
1Interventional Radiology, Ospedale Niguarda, Milan, Italy, 2Urology,
Ospedale Niguarda, Milan, Italy, 3Spinal Unit, Ospedale Niguarda,
Milan, Italy
Purpose: Intermittent catheterization is a safe and effective method
of completely emptying the bladder, specially in patients with spinal
injury. The catheterization can be difficult in the presence of benign
prostatic hyperplasia. The purpose of this study was to assess the
role of PAE in patients with spinal injury.

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Material and methods: Three patients from a spinal unit after a
urological evaluation were referred to PAE. The procedure was
performed under local anesthesia with superselective catheterization of the prostatic arteries according to the PErFecTED technique described by Carnevale, with 300500 m Embosphere
Microspheres. The pre- and post-PAE prostatic volumes were
assessed with ultrasound evaluation by the same operator.
Results: Patient 1: 80 years old with paraplegia due to spinal cord
compression by a cavernous angioma. Patient 2: 72 years old with
post-traumatic C4 tetraplegia. Patient 3: 88 years old with post-traumatic C7 tetraplegia. The mean prostate size reduction was 77%
(Patient 1: 41 ml pre-PAE versus 10 ml post-PAE, Patient 2: 42 ml versus 8 ml; Patient 3: 105 ml versus 26 ml). No pre- and post-procedural
complications were present.
Conclusion: The intermittent catheterization procedure in these
patients was facilitated after PAE. Surprisingly, in these three
patients with spinal injury, the mean prostatic size reduction was
higher than expected (77%). We hypothesized that the lack of neurogenic control is responsible of the higher reduction of prostate
volume after PAE.

Free Paper Session

Imaging
708.1
Extravascular incidental malignant findings in follow-up CT
angiograms in patients post-endovascular aneurysm repair
P.S.Dhillon, M.W.Butt, J.E.Kirk, G.Pollock, P.M.Bungay, C.Squirrell,
M.DeNunzio, P.D.Thurley
Clinical Radiology, Derby Teaching Hospitals NHS Foundation Trust,
Derby, United Kingdom
Purpose: To evaluate the incidence and clinical relevance of extravascular incidental findings (EVIF), particularly malignancies, in follow-up CT angiograms (CTA) of the abdominal aorta in patients who
underwent endovascular aneurysm repair (EVAR) of an abdominal
aortic aneurysm.
Material and methods: This was a retrospective study of 2199 planning and follow-up CTAs of 418 patients who underwent EVAR in
a single tertiary centre between 2006 and 2015. CTA reports were
scrutinized for EVIFs, which were classified according to clinical relevance into significant and non-significant findings. Clinical follow-up
and management were reviewed for significant findings. Follow-up
CTAs of patients with incidental malignancies were re-reviewed by a
consultant radiologist, and early missed malignant findings on previous CTAs were identified.
Results: In total, 934 EVIFs were noted in 418 patients [31 females
(7.4%), 387 males (92.6%); age range 63-93, mean age 78.5 years].
Incidental malignant findings were reported in 46 patients (11.0%),
of which 21 were noted on the initial CTA (5.0%) and 25 on follow-up
CTAs (5.9%). Overall, 14 of 25 patients had early malignant findings
missed or misinterpreted on previous CTAs, while in 11 of 25, there
was no significant abnormality even on retrospective review.
Conclusion: A high number of EVIFs, particularly incidental malignancies, can be identified in follow-up CTAs of patients who
undergo EVAR. Hence, it is prudent to be vigilant in evaluation of
abdominal CTAs and necessary clinical follow-up arranged. Specific
review areas when reporting surveillance CTAs can be recommended on the basis of the findings of our study.

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708.2
Profile of secondary interventions and triggering surveillance
imaging after EVAR
I.N.Roy, S.R.Vallabhaneni
Royal Liverpool Hospital, Liverpool Vascular & Endovascular Service,
Liverpool, United Kingdom
Purpose: To examine secondary intervention (SI) rates, indications
and imaging modality leading to SI in EVARs implanted after 2008 at
one institution.
Material and methods: In total, 638 patients underwent EVAR
between 2008 and 2015, with a median follow-up of 34 months (IQR
1650). Bi-planar radiography and duplex ultrasound imaging were
performed at 1 month and annually thereafter. CT was performed
at 1 month only. In total, 130 patients (24%) died during followup, leaving a total of 1,382 patient years of completed surveillance,
with a 93% compliance rate. SIs performed during this period were
analysed.
Results: In total, 79 patients (14%) underwent 110 SIs: 95 were
planned procedures, 8 of which were triggered by symptomatic
presentation, while the remaining 87 were triggered by surveillance imaging (9 did have symptoms but failed to self-present). The
remaining 15 SIs were emergencies or complications of other SIs.
SIs were as follows:
1) 47% flow related: limb stenosis or component occlusion
2) 40% endoleak or rupture
3) 8% disease progression; effacement of seal (3%), proximal migration (3%), limb migration (2%)
4) 4% Late complication of femoral access
5) 1% stent-graft infection
The primary surveillance modality that triggered SIs was plain X-ray
in 8 (9%), CT in 24(28%) and duplex sonography in 65 (75%) patients.
In 20 (23%) patients, the complication was detected on two modalities simultaneously.
Conclusion: Surveillance remains important despite a change in
the profile of complications and SI. It is possible to achieve excellent compliance with surveillance. The value of plain radiography
is evident from this analysis. Surveillance primarily based on duplex
sonography can be effective.

708.3
Diagnostic performance of iodine quantification in
distinguishing benign from neoplastic portal vein thrombosis
on dual-energy CT in patients with hepatocellular carcinoma
C.Sofia, S.Silipigni, M.A.Marino, G.Ascenti
Department of Radiological Sciences, University Hospital Gaetano
Martino, Messina, Italy
Purpose: To establish the diagnostic accuracy of iodine quantification in distinguishing benign from neoplastic portal vein thrombosis
on dual-energy CT in patients with hepatocellular carcinoma.
Material and methods: In 28 patients (22 men, 6 women; mean age,
62 years) with hepatocellular carcinoma and portal vein thrombosis (bland, n = 21; neoplastic, n = 13), portal vein thrombi were analyzed indipendently by two different readers on contrast-enhanced
dual-energy CT with iodine quantification performed during the
late hepatic arterial phase. Histopathology (n = 7) or MDCT imaging criteria and thrombus evolutionary characteristics compared
with those in a previous MDCT examination (n = 27) were used as
the reference standard. 2tests of contingency were utilized to calculate the diagnostic accuracy of conventional enhancement measurements and iodine quantification. P-values of <0.05 were considered significant.
Results: Enhancement measurement revealed a sensitivity of
92.3%, specificity of 85.7%, PPV of 80%, and NPV of 94.7%. An iodine

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concentration of 0.9 mg/mL represented the optimal threshold for

discrimination between neoplastic and bland thrombi (AUC, 0.993)
at iodine quantification, with a sensitivity of 100%, specificity of
95.2%, PPV of 92.9%, and NPV of 100%. The diagnostic accuracy of
iodine quantification (97%) was significantly higher than that of conventional enhancement measurements (88.2%) (P<.001).
Conclusion: Iodine quantification is more accurate than standard
enhancement measurements in portal vein thrombosis characterization during the late hepatic arterial phase in patients with hepatocellular carcinoma.

708.4
A 3-dimensional (3D) printed endovascular simulation model:
technique and initial data
S.Mafeld1, C.Nesbitt2, J.McCaslin2, A.Bagnall3, P.Davey4, P.Bose5,
R.Williams1
1Interventional Radiology, Freeman Hospital, Newcastle upon Tyne,
United Kingdom, 2Vascular Surgery, Freeman Hospital, Newcastle upon
Tyne, United Kingdom, 3Cardiology, Freeman Hospital, Newcastle
upon Tyne, United Kingdom, 4Vascular Surgery, University Hospital of
North Durham, Durham, United Kingdom, 5Interventional Radiology,
Southend Hospital, Essex, United Kingdom
Purpose: 3D printing is a rapidly evolving field which is becoming
increasingly accessible. The 3D printing of an endovascular benchtop simulation model is described with data to support its feasibility.
Material and methods: 3D printing is a multi-step process that
begins with image acquisition (frequently in format of computed
tomography [CT]) and progresses to segmentation, 3D reconstruction, image optimisation and finally printing. A range of digital
design softwares are available, but most produce the widely recognised STL (surface tessellation language) file format necessary
for 3D printing. Using CT DICOM (digital imaging and communications in medicine) data, a human aorta with its major branches was
converted into an STL file. It was printed to scale with a watertight
design. A sheath was inserted into each common femoral artery,
allowing users to practice key endovascular techniques (catheter
and guidewire skills) in an anatomically accurate environment.
Results: The perceived value of the model and its comparison to
live patients and computerised virtual reality simulators is explored.
Ninety-six physicians used the model and provided feedback to 12
questions using a five-point Likert scale.
Conclusion: This study demonstrates the feasibility of a 3D printed
vascular model for endovascular training. The model is cost effective
while allowing the user to experience enhanced haptics including
pushability, torquability and trackability. Feedback obtained using
Likert scales provides the first evidence of its kind for a 3D printed
vascular model, although greater educational validation is needed.

708.5
Efficacy of CT in diagnosing non-variceal gastrointestinal
bleeding prior to transarterial embolization after endoscopic
failure in managing acute gastrointestinal bleeding
A.Wadhwani1, P.Beck 2, E.Herget1
1Radiology, University of Calgary, Calgary, AB, Canada,
2Gastroenterology, Medicine, University of Calgary, Calgary, AB,
Canada
Purpose: Non-variceal gastrointestinal bleeding (NVGIB) is associated with a high mortality and morbidity. After failed endoscopy,
10%30% of the patients are recommended transarterial embolization (TAE). Studies have suggested that performing pre-angiography
computed tomography (CT) increases the positive yield of visceral
angiography. Our objective was to determine (1) the accuracy of CT

Abstract Book
in diagnosing NVGIB following failed endoscopy and (2) the impact
of CT pre-TAE on the angiographic technique.
Material and methods: Data was collected from 49 consecutive
patients who presented to the emergency department with acute
NVGIB and received TAE after endoscopy failed to manage their
NVGIB. Of these, 15 patients underwent pre-angiography CT. These
CT examinations were retrospectively reviewed by 2 staff radiologists. These findings were compared to angiography, endoscopy, or
surgery. Inter-reader reliability was evaluated with kappa coefficient
().
Results: Sensitivity, specificity, PPV, NPV, and accuracy of CT in diagnosing NVGIB was 89%, 100%, 100%, 86%, and 93%, respectively. CT
was able to accurately diagnose the cause of NVGIB in 80% (12/15)
of patients. The inter-reader reliability coefficient was =0.72. In 8
cases, in whom CT localized NVGIB, no diagnostic catheter angiogram was required. In 2/8 cases, pre-TAE CT enabled the identification of the bleeding site, which would not have been visualized on a
routine diagnostic angiogram.
Conclusion: CT is an accurate diagnostic modality in detecting
NVGIB. Performing abdomen and pelvis CT before TAE improves the
localization of gastrointestinal bleeding. Impact of pre-angiography CT on reducing the overall number of imaging studies, fluoroscopy time, and amount of contrast administered needs to be further
investigated.

708.6
Medium range CT follow-up of imageable iodinated
microspheres after embolization of liver tumors
E.Levy1, K.Sharma2, A.Lewis3, V.Krishnasamy1, S.Willis3,
V.Anderson1, C.Macfarlane3, A.Radaelli4, M.vanderBom4,
W.Pritchard1, J.-F.H.Geschwind5, B.J.Wood1
1Center for Interventional Oncology - Interventional Radiology,
National Institutes of Health, Bethesda, MD, United States of
America, 2Interventional Radiology, Childrens National Medical
Center, Washington, DC, United States of America, 3Non-Clinical
Development, Biocompatibles UK Ltd, a BTG International Group
Company, Camberley, United Kingdom, 4Image Guided Therapy, Philips
Healthcare, Eindhoven, Netherlands, 5Radiology and Biomedical
Imaging, Yale University School of Medicine, New Haven, CT, United
States of America
Purpose: To describe the imaging features and available mediumterm stability of iodinated imageable microspheres over time following hepatic embolization.
Material and methods: Patients with primary and metastatic
hypervascular liver neoplasms were treated with embolization
using 70150- or 100300- imageable microspheres (LC Bead
LUMI). Follow-up imaging was performed with non-enhanced and
enhanced triple-phase CT at routine intervals from initial human
treatments (Jan 2016) to present as part of an ongoing clinical trial.
Preclinical embolization in normal hepatic arteries was also performed in swine, with follow-up CT scans out to 90 days.
Results: Imaging features and stability are described out to 90 days
in preclinical models and between Jan 2016 and present for clinical human use. Beads may be visualized 90 days after embolization
in swine with no perceptible imaging degradation over this time
range. Clinical CT scan 3 weeks after patient embolization also mirrored the 48-hour post-embolization CT. CT 3 weeks post-embolization also reproduced procedural CBCT findings of residual enhancing nodules within the target tumor volume in patients.
Conclusion: Iodinated imageable microspheres (LC Bead LUMI) may
be visualized in the liver long after embolization (at least out to 90
days) with essentially the same CT visibility and same geographic
localization as procedural CBCT. The typical longer-term natural history of the microsphere imageability is yet to be characterized.

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Free Paper Session

Non-vascular IR: biopsies and drainages
1407.1
Performance of percutaneous CT-guided lung biopsy with
an augmented reality navigation system (SIRIO) on 450 lung
lesions
G.Frauenfelder, E.Faiella, G.Luppi, F.Giurazza, B.BeomonteZobel,
R.F.Grasso
Radiology, Campus Biomedico University of Rome, Rome, Italy
Purpose: To investigate the results of a CT navigation system (SIRIO )
in percutaneous lung biopsy (PLBs) based on the dimensions and
location of suspected lesions.
Material and methods: A total of 450 patients (mean age 70; 279
male, 171 female) with suspected neoplastic lesions who underwent SIRIO CT-guided PLB were divided into 3 groups on the basis
of lesion maximum diameter (<15 mm, 205 mm, and >25 mm).
Evaluation of time of procedure (more or less than 30 minutes),
lesion distribution (central or peripheral, lobar localization), histological diagnosis (significant sample), and recovery requirement for
important complications was investigated in each group.
Results: No significant differences about the procedure time were
archived for each group (mean time of 37, 35, and 30 minutes for
groups 1, 2, and 3, respectively). Central and lower lobe-sited lesions
were present in 76%, 56%, and 60% for groups 1, 2, and 3, respectively. A significant sample for histological diagnosis was obtained in
98% of cases for each group. Recovery was necessary for 12 patients
(8%) included in group 3 vs. 3 patients (2%) included in groups 1 and
2.
Conclusion: Independent of lesion dimension, SIRIO can be considered a safety and efficacy navigation system in CT-guided PLB,
obtaining a significant histological diagnosis in 98% of cases and no
significant differences in procedure time and rates of complications;
therefore, patients are to manage the costs despite larger lesions.

1407.2
Postbiopsy pneumothorax reduction using a hydrogel tract
sealant system after percutaneous CT and infrared opticalguided lung biopsy with a 17-gauge coaxial needle
E.Faiella, G.Frauenfelder, G.Luppi, S.DellaSala,
B.BeomonteZobel, R.F.Grasso
Radiology, Campus Biomedico University of Rome, Rome, Italy
Purpose: After CT-guided percutaneous biopsy of the lung, pneumothorax is reported to be the most common complication, requiring prolonged admission and/or chest tube drainage. Aim of the
study was to evaluate the ability of an expanding hydrogel lung
biopsy tract plug to reduce rates of pneumothorax associated with
CT and infrared optical-guide system (SIRIO) PTLB, using a coaxial
17-gauge needle.
Material and methods: A total of 120 consecutive patients (aged
65 12 years) who underwent CT-guided lung biopsy for radiologically suspected masses were included in the study. The treatment
group (n=60) received a hydrogel tract plug deployed through the
17G coaxial needle just before needle removal, while in the control group (n=60), a no-plug was used. In both groups, high-risk
patients for pneumothorax were included (strong smokers, bullous
emphysema). Pneumothorax was investigated immediately with
postbiopsy CT control and with a 3-hour chest X-Ray in all patients;
a 24-/48-hour chest X-Ray was obtained in cases of pneumothorax worsening. Endpoints included absence/presence of pneumothorax, stability/progression of pneumothorax, and requirement of
chest tube drainage.

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Results: Fifteen percent of treatment group and 20% of control

group had a postprocedure pneumothorax. Compared with control
groups, 12% of treatment patients and 5% of control patients had
stationary pneumothorax at X-Ray follow-up; only 3% of treatment
group vs 15% of control group required tube drainage because of
pneumothorax increment.
Conclusion: CT and infrared optical system-guided PTLB are related
to lower PTX rates. The additional use of a lung biopsy tract plug significantly reduced rates of PTX progression, chest tube placement,
and postprocedure hospital admission.

1407.3
Free-hand vs. instrument-guided needle puncture using CT
imaging and optical navigation in vitro
J.Kettenbach1, G.Toporek 2, L.Kara3, S.Weber4
1Institute of Medical Radiology, Diagnostic, Intervention, University
Hospital St. Plten/Karl Landsteiner University of Health Science, St.
Plten, Austria, 2ARTORG Center, Image Guided Therapies, University
of Bern, Bern, Switzerland,3Radiology, Triemli Hospital, Zurich,
Switzerland, 4Image Guided Therapy, ARTORG Center, Bern, Switzerland
Purpose: To evaluate the accuracy of stereotactic free-hand vs.
instrument-guided needle puncture in vitro.
Material and methods: Copper-wire endings (diameter < 1.5 mm)
embedded within a torso phantom were randomly selected as targets. We planned an equal number of axial and oblique non-axial
needle trajectories and applied three guiding methods for needle
puncture (17 G, length 15 cm) using an optical-based navigation system (CAS-One IR, CAScination, Bern, Switzerland): (A) free-hand, (B)
using an instrument-guidance tool with passive and (C) active depth
control. Target planning, assessment of final needle position, needle
insertion depth, angulation, positioning error (PE) and evaluation of
the positioning success rate (PSR) was based on CT imaging.
Results: Sixty navigation-based needle punctures (mean insertion
depth: 6.0 1.5 cm, lateral and cranio-caudal angulation: 53 to
+46 and 13 to +60, respectively) were performed. The Euclidean
PE was significantly lowest in C (6.1 1.4 mm, p<0.001) vs. B (3.1
2.2 mm) and A (11.1 3.9 mm). Within predefined target areas of 5
mm, 7.5 mm and 10 mm in diameter, PSR was 0%, 20% and 50% in
A; 85%, 95% and 95% in B and 15%, 75% and 100% in C, respectively.
The overall PSR of axial trajectories was higher than that in oblique
non-axial trajectories (67 42% vs. 53 38%).
Conclusion: The accuracy of navigation-based needle puncture was
the highest using an instrument-guidance tool and passive depth
control (the accuracy was significantly lesser accurate with active
depth control or freehand, respectively). For target areas < 10 mm,
instrument-guided stereotactic needle placement is recommended
to achieve a high accuracy.

1407.4
Transperineal prostate biopsy: a comparison between two
techniques
A.BabaeiJandaghi1, H.Habibzadeh2, S.Falahatkar2,
A.Heidarzadeh3, R.Pourghorban4
1Department of Radiology, Guilan University of Medical Sciences,
Rasht, Iran, 2Urology Research Center, Guilan University of Medical
Sciences, Rasht, Iran, 3Department of Community Medicine, Guilan
University of Medical Sciences, Rasht, Iran, 4Department of Radiology,
Shahid Beheshti University of Medical Sciences, Tehran, Iran
Purpose: To compare the procedural time and complication rate of
coaxial technique with those of noncoaxial technique for transperineal prostate core needle biopsy.
Material and methods: This prospective study was performed on
240 patients who were suspicious of prostate cancer. Coaxial (first

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group) and noncoaxial (second group) transperineal biopsies were

performed randomly in two groups, each comprising 120 patients.
The mean PSA level and the procedural time were recorded. The
level of pain experienced during the procedure was asked on a
visual analogue scale (VAS), and the rate of complications was evaluated by a comparison between the two techniques.
Results: The mean PSA level in the first and second groups were 14.8
ng/mL and 27.5 ng/mL, respectively. The procedural time was significantly shorter in the first group (p<0.001). In the first group, pain
occurred less frequently (p=0.002), with a significantly lower VAS
score being experienced (p<0.002). Hematuria (p=0.029) and hemorrhage from the site of biopsy (p<0.001) were seen less frequently
in the first group. There was no significant difference in the rate of
urethral hemorrhage between the two groups (p=0.059). Urinary
retention occurred less commonly in the first group (p=0.029). No
significant difference was seen in the rate of dysuria between the
two groups (p=0.078).
Conclusion: The coaxial technique is a faster method for transperineal prostate biopsy, and in regard to complications, it had a significantly lower rate of hematuria, hemorrhage from the site of biopsy,
and urinary retention with a lesser degree of pain being experienced by the patients.

1407.5
Transjugular renal biopsy in high-risk patients
J.Kettenbach1, H.Mueller2
1Institute of Medical Radiology, Diagnostic, Intervention, University
Hospital St. Plten/Karl Landsteiner University of Health Science, St.
Plten, Austria, 2Radiology, VISIORAD, Hamburg, Germany
Purpose: To report the outcome of transjugular renal biopsy (TJRB)
in high-risk patients with contraindications to percutaneous renal
biopsy.
Material and methods: We retrospectively reviewed 57 patients
[72% male, mean age 58 (15 to 82) years] referred for TJRB using an
18-gauge, 60-cm-long automated biopsy device. Specific indications, sampling effectiveness, impact on patient management, and
complication rates were assessed.
Results: TJRB was technically successful in 56 (98%) patients, including renal tissue in 50 (88%) patients. Diagnostic biopsy specimens
were obtained in 44 of 56 (78%) patients. Specific indications for
transjugular access were impaired coagulation profile due to oral
anticoagulation, clopidogrel and/or ASS (42%), thrombocytopenia
(37%), obesity (4%), single kidney (2%), or others (15%). A mean of 3.2
(range, 0-11) cores was obtained with a total number of 8.6 glomeruli (range, 0-41) per procedure: 7.2 glomeruli (range, 0-35) for light
microscopy, 0.2 (range, 0-2) for electron microscopy, and 1.7 (range,
0-6) for immunofluorescence. Histology revealed glomerulonephritis in 14 (26%), vascular nephropathy in 10 (18%), tubular necrosis
in 7 (12%), CAST nephropathy in 3 (5%), amyloidosis in 2 (4%), and
other in 8 (14%) cases. Histology had an impact on patient management in 42 (74%) cases. Capsular perforation was recorded in 8 (14%)
cases and macrohematuria in 2 (4%) cases; however, none of them
required further therapy.
Conclusion: TJRB facilitates histological diagnosis in high-risk
patients, making an important contribution to patient management.
TJRB should be considered when percutaneous biopsy is contraindicated or has failed. Although demanding from the technical aspect,
if performed correctly, it involves little risk.

Abstract Book

1407.6
Directional atherectomy for endovascular tissue sampling
A.Massmann, P.Fries, G.K.Schneider, A.Buecker
Diagnostic & Interventional Radiology, Saarland University Medical
Center, Homburg, Germany
Purpose: To evaluate the technical feasibility and safety of directional atherectomy with the SilverHawk device for sampling of
endovascular tumor specimen.
Material and methods: Eight consecutive patients (6 males; mean
agestandard deviation [range] 57.411.8 [39-73] years) were
referred for endovascular biopsy of endoluminal tumor tissue.
Tumor localization included thoraco-/abdominal aorta (AO) (n=2),
left brachiocephalic vein (BCV) (n=2), inferior caval vein/right atrium
(ICV) (n=1), and left pulmonary artery (PA) (n=3). Usually available
straight two-jaw biopsy-forceps were inappropriate to obtain biopsies out of the eccentric vessel-tumors. Alternatively, off-label use
of directional atherectomy (SilverHawk LS-M, Medtronic) was used
for targeted specimen collection by transfemoral arterial/venous
access.
Results: Technical success for endovascular tumor tissue sampling
was 100%. Two atherectomy passages were sufficient in each vessel region to obtain adequate material allowing diagnostic histologic evaluation. Subsequently, sarcoma and chronic inflammation were diagnosed for AO, angiosarcoma for BCV, hepatocellular
carcinoma for ICV, and angiosarcoma and lymphoma for PA. Falsenegative tissue probing was not present. No procedure-associated
complications, e.g., vessel perforation or peripheral embolization,
were recorded.
Conclusion: Directional atherectomy with the SilverHawk device is a
feasible option for percutaneous endovascular sampling of endoluminal pathologies.

Free Paper Session

Peripheral 1
1408.1
Early results of the endovascular femoropopliteal artery
bypass (EFAB) study using the PQ Bypass system
P.Szopinski1, G.Halena2, G.Oszkinis3
1Clinic of Vascular Surgery, Institute of Haematology and Transfusion
Medicine, Warsaw, Poland, 2Department of Vascular Surgery, Medical
University of Gdask, Gdansk, Poland, 3Department of General Surgery
and Vascular Surgery, K. Marcinkowski Memorial Medical University of
Poznan, Poznan, Poland
Purpose: To evaluate the safety and effectiveness of the PQ Bypass
System (PQ Bypass, Inc., Sunnyvale, CA) in accessing the femoral vessels, delivering guidewires, and implanting stent grafts for a percutaneous femoropopliteal (fem-pop) bypass.
Material and methods: The EFAB study is a multicenter, non-randomized, single-arm study. Patients were evaluated by means of
CTA and ultrasound examination. The PQ Bypass System was used
to place a guidewire from the proximal femoral artery into the femoral vein and back into the distal fem-pop artery, thus bypassing
the lesion within the femoral artery. Stent grafts were deployed in
a modular fashion over the guidewire from distal to proximal using
the adjacent vein as a conduit. Follow-up was conducted at 3 and 6
months via arterial and venous ultrasound examinations.
Results: In total, 45 patients (30M, 15F, mean age 62 years) have
been treated to date. Of these, 15 (33%) have undergone follow-up
at 6 months. The mean lesion length was 23.9 6.3 cm. One patient
experienced an adverse event; the edge stenosis was treated after
6 months via atherectomy. The PQ Bypass System successfully

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delivered guidewires and placed stent grafts and thus completed
a percutaneous fem-pop bypass in 100% of the cases. Primary
patency at 6 months was 93%. Both primary safety and effectiveness
endpoints were met.
Conclusion: A percutaneous bypass of long lesions in the fem-pop
artery can be successfully achieved using the PQ Bypass System and
provides a safe alternative to bypass surgery.

1408.2
One-year outcome of subintimal revascularization with
Supera stenting of long femoropopliteal occlusions in critical
limb ischemia: the Supersub study
L.M.Palena1, L.J.Diaz-Sandoval2, E.Sultato1, C.Brigato1,
A.Candeo1, M.G.Manzi1
1Interventional Radiology Unit, Policlinico Abano Terme, Abano Terme,
Italy, 2Interventional Cardiologist, Metro Health Hospital, Wyoming, MI,
United States of America
Purpose: To assess long-term outcomes of subintimal revascularization with Supera stenting for long femoropopliteal (FP) chronic
total occlusions (CTOs) in patients with CLI.
Material and methods: From January 2014 to August 2015, 34 consecutive CLI patients with FP TASC C and D CTOs were included in
this prospective, single-center, single-arm study. Patients underwent Supera stenting after the subintimal crossing of FP long occlusions. Primary efficacy endpoint was 1-year stent patency and freedom from target lesion revascularization (TLR). Primary safety endpoint was the composite rate of freedom from death due to any
cause, major amputations, and TLR at 1 year. Secondary endpoints at
12 months were stent integrity, clinical improvement, amputationfree survival, quality of life, and cost efficiency.
Results: Mean lesion length was 27.9 10.2 cm. Acute technical success was obtained in 100% of patients. Primary patency was 94.1%.
Freedom from TLR was 97.1%. Limb salvage was 100%. Clinical
improvement was observed in 100% of patients (TCPO2 increased
from 12.7 6.2 to 54.8 8.4 mmHg, p < 0,0001), Rutherford category shifted to class 0 (p < 0.0001), and improvement in quality of
life (QoL) metrics was from 0.46 0.33 to 0.89 0.16 (p < 0.0001)
according to the EQ5D-3L questionnaire. There were no stent fractures. Amputation-free survival was 82.4%.
Conclusion: Subintimal revascularization with Supera stenting in
patients with CLI and long FP occlusions has been shown to outperform efficacy and modify safety performance goals previously set
for patients with less severe disease.

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1408.3
Lithoplasty for the treatment of calcified SFA lesions: the
DISRUPT PAD study program
T.J.Brinton1, U.Illindala2, M.Brodmann3, M.Werner4, G.Tepe5,
A.Holden6, D.Scheinert7, G.Torsello8, F.Wolf9, T.Zeller10
1Cardiology, Stanford Medical Center, Stanford, CA, United States of
America, 2Research, Shockwave Medical Inc, Fremont, CA, United
States of America, 3MEDUK Graz, Division of Angiology, Graz, Austria,
4Angiology, Hanusch Krankenhaus, Vienna, Austria, 5Department
of Diagnostic and Interventional Radiology, Medical Centre of
Rosenheim, Rosenheim, Germany, 6Interventional Radiology, Auckland
City Hospital, Auckland, New Zealand, 7Clinical and Interventional
Angiology, Park Hospital Leipzig, Leipzig, Germany, 8Center for Vascular
and Endovascular Surgery, University Hospital, Mnster, Germany,
9Division of Cardiovascular and Interventional Radiology, Medical
University of Vienna, Department of Biomedical Imaging and ImageGuided Therapy, Vienna, Austria, 10Angiology, Herz-Zentrum Bad
Krozingen, Bad Krozingen, Germany
Purpose: Treatment of calcified peripheral artery disease (PAD)
remains a challenge and is associated with vascular complications, high stent use and poor outcomes. We studied the Peripheral
Lithoplasty Catheter System (Shockwave Medical, Fremont CA), a
lithotripsy-enhanced, low-pressure balloon catheter for calcified
peripheral arteries.
Material and methods: The DISRUPT PAD study program is a twophased, prospective, multicentre, single-arm study that enrolled 95
patients with calcified PAD. Acute procedural success or the effectiveness endpoint was defined as <50% residual diameter stenosis, with or without adjunctive PTA therapy. The primary safety endpoint was freedom from major adverse events (MAE) over 30 days.
Patency defined as <50% restenosis will be assessed at 6 months
(n=95) and 12 months (n=60).
Results: Mean lesion length, percent stenosis and total occlusions
were 7.6 3.8 cm, 77% 13% and 10.0%, respectively. All lesions had
moderate (35.9%) or severe (64.1%) calcification. Lithoplasty treatment resulted in 100% acute procedural success, a mean residual
stenosis of 24% 6% and acute gain of 2.9 0.8 mm. There were
no major adverse events, including flow-limiting dissections or distal embolisation events. Minor dissections occurred in 16% and
only one stent was placed. Six-month patency will be available at
presentation.
Conclusion: In this study, lithoplasty had a favorable safety profile with no major vascular complications. Acute gain was excellent
without a need for significant stent use and should lead to superior
patency compared to traditional therapies for this difficult to treat
patient population.

1408.4
Drug-eluting balloon angioplasty of femoropopliteal arterial
disease: a real world experience
P.Drescher, C.O.Hampson, P.Zalog
Interventional Radiology, AHCMG, Milwaukee, WI, United States of
America
Purpose: Drug-eluting balloon angioplasty (DEB-PTA) in the treatment of femoropopliteal arterial disease (FPAD) has shown superior
patency rates in multicenter randomized trials. Available in the US
for only 1 year, real world experiences outside randomized trial conditions are missing.
Material and methods: In a 12-month period, patients with FPAD,
de novo and prior intervention, undergoing DEB-PTA with 2 commercially available DEBs at a single center were followed up with
color duplex ultrasound (CDUS) and clinical evaluation. Outcome
measures were primary patency, target limb re-intervention (TLR),

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and major complications. Analysis of patient characteristics, lesion

morphology (TASC II), additional treatments, and comparison with
randomized DEB-PTA trials were performed.
Results: In total, 70 patients (mean age: 72.2 years) (77 limbs) underwent DEB-PTA. Eight patients with acute limb ischemia and lack of
follow-up were excluded. Follow-up period for the remaining 69
limbs ranged between 1 and 13 months with a mean of 5.4 months.
Overall lesion length was 104 mm (range: 20300 mm). Most lesions
were TASC II A lesions; 15% of the lesions were TASC II D lesions.
Ten limbs reached primary patency in the observation period with
occlusion or restenosis greater 50% during months 111 with a mean
of 4.7 months. Primary patency rate at 5.4 months was 91.5%. Two
patients underwent bypass operations; the remaining patients
underwent TLR. Four major complications occurred.
Conclusion: Short-term real world experience with DEB-PTA seems
comparable to DEB trial data for FPAD with a primary patency of
91.5% at 5.4 months.

1408.5
Mechanical thrombectomy to treat intraprocedural distal
embolization occurring during lower limb revascularization
R.Gandini, S.Merolla, M.Stefanini, F.DeCrescenzo, E.Pampana,
A.DOnofrio
Diagnostic and Molecular Imaging, Radiation Therapy and
Interventional Radiology, University Hospital Policlinico Tor Vergata,
Rome, Italy
Purpose: Intraprocedural acute distal embolization is a complication that may occur during percutaneous revascularization of the
femoropopliteal and below-the-knee arteries. To date, no standard
treatment has been established.
Material and methods: Eighteen cases using mechanical thromboaspiration to treat distal embolization complications occurred
during SFA and BTK revascularization for critical limb ischemia.
Each case was treated using the Penumbra system (Penumbra Inc.,
Alameda, California), a mechanical thrombectomy device traditionally used during acute ischemic stroke therapy. It involves a trackable catheter connected to a dedicated aspiration pump (Penumbra
MAX Pump, Penumbra Inc.).
Results: Of the 18 cases, preprocedural angiography showed severe
stenosis and/or occlusion of the femoropopliteal axis in 12 and
severe stenosis and/or occlusion of BTK vessels in 6. After percutaneous transluminal angioplasty, control angiograms revealed distal embolization caused by the angioplasty procedure. Mechanical
thromboaspiration was performed with the Penumbra system
(3MAX was used in 13 cases, and 4MAX in 5) connected to the dedicated aspiration pump. Final angiographic imaging showed complete recanalization of arteries occluded by embolic complications in 16 cases (89%). These 16 patients were asymptomatic at the
12-month follow-up. In the remaining 2 patients, an effective thromboaspiration was not obtained, most likely due to a distal microvascular thrombosis; thus, they underwent minor (1 patient at the forefoot level) or major (1 patient above the ankle) amputation.
Conclusion: Our experience using the Penumbra system in the
peripheral vasculature demonstrates a rapid and effective approach
to manage intraprocedural distal embolization and avoid possible
grave clinical sequelae.

Abstract Book

1408.6
DEB and stents: what we have learnt from the Freeway Stent
Study and the PACUBA Trial
J.Lammer1, J.Tacke2
1Vienna, Austria, 2Institut fr Diagnostische und Interventionelle
Radiologie und Neuroradiologie, Klinikum Passau, Passau, Germany
Purpose: Stents are needed in up to 50% of all peripheral interventions, wherein PTA with plain or drug-eluting balloons alone will not
reopen the vessel sufficiently. DEB potentially overcomes the problem of in-stent restenosis when used for postdilatation after primary
stenting in the SFA and P1 segment and may provide an efficient
treatment method for ISR.
Material and methods: The Freeway Stent Study is a prospective,
randomized, international trial. In total, 200 patients were randomized to primary stenting followed by either DEB (Freeway, Eurocor
GmbH) or POBA postdilatation in de novo lesions in the SFA and P1
segment. Primary endpoint was clinically-driven TLR at 6 months.
The PACUBA Trial is a prospective, single-blind, randomized trial.
In total, 74 patients were randomized equally to DEB (Freeway,
Eurocor GmbH) or POBA dilatation of ISR lesions in the SFA and P1
segment. Primary endpoint was primary patency at 12 months.
Results: The 6-month follow-up of the Freeway Stent Study results
favor the use of Freeway DEB over POBA based on clinically-driven
TLRs. This is supported by statistically significant better clinical outcomes for patients in the DEB group.
The PACUBA Trial shows that patients treated with DEB had a significantly higher primary patency rate than those treated with standard
PTA at 12 months.
Conclusion: The 6-month follow-up results of the Freeway Stent
Study provided significant and positive trends in all parameter in
favor of DEB.
The PACUBA Trial highly favors the use of DEB in ISR. The usage of
DEB seems to be an efficient treatment option for patients with ISR.

Free Paper Session

Bone and spine
1506.1
A randomised sham-controlled trial of vertebroplasty for
painful chronic osteoporotic vertebral fractures
D.Carli1, P.N.M.Lohle2
1Radiology, St. Elisabeth Ziekenhuis, Veldhoven, Netherlands,
2Radiology, St. Elisabeth Hospital, Tilburg, Netherlands
Purpose: The standard care in patients with a painful osteoporotic vertebral compression fracture (VCF) is conservative therapy.
Percutaneous vertebroplasty (PV), a minimally invasive technique,
is a relatively new treatment option. Recent randomised controlled
trials (RCTs) have provided conflicting results: two sham-controlled
studies showed no benefit of PV, while an unmasked but controlled
RCT (VERTOS II) found effective pain relief at acceptable costs in
patients with acute VCFs. A still ongoing masked RCT (VERTOS IV)
focuses on acute VCFs defined as 6 weeks. VERTOS III focused on
conservative treatment and found that half of patients still had disabling pain after 3 months or longer. These patients with sustained
pain after 3 months may benefit from PV.
Material and methods: Inclusion criteria are a VCF of the fifth thoracic level or lower with focal tenderness at the fracture level,
assessed by an internist on physical examination, and a visual analogue scale (VAS) score 5 for 3 months or longer, decreased bone
density defined as T score -1 and age 50 years or older. Ninetyfour patients will be included, 47 in each arm. Crossovers are not
allowed. Follow-up is at regular intervals during a 1-year period

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with VAS score for pain as the primary endpoint. Secondary endpoints are back pain-related disability and quality of life measured
with the Quality of Life Questionnaire of the European Foundation
for Osteoporosis and physical function measured with the Roland
Morris Disability questionnaire.
Results: Results thus far in an ongoing study.
Conclusion: Vertos V is a methodologically sound, masked, shamcontrolled RCT of vertebroplasty.

1506.2
Percutaneous pulsed radiofrequency neurolysis in knee
osteoarthritis: evaluation of pain reduction in chronic
refractory cases
D.K.Filippiadis, G.Velonakis, L.Reppas, A.Mazioti, E.Brountzos,
N.L.Kelekis, A.D.Kelekis
2nd Radiology Department, University General Hospital ATTIKON,
Athens, Greece
Purpose: To prospectively evaluate the effectiveness of percutaneous imaging-guided intra-articular pulsed radiofrequency neurolysis (PRF) in patients with knee osteoarthritis suffering from chronic
pain refractory to conservative therapies.
Material and methods: During the last 12 months, PRF was performed on 25 cases of knee osteoarthritis. A 20-G, 10-cm cannula
was percutaneously inserted in the anterolateral region of the knee
joint under fluoroscopy. Coaxially, an RF electrode (10-mm active
tip) was introduced and neurolysis session was performed with
PRF (1,200 pulses at 45 V over a 20-min duration followed by a 480min silent phase). Following this, the intra-articular injection of hyaluronate was performed. Pain before and 1 week, 1 month, and 6
months after the procedure was compared by means of a numeric
visual scale (NVS) questionnaire.
Results: Comparing the pain scores of questionnaires before (mean
value 8.20.8 NVS units) and 1 week after (mean value 3.01.0 NVS
units) the procedure, there was a mean decrease of 5.2 NVS units in
terms of pain reduction and life quality. At 1 and 6 months post-therapy, the mean value of self-reported pain was 1.80.8 NVS units with
a mean decrease of 6.4 NVS units in terms of pain reduction and life
quality. Overall mobility improved in 15/15 (100%) patients. No complication was observed.
Conclusion: PRF seems to be an effective and safe technique for the
palliative management of chronic pain in patients with knee osteoarthritis. Results seem to be reproducible and longer lasting compared with those of an intra-articular injection of hyaluronate solely
performed.

1506.3
Percutaneous internal fixation to prevent impeding
pathological hip fractures: a 1-year follow-up study
F.Deschamps1, T.Carteret2, L.Tselikas1, B.Lapuyade3, T.deBare1,
F.Cornelis4
1Department of Radiology, Gustave Roussy Cancer Campus, Villejuif,
France, 2Radiology, CHU Bordeaux - Hpital Saint Andr, Bordeaux,
France, 3Interventional Radiology, CHU Bordeaux - Hpital HautLvque, Bordeaux, France,4Radiology, CHU Bordeaux, Bordeaux,
France
Purpose: A percutaneous internal fixation device (Y-STRUT,
Hyprevention) has been developed to prevent hip fractures in case
of osteolytic metastases located in the femoral neck. Tolerance of
Y-STRUT and the related operative procedure has been prospectively evaluated in this multicenter pilot study.
Material and methods: A total of 12 cancer patients have been considered for prophylactic consolidation in 2 different hospitals. These
consolidations were performed percutaneously under fluoroscopic

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guidance by interventional radiologists. All patients presented a

high risk of hip fracture (Mirels score 8). Patients were followed by
medical consultations and radiographic exams.
Results: Two patients suffered from a fracture that occurred prior to
the prophylactic consolidation and were excluded from the study
analysis. Ten patients (40% females, mean 616 years) were treated
for impending pathological fractures (mean Mirels score 91). All the
procedures were performed with success. Average hospitalization
was 2.31.4 days. Four of the 10 patients were discharged the day
following the intervention, indicating that the implantation could
be performed as an ambulatory procedure. Wound healing was
achieved in all cases with no access site complication. Mean pain
decreased from 3.62.9 at baseline to 2.40.9 at 2 months. During
the follow-up, 6 patients deceased from severe progression of their
underlying cancer after a mean follow-up of 142 days (24324). All
survival patients have reached a follow-up of 1 year.
Conclusion: Preliminary results demonstrated the feasibility and
the safety of Y-STRUT implantation as well as the tolerance of the
device.

1506.4
Percutaneous MR-guided cryoablation of Mortons neuroma:
rationale and technical details after the first 20 patients
R.L.Cazzato1, J.Garnon1, G.Tsoumakidou2, J.Caudrelier1, P.P.Rao1,
G.Koch1, A.Gangi3
1Interventional Radiology, University Hospital of Strasbourg,
Strasbourg, France, 2Non-Vascular IR, University Hospital of Strasbourg,
Strasbourg, France, 3Imagerie Interventionnelle, NHC, Strasbourg,
France
Purpose: To review our preliminary experience with percutaneous
MR-guided cryoablation (CA) of Mortons neuroma (MN) and discuss
its rationale and advantages.
Material and methods: This is a retrospective study. Procedures
were performed under local anaesthesia on an outpatient basis.
Lesion size and location, procedural outcome (technical success and
complications) and clinical outcome (patient satisfaction according
to a 4-point scale, residual pain according to a 010 visual analogue
scale) were assessed through chart review and a cross-sectional telephone survey after the 20thcase.
Results: Twenty patients (15 female, 5 male; mean age 50.3 years)
were included; 24 MN (mean size 12.7 mm) were treated. The technical success was 100%. One minor complication (superficial cellulitis)
was reported (4.2%). Follow-up (mean 19.7 months) was available for
18/24 MN. Patient satisfaction on a per-lesion basis was completely
satisfied in 77.7%, satisfied with minor reservations in 16.6% and
satisfied with major reservations in 5.7% of cases. The mean pain
score after CA was 3.7. There were no instances of stump neuroma
syndrome.
Conclusion: MR-guided CA of MN is technically feasible and safe
and appears to result in high patient satisfaction. The principal
advantages are accurate ablation-zone monitoring, reduced risk of
stump neuroma syndrome and good tolerance as an outpatient
procedure.

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1506.5
Osteoid osteoma and more: MRgFUS in the treatment of
benign and painful bone lesions
F.Arrigoni1, L.Zugaro2, A.Barile1, C.Masciocchi1
1Department of Biotechnological and Applied Clinical Sciences,
University of LAquila, LAquila, Italy, 2Radiology, San Salvatore Hospital,
LAquila, Italy
Purpose: To evaluate the effectiveness and safety of MRgFUS in the
treatment of benign bone lesions, osteoid osteoma (OO), and other
epiphyseal and intrarticular lesions (EL) (osteoblastoma, periosteal chondroma, and other). The complexity in managing this type
of lesions is due in particular to their location: in fact, surgical treatment involving the articular or metaphyseal region may also lead
to slight, though disabling, complications. Furthermore, RFA can
appear aggressive when it is applied very close to the cartilage and
other sensitive structures of the joints. For its high accuracy, MRgFUS
can be considered a valid opportunity.
Material and methods: Twenty-four OO and 13 EL were treated
with MRgFUS. Before treatment, all patients were evaluted by CT
and MRI and, if necessary, a biopsy to confirm the benign nature of
the lesions. The clinical follow-up was evaluated by VAS. Imaging follow-up (up to 36 months) was performed with MRI and CT.
Results: After treatment, all patients showed a regression in painful
symptomatology (VAS score decreased from 7.8 to 0.4). The diagnostic follow-up in all cases demonstrated the disappearance of radiological signs related to biological activity. In no case were major
complications observed.
Conclusion: In our experience, the use of MRgFUS proved to be a
safe and effective treatment of those benign bone lesions. The
low invasiveness of this technique allows a high compliance by the
patients, thereby ensuring an effective treatment of the lesions: in
no case did we record on the follow-up a progression of disease, and
the treatment was considered curative.

1506.6
Pain palliation and local control of musculoskeletal metastases
with percutaneous cryoablation
A.N.Wallace1, S.Connolly1, J.Symanski1, D.Vaswani1,
R.Vyhmeister2, S.McWilliam1, A.Lee1, T.Hillen1, M.Friedman1,
J.Jennings1
1Mallinckrodt Institute of Radiology, Washington University, Saint
Louis, MO, United States of America,2Mallinckrodt Institute of
Radiology, Washington University School of Medicine, Saint Louis, MO,
United States of America
Purpose: To evaluate the safety and effectiveness of percutaneous
image-guided cryoablation of musculoskeletal metastases in terms
of achieving pain palliation and local tumor control.
Material and methods: Between April 2012 and July 2015, 92 musculoskeletal metastases in 56 patients were cryoablated. Concurrent
cementoplasty was performed after 28% (26/92) of cryoablation
procedures owing to an existing or imminent risk of pathologic
fracture. Procedures were performed for pain palliation only (41%,
33/92), local tumor control only (22%, 20/92), or both pain palliation
and local tumor control (42%, 39/92). The mean age of the cohort
was 53.9 15.1 years: 48% (27/56) men and 52% (29/56) women.
The median tumor volume was 13.0 cm3 (range, 0.5 577.2 cm3).
Pre- and post-procedure median worst pain scores 1 day, 1 week,
1 month, 3 months, and 6 months after treatment were measured
using the Numeric Rating Scale (10-point scale) and compared.
Follow-up imaging of tumors treated for local tumor control was
reviewed for radiographic evidence of tumor progression.
Results: The median pre-procedure pain score of patients treated
for pain palliation was 8.0. These patients reported decreased

Abstract Book

median pain scores 1 day (6.0, P < 0.001), 1 week (5.0, P < 0.001), 1
month (5.0, P < 0.001), and 3 months (4.5, P = 0.01) after treatment.
The median pain score reported at 6-month follow-up was 8.0
(P=0.33, n = 11). Radiographic local tumor control rates were 90%
(37/41) at 3 months, 84% (27/32) at 6 months, and 73% (19/26) at 1
year after treatment. The procedural complication rate was 4.3%
(4/92), including 3 major complications.
Conclusion: Cryoablation appears to be an effective treatment for
palliating painful musculoskeletal metastases and achieving local
tumor control with a low complication rate.

Free Paper Session

Dialysis: whats new
1507.1
Can paclitaxel-coated balloons be beneficial in preventing
restenosis in haemodialysis access? A randomised clinical trial
L.J.Roosen
Radiology, Albert Schweitzer Ziekenhuis, Dordrecht, Netherlands
Purpose: Vascular access is important in haemodialysis patients.
Primary patency rates with conventional balloon angioplasty (CBA)
are moderate. Morbidity is evoked by secondary PTA. PTA induces
an endless cycle wherein recurrent stenosis in fistula induces intima
hyperplasia and recurrent stenosis. Paclitaxel-eluting stents and
-coated balloons have shown good results in treating stenosis in
coronaries and lower extremities. Our aim is to prolong secondary
patency using paclitaxel-coated balloons in recurrent stenosis in
haemodialysis fistula.
Material and methods: In this multicentre randomised clinical trial,
we included 34 patients. After randomisation, 16 patients were
included in the PCB group and 18 in the control group.
Results: No beneficial effects were seen in the PCB group. Patency in
this group was 130 days, whereas the average patency in the control
group was 189 days (p = .197).
Conclusion: Although previous studies showed positive results
regarding PCB in fistula, we did not find any beneficial effect. The
explanation for our results could be that the most beneficial effect
of PCB is found in arteriovenous grafts, whereas in our study, almost
all patients had an arteriovenous fistula. Venous intima hyperplasia is induced by pathways other than the traditional arterial ones.
A thick layer of intima hyperplasia probably prevents locally administered drugs from adequately reaching the media to inhibit smooth
muscle-cell proliferation. Furthermore, wall stress continues after
treatment due to the non-physiological haemodynamics in a fistula,
even after drug delivery. The endless cycle of recurrent stenosis due
to intima hyperplasia evoked by multiple angioplasties cannot be
stopped by paclitaxel-coated balloons.

1507.2
Paclitaxel-coated balloon versus plain balloon angioplasty
for the treatment of symptomatic central venous stenosis
in dialysis access: results from a prospective randomized
controlled trial
P.M.Kitrou, P.Papadimatos, S.Spiliopoulos, K.N.Katsanos,
S.Sourouni, N.Christeas, D.Karnabatidis
Department of Interventional Radiology, University Hospital of Patras,
Patras, Greece
Purpose: To report results from a prospective single-center randomized trial comparing paclitaxel-coated balloon (PCB) versus plain
balloon angioplasty (PBA) for the treatment of symptomatic central
venous stenosis in dialysis access.

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Material and methods: Forty dialysis patients with arteriovenous

fistula (AVF) or graft (AVG) and symptomatic central venous stenosis were randomized in two groups: group PCB (plain balloon predilation and PCB; n=20) and group PBA (plain balloon angioplasty;
n=20). Both de novo and restenotic lesions were treated. Primary
endpoints were technical success and target lesion primary patency
(TLPP). Secondary endpoints included complication rates and circuit
primary patency. Individual subgroup longitudinal analysis was performed in group PCB to compare outcomes of PCB versus previous
treatment in the same patients.
Results: To date, two patients were lost to follow-up in group PTA,
and there is one subject left to complete the 6-month follow up
(available in March 2016). According to KaplanMeier analysis, there
were statistically significant differences in both TLPP [median survival: 176.5 days in group PCB vs. 124.5 days in group PTA, p=0.03;
HR: 0.4415 (95% CI: 0.2103-0.9271)] and longitudinal analysis
between treatments [median survival: 177 days in group PCB vs. 91
days in group PTA, p=0.01; HR: 2.999 (95% CI: 1.306-6.888)] in favor
of PCB.
Conclusion: In this study, PCB significantly improved patency of
symptomatic central venous stenosis in dialysis access. Final results
will be announced.

1507.3
Primary patency of drug-eluting balloon angioplasty in
hemodialysis patients with arteriovenous fistula stenoses
B.M.ilda, K..F.Kseolu
Interventional Radiology, Adnan Menderes University, Aydin, Turkey
Purpose: The aim of this article was to assess and compare the rate
of primary patency achieved by drug-eluting balloon angioplasty
(DEBA) with that achieved by conventional balloon angioplasty
(CBA) in hemodialysis patients with arteriovenous fistulas stenoses.
Material and methods: Between January 2013 and January 2015, 52
patients (mean age, 659 years) with significant dialysis arteriovenous fistula stenoses treated with DEBA (n=26) and CBA (n=26) were
retrospectively analyzed. Primary patency rates of fistulas at 6 and
12 months were evaluated by using ultrasonography. KaplanMeier
method was used to compare the primary assisted patency rates
between the two groups.
Results: Immediate postprocedural success was 100% for both the
DEBA and CBA groups. The types of AVF included 41 (78.8%) radiocephalic and 11 (21.2%) brachiocephalic. Mean survival time was significantly higher in the DEBA group compared with the CBA group
[9.81 months (SD 3.53) vs. 7.58 months (SD 3.73), p<0.05]. Primary
patency rates between the DEBA and CBA groups showed a statistically significant difference at 12 months (p<0.05). However, there
were no statistically significant differences observed at 6 months
(p=0.449). There were no statistically significant differences between
patient age, patient gender, fistula type, and primary patency of the
two groups (p>0.05).
Conclusion: DEBA proved to be a safe and effective treatment for
hemodialysis AVF stenoses with high primary patency rate at 12
months.

SS/FC/HL/HTS/CM
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1507.4
Pilot randomized trial of conventional balloon angioplasty
vs. drug coated balloon angioplasty for the treatment of
dysfunctioning autologous dialysis fistulae
W.VanderMijnsbrugge1, N.Verbeeck 2, D.Henroteaux3,
A.Laenen4, S.Cornelissen1, S.Heye1, G.Maleux1
1Department of Radiology, University Hospitals Leuven, Leuven,
Belgium, 2Department of Diagnostic and Interventional Radiology,
Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg,
3Department of Radiology, CHR de la Citadelle, Lige, Belgium,
4Interuniversity Institute for Biostatistics and Statistical Bioinformatics,
KU Leuven and University of Hasselt, Leuven, Belgium
Purpose: To prospectively compare the efficacy of paclitaxel-eluting
balloon (PEB) angioplasty (IN.PACT Admiral, Medtronic, Minneapolis,
MI, USA) versus conventional balloon angioplasty for the treatment
of venous outflow stenoses in dysfunctional autologous dialysis
fistulae.
Material and methods: Patients demographics, including type of
autologous dialysis fistula, previous interventions and clinical symptoms of fistula dysfunction, procedural and postprocedural data,
and primary patency of the fistula, were evaluated at 3, 6, and 12
months of follow-up. Statistical analysis was based on Fishers exact
test and independent t-test.
Results: In total, 64 patients (22F, 42M) were included; 33 patients
underwent PEB angioplasty and 31 patients underwent conventional angioplasty without procedural or postprocedural complications. After 3, 6, and 12 months of follow-up, the primary patency
after PEB and conventional balloon angioplasty was 88% and
80% (P=0.43), 67% and 65% (P=0.76), and 42% and 39% (P=0.95),
respectively.
Conclusion: Primary patency after PEB angioplasty in autologous
dialysis fistulae is numerically superior without statistical significance in this pilot randomized trial. A powered, large multicenter
prospective comparative trial is needed to definitively define the
place of PEB angioplasty in the treatment of dysfunctioning autologous dialysis fistulae.

1507.5
Our experience in the treatment of failing distal radiocephalic
arteriovenous fistulas: two different brands of paclitaxeleluting balloons for juxta-anastomotic stenoses compared
with standard angioplasty (PTA)
G.Coniglio1, S.Santonocito1, S.Giuffrida2, G.Calcara2, P.Malfa2,
P.Bisceglie2, D.Patan2
1Diagnostic Imaging, Policlinico Universitario, Catania, Italy,
2Diagnostic and Interventional Radiology, Azienda Ospedaliera per
lemergenza Cannizzaro, Catania, Italy
Purpose: Our aim was to evaluate the primary and secondary patencies (PPs and SPs) of juxta-anastomotic stenoses of failing distal radiocephalic hemodialytic arteriovenous shunts treated with PTA using
two different brands of drug-eluting balloons (Bard Lutonix 0.14 vs.
IN.PACT Medtronic) compared with standard PTA.
Material and methods: Two groups of 25 patients each with juxtaanastomotic stenosis of distal radiocephalic hemodialytic shunt
treated with angioplasty using paclitaxel-eluting balloon were compared with a control group of 86 patients treated with standard
PTA. Our main objective was to evaluate PP, defined as the absence
of dysfunction of the vascular access, patent lesion or residual stenosis <30% and no need for further reintervention of the target
lesion (TL). PP and SP at 12 months were evaluated with echo colour
Doppler for the whole arteriovenous fistulas (defined as absolute)
and TL.

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Results: Immediate postprocedural technical and clinical success

was 100% for all the patients. At 12 months, absolute PP was 81.8%
IN.PACT, 87.5% Lutonix, and 56.6% standard PTA; TL PP was 90.9%
IN.PACT, 90.6% Lutonix, and 65% standard PTA. Absolute SP was
95.4% IN.PACT, 93% Lutonix, and 80.7% standard PTA; TL SP was
100% IN.PACT, 96% Lutonix, and 80.7% standard PTA.
Conclusion: This study confirms that the use of drug-eluting balloons, after standard angioplasty, improves PP and SP with statistically significant difference in comparison with standard PTA and
decreases reinterventions of TL in juxta-anastomotic stenoses of failing distal radiocephalic dialytic arteriovenous shunts.

1507.6
Comparing secondary patency of covered and bare stents in
hemodialysis patients: a 2-year study
A.Masrani, J.Soni, U.C.Turba, J.Tasse, S.Madassery, O.Ahmed,
B.Arslan
Interventional Radiology, Rush University Medical Center, Chicago, IL,
United States of America
Purpose: Evaluating the secondary patency rates of covered and
bare stents placed in the hemodialysis access circuit.
Material and methods: Medical records were reviewed retrospectively to identify all hemodialysis fistulogram procedures with stent
placements between 2009 and 2012. Indications for stent placement were as follows: residual significant stenosis post-angioplasty,
extravasation secondary to angioplasty, recurrent stenosis within a
short period, central stenosis leading to limb swelling, and pseudoaneurysm. Secondary patency rates for covered and bare stents were
calculated for 6 months, 12 months, 18 months, and 24 months.
Statistical analysis using chi-square test was performed to compare
the secondary patency rates for covered and bare stents.
Results: We identified 227 stent placement events (60 bare, 167
covered). Technical and clinical success was achieved in all cases.
Secondary patency rates were 59.9% covered and 78.3% bare for
6 months (chi-square=6.586, P=0.0102); 50.3% covered and 51.7%
bare for 12 months (chi-square=0.003, P=0.855); 38.9% covered and
36.6% bare for 18 months (chi-square=0.095, P=0.758); and 21% covered and 25% bare for 24 months (chi-square=0.42, P=0.517).
Conclusion: Bare stents showed significantly better secondary
patency than covered stents during the first 6 months of placement in the hemodialysis access circuit. However, 2-year secondary
patency rates were nearly equal for both. This might be due to intimal hyperplasia in metal bare stents.

Free Paper Session

Oncology: liver
1508.1
Novel non-iodinated radiopaque microbeads for transarterial
embolization and transarterial radioembolization of liver
tumors
V.H.Somasundaram1, A.Ashokan1, N.K.Puthukudiyil2,
A.K.K.Unni1, P.Shanmugasundaram3, S.Nair1, K.Manzoor1
1Amrita Centre for Nanosciences & Molecular Medicine, Amrita Institute
of Medical Sciences and Research Centre, Kochi, India, 2Department of
Radiology, Amrita Institute of Medical Sciences and Research Centre,
Kochi, India,3Department of Nuclear Medicine & PET CT, Amrita
Institute of Medical Sciences and Research Centre, Kochi, India

Abstract Book
agents, once the contrast washes out, location of microbeads is
unknown. We have developed and characterized biocompatible
ceramic microbeads with inherent X-ray attenuation properties
that can also be radiolabeled with 188rhenium. Characteristics and
potential applications of these microbeads was demonstrated in
vitro and in vivo (animal models).
Material and methods: Ceramic microbeads prepared using electrospraying technique. GE 8-slice CT scanner used to optimize X-ray
attenuation offered by the microbeads in vitro and in vivo. Toxicity
tested in vitro in peripheral blood mononuclear cells (PBMCs) and
in vivo in Sprague Dawley (SD) rats and New Zealand White rabbits.
Radiolabeling of microbeads with 99mtechnetium optimized using
Capintec gamma counter. Embolizing potential of microbeads and
their degradation studied in healthy rabbit models under GE OEC9800 C-arm.
Results: Ceramic microbeads of two size ranges, which had uniform X-ray attenuation on imaging: 200300 m and 450550 m.
Material was non-toxic to PBMCs at concentration 250 m/ml
and was well tolerated by SD rats at dose 50 mg/kg. In total, <1g
of microbeads were required to bind 100 mCi of 99mtechnetium.
Microbeads could be visualized during and after the in vivo embolization procedure.
Conclusion: The biocompatible ceramic microbeads allow better
intra-procedural monitoring and post-procedural follow-up of transarterial embolization without the need of iodinated contrast agents.
Same microbeads can be radiolabeled with 188rhenium (having
chemical properties same as99mtechnetium) for radioembolization.

1508.2
Radiofrequency versus microwave liver ablation: preliminary
results of a randomized clinical trial
R.Quesada1, A.Radosevic2, J.Sanchez2, A.Agust2, F.Burdo3
1Localized hyperthermia therapy, Cancer Research Group HBP,
Fundaci IMIM, Barcelona, Spain, 2Radiology, Parc de Salut Mar,
Barcelona, Spain, 3General Surgery, Parc de Salut Mar, Barcelona, Spain
Purpose: This registered randomized study aims to compare the
safety and performance of radiofrequency ablation (RFA) and microwave ablation (MWA) in liver tumors and metastasis.
Material and methods: Forty-two patients involving 70 nodules
were randomly treated with RFA (n=31) and MWA (n=11). RFA was
performed with an internally cooled electrode combined with an
injection of hypersaline bolus of 0.5 ml prior and 1.5 minutes from
the beginning of the ablation. The local control, overall survival, and
local or hepatic recurrence were compared.
Results: No statistically significant differences were found with
regards to the pre- and intraoperative patient characteristics. Sixtynine nodules were treated percutaneously, and artificial ascites was
created in 75% of the patients. The mean number of ablations/nodules was 1.40.6 and 1.80.8 for RFA and MWA, respectively. The
mean ablation time/nodule was similar between groups (7.45.2
min vs. 9.46.0 min for RFA vs. MWA). No differences were observed
in the rate of complications (18%) in the local as well as hepatic
recurrences. The mean hospital stay was also similar between
groups (3.99.7 days vs. 5.48.6 days). The tumor ablation was complete and with a safe margin in 79% and 61% of the cases for RFA
and MWA, respectively.
Conclusion: These preliminary results suggest that RFA is safe and
effective in terms of complications and predictability of the ablation
compared to MWA.

Purpose: Transarterial embolization and radioembolization using

microbeads require soluble iodinated contrast agents to aid visualization. However, apart from allergic reactions to iodinated contrast

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1508.3
New drug-eluting beads for sorafenib delivery in HCC
embolization
L.Bdouet1, L.Moine2, E.Servais1, A.Beilvert1, F.Pascale3,
D.Labarre2, A.Laurent4
1R&D, Occlugel, Jouy En Josas, France, 2LabEx LERMIT, CNRS UMR 8612,
Institut Galien Paris-Sud, Chtenay-Malabry, France, 3R&D, Archimmed,
Jouy En Josas, France, 4Neuroradiology, AP-HP Hpital Lariboisire,
Paris, France
Purpose: Sorafenib tosylate (Nexavar, Bayer) is the only TKI
approved for the treatment of unresectable hepatocellular carcinoma. Sorafenib blocks, at low micromolar concentration range,
kinases involved in cell growth and angiogenesis (Wilhelm 2008).
Its local delivery was proposed in TACE emulsion with lipiodol
(Chatziioannou 2013) or after entrapment in PLGA microspheres
(Chen 2014), but no extemporaneous loading on embolization
beads, such as those performed with doxorubicin or irinotecan, was
described. Our purpose was to test a technique of extemporaneous loading of sorafenib on resorbable embolization microspheres
(REM) in terms of dose loaded and release kinetic.
Material and methods: Poly-(ethylene glycol)-methacrylate
REM (50100m) were synthetized by suspension polymerization (Louguet 2014). REM were incubated in an aqueous solution
of sorafenib tosylate (LC laboratories, USA) (1h, room temperature).
Drug release was performed at 37C in saline buffer. Drug loading
and release were quantified using UV spectroscopy. REM degradation was quantified during the release by measuring the PEGylated
degradation products.
Results: Sorafenib loading on REM was 13.6 1.1 mg/mL of wet
beads (n = 6). Sorafenib delivery was quite linear and sustained until
the complete bead hydrolysis without any burst (5% at 3 h, 50% at
12 h, and 100% at 24 h). The release strongly correlated with REMs
degradation (rho = 0.942, p = 0.0018; Spearman). Sorafenib did not
induce formation of aggregates that could compromise REM injection in the microcatheter.
Conclusion: Consistent amount of sorafenib tosylate could be
loaded extemporaneously on resorbable PEG-hydrogel microspheres and its release was linear during bead degradation.

1508.4
Percutaneous electrochemotherapy of malignant main portal
vein thrombosis: a prospective case series
L.Tarantino1, G.Busto2, A.Nasto3, R.Fristachi4, L.Cacace4,
M.Talamo5, P.Ambrosino6, P.Gallo7, P.Tarantino6, C.Accardo5
1Interventional Hepatology Unit, A. Tortora Oncology Hospital, Pagani,
Italy, 2Medical Oncology Unit, A. Tortora Oncology Hospital, Pagani,
Italy, 3General and Oncologic Surgery Unit, A. Tortora Oncology
Hospital, Pagani, Italy,4Anatomic Pathology Department, A. Tortora
Oncology Hospital, Pagani, Italy, 5Radiology Department, A. Tortora
Oncology Hospital, Pagani, Italy, 6Department of Clinical Medicine
and Surgery, Federico II University, Naples, Italy,7Internal Medicine and
Hepatology, Campus Biomedico University, Rome, Italy
Purpose: We report our experience in thrombosis of portal vein
and/or first-order branches (Vp3-4PVTT) from hepatocellular carcinoma (HCC) treated with percutaneous electrochemotherapy (ECT).
Material and methods: Six cirrhotics (5 males; 6185 years, 4
in Child-Pugh A class, 2 in Child-Pugh B class), prevously studied with three-phase CT, contrast-enhanced ultrasound (CEUS),
and US guided percutaneous biopsy of the thrombus, underwent
ECT(Cliniporator Vitae, IGEA, Carpi, Italy) of Vp3-4PVTT and the associated HCC nodule in the same session under general anesthesia.
Results: Twenty-four hours after treatment, CEUS showed complete absence of enhancement of the treated thrombus in all cases.

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Post-treatment biopsy showed apoptosis and necrosis of tumor cells

in all cases. The follow-up ranged from 3 to 12 months (median: 8
months). In 1 patient, the 3-6-9-12 months CEUS and CT demonstrated complete recanalization of the treated PVTT; in another
patient, 3-6-9 months CEUS and CT showed a partially patent portal
vein, and the other 3 patients (8, 4, and 3 month follow-up, respectively) showed avascular complete thrombosis at CEUS and CT. In all
the 5 patients, CEUS and CT showed absence of abnormal intravascular or perivascular enhancement, consistent with residual tumor
or local recurrence. One patient was lost to follow-up because of
death from gastrointestinal hemorrage 5 weeks after ECT.
Conclusion: ECT seems effective and safe for curative treatment of
Vp3-Vp4 PVTT from HCC.

1508.5
Hypervascular HCC TACE performed with M1 DC Bead: first
long-term follow-up results
P.Lucatelli1, R.Argiro2, M.Corona2, F.Fanelli1, M.Bezzi2, C.Cirelli3,
S.G.Corradini3, C.Catalano2
1Interventional Radiology Unit, Department of Radiological Sciences,
Sapienza - University of Rome, Rome, Italy, 2Vascular and Interventional
Radiology Unit, Sapienza University of Rome, Rome, Italy, 3Division
of Gastroenterology, Department of Clinical Medicine, Sapienza
University of Rome, Rome, Italy
Purpose: To report the first long-term results of epirubicin-preloaded 75150 m (M1)/100300 m DC Bead TACE in the treatment
of hypervascular HCC.
Material and methods: Between 2014 and 2015, 49 typical hypervascular HCC in 39 patients (male n=29; mean age 67,413.3 years)
were prospectively enrolled in the study. All cases were not fit for
surgery; indications, obtained from the multidisciplinary board,
were BCLC-A (n=17) and BCLC-B (n=22), based on MDCT/MR
scans. The TACE procedure was highly standardized: cone beam
CT-assisted procedure; superselective microcatheterizazion (2.7
Fr); embolic agent: 100 mg of epirubicin divided in vials of 75150
m and 100300 m particles; embolization protocol: M1 particles
were injected first; only if arterial flow arrest was not achieved, 150
300 particles were injected till stasis. Procedures were categorized
according to a novel score identifying the degree of superselective
microcatheterization achieved. Results were evaluated, according
to mRECIST criteria, on MDCT/MRI at 1 month, 3/6 months and 9/12
months.
Results: In 19 TACE cases, the score was 0 (no non-target sub-segmental artery embolization), while in 30 TACE cases, the score was 1
(1 non-target sub-segmental artery embolization).
At 1-month follow-up, the following was observed: complete
response (CR), 51%; partial response (PR), 46.9%; stable disease (SD),
2.1% and objective response (OR), 97.9%.
At 36-month follow-up, CR was 33.3%, PD 42.2%, SD 24.4% and OR
75.5%.
At 912-month follow-up, CR was 47.2%, SD 41.6% progressive disease 1% (in 11) and OR 88.8%.
In the follow-up period, 10 patients required a second TACE, and no
complication was observed.
Conclusion: TACE performed with 75150 m (M1) DC Bead provides
excellent long-term control of HCC burden, with a few re-treatment
sessions.

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1508.6
Feasibility, safety and early efficacy of 70150-m drug-eluting
beads loaded with irinotecan (M1-DEBIRI) for the treatment of
unresectable hepatic colorectal metastases
O.Akinwande1, R.C.G.Martin2
1Radiology, Johns Hopkins University, Baltimore, MD, United States
of America, 2Surgery, Division of Surgical Oncology, University of

Abstract Book

Results: First in vitro tests demonstrated a capable TIPS stent graft

design with integrated electronics in a stable PTFE covering after
crimping. Pressure measurements with accuracy of 1.2 mmHg at 1
MHz could be acquired from the inner surface of the stent graft.
Conclusion: Non-invasive pressure measurements after TIPS via
integrated sensors within the PTFE membrane provide a suitable
way of monitoring patency. Further in vivo tests will indicate potential implementation into a product.

Louisville, Louisville, KY, United States of America

Purpose: To evaluate the feasibility, safety and early efficacy of
70150-m drug-eluting beads loaded with irinotecan (M1-DEBIRI)
for treating unresectable hepatic colorectal metastases.
Material and methods: An Institutional Review Board-approved,
prospective, single-arm, multi-institutional treatment registry was
evaluated from February 2009 to August 2013. A total of 15 consecutive patients presenting with liver-dominant metastatic colorectal
cancer (mCRC) were treated with M1-DEBIRI.
Results: The patients underwent 32 DEBIRI treatments. In 75% of the
patients, 100% of the prescribed dose was delivered before complete stasis. In 97% of the patients, at least 50% of the prescribed
dose was delivered. The median prescribed dose was 100 mg (100
200 mg), and the median delivered dose was also 100 mg (25100
mg). There was grade-2 abdominal pain after one treatment (3%).
In another patient, increased total bilirubin (1.1 mg/dL to 3.1 mg/
dL) was observed after one treatment. There was 42% reduction in
median carcinoembryonic antigen (CEA) and 33% RECIST response.
Modified RECIST and EASL responses were both 73%. Disease control rate was 93%. Hepatic progression-free survival and overall survival were 8 and 13 months, respectively. One patient was downstaged to resection (6%).
Conclusion: M1-DEBIRI appears to be safe, feasible and effective for
the treatment of mCRC. Larger studies are needed to validate these
findings.

Free Paper Session

TIPS, portal vein intervention and BRTO
1509.1
Integrated stent graft for non-invasive pressure monitoring
after transjugular intrahepatic portosystemic shunt (TIPS)
implantation
C.Spink1, W.Krautschneider2, J.Bibin2, D.Schrder2, R.Fischbach3,
M.Braunschweig4, J.-H.Buhk 5, G.Adam1, A.Koops6
1Diagnostic and Interventional Radiology, University Medical
Center Hamburg-Eppendorf, Hamburg, Germany, 2Nanoelectronics,
Technical University Hamburg-Harburg, Hamburg, Germany, 3Institute
for Integrated Circuits, Fraunhofer Society, Dresden, Germany,
4Competence Center Research & Development, First Sensor AG,
Dresden, Germany, 5Neuroradiological Diagnostics and Intervention,
University Medical Center Hamburg Eppendorf, Hamburg, Germany,
6Institute for Radiology and Interventional Therapy, Vivantes Clinic
Berlin, Berlin, Germany
Purpose: Design and in vitro testing of a novel stent graft with integrated pressure sensors within the stent covering, capable of wireless digital data transmission for non-invasive pressure monitoring
after TIPS.
Material and methods: We designed 15 TIPS stent grafts (100 x 10
mm) with integrated pressure sensors at both ends within layers of
polytetrafluorethylen (PTFE), mountable on 16F applicators. Digital
data conversion could be performed by integrated microcontrollers
within the PTFE membrane providing energy and data transfer by
inductive coupling. In vitro measurements were simultaneously
taken from both sensors.

1509.2
TIPS: is the underdilation of nitinol stents an illusion?
A.Mollaiyan1, M.Rssle2, D.Bettinger3
1Klinik fr Radiologie, Universittsklinikum Freiburg, Freiburg,
Germany, 2Praxiszentrum fr Gastroenterologie und Endokrinologie,
Praxiszentrum, Freiburg, Germany, 3Klinik fr Innere Medizin II,
Universittsklinikum Freiburg, Freiburg, Germany
Purpose: A common approach in transjugular intrahepatic portosystemic shunt procedures is to employ a nitinol stent with a relative large nominal diameter and to dilate it primarily to a smaller
one. This so-called underdilation is believed to reduce the post-TIPS
encephalopathy rate through a smaller shunt diameter. However,
nitinol stents possess a predetermined shape memory that tends to
passively dilate them to their nominal diameter. The purpose of this
study was to observe the effect of underdilation of nitinol stents in
time.
Material and methods: Angiographic measurements of stent diameters from 100 patients who had received a nitinol stent in our institution were performed shortly after TIPS placement and at a followup revision.
Results: Mean clinical follow-up time was 3 months. At the time of
intervention after underdilation of a 10-mm stent with an 8-mm balloon, the average stent diameter was 7.7 0.8 mm. At follow-up, the
diameter measured 9.4 0.9 mm with a mean dilation of 0.7 0.8
mm/month. After dilation of a 10 mm stent with a 10-mm balloon,
the diameter measured 8.2 0.9 mm with a subsequent deployment to 9.8 0.7 mm, corresponding to an increase of 0.3 0.5 mm/
month. All differences were statistically significant. No differences
between stent graft and bare stents were detected.
Conclusion: Underdilation has only a temporary effect. Around
3 months after implantation, the stent attains its predetermined
nominal diameter. This approach is not then a valid alternative for a
longlasting prevention of post-TIPS encephalopathy.

1509.3
Three-dimensional image fusion guidance for transjugular
intrahepatic portosystemic shunt in cirrhotic patients
H.Derbel1, V.Tacher1, A.Petit1, M.Chiaradia1, F.Ridouani1,
D.Azoulay2, C.Duvoux3, H.Kobeiter1
1Radiology, Henri Mondor University Hospital, Crteil, France,
2Abdominal Surgery, Henri Mondor University Hospital, Crteil, France,
3Hepatology, Henri Mondor University Hospital, Crteil, France
Purpose: To assess the efficiency and the safety of transjugular intrahepatic portosystemic shunt (TIPS) guided by image fusion of preprocedural portal-phase computed tomography with intraprocedural fluoroscopy.
Material and methods: Sixteen cirrhotic patients (12 male; median
age: 57 years) were prospectively enrolled in our interventional unit
for TIPS creation from January 2015 to January 2016. All procedures
were performed in an interventional suite equipped with flat panel,
CBCT and fusion technique under general anesthesia. All TIPS were
created under image fusion guidance. Specifically, after catheterization of the hepatic vein, an unenhanced CBCT acquisition was performed. On a postprocessing station, acquired CBCT volume was

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overlaid on preprocedural portal phase CT images. A virtual needle path between hepatic vein and portal branch was created using
dedicated software. Subsequently, the 3D virtual path was overlaid
on 2D fluoroscopy for guidance of portal branch canulation.
Results: Procedures were technically successful in 15 out of the
16 patients (94%). The failure occurred in one case due to the anatomical complexity and severe liver dysmorphia. The main dose
area product was 99.25 Gy.cm. The average fluoroscopy time
was 13 min 30 s. No periprocedural complications occurred. Stent
patency was noted in all patients (median follow-up of 6 months).
Encephalopathy occurred in two patients and was treated by stent
recalibration.
Conclusion: The 3D image fusion guidance for TIPS was feasible,
safe and effective in these patients. By identifying the virtual needle
path, CBCT and preprocedural CT image fusion enable realtime multiplanar guidance facilitating TIPS creation.

1509.4
Plug-assisted retrograde transvenous obliteration (PARTO)
for gastric variceal bleeding: comparison of its efficacy with
balloon-occluded retrograde transvenous obliteration (BRTO)
U.B.Jeon, J.Y.Jang, J.H.Park
Radiology, Pusan National University Yangsan Hospital, Yangsan,
Korea
Purpose: To assess the feasibility of plug-assited retrograde transvenous obliteration (PARTO) in active gastric variceal bleeding, and
to compare its efficacy with that of balloon-occluded retrograde
transvenous obliteration (BRTO) using ethanolamine oleate (EO) or
sodium tetradecyl sulfate (STS).
Material and methods: In total, 38 patients with active gastric variceal bleeding due to liver cirrhosis were referred for radiological intervention. BRTO with EO (n=11) or STS (n=9) was attempted
in 20 patients, and PARTO was attempted in 18 patients. Technical
and clinical sucess, recanalization of gastric varix (GV) on CT, complications, and fluoroscopic time were compared between the two
procedures.
Results: Techinical and clinical sucess was 55% (BRTO) vs. 88.9%
(PARTO). In total, 22 patients were followed up for 61769 days
(mean 672.5 days) with CT scan. GV (n=20) was obliterated during
the final follow-up except in two patients after BRTO. No major complication occurred in all cases. Mean fluoroscopic time was 29 min 46
s (BRTO) vs. 22 min 8 s (PARTO).
Conclusion: PARTO is better than BRTO for the treatment of gastric
varices in terms of the success rate, obliteration of GV, and fluoroscopic time.

1509.5
Simultaneous trans-hepatic portal and hepatic vein
embolization before major hepatectomy: the liver venous
deprivation technique
B.Guiu1, P.Chevallier2, A.Denys3, M.-A.Pierredon1, L.Escal1,
V.Schembri1, J.Ramos4
1Radiology, St-Eloi University Hospital, Montpellier, France, 2Radiologie,
CHU Archet, Nice, France, 3Radiology and Interventional Radiology,
CHUV, Lausanne, Switzerland, 4Pathology, St-Eloi University Hospital,
Montpellier, France
Purpose: To assess the technical feasibility, safety, and efficacy of
the liver venous deprivation (LVD) technique that combines both
portal and hepatic vein embolization during the same procedure for
liver preparation before major hepatectomy.
Material and methods: Seven patients [mean age: 63.6 years (42
77 years)] underwent trans-hepatic LVD for liver metastases (n=2),
hepatocellular carcinoma (n=1), intrahepatic cholangiocarcinoma

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(n=3), and Klatskin tumour (n=1). The PVE procedure was conducted
using n-butyl-cyanoacrylate (NBCA). The right hepatic vein (HV) was
accessed through the trans-hepatic route and embolized using an
Amplatzer Vascular Plug II (St-Jude Medical, Plymouth, MN) of 1822
mm. Then, the embolization of the distal branches of the right HV
as well as collaterals (inter-hepatic vein communications when visible) was conducted using NBCA. Assessment of future remnant liver
(FRL) volume, liver enzymes, and histology was performed.
Results: Technical success was 100%. No complication occurred
before surgery. Resection was performed in 6/7 patients. CT scan
revealed hepatic congestion in the venous-deprived area (6/7
patients). A mean of 3 days (range: 18 days) after LVD, transaminases increased (AST: from 4224 U/L to 103118 U/L, ALT: from
4525 U/L to 163205 U/L). Twenty-three days (range: 1330 days)
after LVD, FRL increased from 28.2% (range: 22.4%33.3%) to 40.9%
(range: 33.6%59.3%). During the first 7 days, venous-deprived liver
volume increased (+13.4%) probably reflecting vascular congestion, whereas it strongly decreased (-21.3%) at 34 weeks. Histology
(embolized lobe) revealed sinusoidal dilatation, hepatocyte necrosis, and important atrophy in all patients.
Conclusion: Trans-hepatic LVD technique is feasible, well-tolerated
and provides fast and important hypertrophy of the FRL. This new
technique needs to be further evaluated and compared to portal
vein embolization.

1509.6
Prospective comparative study of different strategies to
inducefuture liver remnant (FLR) hypertrophyin 118 cases of
major hepatic resection
P.Marra, M.Venturini, C.Sallemi, F.Ratti, L.Aldrighetti,
A.DelMaschio, F.DeCobelli
Radiology, Vita-Salute University, San Raffaele Hospital, Milan, Italy
Purpose: Liver failure is a severe complication of major hepatic
resections. We prospectively compared percutaneous portal vein
embolization (PVE), portal vein ligation (PVL), and associating liver
partition and portal vein ligation for staged hepatectomy (ALPPS) in
terms of the FLR hypertrophy, complications, and clinical outcome.
Material and methods: From January 2004 to January 2015, 118
patients with inadequate FLR underwent procedures to induce
hypertrophy before major liver resection (73=PVE, 27=PVL,
18=ALPPS). PVE was performed percutaneously under US/fluoroscopy guidance with a 4-F catheter using PVA-particles, coils, and
glue. Liver volumetry and FLR were assessed before both the procedure and surgery. Measures of clinical outcome were operating time,
intraoperative blood loss, hospital stay, and morbidity and mortality rates. Blood samples were collected preoperatively and on the
1st, 2nd, and 5th postoperative days to assess liver function (AST, ALT)
and levels of white blood cells (WBC), C-reactive protein (CRP), interleukin-6 (IL-6), and endothelin-1 (ET-1) as markers of inflammatory
surgical stress response.
Results: Preprocedural volumes, comorbidities, and histopathological findings were homogeneous among groups. In the ALPPS
group, FLR increased faster than that in the PVE and PVL groups
(PVE=5.453.17 cc/day, PVL=5.592.19 cc/day, ALPPS=21.0311.09 cc/
day, p<0.05). More severe complications were recorded in the ALPPS
group compared with the PVE and PVL groups. Postoperative levels
of AST, ALT, WBC, CRP, IL-6, and ET-1 increased more after the first
surgical stage in the ALPPS group compared with the levels in the
PVE and PVL groups.
Conclusion: PVE and PVL comparably induce FLR hypertrophy.
ALPPS induces hypertrophy faster but with more complications. PVE
is preferable over PVL when two-stage hepatectomy is unnecessary.
ALPPS should not be considered a substitute for PVE or PVL but a
technique to extend resectability.

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Abdominal aorta
2206.1
A single-centre experience of the Nellix endovascular
aneurysm sealing (EVAS) in patients with challenging aortic
anatomy
P.Szopinski, E.Pleban, T.Dobrowolski, J.Iwanowski
Clinic of Vascular Surgery, Institute of Haematology and Transfusion
Medicine, Warsaw, Poland
Purpose: The aim of the study was to present our experience of
the treatment of patients with aortic aneurysms with challenging
anatomy.
Material and methods: From January 2014 to February 2016, 38
patients (33 male, 5 female), aged 5691 years, underwent the
implantation of Nellix stent graft for AAA after failed EVAR and
TEVAR. The procedures were performed under spinal, general, or
local anesthesia.
Results: About 45% of the procedures were performed outside the
instructions for use. One celiac, five SMA, and twenty-six renal chimneys were inserted from an axillary access. One aorto-uni-iliac Nellix
was implanted with cross-over bypass. In one of the post-EVAR
cases, there was type I endoleak detected in control angiography.
The mean length of hospital stay was 6 days. Three patients required
secondary intervention during follow-up. Two patients were readmitted due to secondary aneurysm rupture. In the first case, open
conversion was performed, Nellix was explanted and replaced with
a bifurcated graft. In the second case of EVAR, there was a need to
implant two additional Nellix chimneys. Occlusion of the uniiliac
stent graft was treated with successful embolectomy. No deaths
occured during the follow-up; all prostheses remained patent.
Conclusion: EVAS is an innovative concept in the treatment of AAA
designed to target the causes of secondary interventions, such
as endoleaks and migration. The promising results of the chimney technique in patients with pararenal aneurysms offer an alternative to open surgery or custom-made fenestrated or branched
stent grafts, reducing costs and shortening the time of waiting for
interventions.

2206.2
Clinical outcome after endovascular aneurysm sealing of
abdominal aortic aneurysms (EVAS): a retrospective cohort
study
M.Karouki1, C.Swaelens1, L.Iazzolino1, R.G.McWilliams2, R.Fisher1,
A.England3, F.Torella1
1Vascular Surgery, Royal Liverpool University Hospital, Liverpool,
United Kingdom, 2Interventional Radiology, Royal Liverpool University
Hospital, Liverpool, United Kingdom, 3Lecturer in Radiography,
University of Salford, Manchester, United Kingdom
Purpose: To present the clinical outcome of endovascular sealing
of abdominal aortic aneurysms (EVAS) with the Nellix endoprosthesis in patients with abdominal aortic aneurysms treated at our
institution.
Material and methods: This was a retrospective, single-centre,
observational cohort study. A departmental database was interrogated in order to extract demographics, clinical information and
outcome of all patients treated with EVAS between December 2013
and December 2015. Outcome measures included technical success
(successful device deployment and absence of any endoleak at completion angiography), mortality, major complications, incidence of
endoleaks, aneurysm rupture and reintervention.

Abstract Book
Results: Sixty-four patients (48 men) with a mean (SD) age of 78 (6.9)
years were successfully treated with EVAS, with no 30-day mortality. The cohort included one patient with ruptured aneurysm, seven
patients with late complications of previous aortoiliac repairs (two
open, five endovascular) and three patients who required a total of
six visceral chimneys for juxtarenal aneurysms. Four patients (6%)
suffered major postoperative complications and three required
intervention. There were no early or late endoleaks or aneurysm
ruptures. After a median (range) follow-up of 12 (0-24) months,
there was no aneurysm related mortality; two patients (3%) required
aneurysm-related late interventions.
Conclusion: EVAS can be performed with good early- and mid-term
results. Longer follow-up on larger cohorts are needed to prove the
efficacy of this technique.

2206.3
Monocentric evaluation of home-made versus standard renal
fenestrations in endovascular aortic repair for juxtarenal
aortic aneurysms
C.Caradu, J.Morin, D.Midy, E.Ducasse
Vascular Surgery, CHU Pellegrin, Tripode, Bordeaux, France
Purpose: To evaluate early-term results of renal fenestrated endovascular aortic repair (F-EVAR) with home-made (HM) vs standard
(ST) fenestrations for juxtarenal aortic aneurysms (JAA) in patients
contraindicated for open surgery.
Material and methods: Procedure logs and follow-up of all consecutive patients treated in our vascular center from January 2010 to
March 2015 were reviewed.
Results: Twenty patients (17 men) were included in the HM
group and 111 (106 men) in the ST group. Mean age was 74.76.9
vs 71.48.5. Body mass index (BMI) was higher in the ST group
(p=0.006), and pre-operative renal insufficiency rate was higher
in the HM group (p=0.0003). Six HM patients (30%) were treated
in emergency (p<0.0001). Mean number of reconstructed vessels/
patient was 2.60.7 vs 3.00.6 (p=0.005), with 21 HM renal fenestrations vs 207 ST. Two cannulation failures of ST fenestrations were
observed (p=0.66). There was no significant difference between
the groups in terms of post-operative renal insufficiency/infarction
rates. Peri-operative mortality was significantly higher in the HM
group (15% vs 3%, p=0.016). Two (1.0%) <30-day target vessel occlusions were observed in the ST group (p = 0.66), and 1 (4.8%) vs 1
(0.5%) target vessel dissection (p=0.05). At 12 months, survival rates
were 85.0% vs 91.8% (p=0.1) and target vessels primary patency
rates were 100% vs 97.3% (p=0.5).
Conclusion: Short-term results of HM renal fenestrations were inferior to those of ST fenestrations, with higher 30-day mortality rates
but in more challenging patients. At 12 months, no significant difference was found for renal function, endoleaks, target vessels
patency, and survival rates.

2206.4
Percutaneous EVAR: what mortality and morbidity should
we quote our patients as the standard for minimally invasive
aneurysm repair?
A.Mathew, F.Sakhinia, S.M.Thomas, D.Kusumawidjaja, J.M.Regi,
D.Turner, T.J.Cleveland, S.D.Goode
Vascular Radiology, Sheffield Vascular Institute, Sheffield, United
Kingdom
Purpose: Suture-mediated closure devices have facilitated the evolution of endovascular aneurysm repair (EVAR) from surgical to percutaneous access, reducing patient discomfort, complications, and
hospital stay. We review our departmental results for percutaneous

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EVAR (PEVAR) and further propose a new safety standard for aneurysm treatment.
Material and methods: All PEVARs between June 2009 and June
2015 were included. Our data includes patient demographics, AAA
characteristics, CFA diameters, anaesthetic technique, device characteristics, complications, follow-up CT findings and mortality.
Analysis of outcomes between standard versus ultra-low profile
devices was conducted.
Results: A total of 143 patients were analysed. Of which, 85% were
male with a mean age of 77 years. There were total 10 emergency
PEVAR cases. Mean AAA size was 62 mm and mean neck length 32
mm. The 30-day mortality was 0%. Mean CFA diameter was 10 mm
and mean length from the skin to CFA was 32 mm. Closure device
used comprised 89% Proglide and 8% Prostar. In total, 53% procedures were performed under regional anaesthesia, 40% under local
anaesthesia and 7% under general anaesthesia. The cases comprised
9% groin complications, including 4 conversions to surgical closure
and 9 haematomas. Ultra-low profile device (1314 Fr) use led to a
shorter hospital stay. There was a significant difference between the
percentage of patients who stayed 2 days or less (24% standard vs.
49% ultra-low profile; p-value 0.006).
Conclusion: We report low groin complication rates and no 30-day
mortality in our PEVAR service at a large tertiary teaching hospital.
In the era of percutaneous low-profile EVAR, a minimal (close to 0%)
30-day mortality for aneurysm treatment should be the new safety
standard for patients.

2206.5
Three-dimensional image fusion guidance for type II
endoleaks treatment after EVAR: with Onyx
F.Ridouani1, V.Tacher1, K.You1, P.Desgranges2, J.F.Deux1,
H.Kobeiter1
1Radiology, Henri Mondor University Hospital, Crteil, France, 2Vascular
Surgery, Henri Mondor University Hospital, Crteil, France
Purpose: To evaluate the safety and feasibility of type II endoleak
embolization after endovascular repair of the abdominal aorta
(EVAR) with ethylene vinyl alcohol copolymer (Onyx) using CBCT
and fusion imaging guidance.
Material and methods: Forty patients were treated in our institution between January 2011 and January 2016 for type II endoleaks
either by transarterial approach (TAA) or direct percutaneous sac
injection (DPSI). All procedures were performed in an interventional
suite equipped with flat panel, CBCT, and fusion technique. Both
approaches were guided by image fusion of preprocedural CT with
intraprocedural fluoroscopy. The image fusion technique enables
either a virtual needle path or 3D arterial road-map to the endoleak
site.
Results: Thirty-two patients (25 males) were treated by TAA using
systematically Onyx ( coils). Twenty-eight patients (87.5%) had an
initial technical success. Four patients (12.5%) had a technical failure
and were subsequently treated by DPSI. DPSI using systematically
Onyx ( coils) was performed in 12 patients (11 male), including the
4 cases of TAA failure. Ten out of the 12 patients had an initial technical success. No major complications occurred. The median volume
of Onyx used was 4.5 ml. Median procedural time and contrast volume were 87 minutes and 75 ml for TAA and 32 min and 6 ml for
DPSI. The final technical success was obtained in 32 patients (82%),
with a median follow-up of 52 months.
Conclusion: Three-dimensional image fusion guidance for both TAA
and DPSI was safe and feasible for post-EVAR type II endoleaks treatment using Onyx.

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2206.6
Human Thiel-embalmed cadaveric aortic model with perfusion
for aortic stent graft training and device development
J.G.Houston1, H.M.McLeod2, J.Robertson2, J.Anwar1, R.Bhat1,
A.Melzer3, T.Wilkinson4
1Clinical Radiology, Ninewells Hospital, Dundee, United Kingdom,
2Cardiovascular and Diabetes Medicine, University of Dundee, Dundee,
United Kingdom, 3Institute for Medical Science and Technology,
University of Dundee, Dundee, United Kingdom, 4Anatomy, University
of Dundee, Dundee, United Kingdom
Purpose: The introduction of Thiel-embalmed human cadavers
offers significant advantages over animals or fresh/frozen cadavers. The Thiel cadavers retain flexibility and large vessel patency as
well as offering a range of human anatomy and underlying arterial
disease. We evaluated the human Thiel-embalmed cadavers with
the addition pulsatile flow in the aorta as a model for training and
device development.
Material and methods: Extracorporeal pulsatile antegrade heated
fluid flow of 2.5 L per minute at 60 beats per minute was delivered
by bypass pump, (HL30 Maquet, Germany) directly into the aorta of
the Thiel cadavers (age range 78-101 years), via a surgically placed
port in the aortic root (Portex, Smith Medical, USA), and temperature and aortic pressure was measured. Pre- and post-procedural CT
(Siemens Biograph MCT, DE) and procedural fluoroscopy (GE, USA)
were undertaken to measure, plan, perform and follow-up procedure. Medtronic Valliant thoracic and Endurant aorto-uniliac and
bifurcated stent grafts were implanted via surgical cutdown on the
common femoral arteries.
Results: Pre-procedural CT allowed sizing, device selection procedural planning. Conventional angiography, roadmap and fluoroscopy imaging was performed. Aortic stent grafts were all successfully deployed in anatomically acceptable positions in all cadavers. Ancillary procedures of renal angioplasty were performed. The
model allows the use of standard interventional devices, equipment
and imaging. Pre-and post-procedure CT imaging allowed device
sizing, procedure planning and post-implantation assessments.
Conclusion: The human Thiel cadaver, offers an anatomically and
physiologically accurate model to simulate aortic stent graft endovascular procedures which provides an alternative for stent graft
training and device testing.

Free Paper Session

Gynaecological intervention
2207.1
Tunable delivery of niflumic acid from resorbable embolization
microspheres for uterine fibroid embolization
L.Bdouet1, L.Moine2, E.Servais1, A.Beilvert1, D.Labarre2,
A.Laurent3
1R&D, Occlugel, Jouy En Josas, France, 2LabEx LERMIT, CNRS UMR 8612,
Institut Galien Paris-Sud, Chtenay-Malabry, France, 3Interventional
Neuroradiology, APHP Hopital Lariboisire, Paris, France
Purpose: The loading of embolization microspheres with a nonsteroidal anti-inflammatory drug has been proposed to reduce pain
after fibroid embolization. We propose to load resorbable embolization microspheres (REM) with niflumic acid (NFA) because the acid
has high activity on COX-1 and more interestingly on COX-2 (IC50=
0.1 M 28 g/L) (Barnett 1994), which is overexpressed in fibroids
(Ke 2013) and is involved in the inflammatory reaction in the uterus
after embolization. Our purpose was to determine the amount of
NFA that could be loaded and whether its release could be tuned
according to the REM degradation rate.

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Material and methods: Three types of REM (500700 m) with different degradation times (24 h, 2 days, and 5 days) were loaded with
NFA (2 h, RT). Drug release was performed in PBS (37C). Loading and
release were quantified by UV spectroscopy. REM degradation was
quantified by measuring PEGylated degradation products during
the NFA delivery.
Results: The loading of NFA for the 3 groups of REM was 5.08 0.7
mg/mL of wet beads (n = 18). In PBS, 60% of the loading was eluted
in the first hour, followed by a sustained release of the 40% remaining drug, which lasted until the complete bead degradation, i.e, 1,
2, or 5 days. NFA did not generate REM aggregates. REM injection
through a microcatheter (ID = 650 m) was easy.
Conclusion: The amount of NFA loaded on REM and the sustained
delivery of a few milligrams during REM degradation should be sufficient to inhibit prostaglandin synthesis in fibroids and the uterus.

2207.2
Uterine artery embolisation for adenomyosis: portending
factors affecting the clinical outcome
A.Cannavale1, D.Miligkos2, B.Karunyam2, B.Maher3, T.J.Bryant3,
N.Hacking3
1Department of Radiology, East Kent Hospitals University NHS
Foundation Trust, Canterbury, United Kingdom, 2Department of
Obstetrics and Gynecology, University Hospital Southampton,
Southampton, United Kingdom,3Department of Clinical Radiology,
University Hospitals Southampton, Southampton, United Kingdom
Purpose: To investigate any potential factor that can affect the clinical success of uterine artery embolisation (UAE) for adenomyosis
(AM).
Material and methods: We retrospectively collected data from
patients who underwent UAE for AM between 2010 and 2012.
Inclusion criteria were as follows: menorrhagia, dysmenorrhea with
or without bulk symptoms, MRI diagnosis of isolated uterine AM or
AM coexisting with uterine leiomyomata. MRI was performed before
embolisation and at 3, 6, and 12 months of follow-up. The following
imaging/procedural features were analysed and correlated with the
clinical success of the procedure by using uni/multivariate analysis:
pattern of AM (focal or diffuse); percentage of infarcted AM tissue
(technical success if>90%); AM baseline volume; AM volume reduction and uterine volume reduction.
Results: Forty patients underwent treatment with UAE: 15 patients
(37.5%) had pure adenomyosis and 25 (62.5%) had adenomyosis
associated with fibroids. Post-procedural volume of AM was not significantly different in patients who completely healed from symptoms vs patients who had only improvement of symptoms (mean
volume 73.0 vs 43.0ml, p=0.47), but it was significantly different vs
patients who had no change or worsening of symptoms (mean volume 259.0 vs 73.0 ml, p=0.03). Pre- and post-operative uterine volume correlated only with improvement of bulk symptoms, but not
with menorrhagia or dysmenorrhea. Otherwise devascularization
>90% was significantly correlated with improvement of menorrhagia (p=0.05): patients with less than 90% of AM infarction showed
a significant higher mean symptom score for menorrhagia (mean
score=0.72, range 0-3).
Conclusion: Adenomyosis volume and degree of devascularisation
after UAE are the main factors related to the clinical success.

Abstract Book

2207.3
Analysis of patient-controlled analgesia to define the time
course of pain following uterine artery embolization
S.Islam1, S.Ameli-Renani2, L.Ratnam2, L.Mailli1, A.-M.Belli1,
R.Das1
1Interventional Radiology, St. Georges Hospital, London, United
Kingdom, 2Department of Radiology, St. Georges Hospital, London,
United Kingdom
Purpose: Effective management of the post-procedure pelvic pain
after uterine artery embolisation (UAE) remains challenging and is
the primary reason for overnight admission. The aim is to evaluate
the time course of pain in the 24 hours following UAE.
Material and methods: In this retrospective study, the records of
PCA usage and pain scores after UAE in 34 patients were reviewed
and analysed. PCA protocols were standardised using morphine at a
concentration of 1 mg/ml. PCA-delivered morphine usage and pain
score (1-4) documented in the PCA chart were used as objective pain
measurements.
Results: The peak mean pain score was observed 2 hours post-procedure at 1.74 (SD 1.4, range 0-4), but gradually reduced after this
time, with mean pain scores of 1.26, 1.08 and 0.71 at 3, 4 and 9 hours,
respectively. The mean peak morphine usage was 10.28 mg/h (SD
1.9 range 0-9) at 45 minutes and subsequently reduced to 6.18 mg/h,
3.85 mg/h, 3.2 mg/h and 1.36 mg/h at 2, 3, 4 and 9 hours, respectively. Further, 86% of patients used less than 3 mg/h of morphine
PCA by 9 hours, with 16% requiring no further morphine PCA after
this time.
Conclusion: These results show the peak pain experienced following UAE is at 2 hours, and the pain levels and morphine requirements reduce significantly following this. This allows us to counsel patients periprocedurally with regards to expectations of postprocedure pain. It also serves as a baseline to compare more novel
methods of pain control targeted at the periprocedural first 8-10
hours.

2207.4
Why gynecologists do not perceive any conflict with IR over
uterine fibroid treatments
E.J.Keller1, M.Crowley-Matoka2, J.D.Collins1, H.B.Chrisman1,
M.P.Milad3, R.L.Vogelzang1
1Division of Interventional Radiology, Northwestern University,
Chicago, IL, United States of America, 2Medical Humanities & Bioethics,
Northwestern University, Chicago, IL, United States of America,
3Division of Reproductive Endocrinology and Infertility, Northwestern
University, Chicago, IL, United States of America
Purpose: To understand how cultural differences between medical
specialists affect clinical decision-making, focusing on the relationships of interventional radiologists (IRs) with gynecologists (OBGs)
and vascular surgeons (VSs).
Material and methods: Eleven years of treatment/specialty utilization data for symptomatic uterine fibroids and endovascular stent
procedures was collected at a single center. This data was supplemented with 36 semi-structured interviews with IRs, OBGs, and
VSs to facilitate a conversational tone. Interview transcripts were
analyzed according to constructivist grounded theory, a wellvalidated method from anthropology for exploring social processes. Key themes were compared across specialties and practice
environments.
Results: IRs shares of endovascular stent placements and uterine
fibroids treatments have remained relatively constant at our institution despite efforts to attract more referrals (p>0.05). Interviewed
physicians within a given specialty possessed unique ways of
describing their roles, affecting how they viewed medical evidence,

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patient outcomes, and their colleagues. For example, gynecologists highly valued forming long-term relationships with patients
and thus the definitiveness of hysterectomy. Conversely, IRs defined
themselves by their minimally invasive procedures and prioritized
uterine fibroid embolization (UFE) due to its less invasiveness. Many
IRs perceived OBGs devaluing UFE as unethical and self-serving,
whereas not one OBG perceived any tension.
Conclusion: Understanding cultural differences between specialties is imperative for fostering better collaboration. IRs, OBGs, and
VSs demonstrated wide-ranging perspectives regarding their roles,
which correlated with how they valued treatments and professional
relationships. For IR, procedures directly relate to their professional
identity, so devaluing UFE is devaluing IR. Since IRs are not trying to
provide womens primary care, OBGs perceive no conflict.

2207.5
The impact of uterine artery embolization on nonenhancing
fibroids
G.Bao, L.Hu, H.W.Charles, A.R.Deipolyi
Radiology, Division of Vascular and Interventional Radiology, NYU
Langone Medical Center, New York, NY, United States of America
Purpose: Fibroid non-enhancement is considered to be a relative
contraindication to uterine artery embolization (UAE) for symptomatic fibroids because embolization is not thought to have an impact
on necrotic fibroids. The purpose was to assess the impact of UAE
on necrotic fibroids and determine imaging predictors of fibroid
shrinkage.
Material and methods: A retrospective review of all women who
underwent UAE for symptomatic fibroids 5/097/14 and underwent
a follow-up MRI 46 months after UAE was included. There were 59
fibroids (5 non-enhancing, 54 enhancing) among 18 women with a
mean age of 46 (range 4053) years. All fibroids were assessed for
size, position (submucosal, subserosal, and intramural), enhancement on subtraction images, and apparent diffusion constant (ADC).
Results: Enhancing fibroids had an average decrease in diameter
of 21% (SE 3%); necrotic fibroids had an average decrease in diameter of 12% (SE 1%) (p=0.2). Multiple linear regression with percent
change in fibroid diameter as the dependent variable and patient
age, pre-UAE fibroid diameter, enhancement, and ADC as independent variables were not significant (p=0.18), though ADC (p=0.04)
and diameter (p=0.03) as independent predictors were significant.
Smaller diameter and higher ADC were associated with greater
decreases in size.
Conclusion: Non-enhancing fibroids did reduce in size after UAE,
perhaps to a lesser extent than enhancing fibroids. Pre-UAE size and
ADC were predictors of diameter reduction but not enhancement.

2207.6
Efficacy and safety of intrafetal radiofrequency ablation for
twin-reversed arterial perfusion sequence: a single-center
experience
P.P.Goffette1, C.Hubinont2, J.M.Biard2, P.Bernard2
1Interventional and Neuro-Interventional Radiology, Saint-Luc
University Hospital, Brussels, Belgium, 2Obstetric and Fetal Medicine,
Saint-Luc University Hospital, Brussels, Belgium
Purpose: To evaluate the technical results and perinatal outcome of
treatment of monochorionic twin pregnancies complicated by twinreversed arterial perfusion (TRAP) by radiofrequency ablation (RFA).
Material and methods: A rare but severe complication of monozygous twin pregnancy is a monochorionic twin pregnancy with an
acardiac twin. In TRAP, the acardiac twin is a true parasite receiving blood from the pump twin (normal fetus) through arterioarterial anastomosis. This condition is associated with a >50% mortality

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of the normal twin because of high-output cardiac failure and polyhydramnios-related preterm birth. The outcome may be improved
by intrauterine arrest of the circulation of the acardiac twin. Over 5
years, 6 consecutive pregnancies with TRAP sequence underwent,
in the interventional suite, intrafetal ultrasound-guided radiofrequency ablation of the acardiac twin using 2 cm Leveen expandable needle electrodes to occlude flow in the umbilical cord of the
acardiac twin. The median gestational age at intervention was 17(+2)
[range 16(+3)20(+3) weeks].
Results: Technical success was obtained in all cases. The effect of
RFA on postoperative cardiac output in the pumping fetus ranged
between 58% and 82%. Preterm premature rupture of membranes
occured in 2 (33%) patients at 1 and 3 weeks after RFA, leading to
early intrauterine death of the pump twin in one patient. Five
fetuses (83%) were delivered alive at a median gestational age of 36
(+2) weeks (range 3438) and had normal physical examination at 6
months of age.
Conclusion: RFA appears to be a safe, successful, and reliable technique in the treatment of TRAP sequence pregnancies.

Free Paper Session

Thoracic aorta
2304.1
An alternative approach for the intractable complication:
trans-catheter closure of anastomotic leakage after ascending
aortic surgery
W.Wu, J.Pu, L.Huang
Interventional Department, Beijing Anzhen Hospital, Capital Medical
University, Beijing, China
Purpose: To evaluate the safety and efficacy of trans-catheter closure of anastomotic leakage after ascending aortic surgery.
Material and methods: From 2011 to 2015, 19 patients (age range
from 25 to 61 years, 15 males) were detected with anastomotic leakage after aortic surgery for non-infective ascending aortic pathology. The mean period after procedure was 12 17 months (range
from 0.5 to 60 months). Trans-catheter closure was attempted in 7
patients; the other 12 patients underwent surgical repair.
Results: The success rate of the technique was 100% in the transcatheter and surgical groups. ADO II were implanted in 5 patients,
ADO I in 2 patients, and coils in 1 patient. There was no death in the
trans-catheter group. However, the in-hospital and 30-day mortality
was 15.6% in the surgical group. Intraoperative blood loss (35 ml vs.
1585 ml, p = 0.001), procedure room time (144 min vs. 450 min, p =
0.003), intensive care unit time (0 h vs. 119 h, p < 0.049), and length
of stay after procedure (3 days vs. 16 days, p < 0.001) were significantly lesser in the trans-catheter group. One residual shunt was
found in the trans-catheter group and gained hemodynamic significance 4 months later. A second intervention was performed, and the
leakage was occluded completely. Follow-up was carried out in all
the patients. There was no significant difference in survival (100% vs.
75.0%, p = 0.193).
Conclusion: The efficacy of trans-catheter closure for leakage after
ascending aortic surgery was persuasive. This technique should be
primarily considered in patients with suitable anatomic condition.

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2304.2
Virtual stenting in EXTENTO: a tool for therapy planning for
coarctation of the aorta (CoA)
H.Mirzaee1, M.Neugebauer1, C.Schumann1, S.Nordmeyer2,
M.Kelm2, L.Goubergrits2, T.Kuehne2, A.Hennemuth1
1Institute for Medical Image Computing, Fraunhofer MEVIS, Bremen,
Germany, 2Department for Congenital Heart Disease and Pediatric
Cardiology, German Heart Center, Berlin, Germany
Purpose: Intravascular CoA treatment removes local aorta narrowing by means of stenting or balloon angioplasty. The correct size
and location of the implant is crucial for a successful treatment, i.e.,
a treatment that results in a reduced pressure gradient. EXTENTO
allows for a simulation-based estimate of the therapy outcome.
The geometric representation of the desired therapy strategy is an
important step in this process.
Material and methods: EXTENTO allows processing of the complete data pipeline from acquired images (flow and anatomy) to the
simulated outcome. The pre-interventional pressure field is computed from 4D flow data. Provided this information, the clinician
can then interactively place a stent in the narrowed aortic region.
Consequently, the result is sent to a simulation server to compute the post-interventional pressure field. Two clinicians from the
German Heart Institute in Berlin were asked to virtually reproduce
six interventions that they performed.
Results: The clinicians were able to recreate all six therapy strategies. They only applied minor changes to the automatically suggested parameterization. By choosing a low stent stiffness, they
were able to reproduce balloon angioplasty. For one case, they retrospectively would have chosen a different strategy because the
pressure field revealed different locations for the pressure gradient
and the local narrowing.
Conclusion: This first evaluation indicates that the virtual stenting
in EXTENTO allows for a fast geometric definition of therapy strategies and that the additionally provided information can lead to an
improved treatment.

2304.3
Endovascular management of chronic symptomatic aortic
dissection (CSAD) with the streamliner multilayer flow
modulator (SMFM): 12-month outcomes from the global
registry
S.Sultan1, E.P.Kavanagh2, F.Stefanov3, M.Sultan1, A.Elhelali3,
V.Lundon1, V.Costache4, E.B.Diethrich5, N.Hynes2
1Vascular & Endovascular Surgery, Western Vascular Institute, Galway,
Ireland, 2Vascular & Endovascular Surgery, Galway Clinic, Galway,
Ireland, 3Biomedical Engineering, GMedTech, Galway Mayo Institute of
Technology, Galway, Ireland, 4Department of Cardio-Vascular Surgery,
European Clinic Polisano Hospital, Sibiu, Romania, 5Cardiovascular and
Thoracic Surgery, Arizona Heart Foundation, Phoenix, AZ, United States
of America

Abstract Book
Results: Morphological analysis exhibited dissection remodelling by
a reduction in longitudinal length of the dissected aorta and false
lumen volume. A statistically significant reduction in the false lumen
index (p = 0.016) at 12 months and increase in the true lumen volume (p = 0.053) confirmed dissection remodelling. All-cause survival
was 85.3 % Twelve-month freedom from neurological events was
100%, and there were no incidences of end-organ ischemia, paraplegia, or renal insult.
Conclusion: SMFM offers immense promise in the treatment of
complex pan-aortic dissection. Results highlight that placement of
SMFM leads to dissection stabilization with no further aneurysm
progression and no retrograde Type A dissection. Treatment using
SMFM resulted in freedom from aortic rupture, neurological stroke,
paraplegia, and renal failure. Further analysis of the global registry
data will reveal long-term outcomes.
Acknowlegments: Ivo Petrov; Lachezar Grozdinski; Rainer Moosdorf;
Ern Remsey-Semmelweis; Klaus Mathias; Sidney Chocron;
Mohamed Nadjib Bouayad

2304.4
Endoleak complications of thoracic endovascular aortic repair
(TEVAR): long-term outcomes and survival
F.Barbosa1, E.DeFebis1, M.Pegorer1, P.M.Brambillasca1, M.Solcia1,
R.Vercelli1, C.Migliorisi1, F.Romani2, C.Russo3, A.G.Rampoldi1
1Interventional Radiology, Ospedale Niguarda, Milan, Italy, 2Vascular
Surgery, Ospedale Niguarda, Milan, Italy, 3Cardiothoracic Surgery,
Ospedale Niguarda, Milan, Italy
Purpose: To assess the endoleak complications and TEVAR survival
rates.
Material and methods: Between July 2005 and August 2015, 123
consecutive patients (104 male and 19 female) who underwent
TEVAR were retrospectively reviewed. Forty-one of the procedures
were emergency ones and 33 were hybrid. The medium-term follow-up was 55 months (5191 months). Cross-tabulations were
checked by a chi-square test or by Fishers exact test. Survival was
analysed by the KaplanMeier product limit method and by Cox
semiparametric regression.
Results: Twenty-one of 123 patients (17%) presented endoleak during the follow-up (type 1=11, type 2=9 and type 3=1). During the follow-up, 11 patients died. Fifteen patients underwent a second procedure due to endoleak, and 5 of these died. There was no difference in the survival rate between hybrid and nonhybrid procedures
groups (p=0.6645) and between elective and emergency groups
(p=0.2678). Futhermore, there was no difference in the survival rate
between the endoleak group and the rest of patients (p=0.1473),
but the necessity of a second endovascular intervention due to
endoleak reduced survival significatively (p=0.0042).
Conclusion: TEVAR is a safe and effective treatment. The necessity
of a second endovascular intervention due to endoleak significantly
reduces survival.

Purpose: To analyse the initial 12-month outcomes of patients

treated for chronic symptomatic aortic dissection (CSAD) with the
streamliner multilayer flow modulator (SMFM). Endpoints included
freedom from rupture and aortic-related death, reduction in false
lumen index, patency of great vessels and visceral branches, and
freedom from stroke, paraplegia, and renal failure.
Material and methods: Out of 876 SMFMs implanted globally, we
have knowledge of 542. To date, 312 patients are maintained in
the global registry, of which 38 patients were identified as having
an aortic dissection (12.2%). Indications included 35 Stanford Type
B dissections, 2 Stanford Type A and B dissections, and 1 mycotic
Stanford Type B dissection.

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2304.5
Evaluation of multilayer flow modulator in management of
complex thoracoabdominal aortic pathology: a systematic
review and meta-analysis
N.Hynes1, A.Elhelali2, E.B.Diethrich3, E.P.Kavanagh1, P.Delassus2,
L.Morris2, S.Sultan4
1Vascular & Endovascular Surgery, Galway Clinic, Galway, Ireland,
2Biomedical Engineering, GMedTech, Galway Mayo Institute of
Technology, Galway, Ireland, 3Cardiovascular and Thoracic Surgery,
Arizona Heart Foundation, Phoenix, AZ, United States of America,
4Vascular & Endovascular Surgery, Western Vascular Institute, Galway,
Ireland
Purpose: The aim of this review is to consider evidence regarding the multilayer flow modulator (MFM) device in management of
patients with complex thoracoabdominal aortic aneurysm (TAAA) or
dissection.
Material and methods: A methodical search of all health databases
was conducted from January 2008 to 2015 for health-related and
biomedical science literature pertaining to MFM. The primary outcome was aneurysm-related survival. Secondary outcomes were allcause survival, stroke, spinal cord ischemia, renal impairment, and
branch vessel patency.
Results: A total of 15 studies (3 prospective studies, 3 observational reviews, and 9 case reports) were included. The mean age of
patients was 68.85 years (+/12.34 years) and mean aneurysm diameter was 6.67 cm (1.57 cm). Technical success reported in 15 studies was 77.2%. Aneurysm-related survival at one year was 78.7%
(3.92%). One-year all-cause survival was 53.7% (3.94%). There
were no reported cases of spinal cord ischemia or renal insult.
Conclusion: MFM appears safe in the management of TAAA, once
operators abide to its Indications for Use. Since MFM is a new technology, there is paucity of long-term follow-up data, a lack of comparative studies, and a requirement for randomized clinical trials
and continued assessment.

2304.6
Endovascular treatment of thoracoabdominal aneurysm using
the octopus technique
M.-Y.Hsu1, I.-H.Su1, C.-M.Chen1, S.-Y.Chu1, S.-Y.Lin1, Y.-H.Lee1,
P.-J.Ko2, J.-H.Tseng1, C.-F.Hung1
1Department of Medical Imaging and Intervention, Chang Gung
Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan,
2Departments of Thoracic and Cardiovascular Surgery, Chang Gung
Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan
Purpose: To report short-term outcome of use of the octopus technique in treating complex thoracoabdominal aneurysm.
Material and methods: Endovascular aneurysm repair of thoracoabdominal aneurysm involving major side branches was performed at single center between June 2014 and January 2016. The
octopus technique was applied using standard aortic grafts with
adjunct Viabahn stent grafts (WL Gore and Associates, Flagstaff,
AZ) to preserve visceral arteries. Characteristics of patients, aortic lesions, procedure details, and outcome were retrospectively
analyzed.
Results: There were seven men and one woman (mean age 66.9
years, range 41-89 years). The aortic pathology included two mycotic
aneurysms, one acute ruptured dissection aneurysm, and five thoracoabdominal aortic aneurysms. Coil embolization of the celiac trunk
was done in three cases. The mean procedure time was 629 minutes
(range 365-984 minutes). Technical successful rate was 75%. Major
complication rate was 50%, including mortality (N=3) and paraplegia (N=1). Both mycotic aneurysms were successfully excluded and
gradually resolved on follow-up images.

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Conclusion: In emergency or complex thoracoabdominal aneurysm, the octopus technique serves as a feasible choice for treatment. However, the high complication rate and long procedure time
may limit its usage. More data are required to validate the benefits
and risks of this technique.

Free Paper Session

Embolisation 1
2305.1
Elution of vandetanib from radiopaque drug-eluting beads in
vitro and pharmacokinetics of vandetanib in swine following
administration in radiopaque drug-eluting beads
P.Czuczman1, D.Grey1, Z.Bascal2, A.Denys3, A.Lewis2, J.John1,
H.Kilpatrick1, R.Whomsley1, R.Holden1
1Research and Development, Innovation, Biocompatibles, A BTG
International Group Company, Camberley, United Kingdom, 2NonClinical Development, Biocompatibles UK Ltd, A BTG International
Group Company, Camberley, United Kingdom, 3Department of
Diagnostic and Interventional Radiology, Lausanne University Hospital,
Lausanne, Switzerland
Purpose: To compare the elution of vandetanib radiopaque beads
(RDCV, 75150 m) and evaluate the pharmacokinetics of vandetanib following intra-arterial hepatic artery administration in healthy
swine.
Material and methods: In vitro elution data was generated using
a USP IV dissolution system. Healthy swine were treated with
hepatic intra-arterial administration of RDCV at target dose loading strengths of 30 mg/mL (RDCV30), 60 mg/mL (RDCV60) and 100
mg/mL (RDCV100). Blood samples were taken and plasma analysed for vandetanib and metabolites to determine the pharmacokinetic parameters. From an additional group of animals administered
RDCV100, blood samples were taken as well as tissue samples from
embolised and non-embolised liver at necropsy were taken (30 and
90 days) for the determination of vandetanib and metabolite levels.
Results: In vitro elution of vandetanib was essentially complete at
6 h. In vivo, the plasma profile of vandetanib was consistent with a
distribution phase up to 6 h after administration followed by elimination with a half-life of 2023 h. Cmax and AUC was approximately
linear with the dose strength for RDCV. Vandetanib plasma levels
were at or below limits of detection 2 weeks after administration. In
the liver samples, vandetanib and its major metabolite, N-desmethyl
vandetanib, were present in the treated sections at 30 days after
administration. At 90 days, both analytes were still present in the
treated liver sections but were near or below the limit of quantification in the untreated liver sections.
Conclusion: Hepatic intra-arterial administration of RDCV enables
the sustained delivery of vandetanib to target tissues following
embolisation while minimising systemic exposure.

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2305.2
Importance of collateral perfusion to the spleen following
proximal/mid-splenic arterial embolization in adult patients
with blunt trauma
M.Groenwald1, J.Pollak 2, T.Friedman1, I.Latich1, K.B.Quencer3
1Radiology, Yale University, New Haven, CT, United States of America,
2Vascular and Interventional Radiology, Yale University School of
Medicine, New Haven, CT, United States of America, 3Department of
Radiology, Yale New Haven Hospital, New Haven, CT, United States of
America
Purpose: Mid-splenic arterial embolization is currently the standard
of care for hemodynamically stable trauma patients with clinically
significant splenic injuries (AAST grade III or IV). In cases of psuedoaneurysm, AVF or active extravasation seen on angiogram, adjunctive distal embolization is often needed. In this study, we aimed to
investigate the routes of collateral flow to the spleen after proximal/mid-splenic arterial embolization by angiography. Additionally,
we aimed to investigate their clinical importance by assessing the
need for subsequent splenectomy after embolization, implicating collateral flow leading to continued bleeding. We also aimed
to investigate the evidence of splenic dysfunction such as encapsulated organism bacteremia and evidence of splenic abscess after
embolization.
Material and methods: A single-institution retrospective review
identified 48 patients who underwent proximal to mid-splenic arterial embolization between July 2010 and July 2015. The grade of
injury, embolization site, and perfusion to the spleen after embolization by collateral vessels post embolization were recorded.
Additionally, the evidence of post-embolization splenic abscess
or subsequent bacteremia with encapsulated organisms (both in
patients who did and did not receive vaccinations) was documented.
Results: Post-embolization angiograms demonstrated collateral
flow to the spleen in 85.4% of cases. One patient with these collaterals underwent subsequent open splenectomy for hypotension.
No patients developed perisplenic/intrasplenic abscesses. In total,
37% patients received vaccinations following proximal/mid-splenic
arterial embolization. No patient in the vaccination or no vaccination group developed bacteremia or sepsis from encapsulated
organisms.
Conclusion: After mid-splenic arterial embolization for trauma,
immediate collateral flow to the spleen is seen in 85.4% of cases.
This prevents intrasplenic abscess from developing and preserves
splenic immune function.

2305.3
Transarterial embolization as a therapeutic option for focal
nodular hyperplasia (FNH)
J.-H.Sun, G.-H.Zhou, Y.-L.Zhang, C.-H.Nie
Hepatobiliary and Pancreatic Interventional Treatment Center, The First
Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou,
China
Purpose: To evaluate the therapeutic effect of transarterial embolization (TAE) to treat focal nodular hyperplasia (FNH) of the liver.
Material and methods: From 2012 to 2015, superselective TAE
was performed for 6 patients with FNH. The patients consisted of
3 men and 3 women with age range of 22 to 60 years (mean age,
34 14). All patients underwent percutaneous needle biopsies, and
the diagnosis of FNH was proven histologically. The indications for
TAE were the patients with a progressive increase in the size of FNH,
who experienced dull pain in the upper abdomen or hepatic area,
who were not candidates for surgical treatment, or who refused
to undergo surgery. Embolic materials used in this series included
Lipiodol, Embosphere microspheres and polyvinyl alcohol particles.

Abstract Book

Results: Five patients (83.3%) had a single solitary focus and one
(16.7%) had multiple foci. The diameter of the mass varied from 3.8
cm to 14.2 cm, with a mean of 6.4 cm (6.4 3.9 cm). All six patients
were successfully treated with Lipiodol, Embosphere microspheres
and polyvinyl alcohol particles. All patients were regularly followed
up, ranging from 4 to 36 months (15.6 11.3). One month after the
procedure, dull pain in the upper abdomen or hepatic area vanished
completely. Follow-up examination by CT or MRI revealed complete
resolution in three cases and an obvious decrease in the other three
cases. No immediate or delayed post-embolization complications
were encountered.
Conclusion: Transarterial embolization should be considered as a
safe and effective method for the treatment of FNH.

2305.4
Usefulness of conebeam computed tomography and automatic
vessel detection software in emergency transarterial
embolization
A.M.Ierardi1, P.Torcia2, U.G.Rossi3, E.Duka1, M.Cariati4,
G.Carrafiello1
1Radiology, Uninsubria, Ospedale di Circolo, Varese, Italy, 2Radiology
and Interventional Radiology, San Carlo Borromeo Hospital, Milan,
Italy, 3Radiology, San Carlo Borromeo Hospital, Milan, Italy, 4Diagnostic
Sciences, San Carlo Borromeo Hospital, Milan, Italy
Purpose: To evaluate the utility of dual-phase cone beam computed
tomography (DP-CBCT) and automatic vessel detection (AVD) software to guide transarterial embolization (TAE) of angiographically
challenging arterial bleeding in emergency settings.
Material and methods: Forty patients with arterial bleeding at
computed tomography angiography (CTA) and an inconclusive
identification of the bleeding vessel at the initial 2D angiographic
series were included. Accuracy of DP-CBCT and AVD software were
defined as the ability to detect the bleeding site and the culprit arterial bleeder, respectively. Technical success was defined as the correct positioning of the microcatheter using AVD software. The clinical success was defined as successful embolisation. The total volume of iodinated contrast medium and overall procedure time were
registered.
Results: The bleeding site was not detected by the initial angiogram
in 25% of cases, while impossibility to identify the bleeding vessel was the reason for inclusion in the remaining cases. The bleeding site was detected by DP-CBCT in 39/40 (97.5%) patients; in one
case, CBCT-CT fusion was required. AVD software identified the
culprit arterial branch in 36/40 (90%) of cases. In four cases, vessel
tracking required manual marking of the candidate arterial bleeder.
Technical success was 94%. Successful embolization was achieved in
all patients. The mean contrast volume injected for each patient was
75.5 ml, and the mean overall procedural time was 45 minutes.
Conclusion: C-arm CBCT and AVD software during TAE of angiographically challenging arterial bleedings are feasible and may facilitate successful embolization. Staff training in CBCT imaging and
software manipulation is necessary.

2305.5
Safety and efficacy of a new embolic device: initial singlecenter experience using the microvascular plug in routine
clinical practice
R.Corti1, L.P.Moramarco1, G.Leati1, M.Maestri2, P.Quaretti1
1Interventional Radiology, Fondazione Policlinico S.Matteo, Pavia, Italy,
2Department of Surgery, Fondazione Policlinico S.Matteo, Pavia, Italy
Purpose: To report the safety and efficacy of fully retrievable PTFEcovered nitinol embolic devices (microvascular plugs) in emergency
and elective clinical settings.

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Material and methods: From May 2014 to January 2016, 14 patients

(7 male, mean age 58 years) were treated with microvascular plugs
(MVPs) for bleeding (5 traumatic, 2 iatrogenic), pseudoaneurysm
(1 iatrogenic), and pulmonary arterovenous malformation (PAVM)
exclusion (6). Six patients presented acute hemorrhage signs, requiring immediate embolization. All patients presented a vessel diameter between 2 and 4 mm, 8 with acute hemorrhage or pseudoaneurysm of the hepatic artery, gastroduodenal artery, bronchial artery,
and mammarian artery and 6 with PAVM-related OslerWeber
Rendu syndrome. An arterial or venous femoral approach was
engaged in all patients. All MVPs were released through a highflow
microcatheter. Primary study endpoints were technical and clinical success, which were defined as successful MVP release with fast
occlusion of the target vessel.
Results: Technical success was achieved in all patients. Eighteen
MVP, more than one in two patients, were easily released without
dislodgement of the microcatheter. In five patients, coils or glue
embolization completed the multivessel procedure. Completion
angiography showed almost immediate target-vessel exclusion after
MVP implantation within 30 seconds. No migration occurred. The
mean follow-up was 14 months. No rebleeding or pulmonary AVM
revascularization was observed.
Conclusion: Microvascular plug seems to be safe and effective.
The easy release and quick target-vessel occlusion make this device
potentially helpful in emergency situations. Appropriate vessel-size
match is required.

2305.6
A single-centre experience in spontaneous portosystemic
shunt embolisation: what do we know after a decade of work?
C.Parra-Farias, M.PerezLafuente, I.Diez-Miranda,
C.Gonzalez-Junyent, D.HernandezMorales, Q.OrdiiCamprubi,
S.DyerHartnett, A.SegarraMedrano
Radiology, Vall dHebron Hospital, Barcelona, Spain
Purpose: Spontaneous portosystemic shunts (SPSS) are an important cause of refractory hepatic encephalopathy (HE) in patients
with cirrhosis. Medical treatment alone may have limited success
and compliance. The aim of this study was to investigate the risks
and effects of SPSS management.
Material and methods: From 2002 to 2016, a prospective study of
35 consecutive cirrhotic patients with recurrent HE who underwent
SPSS embolisation was performed. Baseline characteristics, diagnostic workup, treatment techniques, and clinical and radiological outcomes were recorded.
Results: Mean age was 60.6715.12 years, with 51.40% male. Chronic
liver damage was caused by alcoholic abuse (32%), HCV (24%), cryptogenic (24%), non-alcoholic steatohepatitis (12%), primary biliary cirrhosis (4%), and autoimmune hepatitis (4%). Prior to embolisation, 14.28% of patients had liver transplants. Proof of the shunt
was provided by angio-CT and/or indirect portography, including
spleno-renal shunts (66.67%), meso-caval/renal (21.21%), gastricazygos/renal (9.09%), and recanalised para-umbilical veins (3.03%).
Shunts were accessed successfully using the common femoral
vein (60%), internal jugular vein (28%), transhepatic (8%), or transsplenic approaches (4%). In 3 patients, 2 embolisations were necessary. Used materials were coils (70.83%), liquid agents (37.50%), and
occlusion devices (29.17%). Follow-up duration was 3-31 months.
All patients had improved autonomy and decreased severity of the
worst HE episode. One patient had transient low cardiac output due
to acute shunt closure. There were no other procedure-related complications, significant increase in development/aggravation of preexisting varices, portal hypertensive gastropathy, or ascites.
Conclusion: SPSS embolisation is an effective and safe procedure
that serves as a complementary treatment to or curative treatment
for HE patients who are refractory to medical therapy.

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Oncology: beyond the liver
2306.1
SIRFLOX study: a novel approach to define the depth of
response (DpR) within a volumetric model in patients with
metastatic colorectal cancer (mCRC)
V.Heinemann1, J.Ricke2, N.K.Sharma3, M.P.Findlay4, M.Peeters5,
V.Gebski6, M.VanBuskirk7, P.Gibbs8, G.A.vanHazel9
1Department of Medical Oncology and Comprehensive Cancer
Center, Ludwig-Maximilian-University of Munich, Munich, Germany,
2Department of Radiology and Nuclear Medicine, University Clinic
Magdeburg, Magdeburg, Germany, 3Department of Radiology,
Penn State Hershey School of Medicine, Reading, PA, United States
of America, 4Cancer Trials New Zealand, University of Auckland,
Auckland, New Zealand, 5Department of Oncology, Antwerp University
Hospital, Antwerp, Belgium, 6Biostatistics, NHMRC Clinical Trials Centre,
Camperdown, NSW, Australia, 7Biostatistics, Data Reduction LLC,
Chester, NJ, United States of America, 8Oncology Department, Royal
Melbourne Hospital, Melbourne, VIC, Australia, 9School of Medicine
and Pharmacology, University of Western Australia, Perth, WA,
Australia
Purpose: To assess DpR based on independent blinded reader
RECIST data from SIRFLOX: a comparison of first-line FOLFOX (bev)
+ Y-90 resin microspheres [SIRT] and FOLFOX (bev) alone [Control]
in patients with non-resectable, liver-only or liver-dominant mCRC.
Material and methods: Spherical tumor volume was estimated
from the longest unidimensional length for 5 target hepatic lesions
(RECIST 1.0) in the SIRFLOX ITT population. Modelling was used to
identify potential predictors of DpR.
Results: The decrease in median liver tumor volume in SIRT vs. control was 75% vs. 68% (P=0.036). Deepest response (median time
to nadir) occurred 60 days later in SIRT compared with control (266
vs. 206 days; P<0.001). A larger treatment effect and longer time to
nadir were observed in patients with >12% hepatic tumor burden
(median DpR 90% in SIRT vs. 77% in Control, P=0.003; median
nadir 298 vs. 196 days, P<0.001), compared to those with 12%
tumor burden (median DpR 93% vs. 94%, P=0.763; median nadir
243.5 vs. 220 days, P=0.152). PFS in the liver by competing risk analysis was significantly longer in patients with >12% hepatic tumor burden receiving SIRT vs. control (median 27.2 vs. 13.1 months, P=0.003),
whereas complete response [CR] for SIRT vs. control was more common in patients with 12% liver tumor burden (12.9% vs. 3.5%;
P=0.001).
Conclusion: In SIRFLOX, the addition of SIRT to standard chemotherapy significantly increased hepatic DpR. The impact of SIRT on
PFS was greatest in patients with a baseline tumor burden >12%,
whereas the impact on CR rate was greater where tumor burden was
<12%.

2306.2
Development and evaluation of a novel biodegradable embolic
agent for transcatheter embolization in a rabbit kidney model:
work in progress
H.Wittgenstein, M.Stechele, J.Breinl, N.Stolzenburg, D.Geisel,
J.Schnorr, B.Hamm, R.W.Gnther, F.Streitparth
Department of Radiology, Charit Berlin, Berlin, Germany
Purpose: Evaluation of embolic effect, inflammatory response, and
resorption behavior of a novel biodegradable embolic agent for
transcatheter arterial embolization in a rabbit kidney.
Material and methods: Using a 3-F catheter, superselective renal
embolization of the caudal segmental artery was performed with

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new biodegradable polymer microspheres (50500 m) in 22 New

Zealand white rabbits (female: 2.53.5 kg; 1216 weeks). Bland (n=14)
and SPIO-loaded (n=8) microspheres were used. To date, 12 animals underwent control angiography and MR imaging (T1 TSE pre-/
post-contrast, T2 TSE, and T2* GRE) immediately (n=3) and 1 (n=2), 4
(n=2), 8 (n=1), and 12 weeks (n=4) post-embolization. Control images
of the embolized kidneys were compared with those obtained preand immediately post-embolization. The kidneys were harvested for
the histopathological analysis of embolic effect, inflammatory reaction, and presence/absence of particles.
Results: Evaluation of angiograms and MR images showed successful selective embolization of the lower renal pole in 20/22 animals. In
two animals, the whole kidney was affected due to reflux of microspheres. Additionally, MRI demonstrated the distributon of SPIOloaded microspheres within the kidneys. Histopathological analysis of 12 animals showed corresponding cell necrosis/infarct in the
embolized areas. There was no significant inflammatory reaction or
foreign body reaction. The embolic material was microscopically visible at all time points while being increasingly reabsorbed after 12
weeks.
Conclusion: The novel bioresorbable polymer microspheres led to
an effective occlusion of target vessels while simultaneously demonstrating good biocompatibility. The embolic agent appeared largely
reabsorbed after 12 weeks, thus offering advantages as a temporary
embolic agent. SPIO-loaded microspheres allowed the non-invasive
visualization of microsphere distribution.

2306.3
Endovascular denervation of the celiac or hypogastric arteries
for management of refractory abdominal cancer pain
B.Damascelli1, V.Tich1, G.Patelli2, D.Miotti3, A.Prino4, S.Pasqua4,
A.DAlessio5
1Department of Hemodynamics, Emo GVM Centro Cuore Columbus,
Milan, Italy, 2Department of Interventional Radiology, Ospedale Pesenti
Fenaroli, Alzano Lombardo, Italy, 3Department of Palliative Care,
Fondazione Salvatore Maugeri, Pavia, Italy, 4Department of Palliative
Care, Ospedale Maggiore della Carit, Novara, Italy, 5Department of
Oncology-Hematology, Policlinico San Marco, Osio Sotto, Italy
Purpose: To assess the safety and efficacy of endovascular denervation of the celiac or hypogastric arteries for the management of
refractory abdominal cancer pain.
Material and methods: Twenty-one patients with intractable pain
due to neuroendocrine pancreatic adenocarcinoma (N=1), pancreatic adenocarcinoma (N=11), cholangiocarcinoma (N=1), gastric cancer metastases (N=3), prostate cancer (N=1), colorectal cancer (N=3),
and bladder cancer (N=1) underwent radiofrequency endovascular
denervation of the celiac artery (N=16) or hypogastric arteries (N=5)
using the EnligHTN system. Radiofrequency was applied to an average of 10 sites along the endoluminal surface following transfemoral
catheterization. The analgesic effect was assessed on a visual analog
scale (VAS) of 0 to 10 considering the mean score recorded for each
patient during follow-up.
Results: The only complication was an inguinal hematoma in one
patient. All patients were discharged the day after the procedure.
Endovascular neurolysis was feasible and effective in all patients.
The pre-procedure mean VAS score of 8.4 1.4 (range 510) was
reduced to 3.5 1.7 (range 06) during a follow-up of 225 weeks
(mean 11.2 11.5). Opioid consumption decreased in 12/21 patients
and all patients experienced an improved quality of life. The procedure was repeated successfully after 10 weeks in one patient with a
recurrence of pain due to disease progression. Importantly, adenocarcinoma-related breakthrough pain was eliminated in 6 patients.
Conclusion: Radiofrequency endovascular denervation of the celiac
or hypogastric arteries is simple, safe, and effective. Therefore, it

Abstract Book

may be considered as a non-pharmacological alternative or adjunctive therapeutic option for the management of refractory abdominal cancer pain.

2306.4
Multi-center study of metastatic lung tumors targeted by
interventional cryoablation evaluation (SOLSTICE): preliminary
safety outcomes
P.W.Eiken1, T.deBare2, F.Deschamps3, J.Palussire4, X.Buy4,
M.R.Callstrom1, D.A.Woodrum1, F.Abtin5, R.D.Suh5, B.Pua6,
D.C.Madoff6, D.Papadouris7, S.Bagla7, D.E.Dupuy8, T.Healey8,
W.Moore9, S.B.Solomon10, H.Yarmohammadi11, H.Krebs12
1Department of Radiology, Mayo Clinic, Rochester, MN, United States
of America, 2Dept. of Interventional Radiology, Institut Gustave
Roussy, Villejuif, France, 3Department of Radiology, Gustave Roussy
Cancer Campus, Villejuif, France, 4Department of Radiology, Institut
Bergoni, Bordeaux, France, 5Radiological Sciences, Ronald Reagan
UCLA Medical Center, Los Angeles, CA, United States of America,
6Interventional Radiology, New York Presbyterian/Weill Cornell Medical
Center, New York, NY, United States of America, 7Cardiovascular &
Interventional Radiology, Inova Alexandria Hospital, Alexandria, VA,
United States of America, 8Diagnostic Imaging, Rhode Island Hospital,
Providence, RI, United States of America, 9Department of Radiology,
Stony Brook University Medical Center, Stony Brook, NY, United States
of America, 10Section of Vascular & Interventional Radiology, Memorial
Sloan Kettering Cancer Center, New York, NY, United States of America,
11Interventional Radiology, Memorial Sloan Kettering Cancer Center,
New York, NY, United States of America, 12Interventional Radiology,
Southeastern Regional Medical Center/CTCA, Newnan, GA, United
States of America
Purpose: To assess the safety of percutaneous cryoablation for
treatment of pulmonary metastases 3.5 cm.
Material and methods: Patients with up to 6 pulmonary metastases
were treated in a multicenter, prospective study with CT-guided percutaneous cryoablation. Patient follow-up was performed at 1 week
and 3, 6, 12, and 24 months. Complications were assessed using the
CTCAE 4.03.
Results: Two-hundred nineteen tumors in 126 patients (64 males,
62 females; mean age 64 years) were treated over 163 procedures,
constituting the largest prospective multicenter lung cryoablation trial to date. Sixty-two percent (n=78) of the patients had 1
tumor, and 40% had 2 or more. Mean tumor size was 1.2 cm (0.4
4.5 cm). General anesthesia was employed in 69% (n=113) of procedures, conscious sedation in 29% (n=47), and local anesthesia in 2%
(n=3). Treatment time ranged from 30 to 225 min. (mean=72.9 min).
Ninety-eight procedure-related events occurred within 30 days of
the treatment. Thirty-seven percent were classified CTCAE grade 1
(n=36), 57% grade 2 (n=57), 5% grade 3 (n=5), and 1% grade 4 (n=1).
The most frequent event was pneumothorax, of which 8% (n=4)
were grade 1, 83% (n=40) grade 2, and 8% (n=4) grade 3. Six percent
(n=6) of all events were grade 3 or higher: grade 3 pneumothoraces
(n=4), grade 3 pleural hemorrhage (n=1), and grade 4 gas embolism
(n=1). All events resolved without further sequelae.
Conclusion: Percutaneous CT-guided cryoablation demonstrates an
acceptable safety profile for treatment of lung metastases 3.5 cm.

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2306.5
Ten-year experience of thermal ablation of colorectal lung
metastases: a retrospective series of 209 patients
J.T.Perez1, M.Fonck 2, X.Buy1, D.Bechade2, V.Catena1,
J.Palussire1
1Department of Radiology, Institut Bergoni, Bordeaux, France,
2Department of Oncology, Institut Bergoni, Bordeaux, France
Purpose: To evaluate the survival outcomes of percutaneous thermal ablation for patients presenting with colorectal lung metastases.
Material and methods: A monocentric prospective database
including all consecutive patients was retrospectively reviewed. Two
hundred and nine patients (mean age 69 years) received 323 ablation sessions (radiofrequency 97%, microwaves and cryo 3%) for
630 lung metastases. An ablation session could consist of two procedures in which the two sides (of the thorax) were treated sequentially. The origin of the metastasis was colon and rectum in 50.2%
and 49.8% of the cases, respectively. The main objective was to evaluate the local control (LC), the overall survival (OS), the disease-free
survival (DFS), and the chemotherapy-free survival (CFS).
Results: The median diameter of the metastases was 10 mm. The LC
at 1 year was 94.6%. The median follow-up was 50 months. Median
OS was 67.6 months, and median PFS was 7.6 months. OS and PFS
rates were 95% and 33.1%, respectively, at 1 year and 54.7% and
11.2%, respectively, at 5 years. Median CFS was 12.2 months (95%CI
10.3-17.7). CFS was statistically higher for patients without any extra
lung metastases: 20.9 months (95%CI 10.3-17.7). About 63.2% and
24.4% of the patients received one and two thermal ablation sessions, respectively (maximum 5 sessions: 1.4%).
Conclusion: Thermal ablation for colorectal lung metastases is efficient and allows for a median chemotherapy-free survival of 12.2
months. Patients with small-sized colorectal lung metastases should
be referred for ablation.

2306.6
Multimodality treatment of 132 consecutive patients with
locally advanced pancreatic cancer
J.A.Vogel1, T.deRooij1, K.P.vanLienden2, J.W.Wilmink 3,
H.W.vanLaarhoven3, J.E.vanHooft4, O.M.vanDelden2,
M.G.Dijkgraaf5, R.C.G.Martin6, O.R.C.Busch1, M.G.H.Besselink1
1Surgery, Academic Medical Center, Amsterdam, Netherlands,
2Radiology, Academic Medical Center, Amsterdam, Netherlands,
3Medical Oncology, Academic Medical Center, Amsterdam,
Netherlands, 4Gastroenterology, Academic Medical Center, Amsterdam,
Netherlands, 5Clinical Research Unit, Academic Medical Center,
Amsterdam, Netherlands, 6Surgery, Division of Surgical Oncology,
University of Louisville, Louisville, KY, United States of America
Purpose: FOLFIRINOX and irreversible electroporation (IRE) show
promising results for locally advanced pancreatic cancer (LAPC).
However, most studies only include patients with stable disease
under chemotherapy. Our aim was to describe outcomes of multimodality treatment with FOLFIRINOX chemotherapy, surgical exploration and IRE in a complete LAPC cohort.
Material and methods: Prospective single-center cohort
(September 2013March 2015), including all consecutive histologically proven LAPC patients (>90arterial/>270venous involvement). Preferred chemotherapy consisted of FOLFIRINOX or if unfeasible, gemcitabine. Radiotherapy was only used for local pain control. After 3 months, restaging was performed to assess RECIST1.1
response, radiological resectability and IRE eligibility (tumor5 cm).
All patients with non-progressive disease (RECIST) and IRE-eligible
tumors underwent explorative laparotomy.

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Results: Of the 132 LAPC patients, 70% (n=93) received chemotherapy [63% (n=59) FOLFIRINOX]. After 3 months, 45% (n=59/132) had
non-progressive disease. Of all 132 patients, 27% (n=36) underwent surgical exploration with resection in 11% (n=14/132, R0 8/14)
and IRE in 11% (n=15/132). After surgical exploration, the Clavien
Dindo grade3 complication rate was 39% (6/14 resection, 7/15 IRE,
1/7 other) and 90-day mortality was 11% (1/14 resection, 2/15 IRE,
1/7 other). Median overall survival (mOS) and 1-year cumulative survival from diagnosis were 11 months and 43%, respectively, for all
patients, 19 months and 71%, respectively, for patients with nonprogressive disease, 23 months and 82%, respectively, in resected
patients, and 16 months and 71%, respectively, in IRE patients, with a
median follow up of 10 months.
Conclusion: A multimodality approach to LAPC is feasible with
acceptable outcomes, especially in patients receiving FOLFIRINOX.
This study highlights the importance of reporting on the outcomes
of consecutive rather than selected cohorts of LAPC. Final survival
data will have to be awaited before the added value of IRE can be
evaluated.

Free Paper Session

Radiation protection
2307.1
Maximising dose reduction in patients undergoing
endovascular aneurysm repair (EVAR) using current hybrid
theatre technology
A.Mayes, K.O.Bashaeb, G.Antoniou
Radiology, The Pennine Acute Hospitals NHS Trust, Oldham, United
Kingdom
Purpose: To maximise dose reduction in patients undergoing
endovascular aneurysm repair (EVAR) using current hybrid theatre
technology.
Material and methods: We conducted a service review using retrospective and prospective data for patients undergoing EVAR using
current technologies available (Discover IGS 740, GE Healthcare,
Chalfont St Giles, UK). The review was to develop and implement
dose reduction strategies (DRS) for patients undergoing EVAR. Three
study groups were assigned (pre- and post-hybrid installation and
pre- and post-DRS implementation). The pre-hybrid group was
assessed using a C-arm image intensifier with subtraction capabilities (OEC 9900,GE). The inclusion criterion for the study was all standard bifurcated endografts. All other endografts or adjunct procedures were excluded. Any amendments to DRS were monitored for
adherence to the Ionising Radiation (Medical Exposure) Regulations
(IRMER) 2000 and the ALARA principle.
Results: The mean dosearea product (DAP) pre-hybrid was a mean
of 41.67 Gycm2, which increased to 63.24 Gycm2post-hybrid installation and reduced to 36.57 Gycm2after DRS implementation (43%
reduction) despite an 8% increase in screening time in the post-DRS
group (1218 s vs. 1118 s). The contrast volume reduced from a mean
of 80 ml of higher strength Niopam370 (Bracco, UK) intravenous
contrast media pre-hybrid to a mean of 70.35 ml of lower strength
Niopam300 (Bracco, UK) post-hybrid pre-DRS and to 54.19 ml postDRS implementation, which totaled to an overall reduction of 32%.
Conclusion: Embracing current technologies alone may not result
in radiation dose reduction, but developing DRS may lead to significant reductions in DAP and intravenous contrast media strength and
volume. DRS maximises radiation dose reduction for patients and
secondarily resulting in a reduction in radiation dose to operators.

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(cerebral angiography) to 0.040.03 mSv (biliary duct interventions)

and did not correlate with DAP (R=0.24), indicating large variations
in staff dose per unit DAP among the procedure types (e.g., high
staff dose per DAP in biliary duct and AV fistula interventions).
Conclusion: Real-time dose monitoring allows identification of
types of interventions with a relatively high staff dose. Further analysis of influence of shielding and types of acquisition are performed
to detect potential sources and patterns of avoidable radiation
exposure.

2307.2
New protocol to reduce fetal radiation dose during
prophylactic balloon insertion in pregnant patients with
abnormal placental adherence
A.Barah, A.Abualruz, M.B.Gomaa, A.Almuzrakchi, V.Chavan,
O.Almokdad, A.Omar
Clinical Imaging, Hamad Medical Corporation, Doha, Qatar
Purpose: To evaluate a new protocol aiming the following:
1. Minimize fetal radiation exposure during prophylactic internal
iliac artery balloon insertion (PIBI) in pregnant patients with abnormal placental adherence (APA).
2. Assess its effect on technical success during angiography.
Material and methods: A retrospective study was conducted to
compare 2 groups of pregnant patients with APA eligible for PIBI. As
the control group, 11 patients underwent standard protocol of radiation dose reduction, and as the study group, 11 patients underwent
a new protocol of radiation dose reduction. Radiation parameter
measurments of the 2 groups were collected, and the fetal absorbed
dose (FAD), peak skin dose (PSD), and fluroscopy time (FT) were
compared.
Results: The mean value of FAD (mGy) was 21.92 +/- 19.1 in control
group and was 1.5 +/- 1.27 in study group (p = 0.0001).
The mean value of PSD (mGy) was 93.54 +/- 80.8 in control group
and was 6.29 +/- 5.39 in study group (p = 0.0001).
There was no significant difference in mean fluoroscopy time (minutes) between the two groups (1.88 +/- 0.66 in control group vs. 2.51
+/- 1.30 in study group, p = 0.167).
No failure resulting from the technique was observed in the 2
groups.
Conclusion: We demonstrated by the present study that the application of a new protocol for radiation dose reduction significantly
reduces the FAD and PSD during PIBI in pregnant patients with APA.
This new protocol can easily be applied and does not affect the technical success of angiography.

2307.3
Real-time patient and staff dose monitoring in IR practice
A.M.H.Sailer1, L.Paulis1, L.Vergoossen1, R.deGraaf1,
G.W.Schurink 2, C.vanderLeij1, M.W.deHaan3, W.H.vanZwam1,
M.Das1, J.E.Wildberger1, C.R.Jeukens1
1Radiology, Maastricht University Medical Centre, Maastricht,
Netherlands, 2Vascular Surgery, Maastricht University Medical Centre,
Maastricht, Netherlands, 3Radiology and Interventional Radiology,
Maastricht University Medical Centre, Maastricht, Netherlands
Purpose: Patient and staff dose monitoring is gaining increasing
interest for legal and personal purposes. In our center, the first dedicated real-time patient and staff dose monitoring system (Philips
DoseWise) was installed in our angiosuites in October 2015. The aim
of this study was to implement a comprehensive procedural and
occupational real-time dose monitoring system to obtain insight in
the procedural and occupational dose for all procedures performed.
Material and methods: All interventional radiologists and technicians wore personal dosimeters (PDMs, Philips Doseaware). The
dose-monitoring system registered simultaneously dose-related
data such as the dose area product (DAP) and effective staff dose
from PDMs for each procedure. Use and type of shielding were
recorded. All procedures (n=387) were analyzed according to procedure type; these included among others venous iliac and caval
recanalization (n=46), AV fistula maintenance (n=35), SFA and infragenual interventions (n=43), and biliary duct interventions (n=26).
Results: MeanSD DAP doses ranged from 2.93.1 Gycm2 (percutaneous gastrostomy) to 12.611.1 Gycm2 (aortic repair procedures). MeanSD first operator doses ranged from 0.0010.001 mSv

2307.4
CT-guided needle biopsy of lung lesions: is there the
possibility of reducing the dose?
G.Coppola1, R.Iezzi1, A.Posa1, E.G.M.Antonuccio1, M.T.Congedo2,
L.Bonomo1
1Department of Radiological Sciences, Institute of Radiology, A. Gemelli
Hospital - Catholic University, Rome, Italy, 2Department of General
Thoracic Surgery, A. Gemelli Hospital - Catholic University, Rome, Italy
Purpose: To investigate the possibility of reducing radiation dose
exposure while maintaining diagnostic and complication rates in
patients undergoing CT-guided percutaneous needle biopsy (PNB)
of lung lesions.
Material and methods: We performed a prospective, single-center,
randomized comparison of two different X-ray exposure CT acquisition protocols in 100 consecutive patients with suspected malignant lung lesions referred for CT-guided PNB. In group A, the acquisition protocol was performed with 120 kV, 380 mAs, 1.25-mm thickness, and 0.6-s rotation time (standard dose); in group B, the acquisition protocol was performed with 80 kV, 10 mAs, 1.25-mm thickness, and 0.8-s rotation time (low dose). Axial images were quantitatively and qualitatively compared in terms of the image quality and
image noise. Total dose received, length of procedure, technical success, and diagnostic and complication rates were also registered and
compared.
Results: Technical success was obtained in all CT-guided procedures. No significant differences were found among the two groups
in terms of procedure length as well as complication rate. No significant differences were registered with regard to diagnostic performance. An overall dose reduction greater than 90% was obtained in
group B.
Conclusion: Low dose CT-guided lung PNB is feasible and effective
with the possibility of reducing radiation dose exposure and performing procedures with less than 1 mSv, without compromising the
safety and diagnostic performance.

2307.5
Percutaneous transhepatic biliary drainage: evaluation of
a sterile, lead-free, radiation-protection shield for reducing
occupational exposure to scatter radiation
A.Fohlen1, Y.Tancray2, M.-A.Jegonday1, V.LePennec1, J.-P.Pelage1
1Department of Radiology, University Hospital and Medical Center,
Caen, France, 2Radioprotection, University Hospital and Medical Center,
Caen, France
Purpose: To demonstrate the efficacy of a radiation-absorbing
shield and drape during percutaneous biliary drainage in reducing
radiation exposure to interventional radiologists.
Material and methods: The validated methods of radiation protection such as pull-down shields cannot be easily used during percutaneous transhepatic biliary drainage. Six consecutives procedures were performed: 3 using a radiation-absorbing shield and
3 without the shield. In each group, procedures were comparable
in terms of technical aspect and radiation dose (mean fluoro times
and mean radiation dose). Radiation exposure was measured using

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thermoluminescent dosimetry for fingers and eye lens. An electronic radiation dosimeter was used to measure the body exposure. The radiation exposure was measured for the primary operator (interventional radiologist) and the second operator (fellow) for
each intervention.
Results: The surgical drape did not interfere with technical performance nor add procedural time. All procedures were successfully
completed. The use of a radiation-absorbing shield was associated
with a reduction of 49% in radiation exposure to the body and 52%
to the eye lens. Radiation exposure to the hands was even more
significantly reduced by 83% for primary operator and 50% for the
assistant.
Conclusion: The use of a radiation-absorbing shield during percutaneous biliary drainage significantly reduced the exposure to the
hands and eye of the primary operator without compromising sterility or technical success. This device may be recommended for routine use during percutaneous transhepatic biliary drainage.

2307.6
Radiation doses to operators performing transjugular
intrahepatic portosystemic shunt using a flat-panel detector
based system and real-time ultrasound guidance for portal
vein targeting
R.Miraglia1, R.Gerasia1, L.Maruzzelli1, M.DAmico2, A.Luca1
1Diagnostic and Therapeutic Services, Mediterranean Institute for
Transplantation and Advanced Specialized Therapies (IsMeTT),
Palermo, Italy, 2Radiology, University of Palermo, Palermo, Italy
Purpose: Effective dose (E) of operators performing transjugular
intrahepatic portosystemic shunt (TIPS) are estimates among the
highest for the non-cardiac fluoroscopic guided procedures. Aim of
this study was to prospectively evaluate E of operators performing
TIPS in a single center.
Material and methods: Between 8/2015 and 1/2016, 20 consecutive TIPS have been performed in our center in adult patients (male
n=15, mean body surface area 1.850.15, mean weight 71.411.3
kg) using a flat-panel detector based system (FPDS) and real-time
ultrasound guidance for portal vein targeting (USG). Low-dose fluoroscopy protocol with 7.5 frames/sec pulsed fluoroscopy was routinely employed. Electronic personal dosimeters, positioned at the
left upper chest outside the lead apron, were used to measure radiation doses to radiologist, anesthesia nurse, and radiographer. E was
determined using a modified Niklason algorithm (E=0.03Hp(10)).
Patients radiation exposure was measured with dose area product
(DAP); fluoroscopy time (FT) was also collected.
Results: Mean E for the radiologist was 1.75 Sv (SD 3.34, median
0.70, range 0.2112.18), for the anesthesia nurse was 0.46 Sv (SD
1.11, median 0.15, range 0.033.99), and for the radiographer was
0.50 Sv (SD 0.72, median 0.27, range 0.032.67). Mean patients DAP
was 73.06 Gycm (SD 77.06, median 50.66, range 11.03281.40), and
mean FT was 16.28 min (SD 8.45, median 13.30, range 6.831.8).
Conclusion: In our experience, the use of FPDS and USG for portal
vein targeting allows a reasonably low radiation exposure to operators performing TIPS.

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Super Endo Tuesday
3005.1
Twenty-four-month results from the MAJESTIC trial of the
Eluvia drug-eluting vascular stent system
S.Mller-Hlsbeck1, K.F.Keirse2, T.Zeller3, H.Schroe4,
J.Diaz-Cartelle5
1Department of Diagnostic and Interventional Radiology /
Neuroradiology, Ev.-Luth. Diakonissenanstalt zu Flensburg, Flensburg,
Germany, 2Vascular Surgery, Regional Hospital Heilig Hart Tienen,
Tienen, Belgium, 3Angiology, Herz-Zentrum Bad Krozingen, Bad
Krozingen, Germany, 4Limburgs Vaatcentrum - ZOL, Ziekenhuis OostLimburg, Genk, Belgium, 5Peripheral Interventions, Boston Scientific,
Marlborough, MA, United States of America
Purpose: The purpose of the MAJESTIC clinical study was to evaluate the performance of the Eluvia drug-eluting vascular stent system
(Boston Scientific Corporation, Marlborough, MA, USA) in treating
the femoropopliteal artery lesions.
Material and methods: MAJESTIC is a prospective, single-arm,
multicenter clinical study of patients with chronic lower limb ischemia and de novo or restenotic lesions in the native superficial femoral artery and/or proximal popliteal artery. Long-term followup includes primary patency (i.e., duplex ultrasound peak systolic
velocity ratio2.5 and absence of target lesion revascularization
[TLR] or bypass) and safety assessments at 2 years as well as safety
monitoring through 3 years.
Results: Mean age (SD) of the patients (N=57) was 693 years, and
83% were male; 35% had diabetes. Baseline Rutherford category was
2 for 35%, 3 for 61%, and 4 for 4% of patients. Mean lesion length
was 70.828.1 mm and 65% had severe calcification. Percent diameter stenosis was 86.3%16.2%, and 46% had total occlusions. At
12 months, primary patency was 96.1% (49/51) with a KaplanMeier
estimate of 96.4%. The MAE rate was 3.8%; the two MAEs were both
TLRs. No stent fractures were identified through 12 months. Twentyfour-month results, including patency and safety assessments, will
be available by the time of presentation.
Conclusion: The results of the MAJESTIC clinical study show that
patients treated with the Eluvia stent had a high patency and low
MAE rate through 12 months. The twenty-four-month follow-up will
be complete by the time of presentation.

3005.2
Zilver PTX post-market surveillance study of paclitaxel-eluting
stents for treating femoropopliteal artery disease in Japan:
3-year results
K.Kichikawa1, H.Yokoi2, T.Ohki3, M.Nakamura4, K.Komori5,
S.Nanto6, A.E.Lottes7, M.D.Dake8
1Radiology, Nara Medical University, Nara, Japan, 2Cardiovascular
Center, Fukuoka Sanno Hospital, Fukuoka, Japan, 3Department of
Vascular Surgery, Jikei University School of Medicine, Tokyo, Japan,
4Division of Cardiovascular Medicine, Toho University, Tokyo, Japan,
5Department Vascular Surgery, Nagoya University, Nagoya, Japan,
6Department of Advanced Cardiovascular Therapeutics, Osaka
University, Osaka, Japan, 7Cook Research Incorporated, West Lafayette,
IN, United States of America, 8Falk Cardiovascular Research Center,
Stanford University School of Medicine, Stanford, CA, United States of
America
Purpose: The paclitaxel-coated Zilver PTX stent is the first drug-eluting stent (DES) approved in Europe, Japan, and the United States
for the SFA. Previously, the results from a large randomized study
and a complementary, large single-arm study supported the safety

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and effectiveness of the DES. Currently, a multicenter, prospective,

post-market surveillance study with 5-year follow-up is underway in
Japan to further evaluate this stent in real-world patients.
Material and methods: The first approximately 900 patients in
Japan treated with the DES were enrolled in the study. Clinicallydriven TLR was defined as re-intervention performed for 50%
diameter stenosis after recurrent clinical symptoms of PAD.
Results: In this study, 905 patients were enrolled at 95 institutions in
Japan. In total, 1,888 stents were placed in 1,086 lesions. Compared
to previous randomized and single-arm studies, these patients had
significantly more renal disease (p<0.01, 44%) and higher Rutherford
classification (p<0.01, 21% CLI). The lesions were also significantly
longer (p<0.01, mean ~15cm) and more complex (p<0.01, 19% instent restenosis, fewer patent runoff vessels). Follow-up through
3 years was obtained for 84% of eligible patients. The rate of stent
fracture through 3 years remains low. The 3-year Kaplan-Meier estimate for freedom from TLR was 79.8%.
Conclusion: Despite more challenging lesions, the current study
continues to show similar outcomes to those from previous Zilver
PTX studies, providing further assurance of the long-term benefit of
the Zilver PTX stent.

3005.3
Is DCB effective in diabetic patients
P.Krishnan1, D.Scheinert2, J.R.Laird3, M.Brodmann4, G.Tepe5,
T.Zeller6, C.Metzger7, P.Schneider8, A.Micari9, D.J.Cohen10,
M.R.Jaff11
1Endovascular Services, Mount Sinai Hospital, New York, NY, United
States of America, 2Clinical and Interventional Angiology, Park
Hospital Leipzig, Leipzig, Germany, 3Cardiovascular Medicine, UC
Davis Vascular Center, Sacramento, CA, United States of America,
4Clinical Division of Angiology, Medizinische Universtitt Graz, Graz,
Austria, 5Department of Diagnostic and Interventional Radiology,
Medical Centre of Rosenheim, Rosenheim, Germany, 6Angiology,
Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany, 7Cardiology,
Wellmont-Holston Valley Medical Center, Kingsport, TN, United States
of America, 8Vascular Surgery, Kaiser Permanente Moanalua Medical
Center, Honolulu, HI, United States of America, 9Interventional CardioAngiology, Maria Cecilia Hospital, Cotignola, Italy, 10Cardiology,
St. Lukes Hospital, Kansas City, MO, United States of America,
11Cardiology, Massachusetts General Hospital, Boston, MA, United
States of America
Purpose: Although endovascular treatment of femoropopliteal
disease with drug coated balloons has shown great promise, the
implications of diabetes mellitus on longer-term outcomes remain
unclear. We evaluate the consequences of endovascular treatment
of the superficial femoral and proximal popliteal arteries on patients
with (DM) or without (Non-DM) diabetes mellitus enrolled in the
IN.PACT SFA trial.
Material and methods: Patients enrolled in the IN.PACT SFA trial
were randomly assigned in a 2:1 ratio to treatment with the IN.PACT
Admiral drug-coated balloon (DCB) or percutaneous transluminal
angioplasty (PTA). Patients were stratified by diabetic status and
intra-group comparisons made on two year outcomes. Outcomes
evaluated included primary patency, defined as freedom from clinically-driven target lesion revascularization (CD-TLR) and duplexderived restenosis; major adverse events, and functional outcomes
at two-years. Of the 331 patients enrolled, 143 had DM (89 DCB and
54 PTA) and 188 were Non-DM (131 DCB vs. 57 PTA).
Results: There were no differences between the two groups (DM
vs. Non-DM) in terms of baseline demographics, clinical, and lesion
characteristics status. DCB treatment was effective in both DM
and Non-DM groups at 24 months with significantly higher primary patency (DM 73.3% vs. 45.8%, p=0.0025 and Non-DM 82.5%
vs. 54.5%, p<0.0002) when compared to PTA. Likewise, the rates of

Abstract Book
CD-TLR were significantly lower for DM patients treated with DCB
when compared to their PTA treated counterparts (p=0.0030) and
for Non-DM patients treated with DCB (p=0.0004). There were no
major amputations and no device- or procedure-related deaths
reported in either group through 24 months.
Conclusion: Outcomes from the IN.PACT SFA randomized trial demonstrate a durable and superior treatment effect of DCB versus PTA
in the entire cohort and specifically in diabetic patients whom historically have performed poorly with endovascular procedures.

3005.4
10-years outcomes from the randomized EMMY trial
A.M.deBruijn1, W.J.K.Hehenkamp1, W.M.Ankum1, J.A.Reekers2
1Department of Obstetrics and Gynecology, Academic Medical Centre,
Amsterdam, Netherlands, 2Department of Radiology, Academic
Medical Centre, Amsterdam, Netherlands
Purpose: The purpose of this study was to compare clinical outcome
and health related quality of life (HRQOL) after 10-years follow-up in
the Emmy study patient group.
Material and methods: Patients were 1:1 randomly assigned to
UAE or hysterectomy. The assessed outcomes after 10 years were
re-intervention rates, HRQOL and satisfaction which were obtained
through (mostly validated) questionnaires.
Results: 177 patients were randomized between 2002 and 2004.
The 10 years questionnaire was mailed when the last included
patient had been treated 10 years earlier. The mean duration of follow up was 133 months (SD: 8.58). Questionnaires were received
from 131/156 patients (84%). 10 years after treatment 35% of UAE
patients (28 of 81) had undergone a secondary hysterectomy (24/77
(31%) after successful UAE). Secondary hysterectomies were performed for persistent complaints in all cases but one (1 for prolapse).
The general HRQOL remained stable after 10 years, without differences between both groups. This occurred after significant improvement of HRQOL after the initial treatment. The urogenital distress
inventory (UDI) and the defecation distress inventory (DDI) showed
a decrease in both groups without significant differences between
study arms.
Conclusion: After 10 years follow-up in approximately two-third of
UAE treated patients with symptomatic uterine fibroids a hysterectomy can be prevented. HRQOL 10 years after UAE or hysterectomy
remained comparably stable. UAE is a well-documented and good
alternative to hysterectomy for symptomatic uterine fibroids on
which all eligible patients should be counseled.

3005.5
Economic analysis of endovascular drug-eluting treatments for
femoropopliteal artery disease in the United Kingdom
K.N.Katsanos1, B.P.Geisler2, A.M.Garner2, H.Zayed3,
T.J.Cleveland4, J.B.Pietzsch2
1Interventional Radiology, Guys and St Thomas NHS Foundation Trust,
London, United Kingdom, 2Wing Tech Inc., Menlo Park, CA, United
States of America, 3Department of Vascular Surgery, Guys and St.
Thomas NHS Foundation Trust, London, United Kingdom, 4Radiology,
Sheffield Vascular Institute; Northern General Hospital, Sheffield, United
Kingdom
Purpose: To estimate the clinical and economic impact of drug-eluting endovascular treatment strategies for femoropopliteal artery
disease compared to current standard of care.
Material and methods: Design: Systematic literature search to pool
target lesion revascularisations (TLR). Model-based per-patient cost
impact and quasi cost-effectiveness projection over 24 months
based on pooled TLRs and current reimbursement.
Setting: The United Kingdoms National Health Service (NHS).

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Participants: Patients presenting with symptomatic femoropopliteal
disease eligible for endovascular treatment.
Interventions: Current NICE guideline-recommended treatment with
percutaneous transluminal balloon angioplasty (PTA) and bailout
bare metal stenting (BMS) versus primary BMS placement, or drugcoated balloon (DCB), or drug-eluting stent (DES) treatment.
Results: Primary and Secondary Outcome Measures: 24-month
per-patient cost impact to NHS (primary outcome). Secondary outcomes: Pooled 24-month TLR rates; numbers needed to treat (NNT);
cost per TLR avoided; and estimated incremental cost-effectiveness
ratio (ICER) in per quality-adjusted life year (QALY).
Results: N=28 studies were identified, reporting on 5,167 femoropopliteal lesions. Over 24 months, DCB, DES, and BMS reduced TLRs
from 36.2% to 17.6%, 19.4%, and 26.9%, respectively, at an increased
cost of 43, 44, and 112. NNTs to avoid 1 TLR in 24 months were
5.4, 6.0, and 10.8, resulting in cost per TLR avoided of 231, 264, and
1,204. DCB was estimated to add 0.011 QALYs, DES 0.010 QALYs, and
BMS 0.005 QALYs, resulting in estimated ICERs of 3,983, 4,534, and
20,719 per QALY gained. A subset analysis revealed more favourable clinical and economic outcomes for a 3.5g/mm2DCB with urea
excipient, compared to the rest of DCBs. A modest reduction of 10%
in DCB and DES prices made drug-eluting treatments dominant.
Conclusion: Widespread adoption of drug-eluting endovascular
therapies for femoropopliteal disease would add meaningful clinical benefit at reasonable additional costs to the NHS. Based on currently available data, drug-coated balloons offer the highest clinical
and economic value.

3005.6
Novel aspiration thrombectomy for intervention of peripheral
and visceral arterial occlusions: the PRISM trial results
J.F.Benenati1, G.L.Adams2, R.R.Saxon3, L.E.Sewall4, C.Teigen5
1Noninvasive Vascular Laboratory, Miami Cardiac and Vascular
Institute, Miami, FL, United States of America, 2Interventional
Cardiology, North Carolina Heart and Vascular Research, Raleigh, NC,
United States of America,3Interventional Radiology, Tri-City Medical
Center, Oceanside, CA, United States of America, 4Interventional
Radiology, Adventist La Grange Memorial Hospital, La Grange, IL,
United States of America, 5Interventional Radiology, Sanford Medical
Center, Fargo, ND, United States of America
Purpose: The Penumbra/Indigo System is a novel aspiration thromboembolectomy device offered as an alternative to current endovascular and surgical interventions. The PRISM trial sought to assess the
initial safety and efficacy of the Penumbra/Indigo System for therapy in cases of confirmed peripheral and visceral arterial occlusions.
Material and methods: The PRISM single-arm, retrospective, multicenter trial concluded enrollment with a total of 83 patients.
Enrolled patients included those suffering from acute limb ischemia,
failed thrombolysis, and embolic events secondary to preceding
intervention. Safety and efficacy endpoints included evaluation of
procedural complications and revascularization.
Results: In total, 83 patients presented with anterior tibial (6.0%),
brachial (1.2%), common femoral (1.2%), external iliac (1.2%), peroneal (7.2%), popliteal (32.5%), posterior tibial (4.8%), profunda femoris (6.0%), renal (2.4%), superficial femoral (27.7%), superior mesenteric (3.6%), tibial peroneal trunk (3.6%), sciatic (1.2%) and pulmonary (1.2%) occlusions. In total, 13.3% patients had prior mechanical
thrombectomy, 24.1% had thrombolytics, and 9.6% had both prior
therapies (9.6%); 53.0% received aspiration thrombectomy as frontline. Complete revascularization to TIMI 2-3 was recorded in 87.8%
patients immediately following Penumbra/Indigo intervention and
in 96.3% of patients following additional therapies. Fifteen serious
adverse events were documented in 8 patients within 24 h of thrombectomy; however, none were related to the study device.

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Conclusion: Favorable results of the PRISM trial support this system for frontline treatment of peripheral and visceral arterial occlusions, demonstrating high rates of revascularization with no devicerelated complications. Further data are needed to support the use of
this device as a frontline thrombectomy tool.

Free Paper Session

Neuro interventions and carotid stenting
3104.1
Comparison between Solumbra and ADAPT: clinical outcomes
of acute ischemic stroke therapy
Y.Kayan1, J.E.DelgadoAlmandoz1, M.L.Young2, J.L.Lease1,
J.M.Scholz1, A.M.Milner1, T.H.Hehr2, P.Roohani2, M.Mulder3,
R.M.Tarrel2
1Division of Neurointerventional Radiology, Abbott Northwestern
Hospital, Minneapolis, MN, United States of America, 2Division of
Vascular Neurology, Abbott Northwestern Hospital, Minneapolis, MN,
United States of America,3Division of Critical Care Medicine, Abbott
Northwestern Hospital, Minneapolis, MN, United States of America
Purpose: Patients suffering from ischemic stroke now benefit from
intra-arterial therapy following validation from recent randomized controled trials; however, uncertainty remains pertaining to
the safety and efficacy of the various treatment modalities. This
study aims to compare the events of symptomatic intracranial hemorrhage (sICH) and good clinical outcome at 90 days in patients
treated with either Solumbra or a direct aspiration first pass technique (ADAPT) for thrombectomy as therapy of emergent large vessel occlusion (ELVO) of the anterior circulation.
Material and methods: Over a 38-month period, our single-center study documented clinical characteristics, procedural variables,
and clinical outcomes at 90 days as well as incidence of sICH in ELVO
patients treated by Solumbra compared with the incidence in those
treated by ADAPT. The SITS-MOST criteria defined sICH, while mRS
0-2 at 90 days determined a good clinical outcome.
Results: Of the 100 patients enrolled, 55 were stratified to Solumbra
and 45 to ADAPT. On an average, the National Institutes of Health
Stroke Scale (NIHSS) score was higher in the ADAPT group compared with the score in the Solumbra group (19.2 vs. 16.8, p=0.02)
and the incidence of internal carotid artery terminus occlusions was
also higher in the ADAPT group compared with the incidence in the
Solumbra group (42.2% vs. 20%, p=0.03) at presentation. Conversely,
the ADAPT group in comparison with the Solumbra group had lower
incidence of sICH (2.2% vs. 12.7%, p=0.07), while showing a significantly better 90-day clinical outcome (55.6% vs. 30.9%, p=0.015)
post-procedure. Intervention by ADAPT was an independent predictor of good clinical outcomes [OR 6 (95% CI 1.0 to 31.2), p=0.049].
Conclusion: In comparison with the treatment by Solumbra, treatment by ADAPT demonstrated a better clinical outcome in ELVO
intervention.

3104.2
Equal technical success rates with TREVO and Capture LP:
device selection may have a role in the prediction of clinical
outcome
S.M.Protto, J.-P.Pienimki, J.Seppnen, I.Matkaselk, J.Ollikainen,
H.Numminen, N.Sillanp
Radiology, Tampere University Hospital, Tampere, Finland
Purpose: Mechanical thrombectomy (MT) has become a proven
method to treat proximal occlusions in acute anterior circulation
stroke. We compared in an observational prospective study the

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technical, imaging, and clinical outcomes of MT performed with

either TREVO or Capture LP.
Material and methods: There were 42 and 43 patients in the
TREVO and Capture LP groups, respectively. Baseline clinical, procedural, and imaging variables; technical outcome (TICI, thrombolysis in cerebral infarction); 24-h imaging outcome; and 3-month clinical outcome (modified Rankin Scale, mRS) were recorded. Group
comparisons were performed and logistic regression models
were devised to study the effect of device selection to the clinical
outcome.
Results: There were no statistically significant differences between
the groups in baseline characteristics. There were more ICA occlusions and fewer M2 occlusions in the TREVO group (p=0.002 and
p=0.01, respectively). This had no impact on the technical success
(TICI 2b or 3 93% with TREVO vs. 88% with Capture LP, p=0.48) or
duration of the procedure (33 vs. 32 min, p=0.79). There was a trend
towards more patients having excellent outcome (mRS1) and lower
mortality in the Capture LP group. In a multivariate model, Capture
LP increased the odds of excellent outcome (OR=5.2, 95% CI 1.515.3, p=0.008) along with distal clot location and good collateral circulation. When the cutoff was mRS2, the device selection was not a
significant predictor.
Conclusion: The technical outcomes with TREVO and Capture LP
are equal. Capture LP may have a small advantage in reaching
mRS1 at 3 months.

3104.3
RACER: a European registry in the treatment of AIS with the
ACE64 reperfusion catheter used as first intention in real life
A.Kowoll1, W.Weber1, C.Loehr2, A.Moreno3, J.Weber4,
J.MassoRomero5, S.Peschillo6, A.Berlis7, G.Gl8, T.Lo9
1Radiology and Neuroradiology, Ruhr-University-Bochum, University
Medical Center Langendreer, Bochum, Germany, 2Radiology and
Neuroradiology, Klinikum Vest, Recklinghausen, Germany, 3Section of
Interventional Neuroradiology, Hospital Clinico Universitario Virgen
de la Arrixaca, Murcia, Spain, 4Institute of Radiology, Kantonsspital
St. Gallen, St. Gallen, Switzerland, 5Institute for Interventione,
Hospital Universitario Donostia, San Sebastian, Spain, 6Endovascular
Neurosurgery/Interventional Neuroradiology, Hospital Policlinico
Umberto I, Rome, Italy, 7Klinik fr Diagnostische Radiologie
und Neuroradiologie, Klinikum Augsburg, Augsburg, Germany,
8Department of Radiology, Odense University Hospital, Odense,
Denmark, 9Department of Interventional Radiology & Interventional
Neuroradiology, University Medical Center Utrecht, Utrecht,
Netherlands
Purpose: Our aim is to assess the effectiveness, safety, and procedure time of aspiration thrombectomy for patients suffering an AIS
using a new aspiration thrombectomy device, ACE64.
Material and methods: Between December 2014 and May 2015,
we identified 125 patients with acute ischemic stroke and occlusion of large cerebral vessels. These were treated with an aspiration thrombectomy using a new large-bore aspiration catheter, the
Penumbra ACE64, on an intention-to-treat basis in 9 European centers. Recanalization results were determined using the thrombolysis
in cerebral infarction (TICI) score both self-reported by each center
and by a corelab.
Results: A self-reported TICI Score of 2b was achieved in 11/125
cases (95.2%), corelab TICI of 2b was achieved in 100/119 cases
(84%), TICI 3 in 50.4%. In 32/125 cases, additional devices were used
either as anchoring technique (17.6%) or in distal vessel thrombosis (8%). The average time of groin puncture to revascularization for
all patients was 34 min. Patients presented with a median National
Institutes of Health Stroke Scale (NIHSS) score of 14.5 and improved
to a median NIHSS score of 4.0 at discharge. Median mRS2 after 90
days was 49.5%. Complications included vasospasm in preceding

Abstract Book
extracranial vessel (1.6%), vessel dissection (3.2%), emboli to new
territory (1.6%), and symptomatic intracerebral hemorrhage (9.6%).
Conclusion: ACE64 provides a safe and effective frontline thrombectomy tool, achieving high recanalization rates of over 50% TICI 3
in corelab control. It is a fast and versatile thrombectomy tool with a
low complication rate.

3104.4
Transverse sinus stenting for idiopathic intracranial
hypertension
A.K.Gupta, H.S.Penderkar, A.H.Gouda, C.Prasad, J.Saini, G.Medhi
Dept. of Neuroimaging and Interventional Neuroradiology, National
Institute of Mental Health and Neurosciences, Bangalore, India
Purpose: Idiopathic intracranial hypertension (IIH) is associated with
a high prevalence of transverse sinus stenosis. Studies suggest that
stent placement within a transverse sinus stenosis with a significant
pressure gradient decreases cerebral venous pressure, improves
CSF resorption in the venous system and thereby reduces CSF pressure and improves the symptoms of IIH. The aim of our study was
to determine if IIH could be reliably treated by stent placement in
transverse sinus stenosis.
Material and methods: Stenting was performed whenever the
pressure gradient across the stenosis was found to be more than 10
mm Hg. Clinical, venographic and CSF pressure data were reviewed
before and after stent placement in transverse sinus stenosis in 13
patients with IIH unresponsive to maximum acceptable medical
treatment, treated since 2010 till 2013 at our institution and followed
between 2 months and 3 years.
Results: Prior to stenting, the mean superior sagittal sinus pressure
was 37 mm Hg with a mean pressure gradient of 16 mm Hg across
the stenosis. The lumbar CSF pressure before stent placement was
more than 250 mm water. In 11 patients, stent placement immediately eliminated the pressure gradient, rapidly improved IIH symptoms and abolished papilledema. In one patient, headache persisted
for 2 weeks. Subdural hematoma was seen in one patient during the
procedure, followed by slow resolution. Recurrent stenosis has not
been observed till now. All have been cured of symptoms of IIH.
Conclusion: Transverse sinus stent placement is a safe and effective
treatment for the management of selected patients with IIH.

3104.5
Incidence and prognosis of plaque protrusion during carotid
artery stenting
K.Takayama1, K.Myouchin1, T.Wada2, K.Kichikawa2, S.Kurokawa3
1Radiology and Interventional Neuroradiology, Ishinkai Yao General
Hospital, Yao City, Japan, 2Radiology, Nara Medical University, Nara,
Japan, 3Neurosugery, Ishinkai Yao General Hospital, Yao City, Japan
Purpose: Plaque protrusion (PP) detected by angiography or intravascular ultrasound (IVUS) sometimes occurs during carotid artery
stenting (CAS). However, its incidence and prognosis is unclear. We
investigated the incidence and prognosis of PP during CAS.
Material and methods: We retrospectively analyzed 330 patients
with 346 atherosclerotic carotid artery stenoses [289 men; age 3997
years (mean 73.5 years); symptomatic stenosis, 153 lesions; and
mean stenosis rate, 80.4%] who underwent CAS and preoperative
MR plaque imaging from October 2007 to January 2016. Incidence
of plaque protrusion evaluated by IVUS and angiography, prognosis of PP within 30 days, and incidence of ischemic lesions within 48
h after CAS were assessed using diffusion weighted images. All CAS
were performed by a standard procedure using embolic protection
devices.
Results: PP occurred in eight patients (2.6%). Neurological ischemic
event occurred in five patients (major: 1, minor: 3, TIA: 1) (55.6%)

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among the PP groups. New ischemic lesions were observed in 88.9%
(8/9) of the patients. There were significant differences with respect
to stroke and ischemic lesions between the PP group and non-PP
group. Unstable plaque in MR plaque imaging and open cell stent
used was a significant predictive factor of PP.
Conclusion: PP during CAS was strongly associated with ischemic
complications. PP prevention is necessary for avoiding ischemic
complications during CAS.

3104.6
Carotid artery stenting using new generation micromesh duallayer stent: the Italian experience from 3 high-volume centres
R.Nerla1, F.Castriota1, A.Micari1, P.Sbarzaglia1, C.Setacci2,
M.A.Ruffino3, A.Cremonesi1
1Cardioangiology Cath Lab, Maria Cecilia Hospital, Cotignola, Italy,
2Vascular and Endovascular Surgery, University of Siena, Siena, Italy,
3Vascular Radiology, AOU San Giovanni Battista di Torino, Turin, Italy
Purpose: Carotid artery stenting (CAS) is a safe and effective treatment for carotid artery disease; however, compared to carotid
endarterectomy, it is associated with a higher rate of early major
adverse neurological events (MANE). The roadsaver carotid artery
stent (Terumo, Belgium) is a double layer micromesh new-generation stent that has the advantage to improve plaque coverage, thus
reducing plaque prolapse. Its clinical impact on the neurological
outcome is still unknown.
Material and methods: In total, 150 patients (age 748, 75% males,
symptomatic 29%) treated with CAS using the roadsaver carotid
stent in 3 high-volume Italian centres were included in the study.
Demographics of all the patients and procedural data were prospectively collected in a dedicated database. Intraprocedural optical coherence tomography (OCT) evaluation was performed in 26
patients (17%), with an off-line frame analysis by a dedicated core
laboratory. Duplex ultrasound and neurological evaluation of all
patients was performed at 24 hours and at 30 days.
Results: CAS was technically successful in all cases. The mean stent
diameter was 8.60.8 mm, whereas the stent length was 25.04.5
mm. No in-hospital and 30-day MANEs were observed. OCT evaluation detected plaque prolapse in 2/26 patients (7.7%). Duplex ultrasound showed stent and external carotid artery patency in all cases
both before discharge and at 30-day follow-up.
Conclusion: A dual-layer micromesh stent is a safe and promising
technology for CAS, with a low percentage of plaque prolapse and
a good short-term clinical outcome. Larger studies with longer follow-up are necessary to confirm these results and to investigate the
association of intraprocedural plaque prolapse with neurological
events at follow-up.

Free Paper Session

Embolisation 2
3105.1
Superior rectal artery embolisation EMBORRHOID as the
first line treatment in patients suffering from haemorrhoidal
disease: final results
V.Vidal1, F.Tradi2, D.Mege2, J.-M.Bartoli2, I.Sielezneff2
1Service de Radiologie, Hpital Timone Adultes, Marseille, France,
2Bouches du Rhnes, Hpital de la Timone, Marseille, France
Purpose: Embolisation of the superior rectal arteries (EMBORRHOID)
has recently been shown to be effective on haemorrhoidal disease
for compassionate patients. We report the final results (1-year follow-up) of the first study of superior rectal artery embolisation as
the first line treatment for patients suffering from haemorrhoidal
disease.

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Material and methods: Twenty-five patients (3072 years old)

with symptoms of haemorrhoidal disease (chronic, disabling, rectal
bleeding and/or pain) were embolised de novo after consensus from
a multidisciplinary team (proctologist, visceral surgeon and radiologist). Embolisation of the terminal branches of the superior rectal
arteries were performed via the inferior mesenteric artery using a
microcatheter and coils (0.018, 2 and 3 mm in diameter).
Results: Technical success of the embolisation procedure was 100%.
Embolisation reduced symptoms and resulted in satisfied patients.
The overall rate of symptom improvement was 61%. In 14 patients
who had complete embolisation, symptom improvement was 70%.
In the other 11 patients with an incomplete embolisation (residual
small vertical patent vessels below the public bone), the symptom
improvement was 40% (p<0.05).
Seven patients who experienced rebleeding and/or pain underwent
an additional embolisation with success in five of them. No ischaemic or other complications were observed in 25 patients.
Conclusion: Coil embolisation of the superior rectal arteries is safe
and effective for the treatment of haemorrhoidal disease. These
results suggest that embolisation should be as complete as possible.
This hypothesis opens the door to additional studies with a more
distal embolisation using other embolic agents.

3105.2
Safety and efficacy in embolotherapy of cecum hemorrhage in
comparison to non-cecum lower gastrointestinal bleeding: is
bowel ischemia a coming nightmare?
S.Li, S.Sun, S.Wang, Y.Guo, L.Lenhart
Radiology, University of Iowa Health Care, Iowa City, IA, United States
of America
Purpose: Cecum may be more prone to post-embolization ischemia
due to its characteristic arterial anatomy. We retrospectively evaluated the incidence of bowel infarct following embolotherapy of
cecal bleeding in comparison with that of other lower gastrointestinal bleeding (LGIB).
Material and methods: During a 10-year period from March 2006
to July 2015, patients who underwent embolotherapy of LGIB were
retrospectively evaluated for development of post-embolization
bowel infarct (PEBI), which was defined as bowel ischemia/necrosis that required surgical intervention within 1 week following
arterial embolization and was confirmed by direct intra-operative
visualization.
Results: A total of 156 (male 112/female 44) patients with LGIB
underwent 182 embolization procedures over the 10-year period.
Of these, 50 patients had angiography-confirmed cecal hemorrhage
from any of the cecal branches in ileocolic or right colic artery, and
subsequently underwent 61 embolization procedures using gelfoam and/or microcoils. The remaining 106 patients of non-cecum
LGIB received 131 embolization procedures. Four PEBI presented
following 61 cecum artery embolization procedures (6.6%) and
resulted in subsequent bowel resection, versus 3 of the 131 embolotherapy in the non-cecum LGIB group (2.2%). The incidence of
rebleed post embolization in cecum group was 28.0% versus 26.1%
in the non-cecum group, without significant difference.
Conclusion: A significantly higher incidence of bowel infarction
following embolotherapy of cecal bleeding was demonstrated
compared to that of LGIB locations. Our study indicates that cecal
branches from ileocolic or right colic artery should be approached
with greater caution whenever embolization of cecal bleeding is
considered.

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3105.3
Bariatric embolization of arteries for the treatment of obesity
(BEAT obesity): 6-month safety and efficacy data
C.R.Weiss1, O.Akinwande1, K.Paudel1, L.Cheskin2, B.Holly1,
K.Hong1, A.Fischman3, R.Patel4, E.J.Shin5, K.Steele6, T.H.Moran7,
D.L.Kraitchman1, A.Arepally8
1The Russell H. Morgan Department of Radiology and Radiologic
Science, Johns Hopkins University School of Medicine, Baltimore, MD,
United States of America, 2Johns Hopkins Weight Management Center,
Johns Hopkins University Bloomberg School of Public Health; School of
Medicine, Baltimore, MD, United States of America, 3Assistant Professor
Radiology and Surgery, Mount Sinai Medical Center, New York, NY,
United States of America, 4Interventional Radiology, Mount Sinai
Medical Center, New York, NY, United States of America, 5Department of
Internal Medicine/Gastroenterology, Johns Hopkins University School
of Medicine, Baltimore, MD, United States of America,6Department of
Surgery/The Johns Hopkins Center for Bariatric Surgery, Johns Hopkins
University School of Medicine, Baltimore, MD, United States of America,
7Department of Psychiatry and Behavioral Sciences, Johns Hopkins
University School of Medicine, Baltimore, MD, United States of America,
8Interventional Radiology, Piedmont Healthcare, Atlanta, GA, United
States of America
Purpose: Bariatric arterial embolization (BAE) is an endovascular
procedure targeting the gastric fundus for the treatment of obesity.
BAE results in decreased serum ghrelin and weight modulation in
animal models. BEAT obesity study was initiated to assess the safety
and efficacy of BAE to treat severely obese patients using 300500m embospheres.
Material and methods: Adult, otherwise healthy, morbidly obese
patients (BMI=4060; n=7) were enroled. Primary safety and efficacy endpoints were 30-day adverse events (AE) and weight loss.
Secondary endpoints were serum obesity hormones (Ghrelin,
Leptin, GLP-1, and PYY), hunger/satiety assessments, quality of life
(QOL) surveys, blood pressure, lipid profile, endoscopy, and gastric emptying results. Six-month data, as collected to date, are
presented.
Results: Mean age was 36.419.1 years and BMI was 44.62.77 kg/
m2 at enrollment. Left gastric artery (LGA) embolization was performed in all patients. Additionally, the gastroepiploic arteries were
embolized in 4 patients. There were 3 minor AEs with no major AEs.
One patient had subclinical pancreatitis, 2 patients had small (<1
cm) superficial mucosal ulcers, one was healing by 2 weeks, and
one was healed by 3 months. There was 5.9%2.4%, 9.5%3.1%,
and 13.3%4% excess weight loss at 1, 3, and 6 months, respectively. Mean percent change of serum ghrelin from baseline was
+8.68%34.74% at 1 month and 17.49%28.98% at 3 months. A
trend toward improvement in QOL parameters was noted. Hunger/
appetite scores were markedly decreased post-BAE and remained
suppressed.
Conclusion: Early follow-up of BAE demonstrates safety, weight loss,
and associated appetite suppression in severely obese patients.

3105.4
Coil embolization of unligated side branches in the grafted left
internal mammary artery causing myocardial ischemia
O.Beton1, M.B.Yilmaz2
1Cardiology, Cumhuriyet University, Faculty of Medicine, University
Hospital, Heart Center, Sivas, Turkey, 2Heart Center, Cumhuriyet
University, Faculty of Medicine, University Hospital, Sivas, Turkey

Abstract Book
Material and methods: A total of 459 patients with prior CABG
undergoing coronary angiography (CAG) were included. The preangiographic exercise stress perfusion scan (SPS) and angiographic
data were investigated. CE was performed in patients with large
LIMA SB. Control SPS was performed in patients after CE.
Results: The incidence of LIMA SB was found to be 40.8%. Univariate
analysis identified three predictors of anterior wall ischemia: first
SB diameter, first SB length, and LIMA-first SB diameter ratio.
Multivariate analysis identified two independent predictors of anterior wall ischemia: first SB diameter (P = 0.027; OR 122.781, 95%CI
1.748-8624.450) and first SB length (P = 0.041; OR 1.510, 95%CI 1.0172.241). ROC curve of first SB diameter cut-off value 1.3 mm had
100.0% sensitivity and 76.2% specificity for detecting anterior wall
ischemia on exercise-SPS (AUC=0.938, p<0.001). ROC curve of first SB
length cut-off value 11 cm had 91.7% sensitivity and 71.4% specificity for detecting anterior wall ischemia on exercise-SPS (AUC=0.911,
p<0.001). CE was performed in 17 patients. Complete reversal of
anterior ischemia on SPS was recorded after coil embolization in
patients with LIMA SB diameter >1.3 mm and length >11 cm.
Conclusion: Large LIMA-SBs are a potential source of ischemia. CE
is a successful treatment option leading reversal of myocardial ischemia especially in patients with LIMA SB diameter >1.3 mm and
length >11 cm.

3105.5
Ethylene vinyl alcohol copolymer for treatment of high flow
arteriovenous vascular malformations: long-term results and
histology
A.S.Gomes1, P.A.Monteleone1, A.Vasan2, J.W.Sayre3, S.V.Bukata4
1Radiological Sciences, David Geffen School of Medicine at UCLA,
Los Angeles, CA, United States of America, 2Medicine, Duke
University School of Medicine, Durham, NC, United States of America,
3Biostatistics, UCLA School of Public Heath, Los Angeles, CA, United
States of America, 4Orthopaedic Surgery, David Geffen UCLA School of
Medicine, Santa Monica, CA, United States of America
Purpose: To describe the use, long-term results, and histologic findings of ethylene vinyl alcohol copolymer for the treatment of high
flow arteriovenous vascular malformations.
Material and methods: Since 2005, we have used the ethylene vinyl
alcohol copolymers (Onyx 18 and Onyx 34) in the treatment of 30
patients with high flow arteriovenous vascular malformations. There
were 20 females and 10 males aged from 1 to 67 years (mean 28
years). Nineteen of the malformations involved the extremities, and
11 involved the chest, abdominal wall, or pelvis. All patients were
evaluated with MRI/MRA pre-treatment and with ultrasound if necessary to document lesion visibility. Onyx was delivered by subselective transarterial and/or venous microcatheter techniques with or
without ultrasound, and fluoroscopy-guided direct injection under
tourniquet control. Tissues from embolized lesions which were subsequently explanted were examined histologically.
Results: Onyx was found to be durable and effective. Its visibility allows observation of filling of the malformation vessels. Postprocedure discomfort with Onyx was minimal. Of the 30 patients,
two developed an area of skin ulceration, and one had worsening
of a pre-existing radiation burn. In patients receiving multiple treatments, multiple imaging obliquities were sometimes needed to
allow visualization of untreated portions of the lesion. On histology,
Onyx filling of the vascular spaces of the malformation with associated foreign body giant cell reaction was observed.
Conclusion: Ethylene vinyl alcohol copolymer is a safe, durable
agent for treatment of high flow arteriovenous malformations.

Purpose: To investigate the prevalence and clinical significance of

the unligated left internal mammary artery (LIMA) side branch (SB)
in CABG patients and determine the patients who will benefit from
coil embolization (CE).

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3105.6
Image-guided percutaneous treatment of chylous leaks: a
single-center experience of 62 patients over 5 years
M.P.Yannes, E.G.SantosMartn
Radiology, University of Pittsburgh, Pittsburgh, PA, United States of
America
Purpose: Managing chylous leaks is notoriously difficult. Patients
are often postoperative and have significant comorbidities. Open
surgical procedures can be curative but subject patients to significant risks. Percutaneous therapies include intranodal lymphangiography (INL), thoracic duct embolization (TDE), disruption (TDD),
sclerotherapy, and CT/US-guided glue injection. In this retrospective
review, we chronicle a single centers sequential experience with INL
and percutaneous management of chylous leaks.
Material and methods: All patients over a 5-year period who
were referred for evaluation were included. Procedures were performed or supervised by a single senior interventional radiologist.
In patients with chylothorax in whom a leak was identified, TDE was
preferentially performed. If the thoracic duct could not be canalized,
TDD was performed. Clinical success was defined as avoidance of
subsequent corrective surgery and removal of draining catheters.
Results: In total, 62 patients underwent evaluation. INL was technically successful in 60/62 patients (97%). Of the 62 patients, 23
patients underwent INL only, 24 underwent INL and TDE, and 13
patients underwent INL and thoracic duct disruption. A chylous leak
was identified in 42/60 patients (70%). The clinical success rate of all
therapies was 70%; in those for whom a leak was identified, the clinical success rate was 74%. There were no complications.
Conclusion: INL is safe and can be used instead of traditional
bipedal lymphangiography. Percutaneous management of chylous
leaks has low associated risks and is effective in the management of
lymphatic leaks.

Free Paper Session

Peripheral 2
3106.1
Six-month results from the first-in-human randomized study
on the Ranger paclitaxel-coated balloon catheter
D.Scheinert1, A.Willfort-Ehringer2, H.Sievert3, V.Geist4,
M.Lichtenberg5, M.R.Sapoval6, A.Sauguet7
1Interventional Angiology, Universittsklinikum Leipzig, Leipzig,
Germany, 2Angiology, Medizinische Universitt Wien, Vienna, Austria,
3Director, Cardiovascular Center Frankfurt, Frankfurt, Germany,
4Internal Medicine, Herzzentrum Bad Segeberg, Bad Segeberg,
Germany, 5Vascular Center, Klinikum Arnsberg, Arnsberg, Germany,
6Dept. of Cardiovascular Radiology, Hpital Europen Georges
Pompidou, Paris, France, 7Cardiology, Clinique Pasteur Toulouse,
Toulouse, France
Purpose: The purpose of this first-in-human randomized clinical
study is to evaluate the performance of the Ranger Paclitaxel-coated
Balloon Catheter (Boston Scientific Corporation, Marlborough, MA,
USA; Hemoteq AG, Wrselen, Germany) vs. an uncoated balloon
catheter for angioplasty of femoropopliteal artery lesions.
Material and methods: This prospective, randomized (2:1,
Ranger:uncoated balloon) study included patients with symptomatic leg ischemia requiring treatment (i.e., Rutherford classification 24) and de novo or restenotic lesions in the native nonstented superficial femoral artery and/or proximal popliteal artery.
The primary endpoint was 6-month angiographic late lumen loss
(change in minimum lumen diameter [MLD] from immediately

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S183

post-procedure to 6 months post-procedure). Safety assessments

include target lesion revascularization, major amputations, and
deaths.
Results: A total of 104 patients were enrolled in the study. Among
patients treated with the uncoated balloon (N=33), 67% were male,
36% had diabetes, and 70% were current or previous smokers. In the
Ranger group (N=71), 75% were male, 39% had diabetes, and 86%
were current or previous smokers. Mean ages (SD) of the patients
were 679.5 years (control) and 688 years (Ranger). Six-month follow-up and analysis will be complete by the time of presentation.
Conclusion: Six-month results from the Ranger first-in-human study,
including late lumen loss, patency, and safety assessments, will be
available by the time of presentation.

3106.2
The Freeway Stent Study: the 6-month results favor the use of
DEB in combination with stenting
J.Tacke1, K.A.Hausegger2, H.Schrder3, S.Mller-Hlsbeck4,
S.Stahnke5
1Institut fr Diagnostische und Interventionelle Radiologie und
Neuroradiologie, Klinikum Passau, Passau, Germany, 2Radiology,
General Hospital Klagenfurt, Klagenfurt, Austria, 3Radiology,
Vascular Center Jewish Hospital, Berlin, Germany, 4Department of
Diagnostic and Interventional Radiology / Neuroradiology, Ev.-Luth.
Diakonissenanstalt zu Flensburg, Flensburg, Germany, 5Clinical
Department, Eurocor GmbH, Bonn, Germany
Purpose: Stents are needed in up to 50% of all peripheral interventions where PTA with plain or drug-coated balloons alone will not
reopen the vessel sufficiently. Nevertheless, the restenosis rate of
stents is a major limitation of peripheral arterial interventions. Drugeluting balloons potentially overcome the problem of in-stent restenosis when used for postdilatation after primary nitinol stenting in
the SFA and PI segments.
Material and methods: The Freeway Stent Study is a prospective,
randomized, international trial conducted in 15 centers in Germany
and Austria. Two-hundred patients were enrolled and randomized
to primary stenting, followed by either DEB (Freeway) or POBA
postdilatation. The primary endpoint IS clinically driven target lesion
revascularization (TLR) at 6 months, and the secondary endpoints
include shift in Rutherford classification and ABI, LLL, patency rate,
and MAE at 6 and 12 months.
Results: The 6-month follow-up has been completed, the 12-month
follow-up is ongoing. The results highly favor the use of Freeway
DEB over POBA based on clinically driven TLR at 6 and 12 months.
This is supported by statistically significant better clinical outcomes
for patients in the DEB group.
Conclusion: The use of DEB as a postdilatation device is investigated
in a new approach to decrease the restenosis rate after nitinol stenting in the SFA and PI segments. The Freeway Stent Study shows that
the usage of DEB as a restenosis prophylaxis seems to be safe and
feasible. The 6-month follow-up results show significant and positive trends in all parameters in favor of DEB.

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3106.3

3106.4

Relationship between albuminuria and renal artery stent

outcomes: results of the cardiovascular outcomes with renal
artery lesions (CORAL) randomized clinical trial

Characterization of atherectomy samples from long SFA CTOs

in correlation with clinical outcomes

T.P.Murphy1, C.J.Cooper2, K.Pencina3, R.DAgostino3, J.Massaro3,

D.Cutlip4, K.Jamerson5, A.H.Matsumoto 6, W.Henrich7, J.Shapiro8,
K.Tuttle9, D.J.Cohen10, M.Steffes11, Q.Gao12, C.Metzger13,
W.Abernethy14, S.C.Textor15, J.Briguglio16, S.Tobe17, L.Dworkin18
1Vascular Disease Research Center, Rhode Island Hospital, Providence,
RI, United States of America, 2Medical School, University of Toledo,
Toledo, OH, United States of America, 3Biostatistics, Boston University,
Boston, MA, United States of America, 4Cardiology, Beth Israel
Deaconess, Boston, MA, United States of America, 5Internal Medicine,
University of Michigan, Ann Arbor, MI, United States of America,
6Radiology, University of Virginia, Charlottesville, VA, United States
of America, 7Medical School, University of Texas San Antonio, San
Antonio, TX, United States of America, 8Medical School, Marshall
University, Huntington, WV, United States of America, 9Nephrology,
Sacred Heart Hospital, Spokane, WA, United States of America,
10 Cardiology, St. Lukes Hospital, Kansas City, MO, United States of
America, 11Pathology, University of Minnesota, Minneapolis, MN,
United States of America, 12Clinical Trials, Harvard Clinical Research
Institute, Boston, MA, United States of America, 13Cardiology,
Wellmont-Holston Valley Medical Center, Kingsport, TN, United States
of America, 14Cardiology, Asheville Cardiology Associates, Asheville,
NC, United States of America, 15Nephrology, Mayo Clinic, Rochester,
MN, United States of America, 16Radiology, Lancaster General Hospital,
Lancaster, PA, United States of America, 17Nephrology, Sunnybook
Research Institute, Toronto, ON, Canada, 18Nephrology, Rhode Island
Hospital, Providence, RI, United States of America
Purpose: Randomized clinical trials have not shown an additional
clinical benefit of renal artery stent placement over optimal medical therapy alone using a number of clinical endpoints. We sought
to examine the effect of baseline albuminuria on clinical outcomes
after renal artery stent placement.
Material and methods: The CORAL study population was stratified based on the median baseline urine albumin/creatinine ratio
(uACR) (n=826) and analyzed for the 5-year incidence of the primary
composite endpoint (myocardial infarction, hospitalization for congestive heart failure, stroke, renal replacement therapy, progressive renal insufficiency, or cardiovascular- or kidney disease-related
death) and overall survival. Longitudinal systolic blood pressure was
compared between the treatment groups.
Results: When baseline uACR was <= the median value (22.5 mg/g),
renal artery stenting was associated with a significantly better eventfree survival with respect to the primary composite endpoint (73%
vs. 59% at 5 years, p=.02), cardiovascular disease-related death (93%
vs. 85%, p=<.01), progressive renal insufficiency (91% vs. 77%, p=.03),
and overall survival (89% vs. 76%, p=<.01). There was no benefit of
stenting when baseline uACR was > the median value. There was no
significant difference in longitudinal systolic blood pressure based
on the treatment group for uACR>22.5 mg/g, but borderline significance favoring stent treatment was observed when uACR>22.5
mg/g (p=.052).
Conclusion: The CORAL study data suggest that low urine
albumin:creatinine ratio indicates a large subgroup of those with
renal artery stenosis who could experience improved event-free and
overall survival after renal artery stent placement plus optimal medical therapy compared with optimal medical therapy alone.

J.George
Cardiology, Einstein Medical Center, Philadelphia, PA, United States of
America
Purpose: Chronic total occlusions (CTOs) have been associated with
higher reocclusion rates and need for revascularization. While ample
studies have analyzed atherectomy samples, to date, no analysis
has focused on chronic total occlusions correlated with clinical outcomes. The purpose of this study was to expand this translational
knowledge.
Material and methods: a. In total, 19 femoropopliteal CTO
lesions were crossed intraluminally using OCT guidance (Ocelot).
Atherectomy samples were excised during TurboHawk revascularization and subjected to histopathological analysis.
b. In total, 38 CTO lesions were crossed intraluminally using OCT
guidance (Ocelot). OCT-guided atherectomy samples were excised
during Pantheris revascularization and subjected to similar histopathological analysis.
The compiled information was paired and correlated with clinical
outcomes, as recorded at patients follow-ups (1-, 3-, or 6-month
visit).
Results: a. All 10 de novo lesions had adventitial resection (up to
57% of total lesion area), 8/10 de novo lesions had thrombus (up to
34% of total lesion area).
In total, 19 CTO lesions, 10 de novo (mean LL 15.4cm) and 9 restenosis (mean LL 22.1cm) were successfully crossed, with no dissections
or perforations. At follow-up, 70% of the de novo lesions (7/10) and
89% (8/9) of the restenotic lesions had TLR.
b. Less than 40% of the lesions had adventitial resection, with an
average of adventitial area at 3.2%.
In total, 38 de novo CTO lesions were successfully crossed with no
dissections or perforations. At follow-up, 7.9% lesions (3/38) showed
TLR.
Conclusion: Pairing the histologic analysis with lesion length and
binary clinical outcomes enabled the generation of a predictive
lesion scoring system. There was a compelling trend indicating a
correlation between lesion scores and TLR occurrence.

3106.5
SUPERA stent versus standard nitinol stents for recanalization
of chronic total occlusions of the femoropopliteal artery: the
SUPERFAST study
I.Paraskevopoulos1, A.Diamantopoulos1, S.Abisi2, H.Zayed2,
P.Gkoutzios1, V.Zymvragoudakis2, K.N.Katsanos1
1Department of Interventional Radiology, Guys and St. Thomas NHS
Foundation Trust, London, United Kingdom, 2Department of Vascular
Surgery, Guys and St. Thomas NHS Foundation Trust, London, United
Kingdom
Purpose: The SUPERA stent is a new-generation biomimetic stent
with high flexibility and resistance to compression. The authors
report the results of a single-center prospective study comparing
the SUPERA-stent with a historical cohort of older generation selfexpanding nitinol stents for recanalization of long chronic total
occlusions of the femoropopliteal artery.
Material and methods: Patients with symptomatic infrainguinal
arterial disease (critical limb ischemia or claudication) who underwent stent placement following intraluminal or subintimal recanalization of chronic total occlusions of the superficial femoral and/
or popliteal artery (TASC C or D lesions) were eligible for inclusion. Primary patency was defined as freedom from any significant
reduction of flow detectable by Duplex ultrasound imaging [binary

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CIRSE 2016
vessel restenosis (>50%) on PSVR 2.4] and without any target vessel revascularization (TVR) in the interim. Regression analysis was
performed to adjust for potential confounders.
Results: From April 2014 to June 2015, 60 consecutive patients with
femoropopliteal CTOs were treated with SUPERA stent placement
(55% males, 64% CLI, lesion length 17.68.6 cm). The group was
statistically matched with a historical control group of another 60
patients (June 2012 to April 2014) treated with older standard nitinol
stents (65% males, 58% CLI, lesion length 16.611.0 cm). Estimated
primary patency at 12 months was 83.37.6% in the SUPERA stent
group compared with 63.810.3% in the control nitinol stent group
(P=0.02). Detailed results, including freedom from all causes of
death, index limb amputation, and TVR rates will be reported.
Conclusion: The SUPERA biomimetic stent is a more effective stent
option for complex occlusive arterial disease of the femoropopliteal
artery.

3106.6
Treating in-stent restenosis using ZERO fluoroscopy:
OCT-guided atherectomy case series
A.Desai1, A.G.Schwindt2
1Anesthesiology, Stanford University, Redwood City, CA, United
States of America, 2Vascular Surgery, St. Franziskus Hospital, Mnster,
Germany
Purpose: To evaluate the use of OCT-guided atherectomy for safe
and effective treatment of in-stent restenosis (ISR) of the superficial
femoral and popliteal arteries. Additionally, to measure the dramatic
reduction or elimination of fluoroscopic radiation when using OCTguided therapy.
Material and methods: Patients received baseline CTA or angiography diagnosing ISR. Thirty consecutive ISR lesions were treated
using the OCT-guided Pantheris atherectomy system (Avinger, Inc.).
Efficacy was measured via %residual stenosis post atherectomy
adjunctive therapy. Both total case and therapeutic fluoroscopy
times were measured. Patients were evaluated upon discharge and
at one, six, and twelve months post-procedure.
Results: Average ISR lesion length treated (n=30 patients) was
15 cm. All lesions were treated to <30% post-Pantheris and <10%
with adjunctive drug-coated balloon. Average therapeutic fluoroscopy time was reduced to <2 min. No adverse events were noted.
Promissory 30-day and 6-month outcomes (in process).
Conclusion: OCT-guided atherectomy is a safe and effective therapy for the treatment of ISR in PAD, with the additional benefit of dramatically reducing or eliminating radiation exposure from
fluoroscopy.

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Papers

CIRSE 2016

Barcelona, Spain

September 10-14

CIRSE 2016
PART 3

Abstracts of
Posters
sorted by presentation
numbers

Cardiovascular and Interventional Radiological Society of Europe

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S188

CIRSE

Aortic Intervention
P-1
Fusion of CT angiography or MR angiography with unenhanced
CBCT and fluoroscopy guidance in endovascular treatments of
aorto-iliac steno-occlusion: preliminary experience
A.M.Ierardi1, F.Fontana2, E.Duka1, F.Piacentino3, G.Piffaretti4,
P.Torcia5, U.G.Rossi6, M.Cariati7, G.Carrafiello3
1Radiology, Uninsubria, Ospedale di Circolo, Varese, Italy, 2Radiology,
Ospedale di Circolo e Fondazione Macchi, Varese, Italy, 3Radiology,
University of Insubria, Varese, Italy, 4Vascular Surgery Department,
Uninsubria, Ospedale di Circolo, Varese, Italy, 5Radiology and
Interventional Radiology, San Carlo Borromeo Hospital, Milan, Italy,
6Radiology, San Carlo Borromeo Hospital, Milan, Italy, 7Diagnostic
Sciences, San Carlo Borromeo Hospital, Milan, Italy
Purpose: To evaluate the feasibility of image fusion (IF) of pre-procedural arterial-phase CT angiography or MR angiography with
intra-procedural fluoroscopy for road-mapping in endovascular
treatment of aorto-iliac steno-occlusive disease.
Material and methods: We prospectively evaluated 10 patients
with chronic aorto-iliac steno-occlusive disease who underwent
endovascular treatment in the angiography suite. Fusion image
road-mapping was performed using angiographic phase CT images
or MR images acquired before and intra-procedural unenhanced
cone-beam CT (CBCT). Radiation dose of the procedure, volume of
intraprocedural iodinated contrast medium, fluoroscopy time, and
overall procedural time were recorded. Reasons for potential fusion
imaging inaccuracies were also evaluated.
Results: Image co-registration and fusion guidance were feasible in
all procedures. Mean radiation dose of the procedure was 599120.5
mGy cm2. The mean total procedure time was 30.2 min. The mean
fluoroscopy time was 11 min and 10 s. The mean procedural iodinated contrast material dose was 25 mL (range 2040 mL).
Conclusion: Image fusion gives interventional radiologists the
opportunity to use new technologies to improve outcomes with significant reduction in contrast media administration.

P-2
Usefulness of cone-beam computed tomography and
automatic vessel detection software in the identification of
type 2 lumbar endoleak
A.M.Ierardi1, E.Duka1, C.Micieli1, G.Piffaretti2, P.Torcia3,
U.G.Rossi4, N.Rivolta2, M.Cariati5, G.Carrafiello6
1Radiology, Uninsubria, Ospedale di Circolo, Varese, Italy, 2Vascular
Surgery Department, Uninsubria, Ospedale di Circolo, Varese, Italy,
3Radiology and Interventional Radiology, San Carlo Borromeo
Hospital, Milan, Italy, 4Radiology, San Carlo Borromeo Hospital, Milan,
Italy, 5Diagnostic Sciences, San Carlo Borromeo Hospital, Milan, Italy,
6Department of Radiology, University of Insubria, Varese, Italy
Purpose: To evaluate the utility of dual-phase cone beam computed
tomography (DP-CBCT) and automatic vessel detection (AVD) software to guide transarterial embolization (TAE) of angiographically
challenging type 2 lumbar endoleak (T2 L EL).
Material and methods: Ten patients with a T2 L EL documented
at computed tomography angiography (CTA) and an inconclusive
identification of the vessel feeding the aneurysmal sac at the initial
angiography were included. Accuracy of DP-CBCT and AVD software
were defined as the ability to detect the endoleak and the feeder,
respectively. Technical success was defined as the correct positioning of the microcatheter in the sac using AVD software. Clinical
success was defined as the successful embolisation. Total volume
of iodinated contrast medium and overall procedure time were
registered.

Abstract Book
Results: The endoleak was not detected by initial angiogram in 80%
of cases; the impossibility to identify the vessel feeding the sac was
the reason for inclusion in all cases. The endoleak was detected by
DP-CBCT in 9/10 patients; in one case, CBCT-CT fusion was required.
AVD software identified the feeder in 9/10 of cases. In one case,
vessel tracking required manual marking of the supposed feeder.
Technical success was 90%. Successful embolization was achieved in
9/10 patients. Mean contrast volume injected for each patient was
90 ml, and mean overall procedural time was 45 minutes.
Conclusion: C-arm CBCT and AVD software during TAE of angiographically challenging T2 L EL is feasible and may facilitate successful embolization. Staff training in CBCT imaging and software
manipulation is necessary.

P-3
Transcaval embolization in the treatment of type II endoleaks
R.Gandini, F.DeCrescenzo, S.Merolla, D.Konda, F.Chegai,
E.Pampana, S.Abrignani, M.Muto
Diagnostic and Molecular Imaging, Radiation Therapy and
Interventional Radiology, University Hospital Policlinico Tor Vergata,
Rome, Italy
Purpose: To evaluate the technical and midterm results in the treatment of type II endoleaks comparing nonselective (nTCE) vs. selective (sTCE) transcaval embolization.
Material and methods: We conducted a retrospective study during
a 4-year period in 26 patients (18 men; median age 73 years, range
68-78) who underwent direct transcaval aneurysm puncture followed by embolization of the sac (nTCE, n=9) or of the feeding vessels (sTCE, n=17). Intrasac pressure was recorded immediately after
aneurysm sac puncture and at the end of the procedure. Technical
success was defined a successful deployment of embolization material in the sac or in the feeding vessel. Clinical success was defined as
absence of endoleak with stabilization of the sac on follow-up CTA.
Results: Technical success was achieved in all the 9 patients (100%)
treated with nTCE. Mean intrasac pressures before and after nTCE
were 58.618.4 (range 51-105) and 6.51.2 mmHg (range 4-9),
respectively. Over a mean 25.911.0 months of follow-up, 4 patients
developed recurrent endoleak at a mean 9.73.9 months. Three
patients were subsequently treated with sTCE, while the last patient
underwent emergency surgery for aneurysm rupture due to an
enlarging sac 5 months after nTCE. The 20 patients in the sTCE group
had a successful procedure with no recurrence during a follow-up
of 24.17.2 months. Mean intrasac pressure was reduced after sTCE
from 63.615.2 mmHg (range 43-120) to 7.82.3 mmHg (range 5-12).
Conclusion: Selective TCE approach appears to be a feasible and
effective primary therapeutic option for treating type II endoleaks.

P-4
Safety and efficacy of resuscitative endovascular balloon
occlusion of the aorta using a 7-Fr sheath
M.Narita1, K.Idoguchi1, R.Usui1, S.Nakao1, Y.Mizushima2
1Division of Endovascular Therapy, Rinku General Medical Center,
Senshu Trauma and Critical Care Center, Osaka, Japan, 2Senshu
Trauma and Critical Care Center, Rinku General Medical Center, Osaka,
Japan
Purpose: Resuscitative endovascular balloon occlusion of the aorta
(REBOA) has been increasingly used for hemorrhage control, and
the device for performing REBOA has improved recently. Despite
the fact that the commonly used sheaths for REBOA have been over
10Fr in size, REBOA compatible 7Fr sheaths (7Fr-REBOA) have been
available in Japan since 2013. However, the safety and efficacy of
the REBOA using a small-diameter sheath remains uncertain. The
objective of this study was to estimate the safety and efficacy of
7Fr-REBOA.

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CIRSE 2016
Material and methods: We analyzed the observational prospective data (from 2/1/2003 to 1/31/2016) from the charts of our facility to compare the safety and efficacy of patients who received
7Fr-REBOA with those who received REBOA compatible with 10Fr
sheath (10Fr-REBOA).
Results: A total of 19 patients received 10Fr-REBOA and 29
received 7Fr-REBOA. Most of the cases were trauma patients (84%
of 10Fr-REBOA cases and 76% of 7Fr-REBOA cases), and the average of ISS was similar in the 2 groups (37.2 versus 33.1; p = 0.38).
The mean arterial pressure equally increased in both groups (+41.4
mmHg versus +39.2 mmHg; p = 0.87) and the mortality rate was similar between groups (63.2% versus 51.7%; p = 0.55). Lower extremity
ischemia occurred in 2 cases (11.1%) of the 10Fr-REBOA group and in
1 case (3.4%) of the 7Fr-REBOA group (in addition, this case required
a double sheath in 1 femoral artery).
Conclusion: 7Fr-REBOA had the same occlusion effect as
10Fr-REBOA. Moreover, complications related to lower extremity ischemic events were fewer with 7Fr-REBOA than those with
10Fr-REBOA.

P-5
Experimental X-ray microtomograph MARS as the future new
tool for the evaluation of infrarenal aneurysms rupture risk
A.V.Svetlikov1, A.Zhemchugov2, D.Kozhevnikov3, G.Shelkov3,
V.Gurevitch1, G.Khubulava4
1Vascular and Endovascular Surgery, North-Western State Medical
University n.a. I.I. Mechnikov 3, Federal Sokolovs Clinical Hospital
#122, St. Petersburg, Russian Federation, 2Nuclear Department, The
Joint Institute for Nuclear Research (Dubna), St. Petersburg, Russian
Federation, 3Dzhelepov Laboratory of Nuclear Problems, The Joint
Institute for Nuclear Research (Dubna), Dubna, Russian Federation,
4Cardiovascular Surgery, Military-Medical Academy named after S.M.
Kirov 5, St. Petersburg, Russian Federation
Purpose: A significant progress has been reached in the development of novel hybrid pixel detectors recently, which combine a sensor of high-Z material for efficient X-ray registration and a readout
chip. The aim of this study was to evaluate the potential of a new
type of detectors for X-ray imaging of ruptured abdominal aorta
aneurysmatic lesions under experimental conditions.
Material and methods: The samples obtained from 45 patients
with ruptured infrarenal aortic aneurysm were fixed in the formalin
solution and investigated in an experimental X-ray microtomograph
MARS (Mars Bioimaging Ltd) equipped with detector constructed
at Joint Institute for Nuclear Research (Dubna) using as a sensor the
modification of gallium arsenide invented and produced in Tomsk
State University. The Medipix readout chip was developed at CERN
(Geneva).
Results: It was shown that the new detector has high efficiency of
X-ray detection up to 80 keV and spatial resolution of 50 m. The
detailed images revealed that the detailed ruptured aneurysms
walls characterized by a well-identified areas of calcification and
other layers with different densities.
Conclusion: For the first time, the images of native non-frozen ex
vivo samples of damaged aortic aneurysm were obtained under
experimental conditions by using X-ray microtomographs. It is
expected that this is a new way to identify the fine structures of the
aneurysm tissue, which could be useful for rupture risk evaluation in
the future.

SS/FC/HL/HTS/CM
Posters

S189

P-6
Image fusion for endovascular repair of complex aortic
aneurysm
P.-A.Barral1, M.Gaudry2, M.DeMasi-Jacquier2, P.Piquet2,
J.-M.Bartoli1, A.Jacquier1
1Service de Radiologie, Hopital de la Timone, Marseille, France, 2Service
de Chirurgie Vasculaire, Hopital de la Timone, Marseille, France
Purpose: To evaluate the feasibility of image fusion of preprocedural arterial-phase computed tomography or magnetic resonance
angiography with intraprocedural fluoroscopy for roadmapping
during the endovascular repair of complex aortic aneurysms.
Material and methods: Twenty-nine patients with complex aortic aneurysms treated with endovascular techniques were retrospectively included. All interventions were performed with General
Electric Discovery IGS 730 using Innova software.
X-ray exposure, injected contrast medium volume, gap between volume rendering from preprocedural computed tomography or magnetic resonance angiography and 2D angiography, and fluoroscopy
time were recorded.
Results: The deployment of the endoprosthesis was successful in 28
of the 29 procedures.
The average gap between volume rendering from preprocedural
computed tomography or magnetic resonance angiography and 2D
angiography was 9 (min 0 max 18) in rotation and 7.5 mm (min 0
mm max 9 mm) in translation.
The average injected contrast medium volume was 135 mL (min 45
mL max 200 mL). The average X-Ray exposure was 71 Gy.cm (min 31
Gy.cm max 77 Gy.cm). The average fluoroscopy time was 27.7 minutes (min 7 minutes max 120 minutes).
No endoleaks were seen on the final control in 24 of the 29 patients.
Five patients presented endoleaks at the end of the procedure and
at mid-term (three type 1a and two type 1b).
Conclusion: The use of image fusion-based roadmapping is a feasible technique for endovascular complex aneurysm repair.

P-7
Aorto-iliac TASC C and D lesions: outcome of first endovascular
approach
T.Donati1, S.Patel1, G.Santoro1, L.Biasi1, P.Saha1, K.N.Katsanos2,
H.Zayed3
1Vascular, Guys and St Thomas NHS Foundation Trust, London,
United Kingdom, 2Interventional Radiology, Guys and St Thomas NHS
Foundation Trust, London, United Kingdom, 3Department of Vascular
Surgery, Guys and St Thomas NHS Foundation Trust, London, United
Kingdom
Purpose: To evaluate the results of endovascular treatment for TASC
C and D lesions and assess the impact of adjunctive procedures on
the outcomes in a consecutive group of patients.
Material and methods: Analysis of prospectively maintained database for consecutive patients who underwent endovascular treatment for TASC C and D aortoiliac occlusive disease during the period
from January 2010 to December 2014. Primary endpoints were target vessel patency, limb salvage (LS), amputation-free survival (AFS),
and freedom from major adverse limb events (MALE).
Results: Overall, 132 limbs in 89 patients were treated. Indications
for treatment were life-limiting claudication (n=36), rest pain (n=39),
and tissue loss (n=14). Treated lesions were TASC C (24%) and TASC D
(76%) according to TASC-II classification. Re-entry devices were used
in 18% (n=16) of the patients. Open adjunctive procedure consisted
of femoral endarterectomy (n=60) and cross-over bypass (n=1).
Technical success was observed in 97% of the patients. Mean followup was 12 (range: 148) months. Primary patency, assisted primary
patency, and secondary patency at 1 year was 84%, 88%, and 95%,

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respectively. LS and AFS at 1 year were 98% and 88%, respectively.

Freedom from MALE was 87% at 1 year. Peri-operative complications
occurred in 14 (16%) patients and included major adverse cardiovascular events (6%) (stroke n=3, MI n=1, and death n=1), vessel perforation (7%), and renal failure (3%).
Conclusion: Endovascular treatment of TASC C and D aortoiliac
lesions is a viable option with satisfactory clinical outcomes and
high technical success rate; however, in our experience, the use of
adjunctive procedures was required in majority of the patients.

P-8

Abstract Book
associated with ischemic complications (organ ischemia), and these
have been reported to occur in up to 30% of all cases. However,
many therapies have attempted to address the acute ischemic complications in aortic dissection.
Clinical Findings/Procedure: The purpose of this poster is to illustrate i) types, ii) pathophysiology, iii) MD-CT and angiography
appearances, iv) and possible endovascular treatments of malperfusion syndromes.
Conclusion: The knowledge of malperfusion syndromes and the
use of endovascular techniques in the setting of aortic dissections
have the potential to improve early survival of the patient.

Endovascular repair of focal thoracic aortic aneurysms

following aortic coarctation patch repair

P-10

A.Alfahad1, J.Thomson2, M.Troxler3, S.J.McPherson1

1Radiology, Leeds General Infirmary, Leeds, United Kingdom,
2Cardiology, Leeds Teaching Hospitals, Leeds, United Kingdom,
3Vascular Surgery, Leeds Teaching Hospitals, Leeds, United Kingdom

Cardiatis stent graft in a symptomatic type IV

thoracoabdominal aortic aneurysm

Purpose: Surgical repair of thoracic aortic coarctation is complicated with late aortic aneurysms in 9% of cases. Reoperation to
repair these aneurysms is challenging and associated with high mortality rates.
Endovascular repair has been proposed as a promising alternative
for managing these patients. Our aim is to report our experience following endovascular repair and to highlight the need for imaging
surveillance post-surgical repair.
Material and methods: Thirteen patients with an aneurysm secondary to surgical repair for aortic coarctation from 2006 to 2016
were identified. Data on technical, clinical success and complications
were collected retrospectively.
Results: Thirteen consecutive patients of mean age of 42 years
(range 2466). Mean aneurysm diameter was 45 mm (range
3065mm). Five required left subclavian artery embolisation. Two
required carotid-carotid bypass graft with left carotid artery occlusion. One had an aberrant left vertebral artery embolisation.
Mean follow-up was 3 years (range 19). One patient developed
early left leg numbness that resolved following lumbar drain insertion; one type 1 endoleak resolved after moulding balloon; two
developed type 2 endoleaks requiring no treatment; another
patient required a bare stent to protect the left carotid circulation
and one developed graft infection managed with long-term antibiotics with no further intervention at 9 years.
Conclusion: Endovascular treatment of post-surgical focal aortic
aneurysms for aortic coarctation is safe and effective.
Given the low morbidity of endovascular treatment, enrolment of
patients into surveillance programmes is recommended to allow the
early identification of aneurysmal dilation following surgical repair.

U.G.Rossi1, P.Rigamonti1, P.Torcia1, D.Santuari2, A.Settembrini2,

R.Dallatana2, M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Vascular Surgery Unit, San Carlo Borromeo Hospital,
Milan, Italy
We describe the case of an 87-year-old female (ASA III) with acute
symptomatic type IV thoracoabdominal aortic aneurysm involving visceral arteries. The patient was treated with a Cardiatis multilayer stent graft. Clinical and MD-CT follow-up at 32 months was
uneventful.

P-11
All in one: EVAR, chimney, iliac side branch, and internal iliac
embolization
U.G.Rossi1, P.Torcia1, P.Rigamonti1, D.Santuari2, R.Dallatana2,
M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Vascular Surgery Unit, San Carlo Borromeo Hospital,
Milan, Italy
We describe a case of a 77-year-old male patient (ASA: III) with complex abdominal aorta and bilateral iliac aneurysms that was treated
by: i) EVAR with associated chimney technique for the left renal
artery (originating from the aneurysm) for the abdominal aorta
aneurysm, ii) iliac branch endovascular system for the left iliac aneurysm, iii) and right internal iliac artery origin embolization (AVP-II)
with consequent iliac artery endovascular limb extension for the
right iliac aneurysm.

P-12
Endovascular treatment of three aortoenteric fistula cases

P-9
Malperfusion syndromes in aortic dissection: what are their
possible treatments?
U.G.Rossi1, P.Torcia1, P.Rigamonti1, F.Petrocelli2, G.Mauri3,
A.M.Ierardi4, G.Carrafiello5, M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Radiology, San Martino University Hospital, Genoa, Italy,
3Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy,
4Radiology, Uninsubria, Ospedale di Circolo, Varese, Italy, 5Department
of Radiology, University of Insubria, Varese, Italy
Learning Objectives: To describe the classification and possible
management of malperfusion syndromes in patients with aortic
dissection.
Background: Despite the multiple treatments that have been used
for Stanford type B aortic dissections, consequences of this disease remain devastating. Acute mortality has been most closely

N.Hosaka1, S.Sai1, N.Seino1, R.Abe1, N.Mizobuchi1, T.Gokan1,

Y.Nakajima2, K.Maruta3, A.Aoki3
1Radiology, Showa University School of Medicine, Tokyo, Japan,
2Division of Gastroenterology, Showa University School of Medicine,
Tokyo, Japan, 3Department of Cardiovascular Surgery, Showa
University School of Medicine, Tokyo, Japan
We report three aortoenteric fistula cases treated by endovascular
repair. The cases are primary aortoduodenal fistula, secondary aortoduodenal fistula, and primary aortosigmoid fistula complicated
with aortojejunal fistula. We review the clinical findings, procedure,
indications, and outcomes of these cases.

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SS/FC/HL/HTS/CM
Posters

P-13

P-18

Transrenal E-XL stenting to prevent type Ia endoleak in the

case of non-optimal proximal neck during endovascular
abdominal aortic aneurysm repair

Direct puncture and embolization with coils and Onyx of a

ruptured aneurysm sac due to a type 2 endoleak

M.I.Generalov1, D.N.Maystrenko2, A.N.Oleschuk 2, A.S.Ivanov2

1Angio/Interventional Radiology, Russian Research Center for
Radiology and Surgical Technologies, Saint Petersburg, Russian
Federation, 2Vascular Surgery, Russian Research Center of Radiology
and Surgical Technologies, Saint Petersburg, Russian Federation
During EVAR, a hostile neck anatomy can promote the occurrence
of type Ia endoleak. We describe the procedure involving transrenal
placement of a self-expanding nitinol stent to remodel the proximal
aortic neck and prevent type Ia endoleaks in cases.

P-14
A novel use of the Gore Excluder iliac branch endoprosthesis
A.H.Shah, J.Hopkins, M.J.Duddy
Interventional Radiology, University Hospitals Birmingham,
Birmingham, United Kingdom
The relining of a mycotic pseudoaneurysmal aortobifemoral graft
is described, with a 14-month follow-up, using a Gore iliac branch
component as the main body in order to accommodate the short
anatomy.

P-15
Endovascular repair for severe graft kinking after total aortic
arch replacement (TAR)
J.-I.Nishimura, S.Fuwa, M.Yamazaki, T.Nakagawa, F.Saito, S.Hase
Department of Interventional Radiology, Kawasaki Saiwai Hospital,
Kawasaki-city, Kanagawa, Japan
Graft kinking is sometimes indicated on CT after TAR. The kinking was corrected by a bare metal stent, and the acute thrombus
was removed by a balloon catheter. A tiny acute brain infarct was
observed on MRI.

P-16
Late-stage Dacron graft aneurysm 28 years after
extraanatomical bypass treated by endovascular stent graft
T.Oda, N.Sakamoto, T.Taniguchi, H.Tomimatsu, T.Kadoba,
S.Noguchi, M.Nishioka, Y.Nakashima, T.Suga, M.Nobuhara,
S.Noma
Radiology, Tenri Hospital, Tenri-shi, Japan
A 44-year-old woman with Takayasus arteritis underwent ascending abdominal aorta bypass with insertion of a Dacron graft 28 years
ago. Follow-up computed tomography scan revealed graft aneurysm at a non-anastomotic site, which was successfully treated by
endovascular stent-graft placement.

P-17
Treatment of infrarenal aortic stenosis: our case series
B.Luki, V.Z.Cvetic, M.Colic, D.Masulovic
Centre for Radiology and MR, Clinical Centre of Serbia, Belgrade, Serbia
Infrarenal aortic stenosis is an infrequent, difficult-to-treat condition.
Good results are proven for endovascular treatment. Device choice
is a limiting factor. We present our three cases with good technical
and long-term results.

S191

A.Masrani, U.C.Turba, B.Arslan

Interventional Radiology, Rush University Medical Center, Chicago, IL,
United States of America
A patient with previous EVAR presented with severe back pain. CT
showed significant aneurysm enlargement with delayed type 2
endoleak. Immediately after CT, the patient became hypotensive,
and massive transfusion protocol was started. Due to the non-surgical status, he underwent successful embolization with direct sac
puncture.

P-19
Two cases of tracheocarotid fistula after tracheostomy:
endovascular management with covered stent placement
R.Woodhams1, T.Yamane1, K.Fujii1, H.Nishimaki2, Y.Inoue1
1Department of Diagnostic Radiology, Kitasato University School of
Medicine, Sagamihara, Japan, 2Cardiovascular Surgery, St. Marianna
University School of Medicine, Kawasaki, Japan
This presentation demonstrates the utility and limitation of covered
stent placement for tracheocarotid fistula after tracheostomy based
on our experience of two patients who died from infection and cerebral infarction after endovascular treatment.

P-20
Type A aortic dissection occurring after EVAR for abdominal
aortic aneurysm in a patient with Marfan syndrome:
management by combined surgery and endovascular
treatment
J.H.Won, J.J.Shim
Department of Radiology, Ajou University Hospital, Suwon, Korea
A patient with Marfan syndrome who had previously undergone
EVAR for AAA developed type A aortic dissection. Following surgery
in the ascending aorta, thoracic stent-graft placement, aortic fenestration, and abdominal stent reinforcement were performed to
restore flow in the true lumen.

P-21
Type I endoleak after TEVAR for traumatic aortic aneurysm
owing to undersizing of the stent-graft during hypovolemia:
treatment by percutaneous NBCA injection
J.H.Won, J.J.Shim
Department of Radiology, Ajou University Hospital, Suwon, Korea
A patient with traumatic aortic dissection underwent TEVAR and
subsequently developed type I endoleak due to undersizing of the
stent-graft while in hypovolemic shock. The endoleak successfully
treated by percutaneous injection of NBCA.

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Abstract Book

P-22

Biliary intervention

Type IB thoracic endoleak successfully sealed with Onyx: the

technique and mid-term follow-up

P-26

J.Urbano1, M.Tomas2, M.Cabrera-Gnzalez1, A.Alonso-Burgos1,

L.Paul-Ferrer1
1Vascular & Interventional Radiology, Fundacin Jimenez Daz, Madrid,
Spain, 2Radiology, Fundacin Jimenez Daz, Madrid, Spain
Two men previously treated with TEVAR for large AAT (>8 cm) suffered type Ib endoleak and aneurysm sac enlargement. Both
endoleaks were sealed using Onyx. At 12 and 36 months later, both
aneurysms were shrunken. We show the technique and results.

P-23
Endovascular repair of chronic type A aortic dissection with
disseminated intravascular coagulation (DIC)
A.S.Jo, M.Khaja, D.Williams
Department of Radiology, University of Michigan, Ann Arbor, MI, United
States of America
DIC secondary to acute or chronic aortic dissection is an uncommon
but well-known complication. Exclusion of turbulent blood flow
through the thrombolytic adventitia/media of the false lumen with
endovascular aortic repair can lead to improvement or resolution of
DIC from aortic dissection.

P-24
Abdominal aortic aneurysm with a fistula to IVC
C.L.MartinezHigueros, J.PeredaRodriguez, C.FernndezRey
Radiology, Hospital Segovia, Segovia, Spain
A 58-year-old man complained of diffuse abdominal pain.
An infrarenal AAA with intramural signs of impending rupture and
fistula to IVC was documented by CTA.
EVAR combined with coil embolization of the shunt was carried out
with success.

P-25
Percutaneous transarterial repair of visceral branches after
surgical implantation of multibranched thoracoabdominal
aortic stent graft for aortic aneurysm exclusion
E.Paci1, E.Gatta2, M.Rosati1, C.Mincarelli1, M.Fichetti1,
P.Boscarato1, R.Candelari1
1SOD Radiologia Interventistica, Az Osp-Univ OORR Torrette, Ancona,
Italy, 2SOD Chirurgia Vascolare, Az Osp-Univ OORR Torrette, Ancona,
Italy
We report cases of 6 patients with stenosis/occlusion of visceral
branches that were revealed during follow-up after aortic aneurysm repair by implantation of multibranched thoracoabdominal
stent graft; the stenoses/occlusions were treated using an endovascular approach, with stenting of those branches in 1 patient after
fibrinolysis.

Percutaneous intraductal radiofrequency ablation in the

management of unresectable Bismuth type III and IV hilar
cholangiocarcinoma
W.Yu, C.Wei, F.Wenzhe, Z.YingQiang, L.Mingjian, Y.Wang,
L.Jiaping
Dept. of Interventional Oncology, 1st Affiliated Hospital of Zhongshan
University, Guangzhou, China
Purpose: To assess the feasibility and safety of percutaneous intraductal radiofrequency ablation in unresectable Bismuth type III and
IV hilar cholangiocarcinoma.
Material and methods: From September 2013 to May 2015, 12
patients with unresectable Bismuth type III or IV hilar cholangiocarcinoma treated by percutaneous intraductal radiofrequency ablation combined with metal stent implantation after the percutaneous transhepatic cholangial drainage were included for retrospective analysis. Procedure-related complications, stent patency and
survival after the treatment were investigated.
Results: Deployment of percutaneous radiofrequency ablation
combined with metal stent implantation was technically successful in all patients. Twenty-four stents had been implanted successfully. No acute pancreatitis, bile-duct bleeding and perforation, bile
leakage or other severe complications occurred. Four cases of procedure-related cholangitis, three cases of postoperative abdominal pain and five cases of asymptomatic transient increase in serum
amylase were seen. The serum direct bilirubin levels decreased 1
week after the procedure. The median stent patency from the time
of the first RFA and survival from the time of diagnosis were 100 days
(95% CI 85115) and 5.3 months (95% CI 2.58.1). One patient with
stent blockage at 252 days postprocedure underwent repeat ablation. Five patients underwent chemotherapy after serum total bilirubin decreased to normal. Seven patients were found to have died
during the follow-up.
Conclusion: Percutaneous radiofrequency ablation combined with
metal stent implantation is a safe and feasible therapeutic option for
the palliative treatment of unresectable Bismuth type III and IV hilar
cholangiocarcinoma. Its long-term efficacy and safety are promising, but need to be further proved with larger randomised and prospective trials.

P-27
Percutaneous management of inoperable intrahepatic CCC by
drainage and subsequent percutaneous biliary recanalization
by endoluminal RFA and stenting
M.Mizandari1, N.Habib2, T.Azrumelashvili1
1Diagnostic and Interventional Radiology, Tbilisi State Medical
University, High Technology Medical Center - University Hospital,
Tbilisi, Georgia, 2Surgery&Oncology, Imperial College, London, United
Kingdom
Purpose: Inoperable CCC-induced biliary block percutaneous management technique is presented.
Material and methods: Percutaneous biliary drainage, followed by
recanalization procedure, was performed in 46 patients with inoperable intrahepatic CCC; the biliary block was classified as Bismuth
I in 21 cases, Bismuth II - 15, Bismuth III - 7 and Bismuth IV - 3. Single
biliary drainage (and recanalization procedure accordingly) was performed in 21 patients, double - 22 and triple - 3 patients (74 drainage procedures in total) using guidewire technique under combined US-fluoroscopy guidance in 72 cases and CT guidance - in the
remaining 2 cases.

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CIRSE 2016
RF was performed using the PTBD fistula in a week after drainage applying 1015 Watts for 2 minutes using 8-Fr diameter bipolar endoluminal RF device, positioned using guidewire technique
via percutaneous biliary drainage fistula. Procedure finishes with
810-mm-diameter metal stent placement and safety drainage
catheter repositioning.
Results: Biliary patency has been restored in all cases, achieving
quality of life improvement; 3 patients generated stent occlusion in
37 months after RFA & stenting, requiring percutaneous drainage.
There was no 30-day mortality, vessel damage or haemorrhage following biliary RFA & stenting.
Conclusion: Endoluminal RFA & stenting is safe and effective in biliary recanalization; patients with inoperable CCC-induced jaundice may benefit having not only restored biliary passage but also
RF-induced antitumor immune response.

P-28
Predicting success in percutaneous transhepatic biliary
drainage
A.Khosla, Y.Xi, S.Toomay
University of Texas Southwestern Medical Center, Dallas, TX, United
States of America
Purpose: Percutaneous biliary drains (PTC) are often placed in the
setting of elevated bilirubin associated with malignant obstruction to relive jaundice and deliver chemotherapy. In 1/3 of patients
with technically successful drain placement, bilirubin levels do not
decrease to the requisite level without any definitive associations. If
factors that lead to decrease in bilirubin can be identified, a model
can be developed to predict successful PTC placement.
Material and methods: 258 patients were identified having undergone PTC drain placement at our institution between 2002 and 2013,
and their medical records and imaging were reviewed. A regression
model was performed on logarithm-transformed collected variables
to predict post-total bilirubin (Tbl). A stepwise variable selection
method based on Schwarz Bayesian Information Criterion to select
the most associated variables. A short program was developed to
output the point estimate and compared to the actual values.
Results: The variables that best predicted bilirubin were initial Tbl,
INR, and ALT. The selected model had an r-square (coefficient of
determination) 0.65 (adjusted r-square 64%), meaning 65% of the
total variation in the post total bilirubin is explained by our model.
The model had a positive predictive value (Tbl is below 2 when predicted) of 74% and negative predictive value of 93%.
Conclusion: Despite technical success, PTC may not decrease bilirubin in patients with a malignant obstruction. This is an initial model
that can help determine which patients may benefit from PTC placement. With larger data input, the models validity can increase and
provide useful clinical determinants to aid patient care.

P-29
Concordance between planned vs. actually performed
percutaneous biliary procedures: quality improvement metrics
from the CIRSE IR Patient Safety Checklist
S.H.Hyon, O.Mazza, M.E.Fratantoni, R.Sanchez-Claria,
M.deSantibanes, M.Ciardullo, J.Pekolj, E.deSantibanes
Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
Purpose: IR is associated with high effectiveness and low morbidity. However, quality assurance and patient safety standards should
be applied and its metrics analysed to evaluate the impact of these
measures on patient care. Here, we assessed the concordance
between planned procedures vs. actual procedures done at patient
sign-out, using the CIRSE IR Patient Safety Checklist.

SS/FC/HL/HTS/CM
Posters

S193

Material and methods: A total of 146 patients (83 women; median

age 64, range 1-90 years) undergoing 263 percutaneous biliary procedures completed the Procedure Planning section of the CIRSE
Checklist usually on the day before schedule, and informed consents were obtained. The sign-in and sign-out sections were filled in
the IR suite and at discharge. Procedures were recorded as planned
(PLAN), planned-but-not-done (NOT-DONE) and done-but-notplanned (NO-PLAN). Concordance was defined as actual/planned
procedures.
Results: PLAN, NOT-DONE and NO-PLAN for procedures were as follows: drain-exchange, 70, 4 and 10; drain-placement, 59, 3 and 4; balloon-dilation, 45, 7 and 2; forceps-biopsy, 22, 9 and 2; stent-placement, 23, 6 and 1; stone-extraction, 7, 5 and 1; cholangiography, 11,
0 and 1; ascites-drain, 2, 0 and 2; and cholecystostomy, 0, 0 and 1,
respectively. Concordance was 90.9% (actual/planned, 263/239); 24
(9.1%) were done without anticipation and 34/239 (14.2%) planned
but finally not done. Detour from planned procedures were based
on technical or patient safety reasons (e.g. coagulopathy). No morbidity or mortality was attributable to unplanned procedures.
Conclusion: Concordance between planned and actual percutaneous biliary procedures is high. Using the CIRSE IR Patient Safety
Checklist, a continuous assessment of metrics may improve quality
assurance and patient safety of IR procedures.

P-30
Local biliary temperature and bile duct damage in catheter
radiofrequency ablation of ex vivo porcine liver
W. Lu
Interventional Medicine, Navy General Hospital of PLA, Beijing, China
Purpose: To explore the changes in the local biliary temperature
and damage to the bile duct after catheter radiofrequency ablation
(RFA) of ex vivo porcine liver under different power parameters.
Material and methods: Ten fresh ex vivo porcine bile duct systems
(gallbladder and common bile duct preserved) filled with human
bile were injected with contrast agent under DSA. Then, the RFA
catheter (Habib EndoHPB) was inserted into the hilar biliary duct
through the common bile duct. Ten groups of ablation parameters were made, i.e., 5 W (120 s), 6 W (120 s),7 W (120 s), 8 W (120 s), 9
W (120 s),10 W (120 s),11 W (120 s),12 W (120 s),13 W (120 s), and 14 W
(120 s); the local temperature at the distal radiofrequency pole and
1, 2 cm away from the pole were examined with temperature needles under fluoroscopy. Pathological examinations were performed
for evaluating the damage to the biliary duct and its surrounding
tissues.
Results: After filling ex vivo porcine livers with human bile, ten liver
bile ducts were successfully ablated. The temperatures of ablation
area were found to be gradually rising along with the increasing
powers (up to 90.3 C), while the temperatures of the other two sites
were not rising (from 28.4C to 40.2C). Coagulation necrosis of the
ablated bile duct area was observed, and no significant damage was
detected in the bile duct and liver tissues that were 1 and 2 cm away
from the ablation area.
Conclusion: A slightly rising temperature of the bile ducts, which
were adjacent to the ablation sites, was detected during catheter
RFA. However, no significant necrosis of the surrounding bile ducts
was observed. Therefore, catheter RFA causes damage to the targeting bile ducts, while it has no significant influence on the adjacent
areas.

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P-31

P-33

Percutaneous treatment of biliary stenosis after liver

transplantation in children: 10-year experience of a single
center in Cali, Colombia

Ultrasound-guided percutaneous cholecystostomy drains in

children: a case series

S.Y.Rodriguez-Takeuchi, A.J.Holgun, J.S.Toro, V.Botero

Radiology, Fundacin Valle de Lili, Cali, Colombia

R.Gnannt, D.A.Parra, B.Connolly

Image Guided Therapy, The Hospital for Sick Children, Toronto, ON,
Canada

Purpose: To describe the experience of percutaneous transhepatic

cholangiography (PTC) with biliary dilatation and drainage after
pediatric liver transplantation, and to determine the long-term outcome of this procedure.
Material and methods: This was a retrospective case series study,
approved by the Institutional Ethics Committee. Between 2001 and
2013, 196 pediatric liver transplants were carried out at our institution. Sixty-eight patients reported biliary complications (biliary
obstruction, stenosis, fistula, or biloma); however, just 40 (20 boys
and 20 girls) underwent PTC. Exclusion criteria included patients
with no evidence of abnormal dilatation, stenosis, or leaks during the procedure. Follow-up after treatment was also made. A survival analysis was performed in patients in whom the procedure and
eventual removal of the catheter were successful.
Results: In all, 196 children received liver transplants, and 34.7%
(n=68/196) presented with biliary complications, including biliary
leak and strictures. Forty patients (20 boys and 20 girls; median age,
4 years) were treated by PTC because of biliary complications. After
at least one cycle of treatment, 85.7% (24/28) of patients were symptom free. Only 7.1% (2/28) of patients required biliary reconstruction
surgery. The probability of a patient not developing unfavorable
outcomes 1, 5, and 10 years after treatment was 88.9%, 83.0%, and
74.1%, respectively.
Conclusion: PTC with balloon dilatation and catheter drainage has
proven to be a good treatment option in this population. The use
of a drainage catheter for as long as a year is associated with good
long-term results.

Purpose: Insertion of a percutaneous cholecystostomy drain (PCD)

in very ill patients is an established image-guided intervention to
drain a critically inflamed gallbladder. However, there is limited
experience of PCD insertion in children. The purpose of this review
was to examine the safety, efficacy, and role of PCD in children.
Material and methods: Between December 1996 and June 2015,
we identified 8 children who underwent PCD, using ultrasound and
fluoroscopic guidance. Both direct and transhepatic routes were
employed. Clinical indications, technique, procedural complications,
catheter dwell times, and outcomes were analyzed.
Results: Eight patients (2 female) aged 10.4 years (range 3.7-17.1)
underwent PCD under general anesthesia. Underlying diagnoses included malignancy and immunosupression and congenital
hepatic fibrosis with severe portal hypertension. Five of 8 patients
had calculous and 2/8 had acalculous cholecystitis; 1/8 had tumoral
obstruction (AML). The latter underwent both a PCD and a right
intrahepatic biliary drain placement. Three of 8 had hydrops of the
gallbladder. The transhepatic route was used in 5/8 and direct access
in 3/8. All-purpose drains were placed, 8 Fr (6/8) or 10 Fr (2/8). All 8
procedures were technically successful; no bile leak occurred. Mean
drainage time was 55 days (range 16-97). Late cholecystectomy was
performed in 4/8. Three patients died of their underlying disease,
with a functioning drain in situ.
Conclusion: This series of PCD in children indicates a high technical
success and low complication rate. PCD insertion is feasible in children and should be considered, when the acutely ill child with an
inflamed gallbladder is not fit for a surgical cholecystectomy.

P-32

P-34

Outcome of percutaneous transhepatic biliary stenting (PTBS)

for bile duct obstruction caused by metastatic disease

Management of percutaneous catheter drainage of pyogenic

liver abscesses: Factors contributing to success

L.Vandenabeele1, E.Dhondt2, F.VanDenBergh2,

P.Vanlangenhove2, K.Geboes1, L.Defreyne2
1Department of Gastroenterology, Ghent University Hospital, Ghent,
Belgium, 2Department of Vascular and Interventional Radiology, Ghent
University Hospital, Ghent, Belgium

S.Haider, M.Tarulli, E.K.Hoffer, N.J.McNulty

Radiology, Dartmouth Hitchcock Medical Center, Lebanon, NH, United
States of America

Purpose: To evaluate symptom relief, intention to start chemotherapy and survival after PTBS in patients with secondary malignant biliary obstruction.
Material and methods: Retrospectively, only patients requiring
PTBS to resolve metastatic biliary obstruction were eligible for inclusion. Indication to perform PTBS was palliation and/or intention to
(re)start chemotherapy. Technical and biochemical success (bilirubin <5mg/dl) of biliary stent placement as well as the effect of
chemotherapy on survival were assessed. Differences in the overall outcome among the different primary tumors were analyzed by
KaplanMeier survival curves.
Results: Ninety-three patients were percutaneously stented with
a technical success rate of 100% and a biochemical success rate of
73%. Thirty-five percent of the patients with a sufficient decrease
in bilirubin received chemotherapy. Overall median survival was
48 days, but it increased significantly to 170 days in patients who
received chemotherapy. The survival benefit was obvious in colorectal and pancreatic metastases, wherein the median survival rose
from 57 to 316 days and from 29 to 135 days, respectively.
Conclusion: PTBS is worthwhile in advanced metastatic disease
causing biliary obstruction not only for palliation but also for offering patients a chance to undergo chemotherapy and a longer survival time.

Purpose: To identify details of pyogenic liver abscess (PLA) percutaneous catheter drain (PCD) management that contribute to successful and efficient treatment.
Material and methods: Between May 2009 and May 2014, 73 consecutive patients underwent primary PCD of 96 abscesses with
IR management during follow-up. Characteristics of patients and
abscesses were analyzed with respect to follow-up procedures,
interval imaging, clinical recurrence, and time course to abscess
resolution.
Results: Primary PCD was successful for 82 (85%) PLAs at mean
drain dwell time of 30 days, while 14 (15%) recurred after mean dwell
time of 16 days. Salvage PCD was successful in 12 recurrences for
95% overall success. Four patients died; not associated with abscess
recurrence (p=0.153). Recurrence was associated with drain removal
(for patient comfort) despite daily output >15 ml (n=7 cases), multiple loculated abscesses with early low output (n=4 cases), and
shorter dwell times (p<0.05 for all). Abscess size, loculation, multiplicity, or recent biliary obstruction, surgery or hepatobiliary malignancy did not predict treatment success. Large abscesses required
more drain revisions and longer dwell time to cavity resolution
(p<0.05 for all). Cavity resolution was reached at a mean of 23 days
for successful drainages (95% CI 20-27). Routine follow up CT and
ultrasound studies did not contribute to drain management, however imaging performed for clinical indications did.

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Conclusion: PCD was an effective first line treatment for all PLAs but
required ongoing drain management. Successful primary PCD was
associated with daily output <15ml at removal and cavity collapse by
3 weeks of drainage.

P-35
The safety and efficacy of percutaneous transhepatic removal
in elderly patients with bile duct stones
M.H.Rho, H.P.Hong, K.H.Lee
Radiology, Kangbuk Samsung Hospital, Sungkunkwan University
School of Medicine, Seoul, Korea
Purpose: Percutaneous transhepatic bile duct stone removal can be
used in elderly patients in whom it is difficult to perform endoscopic
bile duct stone removal due to comorbidities. We retrospectively
evaluated the clinical efficacy of percutaneous transhepatic stone
removal in elderly patients (65 years).
Material and methods: Ninety-nine patients with bile duct stones
aged 65 years and over were selected (elderly group). They underwent percutaneous stone removal from March 2005 to December
2013. Sixty-five patients who were aged under 65 years and had
undergone percutaneous stone removal for biliary stones in the
same period were evaluated as the control group. The stone removal
procedure was performed using a stone basket. Balloon sphincteroplasty was also performed during the procedure. Technical success rate, clinical success rate, complication rate, and recurrence rate
were evaluated.
Results: Technical success rate was 94.9% in the elderly group and
90.2% in the control group (p=.448). Clinical success rate was 91.9%
and 90.2%, respectively (p=.747). Procedure-related minor complications, including fever and pain, occurred in 8.08% patients in the
elderly group and 9.8% patients in the control group (p=.747). No
procedure-related major complication was observed in any of the
groups. Recurrence rate was 12.1% and 9.8%, respectively (p=.779)
during the follow-up period.
Conclusion: Percutaneous transhepatic stone removal is an effective, safe, and technically feasible procedure in elderly patients with
bile duct stones.

P-36
Long-term results of percutaneous treatment for anastomotic
biliary stricture after living-donor liver transplantation
S.Nakatsuka, M.Inoue, M.Tamura, S.Oguro, Y.Suyama, N.Ito,
M.Jinzaki
Diagnostic Radiology, Keio University, Tokyo, Japan
Purpose: Anastomotic biliary stricture (ABS) after living-donor liver
transplantation (LDLT) is exclusively treated with percutaneous
intervention at our institute. The purpose of this study was to access
the clinical efficacy of the percutaneous treatment of ABS after LDLT.
Material and methods: From 2000 to 2015, 45 patients [26 men,
19 women; mean age 36 years (range 0-68 years)] were referred to
our interventional radiology unit for percutaneous biliary intervention against ABS after LDLT. Percutaneous transhepatic biliary drainage (PTBD) for 72 ducts was necessary for patients with clinical or
radiological signs of biliary obstruction. ABS was usually crossed
with a 0.035-inch hydrophilic guidewire or a microcatheter set. In
cases with failed ABS crossing using the abovementioned method,
pull-through technique, stricture penetration under fluoroscopic
or cholangioscopic guidance, or gun-sight technique was applied.
Repetitious balloon cholangioplasty and internalexternal biliary
drainage catheter (IEBDC) placement for 3 months or longer were
followed by removal of IEBDC. Success rates of the procedures and
restricture-free rates were evaluated.

SS/FC/HL/HTS/CM
Posters

S195

Results: Primary and secondary success of PTBD was achieved in

94% and 100% of the patients, respectively. Guidewire crossing of
ABS was successful in 93% of the patients within 4 attempts, while
5 ducts were left uncrossed and resulted in partial atrophy without hepatic insufficiency. Among 33 patients whose IEBDC was
removed, restricture was observed in 2 patients and restricture-free
rates for 5 and 10 years were 92% and 84%, respectively.
Conclusion: A combination of various percutaneous interventional
procedures, including some special techniques in crossing ABS, provides a high clinical benefit for patients with ABS after LDLT.

P-37
Percutaneous extraction of biliary plastic stents
L.Pancione, K.Novacic, I.Syed, A.R.J.Alvi, M.Elsayad
Radiology, Barking Havering & Redbridge University Hospitals NHS
Trust, Romford, United Kingdom
Purpose: Generally, plastic stent insertion and extraction are performed under ERCP. When ERCP fails, a transhepatic approach is
used and the stents are pushed inside the duodenum. Generally, the
stent is evacuated, but sometimes it could cause intestinal perforation. In our presentation, we describe a safe technique for the percutaneous extraction of biliary stents.
Material and methods: In total, 15 patients after unsuccessful ERCP
biliary-stent retrieval were referred to us for biliary drainage.
In 6 patients, a straight stent was inserted, and in 9 patients, a double-J stent was inserted.
After the percutaneous cholangiogram and insertion of the guidewire, a long introducer sheet of 10 French was inserted over the wire.
In case of a straight stent, the stent was cannulated with a balloon catheter. The balloon catheter was inflated, and the stent was
secured and locked with the introducer sheet. Afterward, the system
was easily pulled out of the body of the patient.
In patients with the double-J stent instead of the catheter balloon, a
gooseneck was used.
An internal external catheter drainage was inserted at the end of the
procedure.
Results: All patients underwent successful stent extraction. No early
or delayed complications occurred.
Conclusion: In the literature, percutaneous extraction of plastic biliary stent was done by pushing the stent inside the intestinal loop.
This procedure is not completely safe because there is a risk of intestinal perforation.
On the basis of our experience, true percutaneous removal is a safe
and easy technique without complications.

P-38
Pediatric liver transplant complications: a time for
interventional radiology
S.DyerHartnett, M.PerezLafuente, I.Diez-Miranda, C.GonzalezJunyent, D.HernandezMorales, Q.OrdiiCamprubi, C.Parra-Farias,
A.SegarraMedrano
Radiology, Vall dHebron Hospital, Barcelona, Spain
Purpose:
1. Review pediatric liver transplant complications (PTLC) and the role
interventional radiology has in its treatment.
2. Retrospectively evaluate the efficacy of percutaneous treatment
of PTLC in our centre.
Material and methods: Between 2007 and 2016, 47 interventions,
of which 16 were repeat sessions, were carried out on 25 patients (14
female, mean age 3.1 years) with PTLC previously diagnosed by US,
CT or MRI.
We divided complications into two categories:
- Acute [<30 days post-transplantation (33%)] or late (67%)

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- Vascular [portal vein thrombosis (19%) or stenosis (32%), hepatic

vein stenosis (3%), arterial thrombosis (10%), stenosis (3%) or
pseudoaneurysm (3%)] or biliary [biliary stenosis (23%) or leak
(7%)]
We evaluated treatment procedure, materials and complications,
and long-term outcome.
Results: Vascular complications (patients=19, complications=22),
of which 36% were acute, were treated with angioplasty, fibrinolytics, stents and thrombin. Four patients required repeat angioplasty
due to relapse; two of them received stents. Overall, the treatment
was unsuccessful in two cases, one of which is awaiting retransplant.
Thrombin successfully reduced the pseudoaneurysm. The only complication was stent migration to the portal vein.
Bilioplasty was the treatment of choice for biliary stenosis
(patients=7, complications=7), of which 14% were acute. Five of
these patients relapsed, each repeated bilioplasty at least once and
all but one received a biodegradable stent. Two patients had biliary leaks (50% acute) and were treated with internal-external biliary
drainage catheters.
Conclusion: Interventional radiology procedures are an effective and safe option for the treatment of PTLC, successfully reducing transplant dysfunction and surgical re-interventions with few
complications.

Abstract Book
Background: Hyperbilirubinemia might delay or prevent chemotherapy initiation due to pharmacological interactions, limiting
treatment possibilities in patients with malignant bile duct obstruction. At our institution, depending on patient conditions and drugs
involved, chemotherapy might be initiated with TSB threshold of
up to 3 mg/dL. Decrease in TSB after percutaneous biliary drainage is highly dependent on pre-drainage TSB and INR. Data from 11
patients who underwent PCB due to neoplastic obstruction of the
bile duct were analyzed.
Clinical Findings/Procedure: Pre-drainage TSB was 19.7 mg/dL
(9.228.8). A 50% or more decrease in TSB was achieved in 7 out of 11
patients. Five patients reached a TSB of 3 mg/dL or less, with a mean
time of 31 days (1142).
Conclusion: Although PBD is effective in achieving a significant
drop in TSB, chemotherapy initiation threshold was achieved in
less than half of the patients. Special care should be taken in the
moment chosen for drainage, since we seem to be performing PBD
too late, thus compromising initiation of chemotherapy and potentially reducing life expectancy.

P-41
Recurrent pyogenic cholangitis: imaging and intervention
K.M.Gummalla1, S.Punamiya2
1Diagnostic and Interventional Radiology, Tan Tock Seng Hospital,
Singapore, Singapore, 2Diagnostic Radiology, Tan Tock Seng Hospital,

P-39
Stent-in-stent (Y and T shaped) as palliative treatment in
malignant hilar biliary obstruction patients

Singapore, Singapore

P.Rigamonti1, U.G.Rossi1, P.Torcia1, G.RubisPassonia2,

A.M.Ierardi3, G.Carrafiello3, M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Gastroenterology Unit, San Carlo Borromeo, Milano, Italy,
3Radiology, Uninsubria, Ospedale di Circolo, Varese, Italy
Learning Objectives: To describe step-by-step the implantation of
the stent-in-stent with Y and T-shaped metallic stent as a palliative
treatment of hilar malignant biliary obstruction for establish bilateral hepatic duct patency.
Background: Patients with hilar malignant biliary obstruction are a
therapeutic dilemma for both ERCP and percutaneous techniques.
Various methods have been used for palliative treatment in these
patients, but satisfactory technical results and mid-/long-term
patency of bilateral hepatic duct are still inadequate.
Clinical Findings/Procedure: The purpose of this poster is to illustrate all passages to deploy the stent-in-stent, i.e., Y- and T-shaped
stents, in patients with hilar malignant biliary stenosis/obstruction: i)
pre-treatment CT planning with MPR images, ii) high-resolution fluoroscopy and US guidance for biliary drainage access, iii) stenting,
and iv) post-treatment CT control.
Conclusion: The use of CT as pre-procedural planning and the highresolution fluoroscopy are mandatory for correct planning and
deployment of the stent-in-stent (Y- and T-shaped) metallic stents in
patients with hilar malignant biliary stenosis/obstruction in order to
establish bilateral hepatic duct patency.

Learning Objectives: To discuss imaging features of recurrent pyogenic cholangitis (RPC) and suggest treatment algorithm for radiological intervention.
Background: Recurrent pyogenic cholangitis is characterized by
intrahepatic pigment stone formation, causing biliary strictures, biliary obstruction, and recurrent cholangitis. It is found almost exclusively in people who live or have lived in Southeast Asian countries.
Left untreated, repeated episodes of cholangitis can lead to progressive hepatobiliary damage, resulting in liver abscesses, segmental
liver atrophy, or cirrhosis. Imaging plays a crucial role, both in diagnosing RPC and planning its treatment. A variety of methods are
used for the treatment of RPC, including endoscopic, percutaneous, and surgical techniques, either alone or in combination, guided
appropriately by the findings of imaging.
Clinical Findings/Procedure: Ultrasound, CT, MRCP, and cholangiographic features of RPC will be described. Based on the location and
extent of disease, an algorithmic approach for treatment will be suggested, with special emphasis on interventional radiological procedures, including biliary drainage, bile duct dilatation, and percutaneous stone removal.
Conclusion: Imaging is important in diagnosing RPC and providing
a road map for therapy. Treatment of RPC requires a multidisciplinary
approach of which interventional radiology is a key component.

P-42
Percutaneous approaches to complex biliary lesions: a pictorial
essay

P-40
Changes in total serum bilirubin after percutaneous biliary
drainage in malignant bile duct obstructions
A.Rodriguez, S.Pereyra, J.Garca, F.Borges, M.Langleib
Departamento Clnico de Imagenologa, Hospital de Clnicas Dr.
Manuel Quintela, Universidad de la Repblica, UDELAR, Montevideo,
Uruguay
Learning Objectives: To understand the changes in total serum
bilirubin (TSB) after percutaneous biliary drainage (PBD) in patients
with malignant bile duct obstruction and to identify possible factors
affecting chemotherapy initiation in this group of patients.

I.M.Kably1, G.Narayanan2, J.Yrizarry1

1Radiology, University of Miami, Miami, FL, United States of America,
2Vascular Interventional Radiology, University of Miami-Miller School
of Medicine, Miami, FL, United States of America
Learning Objectives: To showcase advanced biliary techniques in a
series of technically challenging scenarios.
Background: Interventional radiologists are often consulted to help
identify and treat biliary lesions. Radiologic techniques can improve
patient outcome and serve as definitive, first-line therapies in some
cases or as indispensable adjuncts to multidisciplinary approaches
in others.

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CIRSE 2016
Clinical Findings/Procedure: We illustrate the efficacy of percutaneous techniques, some of them first described in this study, in a
variety of complex and technically challenging cases:
1. Tips to access decompressed and actively leaking bile ducts
(anatomic and surgical landmarks, fluoroscopic triangulation,
balloon tamponade technique, retrograde biliary cannulation
from biloma, etc.).
2. Endoscopic-radiologic rendez-vous technique in a transected
duct (Hanover D lesion).
3. Gelfoam embolization of chronic bilomas.
4. Management of post-surgical biliary substance loss.
5. Management biliary leak through the duct of Luschka (coil and
glue embolization with stenting).
6. Single-stick, laser-guided biliary reconstruction with cone beam
CT in Hanover class D (transection) and E (occlusion) biliary lesion.
7. Modified cecostomy catheters for patients requiring long-term
biliary drainage.
8. Primary stent reconstruction of biliary tree in advanced infiltrative
malignancies with cone beam CT.
9. Treatment of benign strictures with balloon dilatation and
retrievable stents.
10. Transjejunal biliary interventions through a Hutson Russell loop.
11. Transhepatic jejunal intervention.
Conclusion: Advanced biliary interventions are useful as palliative
or adjunct pre-operative techniques prior to surgical reconstructions or as first-line therapies in patients who are not surgical or
endoscopic candidates.

P-43
Dual-use endobiliary radiofrequency
U.G.Rossi1, P.Rigamonti1, P.Torcia1, G.Mauri2, V.Pedicini3,
M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Radiology, IRCCS Policlinico San Donato, San Donato
Milanese, Italy, 3Radiology and Interventional Radiology, IRCCS
Humanitas Hospital, Milan, Italy
An 82-year-old male with biliary hilar obstruction underwent percutaneous endobiliary bipolar radiofrequency for cauterization of a
bile duct lesion with intra-hepatic collection and for tumor ablation
with consequently delay in intra-stent growth.

P-44
Bile duct embolization after surgical unroofing for recurrent
hugehepatic cyst
C.H.Kang1, H.Kim2, J.M.Lee3, W.-H.Lee4, J.Ohm5
1Radiology, Gangneung Asan Hospital, Gangneung, Korea,
2Radiology, Daejeon Hankook Hospital, Daejeon, Korea, 3Radiology,
SoonChunHyang University Hospital, Bucheon, Korea, 4Radiology,
SoonChunHyang University Hospital, Cheonan, Korea, 5Radiology,
Chungnam National University Hospital, Daejeon, Korea
We report successful selective bile duct embolization of multifocal
bile leakage after surgical unroofing of a huge hepatic cyst. From 3
days after the procedure, the drainage amount was decreased, and
follow-up CT at 7 months demonstrated marked sac shrinkage.

SS/FC/HL/HTS/CM
Posters

S197

P-45
Iatrogenic occlusion of the common bile duct (CBD) with
spontaneous recanalization: when the bile corrodes good
F.Melchiorre1, C.Luigiano2, F.Morelli1, E.Fumarola1, F.Balestra1,
G.Cornalba1
1Interventional Radiology, AO San Paolo, Milan, Italy,
2Gastroenterology, AO San Paolo, Milan, Italy
A 77-year-old male presented with an insuperable iatrogenic (postcholecystectomy) occlusion of CBD, which, using percutaneous and
ERCP approaches, was treated with external biliary drainage.
One month later, cholangiography revealed unexpected patency of
CBD, which was treated using an endoscopic rendezvous approach
and a removable covered stent was placed in CBD.

P-46
Percutaneous transhepatic cholangioscopic laser lithotripsy
K.Akkan1, M.Yazol1, E.Yaltrk 2, .Sen3, M.Onaran3, B.nal1,
E.T.Ilgit1
1Department of Radiology, Gazi University, School of Medicine,
Ankara, Turkey, 2Radiology Department, Karadeniz Eregli City Hospital,
Zonguldak, Turkey, 3Department of Urology, Gazi University, School of
Medicine, Ankara, Turkey
We report our experience on percutaneous transhepatic cholangioscopic laser lithotripsy (PTCLL) for the treatment of large biliary
stones (> 15 mm) in two cases with strictures after laparoscopic cholecystectomy and hepaticojejunostomy.

P-47
Percutaneous retrieval of a 10-F endoscopic plastic biliary
stent that could not be retrieved by endoscopy
M.LeyvaVsquez-Caicedo, J.E.ArmijoAstrain, J.GonzlezNieto,
J.V.MndezMontero
Vascular and Interventional Radiology, Hospital Universitario Clnico
San Carlos, Madrid, Spain
The patient had an occluded biliary stent that was placed endoscopically. Endoscopists tried to remove it but were unable due to
duodenal tumoral infiltration. Through percutaneous transhepatic
access, we removed the plastic stent and deployed a metallic palliative stent.

P-48
Percutaneous cholangioscopy-guided laser lithotripsy
C.Ferro1, F.Petrocelli2, F.Camerano2, G.Bovio2, A.Utili3,
G.Salsano2
1Department of Radiology, IRCCS University Hospital San Martino
Genoa, Italy, 2Radiology, San Martino University Hospital, Genoa, Italy,
3Radiology and Interventional Radiology, IRCCS San Martino University
Hospital, Genoa, Italy
A patient who underwent duodeno-cephalo-pancreatectomy for
neuroendocrine tumor developed intrahepatic bile duct lithiasis.
The patient was referred for percutaneous cholangioscopy-guided
laser lithotripsy. After removing the biliary drainage, a severe hemorrhage occurred. Hepatic arteriography showed an arterio-biliary
fistula, which was successfully treated by coil embolization.

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Biopsy and drainage

P-49
MRI-guided percutaneous biopsy of adrenal masses using a
large-bore magnet: technical feasibility
G.Koch, J.Caudrelier, R.L.Cazzato, P.P.Rao, G.Tsoumakidou,
M.-A.Thenint, J.Garnon, A.Gangi
Interventional Radiology, University Hospital of Strasbourg, Strasbourg,
France
Purpose: To evaluate the safety and technical feasibility of magnetic
resonance imaging (MRI)-guided percutaneous biopsy of adrenal
masses performed using a wide-bore high-field (1.5T) scanner.
Material and methods: This is a retrospective study including 18
consecutive patients (15 male, 3 female; mean age 63.1 years) who
underwent 20 MRI-guided core needle biopsy of adrenal masses
between April 2009 and October 2015.
The size and side of lesion, approach taken, time for needle placement, overall duration of procedure, and post-procedural complications were evaluated.
The technical success and diagnostic results were also assessed
Results: The mean size of the target lesion was 4.6 cm (range 25.9
cm); lesions were right- and left-sided in 9 and 11 cases, respectively.
Two patients required repeated biopsy (one inconclusive specimen
and one for evaluation of genetic modification of the tumor).
The needle approach was always ascendant (mean angulation 29.6).
The average time for needle placement was 4 min (range 116 min),
and the average duration of the entire procedure was 52 min (range
2495 min).
The technical success was 100%, with specimens successfully
obtained in all 20 procedures.
Two complications were noted (accidental puncture of the kidney
and accidental puncture of the pleural recess).
Histopathology revealed malignant and benign lesions in 17 and 2
cases, respectively; one specimen was inconclusive.
Conclusion: MRI-guided biopsy of adrenal masses is a safe and technically feasible procedure, which offers a high diagnostic accuracy.

P-50
Performance evaluation of a novel tablet ultrasound during
routine interventional procedures
A.M.Ierardi1, E.Duka1, C.Micieli1, P.Torcia2, U.G.Rossi3, M.Cariati4,
G.Carrafiello1
1Radiology, Uninsubria, Ospedale di Circolo, Varese, Italy, 2Radiology
and Interventional Radiology, San Carlo Borromeo Hospital, Milan,
Italy, 3Radiology, San Carlo Borromeo Hospital, Milan, Italy, 4Diagnostic
Sciences, San Carlo Borromeo Hospital, Milan, Italy
Purpose: The aim of the study was to establish if a novel tablet ultrasound (US) may replace a high-end US machine during routine interventional radiology activities.
Material and methods: Thirty consecutive patients were evaluated by two operators comparing the performance of the new US
tablet system (VISIQ, Philips Healthcare) against a high-end US system (iU22, Philips Healthcare) using a curved probe (C5-2). A structured questionnaire was used to rank (on a 4-point scale) the ability
of each system to locate a target as detected by previous examinations and visualize needles and paths during an interventional procedure. Necessity for conversion from the tablet US to the high-end
US system was registered; body mass index (BMI) was annotated for
each patient.
Results: Agreement between the operators was found for all
patients. Mean patient BMI was 25 (range 1734). Image quality of
the tablet US was considered insufficient in 1 case for visualizing

Abstract Book
the target and in another case for visualizing the needle. Mean target image quality was superior with the high-end US system, while
needle visibility scored higher with the tablet US. Conversion to the
high-end system was registered in 40% cases; in most cases (66.6%)
the decision was because of the absence of a dedicated needle
guide for the tablet US.
Conclusion: The novel tablet US was found to provide sufficient
image quality for the majority of routine interventional procedures.
Dedicated accessories and additional experience with this new generation US device may be needed to replace bulky high-end US
systems.

P-51
Preclinical evaluation of a bioresorbable device facilitates
biopsy tract sealing
J.D.Carey1, J.C.Isenburg1, L.M.Pook 2, S.Beam3, S.A.Penegor1
1Research and Development, Vascular Solutions, Inc, Minneapolis, MN,
United States of America, 2Preclinical Research, NAMSA, Northwood,
OH, United States of America, 3Pathology, Preclinical Pathology
Consulting Services, LLC, Minneapolis, MN, United States of America
Purpose: The Hunter V3 biopsy sealing device is a radially compressed gelatin foam pledget provided in a pre-loaded delivery system for use following percutaneous solid organ biopsy via a coaxial
biopsy system.
Once delivered, the bioresorbable gelatin pledgets absorb fluid and
swell to the approximate diameter of the tissue tract to maintain
position and facilitate hemostasis.
The Hunter V3 biopsy sealing device was evaluated for safety and
degradation when deployed in a liver biopsy model in swine.
Material and methods: Through an open laparotomy, Hunter
V3 devices were deployed within 14G and 18G liver biopsy tissue
tracts of 12 domestic swine; animals were survived up to 26 weeks.
Multiple Hunter V3 devices were implanted in biopsy locations
within the liver of each animal. Safety and device degradation evaluations were performed for each animal at 2, 4, 12, and 26 weeks
post-implantation.
Additionally, in a subset of animals, acute efficacy endpoints were
collected to determine the facilitation of hemostasis.
Results: All animals remained in good health throughout the study,
with no adverse event findings related to the test device.
Degradation was relatively slow at 2 weeks, with a precipitous drop
between 2 and 4 weeks, and no gelatin observed at 12 weeks.
Regarding acute efficacy endpoints, Hunter V3 devices showed
improved time to hemostasis and decreased blood loss compared
with the no treatment control.
Conclusion: In a swine liver model, Hunter V3 biopsy sealing
devices were effective in sealing biopsy tracts and demonstrated
no predictable safety concerns, with complete degradation of the
implant material at 26 weeks.

P-52
CT fluoroscopy-guided core biopsy of pancreatic lesions:
technical and clinical outcomes of 104 procedures during a
10-year period
F.F.Strobl, J.B.Schwarz, P.M.Paprottka, M.F.Reiser, C.G.Trumm
Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital
Munich, Munich, Germany
WITHDRAWN

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P-53
CT fluoroscopy-guided percutaneous core needle biopsy of
mediastinal masses: technical outcome and complications
C.A.Burgard, M.F.Reiser, C.G.Trumm
Department of Clinical Radiology, Ludwig-Maximilians-Universitt
Mnchen, Munich, Germany
Purpose: To evaluate technical outcome and safety of computed
tomography fluoroscopy (CTF)-guided percutaneous core needle
biopsies (PCNB) in patients with mediastinal masses.
Material and methods: In all, 145 mediastinal biopsies were performed from 03/2005 to 06/2015 under intermittent CTF guidance
(10-20 mA; 120 kV) and local anesthesia. Lesion size, access path,
number of biopsies, diagnostic yield, complication rate, tumor localization, and histopathological diagnosis were retrospectively analyzed. Complications were assessed using the postinterventional CT
scan and clinical follow-up. Adverse events were classified per the
Society of Interventional Radiology (SIR).
Results: In all, 139 patients (77 men; age, 54.4 18.2 [MSD]) underwent 145 CTF-guided PCNB (16-18 gauge; 10-20cm) with tumors in
the anterior (112; 77.2%), middle (13; 8.9%), and posterior (20; 13.8%)
mediastinum, 141 of which (97.2%) were technically successful. In
88 (60.7%) procedures, the needle was placed using a parasternal access, in 23 (15.9%) by a paravertebral and in 22 (15.2%) by an
intercostal access. Number of biopsy specimen obtained was 1 in 38
(26.2%) procedures, 2 in 50 (34.5%) procedures, 3 in 23 (15.9%), and
4 in 3 (2.1%) procedures. One hundred nineteen (82.1%) of the biopsies were considered adequate for a specific histopathologic analysis. Mean lesion size was 6.13.3 cm. Neoplasia was diagnosed in
114 (78.6%) biopsies, and 31 (21.4%) samples showed no evidence of
malignancy. Minor complications (self-limiting pneumothorax [n=4;
2.8%] and mediastinal hemorrhage [n=14; 9.7%]) were observed in
18 (12.4%) procedures. Major pneumothorax requiring drainage
insertion occurred in 2 (1.4%) patients.
Conclusion: CTF-guided PCNB of mediastinal masses is effective and safe for the initial assessment of patients with mediastinal
tumors.

P-54
Relationship of ascites volume with risk of spontaneous
bacterial peritonitis
A.Sideris, P.Patel, H.W.Charles, J.Park, D.Feldman, L.Teperman,
A.R.Deipolyi
Radiology, Division of Vascular and Interventional Radiology, NYU
Langone Medical Center, New York, NY, United States of America
Purpose: Spontaneous bacterial peritonitis (SBP) is diagnosed by
analysis of ascites obtained by image-guided paracentesis. We
aimed to determine accurate predictors and whether SBP can occur
in low-volume ascites.
Material and methods: From 7/16 to 10/16, 243 paracenteses were
performed in 99 patients (42 women, 57 men; mean age 63 years).
Clinical symptoms, lab values, depth of the deepest pocket on ultrasound, total volume of ascites drained, cultures, neutrophil count
(NC = total fluid nucleated cells x %neutrophils), and complications
were recorded. Multiple logistic regressions were performed with
age, gender, indication, cirrhosis, cancer, abdominal pain, fever, confusion, prior SBP, depth of largest fluid pocket documented on ultrasound, total volume of ascites drained, and most recent labs (INR,
platelets, WBC, and sodium) as independent variables.
Results: Of 243 cases, 11 cases were diagnosed with SBP by NC>250,
2 of which had positive cultures (Citrobacter and Enterococcus). One
case with NC 123 had a positive culture with Citrobacter and considered SBP. Multiple logistic regression for diagnosis of SBP was significant (p<0.0001); abdominal pain (p=0.006) and depth of the deepest

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pocket (p=0.01) were the only significant independent predictors.

All cases of SBP had deepest pockets 5cm; SBP cases had pockets
of mean 7.7 cm, compared with 6.3 cm for negative cases (p=0.03).
There were 2 major hemorrhagic complications (0.8%); regression
demonstrated no predictors of complications.
Conclusion: Large ascites pocket and abdominal pain predicted
SBP; SBP was never diagnosed in patients with pockets <5cm. Given
the potential for hemorrhagic complications (~1%), appropriate
patient selection for paracentesis may include excluding patients
with small ascites pockets on ultrasound.

P-55
Accuracy of correct histopathologic tumor detection:
comparison between 10-G and 18-G biopsy samples
J.C.Apitzsch1, S.Viniol1, A.H.Mahnken2
1Department of Diagnostic and Interventional Radiology, Marburg
University Hospital UKGM, Marburg, Germany, 2Department of
Diagnostic and Interventional Radiology, University Hospital Marburg,
Philipps University of Marburg, Marburg, Germany
Purpose: To evaluate the diagnostic accuracy of histopathologic
findings using 10-G and 18-G samples of the same tumor lesion.
Material and methods: Eight patients underwent CT-guided
biopsy of the pulmonary lesions. Samples were obtained using a
10-G biopsy needle (10G Spirotome, Medinvents, Hasselt, Belgium)
and an 18-G needle (Cook, Winston-Salem, NC, USA). One sample was taken with each needle. The TruCut needle was inserted
through the trocar of the Spirotome needle. Samples were then
examined separately by pathology. The results were compared with
regard to sample size, accurate tumor diagnosis, and false-negative
and false-positive results.
Results: The large-core needle provided the correct diagnosis in
7 out of 8 cases (88%). The small-core needle provided the correct
diagnosis in 6 out of 8 patients (75%). The large-core needle provided 0% false-negative and 0% false-positive results. The smallcore needle provided 0% false-positive and 25% false-negative
results. Pneumothorax rates were 13%.
Conclusion: The Spirotome large-core biopsy needle offers larger
samples with higher probability of obtaining a sufficient sample
while keeping the complication rate low.

P-56
The role of interventional radiology in the management of
vascular complications after percutaneous tissue biopsy
S.A.R.Mustafa, J.Evans, A.C.Gordon, A.M.Wood, R.D.White
Department of Clinical Radiology, University Hospital of Wales, Cardiff,
United Kingdom
Learning Objectives: To delineate the common vascular complications after a range of percutaneous tissue biopsy procedures and
discuss different management strategies.
To examine the various endovascular techniques used in such cases,
taken from our experience as a tertiary centre.
Background: Percutaneous tissue biopsy has a known risk of
vascular complications, not least major bleeding. Management
approaches vary depending on a range of factors, but there is
an increasing trend towards endovascular treatment of these
complications.
Clinical Findings/Procedure: We illustrate the vascular complications from a range of percutaneous procedures from our tertiary
vascular centre, including native and transplant kidney, bone marrow, liver and abdominopelvic mass biopsy procedures. These iatrogenic complications range from simple haemorrhage to arteriovenous fistula formation.

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We discuss the merits and the disadvantages of various endovascular techniques along with rationale for opting for surgical or conservative approaches where relevant.
Conclusion: Vascular injury is an accepted risk of percutaneous tissue biopsy. Endovascular management of these complications is
becoming increasingly common, with different management strategies and rationale discussed here.

Abstract Book
Conclusion: MDCT-guided percutaneous transthoracic needle
biopsy of the lung via the transscapular approach is an alternative
procedure in selected patients.

P-59
Fine-needle aspiration of the pediatric thyroid
M.D.Hermann1, R.Vellody2
1Radiology, University of Michigan, Ann Arbor, MI, United States of
America, 2Department of Radiology, Childrens National Health System,

P-57
How to use your smartphone to assist CT-guided puncture

Washington, DC, United States of America

M.Hirata1, R.Watanabe2
1Radiology, Matsuyama Shimin Hospital, Matsuyama Ehime, Japan,
2Surgery, Matsuyama Shimin Hospital, Matsuyama Ehime, Japan
Learning Objectives:
1. How to use Smart Puncture, which is a free application to make
your gyroscope equipped smartphone into beneficial tool for
CT-guided puncture.
2. What are the advantages of this application.
3. Case report with movies.
Background: CT-guided puncture is a well-established minimally
invasive technique applied to biopsy, drainage, etc. In this procedure, with traditional step-wise approach (non-use of CT fluoroscope), physician has to define the angle of puncture needle by eye
measurement as planned on the reference images. This process
depends on the physicians judgment and can be a cause of inaccurate puncture with large angle error. To overcome this, we developed a smartphone application to assist CT-guided puncture.
Clinical Findings/Procedure: Function of the application
After defining the appropriate puncture site and needle angle, the
needle angle is inputted into the smartphone. Then, the smartphone displays a guideline. While holding the smartphone at any
angle, it automatically rotates the guideline to maintain the appropriate angle using the gyroscope function. The rotation center is
changeable by tapping display. All the physicians have to do is to
just advance the needle along the guideline shown on the device.
Advantages of this application.
1. Quite accurate puncture.
2. Easy preparation. (Just put a smartphone into sterilized nylon
bag.)
3. High availability of devices.
4. Easy to complete procedure without assistant.
Conclusion: We developed an application to assist CT-guided puncture. This application makes a smartphone into beneficial tool for
accurate puncture.

Learning Objectives:
1. Briefly cover the incidence of pediatric thyroid malignancy.
2. Explain the indications/contraindications for pediatric fine needle
aspiration (FNA).
3. Discuss the technique for pediatric FNA and how this differs from
adults.
4. Cover postprocedural management and complications.
Background: Pediatric thyroid cancer is the most common malignancy in children. With its incidence increasing, it is important
for clinicians to know when to perform pediatric thyroid FNA.
Preprocedural management, technique, and postprocedural management are different in children due to their size and need for
anesthesia.
Clinical Findings/Procedure: Preprocedually, the patient should
be evaluated to see whether FNA is actually indicated. (At this institution, we use the Society of Radiologists in Ultrasound guidelines.)
Examples of indications include symptoms of hypo- or hyperthyroidism, serum TSH, and concerning nodule characteristics. Other
items on a preprocedural checklist are whether the child can tolerate anesthesia or is taking antiplatelet agents.
There are many different ways to perform a pediatric thyroid FNA.
Some controversies that will be discussed are whether to use local
anesthesia (as children are usually under general anesthesia), use of
ultrasound gel, and use of suction versus capillary action.
The main complications of pediatric FNA include hematoma (usually from a superfluous number of passes) and inadequate samples.
Minimization of these and other complications will be discussed.
Conclusion: FNA biopsy of the thyroid will continue to be an important part in management of children with suspicious thyroid nodules. Knowledge of the adequate technique and management of
pediatric FNA allows for the best outcomes.

P-60
Targeted prostate biopsies using MRI/ultrasound fusion
technique

P-58

C.OBrien, E.ODwyer, M.OSullivan, E.Ward, R.Browne,

W.Torreggiani
Radiology, Tallaght Hospital, Dublin, Ireland

MDCT-guided transthoracic needle biopsy of the lung using

the transscapular approach
U.G.Rossi1, P.Torcia1, P.Rigamonti1, G.Mauri2, A.M.Ierardi3,
G.Carrafiello4, M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Radiology, IRCCS Policlinico San Donato, San Donato
Milanese, Italy, 3Radiology, Uninsubria, Ospedale di Circolo, Varese,
Italy, 4Department of Radiology, University of Insubria, Varese, Italy
Learning Objectives: To describe the MDCT-guided percutaneous
transthoracic needle biopsy using the transscapular approach.
Background: MDCT-guided percutaneous transthoracic needle
biopsy using the transscapular approach is used for the upper posterolateral lung nodules, when the nodule is difficult or hazardous to
reach with the conventional approach.
Clinical Findings/Procedure: The purpose of this poster is to illustrate step by step the transscapular approach with the coaxial needle technique for MDCT-guided percutaneous transthoracic needle
biopsy for the upper posterolateral lung nodules.

Learning Objectives: The purpose of this review poster is to discuss

and review the role of MRI-ultrasound fusion biopsy techniques in
targeting lesions suspicious for prostate cancer.
Background: MRI has now become the main imaging modality in
staging of prostate cancer. The advent of PI-RADS has made triaging
patients for biopsy an intrinsic part of evaluating patients with prostate cancer. In this educational exhibit, we discuss the role of MRI/
ultrasound fusion biopsy using cases that we have had in our institution as examples.
Clinical Findings/Procedure: Traditionally, trans-rectal ultrasound
(TRUS)-guided biopsies are performed in a systematic fashion to
acquire histological diagnosis. Due to the lack of intrinsic contract
obtained with ultrasound, a suspicious prostate lesion may not be
identified or biopsied. MRI is the gold standard imaging modality
for prostate imaging and cancer detection. Targeted MRI/ultrasound

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fusion biopsy is becoming an essential tool to further diagnose and
stage patients. Fusion of the high-spatial-resolution MRI image and
real-time ultrasound allows accurate visualisation of the suspicious
lesion and a targeted biopsy of the probable cancer.
Conclusion: Fusion of MRI/ultrasound images has opened a new
avenue in targeting prostate tumours for biopsy which is likely to
reduce the number of false negative results non-targeted biopsies yield and the number of repeat procedures patients currently
endure. The diagnostic accuracy achieved with targeted prostate
biopsies is also likely to improve patient outcomes and undoubtedly
become more widespread in the future.

P-61
Bedside ultrasound-guidance for interventional procedures in
intensive care unit patients: how to do it and what is needed?
G.Sempere-Campello, M.D.Ferrer-Puchol, R.RamiroGandia,
E.EstebanHernndez, A.Llavata
Radiology, Hospital Universitario La Ribera, Alzira, Spain
Learning Objectives:
1. Discuss the role of the ultrasound-guidance in the assessment of
interventional procedures performed at bedside in intensive care
patients.
2. Review the indications, contraindications, patient and equipment
preparation and related complications of several interventional
ultrasound-guided procedures performed in the Intensive Care
Unit (ICU) of our institution.
3. Describe through our experience the supplies and procedure
technique in each scenario.
Background: Carrying out interventional procedures at bedside
diminishes the need to transport critically ill patients and thus the
risk of adverse events.
Ultrasound guidance has emerged as an ideal imaging modality
for many bedside diagnostic and interventional procedures owing
to the portability of newer ultrasound machines and ease of use.
Moreover, bedside ultrasound-guided interventional procedures in
the ICUs have increased due to critical-care providers interest and
availability of user-friendly percutaneous catheter kits.
When performing bedside procedures in critically ill patients, preparation is the key. Knowledge of normal anatomy and associated
abnormalities, along with patient positioning, understanding of the
procedure, necessary equipment, and associated complications can
lead to successful procedures while minimizing adverse outcomes.
Clinical Findings/Procedure: In this review, we focus on common interventional procedures frequently performed in our institutions ICU, including thoracocentesis, paracentesis, cholecystostomy,
nephrostomy, drainage of fluid and pleural collections, arthrocentesis, and pseudoaneurysm embolization.
We provide corresponding background on each pathologic condition and review indications and contraindications of each interventional procedure. We detail and illustrate the supplies needed for
every scenario and review the procedural technique, patient positioning, and equipment preparation required.
Conclusion: Bedside ultrasound guidance has been demonstrated
to be safe and effective for interventional therapies in ICU patients.

SS/FC/HL/HTS/CM
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P-62
Percutaneous MR-guided biopsy of intra-orbital retro-globular
masses
R.L.Cazzato1, J.Garnon1, G.Koch1, P.P.Rao1, J.Caudrelier1,
G.Tsoumakidou2, A.Gangi3
1Interventional Radiology, University Hospital of Strasbourg,
Strasbourg, France, 2Non-Vascular IR, University Hospital of Strasbourg,
Strasbourg, France, 3Imagerie Interventionnelle, NHC, Strasbourg,
France
Learning Objectives: To discuss technical and anatomical details
concerning percutaneous MR-guided biopsy of intra-orbital retroglobular masses performed on a 1.5T Unit.
Background: A wide range of tumours and tumour-like conditions
may arise in the intraorbital retroglobular space, both in adults and
children.
Tissue sampling may allow definite diagnosis.
Clinical Findings/Procedure: To perform bioptical and cytological
samplings, 20-G and 22-G needles, respectively, can be used.
Multi-planar MR-fluoroscopy (BEAT T1/T2W sequences) is necessary while advancing the needle; on the other hand, BLADE T2W
sequences are used to confirm its position relative to the target
mass and other surrounding structures.
Major complications are related to iatrogenic injuries to the optic
nerve (ON) or to the ophthalmic artery (OA); simple anatomic considerations may help to avoid such events.
Percutaneous approach should be infero-medial or infero-lateral based on the tumor location. Superior and supero-lateral
approaches should be avoided to prevent iatrogenic injuries to the
lacrimal gland and to the OA (and its main branches), respectively.
Masses arising from or encasing the ON should be approached with
the needle being as parallel as possible to the long axis of the ON
in order to reduce the risk of large ON injuries, including truncation.
Moreover, for ON masses, the inferior border should be sampled to
avoid visual loss in the inferior part of the visual field, which is more
disabling than visual loss in the superior part of the visual field.
Conclusion: Intra-orbital retro-globular masses can be biopsied
under MR guidance. Simple anatomical considerations help to avoid
major complications related to ON and OA iatrogenic injuries.

P-63
Super-rapid multi-planar reconstruction facilitates real-time
oblique CT-guided puncture
R.Sato, T.Aramaki, E.Bekku, K.Yoza, M.Moriguchi, T.Ito
Division of Interventional Radiology, Shizuoka Cancer Center, Shizuoka,
Japan
Learning Objectives: The new technology for oblique CT-guided
puncture.
Background: On CT-guided puncture, oblique puncture is sometimes necessary to avoid important organs and vessels. Although
tilting the gantry sometimes improves the situation, the angle of tilt
that can be obtained is limited. If an angle that exceeds the settings
is needed, the gantry should be moved in small increments following the movements of the needle. This is a challenging technique
that requires some experience.
Clinical Findings/Procedure: Multi-planar reconstruction usually
takes a few minutes and is unsuited to real-time CT-guided puncture. Super-rapid reconstruction, a new technology developed by
area detector CT, takes only 8 s to reconstruct data from a single CT
rotation. This represents almost real-time reconstruction, and four
images can be viewed simultaneously on the monitor (the reconstructed oblique image and axial, sagittal and coronal images) during real-time CT-guided puncture. The angle of oblique images can
be adjusted freely and rapidly. Even inexperienced surgeons can

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perform oblique puncture much more easily, quickly and safely

because oblique reconstructed images are shown as if they were
axial images, meaning that the needle and target lesion can be
viewed simultaneously on oblique images rather than axial images.
Because we use 320-row Angio-CT and have 16-cm volume coverage in a single scan, we can approach using a much longer oblique
route for puncture and perform procedures such as drainage under
fluoroscopy without transfer.
Conclusion: Super-rapid multi-planar reconstruction can facilitate
CT-guided oblique puncture and expands the possibilities for interventional radiology.

P-64
Paediatric traumatic urinoma: percutaneous drainage allowing
conservative management
P.Douglas1, A.Tan1, S.Goodwin2, S.Cascio2
1Radiology, Queen Elizabeth University Hospital, Glasgow, United
Kingdom, 2Radiology, Royal Hospital for Children, Glasgow, United
Kingdom
A 4-year-old boy fell from a stool sustaining grade V injury to his left
kidney with formation of a large urinoma which separated the renal
poles. Percutaneous drainage allowed conservative management.
CT, US and follow-up DMSA are reviewed.

Bone, spine and soft tissue intervention

P-65
Cryoablation of primary soft-tissue tumors: experience in 39
patients
X.Buy1, M.Kind1, E.Stoeckle2, V.Catena1, J.Palussire1
1Department of Radiology, Institut Bergoni, Bordeaux, France,
2Department of Surgery, Institut Bergoni, Bordeaux, France
Purpose: To present our tertiary referral center experience of cryoablation in locally aggressive and malignant primary soft-tissue
tumors.
Material and methods: From January 2013 to January 2016, 39
patients were referred by our sarcoma multidisciplinary staff for
CT-guided cryoablation of soft tissue tumor. Twenty-six tumors were
benign and locally aggressive (20 desmoid, 5 aggressive angiomas,
and 1 myxoid tumor); 13 primary tumors were malignant (11 sarcomas, 1 chordoma, and 1 malignant fibrous pleural tumor). Tumors
were located in the abdominal or thoracic wall (n=21), limbs or pelvic girdle (n=13), retroperitoneum (n=3), and neck (n=2). Tumor size
ranged from 2 to 18 cm. Cryoablation was performed under general
anesthesia, except in four tumors abutting major nerves wherein
conscious sedation was used to maintain neurological control. If
needed, various techniques of thermal protection were used (hydroor carbodissection, thermocouples, and electrostimulation).
Results: Thirty-three tumors were ablated in a single session. Six
desmoid tumors required multiple sessions. Therapeutic intent was
curative in 24 cases. For palliative cases, the intent was focal control
of the tumor progression to avoid or to postpone major changes in
systemic therapies. The ice ball achieved more than 90% tumor-volume destruction in all but one desmoid tumor. No major complication related to cryoablation occurred.
Conclusion: Cryoablation is a very promising technique for the
management of soft tissue masses. For selected recurrent sarcomas, it allows salvage focal treatment after failure of surgery and
radiotherapy; moreover, cryoablation can be repeated if needed. In
locally aggressive benign tumors such as angiomas and symptomatic desmoid tumors, cryoablation seems particularly efficient.

Abstract Book

P-66
Percutaneous vertebroplasty in multiple myeloma: long-term
outcome in a patient series
F.Fasoli1, F.Vecchietti1, A.Siniscalchi2, T.Caravita2, P.deFabritiis2,
M.Guazzaroni1
1UOC Radiodiagnostica e Radiologia Interventistica, Ospedale Sant
Eugenio, Rome, Italy, 2UOC Ematologia, Ospedale Sant Eugenio, Rome,
Italy
Purpose: Percutaneous vertebroplasty (PVP) is a minimally invasive
radiological method for the treatment of back pain related to osteoporotic vertebral compression fractures, vertebral metastases, and
myeloma. The vertebral column is the most common site for secondary bone metastases and lesions arising from hematological
malignancies such as multiple myeloma (MM). Patients with MM are
at a high risk of vertebral compression fracture, and the use of vertebroplasty is expanding in this patient population. We reviewed the
clinical outcome of 534 PVPs to evaluate the safety and effectiveness
of this interventional radiology procedure.
Material and methods: Between January 2012 and September
2015, 274 (544 vertebral collapses) patients in our department were
treated by PVP. Patients were first evaluated by objective examination, VAS evaluation, and X-ray and MR diagnostic investigations.
The procedure was performed on fluoroscopy biplanes high resolution guide. The follow-up was conducted with objective review
(associated with a VAS reassessment) at 30 days and with MR and CT
at 3, 7, and 12 months after the procedure.
Results: Technical success was 94% with a reduction (8.2 to 2.4).
Post- and peri-procedural complications documented were as follows: 1 radiculopatia, 38 discal leaks, and 40 venous leaks of PMMA8
with 1 pulmonary embolism; all the complications were asymptomatic. During an average follow-up at 27.8 months (range: 12 months
to 48 months), vertebral levels previously treated did not show worsening in the morphological and structural aspects.
Conclusion: Percutaneous vertebroplasty is a safe and effective
procedure in the treatment of vertebral collapse with disabiliting
pain refractory to medical conservative therapy, conferring lasting
pain relief, enhanced mobility, and reduced narcotic use for all of the
stages of myeloma associated with painful compression fractures.

P-67
Internally cooled radiofrequency ablation of the vertebral
body with a novel bipolar device: imaging and pathological
findings
S.Bagla1, M.R.Callstrom2
1Interventional Radiology, Vascular Institute of Virginia, Woodbridge,
VA, United States of America, 2Department of Radiology, Mayo Clinic,
Rochester, MN, United States of America
Purpose: Radiofrequency ablation (RFA) of vertebral body metastases is an increasing option for palliation of cancer patients. We present our in vivo pre-clinical experience with a novel internally cooled
bipolar RF device.
Material and methods: Three Yorkshire pigs (4 to 5 months/70
to 90 kg) underwent transpedicular vertebral RFA (OsteoCool;
Medtronic, Minneapolis, MN) at 8 lumbar levels (unilateral 5/bilateral 3) in the following configurations: unilateral body, unilateral
pedicle, or bilateral posterior body. MRI with was performed immediately post-ablation and at either day 1 or 7 prior to euthanasia.
Software segmentation, surface area, and volume calculation of
ablation zones were performed (Mimics Version 18.0, Materialise
HQ, Belgium). Thermal damage was pathologically assessed after
euthanasia.
Results: All ablations were successful without neurologic injury.
Pedicle ablation morphology (length:width ratio) changed (2.2)

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compared with ablation within the body (1.1) without extension

beyond the cortex. Ablation volume (in vivo) was similar to that predicted (ex vivo). There was no significant difference in ablation zone
measurements determined by MRI at day 0 and day 7 or MRI and
pathology at day 7. Bilateral ablation resulted in a confluent ablation zone with a clear posterior margin, rather than two ovoid zones.
There was no extension to the spinal canal or outside the vertebral
body. There was a synergistic effect of the bilateral ablation with a
45% volume increase from that predicted with sequential ablation.
Conclusion: Ablation within the pedicle or posterior vertebral body
is safe, and bipedicular ablation produces a synergistic ablation
zone parallel to the intact posterior cortical wall.

P-68
Percutaneous cryoablation of extra-abdominal desmoid
tumors
J.J.Schmitz, A.N.Kurup, G.D.Schmit, T.D.Atwell, A.J.Weisbrod,
S.H.Okuno, S.I.Robinson, P.S.Rose, M.R.Callstrom, J.M.Morris
Radiology, Mayo Clinic, Rochester, MN, United States of America
Purpose: To report the safety and efficacy of percutaneous cryoablation in the treatment of extra-abdominal desmoid (EAD) tumors.
Material and methods: A retrospective search of our tumor ablation database was performed to identify patients with EAD tumors
treated with percutaneous cryoablation between June 15, 2004
and June 15, 2014. During this 10-year time period, 18 patients
with 26 discrete tumors were treated over 31 separate sessions.
Complications were graded using the ClavienDindo classification
system. Post-cryoablation imaging was performed with contrastenhanced MRI or CT. Any enhancing soft tissue was considered to be
a viable EAD tumor and was measured in 3 planes.
Results: Of the 26 treated EAD tumors, follow-up imaging with
intravenous contrast was available for 23. Mean imaging followup was 16.2 20.0 months. All 31 treatment sessions were technically successful. No residual viable EAD tumor was observed in 9/23
tumors (39.1%). Some degree of volume reduction was evident in
22/23 tumors (95.6%). Progressive disease was observed in 1/23
tumors (4.3%). In the cases with residual or progressive disease, the
recurrence occurred at the margin of the treated tumor. No major
complications were observed.
Conclusion: Percutaneous cryoablation is a safe, effective, and
repeatable treatment option to achieve local tumor control of EAD
tumors.

P-69
Early results of low back pain treatment using percutaneous
thermal disc decompression-like minimally invasive outpatient
procedure
F.Vecchietti, F.Fasoli, R.Cancellieri, M.Guazzaroni
UOC Radiodiagnostica e Radiologia Interventistica, Ospedale Sant
Eugenio, Rome, Italy
Purpose: Chronic low back pain is one of the major causes of social,
economic, and health-related disability worldwide. The aim of our
work is to investigate the use of percutaneous thermal disc decompression (TDD) as a minimally invasive outpatient procedure for
the treatment of contained lumbar disc protrusions using thermal
energy in the leg and back pain treatment due to contained lumbar
disc herniation.
Material and methods: We enrolled 97 patients with back and leg
pain due to MRI-identified unilateral and contained lumbar disc protrusions in whom conservative treatment such as physical and pharmacological therapy or epidural steroid injections had failed. The
selected patients were subjected to TDD treatment using fluoroscopic guidance through a posterolateral approach contralateral to

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the herniation. All patients completed a 12-min 90C decompression

protocol, followed by 1-month sessions of specific physical therapy.
MR follow-ups were performed at 6 and 12 months.
Results: All 97 patients received single-level treatment; 13 patients
needed double-level treatment. All patients were compliant with
post-treatment protocol and follow-up. At the 6-month follow-up,
there was a mean improvement of 3.8 on the VAS and 70% subjective improvement; at the 12-month follow-up, there was VAS
improvement of 3.5 and 85% subjective improvement. Post-12month follow-up showed that 87% of patients returned to work following treatment, about 10% discontinued use of medical therapy;
and only less than 3% required further pain retreatment. More than
95% of all treated patients agreed for repeating the procedure. No
complications were observed.
Conclusion: TDD appears to be a safe and effective treatment for
chronic low back pain due to contained lumbar disc herniation. Most
patients report a significant life quality gain due to the improvement
in leg and back pain, persisting for at least 1 year.

P-70
Percutaneous thermal disc decompression versus
percutaneous disc decompression-like minimally invasive
outpatient procedure of low back pain treatment: 1-year
single-center experience
F.Fasoli, F.Vecchietti, R.Cancellieri, M.Guazzaroni
UOC Radiodiagnostica e Radiologia Interventistica, Ospedale Sant
Eugenio, Rome, Italy
Purpose: The aim of our work was to compare two different minimally invasive outpatient procedures for the treatment of contained lumbar disc protrusions using percutaneous targeted disc
decompression (TDD) vs percutaneous disc decompression (PDD) in
patients with contained lumbar disc herniation.
Material and methods: We enrolled 137 patients with back and
leg pain due to MRI-identified unilateral and contained lumbar disc
protrusion in whom conservative treatment such as physical and
pharmacological therapy or epidural steroid injections failed. The
selected patients were randomized in 2 groups and treated with
TDD (Group A) and with PDD (Group B) under fluoroscopic guidance
using a posterolateral approach contralateral or ipsilateral to the
herniation. Group A completed a 12-min 90C decompression protocol. Group B completed a standard mechanical decompression
protocol. All patients followed 1-month sessions of specific physical
therapy. Follow-ups were performed at 6 and 12 months and compared with paired t-test.
Results: Group A: 47 patients received single-stage treatment; 13
needed double-stage treatment. Group B: 55 patients received single-stage treatment; 21 needed double-stage treatment. All patients
were compliant with post-treatment protocol and follow-up. At the
6-month follow-up: Group A, mean improvement 3.9 on VAS and
75% subjective improvement; Group B, mean improvement 4.1 on
VAS and 77% subjective improvement; at the 12-month follow-up:
Group A, mean improvement of 3.7 on VAS and subjective improvement, 86%; Group B, mean improvement of 3.9 on VAS and subjective improvement, 89%. Post-12-month follow-up showed that 89%
of patients returned to work following treatment, about 7% discontinued use of medical therapy, and only less than 4% required further pain retreatment. More than 95% of all treated patients agreed
to repeat the procedure. One case of spondylodiscitis was observed.
Conclusion: Both approaches appear to be safe and effective for
chronic low back pain due to contained lumbar disc herniation, with
no significant statistical difference in terms of quality of life gained
due to the improvement in leg and back pain, persisting for at least
1 year.

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P-71
Reinforced cementoplasty for lytic malignant lesions of the hip
joint: preliminary results of 10 cases
J.Chiras1, E.Cormier2, F.Clarenon1
1Service de Neuroradiologie, GH Piti Salptrire, Paris, France,
2Neuroradiologie Interventionnelle, GH Piti Salptrire, Paris, France
Purpose: New technique for the percutaneous treatment of femoral
neck prefractural osteolytic malignant lesions.
Material and methods: From December 2013 to November 2015, 10
patients were treated by the stabilization of an osteolytic lesion of
the hip joint by reinforced cementoplasty.
Seven patients presented lytic lesions involving the femoral neck,
two myeloma, for metastases, and one essential cyst. Two patients
had voluminous lytic lesion of the intertrochanteric area. One
patient had metastasis of the main trochanter with fracture. All the
procedures were performed under general anesthesia.
Three to four spindles were implanted into the femoral neck followed by fulfilling of the lytic lesion by Biomet BCV cement. For
intertrochanteric lesions, spindles were introduced through the
superior pertrochanteric approach followed by cementoplasty.
Results: No complications or technical difficulties were encountered
during the procedure. All patients were discharged from the hospital at 24 hours post-operation with AINS and antalgic for 15 days.
At 1 month, all patients could normally walk with no local pain.
No fracture or recurrence of pain was observed at the midterm follow-up at 3 months (2 cases), 6 months (3 cases), 1 year (5 cases).
Conclusion: Reinforced cementoplasty with spindle is an appropriate technique to stabilize the femoral neck in case of osteolytic
lesions with a high risk of fracture.

P-72
Percutaneous radiofrequency ablation of osteoid osteoma in
the spine, feet, and hands: can it be performed safely?
A.A.Nassef1, H.G.Khira2, W.A.Ebeid2
1Radiology, Cairo University, Cairo, Egypt, 2Orthopaedic Surgery, Cairo
University, Cairo, Egypt
WITHDRAWN

P-73
SAFIR: a software tool supporting clinical ablation procedure
studies
C.Rieder, C.Schumann, H.Ballhausen, T.Ptz, T.Preusser
Institute for Medical Image Computing, Fraunhofer MEVIS, Bremen,
Germany
Purpose: A major clinical challenge in ablation procedures such
as RFA or MWA is the high local recurrence rate reported in clinical
studies. Clinical researchers perform statistical analysis of retrospective ablation cases to understand the limitations and improve the
procedures. Typically, length or shape measurements required for
analysis are performed by hand in 2D to approximate the 3D measure, making an accurate quantification difficult.
Material and methods: To support clinicians in the planning and
assessment of ablation procedures, a prototype called Software
Assistant for Interventional Radiology (SAFIR) has been developed.
Several image-processing and visualization methods are integrated
in SAFIR. Depending on the image data, semi-automatic or interactive methods supported by interpolation and snapping allow for the
extraction of the target tumor and thermal necrosis. Geometrical
applicator models of different manufacturers can be placed on top
of the anatomical image data. Using image registration, the pre-,
intra-, and post-interventional images are aligned.

Abstract Book
Results: Using the segmentation methods, tumor and necrosis of
an ablation are retrospectively extracted and measurements such as
volume and diameter are automatically obtained in 3D. Applicator
models are placed on top of intra-interventional images. After the
alignment of all images, surface distances between tumor, necrosis, and applicators are automatically evaluated. Finally, a statistical analysis, which considers the measures of all processed cases, is
performed.
Conclusion: The methods integrated in SAFIR support the accurate
statistical analysis of ablation procedures in 3D. By evaluating large
case databases, SAFIR has the potential to better understand and
quantify limitations of tumor ablation procedures.

P-74
Correlation of height restoration and kyphosis with clinical
outcome after percutaneous vertebroplasty in patients with
vertebral compression fractures
T.Pan1, S.-C.He2, H.-D.Zhu3, J.-H.Guo1, G.-J.Teng2
1Department of Interventional and Vascular Surgery, Zhongda
Hospital, Southeast University, Nanjing, China, 2Department of
Radiology, Zhong-Da Hospital, Southeast University, Nanjing, China,
3Radiology, Zhong-Da Hospital, Medical School, Southeast University,

Nanjing, China
Purpose: To evaluate the correlation of restoration of vertebral
body height and kyphosis with pain relief and clinical outcome after
percutaneous vertebroplasty (PVP) in patients with painful vertebral
compression fractures (VCFs).
Material and methods: Between January 2007 and December 2013,
241 patients with VCFs who had failed conservative treatment and
underwent PVP were included. Restoration of vertebral body height
and kyphosis were measured on standardized radiographs. Pain
and clinical outcome were assessed using the visual analogue scale
(VAS) score and the Ronald Morris Disability Questionnaire (RMDQ)
score, respectively. Pre- and post-operative restoration of vertebral
body height and kyphosis and VAS and RMDQ scores were compared using the paired t test. Correlations between the height restoration and kyphosis and VAS and RMDQ scores were determined via
Pearson correlation coefficient (r).
Results: The height, wedge angle and local angle of the fractured
vertebral body, as well as VAS and RMDQ scores, improved significantly after PVP. VAS and RMDQ scores correlated positively with
the height restoration and kyphosis; the highest correlation was
between the VAS score and wedge angle (r=0.95).
Conclusion: PVP is a simple and viable treatment for VCFs patients
as most patients experienced pain relief and improvement of clinical
function after the pressure. In terms of VAS and RMDQ scores, preoperative height restoration and kyphosis can be prognostic indicators for the outcome of PVP.

P-75
Phantom study on accuracy and radiation dose of cone
beam CT-guided percutaneous vertebroplasty compared
with accuracy and dose of conventional fluoroscopy-guided
percutaneous vertebroplasty
T.Yamamoto, A.Kitagawa, T.Ishiguti
Radiology, Aichi Medical University Hospital, Nagakute, Japan
Purpose: To evaluate the accuracy and the radiation dose for operator with cone beam CT (CBCT)-guided percutaneous vertebroplasty
in comparison with the accuracy and the dose for fluoroscopyguided percutaneous vertebroplasty.
Material and methods: Simulating percutaneous vertebroplasty,
we punctured lumbar vertebrae model contained in a humanbody phantom, 20 times each with CBCT-guided method and with

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fluoroscopy-guided method, using a bone biopsy needle (11 G, 15
cm). The accuracy of each puncture was evaluated by measuring
the distance between the needle tip and the center of the vertebral
body of the phantom. To evaluate radiation dose, fluoroscopy time
for each attempt was recorded. Scatter radiation for the operators
eyes was measured using a RANDO phantom and a dosimeter.
Results: Every puncture was successful. Mean distance between the
needle tip and the center of the vertebral body was 1.80 mm and
7.65 mm and mean radiation time was 0.38 minutes and 1.98 minutes using CBCT-guided method and fluoroscopy-guided method,
respectively. Radiation dose rate for the operators eyes was measured as 8.810.6 Gy/minute (frontal position), 4650 Gy/minute
(X-ray tube was on the operators side) and 4042 Gy/minute (flat
panel was on the operators side).
Conclusion: The CBCT-guided method allows more accurate puncture and less radiation by the operator compared with the fluoroscopy-guided method.

P-76
Percutaneous CT-guided sympathicolysis with radiofrequency
for the treatment of palmar hyperhidrosis
J.M.Madrid1, P.Garca-Barqun1, J.M.Bonda1, A.Espaa2,
J.J.PerezCajaraville3, J.D.AquerretaBeola1
1Dept. of Radiology, Clinica Universidad de Navarra, Pamplona, Spain,
2Dept. of Dermatology, Clinica Universidad de Navarra, Pamplona,
Spain, 3Dept. of Anesthesiology, Clinica Universidad de Navarra,
Pamplona, Spain
Purpose: To evaluate the benefits of percutaneous CT-guided sympathicolysis (CTS) with radiofrequency in patients with palmar
hyperhidrosis (PPHH) in terms of efficacy, patient satisfaction, and
complications over a short and long term.
Material and methods: We retrospectively analyzed the benefits of CTS in 33 patients with PPHH (March 2010September 2015).
We used the Hyperhidrosis Disease Severity Scale (HDSS) to evaluate the severity of the hyperhidrosis before CTS, 1 month after CTS,
and long term after CTS. CTS was performed bilaterally in T2, T3, and
T4 levels with radiofrequency reaching 90C in 8 minutes. Treatment
success was considered an improvement by at least one point in the
HDSS. Treatment failure was defined as no changes or worsening
of HDSS. We also evaluated patients satisfaction using a four-point
scale. The presence of complications like compensatory hyperhidrosis was also analyzed. We used Wilcoxons test to assess the differences in the degree of PPHH.
Results: The mean follow-up time was 40.21 months (662 months).
One month after CTS, 50 of 66 hands had improved by at least one
point in the HDSS, corresponding to a response rate of 75.75%
(p<0.001). At long term 41 hands improved by at least one point in
the HDSS, corresponding to a response rate of 69.69% (p<0.001). 17
of 33 patients (51.51%) were very satisfied or satisfied. In total, 57.7%
presented compensatory hyperhidrosis in the follow-up.
Conclusion: Percutaneous CTS is an effective and safe technique for
the treatment of PPHH. It can be considered as an alternative treatment in patients in whom other therapeutics have failed and by
whom surgery is rejected.

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P-77
Transforaminal balloon decompression using dilating working
cannula in patients with lumbar foraminal stenosis
H.-Y.Kang1, S.-H.Lee2, S.-Y.Moon3
1Radiology, Spine Health Wooridul Hospital (SHWH) Dongrae, Busan,
Korea, 2Neurosurgery, Spine Health Wooridul Hospital (SHWH)
Gangnam, Seoul, Korea, 3Clinical research division, Spine Health
Wooridul Hospital (SHWH) Dongrae, Busan, Korea
Purpose: Recently, transforaminal balloon decompression (TBD) has
been tried to treat lumbar foraminal stenosis (LFS), but placing the
catheter tip at the accurate site was still a problem due to the flexibility of the catheter. The objective of this study was to improve the
success rate and evaluate the effectiveness of TBD.
Material and methods: From April 2014 to December 2015, 14
patients who suffered low back and/or radiating pain caused by LFS
underwent TBD using a dilating working cannula.
Under fluoroscopic guidance, an 18-gauge needle was introduced
and a thin guidewire was inserted through the needle. The needle was then removed, and serial 1-2-3-mm dilating cannulas were
inserted. A balloon catheter was advanced through the working
sheath, and contrast media was injected to confirm a perineural filling defect. The catheter was introduced at the narrowed site, and
then the balloon was inflated 5 to 8 times and gradually moved from
the lateral to medial side of the vertebra. Finally, local anesthetic,
normal saline, and steroid were injected.
Results: TBD was performed at L3-4 in 2 cases, L4-5 in 9 cases, and
L5-S1 in 3 cases. In all cases, positioning of the balloon catheter
was easily done and decompression with inflated balloon was well
performed. The mean visual analog scale improved from 6.8 to 3.1
(range, 8 to 2). All patients reported a significant or some improvement in pain, but 1 patient underwent fusion surgery 3 months after
TBN. There were no complications observed.
Conclusion: TBD using dilating working cannula is a useful and
effective treatment for LFS.

P-78
Efficacy of bone remodelling system in the treatment of painful
vertebral compressive fractures: a preliminary experience
S.Marcia1, E.Piras1, S.Marini1, A.Spinelli1, L.Saba2
1Radiology, ASL8 Cagliari, Cagliari, Italy, 2Radiology, Policlinico
Universitario di Monserrato, Cagliari, Italy
Purpose: The aim of this study (IRB approved) was to evaluate the
effectiveness of a bone remodelling system in the treatment of painful vertebral compressive fractures.
Material and methods: Twenty-seven consecutive patients (8 male,
19 female) with painful vertebral compressive fractures underwent
the bone remodelling system (Tektona, Spine Art, SWI) procedure.
Patients had been previously evaluated by clinical examination and
X-ray, CTms and MRI-T2wSTIR. All the procedures were executed
with local anaesthesia and a bilateral approach under digital fluoroscopic guidance. In total, 30 vertebrae were treated. Clinical evaluation and assessment of pain using a 11-point visual analogue scale
(VAS, 010) were performed at baseline and immediately after the
procedure. Height restoration by volume calculation with CTms was
performed before and immediately after the procedure, as well as
the local kyphosis angle.
Results: We obtained a progressive reduction of the pain in all the
patients (Av. VAS pre: 7.37, post: 3.06, difference: 4.31), a good restoration of the height (Av. h pre: 16.45 mm, post: 18.82 mm, difference: 2.37 mm), and a good increase in the volume of the vertebral
bodies (Av. V pre: 21.2 cm3, post: 22.9 cm3, difference: 1.7 cm3). The
local kyphosis angle showed a1.05 decrease. No major complications arose.

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Conclusion: From our preliminary studies, the use of bone remodelling system was found to be safe and effective in the treatment
of painful vertebral fractures, providing pain relief and anatomical
restoration.

P-79
Percutaneous vertebral augmentation for malignant lesions in
the thoracic spine: an 18-month follow-up on pain reduction
and mobility improvement
G.Velonakis, D.K.Filippiadis, C.Konstantos, K.Palialexis,
E.Alexopoulou, N.L.Kelekis, A.D.Kelekis
2nd Radiology Department, University General Hospital Attikon,
Athens, Greece
Purpose: To assess clinical outcome (pain reduction and mobility improvement) and safety (potential complications and implant
migration) of patients with symptomatic malignant lesions and/or
fractures in the thoracic spine treated by percutaneous vertebral
augmentation with biocompatible polymer (KIVA implant).
Material and methods: During the last 2 years, 10 patients with
symptomatic malignant lesions in the thoracic spine underwent
percutaneous augmented vertebroplasty (wherein a biocompatible polymer was introduced within the vertebral body and filled
with PMMA). Cone-beam CT was performed immediately after performing the percutaneous vertebroplasty augmented with the KIVA
implant. Standard X-rays and CT scans were performed during follow-up. Pain prior, the morning after, and at the last follow-up (average follow-up 12 months) was compared by means of a numeric
visual scale (NVS) questionnaire. Cement extravasation and implant
migration were also recorded.
Results: Comparing the pain scores of questionnaires before (mean
value 8.9 NVS units) and after (mean value 1.5 NVS units) treatment,
there was a mean decrease of 7.4 NVS units in terms of pain reduction and improvement in life quality. Overall mobility improved in
10/10 (100%) patients. No complication was observed. No symptomatic or clinically significant extravasations occurred. No implant
change or migration was observed during the 18-month follow-up
period.
Conclusion: Preliminary results in the treatment of symptomatic
malignant lesions in the thoracic spine report significant pain reduction and mobility improvement with no proof of implant migration.
Further studies, however, are required.

P-80
Computed tomography-guided radiofrequency ablation of
intra-articular osteoid osteoma: clinical application of extraarticular access
D.K.Filippiadis, G.Velonakis, S.Grigoriadis, L.Reppas, E.Brountzos,
N.L.Kelekis, A.D.Kelekis
2nd Radiology Department, University General Hospital Attikon,
Athens, Greece
Purpose: To evaluate the safety and efficacy of radiofrequency ablation with an extra-articular approach through normal bone in the
treatment of intra-articular osteoid osteoma.
Material and methods: During the last 3 years, 14 patients underwent CT-guided radiofrequency ablation of an intra-articular osteoid osteoma. In order to assess and sample the nidus, the OnControl
Bone Marrow Biopsy System (OBM, Arrow OnControl, Teleflex,
Shavano Park, TX, USA) was used. Biopsy was performed in all cases.
Procedure time (drilling, biopsy, and ablation), amount of scans, radiation exposure, and the results of biopsy were recorded.
Results: Access to the nidus through normal bone was feasible in
all cases. Median procedure time was 64 min. Histologic verification
was performed in all cases. Radiofrequency electrode was coaxially

Abstract Book
inserted within the nidus and ablation was successfully performed
in all lesions. Median amount of CT scans performed to control correct positioning of the drill and precise electrode placement within
the nidus was 12. There were no complications or material failure
reported in our study. Pain reduction was significant from the first
morning post-ablation and complete after 1 week and during the
follow-up period (2 years).
Conclusion: Radiofrequency ablation under CT guidance is a safe
and efficient technique for the treatment of painful intra-articular
osteoid osteoma. Imaging guidance, extra-articular access through
normal bone and exact positioning of the needle electrode inside
the nidus facilitate safety of the technique and prevention of damage to the articular cartilage.

P-81
Ultrasound-guided vs. CT-guided approach for the sacroiliac
joint steroid injection in young women: main aspects,
advantages and clinical response
F.Smaldone1, F.Arrigoni1, A.Mancini1, L.Zugaro2, A.Barile1,
C.Masciocchi1
1Department of Biotechnological and Applied Clinical Sciences,
University of LAquila, LAquila, Italy, 2Radiology, San Salvatore Hospital,
LAquila, Italy
Purpose: To evaluate the efficacy, accuracy and clinical response of
US-guided versus CT-guided sacroiliac (SI) joint injections in young
women affected by SI joint arthritis. SI joint intra-articular injections
are usually performed under CT guidance.
Material and methods: In total, 72 young female patients (mean
age 38) affected by SI joint arthritis were treated with anaesthetics
and steroid injections. Of these, 30 patients (Group A) were treated
using US-guided injection and 42 (Group B) with CT-guided injection. The patients were randomly assigned to each group. Exclusion
criteria were histories of significant allergic reactions to injection solutions, local malignancy, bleeding disorders and diabetes.
Symptom intensity was evaluated using the VAS scale before and
after 3 months from treatment. We considered the advantages of
both approaches in terms of the procedure time, radiation exposure
and clinical outcome.
Results: A significant reduction of symptomatology intensity was
observed in both groups after 3 months from treatment with shorter
treatment duration and no radiation dose exposure for patients of
group A. We did not observe any complications in both groups.
Conclusion: US-guided injection is a safe and effective procedure
for SI joint arthritis with similar results as those using CT-guided
injection in terms of the symptom reduction. US is preferred in
young women at a fertile age owing to its shorter duration time and
lack of radiation dose exposure.

P-82
Aspiration of symptomatic Bakers cysts under ultrasound and
fluoroscopic guidance followed by therapeutic injection leads
to a durable reduction in pain symptoms in the majority of
patients
A.G.Ryan1, J.Laurinkiene1, K.Courtney1, H.K.Moriarty2, I.P.Kelly3
1Department of Radiology, University Hospital Waterford, Waterford
City, Ireland, 2Radiology, Mater Misericordiae University Hospital,
Dublin, Ireland, 3Orthopaedic Surgery, Whitfield Clinic, Waterford,
Ireland
Purpose: To evaluate the efficacy of ultrasound- and fluoroscopicguided aspiration and therapeutic injection of Bakers cysts in the
relief of pain and pressure symptoms.
Material and methods: Retrospective, observational, single-arm
study of consecutive patients referred from the Orthopaedic service

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for ultrasound- and fluoroscopy-guided aspiration and therapeutic
injection of symptomatic Bakers cysts. Patients pain was assessed
using standard VAS. Under standard sterile conditions, a 10-cm long
5-Fr Yueh centesis needle was advanced into the cyst under direct
ultrasound guidance; septae disrupted as necessary, the contents
of the cyst aspirated, and a sample sent for microbiological analysis. Bursography was performed in an attempt to demonstrate the
expected communication with the knee joint; the contrast was aspirated, and 40 mg of Depomedrone and 5 ml of Bupivacaine injected
in all but two patients.
Results: In total, 14 patients (11 female and 3 male, average age
61.92 years) underwent 17 procedures (bilateral in 2, repeated in 1)
over a 35-month period. Aspiration yielded an average volume of
16.07 ml. In 3/17 patients, the communication with the knee joint
was demonstrated. Average follow-up was 11.7 months. Patients
VAS scores reduced from 5.7 to zero for an average duration of 5.96
months. After this period, patients reported a gradual return of an
ache, but none returned to the pre-procedural severity, which, in
some, had been enough to prevent them from sleeping.
Conclusion: Aspiration of symptomatic Bakers cysts under ultrasound and fluoroscopic guidance followed by therapeutic injection
of DepoMedrone and Bupivacaine leads to a durable reduction in
pain symptoms in the majority of patients.

P-83
Cryotherapy for fibroadipose vascular anomaly (FAVA)
N.Dasgupta, C.Guevara, M.D.Darcy
Division of Interventional Radiology, Mallinckrodt Institute of
Radiology, Washington University School of Medicine in St. Louis, St.
Louis, MO, United States of America
Purpose: Fibroadipose vascular anomaly (FAVA) is a recently
described entity. Previously, sclerotherapy was utilized to treat such
lesions. Cryoablation has recently been proposed as an alternative
treatment. The purpose of this study was to assess the safety and
efficacy of cryoablation for FAVA.
Material and methods: A retrospective review of all patients who
underwent sclerotherapy or cryoablation for the diagnosis of FAVA
at a single center was conducted. The diagnosis of FAVA was made
based on a combination of history, physical exam, and cross-sectional imaging.
Results: From 2006 to 2015, 3 patients (3 females aged 339 years)
underwent at least one cryotherapy each for a lesion, which was
eventually determined as a FAVA. The median length of follow-up
from initial treatment was 4 years and 3 months (range 18 years).
Following cryoablation, partial or complete response was observed
in 100% of the patients. No significant procedural complications
were identified.
Conclusion: Cryotherapy for FAVA is a novel therapy that is both
safe and effective.

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P-84
Top 10 spine-related pain clinical diagnoses: evidence-based
management algorithms, interventional procedures and
recommendations
H.Brat1, T.Bouziane2, D.Fournier1
1Radiology Department, Institut de Radiologie, Sion, Switzerland,
2Radiology Department, Centre Radiologique Prive du Tournaisis,
Tournai, Belgium
Learning Objectives: Evidence-based spine-related pain teaching
file aiming at:
1. Understanding management algorithms based on clinical
diagnoses
2. Learning current evidence and recommendations of diagnostic
and therapeutic interventions
3. Clarifying existing controversies
4. Updating major references.
Background: Spine-related pain treatments and level of evidence
have not matched very well in the last decades, due to a lack of wellconducted randomised comparative studies with sufficient patient
numbers. Publication of lethal accidents has led to prohibition of
particulate steroids, and a number of controversies have arisen
regarding the usefulness of pain treatments such as epidural steroid
infiltrations.
Material & Methods:
- Comprehensive systematic literature review (PubMed and
Cochrane Database) using adapted USPSTF (United States
Preventive Services Task Force) criteria
- Data published by ASIPP (American Society of Pain Physicians),
NASS (North American Pain Society) and ISIS (International Spine
Intervention Society)
- Reference books edited from 2012
Clinical Findings/Procedure: Each clinical spine-related pain
diagnosis is illustrated by the following:
- Management algorithms
- Current therapeutic interventions evidence and guidelines
- Controversies (when adequate)
- Major references
Top 10 spine-related pain clinical diagnoses:
1. Lumbosacral radicular pain
2. Discogenic low back pain
3. Lumbar facet joint pain
4. Sacroiliac joint pain
5. Coccygodynia
6. Meralgia paresthetica
7. Cluster headache
8. Occipital neuralgia
9. Cervical radicular pain
10. Cervical facet joint pain
Conclusion: Based on a comprehensive review of the literature
using the USPSTF (United States Preventive Service Task Force) analysis criteria, this educational poster presents an update of evidencebased management for the top 10 spine-related pain diagnoses.

P-85
To review different vertebral interventional techniques
R.S.Chivate, S.S.Kulkarni, N.S.Shetty, A.M.Polnaya, K.B.Gala,
S.Panbude
Interventional Radiology, Tata Memorial Hospital, Mumbai, India
Learning Objectives: Interventional radiological procedures offer
minimally invasive, safe and effective diagnostic/therapeutic options
to patients. These procedures include CT-guided biopsy, radiofrequency ablation, sclerotherapy, embolisation, vertebral body augmentation (vertebroplasty/kyphoplasty), etc.

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Background: Pre-operative assessment of vertebral lesion is done

with CT scan or MRI along with blood investigations. Most of these
procedures are done under local anesthesia. Radiofrequency ablation, trans-oral and -nasal approach for biopsy, and vertebroplasty
require general anesthesia. CT or fluoroscopic guidance is used.
Commonly used hardware are biopsy needles, RFA electrode, sclerosant (sodium tetradecyl sulphate (STD), polidocanol, or ethyl alcohol), embolization particles (polyvinyl alcohol, n-acetyl butyl cyanoacrylate glue, etc.), bone cement (polymethyl methacrylate), etc.
Clinical Findings/Procedure: Most common procedure done is
biopsy using Murphys bone biopsy and Ackerman needle. Lesions
in clivus, 1st and 2nd cervical vertebrae through trans-nasal and
trans-oral approach have been targeted. Radiofrequency ablation
of osteoblastoma was performed with technical success and good
clinical outcome. Epidural air and dextrose insufflation was done to
create barrier between spinal cord and RFA electrode. Preoperative
embolization of vertebral metastases as well as primary therapeutic
embolization of sacral giant cell tumors and hemangiomas are commonly done. Sclerotherapy for vertebral hemangioma is been performed. Vertebroplasty for patients with collapse of vertebral body
in cases of myeloma, metastases, and even traumatic fractures have
been effectively treated. Vertebroplasty of clivus and 2nd cervical
vertebra is also performed.
Conclusion: Vertebral interventional procedures offer minimally
invasive, safe, and effective diagnostic and therapeutic options and
have resulted in significant reduction in morbidity.

P-86
Vertebroplasty for cervical lesions
J.Chiras1, F.Clarenon1, E.Cormier2
1Service de Neuroradiologie, GH Piti Salptrire, Paris, France,
2Neuroradiologie Interventionnelle, GH Piti Salptrire, Paris, France
Learning Objectives: Utility of the use of bone filler devices in cases
of difficult vertebroplasty procedures.
Background: We present an original technique that reduces the
risk of leakage in difficult vertebroplasties. The conventional technique of vertebroplasty is a compromise between optimized filling
and risk of leakage, with clinical incidence, as at the end of filling, it is
necessary to wash out the dead space of the needle (1 ml). Injection
of cement through bone filler eliminates the dead space problem
and facilitates a more precise filling of the lesion.
Clinical Findings/Procedure: In all, 27 patients with a cervical
lytic lesion (24 metastases, 2 myelomas, and 1 aggressive angioma)
were treated by vertebroplasty using the bone filler technique (41
vertebrae). Adequate filling of the vertebra was obtained in 85% of
cases. No clinical complication occurred even in cases with posterior
wall disruption or fracture. In the population . All patients were discharged from the hospital at 24 hours. Clinical improvement at the
1-month follow-up was very high.
Conclusion: Vertebroplasty with a bone filler injection should be
recommended in difficult cases of vertebroplasty or cementoplasty
with high risk of dangerous leakage.

Abstract Book
extravasation, with a pseudoaneurysm involving the left L2 lumbar artery, which was successfully embolized with gelfoam and
microcoil.

P-88
Combination of embolization, cementoplasty, and
percutaneous screw fixation for major acetabular destruction
due to kidney cancer metastasis: mid-term outcome
X.Buy1, V.Catena1, M.Gross-Goupil2, J.Palussire1
1Department of Radiology, Institut Bergoni, Bordeaux, France,
2Department of Oncology, Institut Bergoni, Bordeaux, France
A 55-year-old patient presented with a massive renal cancer metastasis of the acetabulum. After transarterial embolization, four sessions of cementoplasty and percutaneous screw fixation to fuse the
cement blocks, in association with antiangiogenics, the patient was
able to run.

P-89
Percutaneous cryoablation of sclerotic metastasis of the
femoral diaphysis: a technical report
R.M.C.Freitas1, M.C.B.V.Fragoso2, B.B.Mendona2, A.M.Lerario2,
M.Q.Almeida2, J.E.B.Neto3, A.O.Hoff3, R.N.Sawaia4, L.A.Buendia4
1Radiology - ICESP, Universidade de Sao Paulo Medical School, Sao
Paulo, Brazil, 2Endocrinology, Universidade de Sao Paulo Medical
School, Sao Paulo, Brazil, 3Oncology, Universidade de Sao Paulo
Medical School, Sao Paulo, Brazil,4Orthopedics, Hospital Sao Camilo,
Sao Paulo, Brazil
A 42-year-old patient with a 4-cm painful sclerotic metastasis of the
femoral diaphysis was successfully treated by CT-guided cryoablation followed by internal fixation. Three angulated perforations from
the same cortical portal allowed one cryoprobe to cover the entire
lesion.

P-90
Combination therapy using denosumab and transarterial
embolization for symptomatic sacral giant cell tumor
R.Tani, T.Okada, T.Gentsu, N.Katayama, E.Ueshima, Y.Koide,
K.Sofue, M.Yamaguchi, K.Sugimoto
Department of Radiology and Center for Endovascular Therapy, Kobe
University Hospital, Kobe, Japan
We report a case of sacral giant cell tumor in a 60-year-old woman
complaining of progressive neurological rectum and bladder dysfunction, which was treated with denosumab and selective embolization with microspheres. Massive tumor shrinkage and rapid recovery from neurological dysfunction were achieved.

P-91
Hypogastric plexus block

P-87
Lumbar artery pseudoaneurysm embolization after vertebral
cryoablation and cementoplasty
S.Quarchioni, F.Bruno, F.Arrigoni, M.Varrassi, S.Carducci,
A.V.Giordano, C.Masciocchi
Department of Biotechnological and Applied Clinical Sciences,
University of LAquila, LAquila, Italy

F.L.Moreno, R.S.GonzalezToranzo, C.Villa, M.Caracoche,

F.J.SuarezAnzorenaRosasco
Diagnostic Imaging, Hospital de Clinicas Jose de San Martin, Buenos
Aires, Argentina
There are various techniques available for the treatment of chronic
pain. We introduced the hypogastric plexus block under CT guidance in two patients with intractable pain after abdominalperineal
surgery. We report a successful hypogastric plexus block.

A patient with metastasis from renal carcinoma at the L2 level was

treated with cryoablation. Five days later, CT revealed a retroperitoneal hematoma. Angiographic examination confirmed active

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Posters

P-92

P-94

Cement nonunion after percutaneous vertebral kyphoplasty:

treatment and discussion

Current trends in interventional radiology literature

F.Ahmed, M.Jesse
Radiology, University of Colorado, Aurora, CO, United States of America
Percutaneous kyphoplasty has been documented as a safe and
effective treatment for vertebral body fractures. Residual or recurrent pain after intervention is uncommonly associated with technical failure. We report 3 cases of cement nonunion as a cause for
treatment failure.

Clinical practice development

P-93
The role of pre-operative bilateral internal iliac artery balloon
occlusion in patients with abnormally invasive placenta
(accreta, increta, percreta)
I.S.AlSalmi1, M.AlHajeri1, T.AlRawahi1, A.Zutshi2,
H.A.AlGhaithi1, M.Madhavan2
1Radiology, Oman Medical Specialty Board, Muscat, Oman, 2Obstetrics
and Gynecology, Oman Medical Specialty Board, Muscat, Oman
Purpose: To evaluate outcomes of patients with abnormally invasive placenta undergoing caesarean section with and without preoperative bilateral internal iliac artery balloon occlusion.
Material and methods: Multicenter retrospective casecontrol
study of patients diagnosed with abnormally invasive placenta who
underwent caesarean section in the Royal Hospital, Sultan Qaboos
University Hospital, Khoula Hospital and Sohar Hospital from the
period between January 2011 and June 2015 with and without preoperative bilateral internal iliac artery balloon occlusion.
Records of 80 patients were retrospectively reviewed. In total, 37
patients had pre-operative bilateral internal iliac artery balloon
occlusion prior to caesarean section (study group) and 43 patients
underwent caesarean section without endovascular intervention
(control group). The two groups were compared in terms of age,
gravidity, parity, gestational age, estimated intra-operative blood
loss, blood units transfused, days of post-operative ICU admission,
total post-operative hospital stay, uterus preservation, adjacent
organ damage and complications. SPSS version 20 was used for data
analysis.
Results: There was a significant difference between study and control groups in the estimated amount of intra-operative blood loss
(mean 2218.9 mL: study group, 2990.2 mL: control group; P: 0.031),
the total units of packed RBC transfused (mean: 4.89: study group
and 5.37: control group; P: 0.023) and the post-operative hospital
stay (mean: 6.89: study group, 10.74: control group, P: 0.004).
Conclusion: Our study showed that bilateral internal iliac artery balloon occlusion is beneficial in reducing the amount of intraoperative
blood loss, total units of PRBC transfusion and post-operative hospital stay in patients with abnormally invasive placenta.

S209

A.Sidhu1, M.Syed2, R.Bashiti1, J.Liu3, L.Vance1, A.Bourgeois3

1Radiology, Michigan State University College of Human Medicine,
Southeast Michigan Campus, Southfield, MI, United States of America,
2Radiology, University of Tennesee School of Medicine, Knoxville, TN,
United States of America, 3Radiology, Medical University of South
Carolina, Charleston, SC, United States of America
Purpose: To review radiology literature over a 3-year period in order
to better understand current research trends.
Material and methods: A total of 7,588 abstracts published in
the highest impact diagnostic radiology (DR, n=10) and interventional radiology (IR, n=5) journals from July 2011 to June 2014 were
reviewed. Only scientific peer-reviewed manuscripts were included.
For IR journals, publications were categorized and trends analyzed
based on annual changes in percent representation of each category. Categories included peripheral arterial disease, interventional
oncology, biopsies, embolizations, vascular access, and preclinical
studies. For both the IR and DR literature, the percentage of articles
representing an investigation of patient safety and/or cost effectiveness were recorded and compared.
Results: Interventional oncology has steadily gained more representation in the IR literature, increasing from 10.7% to 22.6%
from 2011 to 2014. Embolization procedures increased from 9.4%
to 11.9% of total publications, due largely to increasing volume of
manuscripts regarding genitourinary procedures, namely prostate
artery embolization. Conversely, management of peripheral arterial disease, vascular access, and basic science research have experienced modest decreases in representation over this time period.
Manuscripts investigating topics of procedure quality, patient safety,
and/or cost effectiveness were represented more in the DR (4.2%)
than in the IR (1.2%) literature, largely due to their emphasis in the
Journal of the American College of Radiology.
Conclusion: Interventional oncology is the only manuscript category that has changed substantially in the last 3 years, now accounting for nearly one quarter of all new IR publications. Manuscripts
related to quality and patient safety are poorly represented in the
current IR literature.

P-95
Presurgical right portal vein embolization with Onyx: an initial
experience
J.Urbano1, A.Celdran2, V.Castellano3, M.Cabrera-Gnzalez1,
A.Alonso-Burgos1, S.Gonzlez-Ayora2, L.Paul-Ferrer1
1Vascular & Interventional Radiology, Fundacion Jimenez Diaz, Madrid,
Spain, 2Hepatobiliary Surgical Unit, Fundacion Jimenez Diaz, Madrid,
Spain, 3Pathology Department, Fundacion Jimenez Diaz, Madrid, Spain
Purpose: Portal vein (PV) embolization is performed to increase the
future liver remnant (FLR) before surgery in patients with liver malignancies. It is not yet clearly defined as to what is the most effective
embolic agent. Clinical, technical, and pathological preliminary data
of the portal filling with Onyx are presented.
Material and methods: From May 2012 to January 2016 PV embolization with onyx was performed in 10 women and 3 men with a
mean age of 59.4 years (3769). Ten had CCM a three colangioCa.
Average pre-embolization FLR was 21.3% (14%29%). Ipsilateral
approach was used in all cases. Right portal branches were catheterized with a 4-F cobra or simmons2 catheter. Coaxially, a DMSOcompatible microcatheter was advanced as distal as possible into
the portal branches and Onyx was injected from the most distal
branches, allowing reflux until portal vein was completely filled.
Overall, 24 ml of Onyx was used at an average (13.539 ml). Pre- and
post-portal pressure measurement was done.

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Results: Increase in FLR was obtained in all patients. Average postFLR was 33.4% (27%47%). Right hepatectomy was done in 11
patients, 48 weeks after embolization. In two patients, surgery
was not finally possible due to the general poor condition. Thirtyday post-surgical mortality occurred in 2 patients. Histopathological
examination showed Onyx filling portal venules, no signs of recanalization, and mild inflammatory reaction in the perivascular
parenchyma.
Conclusion: PV can be embolized with an injection of onyx, and a
good effect on contralateral hypertrophy can be obtained. In this
series, there were no Onyx-related complications.

P-96
Development of the steering microcatheter
Y.Inaba1, Y.Arai2, M.Sone2, T.Aramaki3, K.Osuga4
1Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital,
Nagoya, Japan, 2Department of Diagnostic Radiology, National
Cancer Center Hospital, Tokyo, Japan, 3Division of Interventional
Radiology, Shizuoka Cancer Center, Shizuoka, Japan, 4Diagnostic
and Interventional Radiology, Osaka University Graduate School of
Medicine, Suita, Osaka, Japan
Purpose: A microcatheter known as the steering microcatheter
equipped with a mechanism that enables the shifting of the direction of the catheter tip by remote operation has been developed by
Sumitomo Bakelite Co., Ltd. We evaluated this microcatheter based
on an animal study and clinical tests.
Material and methods: In the animal study that was conducted on
piglets by 5 operators, the time to insert the catheter into the arterial branches at designated sites, fluoroscopy time, amount of contrast agent used, and number of times guidewires were used were
compared between the developed microcatheter and existing commercial microcatheters. The artery into which the microcatheter was
inserted was excised, and the extent of vascular injury was observed.
In a clinical study comprising 20 patients from 4 hospitals, selective
arteriography of the target arterial branch was performed. The utility and safety were assessed through procedures.
Results: In the animal study, the steering microcatheter without the use of guidewires was compared with existing commercial
microcatheters. A reduction in the operating time was obtained,
and trends toward a reduction in the fluoroscopy time and contrast
agent use were observed. No damage to the inner vascular surface
was observed using either microcatheter.
In clinical tests, the insertion success rate in the target vessels without the use of a guidewire was 96.7%, and the steering microcatheter was judged to have good ease of use. No adverse events related
to the use of the steering microcatheter were observed.
Conclusion: These development studies confirmed the efficacy of
the steering microcatheter; this should take it closer to approval as
a medical device.

Abstract Book

P-97
Radiofrequency ablation combined with hypertonic saline
injection allows creation of coagulation zones similar to those
created by microwave ablation
R.Quesada1, A.Radosevic2, A.Agust2, J.Sanchez2, M.Trujillo3,
E.Berjano4, F.Burdo5
1Localized Hyperthermia Therapy, Cancer Research Group HBP,
Fundaci IMIM, Barcelona, Spain, 2Radiology, Parc de Salut Mar,
Barcelona, Spain, 3Matemtica Aplicada, Universidad Politcnica de
Valencia, Valencia, Spain, 4Biomedical Synergy, Electronic Engineering
Department, Universidad Politcnica de Valencia, Valencia, Spain,
5General Surgery, Parc de Salut Mar, Barcelona, Spain
Purpose: Tumor microwave ablation (MWA) allows the creation of
coagulation zones larger than those created by radiofrequency ablation (RFA) with internally cooled electrodes (IC). However, it is still
unknown whether IC electrodes combined with hypertonic saline
injection could create coagulation zones comparable with those created by MWA.
Material and methods: In the context of a randomized clinical trials comparing RFA and MWA for tumor treatment, we analyzed the
coagulation zones created with a single application (17 with RFA and
10 with MWA), i.e., overlapping and pullback cases were excluded.
RFA was conducted with an IC electrode combined with an injection
of two hypertonic (20% NaCl) saline boluses (pre- and intra-ablation). Maximum transversal diameter (b) and axial diameter (a) were
measured by CT. Ratio b/a and total delivered energy (TDE) were
also analyzed.
Results: No significant differences were observed in the coagulation zone dimensions: transversal diameters of 28.06.9 mm vs.
27.66.8 mm and axial diameters of 37.211.8 mm vs. 40.613.9
mm for RFA vs. MWA. Although no significant relationship between
TDE and these dimensions was found, TDE was almost double for
RFA (40.80.8 kJ vs. 19.98.6 kJ). Ratio b/a was also similar between
groups (0.8 and 0.7 for RFA and MWA, respectively). Mean ablation
time/nodule was also similar (4.00.8 min vs. 4.81.7 min for RFA vs.
MWA). No roll-off case was observed during RFA.
Conclusion: RFA conducted with IC combined with hypersaline
injection could create coagulation zones similar to those created by
MWA.

P-98
Monitoring liver function in patients undergoing transarterial
chemoembolization (TACE) by a 13C-breath test (LiMAx)
M.F.Schulze-Hagen, E.Barzakova, M.Zimmermann, M.Liebl,
F.Pedersoli, P.Isfort, C.Kuhl, P.Bruners
Department of Diagnostic and Interventional Radiology, RWTH Aachen
University Hospital, Aachen, Germany
Purpose: Transarterial chemoembolization (TACE) is associated with
the risk of deteriorating liver function, especially in patients with
pre-existing liver disease. The goal of this study was to investigate
whether it is possible to monitor the effects of TACE on liver function
by using a 13C-breath test (LiMAx). The long-term goal is to develop
a tool that helps predict the tolerance of transarterial treatment in
patients with potentially reduced functional liver reserve.
Material and methods: In the last 12 months, a total of 56 patients
underwent TACE at our institution. LiMax tests as well as routine liver
blood tests were performed on the day before/after and 4 weeks
after TACE. Results of the LiMax test were evaluated, referenced to
liver volume (CT-volumetry), and correlated with the respective
TACE approach (sub-segmental/segemental vs. lobar TACE) and with
serum liver chemistries.
Results: In total, 20/56 patients completed all tests; none of them
exhibited significant changes in liver-related serum chemistries. In

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contrast, there were significant changes in the LiMAx test. Averaged
across all patients, a significant postinterventional impairment of
liver function was revealed (18.2%; p=0.012). Patients with lobar
TACE had a more pronounced decrease based on the LiMAx liver
function (19.0%, p=0.037) than patients with (sub-)segmental TACE
(15.7%, p=0.126). After a period of 4 weeks, the LiMAx values recovered to baseline in all patients.
Conclusion: Monitoring of liver function before and after TACE
using the LiMAx test seems to be more sensitive for possible liver
damage than standard serum chemistry parameters. If results are
confirmed by further studies, we propose to use the LiMAx test for
treatment stratification in interventional oncology.

P-99
24/7 interventional radiology in a new acute hospital
R.Chung, A.Chawla, S.Babu
Department of Diagnostic Radiology, Khoo Teck Puat Hospital,
Singapore, Singapore
Purpose: This study aims to evaluate the frequency of use and
changing practices for all out-of-hours (OOH) interventional radiology (IR) procedures performed in a new acute hospital since inception. The implications for IR staffing levels and workflow pattern are
discussed.
Material and methods: A retrospective review of all OOH procedures performed by the Interventional Radiology team over a 5-year
period, from 2010 to 2015, was conducted. Cases were identified
by the hospital RIS database. Recorded parameters include caseload volume, category of procedures performed, and distribution of
workload through the week.
Results: Over the study period, from day 1 of hospital opening, a
total of 7140 procedures were performed by IR. Of these, 10.7% (764)
were started OOH. The absolute number of OOH cases performed
annually by IR has increased by 240% from year 1 to year 5, with a
rise in work performed over the weekends from 27.1% to 40.2%.
The variety of OOH work has shown a characteristic trend with rising requests for advanced procedures such as active hemorrhage
control.
Conclusion: There has been a consistent annual rising trend in
both number and complexity of IR OOH cases. Drainage procedures
remain the most common procedure performed, but abdominopelvic angiography and embolization procedures are increasing in frequency. The importance of having a sufficient number of trained
interventionalists to support a 24/7 rota is demonstrated, and provides a benchmark for future hospitals. To the authors knowledge,
this is the first available data of IR OOH workload for a new hospital
with trauma facilities.

P-100
Interventional radiology in marine animals: new horizons for
interventional radiologists and veterinarians
R.GarcaMarcos1, D.GarcaPrraga2, J.LenRafael2,
J.MartnezRodrigo1, F.M.Gmez3, J.L.CrespoPicazo2, L.MartBonmat1
1Radiology, La Fe Polytechnics and University Hospital, Valencia, Spain,
2Biology, Oceanografic, City of Arts and Sciences, Valencia, Spain,
3Radiology, Hospital Clinic, Barcelona, Spain
Purpose: Interventional radiology is a well-established specialty in
the clinical practice of human medicine.
There are advances in interventional procedures for pet animals, but
a poor knowledge on the interventional procedures for marine animals exists.
The knowledge of materials and techniques that interventional radiologists possess can form a powerful alliance when combined with

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S211

the clinical experience of the veterinary staff. It provides advantages

over the standard surgical or diagnostic techniques. It may lead to a
decrease in death rates, minimize anesthesia time, and improve the
quality of life of animals.
Material and methods: Several techniques have been developed
to facilitate artificial insemination in belugas.
In dolphins, the techniques used were hysterosalpingography
and uterine lavage using endoscopic guidance for reproductive
purposes.
A Port-a-Cath was inserted in a loggerhead turtle under anesthesia
for parenteral nutrition. Radiofrequency ablation of the thyroid was
performed in a shark.
Results: The knowledge on the use of human interventional materials among veterinarians and the possibility of applying it to the nonconventional species can minimize the risk of diagnostic or therapeutic techniques and also serve as a support in addition to other
complementary therapies such as assisted reproduction techniques.
Conclusion: We believe that this is a rich field for radiologists and
veterinarians who must learn to work in concert to ensure best
results.
Lack of knowledge regarding many marine species provides great
possibilities for scientific development.
New studies are required in order to support the effectiveness and
safety of these techniques to improve knowledge on these species
and help preserve them.

P-101
Sole use of dexmedetomidine for sedation and analgesia
in patients undergoing endovenous thermal ablation for
incompetent saphenous veins: a prospective observational
study
J.H.Hwang, S.W.Park, I.S.Chang
Radiology, Konkuk University School of Medicine, Seoul, Korea
Purpose: To evaluate the safety and effectiveness of sedation and
analgesia using dexmedetomidine for the treatment of varicose
veins.
Material and methods: This study included 148 cases of thermal
ablation in 88 patients (M = 38, F = 50; mean age, 48.7 years). Case
assessment included peripheral oxygen saturation, mean blood
pressure, heart rate and respiratory rate, and evaluation of the
induction and recovery time. The patients experience was recorded
by using a 10-point visual scale after the procedure. Adverse events
associated with sedation/analgesia were also recorded.
Results: The mean induction time was 18.2 minutes. The mean
visual analog scale pain score during the procedure was 2.3 2.
Maximum pain scores of 4 (discomforting) or less were recorded in
66 (78.4%) patients. Six (6.8%) patients complained of pain scores in
excess of 7. Mean blood pressure and heart rate drop between 0 and
15 minutes were 18.2/9.3 mmHg and 13.5 beats/min, respectively.
Three (3.4%) patients required cessation of infusion due to significant drops of blood pressure or heart rate. There was no hypoxic or
resuscitation event during the procedures.
Conclusion: We believe that dexmedetomidine can provide excellent sedative and analgesic effect during endovenous thermal
ablation.

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P-102

P-104

Radiofrequency ablation for uncontrolled hepatic

echinococcosis despite initial surgery and puncture,
aspiration, injection, and reaspiration (PAIR)

Development of micro-balloon catheter as a game-changing

tool: for what and how can we use it?
K.Yamada1, M.Yamamoto1, M.Horikawa2, H.Shinmoto1, T.Kaji1
1Radiology, National Defense Medical College, Tokorozawa, Japan,
2Dotter Interventional Institute, Oregon Health & Science University,
Portland, OR, United States of America

Y.S. Jeon
Interventional Radiology, Integrative Cancer Center, G-SAM Hospital,
Gunpo-si, Gyeonggi-do, Korea
Purpose: To show feasibility, safety, and clinical efficacy of radiofrequency ablation (RFA) for uncontrolled cystic echinococcosis after
first-line treatment, including surgery or puncture, aspiration, injection, and reaspiration (PAIR).
Material and methods: Patients with uncontrolled hepatic echinococcosis, despite initial surgical resection and PAIR were selected
and gave informed consent for RFA.
CT scan and ultrasonography were performed on admission for
evaluating the extent and WHO classification of cystic echinococcosis cysts.
RFA was performed using Cool-tip system (Covidien, Mansfield,
Massachusetts, USA) under ultrasound guidance.
Follow-up CT scans were performed to determine response to
treatment.
Results: After a median follow-up of 33 months, CT scan showed
overall improvement of ablated echinococcosis cysts without disease progression and significant complications.
Conclusion: Radiofrequency ablation is a relatively safe and effective treatment for hepatic echinococcosis.
And it can be a promising treatment option, especially for multivesicular or uncontrolled cystic echinococcosis.

P-103
Variables decreasing tip movement of peripherally inserted
central catheters (PICCs) in pediatric patients
R.Gnannt1, B.Connolly1, D.A.Parra1, J.Amaral1, R.Moineddin2,
A.Thakor1
1Image Guided Therapy, The Hospital for Sick Children, Toronto, ON,
Canada, 2Family and Community Medicine, University of Toronto,
Toronto, ON, Canada
Purpose: The position of the tip of a PICC is crucial; malposition can
lead to malfunctioning of the line or life threatening events (e.g.,
arrhythmias and perforation). The hypothesis of this study was that
arm positioning and vein accessed are not the only factors influencing the tip position of a PICC line.
Material and methods: Inclusion criteria were upper limb PICC
placement, body weight <20 kg, intraoperative imaging with the
arm in 0, 45, and 90 abduction, and an arm view marking the skin
entry site relative to the shoulder. Variables evaluated included
patient demographics, PICC characteristics, and insertion site characteristics. Central tip movement was measured in rib spaces with a
positive value that indicated tip descent deeper into the SVC and a
negative value that indicated tip upward ascent.
Results: In total, 112 pediatric patients who received PICCs were
included in our study (42 females, mean age = 3113 months,
mean weight = 6.54.9 kg). The overall range of central tip movement was -1 to +4 rib spaces (mean = +0.80.7 rib spaces). Silicone
PICCs moved significantly less than polyurethane PICCs (P<0.05).
Cephalic vein accessed PICCs moved significantly less than other
veins (P<0.05). Patient demographics and other PICC characteristics
did not influence the range of the central tip movement of a PICC
(P>0.05).
Conclusion: These findings show that silicone PICCs and PICCs
inserted into the cephalic vein move less than PICCs inserted into
the brachial or basilic vein or PICCs made of polyurethane. These
findings may assist the operators in deciding which PICC to place in
pediatric patients in a given clinical context.

Learning Objectives:
1. To understand the characteristics and benefits of embolotherapy
using a micro-balloon catheter compared to that without a microballoon.
2. To deepen the knowledge on how to perform the typical IR
procedure using a micro-balloon catheter.
Background: The micro-balloon occlusion catheter has been developed and used in Japan over the past decade, and is now becoming a new choice of device for embolization therapy in Europe. It can
be used as much like a microcatheter and can select small vessels,
which cannot be selected by using the conventional balloon occlusion catheter. In recent years, by introducing the micro-balloon catheter for typical IR procedures, such as transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC), transarterial embolization with histoacryl glue or coil, and balloon-occluded retrograde
transvenous obliteration (BRTO) for the gastric varices, the procedure details and therapeutic effects of these procedures have drastically changed.
Clinical Findings/Procedure: This presentation shows the following IR procedures using a micro-balloon, focusing on their advantages and differences from the conventional method without a
micro-balloon:
1. Balloon-occluded TACE for HCC
2. Balloon-occluded glue injection technique
3. Micro-balloon anchored coil embolization technique
4. Super-selective BRTO with micro-balloon and triaxial microcatheter (slender BRTO)
Conclusion: The micro-balloon catheter enhances the efficacy of
embolization. It also expands the range of options for IR. It might be
a game-changing device in embolization therapy.

P-105
NCI cancer center designation: implications for interventional
radiologists
R.Schwind1, R.C.Gaba2, L.Rund2, L.Schook 2, C.E.Ray, Jr.2
1Cancer Center, University of Illinois Medical College, Chicago, IL, United
States of America, 2Radiology, University of Illinois, Chicago, IL, United
States of America
Learning Objectives:
1. Recognize the NCI designations for cancer centers and the differences between each type of center.
2. Understand the requirements for institutions to obtain NCI cancer
center designation.
3. Understand the opportunities for IRs to help institutions obtain
NCI cancer center designation, and specific advantages to
working at NCI cancer centers.
Background: The National Cancer Institute (NCI) is an agency of the
National Institutes of Health (NIH). Although the NCI supports its
own intramural research programs, the majority of its budget goes
towards funding extramural research.
Clinical Findings/Procedure: The NIH designates institutions as
centers of excellence in three tiers: comprehensive cancer centers, clinical cancer centers, and basic laboratory cancer centers.
Comprehensive cancer centers provide diagnostic and therapeutic opportunities for patients and also conduct early phase and NCI
cooperative group clinical trials; conduct laboratory based research;

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provide outreach and education to the community catchment area;
and disseminate scientific advancements to providers and the general public. There are six essential characteristics that the NCI judges
prior to designating a center: cancer focus; center director; institutional commitment; transdisciplinary collaboration; facilities; and
organizational capabilities. IRs play a role in fulfilling all of these
requirements, particularly with regard to cancer transdisciplinary
collaboration. Extramural grant mechanisms through the NCI provide numerous opportunities for IR-centric basic, translational, and
clinical research.
Conclusion: As IR continues to expand into oncology, familiarity
with NCI designations and funding mechanisms will provide opportunities for IRs to become involved with the pursuit of NCI designation for their institutions, as well as funding of collaborative and
translational research.

P-106
What to expect if you are setting up an out-of-hours
interventional radiology service: lessons from Glasgow
M.Hennessy, I.Robertson
Interventional Radiology, Queen Elizabeth University Hospital,
Glasgow, United Kingdom
Learning Objectives: A robust out of hours interventional radiology (IR) service is an essential component of healthcare for any
large centre or region. Emergency haemorrhage control is the most
important service that can be offered but a wide range of procedures will be performed and, if planning a service, this should be
considered. It is important to know when out of hours procedures
are likely to occur as this may impact on plans for an extended working day.
Background: Glasgow has a mature IR out-of-hours service: it was
one of the UKs first, with the aim to provide cover for haemorrhagic
emergencies. Other procedures, largely sepsis related, can also present as emergencies. Because the service has matured, it has been
recognised that other procedures are also better performed out of
hours rather than waiting until the next day.
Clinical Findings/Procedure: Three procedure groups, haemorrhage control, nephrostomy and abscess drainage, dominate,
though they are more often performed by diagnostic radiologists.
High level procedures such as EVAR, TEVAR and TIPSS are infrequently performed out of hours. The weekend is the busiest time for
performing out-of-hours procedures, with procedures before 5 pm
being more common than those after 5 pm.
Conclusion: An out-of-hours IR service should expect to predominantly perform haemorrhage control and nephrostomy as well as fill
any gaps in the abscess drainage skills of the diagnostic radiologists.
It is less common to perform specialised procedures out of hours.
Weekends are the busiest time; this would impact on routine working hours being extended to the weekend.

P-107
Safe and effective sedation practice in interventional
radiology: current trends and challenges
A.Khankan1, S.Alshehri1, M.Arabi1, T.Al-Hazmi2, M.Almoaiqel1
1Medical Imaging, King Abdulaziz Medical City, Riyadh, Saudi Arabia,
2Radiology, Umm Al-Qura University, Makkah, Saudi Arabia
Learning Objectives:
1. To review the current trends and challenges in sedation practice
related to increasing and optimizing use of some pharmacologic
agents such as ketamine outside the field of anesthesiology.
2. To show our institutional programs and processes for providing
safe and effective sedation for interventional procedures by interventional radiology staff.

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Background: Given the expanding in the interventional procedures

performed under sedation, the demand for providing sedation by
interventional radiologists has increased. Many guidelines have
been published to assist the interventional radiologist in providing
proper sedation. However, it is still difficult to determine optimal
sedation practices, especially with the emerging new agents with its
advantages for use in procedural sedation.
Through the institutional sedation committee under the anesthesiology leadership, the interventional radiologist should have both
knowledge and skills and understand the rules and regulations
regarding providing proper sedation.
Clinical Findings/Procedure: The poster will discuss the current
trends and challenges related to sedation for interventional radiology procedures, with focus on the following:
1. Available and new sedative agents
2. Current trends and challenges in providing sedation
3. Developing educational programs and related credentialing
process
4. Our academic institutional model and experience
5. Future directions
Conclusion: Providing safe, effective, and efficient procedural sedation are necessary skills for interventional radiologists. Due to the
expansion in interventional procedures and growing interest in new
agents, the sedation providers should be prepared to ensure that
patient safety always remains the top priority. Successful outcomes
depend on having a well-trained team and good practice respecting
the institutional policy and guidelines developed under the direction of the anesthesiology department.

P-108
The environmental impact of interventional radiology
M.P.Bolger, M.K.OReilly, G.Sugrue, L.P.Lawler
Department of Radiology, Mater Misericordiae University Hospital,
Dublin, Ireland
Learning Objectives: The purpose of this study was to assess
the carbon footprint (kgCO2) of packaging materials in routine IR
practice, inform colleagues and to identify methods to increase
recycling.
Background: As highlighted by the Paris Climate Change
Convention (COP21)-2015, global warming is accepted as a fundamental humanitarian priority for our planet. Carbon-footprinting is
a common tool used to estimate ones contribution to greenhouse
gas (GHG) emission. We believe health systems, as significant contributors to GHG, must play their part in addressing this issue. In routine IR practice, there is potential to significantly decrease waste and
increase recyclable materials, particularly in packaging, by adopting
procedure change.
Clinical Findings/Procedure: This was a component analysis study
adhering to PAS2050, an internationally applicable method for
quantifying product carbon footprints. We assessed and compiled
the estimated GHG emissions from peripherally inserted central
venous catheter (PICC) insertions. The sources of emissions included
waste/landfill/incineration, production, energy use and laundry.
Emissions were calculated using Defra/DECCs Paper for Emissions
Factor. We identified changes in practice to maximise recycling and
projected CO2savings for wider practice.
PICC insertion produced on average 41.5 kg of CO2 emissions per
procedure. We performed 501 PICC in our institution last year, equating to 20.79 tonnes of CO2emissions. The average recyclable material salvageable for this procedure is 35% by careful patient and
operating suite preparation.
Conclusion: IR procedures have the potential to generate significant GHG emissions. By careful attention to patient and operating
suite preparation, the weight of recyclable packaging can be optimised, leading to very significant changes in local CO2generation.

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P-109
Inital experience of embolization for renal AVM with 4D DSA
H.Ashida, K.Enoki
Radiology, Jikei Medical University Hospital, Tokyo, Japan
Recently, 4D DSA was developed for the treatment of brain AVMs.
We applied this technique for the treatment of renal AVMs and successfully treated 3 cases with previous assessment of feeding vessels, internal architecture, and draining vessels.

P-110

Abstract Book
p<0.0001). Catheter-related bloodstream infections as well as thrombotic complications occurred significantly more frequently with
polyurethane catheters, while silicone catheters exhibited a trend
towards a higher rate of mechanical failure such as disconnection
or catheter rupture. Major complications requiring explantation of
the device occurred more frequently with polyurethane-based catheters (10.6%) than with silicone catheter-carrying ports (4.6%, logrank test p<0.001).
Conclusion: Polyurethane catheters are more susceptible to catheter-related infections and exhibit a higher thrombogenicity than silicone catheters. Silicone catheters instead exhibit a trend towards
decreased mechanical stability.

Successful endovascular obliteration with a micro-balloon

catheter: 2 case reports

P-113

N. Ito
Radiology, Tokyo Medical Center, Tokyo, Japan

Dysfunctional hemodialysis arteriovenous fistula: correlation

between physical examination, dialysis flow measurements,
duplex ultrasound, and digital subtraction angiography

A micro-balloon catheter, which has been recently launched globally, allows more complicated retrograde endovascular obliteration.
To demonstrate its utility, we report 2 cases successfully treated with
this device: a pulmonary artery aneurysm caused by tuberculosis
and a rectal varix.

J.A.CamachoOviedo, J.M.Abadal, E.GlvezGonzalez, M.J.Alvarez

Radiology, Hospital Universitario Severo Ochoa, Madrid, Spain

P-111
Splenic cyst radiofrequency ablation: a case report
D.K.Filippiadis, S.Grigoriadis, L.Reppas, A.Mazioti, E.Brountzos,
N.L.Kelekis, A.D.Kelekis
2nd Radiology Department, University General Hospital Attikon,
Athens, Greece
A 22-year-old female patient underwent CT-guided radiofrequency
ablation of a 9-cm splenic cyst with an electrode specifically designed for cyst drainage and ablation. At the 6-month follow-up, the
cyst was reduced in size by 80%.

Dialysis intervention and venous access

P-112
Polyurethane versus silicone catheters for central venous port
devices implanted at the forearm
M.Wildgruber1, C.Lueg1, S.Borgmeyer1, R.Meier2, M.Koehler3,
J.Ettl4, H.Berger1
1Division of Interventional Radiology, TU Mnchen, Munich, Germany,
2Department of Diagnostic and Interventional Radiology, Universitt
Ulm, Ulm, Germany, 3Department of Clinical Radiology, Universitt
Mnster, Mnster, Germany, 4Department of Gynecology, TU Mnchen,
Munich, Germany
Purpose: To analyze short- and long-term complications of polyurethane versus silicone catheters used in totally implantable venousaccess ports (TIVAPs) implanted at the forearm.
Material and methods: Retrospective analysis of 698 consecutively
implanted TIVAPs was performed. Primary endpoints were defined
as rates of major complications associated with either type of central
venous port catheter. Technical success rate, device service interval
as well as minor complications not requiring port explantation were
defined as secondary endpoints.
Results: In total, 698 port devices were implanted in 681 patients:
396 equipped with a polyurethane catheter and 302 with a silicone
catheter. The technical success rate was 99.9% with no major periprocedural complications. During follow-up, a total of 211 complications in 146 patients were observed (1.0/1000 catheter days): 183
were associated with polyurethane catheters (1.8/100 catheter days)
and 28 (0.3/1000 catheter days) with silicone catheters (log-rank test

Purpose: The aim of the study is to compare physical examination

and hemodynamic-dialysis (HD) parameters with duplex ultrasound
(DUS) and digital-subtraction angiography (DSA) in patients with
suspected failure of mature AVF.
Material and methods: A prospective study was conducted with 30
consecutive patients (20132015).
Inclusion criteria: patients with end-stage renal disease undergoing hemodialysis and initial clinical diagnosis of AVF dysfunction.
Nineteen patients had native fistulas and 11 grafts.
Physical examination included auscultation of a high-pitched abnormal thrill, arm swelling, difficulty in cannulation at dialysis, and prolonged bleeding at puncture sites. HD parameters were access flow,
venous pressure, arterial pressure, and recirculation. DUS parameters included flow volume, diameter reduction, and maximum peak
systolic velocity. DSA parameters were luminal stenoses >50% quantified by diameter.
DSA was considered as the gold standard, with the exception of
two patients with contrast allergy (in these two cases the gold standard was DUS).
Results: Physical examination and hemodynamic dialysis parameters correlated with the diagnosis significant stenoses in DSA in 76%
of the patients. In 2 cases of contrast allergy, DUS revealed significant stenoses.
Congruence of results between DUS and DSA occurred in 96% of the
patients. DUS hemodynamic flow quantification correlated in 83%
of the patients with dialysis flow. Best Dopplers parameter for the
detection of a stenosis was the peak systolic velocity.
Conclusion: Dysfunctional AVF diagnosis cannot rely only on physical examination and HD parameters. DUS can be considered to be
an excellent non-invasive test to diagnose AVF dysfunction with
accuracy similar to DSA.

P-114
Comparison of sedoanalgesia versus ultrasound-guided
supraclavicular brachial plexus block for analgesia during
treatment of failed hemodialysis fistulas by interventional
radiology
M.Gedikoglu1, C.Andic1, I.Guzelmansur2, H.E.Eker3, C.Bolgen1
1Radiology, Baskent University School of Medicine, Adana, Turkey,
2Radiology, Mozaik Hospital, Hatay, Turkey, 3Anaesthesiology, Baskent
University School of Medicine, Adana, Turkey
Purpose: Although intravenous sedation and analgesia have been
widely used as a first choice to relieve pain during treatment of failed
hemodialysis fistulas by interventional radiology, the sedoanalgesic

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drugs have a considerable risk of respiratory depression, especially
among dialysis patients. In this study, we compared the utility and
effectiveness of ultrasound-guided supraclavicular brachial plexus
block versus sedoanalgesia in the prevention of pain during treatment of failed hemodialysis fistulas.
Material and methods: Sixty-eight consecutive patients were
enrolled in this prospective study and were randomly divided into
two equal groups: one had sedoanalgesia, and the other had ultrasound-guided supraclavicular brachial plexus block for analgesia during treatment of failed hemodialysis fistulas. A visual analog scale from no pain (0) to worst pain imaginable (10) was used to
assess pain intensity. Patient satisfaction and operator satisfaction
were also recorded immediately after the treatment procedure. Both
groups were compared in terms of pain scores, patient satisfaction,
and operator satisfaction.
Results: Satisfactory regional analgesia was achieved in all patients
in the block group without a need for supplemental intravenous
analgesia. The median pain score was significantly lower for this
group than that for the sedoanalgesia group [0 (0-4) vs 6 (2-10),
P=0.0001]. Patient satisfaction and operator satisfaction were significantly higher in the block group than in the sedoanalgesia group
(P=0.0001). Oxygen desaturation occurred in 5 patients following
administration of sedoanalgesia. No side effects or complications
related to the block procedure occurred in any patient.
Conclusion: Ultrasound-guided supraclavicular brachial plexus
block has advantages over sedoanalgesia. It can provide effective
analgesia with excellent patient and operator satisfaction.

P-115
Patients with thrombocytopenia requiring venous access
devices: re-evaluating the platelet threshold guidelines
B.Patel, J.Tirado, P.Lombardi, M.Al-Roubaie, C.Greben
Radiology, North Shore University, Manhasset, NY, United States of
America
Purpose: Venous access devices are commonly inserted for treatment in a wide variety of patients. Although these interventional
procedures carry a low-to-moderate risk of bleeding, patients with
thrombocytopenia, such as those with hematologic/oncologic disorders, are more prone to complications. Current guidelines for
patients with thrombocytopenia requiring these procedures recommend a minimum platelet count of 50,000/uL. The purpose of our
study is to investigate and propose a lower threshold than currently
recommended, without compromising safety.
Material and methods: We conducted a retrospective analysis
of the interventional radiology procedure log for PICC, central line
and mediport placements during a specific 3-month period over 4
years. Along with the blood bank, we implemented a new algorithm
for patients undergoing venous access device placement. This protocol lowered the threshold to 30,00040,000/uL for dialysis catheters, 20,000/uL for PICCs and triple lumen catheters, and 40,000/uL
for mediports.
Results: The charts of 46 patients were reviewed. The median platelet count for these patients was 27.0 (25th percentile:18.0, 75th percentile:34.0); the mean was 27.6 (standard deviation:11.2). Two of
the 46 patients suffered a complication (4.35%). Both cases involved
minor access site bleeding, resolved by pressure application.
Conclusion: In our experience, venous access device placement in
patients with thrombocytopenia was safely achieved using platelet count guidelines that were lower than those currently recommended. This significantly reduced the cost and utilization of blood
products. Our study suggests that the widely accepted threshold for
placement of venous access devices can safely be lowered.

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P-116
Initial experience of revascularization of occluded
arteriovenous fistulas (AVF) with a thromboectomy device
(ASPIREX)
M.A.Al-Toki, M.Almoaiqel, N.Guzaia
Medical Imaging, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Purpose: To evaluate the effectiveness and safety of the mechanical
thrombectomy device (ASPIREX) in the treatment of the acute AVF
occlusion.
Material and methods: Between May 2014 to May 2015, 13 patients
(6 female and 7 male), aged between 1785 years, with acute (<14
days) brachiocephalic AVF occlusions were treated using a thrombectomy device (ASPIREX).
Thrombectomy was performed using 9F ASPIREX in 9 patients and
6F ASPIREX in 4 patients. Adjunctive treatment with balloon angioplasty was needed in all patients, r-TPA was needed in 6 patients and
an additional thrombectomy device (Cleaner, Argon) was needed in
9 patients.
Results: Technical success, defined as the recanalization of the
occluded fistula, was achieved in 92% (12 patients). Clinical success, defined as resuming dialysis using the fistula within the next 3
days, was achieved in 92% (12 patients). One patient developed arterial occlusion that required surgical embolectomy. Three patients
developed minor venous perforation and extravasation, which were
treated conservatively; no compartment syndrome was observed.
No patient developed pulmonary embolism.
Primary patency rate was 90% (11/12) after 6 months and 66% (8/12)
after 1 year.
Conclusion: Percutaneous mechanical thrombectomy with ASPIREX
catheter may represent a feasible treatment for acute AV fistula
occlusion.

P-117
Combination of endovascular techniques for treatment of
thrombosed hemodialysis grafts: 6-year experience
L.Paul-Ferrer, D.GomezCampos, M.Cabrera-Gnzalez, A.AlonsoBurgos, J.Urbano
Vascular & Interventional Radiology, Fundacion Jimenez Diaz, Madrid,
Spain
Purpose: The aim of this study is to show the experience in percutaneous haemodialysis-occluded grafts repermeabilization with combination of PTA, antegrade Arrow-Teretola device, and retrograde
balloon inflation from femoral vein access.
Material and methods: Seventy-five declotting procedures in brachioaxillary grafts performed between January 2010 and January
2016 in 44 patients were analysed. Technique has 3 steps. First, the
clotted graft was punctured as proximal as possible to the A-V anastomosis; from this approach, a PTA of graft-venous anastomosis was
done. Second, an antegrade mechanic thrombectomy macerating
as well as stripping clot from the graft wall, assisted by 6F ArrowTrerotola device, was performed. When the graft was clean, except
for the thrombus plug that remained occluding the A-V anastomosis, a retrograde approach from CFV is used to advance a 6x20-mm
PTA balloon into the humeral artery. Then, the balloon was inflated
at 12 atmospheres and pulled back along the entire graft. No anticoagulant or thrombolytics were used.
Results: Mean primary graft life was 26.7 months (282 months).
Mean time since the graft thrombosis was 43.2 hours. Success, consisting on immediate declotting and dialysis through the graft,
was 97.1%. Mean of 1.7 thrombectomies per patient (1-5) were performed. Mean primary patency was 6.8 months. Three complications
were reported: one access infection, one humeral artery thrombosis,
and one vein-graft anastomosis perforation. No symptomatic PE or
other major complications took place.

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Conclusion: In this cohort, a combination of percutaneous techniques for graft declotting achieved a high repermeabilization rate
with a low complication rate.

P-118
Comparing success of percutaneous declotting of thrombosed
arteriovenous fistulae (AVF) and arteriovenous graft (AVG): a
retrospective review
H.Shi1, N.K.K.Venkatanarasimha2, K.Damodharan1, A.Gogna2,
S.Leong1, T.A.J.Urlings1, C.W.Too1, F.G.Irani1, A.Patel1, J.M.Chan2,
H.G.R.Lo2, K.-H.Tay1, B.S.Tan1
1DDR, SGH, Singapore, Singapore, 2Diagnostics Radiology, Singapore
General Hospital, Singapore, Singapore
Purpose: The incidence of end-stage renal failure (ESRF) is high in
Singapore. Locally, hemodialysis is the mainstay treatment, with
arteriovenous fistulae (AVF) followed by arteriovenous grafts (AVG)
as the preferred mode of access. One of the main complications is
access failure secondary to thrombosis. Traditionally, AVF thrombosis is surgically treated while AVG thrombosis is percutaneously
declotted; however, there are no comparative data to support this
practice. We aim compare the treatment outcomes between percutaneously declotted AVG and AVF.
Material and methods: This is a single-center, retrospective review
of ESRF patients who underwent at least one percutaneous declotting of a thrombosed AVG or AVF between 2007 and 2012. The outcomes were accessed in terms of primary patency (intervention-free
access survival), assisted primary patency (thrombosis-free access
survival), and secondary patency (access survival until abandonment or surgical intervention).
Results: There were a total of 291 patients, 148 (i.e., 50.9%) of
whom had AVF. Onset of access thrombosis is highly variable, with
a median survival of around 630 days; however, AVF lasted longer
than AVG, with respective medians of 757 and 469 days (p<0.01).
Primary, primary assisted, and secondary patencies of the AVF and
AVG groups are 178 days versus 149 days (p=0.46), 217 days versus 163 days (p=0.83) and 119 days versus 167.5 days (p=0.04),
respectively.
Conclusion: Although percutaneous declotting seems to produce
better primary and primary assisted patencies in patients with AVF
thrombosis, results are not statistically significant. The only statistically different outcome parameter is that of secondary outcome, in
which percutaneously declotted AVG do better than AVF.

P-119
Sharp recanalization of chronic total benign occlusions of the
superior vena cava at the cavoatrial junction: feasibility of the
endovascular SVC conduit
M.Arabi, S.Alammari, S.Alshehri
Medical Imaging, King Abdulaziz Medical City, Riyadh, Saudi Arabia

Abstract Book
port catheter was adjusted into the atrium and remained functional. Dialysis catheter was inserted in the remaining two patients.
No acute periprocedural complications were observed. One patient
died 2 weeks later because of unrelated comorbidities.
Conclusion: The sharp needle-assisted recanalization of the infraazygos chronic total benign occlusions with endovascular creation
of SVC conduit is technically feasible. Safety of this technique is yet
to be confirmed by a larger cohort of patients.

P-120
AngioJet thrombectomy of thrombosed hemodialysis fistulas
M.E.PerezMontilla, S.LombardoGalera, J.J.EspejoHerrero,
J.GarciaRevillo, L.J.ZureraTendero
Radiologia Intervencionista, Hospital Universitario Reina Sofa,
Cordoba, Spain
Purpose: Durable vascular access is a major determinant of longterm survival for patients undergoing hemodialysis.
The aim of this study was to report our initial experience of the
immediate success, complications, follow-up, and patency for
AngioJet thrombectomy of thrombosed hemodialysis fistulas and
grafts.
Material and methods: At our center, 15 patients had been treated
for thrombosed hemodialysis fistula from December 2014 to January
2016. This included hemodialysis fistulas or grafts with acute thrombosis between 24-96 hours, treated using AngioJet thrombectomy
system.
Data collected were patient demographics, procedural details, and
procedural outcomes. All patients were followed up at their respective hemodialysis unit. Follow-up and patency data were obtained
by review of the hospital and dialysis records.
Results: Fifteen patients were treated (mean age 69.86 years),
including 12 men and 3 women. Twelve patients required native
hemodialysis fistulas and 3 required PTFE grafts.
In all the procedures, angioplasty was required to dilate stenosis;
other adjunctive procedures were percutaneous thromboaspiration
(n=2, 13.32%) and stent placement (n=6, 39.96%). Pharmacological
thrombolysis was not used.
Procedural technical success was reported in 14/15 patients (93.33%)
and clinical success in 13/15 (86.66%). The mean time of follow-up
was 5 months (15 days-14 months). Three patients died during follow-up; none of the deaths were considered to be related to the
AngioJet or procedure. Eleven fistulas (73.26%) are still used for
hemodyalisis. Nine patients without intervention, 1 fistula rethrombosed (retreated with thrombectomy) and other restenosed (treated
with angioplasty).
Conclusion: Percutaneous thrombectomy using the AngioJet system is effective for the salvage of thrombosed hemodialysis fistulas
or grafts.

P-121

Purpose: To describe the techniques for the sharp needle-assisted

recanalization of chronic total benign occlusions of SVC at the
cavoatrial junction.
Material and methods: Between April 2015 and January 2016, 5
patients (3 females) with mean age 38.6 years (1560 years) underwent the needle-assisted recanalization of the infra-azygos SVC followed by covered stent placement. Patients had dysfunctional dialysis fistula (n=2), dysfunctional infusion port (n=1), and dysfunctional
dialysis catheters (n=2).
Right atrial puncture toward SVC was done using a trans-septal needle (n=3) and Outback re-entry device (n=1) and direct trans-mediastinal atrial puncture was done using Chiba needle (n=1).
Results: Technical success was achieved in all patients, and dialysis
fistula function was restored in both patients. The tip of the infusion

Do right arm PICC lines have fewer complications than left arm
PICC lines? A randomised controlled trial
R.Lindsay1, F.Paquet2, L.-M.N.J.Boucher1, M.Renzullo1,
D.A.Valenti1
1Radiology, McGill University, Montreal, QC, Canada, 2Transition, McGill
University Health Center, Montreal, QC, Canada
Purpose: To validate the hypothesis that right arm PICC insertions
have fewer complications in adults.
Material and methods: Adult patients in a tertiary care university
hospital with no prior history of central venous access were randomized to left or right arm PICC insertion.
All patients were followed until catheter removal.

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Data including PICC and insertion characteristics, gender, history of
malignancy, reason for insertion/removal, need for reinsertion, presence of a complication, dwell time, discharge from hospital with
catheter in situ, and dominant arm were collected.
One-sided hypothesis testing was done, and logistic regression was
used to calculate adjusted two-sided odds ratios and their 95% confidence intervals and p-values.
Catheter size, dominant arm, history of malignancy, and dwell time
were inserted into the regression model to control for their effects.
Results: Between September 2012 and September 2015, 202
patients were recruited and completed the study, totaling 7657
catheter days (left-sided insertion: 99 patients, 3828 catheter days).
Incidence of one or more complications occurred in 34% of the leftsided insertions and 23% of the right-sided insertions.
There were significantly fewer complications in the right arm
(p=0.031).
The risk of having a complication was reduced by almost half with
right-sided insertions (OR: 0.54, CI: 0.29-1.03, p=0.062).
Conclusion: In the absence of a contraindication to right-sided
insertion insertion on the right side is preferable, irrespective of
hand dominance, because of a significant reduction in all-cause
complications.

P-122
Endoluminal dilatation to remove stuck central venous
devices: a safe and reliable method for interventional
radiologists
I.Fiorina1, L.P.Moramarco1, M.Torresi1, R.Corti1, G.Leati2,
P.Quaretti1
1Interventional Radiology, Fondazione IRCCS Policlinico San Matteo,
Pavia, Italy, 2Radiodiagnostica, Fondazione IRCCS Policlinico San
Matteo, Pavia, Italy
Purpose: Stuck catheter is a device that is impossible to remove
from the central vein using standard removal techniques because of
the formation of the fibrin sheath, but it leads to a life-threatening
condition owing to the risk of thrombosis and infection.
Material and methods: We report the largest series of stuck devices
extracted through endoluminal dilatation.
Indwelling line is cut close to the cuff and an introducer sheath is
placed into the stump of the stuck catheter, avoiding air embolism
and blood loss. Endoluminal dilation with a high-pressure angioplasty catheter is performed along the entire length of the stuck
catheter to break the adherences. The catheter and sheath are
removed together, leaving the guidewire for the insertion of an
eventual new replacement catheter.
We removed 11 cases of stuck central venous catheter (CVC) for
long-term hemodialysis, 5 cases of retained totally implantable
venous access devices for chemotherapy, and 1 case of indwelling
ventricular atrial shunt left in situ for 40 years.
Results: We treated 9 males and 8 females (aged 4873 years). There
was a major prevalence of right side (7 left jugular vein, 10 right jugular vein). Prolonged catheter dwelling time was noted (from 2 to 40
years, average >10 years). We removed 12 stuck lines (5 bilumen, 5
twins, 1 untunneled CVC with a dwell time of about 4 years, and 1
ventricular atrial shunt) and 5 ports, without complications.
Conclusion: Endoluminal balloon dilatation, when performed by
experienced interventional radiologists under fluoroscopic guidance, may represent a simple and effective retrieval method for
retained devices from the central veins.

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P-123
Percutaneous placement of the peritoneal dialysis catheter: an
educational poster
S.Alammari, T.Alanazi, A.Alharbi, M.Arabi
Medical Imaging, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Learning Objectives: Familiarize interventional radiologists with:
Advantages over hemodialysis
Contraindications
Illustration of kits components
Steps of percutaneous catheter insertion
Pitfalls and complications
Management of catheter dysfunction
Background: Peritoneal dialysis has been one of the options in the
management process of patients with end-stage renal disease and
has several advantages over hemodialysis.
Several techniques have been used for insertion of a peritoneal dialysis catheter, including open surgical, laproscopic, and percutaneous procedures.
Clinical Findings/Procedure: The procedure is performed under
fluoroscopic and sonographic guidance.
Using a micro-puncture set, a para-umbilical puncture is performed
under sonographic guidance to avoid inferior epigastric vessels
through the posterior rectus sheath, and the contrast is injected to
confirm the correct position within the peritoneal cavity, followed
by creation of artificial ascites.
A double-cuff peritoneal catheter is then introduced within a peelaway sheath, directed to the pouch of Douglas, and its distal cuff is
anchored to the subcutaneous abdominal tissue. The proximal end
of the catheter is then tunneled, and the other cuff is buried within
the subcutaneous tunnel.
The flow in the catheter is then tested on site before fixation, and a
dry period of 7 days follows before initiating peritoneal dialysis.
Conclusion: Percutaneous placement of a peritoneal dialysis catheter is a feasible, safe, and minimally invasive procedure.

P-124
The effectiveness of transhepatic hemodialysis catheter in
chronic hemodialysis patients: is it safe and functional?
B.Sanal1, O.F.Nas2, N.Dogan3, M.Korkmaz1, K.Hacikurt2, A.Yildiz4,
I.I.K.Aytac5, B.Hakyemez2, C.Erdoan2
1Department of Radiology, Dumlupnar University Faculty of Medicine,
Kutahya, Turkey, 2Department of Radiology, Uludag University Faculty
of Medicine, Bursa, Turkey, 3Radiology Clinic, Private Bahar Hospital,
Bursa, Turkey,4Department of Nephrology, Uludag University Faculty
of Medicine, Bursa, Turkey, 5Department of Cardiovascular Surgery,
Uludag University Faculty of Medicine, Bursa, Turkey
Learning Objectives: To investigate the safety and functionality of
tunneled transhepatic hemodialysis catheters in a wide series and to
review the literature through other case series.
Background: Thirty-eight patients (20 women, mean age 56 10
years and 18 men, mean age 61 11 years) with transhepatic tunneled hemodialysis catheters were evaluated. The date of first transhepatic catheterization, indications, procedure details, functional
time periods of catheters, reasons of the removal or revision of catheters, catheter-related complications, and current conditions of
patients were retrospectively analyzed.
Clinical Findings/Procedure: The catheters were placed properly
in all patients (100% technical success). A total of 69 catheters were
placed over 91 months follow-up period. Thirty-five catheters were
excluded because these were still functional at the start of the study
(some patients died or underwent transplantation or fistulization,
and some catheters were functional). The functionality of catheters
was evaluated with other 34 catheters which necessitated revision

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because of complications. Half of catheters were functional on day

136 when evaluated with KaplanMeier analysis. The four main complications were thrombosis (16/34; 47%, 0.37 days in 100 catheters),
infection (8/34; 23.5%, 0.18 days in 100 catheters), migration (8/34;
23.5%, 0.18 days in 100 catheters), and kinking (2/34; 6%, 0.04 days
in 100 catheters).
Conclusion: Transhepatic venous catheterization is a safe and functional alternative route in patients needing chronic hemodialysis in
case of inaccessible central venous routes. The procedure can be
carried out with high technical success and low complication rates
by using imaging modalities efficiently.

Abstract Book
distal arterial flow to the forearm and hand. An angioplasty balloon
is inflated to nominal pressure within the venous outflow limb. Small
incisions are made on either side, and the vein is dissected on both
sides with a curved haemostatic forceps. Two absorbable suture
loops are placed around the venous outflow limb and profiled over
the inflated angioplasty balloon. A completion angiogram is performed to assess the degree of fistula reduction.
Conclusion: Percutaneous AVF banding is an effective minimally
invasive technique for treatment of steal syndrome due to excess
AVF shunting.

P-127

P-125
Central venous catheter tip malposition: percutaneous tricks
for its correct re-placement
U.G.Rossi1, P.Torcia1, P.Rigamonti1, G.Mauri2, V.Pedicini3,
D.Poretti3, M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Radiology, IRCCS Policlinico San Donato, San Donato
Milanese, Italy, 3Radiology and Interventional Radiology, IRCCS
Humanitas Hospital, Milan, Italy
Learning Objectives: To describe two tricks (high-flow injection
and endovascular) for the correct replacement of central venous
catheter (CVC) tip in case of malposition.
Background: CVC can be associated with numerous potential complications, including malposition of its tip. Ultrasound-guided CVC
placement is useful as a bedside technique and avoids erroneous
venous insertion. Fluoroscopy remains the gold standard method
for verifying the course of the inserted CVC and the location of its
tip. However, these kinds of techniques are not always used. The
absence of fluoroscopy guidance can lead to CVC tip malpositioning.
Clinical Findings/Procedure: The purpose of this poster is to illustrate two tricks for correct re-placement of the CVC tip in malposition cases: 1) high-flow saline injection through the CVC lumen and
2) endovascular CVC tip catch.
Conclusion: Operator experience and the use of ultrasound and fluoroscopy guidance during CVC positioning reduce the risk of malposition, but when it happens, it important to know possible tricks to
resolve this CVC complication.

BuddChiari syndrome: complication of a dialysis line and our

subsequent management
A.Tan1, N.Mathias2
1Department of Radiology, Queen Elizabeth University Hospital,
Glasgow, United Kingdom, 2Radiology Department, Hairmyres
Hospital, Glasgow, United Kingdom
We present a case of a 31-year-old patient with a malpositioned dialysis line at the hepatic venous confluence. This patient subsequently
developed BuddChiari syndrome; described is our management of
the venous stenosis and subsequent line replacement.

P-128
Zero to HeRO: a savior graft for patients reaching end of their
haemodialysis life
M.A.Ghouri, C.Ratcliff, C.Nesbitt, M.Thomas, A.Kaabneh,
S.Milburn, M.Hansrani
Interventional Radiology, James Cook University Hospital,
Middlesbrough, United Kingdom
A 55-year-old woman with ESRD, occluded multiple fistulas in all
limbs and problematic catheter-dialysis underwent Hemodialysis
Reliable Outflow (HeRO) graft placement with good clinical outcome. This involves insertion of a flexible, reinforced, long stent into
the right atrium, which can be attached to the graft which runs in
the limb for easy needling.

Embolotherapy (excluding oncology)

P-126
Percutaneous dialysis arteriovenous fistula banding: technical
review
H.K.Kok, E.Ryan, M.J.Lee
Department of Academic Radiology, Beaumont Hospital Dublin,
Dublin, Ireland
Learning Objectives:
1. To review the indications for arteriovenous fistula (AVF) banding
including symptoms and signs of steal syndrome.
2. To describe the technique of percutaneous AVF banding and
initial local experience in a tertiary-referral and national renal
transplant unit.
Background: AVFs are the preferred method of vascular access for
patients on long-term haemodialysis. A minority of patients suffer
from steal syndrome due to excess shunting of arterial flow through
the fistula, resulting in symptoms in the ipsilateral hand, which can
ultimately result in tissue loss.
Clinical Findings/Procedure: Five procedures have been performed in our centre with 100% technical success and no early
complications. Our technique involves a retrograde access into the
venous outflow limb of the AVF. A vascular sheath is placed; a fistulogram is performed to assess flow through the AVF, and an arteriogram of the brachial artery and forearm is performed to evaluate

P-129
Ethanol sclerotherapy for venous malformations: clinical
outcomes and patient satisfaction a tertiary center
experience
O.Komisar, U.Rimon
Diagnostic Radiology, Chaim Sheba Medical Center, Sackler School of
Medicine, Tel-Aviv University, Tel-Aviv, Ramat-Gan, Israel
Purpose: To retrospectively evaluate the results of ethanol sclerotherapy for venous malformations (VM), with emphasis on patient
satisfaction, complications, and predictors of good response.
Material and methods: Three hundred and nine patients were
treated for VM in our center between 2000 and 2014. All of them
were sent a self-assessment questionnaire for evaluation of their
satisfaction and complications. In total, 153 patients (mean age 21,
range 6 days to 67 years) responded to the questionnaire. We analyzed clinical and imaging data from medical records of these
patients.
Results: Sixty-four (42%) patients had VM in the lower extremities,
35 (23%) in the head and neck, 33 (22%) in the trunk, 14 (9%) in the
upper extremities, and 5 (3%) in the buttock and genitalia. Complete
relief of swelling, pain, functional, and esthetic complaints were

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CIRSE 2016
obtained in 23%, 22%, 17%, and 12% patients, respectively. Thirtyeight (25%) patients were very satisfied with treatment outcomes, 55
(36%) were satisfied, 49 (32%) were not satisfied, and 11 (7%) were
very unsatisfied. We did not find any significant correlation between
demographics, lesion location, size, tissue involvement, total ethanol, and patient satisfaction. The rate of minor complications was
8% and that of major complications was 3%.
Conclusion: Ethanol sclerotherapy is an effective treatment for
VM; nonetheless, the treatment has a significant complication rate.
Patient satisfaction is independent of lesion characteristics, and
patient selection cannot be based on these parameters alone.

P-130
Super-selective arterial embolization with n-butyl
cyanoacrylate (NBCA) for colonic diverticular hemorrhage
S.Fuwa1, S.Hase2, T.Nakagawa2, J.-I.Nishimura2
1Department of Radiology, Tokyo Metropolitan Bokutoh Hospital,
Tokyo, Japan, 2Department of Interventional Radiology, Kawasaki
Saiwai Hospital, Kawasaki-city, Kanagawa, Japan
Purpose: To evaluate the efficacy and safety of super-selective
transcatheter arterial embolization with n-butyl cyanoacrylate for
colonic diverticular hemorrhage.
Material and methods: From January 2013 to December 2015, a
total of 35 consecutive patients underwent endovascular embolization for colonic diverticular hemorrhage in our institution. Patients
included 23 men and 12 women with an age range of 4194 years
(mean age, 71.312.3). Embolization was done using a 1:11:4 mixture of NBCA and iodized oil from the microcatheter tip at the vasa
recta level. Coagulopathy was present in 22 patients, and 13 patients
were hemodynamically unstable before the procedure. Technical
and clinical success rates, recurrent bleeding rates, complications, procedure time, and clinical outcomes were evaluated. Postembolization ischemia was evaluated objectively in 23 patients by
colonoscopy within a few days after the endovascular procedure.
Results: The technical and clinical success rate was 100%, and no
recurrent bleeding occurred. Ulcers induced by embolization were
recognized in 22 patients (100%) who underwent colonoscopy after
embolization. Of these 22 patients, 21 were successfully cured by
conservative treatment. The remaining patient showed circumferential ulcer and stenosis of the ascending colon and underwent
right hemicolectomy. Histologic examination revealed inflammatory
reaction and open ulcer with no intestinal necrosis. Except this case,
no major complications were observed.
Conclusion: Super-selective arterial embolization with NBCA for
colonic diverticular hemorrhage is feasible and could be an effective
treatment for colonic diverticular hemorrhage even for patients with
coagulopathy or who are hemodynamically unstable.

P-131
Volumetric filling density of coil embolization for pulmonary
arteriovenous malformation and its relationship with
reperfusion
M.Shimohira, T.Hashizume, T.Kawai, K.Ohta, K.Suzuki,
Y.Shibamoto
Department of Radiology, Nagoya City University Graduate School of
Medical Sciences, Nagoya, Japan
Purpose: The aim of this study was to evaluate the relationship
between volumetric filling density (VFD) and reperfusion in coil
embolization for pulmonary arteriovenous malformation (PAVM).
Material and methods: Coil embolization was performed in 36
patients with 69 PAVMs, 5 males and 31 females, with a median age
of 53 years (range, 983) between June 2003 and November 2015.
In all embolization procedures, immediate postembolic complete

SS/FC/HL/HTS/CM
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S219

cessation of blood flow was confirmed by digital subtraction angiography. For follow-up examination, time-resolved magnetic resonance angiography or pulmonary angiography was performed after
embolization in all cases. Theoretical VFD was calculated using the
formula: VFD = 100 (total coil volume/embolized PAVM volume).
In cases in which the hydrogel-coated coils were used, the volume
of the hydrogel-coated coils was calculated assuming full hydrogel
polymer expansion. Calculated VFDs exceeding 100% were adjusted
to 100% for data analysis. Reperfusion was confirmed in 22 PAVMs
(reperfusion group) and not confirmed in 47 PAVMs (occlusion
group). VFDs were compared between the reperfusion and occlusion groups.
Results: Median size of the feeding artery of PAVM was 3.6 mm in
the reperfusion group and 3.3 mm in the occlusion group. Median
size of the venous sac of PAVM was 7.35 mm in the reperfusion
group and 7.9 mm in the occlusion group. Median VFD was 23%
(range, 13%47%) in the reperfusion group and 57% (11%100%) in
the occlusion group (P<0.0001).
Conclusion: Lower VFD appears to be closely related to reperfusion
in coil embolization for PAVM.

P-132
Combination of balloon-remodeling and double microcatheter
technique for embolization of wide-neck visceral artery
aneurysms: a review of 11 consecutive cases
M.Inoue, S.Nakatsuka, M.Tamura, S.Oguro, M.Jinzaki
Diagnostic Radiology, Keio University School of Medicine, Tokyo, Japan
Purpose: Coil embolization of wide-neck aneurysms is technically
challenging. Adjunctive techniques are needed to achieve enough
volume embolization ratio. The purpose of this study is to evaluate
the feasibility and efficacy of a combination of balloon remodeling
(BR) and double microcatheter (DM) techniques for the coil packing
of wide-neck visceral aneurysms.
Material and methods: Between October 2008 and December
2015, coil embolization of 26 visceral aneurysms was performed.
Among them, 11 wide-neck aneurysms in 11 patients treated with
coil packing in combination with BR and DM techniques were
included in this study. Wide-neck aneurysm was defined as a dometo-neck ratio of less than 2.0. Mean neck-to-dome ratio and mean
diameter of aneurysm, calculated based on dynamic CT angiography, are 1.440.27 (range, 1.151.97) and 16.84.22 (range, 9.8
22.1), respectively. Bare metal platinum and hydrocoil were used.
Procedure-related complications and volume embolization ratio
(VER) were evaluated.
Results: All aneurysms were embolized successfully without inadvertent coil protrusion into the parent artery. Mean VER before
and after the expansion of hydrocoils were 33.3%8.3% (range:
18.3%41.3%) and 40.4%18.2% (range, 23.0%90.9%), respectively.
Thromboembolic events occurred in 1 of 11 patients, resulting from
heparin-induced thrombocytopenia. Major complications were not
observed.
Conclusion: Combination of BR and DM techniques for the embolization of wide-neck visceral artery aneurysm is feasible and
achieved enough VER in most cases.

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P-133
Preliminary experience with Onyx embolisation in 21 patients
with renal angiomyolipoma
L.Paul-Ferrer, D.GomezCampos, M.Cabrera-Gnzalez, A.AlonsoBurgos, J.Urbano
Vascular & Interventional Radiology, Fundacion Jimenez Diaz, Madrid,
Spain
Purpose: Angiomyolipoma (AML) is a benign renal tumour that
can cause severe spontaneous haemorrhage and lead to urgent
nephrectomy. Embolisation is a well-established first-line treatment.
Onyx has some theoretical advantages and could be used as an
embolic agent. We describe a preliminary experience of AML treated
with Onyx.
Material and methods: A retrospective review of all AML embolisations with Onyx within the last 9 years was performed. The indication for the treatment was any AML size in anti-coagulated or symptomatic patients and an AML size of greater than 4 cm in asymptomatic patients. An ultra-selective microcatheter, which reached the
AML vessels, was used in every case. CT or MR follow-up was scheduled at 6, 12 and 24 months for all patients.
Results: Twenty-six embolisations were performed in 14 men and 7
women. Mean age was 56.5 years. Thirteen patients had single AML,
8 had multiple, and 6 had tuberous sclerosis. Seventeen were scheduled embolisations and 8 were urgent. In all urgent cases, haemorrhage control was successful. No further surgery was needed in any
case. There was no renal failure in any patient as a consequence of
embolisation. No complication related to Onyx was found. There
were 6 patients with post-embolisation syndrome with severe
pain and 1 with mild fever. The mean follow-up duration was 33.1
months. A size reduction was confirmed in all treated AMLs.
Conclusion: In the presented patients the precision and controlled
release of Onyx allowed a safe and effective AML embolisation, leaving health renal parenchyma untouched. Onyx haemostatic power
allowed acute bleeding control, avoiding nephrectomy in all cases.

P-134
Safety and efficacy of pre-operative tumour embolisation in
combination with percutaneous direct puncture technique for
juvenile nasopharyngeal angiofibromas (JNA) with impact on
intra-operative blood loss
R.S.Chivate, S.S.Kulkarni, N.S.Shetty, A.M.Polnaya, K.B.Gala
Interventional Radiology, Tata Memorial Hospital, Mumbai, India
Purpose: Safety, efficacy and techniques of pre-operative embolisation for rare, benign juvenile nasopharyngeal angiofibromas in
reducing intra-operative blood loss.
Material and methods: Forty-eight patients underwent pre-operative embolisation for juvenile nasopharyngeal fibromas over a
period of 5 years in our institute and were graded as per the Fisch
classification. Almost 70% cases were grade III and IV. Four-vessel
cerebral angiography was performed to check blood supply to the
tumour from external carotid or internal carotid arteries. In the same
session, a balloon occlusion test was performed to check for contralateral circulation in cases when the internal carotid artery would
be sacrificed. Transarterial embolisation from branches of ECA was
performed using 250-350 microns PVA particles. Coil embolisation
of the stump of the vessel supplying the tumour helped surgeons
easily ligate the feeding vessel, further decreasing blood loss. In
11 cases, supply was from the internal carotid arteries, and direct
puncture of the tumour was done via the transnasal, temporal or
oral route; the tumour was embolised using either N-butyl cyanoacrylate glue, ethylene vinyl alcohol copolymer (ONYX) or SQUID.
Embolisation was performed till no tumour blush was seen. Surgical
excision of the tumour was performed within 24 hours.

Abstract Book
Results: All patients tolerated the procedure well, with no neurological/cognitive deficits. Significant reduction in blood loss was noted
especially in tumours that were embolised in combination with the
direct puncture technique. Median blood loss was about 1150 cc.
Conclusion: Pre-surgical embolisation for juvenile angiofibroma
resection is safe and effective. It facilitates less intraoperative blood
loss and easy resection of the tumour, thus preventing recurrence.

P-135
Dyna-CT during prostate artery embolisation
D.F.W.Maclean, B.Maher, A.Cannavale, J.Dyer, M.R.Harris,
S.Modi, N.Hacking, T.J.Bryant
Department of Interventional Radiology, University Hospital
Southampton, Southampton, United Kingdom
Purpose: Identification of variable vascular configurations is essential when planning prostate artery embolisation (PAE). Siemens
Dyna-CT is a cone beam CT (CBCT) technique enabling three-dimensional visualisation of the pelvic vessels. The trade-off is an increased
procedural dose. We aimed to investigate how frequently the technique led to a change in approach and the dose penalty associated
with its usage.
Material and methods: Patients undergoing PAE for symptoms
of benign prostate hyperplasia (BPH) between June 2012 and
December 2015 were included. Comparison was made with preprocedural CT angiogram. Any change in approach to embolisation
based of the findings of the intraprocedural CBCT was recorded in
addition to why a change was indicated.
Results: Eighty-one patients underwent prostate artery embolisation with Dyna-CT performed to assess 90 pelvic sides of hemi-prostatic arterial supply in 65 patients. Utilisation of Dyna-CT directly
triggered a change in practice in 29/90 (32.2%) sides. This was
mainly due to the identification of new significant anastomoses
(25 sides) and included the confirmation of inconsequential prostatic branches (4 sides) that were subsequently not targeted. In the
remaining 61 sides, Dyna-CT either confirmed the presence of previously suspected anastomoses (34 sides), ruled out the presence of
suspected anastomoses (2 sides), or confirmed glandular enhancement of the selected vessel (25 sides). Mean dose area product (DAP)
per Dyna-CT was 3651.9 mGycm2, contributing on average 43.0% of
the entire procedural dose (mean DAP 17400.5 mGycm2).
Conclusion: The use of Dyna-CT during prostate artery embolisation changes practice in a significant proportion of cases, thereby
justifying the increased procedural dose.

P-136
Digital subtraction cone-beam CT in preoperative
embolization for pelvic bone tumor
H.-C.Kim1, G.M.Kim2
1Radiology, Seoul National University Hospital, Seoul, Korea,
2Radiology, Yonsei University Severance Hospital, Seoul, Korea
Purpose: To identify the benefits of digital subtraction CBCT
(DS-CBCT) in preoperative embolization of hypervascular tumors
located in the pelvic bone.
Material and methods: From January 2013 to January 2016, a total
of 40 patients who had hypervascular tumors located in their pelvic bone underwent preoperative embolization. DC-CBCT was performed in 12 patients, and only a series of DSA was performed in 28
patients. The interventional procedure time, fluoroscopy time, DSA
runs, radiation dose, and estimated blood loss during surgery were
compared between these two groups.
Results: Comparison of preoperative embolization with and without DS-CBCT revealed that patients whose interventional procedure
was supplemented by DS-CBCT did not benefit from the improved

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CIRSE 2016
devascularization rate from those without DS-CBCT (p=0.824). The
difference of other variables such as intervention time, operative
time, and estimated blood loss was also not statistically significant
between the two groups (p=0.213, p=0.631, p=0.727, respectively).
On the other hand, the number of angiographic runs in the group
with DS-CBCT was significantly lower than that in the group without
DS-CBCT (p<0.001). Moreover, total DAP and fluoroscopy time were
also significantly lower in the former group (p<0.001 and p=0.037,
respectively)
Conclusion: The use of DS-CBCT during the preoperative embolization of hypervascular tumors located in the pelvic bone significantly
reduces the number of angiographic runs and fluoroscopy time at
the cost of increased radiation dose.

P-137
Analysis of radiation dose in varicocele embolization using
thermo-luminescence dosimeter (TLD): what risk for hereditary
line?
F.Melchiorre1, R.Azzeroni2, M.Mancini3, E.M.Fumarola1,
F.Pelliccione3, F.Morelli1, A.Gioppo1, M.Nichelatti4, A.Vella5,
G.Cornalba1
1Interventional Radiology, AO San Paolo, Milan, Italy, 2Medical Physics,
AO San Paolo, Milan, Italy, 3Andrologia Pediatrica e dellAdolescenza,
AO San Paolo, Milan, Italy, 4Medical Statistics, AO Niguarda, Milan,
Italy, 5Radiologia, Ospedale Luigi Sacco ASST Fatebenefratelli Sacco,
Milan, Italy
Purpose: To assess the level of gonad radiations received in the retrograde sclero-embolization of the spermatic vein procedures for
defining the associated hereditary and fatal cancer risk and to propose and analyze radioprotection measures to minimize these risks.
Material and methods: From 2013 to 2015, we performed 100
selective embolizations of the left spermatic vein in patients with
varicocele. For each procedure, we evaluated the gonad dose, fluoroscopy time, dosearea product (DAP), equivalent dose (EDS),
and effective dose (E), which allowed us to estimate the hereditary
risk and the radiation-induced fatal cancer risk. Next, we divided
the first 49 procedures into 2 random groups (A=25, B=24) according to the use (or not) of the anti-scatter grid. In the last 51 procedures (group C), performed by a single expert operator, the grid was
always removed.
Results: In groups A, B, and C, the mean fluoroscopy time was 7:13,
4:53, and 4:20 min, respectively; the mean DAP was 12.72, 1.99. and
1.70 Gy/cm2, respectively; the mean EDS was 29.49, 6.75, and 5.62
mGy, respectively; the mean gonad dose was 0.72, 0.29, and 0.25
mGy, respectively; the mean effective dose was 3.39, 0.77, and 0.48
mGy, respectively; the mean hereditary risk was 1.58x10 -5, 6.24x10 6, and 6.06x10 -6, respectively; and the radiation-induced fatal cancer
risk was 5.36x10 -4, 1.25x10 -4, and 1.2x10 -4, respectively.
Conclusion: The percutaneous sclero-embolization, performed
with a low-dose protocol and with a series of features, including
the removal of the anti-scatter grid, exposes patients to a minimum
and fully justified radiation dose, with a negligible hereditary risk
and radiation-induced fatal cancer risk.

SS/FC/HL/HTS/CM
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P-138
Arterial embolization of rectus sheath hemorrhage secondary
to anticoagulant therapy
J.M.JimenezPerez1, G.Rodriguez-Rosales2, M.GonzlezLeyte2,
A.AlvarezLuque2, M.EchenagusiaBoyra3, E.CallejaCartn3
1Radiodiagnostico, Hospital General Universitario Gregorio
Maran, Madrid, Spain, 2Interventional Radiology, Hospital General
Universitario Gregorio Maran, Madrid, Spain, 3Radiology, Hospital
General Universitario Gregorio Maran, Madrid, Spain
Purpose: To report our experience in transcatheter arterial embolization of rectus sheath hematoma secondary to anticoagulant therapy refractory to conservative treatment.
Material and methods: Twenty patients with rectus sheath hematoma secondary to anticoagulant therapy were treated in our hospital by transcatheter arterial embolization. All patients presented
clinical signs of active bleeding, despite conservative treatment.
A previous CT showed rectus sheath hematoma in all patients with
extravasation of contrast in 19 cases (95%). We classified hematoma
into 3 types: type 1 was confined to the rectus sheath musculature,
type 2 affected the posterior space of the rectus sheath without
blood in the abdominopelvic cavity, and type 3 affected this cavity.
Coils, gelatine sponge, Onix, acrylic glue, and/or polyvinyl alcohol
particles were used as embolic agents depending on the case and
the preference of the operator.
Results: CT showed 12 type 3 (60%), 4 type 2 (20%), and 4 type 1
(20%) rectus sheath hematomas.
Transfemoral arteriogram revealed bleeding of inferior epigastric artery in 19 patients (95%). Technical success was 100%. Clinical
success was 95% [1 patient had rebleeding 24 hours later and was
treated by transcatheter embolization again and 3 patients (15%)
died within 30 days after embolization due to multiple organ failure].
Conclusion: Transcatheter arterial embolization is an effective treatment to control the bleeding in patients with hematoma secondary
to anticoagulant therapy refractory to conservative treatment.

P-139
Varicocele treated by coils or a combination of coils and
sclerosant therapy
J.Egge1, I.K.Tesdal2
1Departement of Radiology, Haugesund Sjukehus, Haugesund, Norway,
2Department of Radiology, Klinikum Friedrichshafen, Friedrichshafen,
Germany
Purpose: To evaluate the technical and clinical success rates and
long-term results for patients who underwent embolization of varicocele using two different methods.
Material and methods: Retrospectively, we evaluated all patients
who underwent embolization of left-sided varicocele from 1/2012
to 12/2015. Procedure-related data were prospectively documented
in a database and analyzed with a focus on the clinical success rate
and long-term outcome. Twelve patients were treated by coil embolization, and 13 patients were treated by a combination of coils and
sclerosing agent (Aethoxysklerol). For follow-up, all patients were
interviewed by telephone or, if possible, by clinical examination.
Follow-up duration varied between 2 and 48 months.
Results: In both groups, we did not observe any complications. In
the group treated with coils only (n=12), 5 patients (41.7%) were satisfied by the treatment and 7 patients (58.3%) had recurrence of the
symptoms (pain and recurrence of palpable mass). The recurrence of
symptoms presented for 2-3 months after treatment. In the group
treated with coils and Aethoxysklerol (n=13), 13 patients (100% were
satisfied and had no recurrence of symptoms.
Conclusion: The results suggest that the combination of coils and
sclerosing agent seems to be beneficial for the clinical success rate
in comparison to coils alone.

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P-140
Empirical embolization of the arterial stump for postoperative
hemorrhage without a definite bleeding focus on radiographs
after gastrointestinal surgery: radiologic findings and
outcomes

Abstract Book
Conclusion: CTA can accurately identify hemoptysis-responsible
arteries prior to BAE. Conventional aortography during the procedure does not provide additional information; therefore, it might be
skipped in most patients to decrease the radiation dose and contrast
volume and likely reduce the procedure time.

E.H.Kim, J.S.Oh, H.J.Chun, H.G.Lee, B.G.Choi

Radiology, Seoul St. Marys Hospital, The Catholic University of Korea,
Seoul, Korea

P-142

Purpose: To evaluate the feasibility of endovascular management of

arterial hemorrhage after major abdominal surgery without a definite bleeding focus on radiographs.
Material and methods: Between November 2009 and June 2015,
473 patients underwent TAE for delayed postoperative bleeding at
our interventional unit. Among these patients, 11 patients showed
no evidence of active bleeding on radiographs and underwent conservative therapy first. Due to the clinical worsening, all 11 patients
underwent an angiography and empirical embolization was performed at the arterial stump. Technical success of the TAE procedure
was defined as complete embolization of the stump without newly
detected contrast extravasation. Clinical success was defined as the
cessation of clinical symptoms and bleeding from drain tubes after
TAE without any further surgical intervention during the follow-up
period.
Results: The interval between initial surgery and hemorrhage
ranged from 2 to 30 days, with a median of 10 days. Except for the
acute hematoma surrounding the stump, active bleeding signs,
such as active contrast extravasation or pseudoaneurysm, were not
identified on CT angiograms and conventional angiography. TAE
was technically successful in 11 patients (100%). Clinical success was
achieved in 8 (72%) of 11 patients. Three patients died within 1 week
after the TAE procedure. Postembolization complications such as
bowel infarction or liver infarction did not occur in all patients during the follow-up period.
Conclusion: Empirical embolization of the arterial stump for postoperative hemorrhage can be an effective treatment method when
a definite bleeding focus is not detected on radiographs.

P.P.Goffette1, X.Wittebole2, P.Laterre2, O.Ciccarelli3

1Radiologie Interventionnelle et Vasculaire Neuroangiographie
Thrapeutique, Cliniques Universitaires Saint-Luc-UCL, Brussels,
Belgium, 2Intensive Care, St Luc University Hospital, Brussels, Belgium,
3Digestive Surgery, St Luc University Hospital, Brussels, Belgium

P-141
Identification of hemoptysis-responsible arteries prior to
bronchial artery embolization: is there an added value of
conventional aortography compared with CT angiography?
C.J.Yoon, C.H.Jeon, H.Lee, Y.-J.Kim, S.W.An, Y.N.Woo
Radiology, Seoul National University Bundang Hospital, Seongnam,
Korea

Coronary stent-graft implantation for the management of

acute visceral arterial bleeding

Purpose: To evaluate the efficacy and safety of coronary stentgraft for the emergent treatment of acute arterial visceral and renal
hemorrhage.
Material and methods: Over a 3.5-year period, 18 consecutive
patients (median age 65) with shock due to acute arterial hemorrhage following surgery (n=9; hepatic 6, renal 2, and GDA 1) or
spontaneously ruptured false aneurysms (n=9; splenic 4, pulmonary 2, and hepatic 3) were treated by emergent Graftmaster stent
implantation. All patients were contraindicated for arterial sacrifice because of a major risk of end-organ ischemia. The Graftmaster
stent (Abbott, Santa Clara, CA, USA), a flexible balloon-expandable
coronary stent-graft ranging from 3 to 5 mm in diameter, is primarily
recommended for PTA-related coronary artery rupture or aneurysm.
All procedures were performed using a 6-Fr sheath to introduce the
0.014-monorail stent system.
Results: The procedure technically succeeded in 17 of 18 patients
(94%). Major bleeding ceased immediately after stent-graft implantation in 15 patients (88%). In the 2 remaining patients, secondary
stent overdilation by 1 mm led to complete arterial repair. No procedure-related complications occured. The 30-day mortality was 0%.
During the follow-up (median 2 year), no recurrent bleeding or sepsis occured, and the survival rate was 88%. Two patients died from
unrelated causes. Among the 15 patients followed up by angio-CT
or DSA (median 22 months), stent patency with preserved distal perfusion was present in 12 patients (80%). Asymptomatic occlusion of
hepatic or mesenteric stents was observed in 3 patients.
Conclusion: Implantation of the coronary Graftmaster stent seems
to be an efficacious and safe emergent therapy to manage hemorrhage from medium-/small-sized visceral/renal arteries.

P-143

Purpose: CT angiography (CTA) plays a crucial role in predicting

hemoptysis-responsible arteries prior to bronchial artery embolization (BAE). The purpose of this study was to determine if there is an
added value of conventional aortography compared with CTA.
Material and methods: Between September 2010 and November
2013, 100 patients (mean age 60.0 years, age range 2085 years)
with major hemoptysis underwent BAE. Bronchial and nonbronchial systemic collateral arteries possibly contributing to hemoptysis
were determined on pre-procedure CTA. Selective embolization of
hemoptysis-responsible arteries was performed without pre-embolization aortography. Completion aortography was obtained to find
missed hemoptysis-responsible arteries.
Results: A total of 293 arteries (148 bronchial, 25 aberrant bronchial,
and 120 nonbronchial systemic collateral arteries) were identified on
CTA as being responsible for causing hemoptysis. Selective angiograms of each artery were obtained and successfully embolized. On
completion angiogram, there were 3 missed hemoptysis-responsible arteries (1 bronchial, 1 aberrant bronchial from thyrocervical,
and 1 branch of thyrocervical artery) in 3 patients (1.0%). Complete
resolution of hemoptysis was achieved in all patients.

Evaluation criteria in patients with hemodynamically stable

pelvic fracture: should angiography be performed or not?
K.Shibuya1, M.Aoki2, S.Hirasawa1, H.Tokue1, M.Miyazaki1,
Y.Koyama1, K.Oshima2, Y.Tsushima1
1Diagnostic and Interventional Radiology, Gunma University Hospital,
Maebashi, Japan, 2Emergency Medicine, Gunma University Hospital,
Maebashi, Japan
Purpose: The purpose of this study was to investigate the criteria to
avoid unnecessary angiography for hemodynamically stable pelvic
fractures.
Material and methods: From January 2010 to December 2015, 69
consecutive patients with hemodynamically stable pelvic fractures
in the emergency department were enrolled in this observational
study. All pelvic fractures were diagnosed in contrast-enhanced
CT, and 19 patients underwent angiography. The criteria included
five points, namely extravasation in contrast-enhanced CT, massive hematoma, receiving anticoagulant and/or antiplatelet therapy, unstable type of fracture, and an age over 65 years, to identify

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the patients who had arterial hemorrhage or abnormality on angiogram, which required to be embolized. The positive definition of the
criteria was set to admit at least two of the five findings.
Results: Arterial embolization was required in 13 of 24 patients
(54.1%) who had two or more of five findings and in one of 45
patients (2.2%) who had less than two findings. The sensitivity and
specificity of the criteria were 92.9% and 80.0%, respectively. The
positive and negative likelihood ratio were 4.65 and 0.09, respectively. All patients who were observed without angiography did not
require any intervention for pelvic hemorrhage.
Conclusion: We proposed the criteria that showed a high sensitivity
for the prediction of arterial hemorrhage on angiogram. The indication of angiography can be limited to patients who meet the criteria.

P-144
Fusion imaging of dual arterial phase CT during angiography
for hepatocellular carcinoma: usefulness for undetectable
lesions at an early arterial phase
K.Ohta, M.Shimohira, T.Hashizume, Y.Shibamoto
Department of Radiology, Nagoya City University Graduate School of
Medical Sciences, Nagoya, Japan
Purpose: To evaluate usefulness of fusion imaging of dual arterial
phase CT during angiography before transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) in detecting the
feeding artery for undetectable HCC at an early arterial phase.
Material and methods: Dual arterial phase CT during angiography
was performed in 71 patients with 137 HCCs before TACE. Fourteen
patients underwent TACE repeatedly. In total, 147 HCCs were examined. An iodinated contrast material was injected at 2-3 ml/sec from
the common or proper hepatic artery. The early and late arterial
phase images were obtained serially during a single breath-hold
with an interscan delay of 6.0 sec. In 116 of 147 HCCs, both the feeding artery and enhancement of HCC were detected at the early arterial phase. However, in 31 of 147 HCCs, enhancement of HCC was not
detected with early arterial phase imaging, so the feeding artery
was not identified with the early phase imaging alone. Thus, in the
31 HCCs, fusion imaging of dual arterial phases was constructed and
evaluated for identifiability of the feeding artery.
Results: The fusion imaging of dual arterial phase CT during angiography revealed both the feeding artery and enhancement of
HCC successfully in 30 of 31 HCCs (97%). In another one, the feeding artery was not visualized at the early arterial phase due to
anastomosis.
Conclusion: Fusion imaging of dual arterial phase CT during angiography appears to be useful to detect the feeding artery in undetectable HCC at an early arterial phase.

P-145
Does reduction in prostate volume post-embolisation correlate
with symptomatic relief?
D.F.W.Maclean, M.R.Harris, J.Dyer, S.Modi, N.Hacking, T.J.Bryant
Department of Interventional Radiology, University Hospital
Southampton, Southampton, United Kingdom
Purpose: Prostate artery embolisation (PAE) is becoming an established technique to manage symptoms of benign prostatic hyperplasia (BPH). However, it remains unclear as to which physical parameters correlate with good clinical outcomes. We aimed to identify if
initial prostate volume or post-operative reduction in volume correlated with symptomatic improvement after embolisation.
Material and methods: Between June 2012 and June 2015, prospective analysis of all patients undergoing PAE for BPH was conducted, including the assessment of prostatic volume, International
Prostate Severity Score (IPSS) and quality of life (QOL) score.

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Post-embolisation MRI was performed after 3 months to assess prostatic volume. Repeat IPSS was calculated at 3 and 6 months postembolisation to assess symptomatic response.
Results: Seventy three patients underwent PAE between June 2012
and June 2015, with exclusion of 22 patients due to incomplete follow-up. The remaining 51 patients had median age of 63 (5280)
years, pre-embolisation prostate volume of 77 (42269) ml and IPSS
pre-PAE of 24 (1533). Patients with a pre-procedural prostate volume of >80 ml had a greater improvement in symptoms compared
with those with a volume of <80 ml (median 14 vs. 8, MannWhitney
U, Z=2.6, p=0.0048), although both groups saw a similar response
rate (>80 ml; 88.0% vs. <80 ml; 84.6%). A significant association was
seen between post-embolisation prostate-size reduction (%) and
IPSS improvement (bivariate linear regression analysis, Spearmans
rank r=0.373, p=0.0099).
Conclusion: Patients with larger prostates had a rate of symptomatic improvement similar to patients with smaller prostates; however, they experienced a greater degree of symptomatic relief.
Percentage reduction in prostate volume also correlated with the
degree of symptomatic relief.

P-146
Embolization of pulmonary MAV in patients affected by HHT:
comparison of results between coils and plugs
M.Grosso, D.Sortino, F.Pedrazzini, I.Baralis, C.Vinay, E.Peano,
S.Bongiovanni, A.Balderi
Radiology, Santa Croce e Carle Hospital, Cuneo, Italy
Purpose: The aim of our study was to determine the efficacy and
safety of the embolization of high-flow pulmonary arteriovenous
malformations (PAVMs) in patients with hereditary hemorrhagic telangiectasia (HHT) comparing Amplatzer plug with coils, micro-coils
and HydroCoils.
Material and methods: From December 2001 to December 2015,
we performed 144 embolizations on 106 patients (62 females and
44 males, mean age 43 years). These patients enrolled by the Italian
center of HHT underwent clinical evaluation, abdominal ultrasound, echocardiography with bubble study, and thoracic computed tomography angiography (CTA) in order to assess the feasibility of treatment.
Results: We reached technical success in 98.6% of cases. Total
PAVMs treated were 325: 113 with Amplatzer plug IV (34.8%), 5 with
Amplatzer I (1.5%), 196 with coils (60.3%), and 11 with HydroCoils
(3.4%). There was no Amplatzer or coil migration or major complications, only one patient developed transient hemiparesis and two
developed TIA. Radiologic follow-up (mean 36 months) with CT
angiography showed a 14% PAVM recanalization rate for coils and
only 1.8% for Amplatzer plugs.
Conclusion: Percutaneous embolization has become the first-line
treatment for small PAVMs in HHT owing to its good results and
minimal invasiveness compared to thoracotomy. Amplatzer plug
IV, available since 2009, has many interesting features: low profile,
versatility, reduced risk of migration, ease delivery, and proved low
recanalization rate. Despite of the high device cost, it allows time
and money saving compared to usual multiple coils. Amplatzer Plug
IV may become the device of choice for the embolization of PAVMs
with feeding arteries smaller than 6 mm in diameter.

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P-147
Imaging spectrum and management of spontaneous hepatic
haemorrhage
F.Corvino1, E.Cavaglia2, M.Silvestre3, A.Cervo1, F.Giurazza4,
A.Corvino1, F.Maglione5
1Department of Advanced Biomedical Sciences, Diagnostic Imaging
Section, Federico II University, Naples, Italy, 2Interventional Radiology
Department, Cardarelli Hospital, Naples, Italy, 3Diagnostica per
Immagini e Radioterapia, AOU Federico II, Naples, Italy, 4Radiology,
Campus Biomedico University of Rome, Rome, Italy, 5Vascular and
Interventional Radiology, Cardarelli Hospital, Naples, Italy
Learning Objectives: The aim of this investigation was to review
comprehensively the role of radiologists in diagnosis and management in patients with spontaneous hepatic haemorrhage.
Background: A spontaneous hepatic haemorrhage (SHH) is a rare
condition resulting from a breach in the hepatic parenchyma that
occurs without an external cause. Hepatocellular carcinoma (HCC)
accounts for 15% of admissions with SHH in areas of high prevalence. In areas of low HCC prevalence, hepatic adenoma is often the
leading cause of SHH followed by HCC, metastatic tumours, benign
tumours and connective tissue disease.
Clinical Findings/Procedure: Cross-sectional imaging with CT
scanning remains the gold standard diagnostic procedure, with
the finding of active contrast extravasation confirming the diagnosis. Transarterial embolisation can effectively induce hemostasis in
hemodynamically unstable patients; acute embolisation should be
undertaken with gel foam rather than with coils to facilitate a possible later chemoembolisation as a primary treatment in case of
HCC. Super-selective catheterisation of the relevant hepatic artery is
also more advisable reducing the risk of liver failure after embolisation, especially in patients with thrombosis of the main portal vein.
Up to 20% of patients undergoing embolisation will require surgical intervention to achieve haemostasis owing to persistent or recurrent bleeding and in some patient groups (paediatric and pregnant
patients) where an initial radiological approach may not be possible.
Conclusion: Cross-sectional imaging with CT scanning is the mainstay of diagnosis and initial management emphasises the use of
arterial embolisation to obtain haemostasis with a hepatectomy
reserved for patients with bleeding tumours after formal staging
and assessment of their liver function.

P-148
Efficacy of concurrent blood flow control on percutaneous
sclerotherapy for soft tissue venous malformation
K.Azama1, F.Ganaha2, Y.Iraha1, J.Heianna1, R.Kinoshita1,
W.Makino1, S.Murayama3
1Radiology, University of the Ryukyus Hospital, Okinawa, Japan,
2Radiology, Okinawa Prefectural Nanbu Medical Center, Okinawa,
Japan, 3Radiology, University of the Ryukyus Graduate School of
Medicine, Okinawa, Japan

Abstract Book
Clinical Findings/Procedure: In our institution, polidocanol is preferably used for VM because it is safer than ethanol in terms of local
complications. On the other hand, the sclerosing effect of polidocanol is not as powerful as that of ethanol. Therefore, we routinely use
draining vein compression during PS when applicable. Furthermore,
we sometimes use superselective arterial embolization in order to
reduce blood inflow. Because VM is typically a slow-flow lesion, PS
is usually effective. However, there are also the so-called intermediate flow lesions in which faster flow is observed on phlebography.
In such cases, PS is often insufficient due to early washout of sclerosant. To predict such intermediate lesions, we refer to preprocedural dynamic MRI. In cases having early staining on MRI, angiography is performed just before PS and superselective embolizations
are performed using gelatin sponge particles before PS.
Conclusion: In our experience, concurrent flow control is very effective in performing PS for VM.

P-149
Unusual causes of upper gastrointestinal bleeding
E.Lake, G.Ananthakrishnan
Radiology Department, Manchester Royal Infirmary, Manchester,
United Kingdom
Learning Objectives:
1. Describe unusual and unexpected causes of upper gastrointestinal bleeding.
2. Discuss imaging findings and protocols.
3. Discuss management strategies with a particular focus on
endovascular management.
Background: Bleeding from the upper gastrointestinal tract is
a commonly encountered problem. Its common causes include
peptic ulcer disease and upper gastrointestinal varices. There are
many other unusual causes of upper gastrointestinal bleeding.
Interventional radiology can be vital in the management of these
often complex cases.
Clinical Findings/Procedure: We present a number of cases of
unusual upper gastrointestinal bleeding, including cystic artery
aneurysm, Dieulafoys lesion, hepatic artery aneurysm, bleeding
gastrointestinal stromal tumour, spontaneous haemorrhage secondary to SuttonKadir syndrome and gastroduodenal pseudoaneurysm as a compliciation of biliary stenting.
We discuss patient presentation, optimum imaging protocols, crosssectional and angiographic imaging findings and clinical management, including endovascular techniques.
Conclusion: An awareness of the unusual causes of upper gastrointestinal bleeding with an understanding of the relevant imaging
findings, anatomy and possible management strategies is essential
for the interventional radiologist.

P-150
Endovascular management of intractable postpartum
hemorrhage caused by vaginal laceration

Learning Objectives: The purpose of this presentation is to

describe our techniques of blood flow control in performing PS for
VM.
Background: Percutaneous sclerotherapy (PS) is an essential therapeutic modality for treating soft tissue venous malformation (VM).
The therapeutic effect of PS is largely influenced by selection of sclerosant, as well as indwelling time of sclerosant within the VM cavity.
The indwelling time is determined by blood flow in VM. Concurrent
flow control, including draining vein compression and sometimes
feeding artery embolization, is useful to reduce blood flow and prolong sclerosant exposure in VM, and thus may contribute to more
effective sclerotherapy.

A.Kuhara1, M.Koganemaru1, T.Kugiyama1, M.Nabeta2, N.Tanaka1,

T.Abe1
1Radiology, Kurume University School of Medicine, Kurume, Japan,
2Emergency and Critical Care Medicine, Kurume University, Kurume,
Japan
Purpose: We evaluated the management of transcatheter arterial embolization for postpartum hemorrhage caused by vaginal
laceration.
Materials and Methods: We reviewed seven cases of patients
(mean age 30.9 years; range 2735) with intractable hemorrhage
and pelvic hematoma caused by vaginal laceration who underwent
superselective transcatheter arterial embolization from January

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2008 to July 2014. Postpartum hemorrhage was evaluated by angiographic vascular mapping to determine the vaginal arterys architecture, technical and clinical success rates, and complications.
Results: The vaginal artery was confirmed to be the source of bleeding in all cases. The artery was found to originate from the uterine
artery in three cases, the uterine and obturator arteries in two, and
the internal pudendal artery in two. After vaginal artery embolization, persistent contrast extravasation from the inferior mesenteric
artery as an anastomotic branch was noted in one case. Nontarget
vessels (the inferior vesical artery and nonbleeding vaginal arterial
branches) were embolized in one patient. Effective control of hemostasis and no post-procedural complications were confirmed in all
cases.
Conclusion: Postpartum hemorrhage caused by vaginal laceration involves the vaginal artery arising from the anterior trunk of the
internal iliac artery with various branching patterns. Superselective
vaginal artery embolization is clinically acceptable for the successful treatment of hemorrhage caused by vaginal laceration, with no
complications. After vaginal artery embolization, it is suggested to
check for the presence of other possible bleeding vessels by pelvic
aortography with a catheter tip at the L3 vertebral level and perform
a follow-up assessment.

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P-152
Superior mesenteric veininferior vena cava shunt: amplatzer
vascular plug embolization
U.G.Rossi1, P.Torcia1, P.Rigamonti1, F.Petrocelli2, M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Radiology, San Martino University Hospital, Genoa, Italy
We describe the case of a 62-year-old female who developed a superior mesenteric veininferior vena cava shunt. She was treated by
percutaneous embolization with an Amplatzer vascular plug. Clinical
and color Doppler US follow-up at 48 months was uneventful.

P-153
Dysautonomia secondary to GuillainBarr syndrome during
prostate artery embolisation
P.Kumar1, S.Srinivasan1, R.Ravi1, S.Amin2, E.A.OGrady1, A.Baird3
1Interventional Radiology, Aintree University Hospital, Liverpool, United
Kingdom, 2Radiology, Aintree University Hospital, Liverpool, United
Kingdom, 3Urology, Aintree University Hospital, Liverpool, United
Kingdom

Imaging spectrum and endovascular management of vascular

steal syndromes

Prostate artery embolisation is a technically challenging procedure.

We present a case of a patient with GuillainBarr syndrome who
experienced significant haemodynamic compromise secondary to
dysautonomia during a procedure.

R. Suri
Interventional Radiology, University of Texas Health Sciences Center
San Antonio, San Antonio, TX, United States of America

P-154

P-151

Learning Objectives:
1. Define vascular steal syndromes as distinct clinical entities
resulting from preferential shunting of blood away from a target
circulation resulting in clinical symptoms.
2. Highlight imaging features and endovascular management of
steal syndromes with a brief comment on surgical management.
3. Intended for radiology residents, fellows and practicing radiologists, this exhibit aims to create awareness and highlight
treatment options for vascular steal syndromes.
Background: Vascular steal syndromes are distinct clinical entities,
resulting from preferential shunting of blood away from a target circulation resulting in clinical symptoms. Knowledge of the multiple
steal syndromes and their imaging features/endovascular management is limited.
Clinical Findings/Procedure: Introduction and teaching points
Pathophysiology of vascular steal syndromes
Common etiologies for vascular steal syndromes
Discussion of various vascular steal syndromes and endovascular
management
Dialysis-associated steal syndromes
Sublclavian steal syndrome
TIPS and/or portosystemic collateral steal, resulting in hepatic
encephalopathy
Splenic artery steal, resulting in liver ischemia post liver transplant
Vascular malformation associated steal, causing distal tissue
ischemia
AAA type II endoleak
Conclusion: Vascular steal syndromes are distinct clinical entities
resulting from preferential shunting of blood away from a target
circulation, and this exhibit aims to create awareness and highlight
treatment options for them.

Endovascular embolization of anomalous systemic arterial

supply to the left lower lung via the left brachial artery
J.M.Lee1, J.Ohm2
1Radiology, SoonChunHyang University Hospital, Bucheon, Korea,
2Radiology, Chungnam National University Hospital, Daejeon, Korea
We present the case of vascular plug and coil embolization in an
anomalous systemic artery supply to the left lower lung via the left
brachial artery approach in a 34-year-old man with hemoptysis.

P-155
Percutaneous transhepatic obliteration for superior
mesenteric vein aneurysm rupture after transcatheter arterial
chemoembolization for huge hepatocellular carcinoma: a case
report and review of the literature
H.Nagayama, T.Fukuda
Radiology, Nagasaki Harbor Medical Center City Hospital, Nagasaki,
Japan
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P-156
Successful retrieval of an amplatzer vascular plug II (AVPII)
used for embolization of pelvic arteriovenous malformation
that migrated to the pulmonary artery
M.Inoue, M.Tamura, S.Oguro, S.Nakatsuka, M.Jinzaki
Diagnostic Radiology, Keio University, School of Medicine, Tokyo, Japan
A 48-year-old male with pelvic arteriovenous malformation underwent sclerotherapy combined with embolization using AVPII.
Postprocedural chest radiograph detected AVPII in the pulmonary artery. Retrieval of AVPII using a snare was performed. An 11-Fr
sheath was needed to draw AVPII into the sheath.

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P-157

P-161

Recovery from a critical complication: successful removal of

a thoracic drainage catheter penetrating through a bronchus
and pulmonary artery with transcatheter embolization under
proximal balloon occlusion

Selective endovascular embolization of pulmonary artery in

blunt polytrauma: a report of 2 cases

T.Moriya1, T.Saguchi1, D.Yunaiyama1, K.Saito1, K.Tokuuye1,

J.Yamashita2, A.Yamashina2, N.Ikeda3
1Radiology, Tokyo Medical University, Tokyo, Japan, 2Second
Department of Internal Medicine, Tokyo Medical University, Tokyo,
Japan, 3Division of Thoracic & Thyroid Surgery, Tokyo Medical
University, Tokyo, Japan
Massive bleeding was suctioned from the thoracic tube inserted
at bedside. CT revealed the tube tip malpositioned in the pulmonary artery. The patient was immediately referred to the IR team.
Pulmonary arterial embolization was successfully performed, allowing tube removal on the same day.

K.Idoguchi1, R.Usui1, M.Narita1, S.Nakao1, Y.Mizushima2

1Division of Endovascular Therapy, Rinku General Medical Center,
Senshu Trauma and Critical Care Center, Osaka, Japan, 2Senshu
Trauma and Critical Care Center, Rinku General Medical Center, Osaka,
Japan
In general, active bleeding from an injured lung requires surgical intervention in blunt polytrauma. We present 2 cases of active
bleeding from injured lungs that were successfully treated with
selective coil or n-butyl-2-cyanoacrylate embolization of the pulmonary artery.

P-162
Embolization of posttraumatic celiac trunk pseudoaneurysm

Successful treatment of terminal ileum arteriovenous

malformation by balloon-occlusion arterial embolization using
n-butyl-2-cyanoacrylatelipiodol

M.GonzlezLeyte1, M.EchenagusiaBoyra2, A.AlvarezLuque1,

G.Rodriguez-Rosales1, J.M.JimenezPerez1, E.CallejaCartn2
1Interventional Radiology, Hospital General Universitario Gregorio
Maran, Madrid, Spain, 2Radiology, Hospital General Universitario
Gregorio Maran, Madrid, Spain

M.Eguchi1, O.Ikeda2, Y.Nakasone2, Y.Yamashita3

1Medicine, Radiology, Kumamoto University, Kumamoto City, Japan,
2Diagnostic Radiology, Kumamoto University Graduate School of
Medical and Pharmaceutical Sciences, Kumamoto, Japan, 3Diagnostic
Radiology, Kumamoto University, Kumamoto, Japan

We report a 47-year-old male who presented to the emergency

department after a fall from height with a contained rupture of the
celiac trunk. Transarterial sandwich embolization with coils and
plugs was performed with optimal technical and clinical results.

P-158

A 70-year-old womans atrial fibrillation was treated with vitamin K

antagonists. Endoscopic and angiographic studies revealed melena
and anemia due to a terminal ileum arteriovenous malformation.
We treated her by injecting n-butyl-2-cyanoacrylatelipiodol during
ileal artery occlusion using a micro-balloon catheter.

P-159

P-163
An unusual right varicocele due to postraumatic arteriovenous
fistula in a young man
F.Petrocelli, F.Camerano, G.Bovio, A.Utili, G.Salsano, C.Ferro
Radiology, San Martino University Hospital, Genoa, Italy
A man presented with a right varicocele. CT scan showed an arteriovenous fistula between the medial circumflex femoral artery and
the right pampiniform plexus. The embolization of the feeding vessel was successfully performed.

Balloon-assisted double-barrel catheter technique for glue

embolization of a ruptured traumatic anterior tibial artery
pseudoaneurysm
K.Idoguchi1, R.Usui1, M.Narita1, S.Nakao1, Y.Mizushima2
1Division of Endovascular Therapy, Rinku General Medical Center,
Senshu Trauma and Critical Care Center, Osaka, Japan, 2Senshu
Trauma and Critical Care Center, Rinku General Medical Center, Osaka,
Japan
A 56-year-old man presented with sudden-onset shock due to rupture of a traumatic anterior tibial artery pseudoaneurysm on the
40thday. Owing to its short proximal neck, conventional embolization was difficult; therefore, the balloon-assisted double-barrel catheter technique with glue was used to resolve the problem.

P-164
Successful transarterial coil embolization of coronary arterypulmonary artery shunts: three cases
T.Sato1, H.Ota1, H.Sakakibara2, H.Takagi1, T.Hasegawa1, K.Seiji1,
K.Takase2
1Diagnostic Radiology, Tohoku University Hospital, Sendai, Miyagi,
Japan, 2Diagnostic Radiology, Tohoku University Graduate School of
Medicine, Sendai, Miyagi, Japan
Coronary artery-pulmonary artery shunts are relatively rare. Although management of these conditions remains controversial,
transarterial embolization is less invasive than surgery. We describe
three cases that were treated by transarterial coil embolization.
All embolizations were successfully performed without major
complications.

P-160
Successful superselective glue embolization for a ruptured
omental artery aneurysm in a patient with fibromuscular
dysplasia
K.Idoguchi1, M.Yamada2, R.Usui1, M.Narita1, S.Nakao1,
Y.Mizushima2
1Division of Endovascular Therapy, Rinku General Medical Center,
Senshu Trauma and Critical Care Center, Osaka, Japan, 2Senshu
Trauma and Critical Care Center, Rinku General Medical Center, Osaka,
Japan
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P-165

P-169

Transcatheter arterial embolization of a Rasmussen aneurysm

with histoacryl glue injection under proximal balloon
occlusion

Urgent treatment of lower gastointestinal bleeding secondary

to hepatic artery pseudoaneurysm: transcatheter embolization
with NBCA and hepatic artery flow preservation

Y.Tanahashi1, H.Kondo1, S.Goshima2, M.Osawa1, H.Kawada2,

T.Yamamoto1, M.Matsuo2, S.Furui1
1Radiology, Teikyo University School of Medicine, Tokyo, Japan,
2Radiology, Gifu University Hospital, Gifu, Japan

M.Langleib, E.Squarza
Departamento Clinico de Imagenologia, Hospital de Clinicas Dr.
Manuel Quintela. Universidad de la Republica UDELAR, Montevideo,
Uruguay

We here describe a case of a Rasmussen aneurysm with multiple feeding arteries and systemic-to-pulmonary artery shunt. TAE
with histoacryl glue injection under proximal balloon occlusion in
the pulmonary artery effectively embolized the aneurysm, feeding
arteries, and systemic-to-pulmonary artery shunt.

Pseudoaneurysm of the hepatic artery is treated with several endovascular techniques and materials. A male patient presented with
lower gastrointestinal bleeding with hemodynamic instability.
We embolized two hepatic artery pseudoaneurysms with NBCA.
Post-embolization control shows preservation of hepatic artery
circulation.

P-166
Emballoonisation: an useful alternative when the edge is too
close
M.GonzlezLeyte, M.EchenagusiaBoyra, A.AlvarezLuque,
G.Rodriguez-Rosales, J.M.JimenezPerez, E.CallejaCartn
Interventional Radiology, Hospital General Universitario Gregorio
Maran, Madrid, Spain
We report the case of an 80-year-old male with a superficial circumflex iliac artery pseudoaneurysm arising at less than 3 mm from the
iliofemoral axis, which was treated successfully by transarterial temporary balloon occlusion as a sole technique.

P-167
Coil embolization with combination of micro-balloon
assistance and double-catheter technique for a huge superior
mesenteric artery pseudoaneurysm secondary to acute
pancreatitis
H.Yamaguchi, S.Murata, H.Saitou, S.Onozawa, T.Ueda,
F.Sugihara, D.Yasui, I.Miki, S.-I.Kumita
Radiology, Nippon Medical School, Tokyo, Japan
A huge superior mesenteric artery (SMA) pseudoaneurysm drained
into the mesenteric vein arose between first and second jejunal
arteries. The SMA trunk between the first and second jejunal arteries
was embolized with micro-coils using the combination of micro-balloon assistance and the double-catheter technique.

P-168
Posttraumatic high-flow priapism: endovascular embolization
with n-butyl-2-cyanoacrylate
M.Langleib1, E.Squarza1, M.Alvez2, A.Icasuriaga2, A.Esperon2
1Departamento Clinico de Imagenologia, Hospital de Clinicas Dr.
Manuel Quintela. Universidad de la Republica UDELAR, Montevideo,
Uruguay, 2Centro Cardiovascular Universitario, Hospital de Clinicas Dr.
Manuel Quintela. Universidad de la Republica UDELAR, Montevideo,
Uruguay
High-flow priapism secondary to traumatic pudendal cavernosal fistula is infrequent. Treatment and embolization materials are controversial. We discuss a 32-year-old male patient treated with superselective pudendal internal catheterizations and NBCA embolization.
Complete detumescence was observed without complications.

P-170
Endovascular treatment for severe hematuria caused by
radiation cystitis
M.LeyvaVsquez-Caicedo, J.GonzlezNieto, J.E.ArmijoAstrain,
J.V.MndezMontero
Vascular and Interventional Radiology, Hospital Universitario Clnico
San Carlos, Madrid, Spain
We report two patients with intractable hemorrhagic cystitis following radiation therapy treated with superselective embolisation of
bilateral vesical arteries.
Transarterial embolisation is a safe and effective procedure that
achieves control of refractory bladder bleeding.

P-171
Combined transpulmonary arterial embolization and
retrograde transpulmonary venous embolization for
pulmonary arteriovenous malformation
H.Tanaka1, T.Tsuda2, T.Mochizuki2
1Radiology, Ehime University Graduate School of Medicine, Matsuyama
Ehime, Japan, 2Radiology, Ehime University Graduate School of
Medicine, Toon Ehime, Japan
We report successful retrograde transpulmonary venous coil embolization after incomplete transpulmonary arterial coil embolization
for complex-type pulmonary arteriovenous malformation (AVM).
Additional retrograde transpulmonary venous embolization is effective for residual inadequate arteriovenous fistula and drainage vein
of complex-type pulmonary AVM.

P-172
An amazing splenic aneurysm!
K.R.Hamza1, R.Abid2
1Radiology, C.E.R.E.V., Tunis, Tunisia, 2Radiology, El Farabi, Sfax, Tunisia
We report the first case in the literature of a splenic vein aneurysm
treated with an endovascular approach in a 62-year-old woman who
was treated for chronic lymphoid leukemia in complete remission
and was suffering from abdominal pain and back pain.

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P-173

P-178

BRTO for SMV-IVC shunt with gastro-renal shunt

Hybrid procedure for multiple pancreaticoduodenal artery

aneurysms associated with superior mesenteric artery (SMA)
occlusion

M.Nakamura, T.Matsumura, T.Nakamura

Radiology, Shimane University Faculty of Medicine, Izumo Shimane,
Japan
A 59-year-old female with chronic hepatitis and hyperammonemia
had to undergo BRTO. Shunt flow from SMV to IVC was collected
with right ovarian vein. Using the jugular approach, complete obliteration was achieved. Second BRTO for gastro-renal shunt was performed after 8 weeks.

P-174
The use of PHIL, a novel embolic agent in the management of
type II endoleaks
N. Shaida
Dept. of Radiology, Addenbrookes Hospital, Cambridge, United
Kingdom

K.Seiji1, H.Sakakibara2, T.Hasegawa2, H.Ota1, T.Shimizu3,

H.Goto3, K.Takase2
1Diagnostic Radiology, Tohoku University Hospital, Sendai, Miyagi,
Japan, 2Diagnostic Radiology, Tohoku University Graduate School
of Medicine, Sendai, Miyagi, Japan, 3Division of Advanced Surgical
Science and Technology, Tohoku University Hospital, Sendai, Miyagi,
Japan
We report a case of multiple pancreaticoduodenal artery aneurysms
associated with SMA occlusion. At first, iliac artery-superior mesenteric artery bypass surgery was developed to preserve SMA blood
flow; subsequently, the sandwich technique of coil embolization
for each aneurysm was performed.

EVAR and TEVAR

Precipitating hydrophobic injectable liquid (PHIL) is a novel embolic

agent. It has iodine bound to polymer, resulting in reduced glare
artefact on follow-up CT compared to Onyx. This is the first documented use of PHIL in type II endoleak.

P-175
Transcatheter Amplatzer plugs and sodium tetradecyl sulfate
burger technique for varicocele embolization
S.R. Alharbi
Radiology, King Saud University, Riyadh, Saudi Arabia
A 26-year-old male patient presented with recurrent left varicocele after microsurgery. This was successfully embolized using two
Amplatzer plugs type 4 and sodium tetradecyl sulfate.

P-176
Inferior mesenteric arteriovenous malformation successfully
treated with a combination of transarterial and transvenous
embolization
M.Kamo, K.Yagihashi
Department of Radiology, St. Lukes International Hospital, Tokyo,
Japan
Inferior mesenteric arteriovenous malformation presented with
ischemic colitis. Main trunk of IMV was occluded. After partially
effective transarterial embolization, transvenous embolization was
performed using microballoon catheter advanced to the venous
component of the lesion via the marginal vein. Complete occlusion
was achieved.

P-177
A novel technique of retrograde transvenous embolization
with balloon-assisted arterial aspiration for peripheral arteriovenous malformation (AVM) with a dominant outflow vein
A.Kuhara1, N.Tanaka1, T.Kugiyama1, M.Nabeta2, M.Koganemaru1,
T.Abe1
1Radiology, Kurume University School of Medicine, Kurume, Japan,
2Emergency and Critical Care Medicine, Kurume University, Kurume,
Japan
We describe a novel technique of transvenous embolization of dominant outflow vein under negative pressure from an arterial balloon catheter in a case of peripheral AVM. This technique can allow
embolization of the dominant outflow vein and the shunting points
retrogradely.

P-179
Embolization of type II endoleaks after endovascular aortic
repair (EVAR) of abdominal aortic aneurysms (AAA) using
ethylenevinyl alcohol copolymer (EVOH, Onyx)
A.Z.Vance, A.Graif, R.Patel, M.McGarry, M.J.Garcia, C.J.Grilli,
G.Kimbiris, D.Leung
Interventional Radiology, Christiana Care Health, Newark, DE, United
States of America
Purpose: To evaluate our experience with embolization of type II
endoleaks using EVOH to prevent AAA sac expansion.
Material and methods: A retrospective review was performed of
patients undergoing embolization of type II endoleaks with EVOH
from 1/2009 to 12/2015. Three approaches were used for endoleak
catheterization: 1. Transarterial approach: transfemoral access with
retrograde transcollateral catheterization of the type II endoleak.
2. Direct approach: access to the excluded aneurysm sac via translumbar or transabdominal access. 3. Perigraft approach: transarterial
access followed by direct access to the excluded sac by catheterizing
the virtual space between the endograft and arterial wall at an iliac
graft apposition site.
Results: Twenty-nine consecutive patients who underwent 32
embolization procedures were identified. The mean time from EVAR
to the index embolization procedure was 43 months. The transarterial, direct, and perigraft approaches were used in 12, 12, and 8 cases,
respectively. The technical success rate was 94%. No major adverse
events were recorded. The mean follow-up period was 8 months.
The initial post-procedural CT (mean 3 months) showed the absence
of a persistent endoleak in 20 of 32 cases (63%). Two patients demonstrated a recurrent type I endoleak at 12-month follow-up. At
the last follow-up CT, 61% of patients showed stability (5 cm2) or
decrease (5 cm2) in the maximal cross-sectional aneurysm sac area.
Conclusion: EVOH embolization of type II endoleaks is safe and
effective. We found a trend over time of abandoning the cumbersome transarterial retrograde and direct translumbar approaches
in favor of the more efficient perigraft and direct transabdominal
approaches.

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CIRSE 2016

P-180
ECG-gating magnetic resonance quantification of aortic
distensibility for the prediction of aortic aneurysmal growth
rate
H.Kawada1, S.Goshima1, Y.Tanahashi2, K.Kajita2, Y.Noda1,
N.Kawai1, H.Koyasu1, H.Kondo2, M.Matsuo1
1Radiology, Gifu University Hospital, Gifu, Japan, 2Radiology, Teikyo
University Hospital, Tokyo, Japan
Purpose: To generate predictive factors for abdominal aortic aneurysm (AAA) growth rate using an ECG-gating Cine-MR images
(C-MRI).
Material and methods: The institutional review board approved
this prospective study, and all patients provided written informed
consent. During the nine months (Nov 2012-July 2013), twenty-one
patients (mean age, 75.0 years; age range, 6188 years) with AAA
underwent an ECG-gating C-MRI prior to elective endovascular aortic repair. A median follow-up period of AAA was 2.3 months (0.738.4 months) before C-MRI. The difference between the approximate aneurysmal volume in systolic and diastolic phases, which was
calculated from C-MRA images, was set to the ejection fraction (EF)
of aneurysm or blood sinus cavity (BSC). Approximate volume was
calculated based on the maximum cross-sectional area or the product of the major and minor axis diameters on the maximum crosssection. The relationship between the growth rate of AAA during
the follow-up period and various parameters obtained from C-MRI
was evaluated by using regression analysis.
Results: The ratio (x) of the aneurysmal maximum area over EF of
BSC was a sole significant predictive factor (P = 0.01) and moderately
correlated with AAA growth rate (y). The following prediction equation was calculated by multivariate analysis: y = 108.908 0.264 x (r
= 0.54).
Conclusion: A moderate correlation was observed between EF of
BSC calculated using C-MRI and the AAA growth rate.

P-181
EVAR: type Ia endoleak treated with balloon-expandable
stents
P.Rigamonti1, U.G.Rossi1, P.Torcia1, D.Santuari2, M.Carmo2,
R.Dallatana2, M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Vascular Surgery Unit, San Carlo Borromeo Hospital,
Milan, Italy
Purpose: To describe our experience in intraoperative management
of persistent type Ia endoleak post-EVAR deployment (after inefficient balloon remodelling) in hostile proximal neck patients using
balloon-expandable stents.
Material and methods: From October 2009 and October 2015, we
treated 15 abdominal aorta aneurysm patients (9 males, 6 females;
mean age 74 years) that underwent EVAR and had a persistent type
Ia endoleak with balloon-expandable stents. In all patients, the proximal part of the main bodies was deployed at the renal level, with no
gap between the first stent and the lower line of the renal artery. All
patients had a hostile proximal neck anatomy (calcified, angulate,
or short). After multiple inefficient balloon remodelling of the proximal stent, all patient underwent intraoperative balloon-expandable
stenting. All 9 patients underwent clinical, color-Doppler US, and
MC-CT follow-up.
Results: Technical success was achieved in all 15 patients (100%).
Complete sealing of the proximal neck was obtained immediately post-balloon-expandable stenting implantation in all cases
(100%), with no intraprocedural or late surgical conversion. No type
Ia endoleak and aneurysm sac enlargement were demonstrated on
follow-up imaging (mean 32 months).

SS/FC/HL/HTS/CM
Posters

S229

Conclusion: Post-EVAR type Ia endoleak has a high risk for a possible future aneurysm sac enlargement and consequence rupture.
When balloon remodelling fails, the deployment of balloon-expandable stent for persistent type Ia endoleak is a rapid, safe, and feasible
treatment that can eliminate surgical conversion.

P-182
Balloon-assisted embolization of the celiac trunk prior to
endovascular repair of thoracoabdominal aortic aneurysm for
the prevention of type II endoleak
Y.Ishizaka1, M.Yabuta2, K.Sawada1, A.Okumura1, T.Koyama1
1Diagnostic Radiology, Kurashiki Central Hospital, Okayama, Japan,
2Radiology, St. Lukes International Hospital, Tokyo, Japan
Purpose: To retrospectively evaluate outcomes of celiac trunk
embolization under balloon oclusion using coils with or without
Amplatzer vascular plug (AVP) prior to endovascular repair of thoracoabdominal aortic aneurysm for the prevention of type II endoleak.
Material and methods: Between February 2009 and November
2015, 21 patients (16 men and 5 women, mean age 70.9 years) underwent celiac trunk embolization under balloon occlusion before
endovascular repair of thoracoabdominal aortic aneurysm in order
to prevent type II endoleak. Technical success, radiation exposure
time, the incidence rate of type II endoleak after endovascular treatment, and complications were assessed.
Results: Technical success was achieved in 20 of 21 patients
(95.2%). In all patients, coils with or without AVP were deployed in
the planned short segment of celiac trunk. The radiation exposure
time ranged from 18 to 108 minutes (mean, 52.4 minutes). The radiation exposure time in 2 patients undergoing the embolization
with AVP was significantly shorter than that in 19 patients without
AVP. The incidence rate of type II endoleak after endovascular treatment was 9.5% (2 of 21 patients). Partial splenic infarction was noted
in 2 patients, and no additional treatment was needed in these 2
patients.
Conclusion: Balloon-assisted embolization of the celiac trunk
before endovascular repair of thoracoabdominal aortic aneurysm
might be effective to prevent type II endoleak. AVP might be effective to shorten the radiation exposure time.

P-183
Justifying the role of multiple CT-A examinations in post-EVAR
surveillance
H.Joshi, V.Shrivastava, R.Alchanan
Interventional Radiology, Hull Royal Infirmary, Hull, United Kingdom
Purpose: Following endovascular aneurysm repair (EVAR), patients
are entered into a surveillance program of regular CT-angiography
(CT-A) for monitoring of complications.
Currently, there is no recognised surveillance program available with
many centres, including ours, advocating CT-A at 3, 6 and 12 months
post-procedure followed by annual surveillance with CT-A, which
increases patient burden of ionizing radiation.
Our objective was to evaluate our current EVAR surveillance program and to determine if the number of CT-A could be reduced
without detrimental effects to the patient.
Material and methods: All EVAR cases for AAA were identified over
a 36-month period. Data was collected from the interventional radiology database, PACS, and patient archive. Cases were reviewed to
assess when full surveillance protocol was completed and when
patient management was altered if complications were identified.
Results: A total of 125 patients were identified, of which 50% completed a full surveillance. In this group, 67% had all normal CT-A and
33% had an abnormal CT-A at some point within the first 12 months
post-procedure with complications identified at either the 3-month

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or 12-month CT-A. No new complication was identified at 6 months

in any case. Endoleak was the most common complication (86%).
This led to no change in management.
Conclusion: Post-EVAR surveillance does have its role in identifying complications early and plan further treatment. Our experience
has shown that despite the identification of a complication, most
patients are managed conservatively. The 6-month CT-A added little
value, and we propose this examination be removed.

P-184
Rationalising EVAR follow-up for an evolving centralised
service
A.L.Stimpson, C.Davies
Vascular Surgery, Morriston Hospital, Swansea, United Kingdom
Purpose: A unified EVAR follow-up protocol is yet to be established;
hence, great variability exists. Currently, our unit performs 30-day
post EVAR CT with USS 6 monthly thereafter. With the increasing
number of EVAR, scanning at this level places pressure on resources.
This study aimed to evidence the rationalisation of our current
practice.
Material and methods: A retrospective audit of 90 consecutive
patients undergoing standard infra-renal EVAR over 2 years was conducted. Sac size at planning as well as 30 days, 6 months, 12 months,
18 months and 24 months post-EVAR was recorded. Sac size,
endoleak presence and intervention requirement were recorded.
Results: At 6 months, 7% of the patients demonstrated an increase
in the sac size; at 12 months, the number reduced to 2.8%. Six
patients demonstrated enlargement at 12 months, 4 were new. At 18
months, additional 2 patients were identified (these patients were
not seen at initial USS), and 2 further patients were identified at 24
months. None of these patients required re-intervention. Evidence
of type-2 endoleak on post-operative CT scan was not predictive of
ongoing sac expansion or intervention. Three patients required reintervention. None presented with an acute rupture post-EVAR.
Conclusion: Re-intervention rate is low with observation of
type-2 endoleaks being safe in this cohort. The data suggests that
12-month USS can be eliminated if the 6-month USS demonstrates
sac stasis or reduction with no endoleak. Therefore, in this cohort,
it would be acceptable to scan at 18 months and yearly thereafter.
This will have significant cost implications and reduced impact on
patients. With follow-up data, it could be possible to rationalise this
further.

P-185
Is automated EVAR planning accurate?
C.Miller1, J.V.Patel1, K.Flood1, C.J.Hammond1, S.J.McPherson1,
P.Walker1, D.R.Shaw2, J.Lenton2, D.O.Kessel1, J.Scott3, S.Puppala1
1Department of Radiology, The General Infirmary at Leeds, Leeds,
United Kingdom, 2Radiology, Mid Yorkshire NHS Trust, Wakefield,
United Kingdom, 3Vascular Surgery, Leeds Teaching Hospitals NHS
Trust, Leeds, United Kingdom
Purpose: EVAR planning is a key skill for vascular surgery and interventional radiology trainees. The aim of this study was to validate
the accuracy of an online EVAR planning application using retrospective data from a large UK-based teaching hospital.
Material and methods: Patients who underwent EVAR with endurant devices between 2012 and 2013 with pre-EVAR sizing sheets
were assessed using the application on www.evarplanning.com. The
programmes suggested device sizes were then compared to the
devices used, and the patient outcomes were recorded.
Results: In total, 97 EVARS (30 emergency, 61 elective, and 8 custom) were performed, of which 36 had sizing sheets. The device
sizes used were completely discordant from the ones suggested by

Abstract Book
the application in 23 cases, including 4 that were off IFU. Thirteen
cases were partially concordant (where one or more of body, limb, or
extension did not match).
Two cases required the addition of a cuff intraoperatively due to low
landing, one required limb extension due to distal type 1 endoleak
and one type 1 endoleak was left to resolve spontaneously. No junctional endoleaks were seen on table or over the following 13 years.
Conclusion: Among the evaluated cases, there were no complete
matches. The most common reason for discordance was in limb
lengths, and more extensions were used than the online application suggested but with no adverse outcomes. Formal sizing sheets
were not utilized in more than 50% of patients. Further validation
with a prospective real-time study will be necessary to confirm the
discordance.

P-186
Remodelling of aortic type B dissections in 12 patients treated
using the streamliner multilayer flow modulator: primary
versus secondary intervention
F.Stefanov1, L.Morris2, E.P.Kavanagh1, A.Helali2, V.Lundon1,
N.Hynes3, S.Sultan1
1Department of Vascular and Endovascular Surgery, University Hospital
Galway, National University of Ireland, Western Vascular Institute,
Galway, Ireland, 2Mechanical and Industrial Engineering, GMEDTECH
Research Centre, Galway-Mayo Institute of Technology, Galway,
Ireland, 3Vascular & Endovascular Surgery, Western Vascular Institute,
Galway, Ireland
Purpose: Evaluation of haemodynamic changes in type B dissections of 12 patients treated using the streamliner device by means of
computational techniques.
Material and methods: One-year follow-up data was extracted
from the multi-centre database hosted by the MFM Global Registry
and subjected to computational fluid dynamics analysis, which comprised simulating the blood flow through the true and false lumens
of the dissections and monitoring the perfusion to the carotid
suprarenal and renal arteries. Seven patients were subjected to primary intervention, while five patients were subjected to secondary
intervention.
Results: In total, 43% of patients showed an increase of 35% in
carotid perfusion, while the rest showed a decrease of 6% in the
perfusion (primary intervention group). Suprarenal perfusion
increased by 77% in 83% of the patients and decreased by 59% in
the rest. Renal perfusion increased by 55% in 83% of the patients
and decreased by 5% in the rest. Secondary intervention analysis
showed an increase of 2.5%, 41% and 124% in carotid perfusion in
40%, 20% and 80% of the patients, respectively. Perfusion decrease
in the rest of the patients was 7.2% (carotid), 21% (suprarenal) and
45% (renal). The aortic wall pressure was reduced in both situations:
primary by 6.5% and secondary by 5%.
Conclusion: The primary intervention showed better outcomes
for carotid and suprarenal perfusions; the secondary intervention
showed a decrease in the minimum renal perfusion and reduction in
the wall pressure. The secondary intervention prevailed in the renal
perfusion increases over the primary. The streamliner device performed better in the primary intervention situation for aortic type
B dissections.

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CIRSE 2016

P-187
Outpatient percutaneous endovascular aortic aneurysm
repair: single-center experience with simple and complex
aortic anatomy
C.-M.Chen1, S.-Y.Chu1, P.-J.Ko2
1Department of Medical Imaging and Intervention, Chang Gung
Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan,
2Departments of Thoracic and Cardiovascular Surgery, Chang Gung
Memorial Hospital at Linkou, Chang Gung University, Taoyuan, Taiwan
Purpose: To present the safety of outpatient percutaneous endovascular aortic aneurysm repair (PEVAR) in simple and complex aortic anatomy.
Material and methods: Retrospective data collection of 113 consecutive patients treated between February 2012 and December
2015 with outpatient PEVAR (including 5 chimney and 8 sandwich
techniques). Patient demographics, 30-day readmissions, complications, and 30-day mortality were recorded.
Results: Cohort mean age was 74 years (range 52-92 years) and
included 12 females (10.6%). Of the 113 patients, 9 (8.0%) required
same-day hospital admission (4 brachial access pseudoaneurysm,
2 lower back pains, 1 groin access bleeding, 1 low postoperative
blood pressure, and 1 distal leg embolus). A further 4 (3.5%) patients
were readmitted within a week (2 contralateral limb occlusion, 1
groin wound infection, and 1 bowel ischemia). There was no 30-day
mortality. Mean procedure time was significantly longer in the 6
access-related complications (4 hours 11 minutes versus 2 hours 28
minutes cohort).
Conclusion: Outpatient PEVAR can be safely performed in simple
and complex aortic anatomy. However, the brachial artery access
should be meticulously sutured and checked for bleeding.

P-188
Clinical outcomes of thoracic endovascular aneurysm repair
using commercially available fenestrated stent graft (Najuta
endograft)
S.Iwakoshi1, S.Ichihashi1, S.Sakaguchi2, K.Kichikawa1
1Radiology, Nara Medical University, Kashihara, Japan, 2Radiology,

SS/FC/HL/HTS/CM
Posters

S231

Conclusion: The perioperative and 3-year outcomes of the Najuta

endograft demonstrated high freedom from aneurysm enlargement
and patency rates of the supra-aortic branches.

P-189
TEVAR planning and simulation training improves trainee
confidence
A.Alsafi1, Z.Alsafi2, M.S.Hamady1
1Radiology, Imperial College Healthcare NHS, London, United Kingdom,
2Medical School, UCL, London, United Kingdom
Purpose: High-stake industries, such as aviation, rely on simulation
for training and continual appraisal. Medical education is gradually
following suit. We organized a simulation-based training course for
London Interventional Radiology trainees and assessed changes in
trainee confidence in both planning and performing TEVAR.
Material and methods: The training course consisted of three
short lectures on planning and performing TEVAR, followed by small
group discussion, hands-on planning and simulation stations as well
as a fully immersive thoracic aortic aneurysm rupture case using
ORCAMP. The ORCAMP station assessed the technical and non-technical skills of candidates with an emphasis on crisis management.
Pre- and post-course questionnaires were used, and a paired twotailed Student t-test was used to compare trainee confidence scores.
Results: Ten senior IR trainees attended the 1-day course, and eight
filled in the questionnaires and consented for their annonymised
data to be used in this study.
Trainee confidence was self scored on a scale of 1-5, 1 being not at
all confident and 5 being very confident.
The average trainee confidence in planning a TEVAR was 2.4 compared with 4.3 after the course (p = 0.0011). The average trainee confidence in performing TEVAR was 1.5 compared with 3.4 after the
course (p= 0.0058).
Conclusion: A 1-day TEVAR simulation and planning course significantly improved trainee confidence in both planning and performing TEVAR. It may be useful to incorporate simulation training into
the IR training curriculum. It remains to be elucidated whether this
translates into improved patient outcomes.

Matsubara Tokushukai Hospital, Matsubara, Osaka, Japan

P-190

Purpose: The Najuta fenestrated endograft (Kawasumi Labo, Inc.,

Tokyo, Japan) was developed to treat aortic arch diseases offering
maximal proximal sealing length while preserving the blood flow to
the supra-aortic branches. We evaluated the perioperative and midterm outcomes of this fenestrated endograft.
Material and methods: Between July 2007 and July 2013, 32
patients were treated with the Najuta endografts at three vascular centers. Mean patient age was 74.59.8 years. Technical success,
complication, overall survival rate, freedom from aneurysm-related
death, secondary intervention, aneurysm enlargement, and patency
of the supra-aortic branches were retrospectively investigated.
Results: The median follow-up period was 2.5 years (range, 0.26.2
years). Seventy-one supra-aortic vessels (30 brachiocephalic arteries, 31 left common carotid arteries, and 10 left subclavian arteries)
were planned to be preserved with fenestrations. The technical success rate was 91% (29/32, three type I endoleaks), and five perioperative complications were recognized. Perioperative death was not
observed. Overall survival rate and rate of freedom from aneurysmrelated death at 3 years were 67% and 97%, respectively. The rate of
freedom from secondary intervention and the aneurysm enlargement at 3 years were 84% and 85%, respectively. There were two
branched occlusions seen in 1 patient due to the endograft infolding. No other branch occlusion was seen in this follow-up period.
As a result, the patency rate of the supra-aortic branch was 97% at
3 years.

Findings of aneurysm sac digital subtraction angiography

(DSA) during transarterial embolization of type II endoleaks
and its outcomes
N.Hongo1, H.Kiyosue2, N.Kamei2, K.Oji2, R.Shuto1, S.Matsumoto1,
H.Mori1
1Department of Radiology, Oita University Faculty of Medicine, Oita,
Japan, 2Radiology, Oita University Faculty of Medicine, Yufu, Japan
Purpose: Endovascular management of type II endoleaks after
endovascular aneurysm repair has been recognized to be difficult
and complex. Recent advancement of the technique allows intrasaccular approach via collateral vessels and enables us to evaluate the
aneurysm sac digital subtraction angiography (DSA) during embolization. The objective of this study was to assess the findings of aneurysm sac DSA with subsequent treatment strategies and clinical outcomes after TAE.
Material and methods: We assessed the DSA findings of 27 patients
acquired by intrasaccular DSA or DSA from the orifices of inflow
arteries during the transarterial embolization of type II endoleaks
and evaluated the number of treatment sessions and outcomes after
treatments. DSA findings were also evaluated, especially focusing on
the existence of type II endoleaks supplied by the vasa vasorum or
visualization of the venous shunt.
Results: In total, 34 embolization sessions were conducted for 27
patients. There were 6 cases that showed type II endoleaks supplied

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by the vasa vasorum. This group necessitates a significantly higher

mean embolization session (1.66 vs. 1.25), lower complete embolization rate (17% vs 58%), and lower stability rate (50% vs. 80.9%) than
the group that showed type II endoleaks not supplied by the vasa
vasorum. Venous shunts via the periaoritc venous plexus were also
visualized in 3 cases. Concomitant type I endoleak was revealed in
2 cases.
Conclusion: The existence of type II endoleaks supplied by the vasa
vasorum may predict a poor outcome following embolization.

P-191
Cerebral embolic protection in thoracic endovascular aortic
repair (TEVAR): a pilot study

Abstract Book
or self-limiting. However, when it is persistent and the aneurysm sac
enlarges, embolisation of the type II endoleak is needed. Nowadays,
many embolic materials are used to control and close post-EVAR
type II endoleak.
Clinical Findings/Procedure: The purpose of this poster is to illustrate the (i) proprieties, (ii) preparation (iii) and delivery technique of
the liquid embolic agent Onyx for the treatment of persistent type II
endoleak in the enlarging aneurysm sac post-EVAR.
Conclusion: Super-selective endovascular embolisation is a wellaccepted treatment for patients with type II endoleak. Onyx should
be considered as supplementary embolic material, especially
because of its intrinsic characteristics.

P-193

G.Grover1, N.Rudarakanchana1, A.Perera1, M.S.Hamady2,

R.G.J.Gibbs2
1Department of Vascular Surgery, Imperial College London, London,
United Kingdom, 2Department of Interventional Radiology, Imperial
College London, London, United Kingdom

Two-year follow-up of patients treated with EMBO-EVAR for

prevention of type II endoleak
M.Natrella, A.Rapellino, G.Lunardi, M.Cristoferi, G.Fanelli,
A.Depaoli, C.Bogetti, T.Meloni
Interventional Radiology, Regional Hospital U.Parini, Aosta, Italy

Purpose: Stroke occurs in 210% and silent cerebral infarction (SCI)

in 70% of patients undergoing thoracic endovascular aortic repair
(TEVAR). SCI is associated with a 24-fold increase in risk of future
stroke, dementia, and cognitive decline.
The Sentinel Cerebral Protection System (SCPS) is a cerebral embolic
filter device (CEPD) that protects the innominate and left common
carotid arteries during intervention.
This study investigates the feasibility and safety of using a CEPD in
patients undergoing TEVAR.
Material and methods: Anatomically suitable patients underwent
TEVAR with SCPS, together with intra-operative transcranial Doppler
(TCD) of the middle cerebral arteries (MCA), pre- and post-operative
diffusion-weighted magnetic resonance imaging (DW-MRI), neurological examination, and pre-, post-, and 6-week neurocognitive
testing to detect any sub-clinical neurological deficit.
Results: Four patients, mean age 65 years underwent TEVAR with
SCPS. Proximal landing zones were 2, 3. Atheroma grade of the aortic arch was 1, 2. SCPS was successfully deployed and retrieved in all
cases.
TCD was performed, and high-intensity transient signals (HITS) were
detected in 3 cases. Maximum HITs were detected during stent
manipulation and deployment (76, 62, 36) and contrast runs (25, 114,
69). Total HITS during CEPD manipulation were 9, 78, 126.
There were no post-operative strokes. Two patients had no new
lesions on post-operative DW-MRI and 2 patients had new low-volume SCI lesions. Female 1: 5 lesions, 15.2 mm2. Male 2: 3 lesions, 25.2
mm2. There was no neurocognitive decline noted.
Conclusion: This is the first study to report use of CEPD in TEVAR. It
appears safe and feasible with encouraging early results.

P-192
Post-EVAR type II endoleak: endovascular embolisation with
Onyx
P.Torcia1, U.G.Rossi1, P.Rigamonti1, D.Santuari2, M.Carmo2,
R.Dallatana2, M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Vascular Surgery Unit, San Carlo Borromeo Hospital,
Milan, Italy

WITHDRAWN

P-194
Stanford type B dissection managed by thoracic stent
graft and zipper fenestration: case report and review of
fenestration techniques
T.Raudsepp1, K.Daly2, I.Robertson3
1Acute Service Division, Grater Glasgow and Clyde NHS Trust, Glasgow,
United Kingdom, 2Vascular Surgery, Grater Glasgow and Clyde NHS
Trust, Glasgow, United Kingdom, 3Interventional Radiology Unit,
Gartnavel General Hospital, Glasgow, United Kingdom
Learning Objectives: Review of fenestration techniques
Background: A 43-year-old man presented with an acute Type B
dissection extending from the left subclavian artery to both common iliac vessels. The true lumen was slit-like with dynamic obstruction of the coeliac axis and superior mesenteric artery. The true
lumen was cannulated via a right axillary artery approach, and a 28
mm X 155 mm Bolton thoracic stent graft deployed. Angiography
confirmed satisfactory placement but persistent malperfusion of
the visceral arteries. An 8-Fr long sheath was inserted over wires in
the true and false lumens and advanced to the lower thoracic aorta,
creating a long fenestration. A delayed presentation with elevated
lactate level and severe abdominal pain mandated immediate laparotomy. Small and large bowels were well perfused; however, there
was full-thickness necrosis of the stomach and duodenum. An emergency Whipple procedure was performed.
Clinical Findings/Procedure: There are two techniques of fenestration. The commonest technique is balloon fenestration. A target is placed in the true lumen and the intimal flap punctured from
the false lumen (Diagram A). This technique produces a focal intimal
tear. Zipper fenestration advances a sheath over wires in the true
and false lumen, creating a long tear along the intimal flap (Diagram
B). This technique creates a larger intimal defect.
Conclusion: Zipper fenestration of the false lumen can allow reperfusion to visceral vessels. Treatment should not be guided by imaging alone, and even with apparently effective fenestration, laparotomy should be considered following vessel malperfusion.

Learning Objectives: To describe how to use Onyx in super-selective embolization in patients with persistent type-II endoleak after
EVAR.
Background: Despite advances in dedicated software for EVAR
planning, preventing endovascular manoeuvre, new materials and
models of EVAR grafts and post-EVAR medical management, type II
endoleak is still unpredictable. In the majority of cases, it is stable

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P-195
Aortitis post-EVAR: imaging and management approach
C.L. Martinez Higueros
Radiology, Spanish Society of Vascular and Interventional Radiology,
Madrid, Spain
Learning Objectives:
1. To recognize the key imaging signs of aortitis during the follow up
of EVAR and TEVAR.
2. To revise the updated imaging approach for this pathology.
Background: Aortic graft infections, while been one of the most
lethal postoperative complications, account for a low incidence. This
latter could mislead the radiologist to overseen the signs and thus to
the delay of management.
Clinical Findings/Procedure: Sources of infection after graft placement can come from direct local contamination during the procedure, as well as, from distant focci, such as uriurinary tract obstruction, bowel diverticulae, haematogenous dissemination, among
others and could appears during the following weeks after the graft
placement up to several years, in the case of distant sources.
The most useful imaging techniques for this patholgy are CT
Angiography and G67 PET Scan and MR Angiography.
Signs of inflammation of the sourrounding tissues, peripheral collections and vivid enhancement of the graft, in addition to clinical
complains of fever, malaise and back pain strongly support graft
infection as first diagnosis and urges to rule out this problem with
priority.
Conclusion:
1. Graft infection should be considered during the follow-up of
EVAR/ TEVAR, specially when the clinical scenario suggests it.
2. It is important to know the available imaging techniques for
approaching this entity and use them wisely, according to each
patient conditions.
3. Recognizing early signs of graft infection is of remarkable importance in the management of these cases and urges to the interventional radiologist be aware of them.

SS/FC/HL/HTS/CM
Posters

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Conclusion: Due to the increase in the number of EVAR procedures,

endoleaks will be encountered with increasing frequency. Advances
in modern imaging (as well as access to CT angiography) and interventional techniques will enable timely intervention in suitable
cases. A review of this topic will benefit both diagnostic and interventional radiologists alike.

P-197
Efficacy of aortic balloon occlusion at sac embolization using
NBCA for type 2 endoleak after EVAR
H.Nishimaki1, K.Chiba1, Y.Ogawa2, Y.Sakurai1, K.Murakami2,
J.-I.Nishimura3, H.Ono1, M.Chikada1, T.Miyairi1
1Cardiovascular Surgery, St. Marianna University School of Medicine,
Kawasaki, Kanagawa, Japan, 2Radiology, St. Marianna University
School of Medicine, Kawasaki, Kanagawa, Japan, 3Interventional
Radiology, Kawasaki Saiwai Hospital, Kawasaki, Japan
During sac embolization with glue for type II endoleak after EVAR,
aortic balloon occlusion is expected to be effective in making the
glue fill the lumbar arteries proximally because of reduced in-flow
from the lumbar arteries.

P-198
A case of endovascular aneurysm repair of a dilated aortic
diverticulum in a patient with a mirror-image right aortic arch
S.Ono1, T.Ichikawa1, T.Hara1, T.Sekiguchi1, J.Koizumi1, Y.Imai1,
S.Shimura2
1Department of Diagnostic Radiology, Tokai University School of
Medicine, Kanagawa, Japan, 2Department of Cardiovascular Surgery,
Tokai University School of Medicine, Kanagawa, Japan
We report a case of a 74-year-old male with a mirror-image right
aortic arch. He had a dilated diverticulum of the descending aorta.
Endovascular aneurysm repair and bypass from the right common
carotid artery to the right axillary artery were performed.

P-196

P-199

Imaging features and treatment of EVAR endoleaks

Transcaval embolization for type II endoleak

D.Brennan1, D.Herlihy2, J.Duignan3, H.K.Kok 2, M.F.Given2

1Department of Cardiology, Beaumont Hospital, Dublin, Ireland,
2Department of Radiology, Beaumont Hospital, Dublin, Ireland,
3Department of Radiology, St. Vincents Hospital, Dublin, Ireland

W.-H.Lee1, C.H.Kang2, S.B.Yang3, J.M.Lee4, J.Ohm5

1Radiology, SoonChunHyang University Hospital, Cheonan, Korea,
2Radiology, Gangneung Asan Hospital, Gangneung, Korea, 3Radiology,
SoonChungHyang University Hospital, Gumi, Korea,4Radiology,
SoonChunHyang University Bucheon Hospital, Bucheon, Korea,
5Radiology, Chungnam National University Hospital, Daejeon, Korea

Learning Objectives:
1. To review and illustrate imaging of different endoleak types.
2. To review and illustrate examples of endovascular treatment
techniques and follow-up strategies.
Background: Endovascular aneurysm repair (EVAR) is a minimally
invasive technique for the treatment of abdominal aortic aneurysms (AAAs). Its increasing use has led to a rise in the prevalence
of endoleaks, a post-procedural complication whereby blood flows
persistently into the aneurysm sac. Endoleaks are classified into
5 types and are seen in 20%40% of patients during follow-up
imaging.
We undertook a retrospective review of EVAR endoleak repair procedures performed in a tertiary referral centre over the past 5 years.
We recorded each procedures indication, imaging finding, proposed treatment and outcome.
Clinical Findings/Procedure: In our poster, we will exhibit the
examples of common endoleaks (focusing mainly on types 1 and 2)
as well as corresponding techniques for embolisation using a combination of materials ranging from coils to liquid embolic agents (e.g.
glue and Onyx). We will also exhibit the different imaging modalities
commonly used in endoleak imaging and highlight the advantages
and limitations of each.

A type II endoleak is one of the troublesome complications after

endovascular aortic repair, and various methods have been introduced to resolve this. We report successful exclusion of a type II
endoleak using direct sac puncture embolization by a trans-caval
approach.

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Experimental work in IR
P-200
An experimental study of the anti-tumor effect of a suspension
of TR fluid and cisplatin
S.Watanabe1, N.Nitta1, S.Ota1, A.Sonoda1, Y.Tomozawa1,
K.Murata1, R.Nakano2, S.Yao2
1Radiology, Shiga University of Medical Science, Otsu, Japan,
2Chemical Engineering, Fukuoka University, Fukuoka, Japan
Purpose: To evaluate the anti-tumor effect of a newly-developed
cisplatin-suspended thermal rheological (cisTR) fluid.
Material and methods:
1) Twelve rabbits were divided into 2 groups, and their renal arteries
were embolized using TR fluid. The groups were sacrificed 7 and
28 days later and kidneys were extracted. Pathological changes in
arterial walls were evaluated.
2) Fifteen rabbits with VX2 liver tumor were assigned to 3 groups
and the following agents were infused from the hepatic artery:
Group 1 (G1), saline; Group 2 (G2), TR fluid; and Group 3 (G3), cisTR
fluid. Tumor growth rates were measured on MRI obtained before
infusion and 7 days after infusion.
3) Blood platinum concentrations (PCs) were measured at 1 hour,
24 hours, 3 days, and 7 days after infusion. Tissue PCs were also
measured in the tumor as well as in surrounding normal liver at 7
days after infusion.
Results:
1) In angiography, embolized vessels were obstructed 28 days after
infusion. In microscopic specimens, TR fluid existed in the mold
form within blood vessels and vascular wall distension and inflammation was observed.
2) The tumor growth rate was significantly lower in G2 and G3
compared with that in G1 (p < 0.05). However, there was no significant difference between G2 and G3 (p = 0.98).
3) Blood PCs peaked at an hour and gradually decreased thereafter.
Tissue PC in the tumor was significantly higher than that in the
normal liver (p < 0.05).
Conclusion: TR fluid has become a new embolic material and has
the potential to sustain cisplatin.
Although further examinations are needed, it seems possible to
apply cisTR fluid in cases where a controlled release of cisplatin is
desired.

P-201
Can irreversible electroporation (IRE) be done in the presence
of metal biliary stents?
E.M.M.Yu1, H.Kavnoudias1, K.R.Thomson2
1Radiology Research Unit, Alfred Health, Melbourne, VIC, Australia,
2Radiology, Alfred Hospital, Melbourne, VIC, Australia
Purpose: IRE, a non-thermal ablative technique, is indicated for
inoperable tumours near large vessels or bile ducts. Since many
locally advanced hepatopancreatobiliary cancer patients have metal
biliary stents, our objective was to compare safety and clinical outcomes in pancreatic cancer patients with and without metal biliary
stents.
Material and methods: Retrospective data was obtained from our
IRE database and electronic records to identify patients who underwent pancreatic IRE from October 2013 to September 2015. Patients
with plastic stents and those who did not have primary pancreatic
cancer were excluded.
Results: Ten patients (8 males, 2 females) with a mean age of 64
10 (range: 4679) fulfilled the study requirements. Four of the
10 patients had metal biliary stents. Ten of 11 procedures were

Abstract Book
performed percutaneously and 1/11 was performed open. Mean
tumour size was 4.2 cm 0.92 (range 2.56 cm), and median follow-up was 10 months (range: 118 months). There were 3 serious adverse events: polymicrobial septic shock (stented patient), a
delayed arterio-enteric fistula and an omental bleed. Of the stented
patients, 50% (n=2) died from disease progression, with the longest
survival at 18 months. At follow-up, 75% (n=3) demonstrated residual/recurrent tumour along and within the stent by 6 months. Of the
6 unstented patients, 1 died and only 1 patient (open procedure)
demonstrated involution of the tumour at up to 6 months.
Conclusion: IRE can be performed safely in the presence of metal
stents. However, stent presence may cause less effective treatment
from unpredictable currents and ablation zones, leading to residual
disease around the stents.

P-202
Transarterial embolization combined with RNA interference
targeting hypoxia-inducible factor-1 alpha for hepatocellular
carcinoma: a preliminary study of a rat model
J.Y.Ni, L.F.Xu
Interventional Radiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen
University, Guangzhou, China
Purpose: To study whether transarterial embolization (TAE) with
hypoxia-inducible factor-1 alpha (HIF-1)-specific small interfering
RNA (siRNA) can inhibit the expression of HIF-1 in hepatoma cells
after TAE.
Material and methods: In this study, the CBRH-7919 rat hepatoma
cell line was used and the liver cancer models of rats were conducted. A HIF-1-specific RNA interfering sequence was selected
from an early vitro experiment. The siRNA transfection mixture was
produced by mixing the specific siRNA and Lipofectamine 2000.
During the TAE procedure, the iodized oil emulsion (lipiodol mixed
with siRNA) was slowly injected through the proper hepatic artery.
The enrolled rats were randomized to four groups: 1) control; 2)
TAE; 3) HIF-1-siRNA; 4) TAE + HIF-1-siRNA. The expression level of
mRNA was detected using the real-time reverse transcription-polymerase chain reaction (RT-PCR). The expression level of protein was
detected and analyzed by western blotting and an immunohistochemistry assay.
Results: In the early vitro experiment, the selected HIF-1-specific
RNAi sequence was successfully transfected into the hepatoma cells.
The transfection of specific siRNAs significantly inhibited the expression levels of HIF-1 in mRNA and protein. In the vivo study, TAE procedures were successfully performed for liver tumors of 32 rats, with
a success rate of 80% (40/50). The survival time of rats treated with
TAE + HIF-1-siRNA was significantly longer than that of rats treated
with TAE or HIF-1-siRNA alone. Compared with the control, TAE, and
HIF-1-siRNA, treatment with TAE + HIF-1-siRNA can significantly
inhibit the expression levels of HIF-1 and VEGF.
Conclusion: TAE with a mixture of lipiodol and HIF-1-specific siRNA
could significantly downregulate the expression levels of HIF-1 and
VEGF in rat hepatoma cells after TAE.

P-203
Comparison between tumor vascularity and hemodynamics in
three rat hepatoma models
H.-C. Kim
Radiology, Seoul National University Hospital, Seoul, Korea
Purpose: To compare tumor vascularity and hemodynamics in
three rat hepatoma models: N1-S1 cells in Sprague Dawley rats,
McA-RH7777 cells in Sprague Dawley rats, and 13762 MAT B III cells
in F344 rats.

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Material and methods: The three rat hepatoma models were
induced in five rats per group. After confirming that the tumors grew
up to 10 mm on magnetic resonance imaging, the rats underwent
dynamic contrast-enhanced ultrasonography (DCE-US). Afterward,
the rats were euthanized for histologic analyses. KruskalWallis test
was used to compare the rat hepatoma models. Correlation coefficients were calculated between the microvessel density (MVD) and
DCE-US parameters.
Results: On DCE-US imaging, arterial enhancement and washout
were demonstrated in all N1-S1 tumors, while persistent peripheral enhancement on arterial to portal phases was demonstrated in
all 13762 MAT B III tumors. McA-RH7777 tumors presented diverse
enhancement patterns on arterial and portal phases. There were
no significant differences in the DCE-US parameters among the
three rat hepatoma models, while MVD was correlated with the
peak intensity (r = 0.565, p = 0.044), mean transit time (r = 0.559,
p = 0.047), and time to peak (r = 0.617, p = 0.025) of individual rats.
The necrosis ratio was significantly different among the models (p =
0.031); 13762 MAT B III tumors showed a significantly higher necrosis
ratio than N1-S1 tumors (p < 0.050 by post-hoc test).
Conclusion: The N1-S1 tumor may be suitable as a model to investigate hypervascular hepatic tumors of the liver such as hepatocellular carcinoma by DCE-US.

P-204
Short-, medium- and long-term follow-up for percutaneous,
minimally invasive irreversible electroporation (IRE) of renal
tumours: a prospective single-centre study
H.Kavnoudias1, E.M.M.Yu2, R.E.NealII2, W.Cheung2, S.Ellis2,
K.R.Thomson2
1Radiology Research Unit, Alfred Health, Melbourne, VIC, Australia,
2Radiology, Alfred Hospital, Melbourne, VIC, Australia
Purpose: IRE, a non-thermal nephron-sparing ablation technique,
offers an alternative treatment for renal tumours. We report on
safety, efficacy and short to long-term follow-up.
Material and methods: Consecutive patients with unresectable
tumours or poor thermal ablation candidates were treated between
2008 and 2015. A 2-6 needle IRE was performed percutaneously with
CT guidance, GA/neuromuscular relaxant and cardiac rhythm synchronisation. Current output was between 1200 and 1800V/cm (2045 amps). Technical success verified with CE-CT. Patients were followed up for AEs and recurrence-free survival.
Results: Nineteen patients (10 males, 9 females), mean-age 7011
(range=43-85), with solitary or multiple tumours, 16/19 (84%) RCC,
and 3/19 (16%) with metastases were included. Of them, 47% had
previous total nephrectomy (7/19), partial nephrectomy (1/19) or
an atrophic kidney (1/19). Twenty-seven tumours (mean diameter
3.31.4cm; range=1.6-6.2cm; 16/27<3cm, 11/273cm) were treated
in one or two procedures (total=29 procedures). 6/19(32%) had salvage procedure for residual-disease. One patient was lost to followup. Three had residual disease and died of other co-morbidities. One
patient failed salvage IRE and went on to have a partial nephrectomy. Four patients followed-up for 5-7 years, (7 tumours, 5/7<3cm,
2/73cm), five with solitary tumours (3/5<3cm, 2/53cm) followed
up for 2-4 years and five with solitary tumours and one with vonHippel-Lindau syndrome and four tumours (6/9<3cm,3/93cm) followed up for 3-14 months had complete ablations without recurrence. Overall complete ablation for tumours <3cm was 88%; for
tumours 3cm, 63%. Sixty-seven percent of procedures were complication free, 31% had minor Grade 1 and 2 and 7% had major
Grade 3 complications consisting of brachial-plexus neuropraxia
and pneumothorax.
Conclusion: Renal IRE is a safe alternative for treatment of renal
tumours. Limited medium- to long-term data suggest efficacy of the
procedure.

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S235

P-205
Real-time thermosensitive MR imaging during microwave
ablation
B.Kaltenbach, A.Roman, K.Eichler, N.-E.A.Nour-Eldin, T.J.Vogl,
S.Zangos
Radiology, Goethe Universitiy Frankfurt, Frankfurt, Germany
WITHDRAWN

P-206
Magnetic resonance-guided focused ultrasound surgery
(MRgFUS) for primary pancreatic and hepatic cancer: a
preliminary experience of tumor control
H.-P.Erasmus, M.Anzidei, S.Dababou, C.Marrocchio, M.Bezzi,
C.Catalano, A.Napoli
Radiological, Pathological and Oncological Sciences, Sapienza University of Rome, Rome, Italy
Purpose: Hepatocellular carcinoma (HCC) and pancreatic cancer
represent two of the most challenging abdominal tumors owing to
their vascular relationship with adjacent structures resulting in an
overall poor prognosis. Both these cancers have been previously
successfully treated with ultrasound-guided focused treatment.
MRgFUS introduces the advantage of realtime monitoring, allowing a more precise lesion ablation and a more accurate in-treatment
patient management. This technique has been widely used in other
applications, while its use to treat HCC and pancreatic cancer is still
in a preliminary phase. Therefore, our purpose was to evaluate the
safety and effectiveness of high-intensity MRgFUS in these types of
cancer.
Material and methods: Five patients with pancreatic cancer
and one with unresectable right lobe HCC underwent MRgFUS
(ExAblate2100, InSightec). Treatments were achieved as part of a single ambulatory session. To evaluate tumor control, perfusion T1WI
after contrast medium administration was obtained before and after
treatment. Follow-up examinations were scheduled at 1, 3, 6, and 12
months.
Results: The treatment was tolerated well by all patients and no
heating-related adverse events were recorded. Immediately after
the procedure, all patients showed coagulative necrosis with a mean
non-perfused volume of 65.4%16.6% (45%90%). All patients with
pancreatic cancer showed a significant decrease of pain. At followup, no local progression was recorded; after MRgFUS, two patients
with pancreatic cancer underwent radiotherapy, while another one
required a second MRgFUS treatment.
Conclusion: Our preliminary experience indicates that MRgFUS
could be a promising noninvasive treatment modality in patients
with unresectable pancreatic cancer or HCC.

P-207
Monitoring thermal-induced changes of liver stiffness by realtime point shear wave elastography (pSWE) in ex-vivo bovine
liver tissue
F.Calcagni1, L.Crocetti2, N.Tosoratti3, C.Amabile3, S.Cassarino3,
F.P.Tarantino1, R.Cioni2
1Division of Radiology, Cisanello University Hospital, Pisa, Italy,
2Division of Interventional Radiology, Cisanello University Hospital,
Pisa, Italy, 3R&D Unit, HS Hospital Service SpA, Aprilia, Italy
Purpose: In point shear wave elastography (pSWE), an acoustic radiation force impulse is used to generate shear waves in the liver tissue. Shear wave velocity (SWV) reflects the underlying tissue stiffness. This study aims to (1) quantify the temperature dependence of

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liver tissue stiffness as measured with SWV, (2) assess the repeatability of this measurement, and (3) evaluate the irreversibility of stiffness changes.
Material and methods: Five samples of ex-vivo bovine liver tissue
were uniformly heated to target temperatures ranging 40-100C
and then cooled down until 50C was reached. B-mode imaging
and pSWE were acquired simultaneously (Virtual Touch Tissue
Quantification, Siemens Healthcare) and SWV, expressed in m/s, was
measured in a fixed region of interest (ROI, <1 cm2) at set temperatures (2.5-5C intervals). Tissue temperature was recorded by two
thermocouples positioned at 1.5 cm from the ROI.
Results: A steep transition in liver stiffness was observed at
63.02.4C with an average SWV value of 3.540.68 m/s (baseline value: 1.410.17 m/s at room temperature). A decrease in SWV
was observed up to 42C (-0.310.07 m/s with respect to baseline),
a gradual increase was detected up to 55-60C, and the described
transition followed above 60C. This pattern was observed in
all experiments, with very similar SWV/temperature curves. The
changes in liver stiffness proved to be irreversible, as average SWV
values of 4.400.41 m/s were measured in the cool-down cycles.
Conclusion: Liver tissue stiffness is strongly affected by temperature changes. pSWE is a highly reproducible, non-invasive technique
that allows to assess in real time the thermal effects on liver tissue.

P-208
Preclinical testing for the safety of a new prototype coaxial
needle in a mimic iatrogenic vascular trauma animal model
P.P.Rao1, G.Tsoumakidou2, B.Elodie1, J.Garnon2, G.Koch2,
J.Caudrelier2, R.L.Cazzato2, M.-A.Thenint2, A.Gangi2
1Division of Robotics and Department of Interventional Radiology,
ICube Laboratory and University Hospital of Strasbourg, Strasbourg,
France, 2Interventional Radiology, University Hospital of Strasbourg,
Strasbourg, France
Purpose: To compare a new prototype coaxial needle (PCN) with
safety guard with a standard coaxial needle (SCN). To elicit its atraumatic nature toward important vascular structures and compare it
with a standard commercially available needle.
Material and methods: A male pig under general anesthesia was
used for this study. Fluoroscopy and ultrasound were used for needle guidance. Angiography and CT angiography were performed
after selective catheterization of the arteries, following each needle puncture. The PCN (17G) and control SCN (17G) were alternately
advanced adjacent to the intercostal, superior mesenteric, and femoral arteries and portal vein with the intent to elicit trauma to vessels mimicking iatrogenic trauma during percutaneous procedures.
This was then controlled by angiography images. The PCN was additionally evaluated from ease of puncture, ease of advancing through
soft tissue, and pneumothorax and bowel puncture as secondary
end points.
Results: PCN had an atraumatic compressive effect on the intercostal, superior mesenteric, and superficial femoral arteries and portal
vein. No trauma was elicited, even under excessive force, and complete reversible occlusion was observed in all cases.
SCN was traumatic and extravasation from the intercostal, superior
mesenteric, and profound femoral arteries was demonstrated. SCN
completely transfixed the portal vein under ultrasound guidance.
Secondary end points were satisfactory, and the needle performance was appreciated by both operators.
Conclusion: Using an experimental animal model, we found PCN to
be less traumatic on vessels compared to SCN during interventional
radiology procedures.

Abstract Book

P-209
Robotic device for needle orientation and insertion under
image guidance: initial preclinical experience
P.P.Rao1, A.Bruyas1, L.Barbe1, P.Renaud1, F.Geiskopf1, B.Wach1,
J.Garnon2, A.Ricoeur2, M.DeMathelin1, A.Gangi2
1Division of Robotics and Department of Interventional Radiology,
ICube Laboratory and University Hospital of Strasbourg, Strasbourg,
France, 2Interventional Radiology, University Hospital of Strasbourg,
Strasbourg, France
Purpose: Proof of concept of a new remotely controlled robotic
device for needle orientation and insertion under image guidance. The goal is to reduce the amount of radiation received by the
physician.
Material and methods: Needle orientation and insertion were performed using a patient-mounted robotic device that is light (400 g)
and compact (15 cm in diameter, 12 cm in height). One component
was dedicated to needle orientation and another to needle insertion
(1 mm/s) using pneumatic energy. The system was remotely controlled and CT, fluoroscopy and MR compatible owing to a novel inhouse 3D-printed design.
Preclinical testing was performed on a phantom (5% gelatine with
multiple iodinated contrast coated PVA inclusions) using a Phillips
Allura FD 20 system with XpertGuide. The target was defined on
CBCT, and XperGuide was used for needle trajectory. The robot
was placed on the gel with needle placed central to the entry
point. Needle was advanced under fluoroscopy guidance following
XpertGuide.
Assessment for ease of positioning, needle orientation and insertion
was performed.
Results: The robot was easy to handle and to position. Needle orientation and insertion was easy to modify and precisely controlled
from the images. After a 60 mm insertion, the targeted inclusion
was reached with an error of 3 mm with respect to the target on
XpertGuide.
Conclusion: Initial preclinical experience shows the robot to be
effective and accurate in needle orientation and insertion. Its remote
control can help reduce radiation dose to operator. More studies in
animal models are needed to show efficacy in moving targets.

P-210
Percutaneous valvuloplasty of proximal GSV valves:
comparison of two hyaluronan gels
J.C. Ragg
Interventional Radiology, Angioclinic Vein Centers, Berlin, Germany
Purpose: Early detection of vein valve leakage and adequate veinpreserving treatment could prevent venous insufficiency. Surgical
valvuloplasty by valve-zone banding is feasible, but there is no
option for early stages of insufficiency. As a first interventional
modality, percutaneous valvuloplasty (PV) by ultrasound-monitored
perivenous injection of gels has been described. Here two pilot
series of PV with different hyaluronan gels underwent a retrospective comparison.
Material and methods: Patients with proximal GSV valve incompetence but preserved and mobile valve structures were included:
in series A (2014), 23 patients (15 w, 8 m; 3867 years, GSV diameter 7.011.5 mm, mean 8.6 mm) underwent PV using hyaluronan gel
consisting of large particles (>1 mm, Macrolane). In series B, (2015)
smooth hyaluronan gel (particles < 0.2 mm, prototype) was used in
18 patients (12 w, 6 m; 3469 years, GSV diameter 7.011.8 mm, mean
8.9 mm).
Results: Orthograde flow was established in 22/23 cases of series
A (95.6%) and 18/18 cases in series B (100%). Gel volumes were
1235 ml (mean: 19.4 ml, A) versus 49 ml (mean: 6.9 ml, B). There

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were no adverse reactions. At the 1-year follow-up, orthograde flow
was present in 15/22 cases (68.2%, A) versus 14/18 cases (78.6%, B).
Cases with reflux successfully received supplementary hyaluronan
injections.
Conclusion: Percutaneous valvuloplasty with large-particle hyaluronans is less precise and initially requires large volumes, while that
with small-particle hyaluronans is more precise but initially tends to
underdosage. Further studies will be performed to define the optimal substance.

P-211
Impact of crimping and balloon dilatation on endothelialized
covered stents
S.Ichihashi1, F.Wolf2, T.Schmitz-Rode2, K.Kichikawa1,
S.Jockenhoevel2, P.Mela2
1Diagnostic and Interventional Radiology, Nara Medical University,
Kashihara, Nara, Japan, 2Applied Medical Engineering, Helmholtz
Institute, RWTH Aachen University, Aachen, Germany
Purpose: Covered stents have been proposed as a class of endovascular devices with the potential to reduce restenosis. The poor
hemocompatibility of the available prosthetic membrane materials, however, limits the use of such stents. Therefore, in vitro endothelialization of the luminal surface before implantation could be
extremely advantageous. In this study, using an injection molding
technique, bare metal stents were covered with fibrin and subsequently endothelialized with human umbilical vein endothelial cells
and conditioned in a bioreactor under a continuous arterial pressure
(80120 mmHg) and shear stress conditions (1 Pa). We quantified the
damage to the endothelial layer of covered stents when subjected
to clinically relevant procedures such as crimping and crimping followed by balloon dilatation.
Material and methods: For each set of experiments, three covered
stents were prepared, one being subjected to crimping alone, one
to crimping in combination with subsequent balloon dilatation, and
one serving as control. The endothelial coverage was quantified by
scanning electron microscopy (SEM). Furthermore, the functionality of the endothelium was evaluated after exposure to platelet-rich
plasma by SEM and immunohistochemistry.
Results: Stent crimping did not result in a significant loss of endothelial cells with respect to the control. However, endothelial cells
detached significantly following balloon dilatation. The cells still
present on the stents surface, either after crimping or after crimping followed by balloon dilatation, remained functional, showing no
platelet adhesion and expressing eNOS and CD31.
Conclusion: The endothelial layer of fibrin-covered stents was not
significantly damaged by a crimping procedure, whereas the following balloon expansion significantly reduced the number of endothelial cells.

P-212
Construction of a hybrid stent graft using a novel in situ
welding technique: initial animal experience
A.I.Bloom1, F.Widlan2, M.Zarek 2, Y.Kalish3, V.Doviner4, D.Cohn2
1Radiology, Hadassah University Medical Center, Jerusalem, Israel,
2Casali Institute, Hebrew University of Jerusalem, Jerusalem, Israel,
3Hematology, Hadassah University Medical Center, Jerusalem, Israel,
4Pathology, Shaare Tzedek Medical Center, Jerusalem, Israel
Purpose: To evaluate the feasibility of in situ construction of a
novel hybrid stent graft device by welding a polymeric sleeve to a
metal stent intraarterially.
Material and methods: A 1015--thick, 3-cm-long thermoplastic
polymer sleeve was manufactured by dip coating, with subsequent
application of radiopaque markers. Initial deployment of precoated

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BE stent (Palmaz, Cordis) was followed by welding of sleeve (crimped

to a PTA balloon) to stent using heated contrast solution for inflation:
pressure (68 atm), welding temperature (Tw) 4548C and time ~20
s. Pre-implant devices underwent scanning electron microscopy
(SEM), thrombogenicity, biocompatibility and pullout force testing.
The experimental device was tested in nine domestic female pigs
(4555 kg), transfemoral arterial access, 8 F sheaths, sequential
device deployment in the iliac arteries/abdominal aorta, diameters
712 mm. Two control animals were compared, covered stents (WL
Gore inc.). Animals received 100 mg aspirin daily. Imaging included
catheter or CT angiography. Device explantation: post-mortem
at 0, 14, 30 and 90 days was subjected to macro- and microscopic
examinations.
Results: Initially experimental devices were constructed in vitro.
SEM confirmed component welding. Separation stress force was
182 N. Basic thrombogenicity/biocompatibility profiles were equivalent or superior to controls. All devices were successfully constructed in vivo. No macroscopic vascular injury, device migration or
immediate thrombosis was seen. At 1430 days, all devices (incuding
controls) remained patent. At 90 days, experimental aortic device
was partially patent with components strongly welded. Histologic
appearances were described.
Conclusion: In situ construction of a hybrid stent graft by component welding is feasible. Further optimization of the technique is
required. This strategy may have important clinical applications.

P-213
Renal sympathicolysis by transaortic periarterial injection of
ethanol in pigs with use of an experimental injection catheter
P.Freyhardt1, J.Schtze1, R.Donners1, J.Schnorr1, N.Stolzenburg1,
J.Rinnenthal2, R.W.Gnther1, B.Hamm1, F.Streitparth1
1Department of Radiology, Charit Universittsmedizin Berlin,
Berlin, Germany, 2Department of Neuropathology, Charit
Universittsmedizin Berlin, Berlin, Germany
Purpose: To evaluate feasibility, safety, and efficacy of renal sympathetic denervation in pigs after transaortic periarterial ethanol injection with an experimental injection catheter.
Material and methods: Percutaneous unilateral periarterial transaortic injection of 10 ml of a mixture of Ethanol-BupivacaineAccupaque (7:2:1) was performed in 11 normotensive pigs.
Catheter advancement and injections were performed under fluoroscopic guidance in all animals.
Blood pressure measurements and CT scans of the kidneys and perirenal structures were performed immediately pre- and post-intervention and 4 weeks after treatment. After euthanasia, the norepinephrine (NE) concentration of both the kidneys was determined.
A histopathologic analysis of the renal arteries and the surrounding tissue was performed to assess the induced nerve-fibre
degeneration.
Results: All procedures were technically successful with good periarterial distribution of the injectant. In two animals, a slight distribution to the contralateral side was observed.
One pig died immediately after the intervention due to cardiac
arrest.
NE concentration of the renal parenchyma was significantly lower
on the treated side in eight of ten pigs with a decrease of up to 68%
and correlating histopathological signs of nerve degeneration.
Conclusion: Renal sympathicolysis by transaortic periarterial injection of ethanol was feasible, effective, and safe in a pig model. This
approach may be an alternative to catheter-based RFA or other
methods of renal denervation.

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P-214
3D printing for pre-/intra-procedural planning in
interventional radiology
A.Ghodadra1, R.Varma1, M.Rabinovitz2, N.B.Mani3,
E.G.SantosMartn1
1Radiology, UPMC, Pittsburgh, PA, United States of America, 2Medicine,
UPMC, Pittsburgh, PA, United States of America, 3Radiology,
Washington University Physicians, St. Louis, MO, United States of
America
Learning Objectives: This exhibit reviews the types of 3D printing and their applications to procedure planning in Interventional
Radiology, illustrate the process required to generate a printable file
from DICOM data, and show how to identify the optimal printing
method for a given application.
Background: The term 3D printing refers to an additive manufacturing process wherein a 3-dimensional object is created one layer
at a time from a digital file. Recently, there has been a surge in the
availability of consumer-grade 3D printers. These relatively low-cost,
easy-to-use printers have made 3D printing viable in the clinical setting. Solid and hollow models of vascular anatomy can be created to
aid in planning for endovascular procedures.
Clinical Findings/Procedure: Applications and advantages of
3D-printed models are presented. Optimal patient and image selection is described. An overview of the major types of 3D printers,
including fused deposition modeling and stereolithography, and
printing materials is provided. The process of image segmentation
and 3D model preparation is also reviewed. The selection of the
optimal printer type for IR applications is discussed. Finally, a small
series of cases in which 3D printed models were used is presented.
Conclusion: The advent of desktop 3D printers presents the opportunity for the use of printed models of patient anatomy for procedure planning in IR. This review provides the reader with an overview of the applications of 3D printing in IR, types of 3D printers, the
process of generating 3D models and selection of the optimal printing method.

P-215
Simulation of embolization of visceral aneurysms with
3D-printed hollow models
E.Shibata, T.Hidemasa, S.Amemiya, K.Ohtomo
Radiology, The University of Tokyo Hospital, Tokyo, Japan
Before endovascular treatment of visceral aneurysms, we performed
simulation of embolization of the aneurysms with 3D-printed hollow models created from CT data. The preoperative simulations
made the patients treatments safe and successful.

GI tract intervention
P-216
The safety and efficacy of embolisation in the treatment of
post-gastrectomy haemorrhages
B.M.Ahmed, M.D.Kim, J.H.Kwon, G.Kim, M.Shin, W.Shin, S.I.Park,
D.Y.Lee, J.Y.Won
Radiology, Severance Hospital, Yonsei University College of Medicine,
Seoul, Korea
Purpose: Internal haemorrhage after gastrectomy can be fatal, but
only few relevant studies have been conducted on the safety and
efficacy of embolisation because of poor collateral vascularities.
The aim of this study was to evaluate embolotherapy for bleeding in
patients who had undergone subtotal (ST) or total (T) gastrectomy

Abstract Book
for gastric cancer. In addition, we identified characteristic differences in offending arteries and clinical outcomes according to the
type of surgery and onset period of bleeding after surgery.
Material and methods: Among 13,427 gastrectomies between
2004 and 2015, 34 patients were retrospectively analysed. Imaging
studies and medical records were reviewed. The most common
embolic material used was glue, followed by coil and gelfoam.
Results: Among the patients, 36 bleeding events requiring embolisation were identified on angiographies. The overall clinical success
rate was 73.5%. The common cause of bleeding was the gastroduodenal artery (GDA; n = 11/21; 52.4%) in ST gastrectomy and splenic
artery (7/11; 63.6%) in T gastrectomy (p < 0.05). One ST gastrectomy
patient demonstrated gastric infarction after splenic artery embolisation. Mortality rates for the splenic artery were 50% and 42% in
the ST and T gastrectomy groups, respectively. No significant difference in clinical outcomes was observed between patients with
early- (<30 days) and delayed-onset bleeding.
Conclusion: Embolisation for post-gastrectomy bleeding is safe and
effective. GDA and splenic artery were common in the ST and T gastrectomies, respectively. Splenic artery embolisation conferred high
risk of mortality, and in patients who underwent ST gastrectomy, it
may result in stomach infarction. Thus, stent-graft placement or secondary surgery may be considered for these patients.

P-217
Provision of interventional radiology, endoscopy and surgery
for acute lower gastrointestinal bleeding in the United
Kingdom: preliminary results of a national comparative audit
K.Oakland1, J.Grant-Casey1, V.Jairath2, R.Guy3, N.Mortensen3,
M.Murphy1, R.Uberoi4
1Clinical Research, NHS Blood and Transplant, John Radcliffe Hospital,
Oxford, United Kingdom, 2Division of Gastroenterology, Western
University & London Health Sciences Centre, London, ON, Canada,
3Colorectal Surgery, Oxford University Hospitals, Oxford, United
Kingdom, 4Radiology, Oxford University Hospitals Trust, Oxford, United
Kingdom
Purpose: Acute lower gastrointestinal bleeding (LGIB) is a common
indication for hospital admission. Treatment may require access to
endoscopic haemostasis, mesenteric embolisation and surgery;
however, the availability and use of these modalities throughout the
United Kingdom is unknown.
Aim: To characterise the use of interventional radiology (IR), endoscopy and surgery in the National Comparative Audit of LGIB and the
Use of Blood.
Material and methods: All hospitals in the United Kingdom admitting patients with LGIB were asked to provide information on the
availability of therapeutic endoscopy, interventional radiology
and surgery for consecutive admissions with acute LGIB within a
2-month period. Audit standards were benchmarked as hospitals
providing 24/7 endoscopic haemostasis on-site and mesenteric
embolisation either on-site or via a network.
Results: In total, 132 hospitals provided data on the organisation
of services and collected 2410 cases of LGIB. Of these, 57 (43%) hospitals reported providing 24/7 access to IR and 1107/2410 (46%)
patients were managed in these centres. Furthermore, 124/2410 (5%)
patients underwent CT angiography, and 17/2410 (0.7%) patients
were treated with embolisation. Laparotomy for bleeding was rare
and was similar in hospitals with or without 24/7 access to IR. There
were similar findings for the use of therapeutic endoscopy. The vast
majority of admissions with LGIB required no intervention, and overall case fatality at day 28 was 74/2410 (3.1%) patients.
Conclusion: Over half of the hospitals in the United Kingdom do
not have 24/7 access to IR either on-site or via a network. The use of
dedicated diagnostics such as CT angiography is infrequent, and the
utilisation of embolisation and endoscopic haemostasis is low.

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P-218

P-221

Onyx embolic liquid in the treatment of acute gastrointestinal

hemorrhage

Percutaneous management of inoperable malignant biliary

and pancreatic duct stricture by endoluminal RFA and stenting

P.Rabuffi, S.Vagnarelli, A.Bruni, D.Morosetti, C.Ambrogi

Department of Interventional Radiology, Azienda Ospedaliera San
Giovanni Addolorata, Rome, Italy

M.Mizandari1, N.Habib2, T.Azrumelashvili1

1Diagnostic and Interventional Radiology, Tbilisi State Medical

WITHDRAWN

P-219
Evaluating the accuracy of CT angiography in the diagnosis of
upper and lower gastrointestinal hemorrhages: a systematic
review and meta-analysis
A.Wadhwani1, R.Leigh2, P.Beck 3, E.Herget1
1Radiology, University of Calgary, Calgary, AB, Canada, 2Medicine,
University of Calgary, Calgary, AB, Canada, 3Gastroenterology,
Medicine, University of Calgary, Calgary, AB, Canada
Purpose: Computed tomography angiography (CTA) plays an
important role in the diagnosis and subsequent management of
gastrointestinal (GI) bleeding. The purpose of the present review is
therefore to determine the diagnostic accuracy of CTA in identifying
upper and/or lower gastrointestinal hemorrhages.
Material and methods: This is a systematic review and meta-analysis of prospective or retrospective studies evaluating the diagnostic accuracy of CTA in identifying gastrointestinal hemorrhage.
Medline (Ovid), PubMed, and the Cochrane Database of Systematic
Reviews were searched systematically by title, abstract, and then full
text for relevant research articles. Articles reporting the accuracy of
CTA in diagnosing GI hemorrhage when compared with a reference
test (endoscopy, visceral angiography, surgery, pathology) were
included. Diagnostic accuracy indices [sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV)]
were pooled and reported as means with 95% confidence intervals.
Results: Twenty-one studies involving 793 participants were identified and included in the review. The overall pooled sensitivity of CTA
was 81.6% (95% CI 74.5% to 88.6%). The overall pooled specificity of
CTA was 81.5% (95% CI 68.5% to 94.5%). PPV and NPV for CTA were
90.5 (95% CI 83.6 to 97.4) and 65.3 (54.5 to 76.1), respectively. Sources
of study heterogeneity including the type of CT (single detector vs
multi-detector), the duration of bleed, and the source of bleed were
not explored.
Conclusion: CTA shows high diagnostic accuracy in identifying gastrointestinal hemorrhages. Understanding the optimal timing of CTA
in relation to endoscopy and the imaging features of CTA that provide direction for further diagnostic work-up requires investigation.

P-220
Radiofrequency ablation (RFA) with a multiple-electrode
switching system for >3.0-<6-cm nodules of hepatocellular
carcinoma (HCC): a preliminary experience
G.Francica1, A.Ragozzino2, C.Giardiello3, F.Romano4,
M.Scaglione4
1Interventional Ultrasound, Pineta Grande Medical Center, Castel
Volturno, Italy, 2Radiology, S. Maria delle Grazie Hospital, Pozzuoli,
Italy, 3Surgery, Pineta Grande Medical Center, Castel Volturno, Italy,
4Radiology, Pineta Grande Medical Center, Castel Volturno, Italy
WITHDRAWN

University, High Technology Medical Center - University Hospital,

Tbilisi, Georgia, 2Surgery&Oncology, Imperial College, London, United
Kingdom
Purpose: The technique of malignant stricture percutaneous recanalization is presented.
Material and methods: One hundred and thirty-four patients
with unresectable biliary and PD strictures underwent 154 recanalization attempts by endoluminal RFA after percutaneous drainage,
with enough time for the patients condition to improve and for the
drainage fistula to form. Biliary cases included 46 cholangiocarcinoma, 32 pancreatic cancer, 26 liver metastatic invasion, 8 gallbladder cancer, 8 papilla of Vater tumor, and 7 hepatocellular carcinoma;
all PD cases included pancreatic head cancer with recently manifested pancreatitis and/or hyperglycemia.
The RFA electrode was inserted over a guidewire after the wire
manipulation across the strictured duct segment using the drainage
track. 15 W was delivered over a 2-min period for each application to
cover the full length of the malignant stricture. The procedure was
completed by metal stent implantation: 810 mm for biliary cases
and 56 mm for PD cases.
Results: The technical success rate of the biliary procedure was
98.7%. In 2 (1.3%) cases, the guidewire conduction failed; stent
occlusion was documented in 14 (11.0%) biliary patients in 3 weeks
to 8 months after RFA and stenting. The PD procedure was completed in 6 (85.7%) cases, being impossible in 1 case (14.3%) because
of guidewire conduction failure; two patients with diabetes had
marked improvement in blood sugar control. In 1 case, a stent
patency problem was detected 11 months after recanalization.
There was no 30-day mortality, hemorrhage, or pancreatitis
documented.
Conclusion: Percutaneous endoluminal RFA and stenting is safe
and effective in biliary and PD duct block recanalization. It should
be routinely suggested as a possible treatment option for inoperable biliary and PD stricture cases.

P-222
Yttrium-90 radioembolization for unresectable intrahepatic
cholangiocarcinoma: survival, efficacy, and safety study
C.Mosconi, A.Cappelli, M.Renzulli, A.Gramenzi, S.Ascanio,
F.Modestino, R.Golfieri
Department of Digestive Disease and Internal Medicine, Policlinico
SantOrsola Malpighi, Bologna, Italy
Purpose: To delineate survival, antitumoral response, and safety following Y90 radioembolization (Y90-TARE) in patients (pts) with unresectable intrahepatic cholangiocarcinoma (ICC).
Material and methods: Twenty-thee patients with unresectable
ICC were treated with Y90-TARE during 20102015. Overall survival
(OS) was calculated based on the procedure. Response was assessed
using the Response Evaluation Criteria in Solid Tumors (RECIST) criteria, modified RECIST (mRECIST) criteria, and European Association
for the Study of the Liver (EASL) criteria. The mRECIST and EASL criteria were modified for application on delayed phases of dynamic contrast-enhanced cross-sectional imaging studies.
Results: Median OS was 17.9 months (95% CI: 14.321.4). The 4 naive
patients had significantly prolonged OS compared with those who
had received prior treatments (52 vs. 16 months, p=0.009).
Radiological assessment was completed at 3 months in 20 pts (87%)
because 3 died before the first assessment. No correlation between

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survival and RECIST1.1 response was found. Only patients with control disease (CD: CR+PR+SD), both in terms of target and overall
response, according to mRECIST showed significantly prolonged
OS compared to patients with disease progression (21 vs. 7 months,
p=0.014; 24 vs. 11 months, p=0.013). Similarly, according to EASL criteria, pts with CD had significantly prolonged OS (21 vs. 7 months,
p=0.014).
Clinical toxicities according to the NCI CTCAE criteria v3.0 included
abdominal pain (G1, 21%), fever (G1, 8%), and fatigue (G1, 8%).
Conclusion: Y90-TARE is safe and effective for unresectable ICC; it
could be used as first-line therapy in patients with unresectable ICC.
Moreover, tumor response assessment according to mRECIST and
EASL criteria may be a good predictor of survival.

P-223
Relationship between applied energy and ablation volume for
different ablation techniques: comparison between colorectal
liver metastases and hepatocellular carcinoma
W.J.Heerink1, M.Solouki1, R.Vliegenthart1, M.Oudkerk 2,
G.Sieders3, K.P.deJong3
1Radiology, University Medical Center Groningen, Groningen,
Netherlands, 2University Medical Center Groningen and State
University, Groningen, Netherlands, 3Hepatobiliary Surgery, University
Medical Center Groningen, Groningen, Netherlands
Purpose: To identify differences in ablation effect between colorectal liver metastases (CRLM) and hepatocellular carcinomas (HCC)
after treatment with CT-guided radiofrequency ablation (RFA) or
microwave ablation (MWA).
Material and methods: Forty-five HCCs in 34 patients with cirrhotic livers and 45 CRLMs in 43 patients with otherwise healthy livers treated with either RFA or with one of two 2.45 GHz MWA devices
(A and B) were retrospectively included, resulting in 6 groups of 15
lesions. Coagulated volume (V) was semi-automatically segmented
on the 1-week follow-up CT scan. Amount of applied energy (E) was
determined for each procedure and tested as a predictor of V using
linear regression. Goodness of fit was expressed in R 2and regression
coefficient B was compared between CRLM and HCC for each device
using between-subject effects.
Results: For RFA, the goodness of fit was R2HCC=0.22 and
R2CRLM=0.73. For MWA A, it was R2HCC=0.79 and R2CRLM=0.65,
and for MWA B, it was R2HCC=0.42 and R2CRLM=0.67. The regression coefficients for RFA were similar for HCC and CRLM: BHCC=0.15
and BCRLM=0.15. The regression coefficients for MWA device A
and B were higher for HCC: device A, BHCC=0.80 and BCRLM=0.37
(p<0.001); device B, BHCC=0.60 and BCRLM=0.45 (p<0.001).
Conclusion: There is a linear relation between applied energy and
ablation volume for all ablation devices. For RFA, the regression
coefficient was similar in HCC and CRLM treatments. Both microwave devices required less energy during treatment of HCCs compared with the treatment of CRLMs to achieve a specific ablation volume. Treatment protocols for HCCs and CRLMs should be adapted
accordingly.

Abstract Book

P-224
Self-expanding colonic stent implantation in acute intestinal
occlusion: our experience
A.M.FernndezMartnez1, J.D.SamperWamba2, L.A.Domitrovic3,
J.ValdiviaRuiz4, O.BalboaArregui1
1Vascular and Interventional Radiology, Universitary Hospital of Len,
Leon, Spain, 2Radiology, Hospital General Virgen de la Salud, Elda,
Spain, 3Radiology, Universitary Hospital of Len, Leon, Spain, 4Intensive
Care Unit, Universitary Hospital of Len, Leon, Spain
Purpose: To describe our experience of the implantation of selfexpanding colonic stents in acute intestinal occlusion.
Material and methods: This was a retrospective descriptive study
based on data collected over a period of 18 years from 19962015.
Data was collected from all procedures of colonic stent implantation. In all cases, the implantation was performed under fluoroscopic guidance. We evaluated variables such as age, sex, cause and
location of intestinal obstruction, indication, technical success, clinical success and complications.
Results: We included 737 patients, 461 men (62.5%) and 276 women
(37.5%). The mean age was 74.1 12.3 years. The most common
cause of intestinal obstruction was a primary colon tumor (668 cases,
90.6%), followed by extrinsic compression (29 cases, 3.9%). The most
frequent location was in the sigma (40.7%), followed by in the rectosigmoid union (21.7%) and in the splenic angle (9%). Technical success was achieved in 689 procedures (93.4%). In 41 patients (5.5%),
it was necessary to place a second prosthesis. Clinical success was
achieved in 635 patients (86.1%). In 386 patients (52.3%), stent
implantation was the palliative treatment; the remaining patients
were operated on a scheduled basis.
Conclusion: Colonic stent implantation in acute intestinal obstruction is a solution with a high percentage of technical and clinical
success.

P-225
Pancreatic duct percutaneous image-guided drainage: what
for and how?
M. Mizandari
Diagnostic and Interventional Radiology, Tbilisi State Medical
University, High Technology Medical Center - University Hospital,
Tbilisi, Georgia
Purpose: Indications and technique of percutaneous image-guided
pancreatic duct (PD) drainage is presented.
Material and methods: Thirty patients with PD obstruction from
pancreatic head tumor or pancreatitis underwent percutaneous
image-guided PD drainage. PD puncture was performed using
either ultrasound (US) or computed tomography (CT) guidance
with 1822-G needles. After successful PD tail (5 cases), body (21),
or neck (3) segment puncture, performed either under real-time US
or CT guidance, a locking loop drainage catheter was placed using
conventional guidewire techniques under real-time fluoroscopy
guidance.
Results: Percutaneous drainage of obstructed PD was successful
in 29 (96.7%) cases. Clinical improvement after drainage was documented by the gradual reduction in clinical symptoms, including pain, nausea, and fever as well as improved blood test results,
showing the significant decrease of amylase concentration in all
cases. The amount of pancreatic fluid drained post-procedure was
between 300 and 900 mL/day. No major procedure-related complications were observed. Subsequently, 14 of 29 patients underwent
further procedures, including endoluminal placement of metal stent
with/without radiofrequency ablation, balloon-assisted percutaneous descending litholapaxy (BAPDL), endoluminal biopsy, and balloon dilatation using PD drainage fistula.

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Conclusion: Percutaneous PD drainage appears to be a safe and
effective procedure and should be considered for patients with
obstructed PD, especially in cases when PD retrograde cannulation
fails or is impossible for any reason. The procedure can be considered either as an independent treatment option or as an initial step
for subsequent therapeutic endoluminal procedures.

P-226
Safety of percutaneous transesophageal gastrotubing (PTEG):
comparison between the procedures and puncture routes
Y.Arai1, T.Haraguchi1, Y.Himeno2, M.Sone3, Y.Arai3, H.Mimura1,
Y.Nakajima1
1Department of Radiology, St. Marianna University School of Medicine,
Kanagawa, Japan, 2Department of Radiology, Musashino Red Cross
Hospital, Tokyo, Japan, 3Department of Diagnostic Radiology, National
Cancer Center Hospital, Tokyo, Japan
Purpose: I investigated retrospectively about the safety of percutaneous transesophageal gastrotubing (PTEG) affected by the differences of the procedure and the cervical route.
Material and methods: 101 patients underwent PTEG from October
2009 to September 2014. I investigated the complications based on
the medical records, and I evaluated the puncture route using computed tomography.
Results: In average of 89.0 days of observation period, there were 2
cases of bleeding and 2 cases of wound infection as acute complication that needed no additional treatment. There were 5 cases of
accidental tube dislocation and 2 cases of the tube obstruction as
late events. There was no difference among complication regardless
of using the rupture-free balloon catheter.
39 patients underwent computed tomography after the procedure.
20 patients in the 39 patients had undergone PTEG through the
trans-thyroid route and 19 patients through the extra-thyroid route.
There was no difference among the complication rates. The transthyroid route involved the longer distance between the tube and
the cervical arteries than the extra-thyroid route with statistically
significant difference.
Conclusion: PTEG is a safe procedure. There was no difference
among the complication rates regardless of the procedure methods
and the puncture routes. However, the trans-thyroid route might
avoid the rare late complications such as cervical artery rupture.

P-227
Radiologic percutaneous gastrostomy in nondistended
stomach: a modified approach
F.Petrocelli, G.Salsano, G.Bovio, F.Camerano, A.Utili, C.Ferro
Radiology, San Martino University Hospital, Genoa, Italy
Purpose: To describe a simple technique to prevent air escape from
the stomach during gastrostomy placement.
Material and methods: Nine patients with unsuccessful percutaneous endoscopic gastrostomy were referred for fluoroscopy-guided
gastrostomy. Three patients had a neck cancer, and six had an ischaemic stroke causing dysphagia. Gastric distention was not achieved
in the patients due to air escaping into the bowel during the standard RIG procedure. A modified approach using a balloon catheter
inflated in the pylorus to avoid air passing into the duodenum permitted successful RIG.
Results: The modified RIG procedure was successfully carried out in
all cases without complications.
Conclusion: The positioning of a balloon catheter in the duodenum to block the passage of air in the bowel is an effective, simple
and well-tolerated manoeuvre. It may be used as a valid alternative when inadequate gastric distension makes percutaneous techniques impossible, or at high risk of complications.

SS/FC/HL/HTS/CM
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P-228
Percutaneous approach and management of postoperative
gastro-intestinal fistulas
G.DiCostanzo, R.Inchingolo, M.Nestola, M.Nardella
Diagnostic and Interventional Radiology Unit, Madonna delle Grazie
Hospital, Matera, Italy
Purpose: This study was designed to investigate the benefit of percutaneous interventional management of patients with postoperative gastro-intestinal fistulas. Here we report our experience with
minimally invasive treatment of gastric, enteric and colorectal fistulas, principally secondary to surgical interventions.
Material and methods: Between January 2009 and December 2015,
we treated 24 patients who referred to our unit for various types of
gastro-intestinal fistulas; most of them underwent one or more surgical interventions; in particular, 10 (42%) patients presented with
gastric fistulas, eight (33%) with enteric (or bilio-enteric) fistulas,
and six (25%) with colorectal fistulas due to post-surgical complications. All patients underwent contrast radiography (Gastrografin)
and computed tomography (CT) for accurate diagnosis. On the basis
of the radiological findings, patients eligible for percutaneous interventions were treated with long-term drainage, with utilisation of
coils and/or cyanoacrylic glue.
Results: All the patients eligible for the percutaneous approach
underwent preliminary image-guided drainage and were successivelytreated with two types of embolic agents (coils and cyanoacrylic glue). Under fluoroscopic guidance, the catheters were
advanced to the site of fistulas via the percutaneous or transhepatic approach. Ten patients with gastric leaks secondary to sleeve
gastrectomy were treated with long-term drainage and glue; 14
patients presented with enteric (or bilio-enteric) and colorectal fistulas with drainage, coils and cyanoacrylic glue.
Conclusion: In all cases, it was possible to reach the site of fistula
with a drainage catheter, releasing coils or injecting glue; our experience confirms the feasibility, safety and effectiveness of this tecnique that represents a good option to avoid surgical reoperation.

P-229
Endovascular thrombolysis and angioplasty for the
management of early hepatic artery thrombosis after livingdonor liver transplantation: our experience of 570 cases
O.Abdelaziz, M.Mostafa
Department of Diagnostic and Interventional Radiology, Cairo
University Hospital, Kasr Al-Ainiy, Cairo, Egypt
Purpose: The aim of this work was to assess the feasibility and
potential complications of endovascular intervention for the management of early hepatic artery thrombosis (HAT) at the first postoperative day after living-donor liver transplantation (LDLT).
Material and methods: A retrospective review of 570 recipients
who underwent LDLT between August 2001 and January 2016 at 2
centers. Endovascular interventions were performed using standard catheter techniques. Thrombolysis was performed using tPA or
streptokinase, whereas angioplasty and stent placement were performed if there was an underlying stricture.
Results: Early HAT within 2 weeks postoperatively occurred in 21
patients (2.7%). Endovascular interventions were performed for 18
cases with initial success in 14/18 (81.8%) and failure in 4/18 (18.2%).
Rebound thrombosis developed in 3/18 (16.6%). Complications
occurred in 5/18 (27.7%): bleeding (3/18), anastomotic rupture (1/18),
and dissection (1/18). The overall definite endovascular treatment
sucess rate of HAT was 11/18 (61.1%), whereas that of definite surgical/endovascular or combined treatment was 16/21 (76.1%).
HAT occurred on the first postoperative day in 9/21 patients.
Endovascular intervention was attempted in 5 patients and

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succeeded in 3 patients (60%). Surgery was attempted in 4 patients

and succeeded in 3 patients (75%). Endovascular complications
occurred in 3/5 (60%) patients; bleeding occurred in 2 patients, and
anastomotic rupture occurred in 1 patient.
Conclusion: Endovascular intervention for the mangement of HAT
on the first postoperative day after LDLT carries a considerable risk
of potential complications related to the technique and thrombolytic therapy. However, it is feasible and can be attempted for graft
salvage if surgery is considered futile.

TACE with emphasis on (i) different phases of imaging planning, (ii)

rotational angiography C-arm CT MIP and VRT reconstruction during
the super-selective catheterization as guide before chemoembolization, and (iii) final rotational angiography C-arm CT for procedural
assessment of treatment success.
Conclusion: Correct imaging planning and rotational angiography
C-arm CT for HCC TACE lead to a reduction of procedural time, better planning of feeding arteries, and final confirmation of the procedural success.

P-230

P-232

Acute gastrointestinal bleeding after endoscopic polypectomy:

super-selective endovascular embolization with n-butyl-2cyanoacrylate in clinically unstable patients

Interventional radiology and esophagogastric surgery

P.Rigamonti1, U.G.Rossi1, G.RubisPassonia2, P.Torcia1, V.Pedicini3,

D.Poretti3, G.Carrafiello4, M.Cariati5
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Gastroenterology Unit, San Carlo Borromeo, Milan, Italy,
3Radiology and Interventional Radiology, IRCCS Humanitas Hospital,
Milan, Italy,4Department of Radiology, University of Insubria, Varese,
Italy, 5Radiology, San Carlo Borromeo Hospital, Milan, Italy

E.Lonjedo, J.Gomez, J.Salvador, E.Casula, A.Ruiz,

J.A.AguilarGutierrez
Radiology, Universitary Hospital DR Peset, Valencia, Spain

Learning Objectives: To describe indications, preparation and superselective embolization with n-butyl 2-cyanacrylate + Lipiodol in
clinically unstable patients for acute gastrointestinal bleeding after
endoscopic polypectomy.
Background: Despite advances in medical management, acute
gastrointestinal bleeding after endoscopic polypectomy remains
a major complication with a high morbidity and mortality. Interventional endoscopy and angiography are quick and less invasive
therapies to control this major complication. However, for massive
hemorrhage and clinically unstable patients, endovascular embolization is the preferred therapy. Nowadays, many embolic materials
are used to control and stop the acute gastrointestinal bleeding.
Clinical Findings/Procedure: The purpose of this poster is to illustrate (i) indications, (ii) preparation, (iii) and delivery of the liquid
embolic material n-butyl-2-cyanoacrylate + Lipiodol in acute gastrointestinal bleeding.
Conclusion: Super-selective endovascular embolization is a wellaccepted treatment for clinically unstable patients with acute gastrointestinal bleeding after endoscopic polypectomy. N-butyl-2cyanoacrylate + Lipiodol should be considered because of its intrinsic characteristics.

Learning Objectives: Describe and illustrate the complications of

esophagogastric surgery and the role that Interventional Radiology
plays in prevention and treatment.
Background: Esophageal and gastric surgeries are complex, major
procedures with high postoperative complication rate, whose incidence depends on multiple factors (comorbidity, surgery technique), varying between 20% and 80%.
Interventional radiology plays an important role in the management
of local and systemic complications, not only in treatment but also
in prevention.
Clinical Findings/Procedure: As preventive interventional procedures, gastric ischemic conditioning, which improve esophagogastric anastomotic healing leading to a decreased incidence of leak
and stricture formation, and inferior vena cava filters, which prevent
pulmonary embolism in patients with high thromboembolic risk, are
the most commonly used.
Local complications can be treated, with covered stents in the management of leaks, drainage of postsurgical collections and dilatation
of anastomotic strictures. In cases of active bleeding, selective transcatheter arterial embolization is a safe and effective procedure to
treat this life-threatening complication.
In lymphatic complications refractory to treatment, chylothorax
drainage and, if necessary, percutaneous embolization of a thoracic
duct leakage can be performed.
Conclusion: The interventional radiologist, from a multidisciplinary
environment, has the necessary skills and tools for the management
of the different esophagogastric surgery complications.

P-231

P-233

Rotational angiography C-arm CT: an added value in superselective TACE for HCC

Fluoroscopy-guided preoperative colonic stenting for

malignant colonic obstruction

U.G.Rossi1, P.Rigamonti1, P.Torcia1, G.Mauri2, F.Petrocelli3,

A.M.Ierardi4, G.Carrafiello5, M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo
Hospital, Milan, Italy, 2Radiology, IRCCS Policlinico San Donato, San
Donato Milanese, Italy, 3Radiology, San Martino University Hospital,
Genoa, Italy, 4Radiology, Uninsubria, Ospedale di Circolo, Varese, Italy,
5Department of Radiology, University of Insubria, Varese, Italy

S.H.Kwon, J.H.Oh
Radiology, Kyung Hee University Hospital, Seoul, Korea

Learning Objectives: To describe the utility of rotational angiography C-arm CT, during hepatocellular carcinoma (HCC) transcatheter
arterial chemoembolization (TACE).
Background: TACE is widely performed for unresectable nodules of
HCC. Selective or super-selective TACE has to be performed in order
to avoid embolization and toxicity of the surrounding non-target
hepatic parenchyma. As known from the literature, super-selective
TACE improves local control of HCC as well as the survival rate.
Clinical Findings/Procedure: The purpose of this poster is to illustrate the use of rotational angiography C-arm CT for super-selective

Learning Objectives:
1. Clinical perspective for the management of malignant colonic
obstruction.
2. Indications for fluoroscopiy-guided preoperative colonic stenting.
3. Devices and technique for fluoroscopiy-guided preoperative
colonic stenting; radiologic assessment, choice of the stent,
patient prepration, stent deployment, post-procedure evaluation,
delayed evaluation.
4. Complications and controversies.
5. Literature review for fluoroscopiy-guided preoperative colonic
stenting.
Background: Approximately 8%29% of colon cancer patients present with obstructive symptoms at the time of diagnosis. In these
cases, emergency surgical decompression becomes mandatory as a
traditional treatment option. It involves a defunctioning stoma with

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CIRSE 2016
or without primary resection of the obstructing tumor. Although
effective, this is associated with high mortality ranging from 23%
to 45% due to old age, pre-existing co-morbidities, anesthetic risks,
and emergency surgery risks.
Clinical Findings/Procedure: Fluoroscopy-guided preoperative
colonic stenting can be performed under fluoroscopic guidance
alone by interventional radiologists. The self-expandable metal
stent (SEMS) is now considered to be a safe and effective alternative
modality for decompressing malignant large-bowel obstruction, as
several meta-analyses have demonstrated favorable short-term outcomes of SEMS insertion followed by surgery, bridge to surgery,
compared with emergency surgery. Preoperative SEMS insertion can
prevent high-risk emergency surgery and may allow elective radical
surgery following full preoperative staging, screening for synchronous proximal lesions, and appropriate bowel preparation.
Conclusion: Fluoroscopy-guided preoperative colonic stenting for
malignant colonic obstruction serves as a safe and effective bridge
to subsequent surgery. It can significantly improve one-stage surgery rates and decrease the rates of permanent stoma and wound
infection.

P-234

SS/FC/HL/HTS/CM
Posters

Background: BCS is a rare syndrome. It is characterised by the disruption of the venous outflow of the liver, anywhere from the small
hepatic veins to the atrio-caval junction. It is associated with prothrombotic states, and its presentation ranges from no symptoms
to liver failure. Hence, one must have a high index of suspicion.
Management depends on the aetiology, duration and severity of
symptoms. Treatment options range from anticoagulation to revascularisation to liver transplantation. Interventionalists play an important role in revascularisation to restore the normal liver drainage.
Clinical Findings/Procedure: Using various cases from our clinical
experience, we will discuss the indications for interventional, particularly patient selection and the timing of intervention. Various interventional techniques exist, which include balloon angioplasty, IVC
stenting, hepatic vein stenting and TIPS. We will discuss the technical details of each of these procedures, including pre- and post-procedural details. We will discuss the complications associated with
these interventions. The cases will be richly illustrated with not just
angiographic images but also cross-sectional imaging (sonographic
and CT images).
Conclusion: Early diagnosis and intervention in BCS is associated
with good prognosis. It is important for interventionalists to know
the various techniques to improve outcomes in these cases.

Spontaneous isolated superior mesenteric artery dissection:

from diagnosis to therapy

P-236

U.G.Rossi1, P.Rigamonti1, P.Torcia1, G.Mauri2, D.Poretti3,

A.M.Ierardi4, G.Carrafiello5, M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Radiology, IRCCS Policlinico San Donato, San Donato
Milanese, Italy, 3Radiology and Interventional Radiology, IRCCS
Humanitas Hospital, Milan, Italy, 4Radiology, Uninsubria, Ospedale di
Circolo, Varese, Italy, 5Department of Radiology, University of Insubria,

Back to the gelatin sponge: temporal haemostatic

embolisation for massive upper GI bleeding

Varese, Italy
Learning Objectives: To describe causes, clinical symptoms, radiological diagnosis and treatment algorithm of spontaneous isolated
superior mesenteric artery (SMA) dissection.
Background: Spontaneous isolated SMA dissection is an extremely
rare disease. Due to the increasing use of MD-CT scans in the evaluation of nonspecific abdominal pain, spontaneous isolated SMA
dissection is being more frequently detected. The natural history is
unpredictable, with spontaneous resolution, definitive occlusion of
SMA, aneurysm formation, or rupture evolution. Till now, there has
been no well-defined established management protocol for spontaneous isolated SMA dissection.
Clinical Findings/Procedure: The purpose of this poster is to illustrate 1) causes, 2) clinical presentation, 3) investigations, 4) radiological classification, 5) management algorithm (conservative, endovascular, and surgical treatment), 6) and follow-up.
Conclusion: A clear and precise management algorithm can help in
dealing with this extremely rare disease.

P-235
Role of interventional radiology in BuddChiari syndrome
V.Rachapalli1, N.Kundaragi1, D.Thiruchunapalli2, S.Inuganti2,
S.Chappiidi3, M.Uthappa1
1Interventional Radiology, BGS Global Hospital, Bangalore,
India, 2Interventional Radiology, Global Hospital, Chennai, India,
3Interventional Radiology, Global Hospital, Hyderabad, India
Learning Objectives: Upon review of this poster, the reader
1. should be able to identify the clinical and imaging features of
Budd-Chiari syndrome (BCS);
2. will have an awareness of the various interventional techniques
that can be used in its treatment.

S243

A.Alonso-Burgos, M.Cabrera-Gnzalez, L.Paul-Ferrer, J.Urbano

Vascular & Interventional Radiology, Fundacion Jimenez Diaz, Madrid,
Spain
A 76-year-old male patient had massive upper GI bleeding due
to advanced unresectable gastric carcinoma. Haemostatic temporal embolisation was performed using a gelatin sponge as an
embolic agent to prevent ischaemic complications. Haemostasis was
achieved immediately.

P-237
Percutaneous embolization of rectal fistula using NBCA in
patients with supralevator and translevator perianal fistula: a
technical case report
Y.Yamamoto1, M.Yabuta2, S.Kubo1
1Diagnostic Imaging and Intervention, Rakuwakai Otowa Hospital,
Kyoto, Japan, 2Radiology, St. Lukes International Hospital, Tokyo,
Japan
Supralevator and translevator perianal fistula is sometimes associated with intractable rectal fistula, leading to abscess formation. We
report three cases of rectal fistula associated with supralevator and
translevator perianal fistula that underwent percutaneous embolization using N-butyl-2 cyanoacrylate (NBCA).

P-238
Upper gastrointestinal haemorrhage arising from an aberrant
left gastric artery
V.G.Helyar1, A.Shaw2, K.N.Katsanos1, A.Diamantopoulos1
1Interventional Radiology, Guys and St Thomas NHS Foundation Trust,
London, United Kingdom, 2Interventional Radiology, Maidstone and
Tunbridge Wells Hospitals, Kent, United Kingdom
A 57-year-old presented with post-operative haematemesis following multiple attempts at endoscopic and surgical management. A
pseudoaneurysm arising from a branch of the left gastric artery with
direct aortic origin was eventually identified. Learning points, tips
and tricks are discussed.

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P-239

P-243

Percutaneous embolisation with histoacryl of an enteric

fistula: a case report

Recanalization of subacute distal occlusion of the superior

mesenteric artery using mechanical thrombectomy and
stenting

C.H.N.Bezerra1, T.F.Nunes2, R.Magnani3

1Students Department, IPADE, Fortaleza, Brazil, 2Radiodiagnostico,
UFMS, Campo Grande Ms, Brazil, 3Hemodinamica, Hospital do Penfigo,
Campo Grande Ms, Brazil
Embolisation of an enteric fistula in the late postoperative period of
right hemicolectomy using n-butyl-2-cyanoacrylate (NBCA) is a feasible, safe and effective therapeutic option.

P-240
Efficacy of coil embolization of superior rectal arteries (SRAs) in
the treatment of hemorrhoids associated with rectal bleeding
F.Melchiorre1, M.Rovati2, P.DeNardi3, F.Morelli1, P.Marra4,
A.Giori2, M.Venturini4
1Interventional Radiology, AO San Paolo, Milan, Italy, 2Surgery, AO
San Paolo, Milan, Italy, 3Surgery, Vita-Salute University, San Raffaele
Hospital, Milan, Italy, 4Radiology, Vita-Salute University, San Raffaele
Hospital, Milan, Italy

R.Salman1, N.Guzaiz2, A.Khankan3, M.Almoaiqel1, M.A.Al-Toki1

1Medical Imaging, National Guard Health Affairs, Riyadh, Saudi Arabia,
2Medical Imaging, King Abdullah Medical City, Mecca, Saudi Arabia,
3Medical Imaging, King Abdulaziz Medical City, Riyadh, Saudi Arabia
A case of sub-acute distal SMA thrombosis on top of chronic
changes. The patient presented with progressive RUQ abdominal
pain and lower GI bleeding. The distal occlusion of the SMA was
successfully recanalized using percutaneous mechanical rotational
thrombectomy (Aspirex) and stenting.

Gynaecological intervention (including UFE)

P-244
Radiation exposure during uterine fibroid embolization (UFE):
a confounder-controlled comparison between a state-ofthe-art angiography device and a conventional device

Coil embolization of all SRA branches was performed in two patients

(a 45-year-old male and a 69-year-old male) with bleeding hemorrhoids, with technical and clinical success and without procedurerelated complications.
The first patient underwent pre- and post-transrectal Doppler
sonography showing changes in SRA resistance index (0.61 from
0.88).

P-241
Ultraselective intrasaccular embolization of a jejunal artery
branch aneurysm in a complex patient
N.Marotti, E.Laiolo, M.Pieraccini
Radiology Department - Interventional Radiology Unit, Grosseto
Misericordia Hospital, Grosseto, Italy
A man on dual antiplatelet therapy because of a drug-eluting coronary stent had acute gastrointestinal bleeding.
The CT scan revealed a saccular aneurysm of a jejunal artery branch.
We performed ultraselective embolization of the aneurysmal sac
with neuro detachable coils.

P-242
Percutaneous transperitoneal insertion of a colonic stent
A.Shaw1, J.Spiking1, C.Wetton1, N.Scully1, C.Elwood1, C.Wright2,
P.Ignotus1
1Interventional Radiology, Maidstone and Tunbridge Wells Hospitals,
Kent, United Kingdom, 2Colorectal Surgery, Maidstone and Tunbridge
Wells Hospitals, Kent, United Kingdom
An elderly patient presented with an obstructing transverse colon
tumour. He refused transanal stenting. Percutaneous transperitoneal placement of a colonic stent was successfully performed. This
technique may be useful in the cohort of patients in whom conventional stenting has failed/is unsuitable.

M.KlappOliger1, C.M.Sommer1, A.Hatopp1, S.Erpenbach1,

P.Kurz1, C.Schlett2, G.M.Richter3
1Clinic for Diagnostic and Interventional Radiology, Klinikum
Stuttgart, Stuttgart, Germany, 2Clinic for Diagnostic and Interventional
Radiology, University Hospital Heidelberg, Heidelberg, Germany,
3Director Clinics for Diagnostic and Interventional Radiology, Klinikum
Stuttgart, Stuttgart, Germany
Purpose: To compare the radiation exposure of patients undergoing uterine fibroid embolization (UFE) using either a state-of-the-art
angiography device or a conventional angiography device.
Material and methods: Between January 2009 and December
2014, a total of 245 patients underwent UFE at our fibroid center.
Inclusion criteria for this study were (1) first-time transarterial embolization for symptomatic uterine fibroids, (2) bilateral embolization according to a highly standardized treatment plan, (3) procedures applying a state-of-the-art angiography device (Artis Zeego Q;
Siemens Healthcare; Group I) or a conventional angiography device
(Axiom Artis; Siemens Healthcare; Group II), and (4) bilateral technical success with adequate embolization endpoints after the injection of size-calibrated microspheres (Embozene 700 or 900, Boston
Scientific). Linear regression analysis and propensity score matching
were used to control clinical and procedural confounders between
both study groups. Endpoints were radiation exposure and major
complications.
Results: In Groups I and II, a total of 27 and 177 patients, respectively, matched the inclusion criteria. After linear regression analysis and propensity score matching, 25 patients of Group I were
compared with 50 patients of Group II. As a result, the body mass
index, dominant fibroid volume, uterus volume, fluoroscopy time,
amount of embolic agent, and operators were comparable (for
all parameters p0.24). The dosearea product was significantly
lower for Group I compared with Group II (1363.7939.1 cGycm2vs.
5283.912670.4 cGycm2; p<0.001). Major complication rate was comparable in both study groups (0% vs. 0%; p>0.99).
Conclusion: A state-of-the-art angiography device allows a significant dose reduction for patients undergoing UFE without increasing
the risk of major complications.

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CIRSE 2016

P-245
Application of contrast-enhanced CT to the management of
primary postpartum hemorrhage
H.Kondo1, Y.Tanahashi1, S.Goshima2, H.Kawada2, M.Osawa1,
T.Yamamoto1, M.Matsuo2, S.Furui1
1Radiology, Teikyo University School of Medicine, Tokyo, Japan,
2Radiology, Gifu University Hospital, Gifu, Japan
Purpose: To evaluate the efficacy of contrast-enhanced CT (CECT) in
the management of primary postpartum hemorrhage (PPH).
Material and methods: Over 10 years, 116 patients with primary
PPH were transferred to our institution. Eighteen of them were
treated without CECT; emergency hysterectomy (n = 4) and transcatheter arterial embolization (TAE) (n = 11) were used for those
with hemodynamic instability and conservative treatment (n = 3)
was used for those with hemostasis. The remaining 98 patients (age
range, 2043 years; mean age, 32.5 years) who underwent CECT
were enrolled in this study. The subsequent therapy was determined
on the basis of the CECT findings. The CECT findings, clinical course,
angiographic findings, and clinical success rate for achieving hemostasis and preserving the uterus were assessed.
Results: CECT showed contrast extravasation in 64 of 98 patients
(65.3%). All bleeding sites were detected using CECT. Among
these 64 patients, surgical intervention was performed in 4: hysterectomy (n = 2) and laparotomy or vascular ligation (n = 2). The
other 60 patients underwent TAE, including 2 patients who were
switched to emergency hysterectomy because TAE was unsuccessful. Angiography revealed active bleeding in 60 of 69 bleeding sites
(86%). Thirty-four patients who did not show contrast extravasation on CECT were successfully treated with conservative therapy. All
patients survived. The clinical success rate for preserving the uterus
was 97% (94/98).
Conclusion: The application of CECT to the management of primary
PPH may contribute to the avoidance of unnecessary TAE, detection
of bleeding sites, and analysis of the vascular anatomy with maintenance of a high clinical success rate for preserving fertility.

P-246
Analysis of risk factors for the recanalization of gelatin
sponge during transcatheter arterial embolization for primary
postpartum hemorrhage
R.Woodhams1, K.Fujii1, G.Ogasawara1, T.Yamane1, H.Sugawara1,
K.Matusnaga1, H.Nishimaki2, Y.Inoue1
1Department of Diagnostic Radiology, Kitasato University School of
Medicine, Sagamihara, Japan, 2Cardiovascular Surgery, St. Marianna
University School of Medicine, Kawasaki, Japan
Purpose: To evaluate the risk factors related to recanalization after
gelatin sponge embolization during TAE for primary postpartum
hemorrhage (PPH).
Material and methods: In total, 79 patients (84 procedures) (mean
age, 34 years; range, 2142 years) were treated with TAE using gelatin sponge as a first choice of embolic agent for primary PPH. After
embolization, repeated angiography of embolized arteries was performed to evaluate recanalization during all procedures. Bleeding
volume, shock index (S.I), blood coagulating factors, including blood
hemoglobin, platelet, plasma fibrinogen, international normalized
ratio (INR), prothrombin time (PT), and activated partial thromboplastin time (APTT), presence of extravasation, and spasm during
angiography and the amount of gelatin sponge used were recorded.
Univariate and multivariate analyses were performed to determine
the factors related to recanalization.
Results: Recanalization after embolization using gelatin sponge
during the session was observed in seven procedures. Low plasma
fibrinogen level and arterial spasm were the predictive factors for

SS/FC/HL/HTS/CM
Posters

S245

recanalization based on univariate analysis (P<0.05). Low plasma

fibrinogen level was the significant predictive factor of recanalization based on multivariate analysis (P<0.05). The mean fibrinogen
level for the recanalization group was 84.2 mg/dl and that for the
non-recanalization group was 157.4 mg/dl.
Conclusion: This study indicates the possibility of low plasma fibrinogen level being an independent risk factor for recanalization after
gelatin sponge embolization during primary PPH.

P-247
Transcatheter arterial embolization for primary
postpartum hemorrhage: predictive factors for embolic
material conversion of gelatin sponge particles to n-butyl
cyanoacrylate
Y.Tanahashi1, H.Kondo1, S.Goshima2, M.Osawa1, H.Kawada2,
T.Yamamoto1, M.Matsuo2, S.Furui1
1Radiology, Teikyo University School of Medicine, Tokyo, Japan,
2Radiology, Gifu University Hospital, Gifu, Japan
Purpose: To identify predictive factors for embolic material conversion of gelatin sponge (GS) particles to n-butyl cyanoacrylate (NBCA)
for the treatment of intractable primary postpartum hemorrhage
(PPH) by conventional transcatheter arterial embolization (TAE).
Material and methods: Fifty-seven consecutive patients who
underwent emergent TAE for the treatment of primary PPH between
January 2006 and March 2015 constituted the study population. TAE
was initially performed using GS particles in all cases and then converted to NBCA as needed. The patients background, uterine fundal
height, vital signs, blood test results, and DIC score were reviewed.
Significant factors related to embolic material conversion were statistically examined.
Results: Technical success rate was 100%. Fourteen patients (25%)
needed embolic material conversion to NBCA. Univariate analysis
showed that fundal height, systolic blood pressure, and hemoglobin level were related to embolic material conversion to NBCA (P =
0.029, 0.030, and 0.015, respectively). Logistic regression analysis
showed that the fundal height (odds ratio, 1.30; P = 0.11) and systolic
blood pressure (odds ratio, 0.96; P = 0.06) were associated with the
necessity of embolic material conversion.
Conclusion: The uterine fundal height and systolic blood pressure
can be potential predictive factors for embolic material conversion
to NBCA for the treatment of intractable PPH.

P-248
Postpartum haemorrhage from nonuterine arteries:
clinical importance of its detection and results of selective
embolisation
Y.H.So, Y.H.Choi, C.K.Sung, M.H.Moon
Radiology, SMG-SNU Boramae Medical Center, Seoul, Korea
Purpose: To evaluate the clinical importance of the detection of
nonuterine arteries causing postpartum haemorrhage and the
results of the selective embolisation of the haemorrhage.
Material and methods: From June 2009 to January 2016, 52
patients (mean age 32.6 years, age range 2443 years) underwent
embolisation for postpartum haemorrhage. Angiographic findings
and medical records of the patients were reviewed to determine
whether the nonuterine arteries contributed postpartum haemorrhage. The arteries that showed extravasation or significant hypervascularity of the uterus were regarded as one of the haemorrhage
sources. The results of the selective embolisation of the haemorrhage were analysed.
Results: Among 52 patients, 16 patients underwent embolisation for nonuterine arteries which contributed postpartum haemorrhage. The arteries were ovarian (n=6), round ligament (n=5),

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vaginal (n=3), external pudendal (n=3), inferior epigastric (n=2), vesical (n=1), and rectal (n=1). These arteries were embolised by using
gelatin sponge particle (n=9), NBCA (n=6), and PVA particle (n=1).
In 11 patients, combined bilateral uterine artery embolisation was
performed. Adequate haemostasis was achieved in 15 patients
(93.8%). One patient who had persistent haemorrhage finally underwent hysterectomy despite repeated embolisation and experienced
major complications due to pelvic ischaemia. One patient underwent hysterectomy due to uterine infarction 4 months later.
Conclusion: Nonuterine arteries can be one of the major sources of
postpartum haemorrhage. In addition, the detection of the haemorrhage and its selective embolisation are important for successful
haemostasis in patients with postpartum haemorrhage.

P-249

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P-251
Transcatheter arterial embolization for acquired uterine
arteriovenous malformation
U.G.Rossi1, P.Rigamonti1, P.Torcia1, A.M.Ierardi2, G.Carrafiello3,
M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Radiology, Uninsubria, Ospedale di Circolo, Varese, Italy,
3Department of Radiology, University of Insubria, Varese, Italy
We describe 3 cases of acquired uterine arteriovenous malformations with conspicuous vaginal bleeding that underwent transcatheter arterial embolization as bridge therapy before surgery to reduce
intraoperative blood loss.

P-252

The interventional treatment of gestational trophoblastic

tumor

A case of round ligament artery embolization for atonic

uterine bleeding

Z.J. Hao
Radiology Intervention, The First Affiliated Hospital of Zhengzhou
University, Zhengzhou, China

H.Kawada1, S.Goshima1, Y.Noda1, N.Kawai1, H.Koyasu1,

Y.Tanahashi2, H.Kondo2, M.Matsuo1
1Radiology, Gifu University Hospital, Gifu, Japan, 2Radiology, Teikyo
University Hospital, Tokyo, Japan

WITHDRAWN

P-250
Secondary postpartum hemorrhage: clinical manifestations
and angiographic findings
S.H.Jeong1, Y.H.Kim1, Y.H.D.Kim1, C.S.Kim1, J.H.Kim1, S.H.Kim1,
U.R.Kang2
1Radiology, Keimyung University School of Medicine, Dongsan Medical
Center, Daegu, Korea, 2Radiology, Daegu Catholic University Medical
Center, Daegu, Korea
Learning Objectives: To evaluate clinical manifestation, angiographic findings and effectiveness of transcatheter arterial embolization (TAE) for secondary postpartum hemorrhage (PPH).
Background: PPH remains one of the major causes of maternal mortality. Secondary PPH is usually defined as excessive vaginal bleeding from first 24 hours following delivery up to 6 weeks postpartum.
Most cases of secondary PPH are associated with minor morbidities but may still require re-admission to hospital. In more extreme
cases, major morbidity may require hysterectomy, arterial ligation,
or radiological intervention.
Clinical Findings/Procedure: From Feb 2005 to Dec 2015, 32 female
patients underwent TAE. The cause of bleeding was iatrogenic vascular injury in 12, retained placenta in 10, acquired AVM in 6, and
uterine atony in 4. Intermittent massive vaginal bleeding was presented in 16 (50%) and persistent vaginal bleeding in 16. Seven
revealed hypovolemic shock at the time of admission (21.9%).
Positive angiographic finding appeared in 15 (46.9%); pseudoaneurysm with/without extravasation of uterine artery in 10, AVM in
3, vaginal artery bleeding in 2. Technical success was achieved in
all (100%), and clinical success was achieved in 31 (96.9%). The case
of clinical failure underwent hysterectomy due to recurrent vaginal
bleeding. No procedure-related complication was found. Among
15 patients with long-term follow-up, a regular menstrual cycle
resumed in all (100%) and 1 had pregnancy.
Conclusion: TAE appears to be effective for treatment in patients
with secondary PPH. Early angiographic assessment is recommended for optimal treatment because secondary PPH may cause
life-threatening clinical manifestation and the rate of positive angiographic finding is significantly high.

A case of a 44-year-old woman with atonic uterine bleeding. Despite

embolization of the uterine artery, she continued to have unstable
hemodynamics. Therefore, the round ligament artery was distended
and connected to the uterine artery. We present this interesting case
with reported anatomy.

P-253
Cervical ectopic pregnancy: management with uterine artery
embolization
F.Petrocelli, G.Bovio, F.Camerano, A.Utili, G.Salsano, C.Ferro
Radiology, San Martino University Hospital, Genoa, Italy
A 25-year-old woman with a 12-weeks cervical ectopic pregnancy
was unsuitable for methotrexate therapy. To prevent massive bleeding, the patient received a conservative approach with a combination of uterine artery embolization and suction curettage.

P-254
Bilateral uterine artery embolisation to treat a gigantic fibroid:
personal experience and literature review
G.Gabbani1, C.Raspanti1, M.Citone2, F.Mondaini1, E.Mazza1
1Interventional Radiology Unit, Careggi University Hospital, Florence,
Italy, 2Radiology, Careggi University Hospital, Florence, Italy
Early publications suggested that UAE should not be performed
for large fibroids because of high complication rates. According
to recent publications debating these suggestions, we treated 2
patients with gigantic fibroids (1416 cm), with good clinical and
radiological results.

P-255
An unusual case of secondary postpartum haemorrhage
T.Carlsson1, G.Brehaut2, F.Naaisa2, N.Collin1
1Radiology, Southmead Hospital, Bristol, United Kingdom, 2Obstetrics
and Gynaecology, Southmead Hospital, Bristol, United Kingdom
A 24-year-old nulliparous female presented with secondary PPH following an uneventful SVD. Ultrasound excluded RPOC but demonstrated an endometrial fluid-filled vascular structure. CTA revealed

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endometrial pseudoaneurysm without active bleeding. DSA confirmed uterine artery pseudoaneurysm with AV shunting, which was
successfully embolised with Gelfoam.

P-258

P-256

D.F.W.Maclean1, B.Maher1, A.Cannavale1, M.R.Harris2, J.Dyer2,

S.Modi1, N.Hacking1, T.J.Bryant1
1Department of Interventional Radiology, University Hospital
Southampton, Southampton, United Kingdom, 2Urology, University
Hospital Southampton, Southampton, United Kingdom

Embolization of the uterine artery during caesarean

hysterectomy in patients with total placenta previa and
placenta accreta: a study of 2 cases
R.Abe, S.Sai, N.Mizobuchi, N.Hosaka, N.Seino, T.Gokan
Radiology, Showa University School of Medicine, Tokyo, Japan
By using internal iliac artery balloon occlusion, we can reduce bleeding during caesarean hysterectomy in a patient with total placenta
previa and placenta accreta. A hybrid operating room makes cooperation with other departments easy and reduces the complexity of
the procedure.

Imaging
P-257
Initial signs on prostate MRI after prostatic artery embolization
in patients with symptomatic BPH
T.Franiel1, S.Trupp1, M.-O.Grimm2, U.Teichgrber1,
R.Aschenbach1
1Radiology, University Hospital Jena, Jena, Germany, 2Urology,
University Hospital Jena, Jena, Germany
Purpose: The aim of this study was the investigation of early
changes in the prostate gland by multiparametric magnetic resonance imaging (mp-MRI) after prostate artery embolization.
Material and methods: This retrospective study was waived by
the local institutional review board. Sixteen patients with lower urinary tract symptoms were included. In all patients, a pharmacological treatment was not sufficient. All patients underwent a diagnostic
mp-MRI before and within 24 hours after embolization. Examination
protocol comprised morphologic imaging, diffusion weighted imaging (DWI), and dynamic contrast enhanced magnetic resonance
imaging using a 3.0T whole body scanner. Embolization procedure
was performed using 250 m biocompatible particles superselectively applied in prostatic arteries. Qualitative assessment was performed based on morphologic images of the interface between the
peripheral and central gland, capsule of BPH nodules, and visualization of peripheral zone tissue and central gland tissue using a fivepoint scale (from 1 excellent to 5 very poor). For quantitative assessment, the parameters Ktrans, kep, and ve using an open 2-compartment model and ADC values based on DWI were calculated.
Results: All embolization procedures were performed without
adverse events. Qualitative assessment showed no significant
changes. In the transition and peripheral zone, quantitative parameters showed a statistically significant reduction after embolization and were for transition zone: Ktrans0.43min-10.20 vs. 0.28min10.20, kep0.72min-10.26 vs. 0.44 min-10.24, ADC 1297 mm/s124
vs. 1159 mm/s138 and for peripheral zone: Ktrans 0.29 min-10.13
vs. 0.19 min-10.08, kep 0.54 min-10.25 vs. 0.34 min-10.11, ADC
1404 mm/s190 vs. 1348 mm/s175.
Conclusion: Early prostate MRI changes within 24 hours after prostate artery embolization are best detected by the quantitative
parameters Ktrans, kep, and ADC. Morphologic images showed no
significant changes.

Is CT angiogram an essential investigation prior to prostate

artery embolisation?

Purpose: Prostatic blood supply is highly variable with multiple

arterial origins within the pelvis in addition to frequent anastomoses in adjacent organs. Not all centres perform pre-procedural CT
angiogram to facilitate embolisation planning. Therefore, we aimed
to evaluate the utility of prostatic CT angiogram by assessing its
capacity to identify the prostatic arteries and highlight troublesome
anastomoses.
Material and methods: A review of patients undergoing prostate
artery embolisation for symptoms of benign prostate hyperplasia
(BPH) between June 2012 and December 2015 was conducted, with
analysis of the pre-procedural CT angiogram. CT findings were compared with subsequent intra-procedural angiograms to assess the
accuracy with which CT angiogram predicts the origin of prostatic
arteries and identify anastomoses.
Results: In total, 81 patients underwent prostate artery embolisation, with a pre-procedural CT angiogram acquired in all patients,
enabling assessment of 162 pelvic sides of hemiprostatic arterial
supply. Mean dose length product (DLP) was 808.4 mGycm2. CT
angiogram successfully identified prostatic arterial supply in 158/162
pelvic sides, with just 3.7% of CT angiograms not identifying the correct vascular anatomy. Anastomoses of prostatic vessels were suggested by CT angiogram in 36 pelvic sides. These were confirmed by
angiogram in 34/36 sides (94.4%). True anastomoses were identified
on procedural angiogram in 59 pelvic sides; therefore, CT angiogram
demonstrated a sensitivity of 58% and specificity of 94%.
Conclusion: CT angiogram prior to embolisation of prostatic arteries reliably predicts the arterial anatomy and facilitates procedural
planning. Therefore, it should be a routine pre-procedural investigation for patients undergoing prostate artery embolisation for BPH.

P-259
Pulmonary lymphatic perfusion syndrome in patients with
plastic bronchitis: diagnosis and embolization treatment
M.Itkin1, Y.Dori2, F.McCormack 3
1Department of Radiology, University of Pennsylvania Medical Center,
Philadelphia, PA, United States of America, 2Cardiology, Childrens
Hospital of Philadelphia, Philadelphia, PA, United States of America,
3Pulmonary, University of Pennsylvania, Cincinnati, OH, United States

of America
Purpose: To report findings of abnormal pulmonary lymphatic flow
on dynamic contrast-enhanced magnetic resonance lymphangiography (DCMRL) and the results of percutaneous lymphatic embolization treatment in a patient with idiopathic plastic bronchitis (PB).
Material and methods: This is a retrospective review of medical
records and imaging of 7 patients [M/F = 3/4, mean age 50 years
(range 3575 years)] with idiopathic PB who presented to our institution for lymphatic imaging (heavy-weighted T2 MRI and DCMRL)
and intervention. All patients underwent bilateral intranodal lymphangiogram and thoracic duct (TD) cannulation using a 3 Fr microcatheter. In cases where abnormal pulmonary lymphatic flow was
demonstrated, lymphatic embolization of abnormal pulmonary lymphatic flow was performed.
Results: MRI demonstrated the presence of abnormal pulmonary
lymphatic perfusion in 6/7 patients. All the patients underwent successful intranodal lymphangiogram and TD cannulation. Injection

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of TD demonstrated abnormal pulmonary lymphatic flow in 6/7

patients that correlated well with DCRML. Six patients with proven
abnormal pulmonary lymphatic flow underwent lymphatic embolization using a combination of lipiodol, endovascular glue, and
endovascular coils. In two patients, the embolization was performed
twice. Five patients reported immediate and complete resolution
of the symptoms, and one patient reported partial but significant
improvement. The mean length of follow-up was 11 months (range
4.316 months).
Conclusion: In this study, we demonstrated abnormal pulmonary
lymphatic flow in 6/7 patients with idiopathic PB using DCRML.
Embolization of the lymphatic flow appears to be an effective treatment for this disorder. A longer follow-up is needed to determine
the long-term effects of the treatment.

P-260
CT during pancreatic arteriography for the localization of
neuroendocrine tumors
K.Kajiwara1, M.Ishikawa1, Y.Baba2, W.Fukumoto1, T.Fuji1, K.Awai1
1Diagnostic Radiology, Institute and Graduate School of Biomedical
Sciences, Hiroshima University, Hiroshima, Japan, 2Diagnostic
Radiology, Graduate School of Biomedical Sciences, Hiroshima
University, Hiroshima, Japan
Purpose: To evaluate the clinical utility of CT during pancreatic arteriography (CTPA) for the localization of neuroendocrine tumors in
the pancreas.
Material and methods: Twenty-nine consecutive patients (14 men,
15 women; median age 58 years, range 1480 years) with suspected
neuroendocrine tumors were included in this study between March
2013 and November 2015. The average number of tumors was 1.2
tumors (range 08) and the mean diameter of the 37 tumors was 9
mm 5.3 [standard deviation] mm. All 29 patients underwent surgery or EUS. Of the 37 tumors, 13 were located in the pancreatic
head, 10 in the pancreatic body, 11 in the pancreatic tail, and 3 in the
duodenum. All 29 patients underwent CTPA, dynamic CT, and DSA;
in 22, we also performed MRI. We calculated the sensitivity of each
imaging modality.
Results: The sensitivity of CTAP, dynamic CT, DSA, and MRI was
94.6% (35/37), 70.3% (26/37), 35.1% (13/37), and 79.2% (19/24),
respectively. In 4 patients, CTPA detected 9 nodules that were not
seen on dynamic CT, DSA, and MRI scans. In 2 of these 4 patients,
CTAP detected new nodules; nodules smaller than 5 mm in diameter
were scattered throughout the pancreas.
Conclusion: CTPA was superior to dynamic CT, DSA, and MRI with
respect to the detection of pancreatic neuroendocrine tumors. We
think that it can identify micro-neuroendocrine tumors that are not
visualized on dynamic CT, DSA, and MRI scans.

P-261
US HCC screening behavior before and after implementation of
a structured reporting initiative
J.Wildenberg1, T.Gade2, S.Hunt1, G.J.Nadolski3, M.C.Soulen1
1Radiology, University of Pennsylvania, Philadelphia, PA, United
States of America, 2Diagnostic Radiology, University of Pennsylvania,
Philadelphia, PA, United States of America, 3Radiology, Hospital of the
University of Pennsylvania, Philadelphia, PA, United States of America
Purpose: Current guidelines recommend semiannual ultrasound
(US) screening for hepatocellular carcinoma (HCC) in cirrhotics and
subpopulations with hepatitis B. Performance of liver US screening
is dependent on the operator and how the clinician interprets the
results within the clinical context. This study compares the results of
US HCC screening before and after implementation of a structured

Abstract Book
reporting initiative with standardization of both language and recommendations to determine if structured reporting improved compliance with screening guidelines.
Material and methods: Screening US examinations for HCC performed in the 2 years following implementation of a structured
reporting initiative were compared to those performed in the 2 preceding years. A non-negative study was one in which a lesion was
seen and not definitively benign or a study where the liver was not
sufficiently evaluated. For all non-negative studies, the patients
history was reviewed to determine if they had additional imaging to
complete the liver evaluation.
Results: Six hundred and seven patients had a screening US in the 2
years prior to the structured reporting initiative and 1385 after. The
non-negative rate was 13.8% and 13.0%, respectively (p=0.610,
chi-square). Prior to structured reporting, 63.1% of patients complied with guidelines and underwent subsequent additional imaging following a non-negative study compared to 58.8% following
implementation (p=0.572).
Conclusion: Thirty-nine percent of patients with non-negative screening US were not referred for additional imaging.
Implementation of structured reporting did not improve compliance with recommended follow-up. This suggests that for patients
at risk for HCC, the standardization of US reports has not impacted
behavior for either the radiologist or clinician.

P-262
Non-enhanced T1-weighted images acquired after microwave
ablation are useful in the accurate evaluation of coagulated
necrosis
Z.Jia, Z.-Q.Yang
Radiology, The First Affiliated Hospital of Nanjing Medical University,
Nanjing, China
WITHDRAWN

P-263
Novel 4D MRI-based splenic function index for predicting
hypersplenism-associated thrombocytopenia
E.J.Keller1, L.Kulik 2, Z.Stankovic3, R.J.Lewandowski4, R.Salem4,
J.C.Carr1, S.Schnell1, M.Markl1, J.D.Collins1
1Radiology, Northwestern University, Chicago, IL, United States of
America, 2Gastroenterology and Hepatology, Northwestern University,
Chicago, IL, United States of America, 3Radiology, University of
Freiburg, Freiburg, Germany, 4Interventional Radiology, Northwestern
University, Chicago, IL, United States of America
Purpose: To evaluate the role of quantitative splenic hemodynamics and spleen volume as predictors of hypersplenism-associated thrombocytopenia in patients with cirrhosis and portal
hypertension.
Material and methods: Thirty-nine patients (52 10 years, 14
women) with cirrhosis and portal hypertension underwent noncontrast 4D flow MR imaging at 3.0 T with velocity sensitivities of
50/55 and 100/110 cm/sec. Splenic volumes were measured on axial
3D T1-weighted gradient-recalled echo. Correlation coefficients
were used to assess the relationships between patient demographics, ChildPugh scores (CPS), blood component counts, splenic volumes, splenic blood flow, shunted portal flow percentages, and indices combining these variables. Receiver operator curves were used
to compare the ability of these measures to predict platelet counts
<50 x 103/L.
Results: Demographics exhibiting significant (p<0.05) correlations
included body surface area (BSA) and spleen size (r=0.38) and CPS
and low blood component counts (r=0.380.59). Larger splenic

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volume, arterial flow, venous flow, and shunted portal flow were
each found to correlate with lower platelet counts (=0.63, 0.69,
0.57, and 0.36, respectively). Indices linking splenic volume and flow
showed less predictive value than treating each as independent
risk factors. Adding splenic volume to arterial flow and the product of venous flow and percent shunted portal flow indexed to BSA
yielded the strongest correlation with lower platelet counts (=0.78)
and prediction of thrombocytopenia (100% sensitive; 81% specific).
Splenic function index = [VS+ QSA+ (QSV* Shunt%)]/BSA
Conclusion: Increased splenic volume, blood flow, and portosystemic shunts in the setting of portal hypertension are all correlated
with hypersplenism-associated thrombocytopenia but less predictive than a splenic function index incorporating all these variables
indexed to BSA.

P-264
Visualization of CTO micro-channels in PAD patients with
contrast-enhanced ultrasound
R.Allan, H.-Y.Tan, P.Puckridge, I.Spark
Vascular and Endovascular Surgery, Flinders University, Bedford Park,
SA, Australia
Purpose: Micro-channels have been identified within chronic total
occlusions (CTO) in animals. They have been proposed as a method
of obtaining transluminal crossing of an occluded artery. There is
currently no method to reliably identify these micro-channels in
humans. The purpose of this study was to investigate whether contrast-enhanced ultrasound (CEUS) can identify micro-channels in
CTOs in patients and aid transluminal crossing.
Material and methods: Ten patients with radiographically confirmed femoral or popliteal CTO were assessed with CEUS. Scanning
was performed with Definity contrast medium using standard contrast-specific imaging modes and MicroFlow Imaging bubble tracking software. Identification of micro-channels was performed by
the presence of microbubbles in areas of the lesion with no patent
lumen on conventional imaging. Micro-channels appearances were
categorised as linear or tortuous.
Results: Ten patients with confirmed CTO were imaged (M:7 F:3,
mean age:74 years). Micro-channels were seen in 7 cases (linear pattern in 5 cases and tortuous in 2 case). To date, treatment has been
attempted in 7 cases (micro-channels seen=4, not seen=3). Crossing
was successful in all 4 cases where micro-channels were identified
(transluminal=3, sub-intimal=1) and in 2 of 3 where they were not
seen (transluminal=1, sub-intimal=1).
Conclusion: This is the first report of in-vivo imaging of CTO microchannels in PAD patients. Non-invasive imaging of micro-channels
with CEUS is feasible and able to be performed with standard imaging technology. The application of this method provides new opportunities to study the pathophysiology of CTO and the role of microchannel identification in endovascular treatment.

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P-265
C-arm computed tomography (CACT) adds diagnostic
information in patients suffering from chronic
thromboembolic pulmonary hypertension (CTEPH) with a
positive V/Q SPECT mismatch pattern
J.Hinrichs1, T.Werncke1, T.Kaireit1, M.M.Hoeper2, K.M.Olsson2,
F.Wacker1, F.Bengel3, I.Schatka3, B.C.Meyer1
1Institute for Diagnostic and Interventional Radiology, Medizinische
Hochschule Hannover, Hannover, Germany, 2Clinic for Pneumology,
Medizinische Hochschule Hannover, Hannover, Germany, 3Clinic for
Nuclear Medicine, Medizinische Hochschule Hannover, Hannover,
Germany
Purpose: To provide insights in the added diagnostic value of CACT
in patients suffering from CTEPH with a positive mismatch pattern in
V/Q SPECT.
Material and methods: Twenty-eight patients (23 males; 6218
years) with CTEPH who had undergone SPECT followed by CACT
and right heart catheterization (RHC) were included. Two independent readers reviewed SPECT and CACT. CTEPH indicating findings
and their location (segmental or sub-segmental) were identified.
Inter-modality agreement was calculated (Cohens Kappa). Findings
in both modalities were scored on a 3-point scale. The sum of the
score (pulmonary artery CTEPH severity score (PACSS)) was calculated for each imaging modality, correlated to RHC (Spearmans rho),
and compared to the final therapeutic decision of the CETPH board.
Results: Five hundred and four pulmonary artery segments were
assessed in both modalities. SPECT detected 266/504 (53%) arterial segments without and 238/504 (47%) with pathologic findings.
CACT detected 131/504 (26%) segments without pathologic findings and 373/504 (74%) with pathologic findings. CACT showed 145
sub-segmental pathologic findings rated as normal in SPECT. Intermodality agreement for pathologic findings in SPECT vs. CACT was
fair (=0.38). SPECT detected V/Q mismatches with a median PACSS
of 10 compared to 15 in CACT. PACSS-CACT correlated mildly significant with mean pulmonary artery pressure (R=0.47; p=0.01), whereas
SPECT missed significance (R=0.3; p=0.12). PACSS-CACT showed a
mildly significant difference between conservative or invasive treatment (p=0.04), whereas PACSS-SPECT did not (p=0.06).
Conclusion: In patients with CTEPH, contrast-enhanced CACT is
of additional value for a precise morphological assessment of distal pulmonary arteries. CACT indicates abnormalities even in segments without V/Q abnormalities and may influence clinical decision
making.

P-266
Selective intra-arterial dual-energy CT angiography (s-CTA) in
lower-extremity arterial occlusive disease
J.Swanberg, A.Wanhainen
Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
Purpose: To report the preliminary experience of selective dualenergy lower-extremity CT angiography (s-CTA), in which arterial
contrast enhancement is obtained by the intra-arterial injection
of a very small amount of iodine contrast media (I-CM), thus making it applicable for patients unsuitable for conventional contrastenhanced imaging due to renal insufficiency.
Material and methods: In total, 12 mL of I-CM 400 mg I/mL diluted
with 36 mL of NS was injected at 2 mL/s through a 4 F micropuncture catheter inserted into the common femoral artery and dualenergy CT scanning of one leg was performed with a scan time of
2530 s after a 14 s delay. Hemostasis was obtained by 10 min:s manual compression. Patients were discharged after 2 hours.
Results: In a pilot study published in EJVES 2014, 10 patients with
CLI and renal insufficiency underwent s-CTA. A median 17 mL (range

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1019 mL) I-CM (400 mg I/mL) was used. Median baseline plasma
creatinine was 163 mol/L (range 105569 mol/L) pre s-CTA vs. 153
mol/L (range 105562 mol/L) post s-CTA, p=0.24. There was no
puncture site complication. Among the patients selected for intervention (n=6 with 30 arterial segments), the s-CTA findings correlated well with the DSA findings. The diagnostic sensitivity was
100%, the specificity was 89%, and the accuracy was 93%.
Conclusion: s-CTA can provide high-quality arterial imaging with a
very small amount of I-CM. The technique is now in routine use at
our institution, and a prospective accuracy and safety study is currently being conducted. Additional data will be ready to present in
September.

P-267
Prospective intraindividual comparison of time-resolved
peripheral MRA with continuous table movement and
64-section CT angiography in patients with critical limb
ischemia
S.S.Byun, J.W.Kim
Radiology, Gachon University Gil Medical Center, Incheon, Korea
Purpose: The aim of this study is to compare 3D contrast-enhanced
lower extremity MR angiography (MRA) with continuous table
movement in combination with temporal interpolation and stochastic spiral trajectories (TWIST) and 128-slice CT angiography (CTA) in
the same patients with diabetic critical limb ischemia for assessment
of the lower extremity peripheral arteries with digital subtraction
angiography (DSA) as the standard of reference.
Material and methods: This prospective study included 30 consecutive patients (70.5 years, M:F=16:14) with diabetic critical limb ischemia who underwent 64- or 128-slice CTA and scheduled endovascular treatment using DSA. All patients also underwent 3D contrastenhanced lower extremity MRA with continuous table movement in
combination with TWIST before endovascular treatment. The scancovered arteries were divided into 10 anatomic segments for review.
The status of each segment was graded as grade 1, normal vessel or
vessel irregularities (<10% luminal narrowing); grade 2, mild arterial stenosis (10%49% luminal narrowing); grade 3, severe arterial
stenosis (50%99% stenosis); and grade 4, occlusion. The sensitivity
and specificity of MRA and CTA were determined using DSA as the
gold standard.
Results: For the detection of hemodynamically significant stenosis
(>50%), the sensitivity and specificity were as follows: MRA, 96.3%
and 97.3% and CTA, 91.9% and 97.3%; respectively (on a segmentbased analysis). Positive predictive value and negative predictive
value of CTA were 91.9% and 95.2% and MRA were 95.6% and 95.2%,
respectively.
Conclusion: Our study demonstrated that TWIST MRA with continuous table movement is promising for the evaluation of peripheral
artery disease in patients with critical limb ischemia and diabetes.

P-268
The value of true-FISP sequences in the pancreas and renal
transplantation: a comparison with vascular sequences with
gadolinium
A.CerveraAraez, P.Bermudez, M.Burrel, M.Barrufet,
A.Sotomayor, F.M.Gmez
Vascular Interventional Unit, Hospital Clnic Barcelona, Barcelona,
Spain
Purpose: The purpose of our study was to assess the possibility of evaluating the iliac and celiac trunk branches using nonenhanced sequence, true-fast imaging with steady-state precession

Abstract Book
(true-FISP) and compare the technique with conventional vascular MRI sequences with gadolinium in order to depict the vascular anatomy with high detail in renalpancreas recipients prior to
transplantation.
Material and methods: This is a retrospective study from May 2015
comprising 7 diabetic patients with end-stage renal disease who
were referred to our hospital in order to be candidates for double
renalpancreas transplant. Seven vascular studies were performed
in order to investigate the suitability of the vascular anatomy of the
recipients for a double transplant prior to surgery. Non-contrast CT
was performed to identify calcifications in the iliac sector as well as
conventional angio-MRI with contrast and true-FISP sequences without contrast to evaluate the iliac artery and celiac trunk. Informed
consent was required. We evaluated the true-FISP sequences and
estimated the accuracy of the vascular map obtained without contrast; we also assessed whether the sequences were potentially
comparable with the contrast MRI vascular sequences.
Results: Seven MRI vascular studies were performed prior to double transplant surgery. Good correlation was achieved between the
vascular contrast MRI sequences and true-FISP sequences in 71 (5/7
studies). Two/seven patients (28%) were rejected for double transplant due to significant atheromatous calcifications in the iliac sector and due to a 40% stenosis of external iliac artery. Three patients
were recipients of the double transplant, and no complications were
related to the previous vascular study.
Conclusion: MRI true-FISP sequences can potentially provide an
optimal vascular study prior to renalpancreatic transplantation in
order to avoid gadolinium contrast in vascular studies with MRI.

P-269
Usefulness of MR angiography high temporal resolution (twist)
in the assessment of peripheral artery disease of lower limbs
A.AlegreCastellanos1, M.RedondoOlmedilla1,
J.DelgadoEscudero1, M.A.GarridoCollado1, J.GarciaRevillo2
1Unidad de Radiologa Vascular e Intervencionista, Complejo
Hospitalario de Jan, Jan, Spain, 2Radiologia Intervencionista,
Hospital Universitario Reina Sofa, Cordoba, Spain
Purpose: Assessment of the distal vessels (infrapopliteal vascularization) is a determining factor in treatment planning of patients
with lower limb ischemia.
Our goal with this review is to determine the diagnostic efficacy of
an MRA sequence called TWIST (time-resolved angiography interleaved with stochastic trajectories, Siemens Healthcare), comparing
its performance against other that of diagnostic techniques such as
CT angiography or DSA.
Material and methods: The TWIST sequence consists of a dynamic
sequence that prevents arterial venous contamination. In addition,
with the intraluminal arteries opacification, artifacts of calcification
are minimized.
In our study, we retrospectively reviewed the MRA studies (Siemens
Magnetom Avanto 1.5T) using the TWIST sequence from January
2013 to May 2015, resulting in a total of 42 studies (33 males and 9
females) with a mean patient age of 63 years.
In further analysis of the studies, the permeability of the infrapopliteal beds were valued, and these results were compared with those
obtained with CT angiography and/or DSA when these explorations
were available.
Results: In 39 patients (93% of total), MRA with the TWIST sequence
allowed an accurate assessment of the permeability of the infrapopliteal artery, without calcification artifacts or venous contamination
invalidate exploration.
In 3 patients (7% of total), the examination was not valid for the diagnosis (in 2 patients because of technical problems and in 1 patient
due to failure in contrast administration).

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Conclusion: MRA with the TWIST sequence is a useful noninvasive
diagnostic technique for the assessment of distal arterial bed of
lower limbs.

P-270
Go ballistic: gunshot trauma and the role of interventional
radiology
D.Ballah, M.Wilson, E.Velez, V.Kumar, S.Nanavati, E.Lehrman,
M.B.Conrad
Department of Radiology and Biomedical Imaging, University of
California San Francisco, San Francisco, CA, United States of America
Learning Objectives:
1. To review different types of projectiles encountered in firearm
injuries.
2. To learn the difference between the morphologic types of ballistic
injuries.
3. To learn the mechanisms of tissue injury from gunshot wounds.
4. To review multiple interventional radiology cases in gunshot
wound victims.
Background: In 2011, there were approximately 32,000 fatalities
from firearms and 74,000 nonfatal firearm injuries. These patients
often undergo contrast-enhanced imaging in the emergency care
setting. Understanding the type of penetrating trauma and predictable pattern of injury based on the ballistic type can help attune
the radiologist to injuries while interpreting their examination.
Furthermore, patients may experience vascular injuries that are
amenable to treatment by interventional radiology.
Clinical Findings/Procedure: This exhibit will discuss several characteristics regarding gunshot wounds and ballistics as well as the
role of interventional radiology in treating gunshot wound patients.
Characteristics of projectiles from bullets, rifles, and shotguns will
be reviewed. Morphologic types of ballistic tissue injuries, which
include penetrating, perforating, and avulsive injuries, will be illustrated. Mechanisms of soft tissue injury from gunshot wounds are
related to projectile type and velocity. Low- and high-velocity projectiles along with the concepts of temporary and permanent cavities of gunshot wounds will be discussed. Several cases of patients
suffering gunshot trauma with vascular injury who underwent diagnostic imaging and interventional radiology procedures will be
shown.
Conclusion: Familiarity with projectile characteristics can aid in
imaging assessment of firearm injuries. Interventional radiology has
an important role in the treatment of gunshot wound patients with
vascular injury.

P-271
Iodinated contrast media for junior interventionalists: a
potpourri of safety issues
A.Khankan1, S.Alshehri1, M.Arabi1, T.Al-Hazmi2, F.Aris3,
M.Almoaiqel1
1Medical Imaging, King Abdulaziz Medical City, Riyadh, Saudi Arabia,
2Radiology, Umm Al-Qura, Makkah, Saudi Arabia, 3Radiology, McGill
University Health Center, Montreal, QC, Canada
Learning Objectives:
1. To briefly review the iodinated contrast media (ICM) and its use in
a manner that maximizes the patient safety according to available
international guidelines and recommendations.
2. To discuss the practical aspects and safety considerations related
to administration of ICM in various medical conditions.
Background: ICM is continuously growing in a wide range of imaging and interventional procedures. Most of the patients who are
subjected to such radiologic procedures are with multiple medical
conditions and/or receiving a variety of drugs or even belong to a

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special age group. ICMs have adverse reactions that are most likely
to have serious sequelae if not anticipated, recognized promptly,
and treated effectively.
Although overall reactions are declining due to the significant
improvement in the physicochemical properties of ICM molecules
and better understanding of the pathophysiology of their adverse
reactions, there are still multiple risk factors predisposing patients to
such reactions that have not be eliminated.
Clinical Findings/Procedure: The poster will discuss the practical
aspects related to administration of ICM safely, focusing on
1. Anticipating and recognizing the risk factors
2. Interactions and compatibility with some drugs
3. Administration in pediatric population
4. ICM in special medical conditions
5. Subcutaneous extravasation
Conclusion: It is imperative for junior interventionalists to be intimately familiar with the characteristics, indications, and potential
side effects of ICM. In addition to knowledge and technical skills,
they must be able to recognize the predisposing risk factors and
anticipate the adverse reactions of ICM promptly and treat them
effectively to avoid the substantial morbidity and even mortality.

P-272
Grading of diaphragmatic injuries in major thoraco-abdominal
trauma for planning interventional radiology management
P.Torcia1, U.G.Rossi1, P.Rigamonti1, G.Mauri2, V.Pedicini3,
D.Poretti3, A.M.Ierardi4, G.Carrafiello5, M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Radiology, IRCCS Policlinico San Donato, San Donato
Milanese, Italy, 3Radiology and Interventional Radiology, IRCCS
Humanitas Hospital, Milan, Italy, 4Radiology, Uninsubria, Ospedale di
Circolo, Varese, Italy, 5Department of Radiology, University of Insubria,
Varese, Italy
Learning Objectives: To describe and illustrate type and grading for diaphragm injuries in thoraco-abdominal major trauma for
the planning of conservative, interventional radiology and surgery
management.
Background: A major thoraco-abdominal trauma can lead to various organ and structure injuries, including that of the diaphragm.
Diaphragm injury is due to the barotrauma between the abdomen
and the thorax. MD-CT in a major thoraco-abdominal trauma is the
first-line imaging modality for determining the diagnosis and planning the possible therapies. Interventional radiology management
with transcatheter embolization is one of the possible treatments
alone or combined with surgery.
Clinical Findings/Procedure: Most frequent major thoracoabdominal trauma involves the mediastinum, lung, spleen, kidney, and liver, and we are used to focus our attention on these vital
organs; however, collateral injuries are generally present too, e.g.,
the diaphragm. The aim of this poster is to illustrate 1) imaging evaluation of diaphragm injury, 2) the possible conservative, endovascular and surgery therapies and 3) focus on possible advantages of
interventional radiology procedures.
Conclusion: A better knowledge all possible organs injuries in major
thoraco-abdominal trauma, in particular on MD-CT, can lead to a
more rapid diagnosis and, consequently, a correct treatment from
conservative management to interventional radiology and surgery.

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P-273

P-275

Anatomic variations of renal arteries: what the interventional

radiologist needs to know

The role of pulmonary angiography (PA) in the evaluation

and management of patients with chronic thromboembolic
pulmonary hypertension (CTEPH)

P.Torcia1, U.G.Rossi1, P.Rigamonti1, A.M.Ierardi2, G.Carrafiello3,

M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Radiology, Uninsubria, Ospedale di Circolo, Varese, Italy,
3Department of Radiology, University of Insubria, Varese, Italy

A.S.Jo1, M.Khaja1, J.Haft2, V.Mclaughlin3, D.Williams1

1Department of Radiology, University of Michigan, Ann Arbor, MI,
United States of America, 2Cardiac Surgery, University of Michigan, Ann
Arbor, MI, United States of America, 3Internal Medicine - Cardiology,
University of Michigan, Ann Arbor, MI, United States of America

Learning Objectives: The aim of this study was to review the

embryology and imaging of the renal arteries in order to understand
the possible variations in origin, number and diameter, and clinical
implications.
Background: Anatomic variations of renal arteries are usually clinically silent and are understudied till a clinical symptom or an endovascular/surgical procedure has to be done. Due to the complex
embryogenesis, the anatomy of renal arteries may have a sizeable
number of variations. The knowledge of such possible vascular variations is crucial for radiologists, interventional radiologists, and
surgeons.
Clinical Findings/Procedure: The purpose of this poster is to illustrate 1) description of embryogenesis, 2) knowledge of normal
renal artery vascular anatomy and its possible variations, 3) imaging
evaluation of renal artery, and 4) possible implication in future endovascular therapies and/or open surgery.
Conclusion: Renal arterial variants are various and quite frequent.
For such reasons, imaging and knowledge of renal artery anatomy
variation is an absolute prerequisite, especially when a patient is
candidate to endovascular and/or surgical procedure.

P-274
Abdominal visceral pseudoaneurysm: spectrum of MDCT
findings
N.Hosaka, S.Sai, N.Seino, R.Abe, N.Mizobuchi, T.Gokan
Radiology, Showa University School of Medicine, Tokyo, Japan
Learning Objectives: The goal of this exhibit is to understand multi
detector-row computed tomography (MDCT) features of abdominal
visceral pseudoaneurysm. Assessing the benefits of MDCT will be
helpful for proper diagnosis and evaluation of splanchnic pseudoaneurysm. Furthermore, it will provide information for planning the
interventional therapy.
Background: Abdominal visceral pseudoaneurysm is rare, but its
diagnosis is clinically important due to the accompanying high mortality and potential complications. MDCT has become a rapid and
non-invasive tool. It provides important information of abdominal visceral pseudoaneurysm by accurate detection. This detailed
assessment is crucial because the treatment depends on its location, type, size of the aneurysm, and the medical condition as well.
Therefore, every emergency interventional radiologist should
detect and evaluate abdominal visceral pseudoaneurysm correctly.
Clinical Findings/Procedure: In this exhibit, we review MDCT features, surgical findings, key diagnostic points, pitfalls, and mimics in each case. We also review clinical manifestation and causes.
Therapeutic management will be highlighted in this discussion. In
particular, we show MDCT diagnosis with discussion of usefulness
of 3DCT angiography, including pitfalls and mimics. Clinical manifestation includes shock, hemorrhage, hemobilia, fever, etc. Cause
includes pancreatitis, trauma, iatrogenic origin, neoplasm, etc. We
also discuss management and treatment, with emphasis on endovascular therapy.
Conclusion: MDCT can be reliably used as an initial diagnostic technique for the evaluation and characterization of abdominal visceral pseudoaneurysm. We should acquire various MDCT findings of
abdominal visceral pseudoaneurysm.

Learning Objectives:
1. Review diagnostic criteria of CTEPH
2. Describe technique of performing PA for CTEPH planning
3. Illustrate angiographic findings of CTEPH
4. Describe medical and surgical therapy options
Background: CTEPH is a potentially curable form of pulmonary
hypertension (PH). Approximately 2%4% of patients with acute PE
develop CTEPH. Despite technical advances in CT-PA, PA is essential
in the work-up of patients with CTEPH.
Clinical Findings/Procedure: CTEPH is defined as systolic and
mean pulmonary arterial pressure (PAP) persistently exceeding 40
mmHg and 25 mmHg, respectively, in patients with angiographic
findings of thromboembolic disease. The diagnosis of CTEPH
requires history taking and physical exam, echocardiography, VQ
scan, right heart catheterization, and PA.
Pulmonary thromboendarterectomy (PTE) has been established
as the curative surgical intervention for patients with CTEPH.
Inoperable disease or refractory/residual PH after PTE may benefit
from medical therapies with vasoactive agents such as prostaglandins, PDE5 inhibitors, and guanylate cyclase activators.
To identify candidates for PTE, careful attention to the angiographic technique is critical. A non-traumatic flush catheter is positioned in the proximal descending pulmonary artery, and magnification PA is performed with LAO/RAO views, 6 frames/second filming
rate, and pulmonary manometry-based injection rate and volume.
Characteristic imaging findings on PA include proximal webs, stenoses, occlusion, or pruning of vessels.
Conclusion: Optimization of PTE requires IR to obtain high-quality
PA to plan the treatment. Elevated PAP with central stenoses may be
findings that can be successfully treated with PTE. Understanding
the imaging technique and open communication between the
IR and surgical teams are of utmost importance in treating these
patients.

P-276
Delayed hemorrhage caused by biliary metallic stent
placement for malignant bile duct obstruction: clinical
manifestations and endovascular treatment
S.Noguchi, N.Sakamoto, T.Taniguchi, Y.Nakashima, T.Oda,
M.Nishioka, T.Kadoba, H.Tomimatsu
Radiology, Tenri Hospital, Tenri, Japan
Delayed hemorrhage is a rare but fatal complication of biliary metallic stent placement. The purpose of this exhibition is to present clinical manifestations, radiologic findings, and endovascular treatment
of this complication. We report three such cases, with a review of
literature.

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P-277
Percutaneous transvenous embolization of the thoracic duct in
the treatment of chylothorax
E.Paci1, M.Refai2, C.Mincarelli1, P.Boscarato1, M.Fichetti1,
M.Rosati1, R.Candelari1
1SOD Radiologia Interventistica, Az Osp-Univ OORR Torrette, Ancona,
Italy, 2Thoracic Surgery, Ospedali Riuniti Torrette, Ancona, Italy
We report percutaneous transvenous embolization of the thoracic
duct in a patient with life-threatening metabolic deterioration due
to persistent high-output chylothorax. Selective embolization of the
thoracic duct was performed, with the help of ultrasound-guided
intranodal lymphangiogram via the femoral vein.

P-278
Diagnosis and treatment of iatrogenic vertebrobasilar
insufficiency caused by screws of posterior cervical spinal
fusion
S.Yamazoe1, M.Katayama2, Y.Nozawa1, A.Baba1, S.Inoue2,
Y.Munetomo1, Y.Kobashi1, T.Mogami1
1Radiology, Tokyo Denatal College, Ichikawa General Hospital, Chiba,
Japan, 2Neuro-Surgery, Tokyo Dental College Ichikawa General
Hospital, Chiba, Japan
A 74-year-old patient presented with positional dizziness after posterior cervical spinal fusion. Dynamic 3D-DSA demonstrated left VA
occlusion and right VA positional compression at cervical extension
due to operation screws. We performed treatment by interventional
embolization and operation.

P-279
Ergotism: a rare cause of peripheral vascular ischemia
M.LeyvaVsquez-Caicedo, J.GonzlezNieto, J.E.ArmijoAstrain,
J.V.MndezMontero
Vascular and Interventional Radiology, Hospital Universitario Clnico
San Carlos, Madrid, Spain
We describe the rare case of a patient with toxicity due to ergot
derivatives who developed arterial ischemia in upper limbs, with a
good clinical course after the cessation of ergotamine and IV infusion of prostaglandin.

Neuro and carotid intervention

P-280
Experience with pCONus bifurcation aneurysm implant for
wide-neck intracranial aneurysm treatment
E.Pampana, A.Bozzi, S.Abrignani, S.Merolla, F.Chegai, D.Konda,
R.Gandini
Diagnostic and Molecular Imaging, Radiation Therapy and
Interventional Radiology, University Hospital Policlinico Tor Vergata,
Rome, Italy
Purpose: The pCONus bifurcation aneurysm implant is an intraluminal device intended to assist coiling in the treatment of complex
and wide-neck intracranial bifurcation aneurysms. We report our
preliminary experience with the pCONus device (Phenox, Bochum,
Germany).
Material and methods: Twelve patients with 12 wide-neck aneurysms (3 recently ruptured) were treated with pCONus-assisted
coiling. Eight aneurysms were located in the anterior circulation (5
ACoA and 3 MCA) and 4 in the posterior circulation (basilar artery).

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The pCONus device was preferred to other techniques owing to its

secure anchoring and optimal placement, mainly related to its precise deployment and complete recoverability. Primary endpoints
were complete aneurysm occlusion and clinical safety considered as
the absence of death or of major or minor stroke.
Results: In our experience, immediate angiographic controls
showed complete aneurysm occlusion in 75% (9/12), residual neck
remnant in 25% (3/12), and incomplete occlusion in 0% (0/12) cases.
Clinical safety was obtained in all patients as no ischemic complications were observed. The neurologic status remained unchanged
at follow-up. No procedural angiographic complications were
observed. No aneurysms were found to bleed or rebleed after
treatment.
Conclusion: The use of the pCONus bifurcation aneurysm implant
system has been confirmed to be safe and very effective, with
acceptable clinical and anatomical outcomes and a precise deployment control that extends the possibility of endovascular treatment
of complex and wide-neck intracranial bifurcation aneurysms.

P-281
External carotid artery angioplasty and stenting for patients
with ischemic events
A.Dimitriade1, A.C.Carp1, A.Mergeani2, B.Dorobat1, F.A.Anochi2,
G.Iana3
1Department of Angiography and Endovascular Therapy, Bucharest
Emergency University Hospital, Bucharest, Romania, 2Department
of Neurology, Bucharest Emergency University Hospital, Bucharest,
Romania, 3Radiology, Bucharest Emergency University Hospital,
Bucharest, Romania
Purpose: The aim of our study was to present 11 patients with ECA
stenosis and ipsilateral ICA occlusion in whom stenting of ECA was
performed for cerebral circulation through collateral vessels.
Material and methods: Our study comprised 6 male and 5 female
patients aged between 48 and 74 years who were admitted to our
clinic for transient ischemic attack (6 patients) and ischemic stroke
(5 patients).
All the patients had medical history of arterial hypertension, dyslipidemia, and cardiac ischemic disease. One male patient had diabetes
and another had impaired fasting glucose levels.
Dopplers ultrasonography of the cervicocerebral arteries revealed
bilateral ICA occlusion in 5 patients and unilateral ICA occlusion
associated with hemodynamically significant contralateral ICA stenosis in 6 patients. In all the patients, there was ECA stenosis ipsilateral to the symptomatic occluded ICA.
Digital substraction angiography of the cervicocerebral vessels confirmed the following ultrasonographic findings: ICA occlusion ipsilateral to the ischemic event, intracerebral blood flow in middle and
anterior cerebral arteries being supplied by the ipsilateral ECA, ipsilateral ECA stenosis between 80%99%, and 10 patients showing
stenosis of the left ECA and 1 patient showing the stenosis of the
right ECA.
Results: We proceeded to angioplasty with the stenting of ECA with
optimal postangioplasty results and improved intracranial cerebral
blood flow, without periprocedural incidents. The patients were discharged few days later with double antiplatelet therapy.
Conclusion: We present these cases to underline the importance of
preventing further ischemic events and vascular cognitive impairment in patients with occluded ICA and ipsilateral ECA stenosis
using angioplasty and stenting of ECA.

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P-282

P-284

Mechanical thrombectomy using a Solitaire AB stent for

cerebralvenous sinus thrombosis

Mechanical thrombectomy is superior to intravenous

thrombolysis only in the most proximal anterior circulation
occlusions

S.Shui, T.-F.Li, X.-W.Han, J.Ma

Interventional Radiology, First Affiliated Hospital, Zhengzhou
University, Zhengzhou, China

N.Sillanp1, S.M.Protto2
1Medical Imaging Center, Tampere University Hospital, Tampere,
Finland, 2Radiology, Tampere University Hospital, Tampere, Finland

Purpose: To investigate the efficacy and safety of the endovascular management strategy of mechanical thrombectomy using a
Solitaire AB stent for cerebral venous sinus thrombosis (CVST).
Material and methods: Twenty-eight cases of digital subtraction angiography-confirmed CVST were treated using a Solitaire AB
stent. Active treatment of primary disease was carried out after cerebral venous sinus recanalization, and the subsequent anticoagulant
therapy lasted for 6 months.
Results: Recanalization of the cerebral venous sinus was achieved
in all 28 patients, and no endovascular treatment-related complications occurred during or after the procedure. At discharge, the
Glasgow Coma Scale (GCS) score of the patients had improved from
an average of 11.7 points to 15 points, and clinical symptoms had
also been improved in 100% of the patients. Follow-up duration
ranged from 10 to 67 months (mean, 43.7 months), and no thrombus re-formation or new neurological deficits occurred during this
period.
Conclusion: Based on our small study population, mechanical
thrombectomy using a solitaire AB stent appears to be a safe and
effective treatment for CVST. However, further research is needed to
confirm this.

P-283
Predictors of poor outcome in anterior circulation mechanical
thrombectomy
S.M.Protto1, N.Sillanp1, J.-P.Pienimki1, I.Matkaselk1,
H.Numminen2, J.Seppnen1
1Radiology, Tampere University Hospital, Tampere, Finland,
2Neurology, Tampere University Hospital, Tampere, Finland
Purpose: Mechanical thrombectomy (MT) is an effective and safe
treatment in patients presenting with acute anterior circulation
stroke and sufficient penumbra on perfusion imaging. We evaluated
the technical success and clinical outcome at three sites of occlusion
in the anterior circulation (ICA, M1 and M2 segments of the middle
cerebral artery) in order to identify the factors that are predictors of
poor outcome (3-month Modified Rankin Scale, mRS, from 3 to 6).
Material and methods: We prospectively reviewed 105 patients
who underwent MT to treat anterior circulation stroke. We recorded
baseline clinical, procedural and imaging variables, technical outcome (thrombolysis in cerebral infarction, TICI), 24-h imaging outcome and 3-month clinical outcome (mRS). Differences between the
groups were determined using statistical tests according to the type
of variable.
Results: TICI>2a was achieved in 92 patients (88%), and good clinical
outcome was achieved in 57 patients (55%), with no statistically significant difference between the ICA, M1 and M2 groups. A tendency
of a larger proportion of patients experiencing excellent outcome
was observed in the ICA and M1 groups (ICA: 44%, M1: 41%, M2: 23%
of patients, p=0.22). The only significant predictor of poor outcome
was a low ASPECTS score on cerebral blood volume (CBV) imaging
at admission (p=0.01). In addition, there was a trend towards worse
outcome in patients who did not receive IVT before MT (p=0.08).
Conclusion: A low ASPECTS score assessed based on the CBV map
at admission, which implied large infarct volume, is a predictor of
poor prognosis in patients treated with MT.

Purpose: Mechanical thrombectomy (MT) is an established treatment in patients with acute anterior circulation stroke caused by
large vessel occlusion. We compared the clinical outcome (3-month
Modified Rankin Scale, mRS) in hyperacute (<3 h from the onset of
symptoms) ischemic stroke between an MT and an intravenous
thrombolysis (IVT) cohort at different sites of occlusion: ICA and the
proximal M1, the distal M1, and the M2 segment of the middle cerebral artery.
Material and methods: We prospectively reviewed 67 patients who
underwent MT with a newer generation device and 98 patients who
received IVT only during the time MT was not available in our institution. We recorded baseline clinical, procedural, and imaging variables, technical outcome, 24-h imaging outcome, and 3-month clinical outcome (mRS). Differences between the groups were studied
using statistical tests according to the type of variable.
Results: Overall, good clinical outcome (mRS2) was experienced
by 84 patients (52%) with no statistically significant difference
between the MT and IVT groups. Excellent clinical outcome (mRS1)
was observed more often in the MT group (42% vs. 22%, p=0.005).
After adjusting for stroke severity, onset-to-treatment time and age,
mRS2 was achieved significantly more often in ICA and proximal
M1 occlusions (p=0.004 and p=0.009, respectively) but not in distal
M1 and M2 occlusions (p=0.84 and p=0.31, respectively).
Conclusion: Mechanical thrombectomy is superior to intravenous
thrombolysis in achieving good clinical outcome in the treatment
of hyperacute anterior circulation stroke in the most proximal occlusions, but if the thrombus is situated more distally, no statistically
significant difference is seen.

P-285
Viabahn stent-graft placement for emergent/urgent
innominate, carotid, or vertebral artery disease: a singlecenter experience of 21 cases
M.Horikawa, B.D.Petersen, R.Priest, H.Bozorgchami, A.Dogan,
G.Nesbit, J.A.Kaufman
Dotter Interventional Institute, OHSU, Portland, OR, United States of
America
Purpose: To report our single-center experience of Viabahn stentgraft placement for acute bleeding or pseudoaneurysms of innominate, cervical carotid, or vertebral artery in emergent/urgent clinical conditions.
Material and methods: A retrospective study was conducted
between 2003 and 2015. A total of 21 patients (13 male, 8 female;
age range 1882 years, mean 55.4 years and median 55 years) were
treated with 21 Viabahn stent grafts (8 carotid blow-out syndrome
and 13 pseudoaneurysms with or without dissection: 4 innominate,
4 common carotid, 11 internal carotid, 1 both common and internal
carotid, and 1 vertebral artery involvement). The stent-graft patency
was evaluated by angiogram, contrast-enhanced CT, MRA, ultrasonography, or direct observation during surgery.
Results: The mean and median imaging follow-up periods were 741
and 203 days, respectively. Technical success was 100% (21/21). Dual
antiplatelet agents were given in 19 patients. No acute procedurerelated complications occurred. Two unstable patients with carotid
blow-out syndrome died of severe systemic disturbance within 8
days, despite successful bleeding cession by the procedure. Three

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patients underwent subsequent bypass surgery within 17 days. One
stent-graft occlusion occurred 195 days after the procedure with
unexpected cession of antiplatelet therapy. One significant hemorrhagic complication was observed 125 days after the procedure
(esophagocutaneous fistula) with dual antiplatelet therapy. Two
patients were lost to follow-up. Among the remaining 12 patients,
11 patients demonstrated 6 months or longer stent-graft patency,
while 1 patient demonstrated asymptomatic 50% intimal hyperplasia on the 18-month follow-up angiogram.
Conclusion: Viabahn stent grafts may be safe and useful for the
management of emergent/urgent arterial bleeding or pseudoaneurysms involving innominate, cervical carotid, or vertebral artery.

P-286
Endovascular recanalization for ICA occlusion at the subacute
to chronic stage: results and follow-up of a single-center
experience
V.MayoralCampos1, A.Laborda2, J.A.GuirolaOrtz1, C.Tejero3,
M.J.GimenoPeribez1, M.A.deGregorio4
1Radiology, HCU Lozano Blesa, Zaragoza, Spain, 2GITMI, University of
Zaragoza, Zaragoza, Spain, 3Neurology, HCU Lozano Blesa, Zaragoza,
Spain, 4Interventional Radiology, University of Zaragoza, Zaragoza,
Spain
Purpose: Patients with occlusion of the internal carotid artery (ICA)
are at risk of cerebral infarction. Neither surgical nor endovascular recanalization has showed to benefit this population. This study
reports the technical details and clinical results of ICA stenting in the
setting of subacute carotid occlusion in symptomatic patients.
Material and methods: From 2006 to 2015, endovascular recanalization was attempted in 29 patients (27 men, 2 women). All patients
had subacute ICA occlusion with or without contralateral stenosis.
Recurrent neurological deficit after ICA occlusion was noted by a
cognitive score test.
Endovascular recanalization was attempted using extracranial stenting (Acculink). Adverse events during hospital stay were recorded.
Clinical follow-up (cognitive test) and carotid ultrasound were
scheduled at 1, 3, 6, and 12 months after intervention. All clinical
events were documented.
Results: Demographic and angiographic characteristics are
described. Eighteen patients (64,3%) had right ICA occlusion. Ten
patients (35,7%) had contralateral ICA stenosis >50%.
Successful recanalization was achieved in 24 of 29 patients (82.7%).
One fatal brainstem infarction occurred 1 day after successful ICA procedure in the context of a hyperperfusion syndrome
with unfavorable evolution and death. There were no other major
complications.
Transcranial Doppler (TCD) showed a significant improvement
of cerebral hemodynamic reserve in the successfully recanalized
patients. Neurocognitive improvement demostrated by the cognitive score and the clinical evaluation was observed in all patients.
There was no new cerebral ischemic event or neurologic death during follow-up.
Conclusion: Endovascular recanalization for ICA occlusion is feasible with good clinical results and with a low rate of complications.

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P-287
Association of brain venous drainage with cerebral aneurysm
formation and aneurysm rupture
E.Duman1, I.ven2, E.Yldrm1
1Radiology, Baskent University, Konya, Turkey, 2Neurosurgery, Baskent
University, Konya, Turkey
Purpose: The brain venous drainage dominance was generally
divided into three groups: right, left, and co-dominance. Our aim in
this study was to evaluate the association of venous dominance with
aneurysm formation and rupture. There is no study in the literature
examining the link between brain venous drainage and aneurysm
formation or rupture.
Material and methods: Eighty-six patients who underwent cerebral digital subtraction angiography and who had cerebral aneurysms were included in the study. The angiographic images, patient
charts, and computed tomography images were reviewed retrospectively. We recorded the aneurysms location, size, dome-to-neck
ratio (D/N); patients gender and age and whether they had ruptured
aneurysm, smoked, or had hypertension; dominance of venous
drainage, aneurysm sides, Fisher scores, and the World Federation
of Neurological Surgeons Grading System for Subarachnoid
Hemorrhage (WFNS) scores for patients who had ruptured aneurysm. We assessed whether venous drainage is associated with rupture of the aneurysm and if venous dominance is a predisposing factor for aneurysm formation such as location, size, and hypertension.
Results: There is a statistically significant association between
venous dominance and sides of aneurysm and also between venous
dominance and rupture. There is a positive correlation between
hypertension and rupture. The most common aneurysm location is
in the anterior communicating artery, followed by the middle cerebral artery.
Conclusion: Brain venous drainage dominance may be a predisposing factor for aneurysm formation, and it can be a predictive sign for
rupture.

P-288
Comparison of embolization protection devices with proximal
balloon device and filter device: procedural complications and
embolic infarctions on DWI
M.H.Rho, H.P.Hong
Radiology, Kangbuk Samsung Hospital, Sungkunkwan University
School of Medicine, Seoul, Korea
Purpose: Proximal balloon-type embolization protection device
(EPD) and distal filter-type EPD have been used during CAS. This
study compares the related complications and thromboembolic
infarctions on diffusion weighted image (DWI) encountered using
these two types of EPDs.
Material and methods: A retrospective review of 103 patients
undergoing CAS using a balloon occlusion EPD (MOMA) or filter EPD
(Spider FX, FilterWire) was conducted. Symptomatic stenosis, degree
of stenosis, site of stenosis, ulceration, and collateral status were
evaluated. Complications and technical, reversible, and neurological compromises during EPD deployment were assessed. Procedure
time, new infarctions on DWI after CAS (tiny: <3 mm, small: <10 mm,
medium: < 20 mm, and large: >20 mm), and 30-day clinical results
after CAS also were evaluated.
Results: Symptomatic and asymptomatic complication rate was
slightly higher in the MOMA group (20%) compared with the Spider
group (15%), and in-stent thrombosis with near complete and complete occlusion was noted in two patients in the MOMA group during the procedure. New tiny infarctions on DWI were higher in the
Spider group compared with the MOMA group (P < .05).

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The 30-day stroke rate was 2.3% in the balloon group (n = 43)
and 3.3% in the filter group (n = 60, P < .05). Technical difficulties
included a 10% incidence of intolerance during balloon deployment
compared with 0% in the filter group (P = .043).
Conclusion: Both balloon occlusion and filter devices provide
acceptable results with similar complication rates and clinical
results. Although filter showed higher new tiny infarctions than balloon occlusion, this device can be used preferentially to avoid a 10%
incidence of intolerance associated with balloon occlusion and 4.7%
incidence of in-stent thrombosis.

P-289
Targeting microRNA for treating ischemic stroke
L.Zhang, Y.-J.Li, W.-S.Wei
Department of Neurology, Hospital, Fudan University, Shanghai, China
Purpose: The aim of this study was to measure the levels of circulating microRNA after acute ischemic stroke, and the correlation
between serum miR-19a level and clinical outcome after stroke. In
addition, the potential function of miR-19a in ischemic stroke therapy were also evaluated.
Material and methods: The ischemic stroke patients were prospectively recruited from the Department of Neurology, Huadong
Hospital, Fudan University, Shanghai, China. Healthy controls
were volunteers with no history of acute or chronic illness. Serum
microRNA levels were measured by real-time PCR. The median
value of all stroke cases was chosen as the cut-off point separating patients with high levels of miR-19a from those with low levels
of miR-19a. Stroke severity was assessed with the National Institutes
of Health Stroke Scale (NIHSS) at day 1. Dependency was measured
at baseline and 6 months using the modified Barthel index (mBI).
Primary rat microglial cells were transfected with miR-19a to evaluate its effects on neural apoptosis and cognitive impairment.
Results: A total of 45 stroke patients and 45age- and gendermatched healthy controls were recruited and evaluated. There was
significant difference between stroke patients and controls in miR19a levels; There was a significant decrease in serum miR-19a levels
after stroke. (p<0.001). No difference between the patients with high
or low serum miR-19a level in the severity of the stroke as measured
by NIHSS, and in the dependency at onset as measured by the mBI,
was observed. However, the outcome of patients with high serum
miR-19a level following stroke, as measured by the mBI at 6 months,
was significantly better than that of patients who had lower levels
of serum miR-19a (p=0.024). Further functional studies showed that
hypoxia downregulated miR-19a expression, therefore upregulating its target gene TNF-a expression in primary microglia. The overproduction of TNF-a following ischemia induced neuronal apoptosis. In addition, lentiviral overexpression of miR-19a in CA1 subregion inhibited neuronal apoptosis and microglia activation following ischemia and cognitive impairment.
Conclusion: Our study demonstrated that serum miR-19a level
could be used for predicting outcome after ischemic stroke, and
enhancement of miR-19a after stroke could be a useful means of
improving neuroprotection and recovery after ischemic stroke.

Abstract Book

P-290
Internal carotid artery stenting in patients with the carotid
string sign and/or its segmental obstruction
P.Myrcha, P.Ciostek
1st Chair and Clinic of General and Vascular Surgery, Medical University
of Warsaw, Warsaw, Poland
Purpose:
1. Assessment of differences between approach towards stenting of
a typical ICA stenosis and that with narrowing (the string sign) or
segmental obstruction.
2. Assessment of the results of the ICA stenting in cases with the
carotid string sign or segmental obstruction.
Material and methods: Between 2009 and 2013, we performed
302 carotid stentings (CASs) in the clinic. In 19 (6.3%) of these cases,
an attempt was made to administer endovascular treatment to the
patients with the carotid string sign and/or segmental obstruction
in the cervical segment. CAS was performed in 7 women and 12 men
aged between 58 and 81 years (average, 65.2). During the preoperative period, 5 patients were asymptomatic. In 10 patients, ischemic
stroke was registered; in 8 of these cases, the ICA with the carotid
string sign was symptomatic. The remaining 4 patients displayed
symptoms of retinal ischemia: chronic in 3 patients and amaurosis
fugax in 1 patient.
Results: In the examined group submitted to CAS, no intraoperative
and perioperative death or stroke was registered. TIA was observed
in 3 patients.
In the 13 cases, CAS was completed with complete or partial success.
In 3 patients, an asymptomatic occlusion of the ICA was observed.
Conclusion:
1. In contrast to classical carotid stenting, endovascular treatment in
cases of occlusion/string sign requires an individualized approach.
2. In case of successful stenting, restoring blood flow in ICA was
possible in most patients.

P-291
MicroNet covered stent in the treatment of vulnerable carotid
plaque: short- and mid-term results
V.Gavrilovic, A.Vit, A.Pellegrin, P.Divis, S.Cannizzaro, M.Sponza
Interventional Radiology, University Hospital Santa Maria della
Misericordia, Udine, Italy
Purpose: To evaluate the periprocedural safety and mid-term efficacy of MicroNet covered stent implantation for vulnerable carotid
plaque in neurologically symptomatic and asymptomatic patients
(Pts) suitable for carotid artery stenting (CAS).
Material and methods: From August 2015 to December 2015, 26
Pts (22M; 4F; mean age 72.92 years, range 6283) underwent CAS.
High-grade carotid stenosis using NASCET methodology with vulnerable carotid plaque was detected on duplex sonography study
and confirmed on angio-CT exam in 22 symptomatic and 4 asymptomatic Pts. All Pts. had cerebral MRI evaluation 24-h pre-treatment.
In 4 Pts, near-occlusion lesions were predilated with 4-mm coronary
balloon. The stent was deployed under distal filter protection (n=26).
All lesions were postdilated. Clinical neurologic evaluation and
duplex sonography follow-up (FU) was performed at 24 h postprocedure and 1 and 6 months after treatment. Cerebral MRI was performed in all Pts 24 h postprocedure.
Results: Treatment with MicroNet covered stent was technically feasible in all patients with no periprocedureal complications. Carotid
stenosis evaluated at angiography before and immediately after the
procedure was 84.8%7.1% and 4.8%3.3%, respectively. Duplex
ultrasound FU at 24 h (n=26) and 1 (n=26) and 6 (n=13) months
showed stent patency without signifcant intrastent stenosis. No Pt
developed MACE (death, stroke, and MI) at the 30-day FU without
new ischemic lesions at the 24-h cerebral MRI FU.

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Conclusion: In patients with high-grade carotid artery stenosis and
vulnerable plaque, MicroNet covered stenting is a safe technique
that could offer clinical benefits to patients undergoing CAS; this
was confirmed at the short- and mid-term follow-ups.

P-292
Learning curve of the transradial approach of percutaneous
carotid intervention
E.M.Vgh1, B.Nemes1, B.Teleki2, B.Merkely1, K.Httl1, Z.Ruzsa2
1Heart and Vascular Center, Semmelweis University, Budapest,
Hungary, 2Radiology, Bcs-Kiskun Country Hospital, Kecskemt,
Hungary
Purpose: Recently, the transradial (TR) approach became a safe and
effective alternative of percutaneous carotid intervention. We report
the learning curve over 6 years in two high-volume interventional
centers during the transition from the transfemoral (TF) to transradial approach.
Material and methods: Between 2010 and 2015, 1773 patients
underwent carotid intervention in our centers. Clinical characteristics, radiation doses, volume of contrast material, screening and procedure times of consecutive patients were prospectively recorded in
a register and restrospectively analysed.
Results: The transradial approach was applied in 494 patients (mean
age, 688 years; 67% male). The ratio of TR increased from 3 to 7, 25,
43, 48 and 60% of the carotid interventions during the years, respectively. While the duration of the procedure (26, 30, 25, 25, 22.5 and
25 min), fluoroscopy time (11, 11, 10, 8, 8 and 9 min), and applied contrast material (128, 142, 95, 69, 90 and 75 ml) significantly decreased
in the first 4 years, an elevation was observed as more complicated
cases were enrolled. Significant improvement was observed after
the first 50 cases in each parameter. Conversion to TF was needed in
7.5% and did not change significantly. No difference was observed in
the incidence of minor or major vascular events and hospitalization
days over the years.
Conclusion: An initial learning curve was observed in the intervention parameters of transradial carotid stenting. The transition from
the TF to TR approach was achievable with 50 cases in experienced
centers.

P-293
Initial clinical experience with the micromesh roadsaver
carotid artery stent for the treatment of patients with
symptomatic carotid artery disease
R.Gandini, F.Chegai, E.Pampana, S.Merolla, M.Stefanini
Diagnostic and Molecular Imaging, Radiation Therapy and
Interventional Radiology, University Hospital Policlinico Tor Vergata,
Rome, Italy
Purpose: To assess the effectiveness, technical aspects, handling,
and safety of the micromesh roadsaver carotid artery stent in the
treatment of patients with cerebrovascular symptoms and DWI cerebral lesion from microemboli due to the presence of a low-grade
carotid artery stenosis with high-risk, lipid-rich, ulcerated plaque.
Material and methods: In total, 13 patients (8 men; mean age
6811.4 years) suffering from symptomatic internal carotid artery
(ICA) stenosis (mean 62% diameter reduction) were treated with dual
layer closed-cell stent without embolic protection. Pre-procedural
evaluation of the patients was performed with echo Doppler, magnetic resonance angiography, or computed tomographic angiography and a neurological examination.
Results: All patients had DWI cerebral ischemic lesions and neurological symptoms. All devices were satisfactorily deployed. No complications were detected during or after the procedure. Mean fluorscopy time was 26 min. At 1 and 3 months, ultrasound examination

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demonstrated patency of stents and the external carotid arteries.

We did not observed any incidence of new DWI cerebral lesions after
carotid artery stenting.
Conclusion: The micromesh roadsaver carotid artery stent seems to
be safe and effective in the treatment of extracranial ICA with highrisk, lipid-rich, ulcerated plaque. Further studies with larger populations are warranted.

P-294
Endovascular embolization of a traumatic pseudoaneurysm of
the superficial temporal artery
V.Z.Cvetic, B.Luki, M.Colic
Centre for Radiology and MR, Clinical Centre of Serbia, Belgrade, Serbia
Pseudoaneurysms of the superficial temporal artery (STA) are rare
vascular lesions that mainly occur after blunt head trauma. We present the case of a 28-year-old male patient with a traumatic pseudoaneurysm of STA, which was treated with vascular plug embolization.

P-295
Spontaneous occlusion of cerebral arteriovenous
malformation following partial embolization with Onyx
O.F.Nas, K.Ozturk, G.Gokalp, B.Hakyemez
Department of Radiology, Uludag University Faculty of Medicine,
Bursa, Turkey
A rare case of spontaneously occluded cerebral arteriovenous malformation following partial embolization with Onyx was demonstrated. During preoperative evaluation, diffusion-tensor and functional magnetic resonance imaging methods were used to reveal
the proximity of the lesion to the visual cortex.

P-296
Preoperative embolization in patients with tympanic glomus
tumor recurrence
A.Montana1, S.Bonomo2, G.Coniglio1, S.Santonocito3, C.Tilocca3,
G.Petrillo1, V.MagnanoSanLio 4, G.Giordano4
1Diagnostic Imaging, Policlinico Universitario, Catania, Italy,
2Diagnostic and Interventional Radiology, Garibaldi Nesima Hospital,
Catania, Italy, 3Radiology, AOU Policlinico-Vittorio Emanuele, Catania,
Italy, 4Interventional and Diagnostic Radiology, ARNAS Garibaldi NESIMA, Catania, Italy
We treated a patient with tympanic glomus tumor recurrence with
microcatheter (coaxial technique) by individual catheterization of
each afferent from the external carotid artery. We used particles
(300500 m) until complete devascularization of the lesion. The
next day, the tumor was removed. No complications were observed.

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Oncologic intervention
P-297
Validation of clinical scoring systems ART and ABCR after
transarterial chemoembolization of hepatocellular carcinoma
R.Kloeckner1, M.B.Pitton1, C.Dber1, I.Schmidtmann2, S.Koch3,
P.R.Galle4, M.A.Wrns4, A.Weinmann4
1Diagnostic and Interventional Radiology, University Medical Center of
the Johannes Gutenberg University Mainz, Mainz, Germany, 2Institute
of Medical Biostatistics, Epidemiology and Informatics, Johannes
Gutenberg University Mainz, Mainz, Germany, 3Clinical Registry Unit
(CRU), University Medical Center of the Johannes Gutenberg University
Mainz, Mainz, Germany, 4Department of Internal Medicine, University
Medical Center of the Johannes Gutenberg University Mainz, Mainz,
Germany
Purpose: Transarterial chemoembolization (TACE) is the standard
of care for intermediate-stage hepatocellular carcinoma (HCC). It
remains challenging to decide whether to repeat treatment. We performed external validations of two scoring systems recently developed to evaluate TACE: the assessment for retreatment with TACE
(ART) and the alpha (AFP), Barcelona clinic liver (BCLC) stage, Child
Pugh score, and treatment response (ABCR). We also compared their
prognostic value.
Material and methods: From 2000 to 2015, 871 patients with HCC
underwent TACE at our tertiary referral hospital. We acquired baseline data of BCLC stages and AFP levels and data measured before
the second TACE on ChildPugh scores, aspartate aminotransferase
levels, and radiologic tumor responses. The overall survival was calculated. Scores were validated and compared with Harrells C-index,
the integrated Brier score (IBS), and prediction error curves.
Results: In total, 176 patients were included. Low and high ART
scores predicted median survivals of 20.8 and 15.3 months, respectively. Low, intermediate, and high ABCR scores predicted median
survivals of 24.5, 15.8, and 5.8 months, respectively. Harrells
C-indexes were 0.572 and 0.608, and IBS values were 0.135 and 0.128
for ART and ABCR, respectively. For both scores, an increase in Child
Pugh of 2 points and a radiological response independently predicted survival (all p<0.05).
Conclusion: ART and ABCR scores provided some indication of
which patients had a dismal prognosis and were unlikely to benefit from repeated TACE. ABCR had a slightly greater predictive value.
However, neither score was sufficient to support clear-cut clinical
decisions. Further effort is necessary to determine criteria for valid
predictions.

P-298
Clinical value of transcatheter (chemo-) embolization for older
patients with hepatocellular carcinoma
T.Aramaki1, E.Bekku1, R.Sato1, K.Yoza1, M.Moriguchi1,
K.Asakura2, M.Endo2
1Division of Interventional Radiology, Shizuoka Cancer Center,
Shizuoka, Japan, 2Division of Diagnostic Radiology, Shizuoka Cancer
Center, Shizuoka, Japan
Purpose: In 2014, the mean lifespan of Japanese people was 86.8
years for women and 80.5 years for men. This retrospective study
evaluated the clinical value of transcatheter (chemo)-embolization
(TA(C)E) for older patients with hepatocellular carcinoma (HCC).
Material and methods: We evaluated patients with HCC who
received TA(C)E in our hospital from September 2002 to December
2013. Eligibility criteria were 1) age older than 81 years, 2) no previous treatment with TA(C)E or chemotherapy, and 3) no extra-hepatic
metastases. We evaluated survival and cause of death.

Abstract Book
Results: Between September 2002 and December 2013, 728
patients who had no previous treatment with TA(C)E or chemotherapy underwent TA(C)E in our hospital; 53 patients (11 women/42
men) met all eligibility criteria. Clinical characteristics were as follows: HBV/HCV/NBNC=6/32/15, Child-Pugh A/B/C=50/3/0, and
ECOG performance status 0/1/2/3/4=43/8/1/1/0. The mean followup period was 788 days, and the overall survival time was 1032
days. Twenty-eight patients died. The cause of death was HCC in 19
patients, rupture of varices in 4, other cancers in 2, acute myocardial
infarction in 1, and unknown in 2.
Conclusion: TA(C)E has clinical value for older patients with HCC if
the patient has good performance status and liver function.

P-299
Radial versus femoral access for peripheral artery embolization
E.Khayrutdinov1, A.Arablinskiy1, V.Tsurkan1, I.Vorontsov2
1Interventional Radiology, Botkin Hospital, Moscow, Russian
Federation, 2Interventional Radiology, Emergency Hospital #1, Omsk,
Russian Federation
Purpose: We aimed to determine whether the radial approach (RA)
was superior to the femoral approach (FA) in patients undergoing
peripheral artery embolization.
Material and methods: In total, 331 peripheral artery embolization
procedures were performed from October 2013 to February 2016.
Uterine fibroid embolization (UFE) was performed in 104 patients,
transarterial chemoembolization (TACE) in 181, prostate artery
embolization (PAE) in 25, and bronchial artery embolization (BAE)
in 21. RA was used in 169 patients, and FA was used in 162 patients.
Clinical characteristics of the patients were comparable between the
two groups.
Results: Embolization procedures were successfully performed
in all patients. The duration of TACE and BAE (33.1 vs. 38.9 minutes
and 35.1 vs. 40.2 minutes, p>0.05) and radiation exposure (0.41 vs.
0.47 mZv and 0.42 vs. 0.53 mZv, p>0.05) were comparable between
the two groups. The duration of UFE and PAE (21.6 vs. 35.1 minutes
and 53.2 vs. 78.1 minutes, p<0.05), the time needed for catheterization of target arteries (7.3 vs. 15.5 minutes and 35.1 vs. 54.3 minutes, p<0.05), and radiation exposure (0.3 vs. 0.57 mZv and 0.49 vs.
0.68 mZv, p<0.05) were significantly lower in the RA group. The rate
of major vascular complications (0% vs. 1.85%) was lower in the RA
group. RA was associated with a statistically significant reduction in
all parameters of procedural discomfort.
Conclusion: The duration of the procedure and radiation exposure were significantly lower among the patients undergoing UFE
and PAE using RA. The rate of major vascular complications is significantly lower among the patients undergoing PAE using RA.

P-300
Preoperative devascularization of juvenile nasopharyngeal
angiofibromas: direct percutaneous tumoral injection
with cyanoacrylate glue in conjunction with particulate
endovascular embolization
M.A.O.Kasem1, A.S.Awad1, H.ElBosraty2, A.Ismail1
1Diagnostic and Interventional Radiology, Cairo University Hospital,
Cairo, Egypt, 2ENT, Cairo University Hospital, Cairo, Egypt
Purpose: To assess the role of direct percutaneous embolization of
nasopharyngeal angiofibromas by using cyanoacrylate glue in conjunction with standard endovascular embolization techniques. We
describe the technical aspects of the procedure and its efficacy in
reducing intraoperative blood loss.
Material and methods: The study was done on 29 patients (29
males; mean age, 13.4 years; range, 919 years) presenting with nasopharyngeal angiofibromas who underwent direct percutaneous

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embolization with cyanoacrylate glue in conjunction with particulate embolization. Documented blood loss was obtained from operative reports in these patients with surgical resection performed
2472 hours after the embolization.
Results: Intratumoral penetration with progressive blood flow stasis
was achieved during each injection. A mean of 2 needles (20-gauge
3.5-inch spinal needle) were placed percutaneously into the lesion
(range 14). Near total angiographic devascularization was achieved
in 17 of 21 tumors. There were no local complications or neurologic
deficits from the percutaneous access or endovascular embolization
of these hypervascular tumors. The mean intraoperative blood loss
was 780 mL (range 502200 mL).
Conclusion: The use of percutaneously injected cyanoacrylate glue
in conjunction with standard endovascular embolization techniques
in patients with nasopharyngeal angiofibromas proved to enhance
the ability to devascularize these tumors before surgical removal,
with no procedural complication.

P-301
Embolization for renal angiomyolipoma using a micro-balloon
catheter and ethanol
Y.Sawada1, M.Shimohira1, T.Hashizume1, T.Kawai1, K.Ohta1,
K.Suzuki1, Y.Furuta1, K.Nakayama1, T.Naiki2, T.Nagai2, T.Yasui2,
Y.Shibamoto1
1Department of Radiology, Nagoya City University Graduate School
of Medical Sciences, Nagoya, Japan, 2Department of Nephro-urology,
Nagoya City University Graduate School of Medical Sciences, Nagoya,
Japan
Purpose: A 2.7-Fr micro-balloon catheter that can be inserted into
a 4-Fr catheter has recently become available in our country. The
aim of this study is to evaluate the usefulness and safety of arterial
embolization for renal angiomyolipoma using the micro-balloon
catheter and ethanol.
Material and methods: Six patients with 9 angiomyolipomas (5
female, 1 male), with a median age of 36 years (range, 1149), underwent embolization for renal angiomyolipoma using the micro-balloon catheter and ethanol between 2011 and 2015. In all procedures,
a 4-Fr catheter was inserted into the renal artery and the 2.7-Fr
micro-balloon catheter was then introduced into the feeding artery
of the tumor. Embolization was performed with ethanol under balloon inflation. We reviewed medical records and images and evaluated the technical success rate, clinical success rate, and complications. Technical success was defined as a devascularization rate of
90% or higher, and clinical success was defined as any reduction in
tumor size.
Results: In 8 of the 9 lesions, the devascularization rate was 90%
or higher. Thus, the technical success rate was 89%. Follow-up CT
was performed in 8 of the 9 lesions, and the size reduction was confirmed in 7 of the 8 lesions, with a follow-up of 1 to 40 (median,
6) months. Thus, the clinical success rate was 88%. The median
reduction ratio was 36.5% (range, 0100%). Four patients had mild
postembolisation syndrome, which improved with observation.
Conclusion: Embolization for renal angiomyolipoma using a
micro-balloon catheter and ethanol might be a safe and effective
treatment.

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P-302
Preoperative embolization of metastatic vertebrae tumors
K.Karska, K.Wojtal, M.Miazga, M.Sojka, T.Roman, K.Pyra,
M.Szczerbo-Trojanowska
Department of Interventional Radiology and Neuroradiology, Medical
University of Lublin, Lublin, Poland
Purpose: The aim of the study was to evaluate the effectiveness of
preoperative embolization of metastatic tumors of the vertebrae.
Neoplastic tumors within the vertebral column can be a cause of
myelopathic changes. They also lead to increased risk of pathological fractions of the affected vertebrae. Both those reasons may proceed to serious neurological complications, such as paresthesiae,
strength attenuation, sphincters dysfunction, or even tetraplegia.
Surgical resection of diseased vertebrae is the first choice treatment.
However, due to massive blood supply of tumors, there is a big risk
of intraprocedural hemorrhage. Preoperative embolization of highly
vascularized tumors enables surgeons to perform the procedure
with enhanced safety and leads to lower blood loss.
Material and methods: Embolization of highly vascularized vertebral metastases from renal cell carcinoma was performed in 31
patients. Among the patients there were 3% of women and 97% of
men, aged 28 to 77 years.
To embolize the pathological vasculature hydrogel microspheres
of 500-1100 m in diameter were used; the amount of embolization
agent used for a procedure was between 1 and 3 ampoules.
Results: Totally successful embolization was obtained in 57% of
patients; all of the pathological arteries were occluded. In 22%
embolization was partial: over 70% of pathological vessels were
closed. Due to involvement of spinal arteries, 21% of patients were
dismissed from procedure. There were no complications registered.
Conclusion: Preoperative embolization is a valuable method of
preparation for surgical treatment of highly vascularized vertebral
tumors. However, this procedure may have a higher risk of neurological complications if untargeted arteries that are vital for the spinal
cord are embolized.

P-303
Release of Yttrium 90 from resin or glass microsphere used
in radioembolisation of hepatocellular carcinoma: an in vitro
stability study
V.Ardisson1, N.Lepareur1, E.Garin1, Y.Rolland2
1Nuclear Medicin, CRLCC Eugne Marquis, Rennes, France, 2Radiology,
CRLCC Eugne Marquis, Rennes, France
Purpose: Trans-arterial radioembolization with 90Y microspheres is
used for delivering high doses of radiation to HCC tumors. The stability of these microspheres is critical to ensure the radiation dose
delivery, thereby minimizing the systemic exposure. We studied the
stability properties of various 90Y microsphere products by measuring their in-vitro 90Y leaching.
Material and methods: 90Y is either bound to resin or embedded
in a glass matrix. Leaching was studied in different media: saline or
human serum at 37C. To avoid the precipitation of yttrium or its
binding to serum proteins, the same analyses were performed with
1N HCl or 89Y in excess. Free 90Y was determined in the medium
during 72 hours by gamma counting.
Results: We found 0.6% and 0.05% of free 90Y in resin and glass
shipment medium, respectively. In 0.9% NaCl, 0.05% of 90Y leached
from glass and up to 1.59% from the resin microsphere at 1 hour.
From 1 to 72 h in serum, leaching increased by 0.15 to 2% with glass
spheres and from 0.2 to 5% with resin microspheres. However, with
resin in the presence of 89Y, 15 to 60% free yttrium found in the
supernatant.

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Conclusion: 90Y directly integrated in glass showed a higher stability than the resin microspheres product. Solubilization of 90Y
can depend on many parameters, which can lead to a large variability in the results. The addition of 89Y in the serum causes a massive
release of 90Y from resin microspheres. In this situation, leaching is
more significant with resin than with glass microspheres.

P-304
Evaluation of therapy response to transarterial embolization
by hyperpolarized13C magnetic resonancespectroscopic
imaging in a rat model of HCC
G.Kaissis1, S.Dwel2, M.Durst2, C.Gringeri3, Y.Kosanke1, C.Gro1,
M.Janich4, A.Haase4, S.Glaser5, M.Schwaiger3, R.Schulte4,
M.Menzel4, R.F.Braren1
1Institut fr diagnostische und interventionelle Radiologie, Klinikum
rechts der Isar der TU Mnchen, Munich, Germany, 2Institute for
Medical Engineering, Technische Universitt Mnchen, Garching,
Germany, 3Klinik und Poliklinik fr Nuklearmedizin, Klinikum rechts
der Isar der TU Mnchen, Munich, Germany, 4Diagnostics & Biomedical
Technologies Europe, GE Global Research, Garching, Germany, 5Cancer
and Haematology, Walter and Eliza Hall Institute of Medical Research,
Melbourne, VIC, Australia
13C

compounds
Purpose: This work investigates hyperpolarized
and the 18F-FDG PET tracer in rat hepatocellular carcinoma (HCC)
before and after transcatheter arterial embolization (TAE).
Material and methods: Measurements with13C labelled and hyperpolarized substrates (pyruvate and fumarate) and18F-FDG were performed in tumor-bearing rats before and after TAE. Magnetic resonance spectroscopic imaging (MRSI) and positron emission tomography (PET) was used to obtain spatially resolved maps of metabolic
conversion rates (MRSI) and18F-FDG uptake. Results were correlated
with MALDI-MS and immunohistochemistry.
Results: TAE induced a decrease in tumor perfusion and thus a
decrease of tumor/muscle and tumor/liver ratios of pyruvate and its
metabolites, alanine and lactate. Conversion rates remained stable
or increased upon TAE in tumor, muscle and liver tissues. Conversion
from fumarate to malate successfully indicated individual levels of
necrosis and systemic malate signals after TAE suggest washout of
fumarate or malate itself upon necrosis.
Conclusion: This study presents hyperpolarized 13C compounds as
candidate biomarkers for the comprehensive biological characterization of HCC using MRSI, enabling the simultaneous detection of
differences in tumor perfusion, metabolism and necrosis.

P-305
Transarterial chemoembolization using polyethylene glycol
drug-eluting beads pre-charged with doxorubicin (LIFDOX)
for the treatment of primary liver cancer: preliminary results
C.Aliberti1, R.Carandina1, D.Sarti2, V.Catalano2, L.Mulazzani3,
A.Felicioli3, P.Coschiera3, G.Fiorentini2
1Oncology Radiodiagnostics, Oncology Institute of Veneto, Institute
for the Research and Treatment of Cancer (IRCC), Padova, Italy,
2Oncology-Hematology, Azienda Ospedaliera Ospedali Riuniti Marche
Nord, Pesaro, Italy, 3Diagnostics for Images Unit and Interventional
Radiology, Azienda Ospedaliera Ospedali Riuniti Marche Nord, Pesaro,
Italy
Purpose: The purpose of this study was to assess the feasibility, tolerability, quality of life, and tumor response in every day real oncology after transarterial chemoembolization using polyethylene glycol (PEG) drug-eluting beads (LifePearl) pre-charged with doxorubicin (LIFDOX) for the treatment of primary liver cancer: hepatocellular carcinoma (HCC) and cholangiocarcinoma. The innovation of

Abstract Book
LifePearl product is its material, PEG, which makes the pearls more
resilient to stress and attrition. PEG is a hydrophilic material, which
guarantees more compressibility and elasticity and maximizes the
time of the beads in suspension.
Material and methods: We treated 50 patients affected by unresectable HCC and cholangiocarcinoma with chemoembolization
using doxorubicin pre-loaded LifePearl (LIFDOX) as the secondline therapy.
Results: Tumor response rate were high, i.e., >80% in most patients,
with 53% showing complete response (CR) and 27% showing partial
response (PR). We observed no complications during the chemoembolization procedure, which was well tolerated by all the patients
(median hospitalization 2 days). No severe general drug-related side
effects were observed as a consequence of chemoembolization.
Post-embolization syndrome (PES), hypertension, nausea, and upper
quadrant abdominal pain (UQAP) were the most reported mild side
effects.
Conclusion: Our data suggest that chemoembolization with
LifePearl is efficacious and safe for the treatment of primary liver
cancer, as indicated by good tolerability, quality of life, and high
tumor response.

P-306
Practical tips for hepatic transarterial embolization with LC
LUMI radiopaque microspheres
E.Levy1, G.Narayanan2, V.Krishnasamy1, R.Lencioni3, S.Venkat2,
K.Sharma4, A.Lewis5, B.J.Wood6
1Interventional Radiology, National Institutes of Health, Bethesda, MD,
United States of America, 2Vascular Interventional Radiology, University
of Miami-Miller School of Medicine, Miami, FL, United States of
America, 3Interventional Oncology Research, University of Miami Miller
School of Medicine, Sylvester Comprehensive Cancer Center, Miami,
FL, United States of America, 4Interventional Radiology, Childrens
National Medical Center, Washington, DC, United States of America,
5Biocompatibles UK Ltd, Surrey, United Kingdom, 6Department of
Radiology, NIH Clinical Center / NCI, Bethesda, MD, United States of
America
Purpose: To review tips and tricks for LC LUMI radiopaque microsphere administration for transarterial embolization (TAE) of hepatic
malignancies.
Material and methods: Procedures performed at two centers were
reviewed to identify optimal methodology for TAE with LC LUMI
radiopaque microspheres. Eight patients with hepatocellular carcinoma or hypervascular liver metastases underwent TAE with 12ml (packed bead volume) of 70150 or 100300-m LC LUMI microspheres suspended in Onmipaque 350 or Visipaque 320 to nearcomplete flow stasis. Data included procedure logs, fluoroscopy,
digital single shot radiographs, and cone beam CT (CBCT).
Results: Resuspension of LC LUMI prepared in Omnipaque 350 was
required every 3060 seconds, whereas Visipaque 320 had longer
suspension times. Syringes containing the suspended microspheres
had to be held parallel to the procedure table to avoid microsphere
settling or catheter occlusion. 2.8-F Progreat microcatheter occlusion with microbeads was observed during a single prolonged vertical injection with 70150-m LC LUMI in Omnipaque. Slow horizontal injection of small microbead aliquots prevented premature
target vessel stasis and incomplete microsphere dose or patchy distribution. Distribution of LC LUMI could be observed directly with
single-shot digital radiography (SSD) and indirectly with digital subtraction arteriography as a linear subtraction registration artifact.
Fused dual-view CBCT from dual-phase datasets permitted identification of incomplete target vessel embolizations as well as off-target microspheres, presumably from reflux.

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Conclusion: Potential pitfalls include LC LUMI microsphere settling, microcatheter catheter occlusion, or flow stasis from proximal occlusion. Fused dual-view CBCT may augment the flow stasis
endpoint.

P-307
Carbon dioxide gas digital subtraction angiography under
temporary microballoon occlusion during transcatheter
arterial chemoembolisation for hepatocellular carcinoma
J.Koizumi1, T.Hara2, T.Sekiguchi2
1Department of Diagnostic Radiology, Tokai University School of
Medicine, Kanagawa, Japan, 2Diagnostic Radiology, Tokai University
School of Medicine, Isehara, Japan
Purpose: To evaluate the hemodynamics of hepatocellular carcinoma (HCC) using CO2-DSA before transcatheter arterial chemoembolization (TACE).
Material and methods: From June to December 2015, 23 consecutive patients with HCC were included in this study. Before TACE, HCC
was evaluated by intrahepatic arterial DSA using iodinated contrast
first, and then the same volume of CO2 without and with microballoon occlusion (BO). The tumor stain/gas retention (0: none, 1: <50%,
2: 50-70%, 3: 70-100% area of the tumor visualized by C-arm CT during hepatic arteriography) and arterioportal shunt; APS (0: none, 1:
behind a tumor, 2: distal to portal trunk, 3: proximal to trunk) were
graded correspondingly. Each grade was compared by Wilcoxon
signed rank test and to the treatment effect of the tumor by TACE at
3 months.
Results: In 23 patients, 31 intrahepatic arteriographies were compared. The tumor stain was significantly (p<0.05) better visualized on conventional iodinated contrast under BO (1.80.98) than
without BO (1.31.09). The gas retention was observed in 23 CO2DSA and detected significantly (p<0.05) bigger on DSA under BO
(1.51.21) than without BO (0.81.14). APS was significantly (p<0.05)
better visualized on CO2-DSA under BO (0.940.99) than without BO
(0.480.77), whereas any APS was not detected on iodinated contrast DSA. In tumor response group (74.2%), gas retention under
BO (1.651.27) was significantly bigger than non-response group
(1.000.93).
Conclusion: CO2-DSA under microballoon occlusion is excellent to
detect arterioportal shunt and gas retention in tumors and may contribute to better outcomes by TACE.

P-308
First human experience with directly imageable iodinated
embolization microbeads
E.Levy1, V.Krishnasamy1, A.Lewis2, S.Willis3, C.Macfarlane2,
V.Anderson1, M.vanderBom4, A.Radaelli4, M.Dreher3, K.Sharma5,
A.Negussie1, A.Mikhail1, J.-F.H.Geschwind6, B.J.Wood1
1Center for Interventional Oncology - Interventional Radiology,
National Institutes of Health, Bethesda, MD, United States of
America, 2Non-Clinical Development, Biocompatibles UK Ltd, A
BTG International Group Company, Camberley, United Kingdom,
3Biocompatibles, BTG, Surrey, United Kingdom, 4Image Guided
Therapy, Philips Healthcare, Eindhoven, Netherlands, 5Interventional
Radiology, Childrens National Medical Center, Washington, DC, United
States of America, 6Radiology and Biomedical Imaging, Yale University
School of Medicine, New Haven, CT, United States of America
Purpose: To describe the first clinical experience with directly
imageable, inherently radio-opaque microspherical embolic agent
for the transarterial embolization of liver tumors.
Material and methods: LC Bead LUMI is a new microsphere
with covalently bound iodine (~260 mg I/mL). In total, 70150- or

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100300-m LC Bead LUMI iodinated microbeads were injected

selectively via a 2.8-Fr microcatheter for near-complete flow stasis
into the hepatic arteries of 4 patients with hepatocellular carcinoma
or carcinoid or neuroendocrine tumor. A custom imaging platform
tuned for LC LUMI microbead conspicuity using cone beam CT
(CBCT)/angiographic C-arm system (Allura Clarity FD20, Philips) was
used along with CBCT embolization treatment planning software
(EmboGuide, Philips).
Results: LC Bead LUMI imageable microbeads were easily delivered and monitored during the procedure using fluoroscopy, singleshot radiography (SSD), digital subtraction angiography (DSA), dual
phase-enhanced and unenhanced CBCTs, and unenhanced conventional CT obtained 48 hours after the procedure. Intraprocedural
and 48-hour imaging demonstrated tumor potentially at risk of
undertreatment, defined as paucity of imageable microbeads within
a portion of the tumor. Fusion of pre- and post-embolization CBCTs
identified vessels without beads that corresponded to enhancing
undertreated tumor in the same location.
Conclusion: LC Bead LUMI imageable microbeads provide realtime feedback and geographic localization of treatment realtime
during treatment. Intraprocedural CBCT obtained immediately postembolization showed correspondence in microbead distribution
with conventional CT obtained 48 hours later. In addition to the traditional endpoint metric of flow stasis, the distribution and density
of imageable beads within a tumor need further evaluation as an
additional endpoint for embolization.

P-309
Transarterial ethanollipiodol embolization (TAELE): our
experience of TAELE for intermediate HCC
F.Fiore, R.DAngelo, F.Somma
Interventional Radiology, National Cancer Institute, Naples, Italy
Purpose: Hepatocellular carcinoma is nowadays the third leading cause of cancer deaths worldwide, with over 500,000 people affected, while liver metastases are common in a wide range
of malignancies, especially in patients with gastrointestinal cancers. Our aim is to retrospectively evaluate the efficacy and safety of
transarterial ethanollipiodol embolization (TAELE) compared with
those of conventional TACE in the treatment of HCC.
Material and methods: In total, 112 patients (37.5% male; 62.5%
female; range of age 3283 years) with documented hepatic
lesions of size 1.47.4 cm were elected for cTACE using a mixture of
50 mg epirubicin and 5 cc lipiodol or TAELE using a 1:1 mixture of
lipiodol:ethanol directly injected in the tumor-feeding arteries after
super-selective catheterization, followed by embolizing agents.
Results: cTACE and TARE were performed in 59 and 53 patients,
respectively. One month after the procedure, a multi-detector computed tomography (MDCT) showed that all patients had at least partial response according to RECIST1.1 and EASL criteria, with complete
resolution in more than half the total number of patients (63/112).
Conclusion: In comparison with cTACE, TAELE showed similar radiological outcomes at the 1-, 3-, and 6-month control MDCT but less
toxicity, which makes it useful in patients with more than one lesion
or in case of relapse.

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Distant new intrahepatic recurrences occurred in 15/22 (68%) (630
months, mean 18 months). Ten patients died within 2757 months
after treatment. Twelve patients are still alive.
Conclusion: SC-RF proved to be safe in cirrhotic patients and effective for the treatment of medium and large HCCs.

P-310
Technical complications of hepatic arterial infusion
chemotherapy: retrospective comparison of the placement
of the catheter tip in the proper hepatic artery and in the
gastroduodenal artery
R.Imamine, T.Shibata, K.Shinozuka, A.Furuta, S.Arizono, H.Isoda,
K.Togashi
Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate
School of Medicine, Kyoto, Japan
Purpose: To retrospectively compare the technical complications
of hepatic arterial infusion chemotherapy between the techniques
inserting the catheter tip in a proper hepatic artery (group 1) and in
a gastroduodenal artery (GDA) (group 2).
Material and methods: Between April 2001 and March 2015, 108
patients (80 males, 28 females; age range, 3280 years; mean, 64
years) with unresectable liver cancer underwent percutaneous
insertion of side-hole indwelling catheters via the femoral artery.
The technical complications related to placement of a port-catheter
system, duration available for a port-catheter system, and technical
success rate were evaluated.
Results: The technical success rate was 100%. In total, 47 (44%) of
108 patients were in group 1 and 61 (56%) patients were in group 2.
Hepatic artery obstruction occurred in 1 of the 108 patients (0.9%:
1 in group 2); gastroduodenal ulcer (gastric mucosal lesions) in 6
(5.6%: 2 in group 1 and 4 in group 2); catheter dislocation in 2 (1.9%:
1 in group 1 and 1 in group 2); and catheter system obstruction in 7
(6.5%: 5 in group 1 and 2 in group 2). The other variables showed no
significant differences between the 2 groups.
Conclusion: The technique of placement of a side-hole indwelling
catheter in a proper hepatic artery or a GDA might be equally feasible with respect to the technical complications during hepatic arterial infusion chemotherapy.

P-311
Radiofrequency ablation with a switching controller system of
medium and large hepatocellular carcinoma: 3-year follow-up
L.Tarantino1, P.Ambrosino2, P.Gallo3, P.Tarantino2, A.Nasto4
1Interventional Hepatology Unit, A.Tortora Oncology Hospital,
Pagani, Italy, 2Department of Clinical Medicine and Surgery, Federico
II University, Naples, Italy, 3Internal Medicine and Hepatology, Campus
Biomedico University, Rome, Italy, 4General and Oncologic Surgery

P-312
Microwave ablation of large HCCs by simultaneous multiple
antennae insertion:long-term follow-up
L.Tarantino1, P.Ambrosino2, P.Gallo3, P.Tarantino2, A.Nasto4
1Interventional Hepatology Unit, A.Tortora Oncology Hospital,
Pagani, Italy, 2Department of Clinical Medicine and Surgery, Federico
II University, Naples, Italy, 3Internal Medicine and Hepatology, Campus
Biomedico University, Rome, Italy, 4General and Oncologic Surgery
Unit, A.Tortora Oncology Hospital, Pagani, Italy
Purpose: We report long-term results of microwave (MW) ablation
with simultaneous insertion of multiple antennae in the treatment
of large hepatocellular carcinoma (HCC).
Material and methods: Between 2008 and 2013, 36 cirrhotics with
a single HCC nodule >3 cm (3.2-7.0 cm; mean: 4.4 cm) underwent MW
ablation in a single session by simultaneous insertion of multiple
13-gauge MW antennae (Viva-Wave, Covidien, USA). After intraoperative contrast-enhanced ultrasound (CEUS), residual viable tumor
was treated in the same session by reinsertion of 2-3 MW antennae.
Results: According the tumor size, 10 and 18 patients were treated
with a single insertion of 2-3 synchronous antennae, respectively.
Eight patients were treated with 2 insertions of 3 antennae in the
same session. Intraoperative CEUS showed residual tumor in 12
patients, and these patients underwent an additional insertion of
2 or 3 antennae. Intraoperative CEUS at the end of the procedure
showed complete necrosis in all patients. One-month CT showed
complete necrosis in 33/36 patients. Only a severe hemoperitoneum
occurred in 1 patient after treatment. Local recurrence occurred in
7 patients. Recurrences in other liver segments occurred in 35/36
patients within 6-24 months (mean: 15 months). Twenty patients
were alive at the 18-78-month follow-up (mean: 42 months).
Conclusion: Aggressive ablation of large HCC by simultaneous
insertion of multiple MW antennae is safe and seems to result in
patients survival comparing with surgery and small HCC ablation.

P-313

Unit, A.Tortora Oncology Hospital, Pagani, Italy

Percutaneous ablation of small HCCs:comparison of three

commercially available microwave devices

Purpose: We report 3-year follow-up results in the treatment of

medium and large hepatocellular carcinoma (HCC) by multiple electrode insertion and switching controller radiofrequency ablation
(SC-RF).
Material and methods: Between 2009 and 2015, 22 cirrhotics (62
84 years; 14 female; 13 ChildPugh A and 9 B class) with a single
HCC nodule (3.05.8 cm; mean, 4.3 cm) were treated by US-guided
percutaneous SC-RF using a monopolar multiple-electrode radiofrequency ablation system (Cool-tip radiofrequency Switching
Controller, Covidien). Intraoperative CEUS and an additional electrodes insertion was performed in case of residual viable tumor
at CEUS. Definitive treatments efficacy was assessed by CT after
3 weeks and followed up by US every 3 months and CT every 12
months.
Results: The treatment duration ranged from 20 to 80 minutes
(mean: 30 minutes). A single insertion and 2 insertions of 3 electrodes occurred in 15 patients and 7 patients, respectively. CT
showed complete necrosis in 19/22 (86%) patients. The remaining
3 patients underwent a second ablation session. No major complication occurred. During follow-up (657 months, mean 36 months),
local recurrence occurred in 3/22 (14%) patients in 1224 months.

L.Tarantino1, P.Ambrosino2, P.Gallo3, P.Tarantino2, A.Nasto4

1Interventional Hepatology Unit, A.Tortora Oncology Hospital,
Pagani, Italy, 2Department of Clinical Medicine and Surgery, Federico
II University, Naples, Italy, 3Internal Medicine and Hepatology, Campus
Biomedico University, Rome, Italy, 4General and Oncologic Surgery
Unit, A.Tortora Oncology Hospital, Pagani, Italy
Purpose: We compared the effectiveness of three microwawe (MW)
devices for percutaneous treatment of small HCCs.
Material and methods: Twenty-four patients with cirrhosis and a
single HCC nodule (<2 cm; range: 1.32 cm) were treated by a single
insertion of one of the following MW devices: 1) 10 patients with 14
G-915 MHz antenna with a 45-W MW generator (Vivawawe, Covidien,
USA); 2) 5 patients with 14 G-2450 MHz antenna with a 100-W generator (AMICA, Hospital Service, Italy); and 3) 9 patients with 13 G-2450
MHz antenna with a 180-W generator (Acculis, Microsulis Medical
Ltd, England).
Results: The diameter of HCC nodules ranged from 11 to 20 mm
(mean: 15 mm). Post ablation CEUS and CT showed complete necrosis in all cases with different size of ablation obtained. Differences in
transverse diameter of the area of necrosis between the Covidien

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device and the other two devices was statistically significant (p
= 0.01). There was no statistically significant difference between
AMICA HS and Acculis devices. However, the time of application to
obtain a similar result was consistently lower with Acculis device
than with AMICA HS.
Conclusion: All devices seem to be effective and safe in the treatment of small HCC by a single antenna insertion. Howewer, the sizes
of necrosis obtained were consistently lower than those indicated
by the manufacturers.

P-314
Radiofrequency ablation of gas gangrene of the liver in a highrisk patient: a case report
L.Tarantino1, V.Iovino2, A.Sullo3, F.DeMarco4, P.Gallo5, A.Nasto6
1Interventional Hepatology Unit, A.Tortora Oncology Hospital,
Pagani, Italy, 2Oncology Department, A.Tortora Oncology Hospital,
Pagani, Italy, 3Infectious Diseases, Umberto I Hospital, Nocera, Italy,
4Anesthesiology and ICU Department, A.Tortora Oncology Hospital,
Pagani, Italy, 5Internal Medicine and Hepatology, Campus Biomedico
University, Rome, Italy, 6General and Oncologic Surgery Unit, A.Tortora
Oncology Hospital, Pagani, Italy
Purpose: We report a case of gas gangrene (GG) of the liver, which
occurred after percutaneous microwave (MW) ablation of hepatocellular carcinoma (HCC), resulting in progressive multiorgan failure.
Material and methods: A 76-year-old female with Child A cirrhosis underwent synchronous insertion of 3-MW antennae for large
HCC (5.5 cm). Twenty-four hours after treatment, the asymptomatic
patient left the hospital, but 2 days later, she complained of fever,
abdominal swelling and pain. She was promptly hospitalized with a
diagnosis of anaerobic liver abscess and antibiotic therapy was initiated. On the fourth day, the patient was moved to the ICU because
of multiorgan failure. Percutaneous drainage was attempted but
was of no use. Because of a high perioperative mortality risk, after
informed consent, we performed radiofrequency ablation (RFA) of
GG, under conscious sedation, by double insertion of 3 cool-tip needles (Covidien LDT, USA) into the infected area.
Results: The procedure was well tolerated by the patient. A marked
improvement in the patients condition was observed subsequently.
Ten days after the RFA, the patient was discharged from the hospital. At 18 months follow-up, the patient is well compensated (Child B
class), without any HCC recurrence at imaging.
Conclusion: Percutaneous RFA could be a valuable therapy for
focal GG of the liver in patients unresponsive to antibiotics and
when surgery and liver transplantation are not feasible. A fast and
early indication is needed in case of rapid worsening of the patients
condition.

P-315
Survival benefit of transarterial chemoembolization for
hepatocellular carcinoma
O.Majeed1, I.Rehman1, W.Ahmad1, A.Iqbal1, S.Khawar2, K.Aftab3,
I.Niazi1
1Radiology Department, Shaukat Khanum Memorial Cancer Hospital
& Research Centre, Lahore, Pakistan, 2Radiology Department, Houston
Medical Center, Warner Robons, GA, United States of America,
3Radiology Department, Sheikh Khalifa Medical City, Abu-Dhabi,
United Arab Emirates
Purpose: Transarterial chemoembolization (TACE) is a palliative
treatment option for hepatocellular carcinoma (HCC), with improved
patient survival. The aim of the study was to evaluate the outcome
of our patients at SKMCH & RC 2 years after TACE.
Material and methods: Electronic records were retrospectively
reviewed for patients who underwent TACE from November 1,

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2009, to October 31, 2012. Baseline imaging, multidisciplinary team

and clinical notes, pathology labs, TACE angiograms, and followup imaging were reviewed for 2 years after first TACE. Procedural
complications, clinical status, and findings at follow-up CT were
reviewed and analyzed in SPSS version 19. Survival was assessed
using KaplanMeier curves.
Results: In all, 104 patients underwent TACE for HCC. Among these,
21 were lost to follow-up and were excluded to minimize bias.
Among the 83 included, 57 were male and 65 were 5170 years of
age during the first TACE. In 74 patients, the most common cause
for HCC was HCV. Target lesion size at baseline CT was <5 cm in 38
patients and 510 cm in 37. Twenty-five patients needed more than
1 session of TACE. On post-TACE CT, 46 (55.4%) patients had good
packing of lipiodol in the lesion. Eighteen (21.7%) patients progressed with TACE lesions while another 21 (25%) progressed with
new lesions. One patient had metastasis to the adrenal gland.
Only 8 patients had liver failure and 1 had hepatorenal syndrome.
One patient died within 30 days after TACE.
Two years after TACE, 47 patients were alive, indicating good
outcome.
Conclusion: TACE improves survival in HCC. In our study, the 1-year
survival was 80% and 2-year survival was 56.6%.

P-316
Percutaneous isolated hepatic perfusion (chemosaturation) in
patients with primary or secondary liver tumours: experience
in 20 patients
S.Marquardt1, M.Peperhove1, T.Rodt1, A.Vogel2, F.Wacker1
1Institute for Diagnostic and Interventional Radiology,
Hannover Medical School, Hannover, Germany, 2Department of
Gastroenterology, Hepatology and Endocrinology, Hannover Medical
School, Hannover, Germany
Purpose: To assess the feasibility, safety, side effects and efficacy of
percutaneous isolated hepatic perfusion (PHP) as salvage therapy in
patients with primary or secondary liver tumours.
Material and methods: Surgical isolated hepatic perfusion has
been established and shown in the early 90s to be effective.
Recently, a minimally invasive percutaneous system has been introduced using a double-balloon catheter for the isolation of the
hepatic inferior caval vein segment. During arterial chemoperfusion
of the liver with melphalan, venous blood from the liver is extracted
through the double-balloon catheter and filtrated via an extracorporeal haemofiltration circuit before it is returned.
Twenty patients with hepatic metastasis from ocular melanoma
(n=5), cholangiocarcinoma (n=4), colorectal carcinoma (n=1), mammary carcinoma (n=1), uterine carcinoma (n=1) and prostate carcinoma (n=1) as well as patients with primary hepatocellular carcinoma (n=5) and intrahepatic cholangiocarcinoma (n=2) received up
to 4 treatments of PHP under general anaesthesia.
Follow-up period with cross-sectional imaging was maximum 14
months.
Results: At the first follow-up after 2 months, a local response rate
(stable disease or partial response) of 80% was observed. Four
patients showed progressive disease. Mean hepatic progressionfree survival was 3.2 months using the KaplanMeier estimator.
Technical success was achieved in all procedures. No major periprocedural complications could be observed. A distinct, reversible drop
of blood pressure could be seen in all patients when flushing the filters. Complications due to bone marrow suppression were common
but controllable.
Conclusion: Patients with primary and secondary liver tumours
that show progression undergoing standard therapy may profit
from PHP with melphalan. Technical execution is problem free.
Complications are manageable.

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[HASTE, n=30 (81 %) and BLADE, n=30 (81 %%)] to the surrounding liver parenchyma at 2472 hours postprocedure. At 6-month
follow-up, ablation zones were hypointense or heterogeneously
hypo-/isointense in T1w (precontrast, 47%; arterial phase, 65%; portal phase, 100%; and hepatobiliary phase, 100%) and had peripheral
rim enhancement during portal phase in 29% cases.
Conclusion: MRI detects characteristic morphologic changes after
irreversible electroporation in liver parenchyma treatment.

P-317
Long-term survival following ablation of colorectal liver
metastases
I.R.Andersen1, F.Rasmussen1, F.V.Mortensen2, D.T.Nielsen1
1Dept of Radiology, Aarhus University Hospital, Aarhus, Denmark,
2Dept of Surgery, Aarhus University Hospital, Aarhus, Denmark
Purpose: To retrospectively evaluate the long-term survival of
patients with CRLM ablated at our institution.
Material and methods: All patients with CRLM referred by the multidisciplinary team for hepatic disease between 1998 and 2014 were
ablated according to the national guidelines (Max 5 tumors 3 cm).
Survival was defined as the time between the diagnosis (A) or the
first ablation procedure (B) and death or the end of the follow-up
period.
Data was divided into 4 subgroups according to the time of diagnosis to reduce the confounding factors due to changes in referral patterns and other factors over time.
Results: A total of 753 ablative procedures were performed in 451
patients with CRLM (293 males, 158 females). The estimated 5-year
survival of patients calculated based on the diagnosis (A) was 30.6%
for 19952001, 25.3% for 20022005, 41.3% for 20062009, and
45.6% for 20102014. The estimated 5-year survival of patients calculated based on the first ablation (B) was 18.2%, 22.3%, 35.5%, and
47.6%, respectively.
Using the log rank test to compare the survival between the 4 subgroups, a significant difference was found (A: p=0.0026; B: p=0.0017),
indicating that the increase in the survival over time is statistically
significant.
Cox proportional hazards regression model showed that the hazard ratio (HR) decreased between successive subgroups over time
(HR=0.78; 95% CI: 0.67-0.88; p < 0.001). Overall, from 1998 to 2014,
the hazard ratio was reduced by half (HR=0.54; 95% CI: 0.32-0.90; p
< 0.02).
Conclusion: Ablation is an effective method for treating CRLM. The
5-year survival after ablation at our institution has increased over
time and is at present comparable to that after surgical resection,
when patients are selected according to the national guidelines.

P-318
IRE of malignant hepatic tumors: subacute and follow-up MRI
appearance of ablation zone
M.Dollinger1, P.Koch2, C.Niessen2, L.P.Beyer2, T.Bley1,
C.Stroszczynski2, P.Wiggermann2
1Department of Diagnostic and Interventional Radiology, University
Hospital Wrzburg, Wrzburg, Germany, 2Radiology, University
Hospital Regensburg, Regensburg, Germany

P-319
Feasibility and histopathological performance of postablative
hepatocellular carcinoma biopsy: is preprocedure biopsy still
needed?
S.D.Hajdu1, R.Duran1, P.E.Bize1, C.Sempoux2, A.Denys1
1Department of Diagnostic and Interventional Radiology, Lausanne
University Hospital, Lausanne, Switzerland, 2Institute of Pathology,
Lausanne University Hospital, Lausanne, Switzerland
Purpose: Iatrogenic tumor seeding is a known complication following the needle biopsy of hepatocellular carcinoma (HCC). The purpose of this study was to assess the feasibility and diagnostic performance of the histopathological evaluation of post-procedural needle biopsy following percutaneous radiofrequency ablation (RFA) of
HCC.
Material and methods: This ongoing, IRB-approved, prospective study included 20 patients with known liver cirrhosis (15 men,
5 women; median age, 67 9.6 years; ChildPugh A, n = 14 and B, n
= 6) bearing 20 suspected HCC lesions (mean diameter, 1.9 0.6 cm),
who were eligible for RFA. Hepatic lesions were biopsied via a coaxial system using an 18-G triaxial full-core biopsy instrument prior to
and immediately following RFA during the same procedure to compare the diagnostic histopathological performance.
Results: Seventeen HCC lesions having pre- and post-RFA biopsies
were histopathologically evaluated. Three lesions were not satisfactory for histopathology. Eleven post-RFA histopathological specimens (64.7%) revealed either well- or moderately-differentiated
HCC and matched pre-RFA biopsy results. Four post-RFA specimens
(23.5%) did not show any signs of HCC discordant to their matching
pre-RFA biopsies (well-differentiated HCC), suggesting that postRFA biopsies missed the lesion. Two lesions (11.8%) did not contain
pathological evidence of HCC in both pre- and post-RFA specimens.
Sensitivity and specificity were 73% (95% CI = 44.992.2) and 100%
(95% CI = 15.8100), respectively.
Conclusion: Post-RFA biopsy is a feasible technique with consistent
histopathological results when compared to pre-RFA and may be an
alternative technique to reduce the risk of tumor seeding.

P-320

Purpose: To describe the findings on contrast-enhanced MRI of

malignant hepatic tumors 2472 hours after percutaneous ablation
by irreversible electroporation (IRE) and at midterm follow-up.
Material and methods: A retrospective analysis of 37 malignant
liver tumors, 27 primary hepatic tumors, and 10 hepatic metastases
in 27 patients (19 men, 8 women, mean age 63 years) treated by IRE.
The mean tumor diameter was 2.1 cm. Ablation zones were evaluated by 2 examiners in a consensus reading by means of a 3T MRI
performed 2472 hours after IRE and at follow-up.
Results: At 6-month follow-up, the mean diameter of ablation
defects was reduced to 56% of the initial value. In comparison with
the surrounding liver parenchyma, ablation zones at the 2472-hour
follow-up were either hypointense or heterogeneously hypo-/isointense during T1w [precontrast, n=17 (46 %); arterial phase, n=34 (92
%); portal phase, n=34 (92 %); and hepatobiliary phase, n=33 (89
%)] and had peripheral rim enhancement during portal phase in
19 (51 %) cases. During T2w, ablation zones were mostly isointense

Provision of interventional oncology services in the United

Kingdom: a pilot study
J.Zhong1, P.Atiiga1, D.J.Alcorn2, D.Kay2, R.Illing3, D.J.Breen4,
N.Railton5, I.J.McCafferty6, P.J.Haslam7, T.M.Wah1
1Clinical and Interventional Radiology, St. Jamess Institute of Oncology,
St. Jamess University Hospital, Leeds, United Kingdom, 2Interventional
Radiology, Glasgow Royal Infirmary, Glasgow, United Kingdom,
3Interventional Radiology, University College Hospital, London,
United Kingdom, 4Radiology, Southampton University Hospitals,
Southampton, United Kingdom, 5Interventional Radiology, Mid Essex
Hospital NHS Trust, Chelmsford, United Kingdom, 6Dept. of Radiology,
The Queen Elizabeth Hospital Birmingham, University Hospital
Birmingham NHS Trust, Birmingham, United Kingdom, 7Interventional
Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom
Purpose: The aim of this national survey was to map out the current provision of interventional oncology (IO) services in the UK. The

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CIRSE 2016
survey was designed and undertaken by the interventional oncology UK (IOUK) team, a specialist interest group of the British Society
of Interventional Radiology.
Material and methods: All NHS trusts in England and Scottish
health boards were contacted by email and followed up by telephone. The survey key points were to see if IO procedures (either
supportive and/or disease modifying) were offered. If not, was a formal pathway to another institution available or were there plans to
implement an IO pathway in the next 12 months.
Results: A total of 153 NHS trusts were contacted. We received a
100% response rate. In total, 127 (83%) trusts provided IO services
or had a formal pathway of referral. Out of the 26 that did not provide IO, 21 (14%) trusts had a formal referral pathway for patients to
have IO at another trust. Five (3%) trusts did not have a pathway of
referral and no plans to implement one. Fifty seven out of 127 (45%)
trusts providing IO offered both supportive and disease-modifying procedures. Seventy out of 127 (55%) provided only supportive
procedures.
Conclusion: The provision of IO services in the UK is promising;
however, collaboration is necessary to ensure that disease-modifying IO procedures are made available to all patients throughout
the UK. More interventional radiologists with an interest in IO are
needed with a radiographer and nursing staffing to ensure a sustainable IO service.

P-321
Phase II study of hepatic arterial infusion chemotherapy
with oxaliplatin and 5-fluorouracil for advanced hilar
cholangiocarcinoma
X.Wang1, J.Hu2, G.Cao2, Y.Cui2, X.Li3, X.Ji4, X.Zhu2, J.Li5, C.Hao6,
B.Xing6, S.Lin5
1Interventional Radiology, Peking University Cancer Hospital, Beijing,
China, 2Interventional Oncology, Peking University, Beijing, China,
3Department of Mathematics and Statistics, University of Minnesota
Duluth, Duluth, MN, United States of America, 4Medical Statistics,
Peking University, Beijing, China, 5GI Oncology, Peking University,
Beijing, China, 6Surgery, Peking University, Beijing, China
Purpose: Hilar cholangiocarcinoma is a challenging disease with
dismal prognosis. The objective of this trial was to evaluate the efficacy and safety of hepatic arterial infusion (HAI) chemotherapy for
advanced hilar cholangiocarcinoma.
Material and methods: Patients with irresectable hilar cholangiocarcinoma were included in a prospective, open phase II study
investigating HAI provided through implanted port catheters.
Intraarterial chemotherapy consisted of infusions of oxaliplatin 40
mg/m2 for 2 hours, followed by 5-fluorouracil 800 mg/m2 for 22
hours on days 13 every 34 weeks. A maximum of 6 cycles of HAI
were applied for tumor control patients followed by maintenance
with oral capecitabine until tumor progression. The primary endpoints were tumor response and progression-free survival (PFS). The
secondary endpoints were local PFS (LPFS), overall survival (OS), and
adverse events.
Results: Between 2012 and 2015, 37 patients were enrolled. The
overall response rate was 67.6% (25/37), and the disease control rate
was 89.2% (33/37). Median PFS was 10.3 months. Median LPFS was
not reached. Median OS was 21.0 months. All three survivals in periductal infiltrating patients were found to be significantly longer
than those in mass-forming patients (p = 0.000, HR < 0.2), although
median PFS and OS were not reached. The most frequent adverse
events were grade 1/2 gastrointestinal side effects and sensory neuropathy in 31 (83.8%) and 28 (75.7%) patients, respectively.
Conclusion: HAI with oxaliplatin and 5-fluorouracil is encouraging
as a first-line treatment for its high tumor control, survival benefit,
and low toxicity for advanced hilar cholangiocarcinoma.

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P-322
Efficacy and safety of drug-eluting bead (DEB) TACE with
microspheres < 150 m in the treatment of hepatocellular
carcinoma
T.Sattler, C.Bredt, N.Woehrle, J.Rieger, T.F.Jakobs
Department of Radiology, Krankenhaus Barmherzige Brder Mnchen,
Munich, Germany
Purpose: To evaluate the efficacy and safety of DEB < 150 m by
determining overall survival (OS), progression-free survival, tumor
response, and periinterventional toxicity.
Material and methods: In this retrospective single-center study,
we examined 32 patients with HCC who were treated with epirubicin-loaded beads < 150 m between 2011 and 2015. During the follow-up period of at least 6 months, we analyzed the data before (t0)
and after (t1=first follow-up, t2=last follow-up within 6 months). The
assessment of the tumor response was performed by MRI and CT
considering mRECIST and the EASL criteria as well as the AFP level.
Results: We found a significant tumor response between all times
of examination by using mRECIST and a significant tumor response
between t0 vs t1 and t0 vs t2 with respect to the EASL criteria. There
was a significant decrease in the AFP level between t1 and t0. The
objective response rate of target lesions was 64.3% corresponding
to mRECIST and 78.5% corresponding to EASL. The median OS was
30.5 months and progression-free survival in relation to the target
lesion was 14.3 months. In the period of 30 days after the treatment,
we found no deaths or grade 5 adverse events according to CTCAE
criteria (version 3).
Conclusion: The efficacy of DEB TACE with beads < 150 m in size
was comparable to that reported in previously published studies
that used beads < 150 m and superior to studies that used larger
beads. We could not confirm the reported higher toxicity of beads
> 150 m.

P-323
Prospective study to evaluate safety of DEB-TACE with 100
beads in patients with non-resectable HCC
J.Urbano1, L.LLanosJimnez2, J.Echevarria3, J.SanchezCorral4,
C.Lanciego5, J.J.CiampiDopazo6, B.PeaBaranda7,
M.GonzlezdeGaray7, R.GonzlezCostero8, S.Mendez8,
J.J.MuozRuiz-Canela9, L.Lopez-Carreira10, J.CuestaPrez11,
V.NacarinoMejias12, J.R.PulpeiroRos10, J.PeirdelasHeras12,
A.GarcaSurez8
1Vascular & Interventional Radiology, Fundacion Jimenez Diaz,
Madrid, Spain, 2Instituto de Investigacin, Fundacion Jimenez
Diaz, Madrid, Spain, 3Vascular & Interventional Radiology, Hospital
Universitario de Galdakano, Bilbao, Spain, 4Vascular & Interventional
Radiology, Hospital Universitario Ramn y Cajal, Madrid, Spain,
5Radiologia Intervencionista, Hospital Virgen de la Salud, Toledo,
Spain, 6Interventional Radiology Department, Complejo Hospitalario
de Toledo, Toledo, Spain, 7Vascular & Interventional Radiology, Hospital
de Basurto, Bilbao, Spain, 8Vascular & Interventional Radiology,
H. U. Puerta de Hierro, Majadahonda (Madrid), Spain, 9Vascular &
Interventional Radiology, Hospital Regional Universitario de Mlaga,
Mlaga, Spain, 10Vascular & Interventional Radiology, H.U Lucus
Augusti, Lugo, Spain, 11Vascular & Interventional Radiology, H.U de la
Princesa, Madrid, Spain, 12Vascular & Interventional Radiology, H. U.
Virgen del Roco, Sevilla, Spain
Purpose: This is a multicenter, single-arm, prospective study (trial
NCT2670122) to evaluate safety and tolerability of drug eluting
beads transcatheter intraarterial chemoembolization (DEB-TACE)
for the treatment of non-resectable hepatocellular carcinoma (HCC).
The hypothesis is that 100 beads DEB-TACE penetrate deeper into
the tumor than those with larger volumes, without increasing the
risk and complications.

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The primary aim of the study is to describe treatment safety and tolerability of 100 beads. As a secondary end-point, a description of
efficacy parameters will be obtained.
Material and methods: Ten university hospitals with recognized
expertise in TACE treatments are involved in this study. The approval
of national and local health authorities and also of all ethics committees at each hospital was obtained. All patients provided specific informed consent, an indication for receiving DEB-TACE according to usual clinical practice. DEB-TACE was carried out with selective
and ultra-selective administration of up to 3 ml of tightly calibrated
100 drug eluting microspheres with up to 150 mg of doxorubicin to
patients with Child-Pugh B7, ECOG 0-1, and BCLC B or A.
All procedure-related adverse reactions will be recorded. mRECIST
will be used for response evaluation. Two-year follow-up is planned.
Estimated enrollment, 150 patients. Study started, March 2015.
Estimated completion, November 2017.
Results: By February 7, 82 patients were enrolled. Until this date,
14 adverse events have been registered. We will show preliminary
results according to the data that we will obtain by August 2016.
Conclusion: This study provides objective information about the
safety of HCC DEB-TACE with small microspheres.

P-324
Irreversible electroporation of the liver: is there a threshold for
the volume of tissue to be ablated?
F.Burdo1, A.Ivorra2, P.Sanchez1, A.Radosevic3, Q.Castellvi2
1Surgery, Hospital del Mar, Barcelona, Spain, 2TIC, Universidad Pompeu
Fabra, Barcelona, Spain, 3Radiology, Hospital del Mar, Barcelona, Spain
Purpose: Irreversible electroporation (IRE) is a fast-growing liver
ablation technique in which enhanced permeabilization of the cell
membrane permits free diffusion between ions in the extra and
intracellular media. Although safety has been well documented in
small ablations with infrequent ionic disturbances, little has been
reported when performing large or many ablations. The aim of the
study was to assess the safety and feasibility of IRE when large volume of the liver is subjected to ablation.
Material and methods: A tumor from the KM12C cell line was
grown in athymic-nude and immunocompetent mice and electric
pulses were directly delivered with parallel plate electrodes involving around 40% of mouse liver. A total of 87 animals were divided
according to the delivered field strength (1000 V/cm or 2000 V/cm)
and whether or not they received anti-hyperkalemia therapy.
Results: Early mortality (less than 24 hours post-IRE) in the 2000 V/
cm group was observed and revealed considerably higher mean
potassium levels in both mice strains. In contrast, the animals subjected to a 2000 V/cm field treated with the anti-hyperkalemia therapy had higher survival rates (OR=11.0, 95% CI=3.139.2, p<0.001). No
other ionic disturbances were related to early survival. As expected,
early mortality also depended on the electric field magnitude of
the IRE protocol because mice of both strains given 1000 V/cm survived longer than those given 2000 V/cm (OR=4.7, 95% CI=1.811.8,
p=0.001).
Conclusion: Our findings suggest that IRE safety is not guaranteed in large-volume ablations mainly due to potassium-related
disturbances.

Abstract Book

P-325
Frankfurt FAST-study: randomized trial using lipiodol + TACE
or lipiodol + EmboCeptS + TACE in the treatment of patients
with hepatocellular carcinoma
T.J.Vogl, M.Langenbach, T.Gruber-Rouh, N.-E.A.Nour-Eldin,
N.N.Naguib
Institut fr Diagnostische und Interventionelle Radiologie, Klinikum der
Johann Wolfgang Goethe-Universitt, Frankfurt, Germany
Purpose: To evaluate local tumor control for patients with hepatocellular carcinoma (HCC) treated with transarterial chemoembolization (TACE) by two different embolization protocols and to observe
the outcome regarding tumor volume, RECIST/mRECIST criteria, and
area diffusion coefficient (ADC) in a double-blind randomized study.
Material and methods: In total, 64 patients (mean, 59 years; range,
4384) with HCC were included. Until now, 58 patients have completed the treatment protocol, which includes 3 TACE sessions at
4-week intervals, with MRI prior to each TACE and 4 weeks after the
last TACE (endpoint). Two treatment groups were determined: group
1 (lipiodol + TACE) and group 2 (Lipiodol + EmboCeptS + TACE).
Tumor volume, RECIST, and mRECIST were evaluated for each scan,
and ADC was evaluated only for the first and last MRI.
Results: After analyzing 47 patients, an average tumor reduction of
0.77% was documented in group 1 and 12.97% was documented in
group 2. Regarding the RECIST/mRECIST criteria, stable disease (SD)
and progressive disease (PD) was documented in 13 and 4 cases,
respectively, in group 1, and partial response was documented in
3 cases, SD in 17 cases, and PD in 2 cases in group 2. During treatment, the ADC coefficient increased to 878.46 mm2/s on average
in the Lipiodol + TACE group vs. 451.52 mm2/s in the Lipiodol +
EmboCeptS + TACE group
Conclusion: Compared with the Lipiodol + TACE group, the Lipiodol
+ EmboCeptS + TACE group had a statistically nonsignificant local
tumor control rate. Based on the existing dataset, a correlation was
observed between the approach after TACE and an increase in ADC.
This indicates that ADC might be an individual predictor for the success of TACE.

P-326
Hepatic arterial infusion of FOLFOX for unresectable
liver metastases due to colorectal cancer after systemic
chemotherapy failure
T.Ihaya1, S.Takasugi1, T.Ogawa2
1Department of Diagnostic and Interventional Radiology, San-in
Rosai Hospital, Yonago, Japan, 2Radiology, Tottori University Hospital,
Yonago, Japan
Purpose: To evaluate the feasibility and efficacy of hepatic arterial
infusion (HAI) of FOLFOX for unresectable colorectal liver metastases (CRLM) after standard systemic chemotherapy failure.
Material and methods: Indwelling catheter with a side hole was
placed into the hepatic artery percutaneously, and the catheter tip
was fixed with microcoils to the gastroduodenal artery for reducing
mechanical irritations to the intima.
Patients with unresectable CRLM after failure of both oxaliplatinand irinotecan-based combination chemotherapies were treated
with HAI oxaliplatin (35 mg/sqm, 2 hours) followed by 5-FU (1500
mg/body, 46 hours) combined with intravenous levofolinate (200
mg/body, 2 hours) and molecular targeted agents based on biomarkers every 2 weeks until disease progression. Treatment effect
was evaluated by imaging studies every 2 months after the onset of
the therapy.
Results: Eight patients (mean age 71.9 years) were included.
Although five of them had primary lesion and/or extrahepatic
metastases, hepatic lesions were considered as the life threatening

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factor. The indwelling port catheter system was successfully
implanted in all cases without any major complications. There were
no severe side effects except grade 1 fatigue, anorexia, hypertension, and grade 2 rash acneiform observed only in cases treated with
intravenous anti-EGFR antibodies. The response rate was 75.0% and
median survival time after the onset of HAI was 12.0 months. Five
patients died due to cancer progression, but hepatic lesions were
well controlled until death.
Conclusion: Hepatic arterial infusion of FOLFOX is a feasible, safe,
and promising alternative treatment for unresectable CRLM after
systemic chemotherapy failure.

P-327
Secondary resectability of ocular melanoma liver metastases
following percutaneous hepatic perfusion
M.Zeile1, F.Bonk1, G.A.Stavrou2, C.U.vonSedewitz 3, P.Mohr4,
M.Beumer5, K.Niehaus2, A.Stang3, K.J.Oldhafer2, R.D.Brning1
1Radiology and Neuroradiolgoy, Asklepios Hospital Barmbek,
Hamburg, Germany, 2Surgery, Asklepios Hospital Barmbek, Hamburg,
Germany, 3Oncology, Asklepios Hospital Barmbek, Hamburg, Germany,
4Dermatology, Elbe Klinikum Buxtehude, Buxtehude, Germany,
5Anesthesiology, Asklepios Hospital Barmbek, Hamburg, Germany
Purpose: Percutaneous hepatic perfusion (PHP, chemosaturation) is
used for high-dose regional hepatic chemotherapy combined with
extracorporeal filtration of a chemotherapeutic agent (melphalan)
to avoid severe side effects. The purpose of this retrospective study
was to determine the response to therapy assessed by computed
tomography (CT) as well as the rate of secondary resectability in
patients who were initially deemed unresectable.
Material and methods: Between October 2013 and December
2015, we performed a total of 12 PHP procedures in 7 patients
(median age 569.1 years, range 4573 years) with unresectable
ocular melanoma liver metastases (OMLM). These patients received
a median of two cycles of PHP (range 13). After each cycle of PHP,
secondary resectability as well as response to therapy were assessed
by computed tomography.
Results: Mean objective response after both cycles of PHP was
71.4% (5/7); one patient showed stable disease and one patient
exhibited progression after first PHP and did not receive a 2nd cycle.
Two of seven (28.5%) patients showed secondary resectability on
imaging after completing two cycles. In both, resection was performed by extracting all tumors visible on imaging. However, both
patients showed few residual subcapsular metastases that were
not visible on imaging. The histopathological regression index was
10%50% in all resected metastases.
Conclusion: Significant downsizing of OMLM can be accomplished
by PHP, and secondary resectability may be achieved. Compared to
other established therapies, the image-based objective response to
therapy was high (74%) in our cohort. These promising results may
lead to a new standard in the therapy for OMLM. Larger collectives
are required to confirm this hypothesis.

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P-328
Clinical utility of lung radiofrequency ablation in patients with
pulmonary metastases due to malignant uterus tumor
Y.Sugino1, T.Yamanaka1, K.Nakajima1, N.Matsushita1,
T.Hasegawa2, M.Fujimori1, H.Takaki3, J.Uraki1, A.Nakatsuka1,
K.Yamakado3
1Radiology, Mie University School of Medicine, Tsu, Mie, Japan,
2Radiology, Aichi Cancer Center Hospital, Nagoya, Aichi, Japan,
3Radiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
Purpose: To retrospectively evaluate the clinical utility of lung radiofrequency ablation (RFA) for pulmonary metastases due to malignant uterus tumor.
Material and methods: From January 2006 to December 2015,
27 patients with a mean age of 62.311.0 years (range 3782 years)
underwent RFA for the treatment of 113 pulmonary metastases measuring 0.54.8 cm (mean 1.61.0 cm). All primary uterus tumors,
including sarcoma (n=7) and extrapulmonary metastases (n=2),
had been controlled. Feasibility, safety, technical success of RFA,
and local tumor progression, survival, and prognostic factors were
evaluated.
Results: 105 tumors (105/113, 92.9%) were covered by grand glass
area in one session, and 8 tumors were performed secondary session. All pulmonary metastasis were completely ablated. There was
no death related to the procedure, and the major complication rate
was 3.1% (3/96); pleural effusion and empyema were treated by
chest tube placement, and pneumomediastinum was treated in the
intensive care unit. Local tumor progression was found in 9 tumors
(8.0%). During the mean follow-up period of 44.730.6 months
(range, 1.7110.5 months), 6 patients died (22.2%, 6/27). The 1-, 3-,
and 5-year overall survival rates were 96.0% [95% confidence interval (CI), 92.1%99.9%], 82.3% (95% CI, 74.2%90.3%), and 61.0% (95%
CI, 48.8%73.2%), respectively. The median survival time was 33.5
months. No evidence of disease after RFA was the only better prognostic factor (p=0.0022, Hazard ratio, 11.0, 95% CI, 1.2122.3).
Conclusion: Lung RFA is a feasible and useful therapeutic option to
treat pulmonary metastases due to malignant uterus tumor. It was
estimated that no evidence of disease after RFA contributes to better prognosis.

P-329
Validation of the ART and HAP scoring systems for predicting
response to retreatment with TACE in a Dutch multicenter HCC
population
J.F.Kint1, R.B.Takkenberg2, A.Moelker3, M.C.Burgmans4,
H.J.Klumpen5, E.Ghariq4, O.M.vanDelden1
1Department of Radiology, Academic Medical Center, University
of Amsterdam, Amsterdam, Netherlands, 2Department of
Gastroenterology, Academic Medical Center, University of Amsterdam,
Amsterdam, Netherlands, 3Radiology, Erasmus Medical Center
Rotterdam, Rotterdam, Netherlands, 4Radiology, Leiden University
Medical Center, Leiden, Netherlands, 5Department of Oncology,
Academic Medical Center, University of Amsterdam, Amsterdam,
Netherlands
Purpose: Transcatheter arterial chemo-embolization (TACE) is the
mainstay of treatment for intermediate-stage hepatocellular carcinoma (HCC). Many patients need multiple TACE treatments.
Prognostic scoring systems are developed to assess response
after TACE. The hepatoma arterial-embolization prognostic (HAP)
score based on alfa-fetoprotein, albumin, bilirubin, and tumor size
assesses which patients may benefit from initial TACE. The assessment for retreatment with TACE (ART) score based on Child
Pugh score, AST, and tumor response predicts the usefulness of

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re-treatment with TACE. The aim of this study was to validate both
the scoring systems in a Dutch patient population and assess their
use for predicting the need of re-TACE.
Material and methods: We performed a retrospective analysis of
patients who underwent TACE in 3 large Dutch academic centers.
In patients, >1 TACE, ART, and HAP scores were assessed after initial
TACE and compared with the overall survival (OS).
Results: Between October 2003 and November 2015, >1 TACE
was performed in 122 patients. The ART and HAP scores could be
assessed in 98/122 (80.3%) and 85/122 (69.7%) patients, respectively.
Mean OS for 75 patients with a positive ART score (>2.5) was 40.6
months (SD 34.946.3) and that for 23 patients with a negative ART
score was 24.4 months (SD 18.730.0) (p=0.074). Mean OS for a positive HAP score was 43.6 months (37.150.0) and that for a negative
HAP score was 32.8 months (21.042.9) (p=0.022).
Conclusion: The HAP score and not the ART score predicted the
benefit of re-TACE.

P-330
Results of the MIRACLE I study of DEB-TACE with doxorubicinloaded Embozene Tandem Microspheres for hepatocellular
carcinoma
G.M.Richter1, B.A.Radeleff2, C.Stroszczynski3, P.L.Pereira4,
T.K.Helmberger5, P.E.Huppert6
1Clinics for Diagnostic and Interventional Radiology, Klinikum
Stuttgart, Stuttgart, Germany, 2Diagnostic and Interventional
Radiology, University of Heidelberg, Heidelberg, Germany, 3Radiology,
University Hospital Regensburg, Regensburg, Germany, 4Dept of
Radiology, Minimally Invasive Therapies and Nuclearmedicine,
SLK-Kliniken Heilbronn GmbH, Heilbronn, Germany, 5Institut fr
Diagnostische und Interventionelle Radiologie und Nuklearmedizin,
Klinikum Bogenhausen, Munich, Germany, 6Diagnostic and
Interventional Radiology, Klinikum Darmstadt, Darmstadt, Germany
Purpose: The MIRACLE I pilot study was designed to evaluate the
safety and efficacy of Embozene Tandem Microspheres (Celonova/
Boston Scientific Corporation, Marlborough, MA, USA) loaded with
doxorubicin for DEB-TACE treatment of unresectable hepatocellular
carcinoma (HCC).
Material and methods: Patients with HCC (mono- or bilobar disease, ECOG performance status 0-2, ChildPugh A or B) were
enrolled in this single-arm multicenter study. DEB-TACE was performed using 75-m Embozene Tandem Microspheres loaded with
doxorubicin. Freedom from procedure-related serious adverse
events (SAE) and freedom from primary tumor progression were
assessed at 6 months.
Results: Twenty five subjects with 44 lesions were treated (mean
age 65 years); 92% had monolobar disease, 72% were BCLC-B, 16%
were BCLC-C, 64% were Child-Pugh A, and 40% had ascites. Most
(72%) underwent 2 DEB-TACE procedures. Average doxorubicin dose was 124.536.1 mg (median 150 mg) per procedure. Two
patients had procedure-related SAE (liver necrosis, worsening of
liver insufficiency) within 30 days of the first DEB-TACE procedure.
Six-month freedom from procedure-related SAE or death was 71% (1
hepatic encephalopathy, 5 deaths). Tumor response was achieved in
95% (20/21) of subjects. Freedom from tumor progression or death
at 6 months was 76%. One-year survival among patients without
ascites was 73%.
Conclusion: MIRACLE I results suggest that Embozene Tandem
Microspheres loaded with doxorubicin can provide good local
tumor control with few SAEs in a heterogeneous group of patients
with unresectable HCC.

Abstract Book

P-331
Transarterial chemoembolisation of hepatocellular
carcinoma with 70150 m (M1) doxorubicin-loaded beads: a
retrospective single-centre analysis
S.Mafeld1, A.Al-Khatib1, F.Colgan1, H.Reeves2, N.Moyse3,
R.Jackson1, P.Littler1
1Interventional Radiology, Freeman Hospital, Newcastle upon Tyne,
United Kingdom, 2Liver Medicine, Freeman Hospital, Newcastle upon
Tyne, United Kingdom, 3Pharmacy, Freeman Hospital, Newcastle upon
Tyne, United Kingdom
Purpose: Transarterial chemoembolisation (TACE) using doxorubicin-loaded beads is an established treatment option for patients
with intermediate-stage hepatocellular carcinoma (HCC). Smaller
bead size may improve uniformity of drug distribution and enable
more distal embolisation, thereby improving efficacy. One of the
smallest beads to become available recently is the 70150 m M1 DC
bead (BTG Ltd, UK). Despite a theoretically promising design, little is
known regarding the safety and tolerability of M1 beads.
Material and methods: A retrospective review of M1 bead TACE
cases for patients with HCC from 20132015 from a single institution.
Data was obtained from electronic and PACS patient records.
Results: Sixty-three M1 bead TACE procedures were carried out in
45 patients with ChildPugh A or B (38 males, 7 females, mean age
70, range 4786 years). The mean number of TACE procedures was
2.6. Causes for liver disease included non-alcoholic fatty liver disease, alcoholic liver disease, HCV, HBV, haemochromatosis, primary
biliary cirrhosis, autoimmune liver disease and cryptogenic cirrhosis. Mean hospital stay was 2.1 days. Dose range per procedure was
10150 mg with a mean of 58 mg doxorubicin. No procedural complications occurred. Post procedure complications included abdominal pain (5%), lethargy (5%), groin haematoma (3%), transient deterioration in liver function (1%), pyrexia (1%), chest pain (1%) and nausea and vomiting (1%). There was no 30-day mortality. Follow-up
data using mRECIST demonstrated an overall response rate of 72%
(n=31), stable disease in 16% (n=7) and progressive disease in 11.6%
(n=5).
Conclusion: TACE with 70150 m M1 DC beads shows excellent
tolerability and minimal side effects. More data is needed to assess
treatment efficacy.

P-332
Intra-arterial (IA) chemotherapy of locally advanced pancreatic
head cancer
P.Tarazov, A.Polikarpov, A.Pavlovskij, A.Kozlov
Angio/Interventional Radiology, Russian Scientific Center of Radiology
and Surgical Technologies, St. Petersburg, Russian Federation
Purpose: To study the results of IA chemotherapy in patients with
unresectable, locally advanced pancreatic cancer.
Material and methods: Between 2002 and 2014, IA chemotherapy was performed in 155 patients (77 men, 78 women, mean age
60 years) with morphologically proven pancreatic head adenocarcinoma of TNM stages T3-4N0-1M0. Obstructive jaundice was eliminated by surgery or PTBD in all patients.
Celiac artery infusion (CAI, gemcitabine 1000 mg/m2 over 40-60
min; every 4 weeks) was performed in 87 patients (168 infusions, 1 to
6, mean 2 per patient). Oily chemoembolization (OCE, gemcitabine
600-1000 mg/m2mixed with 3-5 ml lipiodol, injection in the feeding
arteries; every 4 weeks) was made in 35 patients (85 procedures, 1
to 8, mean 2.5). Combined OCE + CAI (gemcitabine 500+500 mg/m2;
every 4 weeks) was used in 33 patients (106 procedures, 1 to 6, mean
3.2). Patients were stratified according sex, gender, tumor stage, and
dose of gemcitabine. Only patients who received >3 courses of IA
therapy were considered.

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Results: Sixty patients (20+20+20) were stratified. CAI resulted in
partial response in 6 (30%), stable disease in 7 (35%), and tumor progression in 7 patients (35%). The rates of PR, SD, and PD were 40%,
25%, and 35%, respectively, after OCE and 30%, 40%, 30%, respectively, after OCE+CAI. All 60 patients died; the mean survival was
15.0+4.8, 14.1+3.9, and 17.9+3.3 months, respectively (P>0.05).
Conclusion: Regular courses of IA therapy cause tumor control in
2/3 of patients with locally advanced pancreatic head adenocarcinoma. A tendency to better survival of these patients is seen.

P-333
Retrograde-outflow percutaneous isolated hepatic perfusion
using cisplatin: results and drug-dose correlation to adverse
events
S.Murata1, S.Onozawa1, T.Ueda1, F.Sugihara1, H.Yamaguchi1,
D.Yasui1, I.Miki1, A.Sakamoto2, T.Mine3, S.-N.Kumita1
1Radiology, Nippon Medical School, Tokyo, Japan, 2Anesthesiology,
Nippon Medical School, Tokyo, Japan, 3Radiology, Tokai University
Hachioji Hospital, Tokyo, Japan
Purpose: This study aimed to establish a safe regimen of the retrograde-outflow technique for percutaneous isolated hepatic perfusion (PIHP) using cisplatin in pretreated patients with advanced liver
malignancies.
Material and methods: We conducted a phase I dose-escalation
trial to evaluate the safety, efficacy, and maximum tolerated dose
(MTD) of cisplatin delivered by retrograde-outflow PIHP (R-PIHP).
Pretreated fifteen patients with cholangiocarcinoma (n=4) or liver
metastases (n = 11) who did not have liver cirrhosis were enrolled
between June 2013 and April 2015. All patients had received standard chemotherapies, and their liver tumors had progressed. R-PIHP
was performed by redirecting hepatic outflow through the portal
vein. R-PIHP used escalating cisplatin from 30 mg/m2. The grade of
adverse events (AEs) of R-PIHP therapy, pharmacokinetics, and antitumor response were evaluated.
Results: R-PIHP was successfully performed 26 sessions in 15
patients. At the first session, dose-limiting severe liver dysfunction
was observed at 50 mg/m2. Only transient liver dysfunction was
observed at the MTD of 45 mg/m2cisplatin. At the second session,
MTD was observed at 40 mg/m2 cisplatin. The plasma hepatic-tosystemic exposure ratio was 49 based on the maximum concentration and 38 based on the concentration-time curve at the MTD of
45 mg/m2. Response rate was 40%. In particular, 3 of 4 patients with
cholangiocarcinoma had partial response.
Conclusion: R-PIHP may offer the safe delivery of 45 mg/m2 or 40
mg/m2cisplatin with negligible AEs at the first and second sessions,
respectively.

P-334
Microwave ablation of colon cancer pulmonary metastases
A.J.GonzalezAguirre1, E.N.Petre1, H.Kodama1, J.P.Erinjeri1,
S.B.Solomon1, N.E.Kemeny2, C.T.Sofocleous1
1Interventional Radiology Service, Memorial Sloan Kettering Cancer
Center, New York, NY, United States of America, 2Gastrointestinal
Oncology Service, Memorial Sloan-Kettering Cancer Center, New York,
NY, United States of America
Purpose: To assess the safety and efficiency of microwave ablation
(MWA) for CRC pulmonary metastasis (CRC-PM)
Material and methods: Patients with CRC-PM treated by imageguided MWA were eligible. Success was assessed by CT at 4-6 postMWA. Follow-up imaging every 3 months assessed local or distant
progression. PET-CT was obtained as needed to assess progression.
Success and complications were calculated. Local tumor progression
(LTP)-free survival and overall patient survival (OS) were calculated
using the Kaplan-Meier method.

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S269

Results: Of 55 patients with CRC-PM treated with MWA, 16 were

excluded due to follow-up under 6 months. Sixty-three metastases
(median 1, range 1-4 per patient) ablated in 39 patients were analyzed. Tumor size ranged from 0.5 to 3.2 (mean 1.3, median 0.9 cm).
Median OS from MWA was 29 months (95% CI, 25.02-32.98), and 1-,
2-, and 3-year OS rates from the time of MWA 92%, 87%, and 64%,
respectively.
Within a median follow-up of 24 months (range 7-61 months), 13 of
63 lesions (20%) progressed, of which 4 were retreated with MWA.
Further, 1-, 2- and 3-year primary and assisted (after additional MWA)
LTP-free survival for lesions <1.5 cm was 92%, 88%, and 85% and
96%, 94%, and 92%, respectively.
The 1-, 2- and 3-year total and assisted LTP-free survival for lesions
>1.5 cm was 67%, 60%, and 60%, respectively. There were 26 pneumothoraxes (40%), 23 requiring chest tube (34%). One bronchopleural fistula and 1 empyema were also treated by thoracostomy.
Conclusion: MWA of lung metastases is a safe and effective minimally invasive, parenchymal-sparing technique that offers good
local control rates in patients with CRC-PM.

P-335
Comparison between image quality and diagnostic
performance of cone-beam computed tomography (CBCT)
during drug-eluting bead transarterial chemoembolization
and multidetector computed tomography for the detection of
hepatocellular carcinoma
P.Lucatelli1, R.Argiro1, C.Cirelli1, S.G.Corradini2, M.Bezzi1,
C.Catalano1
1Vascular and Interventional Radiology Unit, Sapienza University
of Rome, Rome, Italy, 2Division of Gastroenterology, Department of
Clinical Medicine, Sapienza University of Rome, Rome, Italy
Purpose: To compare image quality and diagnostic performance of
cone-beam computed tomography (CBCT) and multidetector computed tomography (MDCT) in the detection of hyper-vascular hepatocellular carcinomas (HCC) in cirrhotic patients undergoing drugeluting beads transarterial chemoembolization (TACE).
Material and methods: Fifty-five cirrhotic patients referred for
TACE on previously diagnosed typical hyper-vascular HCC were prospectively enrolled in the study. Imaging timeline included a preprocedural MDCT within 1 month from planned treatment, intraprocedural CBCT, and 1-month follow-up MDCT. Analysis of image
quality was performed on pre-procedural MDCT and CBCT datasets
with calculations of lesion-to-liver contrast-to-noise ratio (LLCNR)
and lesion-to-liver signal-to-noise-ratio (LLSNR); statistically significant differences were evaluated by the Wilcoxon test. One-month
follow-up MDCT was considered the reference standard for the
detection of HCC nodules.
Results: Median LLCNR values were 3.94 (95% CI: 3.06-5.05) and 6.90
(95% CI: 5.17-7.77) for pre-procedural MDCT and intra-procedural
CBCT, respectively (p<0.0001). Median LLSNR values were 11.53 (95%
CI: 9.51-12.44) and 9.36 (95% CI: 8.12-10.39) for pre-procedural MDCT
and intra-procedural CBCT, respectively (p<0.0104). Pre-procedural
MDCT detected 115 hyper-vascular nodules with typical HCC behavior, and CBCT detected 15 additional hyper-vascular nodules also
visible at 1-month follow-up MDCT. All the 15 occult nodules seen
at CBCT, but not at pre-procedural MDCT, were diagnosed as typical
HCC > 1 cm at 1-month follow-up MDCT and subsequently treated.
Conclusion: CBCT has a significantly higher diagnostic performance
than pre-procedural MDCT in the detection of hyper-vascular nodules and can influence management of cirrhotic patients with HCC
by identifying a subgroup of patients with particularly aggressive
tumors.

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P-336

P-337

Percutaneous cryoablation of tumors in solitary kidneys:

safety, renal function and oncologic outcomes

Embolotherapy for neuroendocrine tumor liver metastases:

prognostic factors for hepatic progression-free survival and
overall survival

C.Cicero1, A.Marzio1, B.DeConcilio2, F.Stacul3, S.Siracusano4,

L.Balestrieri5, M.Urbani5, A.Pinzani6, F.Lagan7, M.Ciaccia8,
G.Casarrubea9, F.Pittarello10, P.Pellegrini11, A.Celia2, A.Guarise1
1Radiology, Ospedale San Bassiano, Bassano Del Grappa, Italy,
2Urology, Ospedale San Bassiano, Bassano Del Grappa, Italy,
3Radiology, AOU Riuniti, Trieste, Italy, 4Urology, Ospedale Cattinara,
Trieste, Italy, 5Radiologia, CRO centro di riferimento oncologico,
Aviano, Italy, 6Radiologia, Ospedale Civile di Dolo, Dolo, Italy,
7Urologia, Ospedale Civile di Dolo, Dolo, Italy, 8Urology, Ospedale di
Treviso C Foncello, Treviso, Italy, 9Radiologia, Azienda Ospedaliera di
Padova, Padova, Italy, 10Radiologia, Ospedale Piove di Sacco, Piove Di
Sacco, Italy, 11Radiologia, Ospedale di Gorizia, Gorizia, Italy
Purpose: The purpose of this study was to determine the effect of
percutaneous cryoablation of tumors in a solitary kidney on renal
function, treatment-related complications, and oncologic outcomes.
Material and methods: We performed an Italian multicentric retrospective study of patients who underwent cryoablation with a
solitary kidney treated with percutaneous renal cryoablation from
December 2008 to June 2015.
We evaluated age, tumor size, and PADUA score in association with
recurrence.
Renal function was analyzed with serum creatinine concentration
and glomerular filtration rate measured before ablation and on the
first day after ablation.
Results: Twenty-seven patients, mean age 70 years (range, 6280
years), with 27 tumors (mean maximum diameter, 2.7 cm; range, 1.7
4.5 cm) were treated with percutaneous cryoablation procedures
with a mean follow-up period of 20 months (range, 535 months).
There was no significant change in creatinine pre- and post-ablation.
No patient needed dialysis. One grade 3 or greater complications
(ClavienDindo score) occurred after the 27 procedures (4% complication rate). The median hospital stay was 1.8 days (range, 13 days).
The local tumor control rate was 89%, and patients with tumors
smaller than 4 cm had a lower probability of recurrence (p=0.01).
Conclusion: Percutaneous cryoablation is effective in the management of renal tumors in patients with a solitary kidney. This technique has a low morbidity rate with preservation of renal function
and good local tumor control.

J.X.Chen1, S.C.Rose2, S.B.White3, G.El-Haddad4, N.Fidelman5,

H.Yarmohammadi6, D.Y.Sze7, N.Kothary7, K.Stashek8, E.P.Wileyto9,
R.Salem10, D.C.Metz11, M.C.Soulen1
1Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA,
United States of America, 2Radiology, UCSD Health Sciences, San Diego,
CA, United States of America, 3Radiology, Medical College of Wisconsin,
Milwaukee, WI, United States of America, 4Interventional Radiology,
Moffitt Cancer Center, Tampa, FL, United States of America, 5Radiology,
University of California, San Francisco, San Francisco, CA, United States
of America, 6Interventional Radiology, Memorial Sloan Kettering
Cancer Center, New York, NY, United States of America, 7Radiology,
Stanford Medical Center, Palo Alto, CA, United States of America,
8Pathology, Hospital of the University of Pennsylvania, Philadelphia,
PA, United States of America, 9Biostatistics, University of Pennsylvania,
Philadelphia, PA, United States of America, 10Interventional Radiology,
Northwestern University, Chicago, IL, United States of America,
11Gastroenterology, Hospital of the University of Pennsylvania,
Philadelphia, PA, United States of America
Purpose: This study evaluated the impact of disease- and treatment-related factors on outcomes following embolotherapy for
neuroendocrine tumor (NET) liver metastases.
Material and methods: This was a multicenter retrospective study
of 150 patients with NET liver metastases arising from the gut
(n=68), pancreas (n=67), lungs (n=8), or other (n=7) primary sites
treated with conventional transarterial chemoembolization (TACE,
n=47), transarterial embolization (TAE, n=41), or transarterial radioembolization (TARE, n=62) between 2004 and 2015. Analysis of
hepatic progression-free survival (HPFS) and overall survival (OS)
was performed.
Results: Median follow-up time was 22 months (range: 2125
months). Higher tumor grade demonstrated decreased HPFS and
OS, with a median HPFS of 18.5, 11.4, and 4.9 months (p<0.0001) and
OS of 125.1, 32.9, and 21.4 months (p<0.0001) for grade 1 (n=74), 2
(n=56), and 3 (n=20) tumors, respectively. Hepatic tumor burden
>50% demonstrated lower HPFS and OS. No significant differences
in HPFS or OS were seen among the gut, pancreas, or lung primaries. TARE demonstrated longer HPFS compared with TACE for grade
1 and 2 tumors (median HPFS of 26.1 and 15.7 months vs. 8.4 and 8.1
months, p<0.05) and shorter HPFS and OS compared with TACE for
grade 3 tumors (median HPFS and OS of 3.4 and 3.4 months vs. 5.0
and 25.5 months, p<0.05). HPFS and OS after TAE were not significantly different between TACE and TARE.
Conclusion: TARE demonstrated improved HPFS in grade 1 and 2
tumors but worse HPFS and OS in grade 3 tumors compared with
TACE. Higher tumor grade and tumor burden were associated with
worse HPFS and OS.

P-338
Small renal tumor percutaneous ablation versus nephrectomy:
treatment and clinical outcomes
P.Lourenco, N.Bilbey, B.Gong, B.Halkier
Department of Radiology, University of British Columbia, Vancouver,
BC, Canada
Purpose: To compare the outcomes of small renal tumor percutaneous ablation versus nephrectomy in adult patients with nonmetastatic renal cell carcinoma (RCC) and evaluate the role ofa prioribiopsy in the rate of intervention for benign lesions.
Material and methods: Retrospective cohort analysis of patients
subjected to renal tumor ablation or nephrectomy for small renal

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masses (<5 cm) from January 2006 to July 2014. Data was collected
from medical records, and the outcomes were compared. Ethics
approval was obtained from our Institutional Review Board.
Results: In total, 340 patients were identified with 101 ablation and
57 surgical patients fulfilling the inclusion criteria. Age, gender, and
comorbidities were matched. Mean tumor size was smaller in ablation patients (2.640.97 cm vs. 2.921.51 cm). Rate of ablation (16%)
or nephrectomy (14%) for benign lesions was similar when preintervention biopsy was not routinely performed. Introduction of
pre-procedure biopsy prior to intervention for equivocal lesions
resulted in 35% relative reduction of ablation for benign lesions.
Complication rates were less in the ablation group (7% vs. 32%,
p<0.05). Hospitalization was 0.60.7 days for ablation and 6.79.6
days (p<0.05) for surgical patients. No statistical pre- and post-procedural eGFR difference was observed between ablation and surgical groups, albeit 31/57 patients (54%) of the surgical cohort
received total nephrectomy. Tumor recurrence was 0.9% and 5% in
the ablation and surgical patients, respectively.
Conclusion: Ablation is a safe alternative to nephrectomy in the
treatment of small renal tumors, with similar long-term outcomes
and significant reduction in the hospitalization and complication
rates. Our data supports the routine practice of pre-procedural
biopsy to reduce the rate of intervention for benign lesions.

P-339
Chemoembolization for HCC: results of a national survey
conducted in 2015 on practices in France
A.Fohlen1, J.-P.Tasu2, H.Kobeiter3, J.-M.Bartoli4, J.-P.Pelage1,
B.Guiu5
1Department of Radiology, University Hospital and Medical Center,
Caen, France, 2Department of Radiology, University Hospital and
Medical Center, Poitiers, France, 3Department of Radiology, Henri
Mondor Hospital, Crteil, France, 4Radiologie Adulte, APHM CHU
La Timone, Marseille, France, 5Department of Radiology, Saint-Eloi
University Hospital - Montpellier School of Medicine, Montpellier,
France
Purpose: Because TACE is not standardized, we aimed to evaluate
the technical practice of TACE for HCC through a large French survey.
Material and methods: The survey was sent by e-mail to all French
radiologists practicing TACE in private and public centers.
Results: Among 232 radiologists, 27% (n=64) working in 32 different
cities (75% in public centers) answered. Each radiologist performed
a mean of 49 TACE procedures per year (range: 2250). Drug-eluting
beads (DEBs) and radioembolization were available for 76% and 62%
of radiologists, respectively. Prophylactic antibiotics were not used
in 67% of cases, and general anesthesia was rarely used (<5%) for
90%.
In total, 19% of radiologists never treat BCLC A patients and only
6% treat BCLC B patients. Ninety-two percent of radiologists have
already treated patients with non-troncular portal invasion.
The most frequently used criterion to select conventional TACE
(cTACE) vs. DEB-TACE was the number of nodules (35%). Performance
status and ChildPugh status were taken into account by only 12%
of radiologists.
For cTACE, in case of unilobar disease, 72% of radiologists treated
nodules selectively. Only 33% planned a systematic second session.
Doxorubicin was the most frequent chemotherapy drug used (81%)
and 23% of radiologists used gelfoam as the only embolic agent.
For DEB-TACE, DC Beads 100300 m were used in 53% of cases. No
additional embolization was performed by 39% of radiologists.
Only 26% of radiologists perform non-contrast CT after cTACE.
Conclusion: Indications as well as technique of TACE for HCC varied among radiologists. More standardized practices should be
established.

SS/FC/HL/HTS/CM
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P-340
Percutaneous transluminal forceps biopsy combined
with percutaneous transhepatic biliary drainage in the
management of patients with obstructive jaundice
A.Fohlen1, C.Bazille2, M.-A.Jegonday1, B.Dupont3, J.Lubrano4,
J.-P.Pelage1
1Department of Radiology, University Hospital and Medical Center,
Caen, France, 2Department of Anatomopathology, University Hospital
and Medical Center, Caen, France, 3Department of Hepathology,
University Hospital and Medical Center, Caen, France, 4Department of
Hepato-Biliary Surgery, University Hospital and Medical Center, Caen,
France
Purpose: To investigate the feasibility, safety and accuracy of percutaneous transluminal forceps biopsy (PTFB) during percutaneous
biliary drainage in patients suspected of having a malignant biliary
stricture.
Material and methods: Fifty consecutive patients (mean age,
69.5 years) with obstructive jaundice underwent PTFB during biliary drainage. Biopsy specimens were obtained using 5.2-F flexible
biopsy forceps (Cook). Analysis was conducted by 2 pathologists
independently. Consensus was obtained in case of discrepancy. Final
diagnosis was compared with surgical findings (n=6), additional histocytologic data (n=11) or clinical and radiologic follow-up (n=33).
Results: Percutaneous biliary drainage was successful in all patients.
Its sensitivity was 70%, specificity was 100%, and accuracy was 72%.
Among 20 patients with a suspicion of cholangiocarcinoma based
on imaging, PTFB confirmed the diagnosis in 17 (85%) patients.
Among patients with a suspicion of pancreatic adenocarcinoma,
diagnosis was confirmed in 8/17 (47%) patients. Sensitivity was
lower when the lesion involved the common bile duct (53%) compared to the ampullary segment (80%), the hilum (80%), the common hepatic duct (100%) or the entire extrahepatic duct (100%).
If intraductal invasion was suspected on imaging evaluation, the
probability of a the biopsy being contributive was 86%. No correlation was found between lesion size on imaging and biopsy performance. Four minor complications, including haemobilia in 2 cases,
were reported.
Conclusion: PTFB combined with biliary drainage is feasible and
safe to diagnose biliary strictures. The overall accuracy of PTFB was
72%; it was higher in patients with a suspected diagnosis of cholangiocarcinoma and in whom the common bile duct was not involved.

P-341
Transarterial chemoembolization of advanced hepatocellular
carcinoma using degradable starch microspheres
T. Yamanishi
Radiology, Kochi Medical School, Kochi, Japan
Purpose: To examine the outcomes of transarterial chemoembolization (TACE) using degradable starch microspheres (DSM) for
advanced hepatocellular carcinoma (HCC) in our hospital.
Material and methods: This retrospective study included 23
patients (mean age, 70.6 years; range, 54-89 years) who had undergone DSM-TACE for advanced HCC in our hospital between
September 2010 and May 2014. All patients had received previous
treatment such as TACE using epirubicin and miriplatin or transarterial infusion using cisplatin. Fifteen cases were Child-Pugh A, and
eight were Child-Pugh B. Treatment comprised embolization therapy with a DSM and mitomycin (20 mg). We repeated treatment
every 4-6 weeks to allow sufficient progression. If this approach
failed, treatment was continued with other modalities such as intraarterial chemotherapy (low-dose 5-fluorouracil and cisplatin) or
sorafenib administration. Therapeutic effects and adverse events

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were evaluated using the Response Evaluation Criteria in Solid

Tumors and the Common Terminology Criteria for Adverse Events
4.0, respectively.
Results: Technical success was achieved in all patients, with a mean
of 2.7 courses administered (range, 1-7). Complete response/partial response/stable disease/progressive disease were 2/9/10/2
(response rate, 47.8%), with a complete response rate of 8.7%.
Median survival time was 422 days (range, 34-1069 days). Adverse
events included thrombocytopenia in 10 cases, but grade 3 thrombocytopenia was only seen in two patients who improved with conservative observation. Other adverse events included kidney failure
and gastrointestinal toxicity in 6 cases.
Conclusion: DSM-TACE for advanced HCC is both safe and effective and appears to offer an extremely useful treatment option for
advanced HCC.

P-342
HIFU for prostate cancer: a 9-year experience of 1150 patients
V.A.Solovov, M.O.Vozdvizhenskiy, A.E.Orlov
Interventional Radiology, Samara Oncology Centre, Samara, Russian
Federation
Purpose: To report the results of HIFU treatment for prostate cancer
and failure after external beam radiotherapy (EBRT) and radical prostatectomy (RPE) stratified by tumor recurrence risk according to the
DAmico risk classification.
Material and methods: In total, 1150 patients were treated at our
center between September 2007 and November 2015: 339 with lowrisk progression, 355 with intermediate-risk progression, 409 with
high-risk progression, and 47 after EBRT and RPE failure. Of these,
925 patients underwent TURP+HIFU and 225 underwent only HIFU
(volume prostate <40 cc). Mean follow-up was 62 (range 398)
months. The mean age of the whole group of patients was 69.2 (52
89) years.
Results: Median PSA level 72 months after HIFU treatment was 0.5
(0.03.6) ng/ml for the low-risk group, 1.04 (0.26.3) ng/ml for the
intermediate-risk group, 3.2 (021.3) ng/ml for the high-risk group,
and 1.7 (0.09.8) ng/ml for the failure after EBRT and RPE group. Six
percent of patients in the low-risk group showed progression, 8% in
the intermediate-risk group showed progression, 36.9% in the highrisk group showed progression, and 19.7% in the failure after EBRT
and RPE group showed progression. KaplanMeier analyses of the
groups indicated that the risk of progression after the 9-year followup was 24.9% for all patients.
Conclusion: HIFU ablation is a safe and minimally invasive treatment for localized and locally advanced prostate cancer, effective
in 85.1% of cases with mild and transient side effects; HIFU-therapy
can also be successfully performed in patients with local recurrence
after RPE and EBRT.

Abstract Book

P-343
Safety of transarterial embolization using 40-m drug-eluting
spheres loaded with irinotecan for treating hepatic metastases
from colorectal cancer: a prospective evaluation
G.M.Varano1, G.Mauri1, R.Fo2, L.Monfardini3, G.Bonomo1,
P.DellaVigna4, M.Zampino5, P.Ravenda4, F.Orsi6
1Division of Interventional Radiology, European Institute of Oncology,
Milan, Italy, 2School of Radiology, University of Milan, Milan, Italy,
3Radiology, Interventional Radiology Unit, Fondazione Poliambulanza,
Brescia, Italy, 4Radiology, European Institute of Oncology, Milan,
Italy, 5Division of Oncology, European Institute of Oncology, Milan,
Italy, 6Division of Interventional Radiology, IEO Istituto Europeo di
Oncologia, Milan, Italy
Purpose: To evaluate the safety of transarterial embolization using
40-mm drug-eluting spheres loaded with irinotecan for treating
hepatic metastases from colorectal cancer.
Material and methods: In total, 18 patients (11 males, 7 females,
mean age 62 years), with a mean of 9 (range 130) hepatic metastases were perspectively enrolled. Eleven patients had bilobar.
Enrolled patients underwent at least two prior lines of chemotherapy. Fourteen patients had extra-hepatic disease; thirteen had previously undergone hepatic surgery or ablation. Mean diameter of
the lesions was 47.6 mm (range 12161). Procedure was performed
by using microparticles of 40 mm loaded with 100 mg of irinotecan. Treatment was given every 4 weeks up to disease progression. Adverse events (AEs) were classified from G1 to G5 according
to the NIH criteria. Response to treatment was evaluated according
to RECIST 1.1 criteria. KaplanMeier analysis was used to estimate
median time to local tumor progression.
Results: In total, 42 (60.8%) AEs occurred in 69 treatments, all being
G1 or G2. There were 35/42 (84%) post-embolization syndromes
(pain, fever, nausea and fatigue), 2/42 (4%) allergic reaction, 1/42
(2%) atrial fibrillation, 1/42 (2%) access bleeding, 1/41 (2%) alopecia,
1/42 (2%) diplopia, and 1/42 (2%) limbs edema. No G3, G4, or G5 AEs
occurred. Local tumor control was achieved in 14/18 (77.8%) patients
at 3 months and in 10/18 (55.6%) patients at 6 months. Median time
to local tumor progression was 7 months.
Conclusion: Drug-eluting microspheres loaded with irinotecan
were safe for the treatment of patients with hepatic metastases from
colorectal cancer, and only low-grade AEs occurred.

P-344
Impact of different embolic agents for TACE procedures on
VEGF levels post-treatment
P.Wiggermann1, K.Krger2, C.Niessen1, L.P.Beyer1,
E.Hohenstein2, C.Stroszczynski1, P.L.Pereira3
1Department of Radiology, University Hospital Regensburg,
Regensburg, Germany, 2Clinic for Radiology, Minimally-invasive
Therapies and Nuclear Medicine, SLK Kliniken Heilbronn GmbH,
Heilbronn, Germany, 3Dept of Radiology, Minimally Invasive Therapies
and Nuclearmedicine, SLK-Clinics GmbH, Ruprecht-Karls-University
Heidelberg, Heilbronn, Germany
Purpose: To analyze blood VEGF level response to different embolic
agents during TACE for HCC.
Material and methods: A total of 22 patients were enrolled in this
prospective IRB approved trial. Patients were assigned to one of
three different TACE regimes: degradable starch microspheres (DSM)
TACE, drug-eluting bead (DEBDOX) TACE, or lipiodol TACE (cTACE).
All patients received 50 mg doxorubicin/m2 bsa. VEGF levels were
assessed right before TACE treatment, 24 h post treatment, and 4
weeks after TACE treatment.
Results: A total of 30 TACE procedures were performed. Compared
to baseline VEGF levels, a marked increase in the levels 24 h

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post-TACE (164% of the baseline level) and during the 4-week follow-up (170% of the baseline level) was observed for the cTACE arm
(p<0.05). The respective figures were 114% and 123% for DEBDOX
and 121% and 124% for DSM TACE. DEBDOX and DSM TACE increase
in VEGF levels was not statistically significant at 24 h post-TACE or
during the 4-week follow-up.
Conclusion: Conventional TACE using lipiodol as an embolic agent
shows marked increase in blood levels of VEGF. DEBOX and DSM
TACE show only a moderate VEGF response.

P-345
Validation of the clinical scoring system SNACOR (tumour Size
and Number, baseline Alpha-fetoprotein, Child-Pugh, and
Objective radiological Response) after TACE of HCC
R.Kloeckner1, M.B.Pitton1, A.Mhringer-Kunz1, C.Dber1,
I.Schmidtmann2, S.Koch3, P.R.Galle4, A.Weinmann4
1Department of Diagnostic and Interventional Radiology, University
Medical Center of the Johannes Gutenberg University Mainz, Mainz,
Germany, 2Institute of Medical Biostatistics, Epidemiology and
Informatics, Johannes Gutenberg University Mainz, Mainz, Germany,
3Clinical Registry Unit (CRU), University Medical Center of the Johannes
Gutenberg University Mainz, Mainz, Germany, 4Department of Internal
Medicine, University Medical Center of the Johannes Gutenberg
University Mainz, Mainz, Germany
Purpose: Transarterial chemoembolization (TACE) is the standard
of care for intermediate stage hepatocellular carcinoma (HCC).
Deciding to what extent treatment should be repeated remains
challenging. Therefore, we performed an external validation of the
recently published SNACOR risk prediction model.
Material and methods: In all, 933 patients with HCC underwent
TACE at our institution from 01/2000 to 09/2015. All variables needed
to calculate the SNACOR (at baseline: tumour Size and Number,
baseline Alpha-fetoprotein, and Child-Pugh, and after the first TACE,
Objective radiological Response) were determined. Overall survival,
Harrells C-index, and integrated Brier score (IBS) were calculated.
Furthermore, multivariate analysis was performed to identify independent predictors of survival.
Results: Two hundred ninety-one patients were finally included.
Low, intermediate, and high SNACOR scores predicted median survivals of 29.9, 19.2, and 10.6 months, respectively. Harrells C-index
was 0.612 and IBS was 0.148. Baseline Child-Pugh and alpha-fetoprotein as well as objective radiological response after the first TACE
were independent predictors of survival (all p<0.05). Tumour size
and tumour number were not significantly associated with survival.
Conclusion: The SNACOR risk prediction model is able, after the first
TACE, to identify patients with a dismal prognosis who are unlikely
to benefit from further TACE. Nonetheless, Harrells C-index showed
only a moderate performance. Hence, this risk prediction model
tends to over-simplify clinical decision-making as this is usually
based on a greater number of variables. Accordingly, this risk prediction model can only serve as one of several components in forming
the decision whether the treatment should be repeated.

P-346
Relationship between pre-TACE angiographic findings and
post-TACE lipiodol deposition pattern on CT scan: correlation
with pathologic findings
S.Li, S.Sun, S.Wang, Y.Guo, L.Lenhart
Department of Radiology, University of Iowa Hospital and Clinics, Iowa
City, IA, United States of America
Purpose: Full homogeneous lipiodol deposition pattern post-conventional TACE may predict better tumor destruction after TACE.
This study assessed whether hepatic arteriogram findings during

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conventional TACE can predict lipiodol deposition pattern (LDP) on

CT scan immediately post-TACE.
Material and methods: In all, 536 patients with hepatocellular carcinoma were treated by superselective conventional TACE at our
institution from 2005 to 2014. Angiographic findings and LDP were
classified and compared in all patients. Correlations with pathological findings were assessed in 42 patients who underwent liver transplantation post-TACE.
Results: Homogeneous nodular tumor blush in capillary phase of
angiogram was found in 53% patients, heterogenous nodular tumor
blush in 38%, and partial tumor blush (PTB) with geographic defect
within tumor in 9%. LDP on CT scan performed post-TACE was classified. 52.1% patients had type I LDP, 98.2% patients presented with
HTB and had type I LDP, 36.8% patients had heterogenous nodular tumor blush, and 5 HNTB patients presented with type II LDP.
Forty-eight patients with PTB and 7 patients who had HNTB on
arteriogram presented with type III LDP. Forty-two patients underwent liver transplant post-TACE. 59.5% patients with type I LDP presented with total tumor necrosis and 19.1% patients with >90%
tumor necrosis. Six patients with type II LDP presented with no viable tumor (n=3) or >60% of tumor necrosis (n=3). Three patients with
type III LDP presented with <60% tumor necrosis.
Conclusion: Pre-TACE angiographic findings appear to correlate
well with post-TACE LDP. For patients with PHTB and type III LDP, viable tumor may exist and repeated TACE may be necessary.

P-347
Radiofrequency ablation of primary lung carcinoma: results of
a prospective multicenter trial
J.Palussire1, J.-Y.Gaubert2, C.Meunier3, O.Bonnefoy4, F.Laurent5,
F.Chomy6, T.deBare7
1Department of Radiology, Institut Bergoni, Bordeaux, France,
2Department of Adult Radiology, CHU Timone 2, Marseille, France,
3Imaging Department, CHU Rennes, Rennes, France, 4Imaging
Department, CH PAU, Pau, France, 5Imaging Department, CHU
Bordeaux, Bordeaux, France, 6Department of Oncoloy, Institut
Bergoni, Bordeaux, France, 7Dept. of Interventional Radiology, Institut
Gustave Roussy, Villejuif, France
Purpose: To evaluate the survival outcomes of percutaneous radiofrequency ablation (RFA) for patients presenting with stage IA nonsmall cell lung cancer (NSCLC) ineligible for surgery and included in
a prospective multicenter phase 2 trial.
Material and methods: Forty-two patients (mean age 71.7 years)
were enrolled prospectively from 6 centers. All presented with
biopsy-proven stage IA NSCLC. The main objective was to evaluate
the local efficacy of RFA with local control at 1 year. Patients were followed up with CT and PET CT. The other objectives were to estimate
the overall survival (OS) at 1 and 3 years, local control at 3 years, lung
function, and quality of life. The adverse events were recorded and
categorized using CTCAE V.3.
Results: The local control rate at 1 year was 84.38% (95% CI 67.2195.72). The local control rate at 3 years was 81.25% (95% CI 54.3595.95). The overall survival rate was 91.67% (95% CI 77.53-98.25) at 1
year and 58.33% (95% CI 40.76-74.49) at 3 years. Lung function measurements were not significantly modified after RFA. There was no
significant change in the global health status or functioning and
symptomatic scales after RFA. The most frequent complication was
pneumothorax (61%).
Conclusion: RFA is efficient in the treatment of medically inoperable patients with stage IA NSCLC. RFA is well tolerated, does not
adversely affect pulmonary function tests, and provides a 3-year
overall survival rate that is comparable to the rate reported after stereotactic body radiotherapy in similar patients.

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P-348
Cross-sectional and angiographic predictors for arterio-venous
shunting in HCC
S.Alzaabi, Z.AlSafran, N.Hamour, F.AlMolani, A.AlNammi,
M.AlMuhaish
Interventional Radiology - Medical Imaging Department, King Fahad
Specialist Hospital -Dammam, Dammam, Saudi Arabia
Purpose: Predicting degree of AV shunting in HCC patients undergoing TARE is crucial in preventing excessive Y90 radioactivity shunting to lungs beyond safety limits, which may consequently lead to
irreversible morbidities. Factors determining degree of shunting are
inadequately evaluated in the literature. This particular retrospective study looks into evaluating imaging findings as predictors to
tumor-pulmonary shunting.
Material and methods: Thirty-eight patients with liver cancer who underwent trans-arterial radioembolization (TARE) in
our site between 2011 and 2015 were evaluated. Twenty-four men
(63.2%) and 14 women (36.8%) with age range from 39 to 79 years
(mean=59.1 years) were included. All pre-procedural cross-sectional
imaging findings, as well as president -TARE angiographic study
findings were assessed. Results were cross-referenced with the gold
standard Tc-99m MAA nuclear medicine (NM) scan.
Results: Seventeen (44.7%) patients demonstrating heterogenous
complex lesions showed pulmonary shunting up to 23.1% (mean=
9.5%) compared to 15.4% (mean= 5.6%) shunting in the homogeneous group of 21 patients (55.3%).
Angiographically visible AV shunting was observed in 19 patients
(50%). Mild, moderate, and severe angiographically detectable arterio-venous shunts are associated with mean Tc-99m MAA NM tumorto-lung shunting of 7.3%, 8%, and 13.4%, respectively.
Tumors smaller than 6.4 cm (study mean tumor size) depicted mean
pulmonary shunting of 3.2%, while tumors equal to or larger than
6.4 cm demonstrated AV shunt averaging at 8.5%.
Conclusion: Angiographically visible AV shunting proves the best
predictor to tumor-pulmonary shunting. The tumor complexity, heterogeneity, as well as increased size on cross-sectional imaging positively correlate with increased radioactivity shunting into the lungs.

P-349

Abstract Book
treatment of EACs in our institute. Complication rate of facial nerve
palsy was seen in 19% of the RADPLAT group and in 62% of the surgery group.
Conclusion: Although the study design was retrospective non-randomized, the therapeutic outcome of RADPLAT for EACs was found
to be equal to that of conventional surgery. Our results indicate that
higher organ preservation with equal survival can be achieved by
RADPLAT in the treatment for patients with EACs.

P-350
Transarterial chemoembolization with 40-m drug-eluting
beads for treatment of hepatocellular carcinoma
G.Greco1, T.Cascella1, F.G.Greco1, G.Calareso1, M.Vaiani1,
A.Casale1, A.V.Marchian1, R.Lanocita1, C.Morosi1, R.Nani2,
C.Spreafico1
1Interventional Radiology, Instituto Nazionale Tumori, Milan, Italy,
2Radiologia, Ospedali Riuniti di Bergamo, Bergamo, Italy
Purpose: The goal of the study was to evaluate the safety and efficacy of a new generation of 40-m particles using transarterial chemoembolization (DEB-TACE) for the primary treatment of HCC not
amenable to curative therapies or as a bridge to orthotopic liver
transplantation (OLT).
Material and methods: Forty-eight consecutive patients were
subjected to TACE with 40-m Embozene Tandem microspheres
pre-loaded with 100 mg of doxorubicin. Response to therapy was
assessed according to RECIST and mRECIST applied to CT or MRI. In
cases of no response/partial response, it has programmed a subsequent treatment cycle within 40 days.
Results: All patients had compensated cirrhosis (ChildPugh < B7).
The objective response rate (CR + PR) of the treated lesions was 71%
and 25%, respectively, according to mRECIST and RECIST criteria.
In 11 patients undergoing OLT, histological exam of the explanted
liver demonstrated a degree of necrosis equal to 100% in 64.2% of
treated nodules (9/14). The TACEs were well tolerated with no major
complications. The overall time to progression (TTP) was 13 months
(11-21).
Conclusion: DEB-TACE with 40-m particles is a safe procedure with
promising results in terms of efficacy in the treatment of HCC not
amenable to curative therapy and as a bridge to transplantation.

Clinical outcome of RADPLAT for external auditory canal

carcinomas: chronological comparison with surgery

P-351

N.Tanaka, A.Kuhara, M.Koganemaru, M.Kusumoto, M.Nabeta,

T.Abe
Radiology, Kurume University School of Medicine, Kurume, Japan

Size of drug-eluting beads does not influence OS in patients

with colorectal liver metastases in a salvage setting. A
retrospective analysis of 167 patients

Purpose: External auditory carcinoma (EAC) is rare entity and consists of less than 1% of head and neck carcinomas. Surgical resection
with or without radiation therapy remains the mainstay of the treatment. However, subtotal or lateral temporal bone resection severely
compromises the quality of life. The purpose of this study was to
chronologically compare survival outcome, organ preservation rate,
and complications between RADPLAT and surgery for EACs in our
institution.
Material and methods: Our RADPLAT protocol consists of concurrent intra-arterial infusion of 100 mg cisplatin four times per week
with radiation therapy of 6070 Gy. Twenty patients with EACs were
treated by extended surgery with/without radiotherapy from 1980
to 2002, and sixteen patients were treated by RADPLAT from 2003
to 2013. Disease-specific survival and organ preservation rates were
chronologically compared.
Results: The 5-year cause-specific survival rate of RADPLAT was 60%
and was statistically equal to that of surgery (53%). Organ preservation rate improved from 14% to 69% after introducing RADPLAT into

S.Pluntke1, C.Schmitt2, M.Stahl2, S.Held3, D.Strumberg4,

R.Dappen5, J.-A.Koch5
1Oncology, Kliniken Essen-Mitte, Essen, Germany, 2Medical Oncology,
Kliniken Essen-Mitte, Essen, Germany, 3Biometrie, ClinAssess GmbH,
Essen, Germany, 4Medical Oncology, Marien Hospital Herne, Herne,
Germany, 5Radiology, Kliniken Essen-Mitte, Essen, Germany
Purpose: DEBTACE with irinotecan-loaded drug-eluting beads
(DEBIRI) has shown activity in colorectal liver metastases. It is not yet
clear whether the size of the beads influences the outcome.
Material and methods: Patients with predominant and life threatening colorectal liver metastases, who were refractory to all drugs
approved for metastasized colorectal cancer, were treated with irinotecan-loaded drug-eluting beads either with a size of 100300
m (DEBIRI) or 70150 m (DEBIRI M1) in this salvage situation.
Results: From February 2011 to December 2015, 167 patients
(108 males/59 females, median age 65 years) were treated with
DEBTACE. Median OS was 27.6 weeks in the DEBIRI cohort (n 87) and
32.6 weeks in the M1 cohort (n 80). This difference in OS was not

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statistically significant (p 0.29). At initial diagnosis, a strong trend in
the M1 cohort toward better survival was seen if the nodal status
was negative (64.1 weeks vs. 31.0 weeks, p 0.063). The trend was also
seen in the DEBIRI cohort (48.3 weeks vs. 26.7 weeks, p 0.11).
Conclusion: DEBIRI in this retrospective analysis showed an encouraging signal in terms of overall survival in a salvage situation of
patients with colorectal liver metastases. OS was not influenced by
the size of the beads. The primary nodal status seems to be a prognostic marker in these patients and may help in patient selection.

P-352
Needle-based confocal laser endomicroscopy (nCLE) during
chemoembolization
P.P.Rao1, I.Enescu2, E.Boatta2, J.Garnon2, G.Tsoumakidou2,
G.Koch2, J.Caudrelier2, R.L.Cazzato2, M.-A.Thenint2, A.Gangi2
1Division of Robotics and Department of Interventional Radiology,
ICube Laboratory and University Hospital of Strasbourg, Strasbourg,
France, 2Interventional Radiology, University Hospital of Strasbourg,
Strasbourg, France
Purpose: To monitor the passage of chemolipiodol (cTACE) emulsion and drug-eluting beads (DEBTACE) into tumors during chemoembolization (TACE). To identify the changes occurring in the tumor
microenvironment during the procedure.
Material and methods: TACE was performed on two patients with
hepatocellular carcinoma: one treated with cTACE (75 mg of doxorubicin in 10 ml of lipiodol) and the other with DEBTACE (75 mg of
doxorubicin in 1 vial of 100300- beads). Patients consented for
nCLE.
The confocal imaging miniprobe (diameter 0.85 mm, FOV 325 m,
resolution 3.5 m, imaging depth 4070 m) was used in conjunction with a coaxial needle (17 gauge). The coaxial needle was positioned in the tumor under ultrasound guidance adjacent to the
artery feeding the tumor. A volume of 2.5 ml of 10% fluorescein was
injected intravenously before endomicroscopic imaging using a 488
nm laser source. nCLE monitoring was performed during TACE.
Results: In the cTACE procedure, the arrival of the emulsion was
noted in the tumor (confirmed on fluoroscopy), with changes seen
in the emulsion droplets over time and drug release from some of
the droplets. Cohesion of the drug containing lipiodol droplets was
observed.
In the DEBDOX patients, few beads were seen in the tumor and the
rest predominantly at the periphery of the lesion.
Post-TACE changes seen in the tumor microenvironment were different in both the types of TACE procedures.
Conclusion: nCLE is effective in identifying drug delivery into the
tumor environment and changes thereafter. It can be an important tool to monitor quality of drug delivery and to optimize TACE
procedures.

P-353
Needle-based confocal laser endomicroscopy during
cryoablation
P.P.Rao1, G.Koch2, J.Garnon2, G.Tsoumakidou2, R.L.Cazzato2,
J.Caudrelier2, M.-A.Thenint2, A.Gangi2
1Division of Robotics and Department of Interventional Radiology,
ICube Laboratory and University Hospital of Strasbourg, Strasbourg,
France, 2Interventional Radiology, University Hospital of Strasbourg,
Strasbourg, France
Purpose: To monitor cellular and extracellular changes during cryoablation. To check the utility of realtime needle-based confocal laser
endomicroscopy (nCLE) during cryoablation.

SS/FC/HL/HTS/CM
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S275

Material and methods: Two patients, one with metastatic axillary

lymph nodes and second with renal cell carcinoma of the right kidney, were treated with CT scan-guided percutaneous cryoablation.
Both patients consented to nCLE during the procedure.
The confocal imaging miniprobe (diameter 0.85 mm, FOV 325 m,
resolution 3.5 m, imaging depth 40 to 70 m) was used in conjunction with a coaxial needle (17 gauge). The coaxial needle was first
positioned in the lesion under CT scan-guidance adjacent to the
cryoprobes. The miniprobe was then inserted inside the coaxial needle and placed adjacent (renal) and 1.5 cm away (lymphnodes) from
the cryoprobe. A volume of 2.5 ml of 10% fluorescein was injected
intravenously before endomicroscopic imaging using a 488 nm laser
source.
The cellular and extracellular changes occurring during iceball formation and active and passive thaws were recorded.
Results: nCLE was useful to identify malignant cells. nCLE successfully defined the cellular and extracellular changes occuring during the different stages of iceball formation and active and passive
thaws. Extracellular ice, intracellular ice, extracellular fluid flooding, and cell rupture were identified in stages. Loss of tissue and
cell structure was seen at the end of the procedure. Crystal patterns were different in the different tumors and the normal organ.
Complete ablation could be identified.
Conclusion: nCLE can be a useful tool to identify incomplete ablations and also to protect sensitive structures at the periphery. More
studies are needed to confirm the results.

P-354
Assessment of the parenchymal blood volume by C-arm
computed tomography for radioembolization dosimetry
G.Grzinger1, R.Syha1, K.Nikolaou1, C.laFougre2, D.Ketelsen1
1Diagnostic and Interventional Radiology, Eberhard-Karls-University,
Tbingen, Germany, 2Nuclear Medicine, Eberhard-Karls-University,
Tbingen, Germany
Purpose: Aim of the study was to evaluate the impact of parenchymal blood volume (PBV) C-arm CT in transarterial radioembolization
(TARE) planning procedure regarding the appropriateness of angiographic defined liver segmental vascular supply and to determine
the influence of changed target volumes on dose calculation.
Material and methods: A total of 22 consecutive patients (median
age, 62 years) receiving a TARE planning procedure were included
in this retrospective study. Selective angiograms and selective PBV
C-arm CT (right and left liver lobes) were evaluated in a blinded manner regarding segmental hepatic artery variants. Volumetry of target volume and dosimetry of glass and resin microspheres were
performed to compare differences between the angiographic and
C-arm CT-based segmental distribution.
Results: Assignment of segment IV and segment I was appropriate in 91.0% (20/22) and 86.4% (19/22) for angiography and C-arm
CT, respectively. Except one case, all other liver segments were
assigned properly to the left and right hepatic arterial supply. Based
on the mismatch of the angiographic and the C-arm CT approaches,
changes of target volume were evident in 27.3% of patients, resulting in a mean mismatch volume of 9054 ml (range, 51198 ml) and
a percentage of dose differences of 14.2%11.8% and 12.6%10.6%
for the right and 12.5%8.5% and 11.1%7.8% for the left liver lobe
in glass and resin microspheres, respectively.
Conclusion: The C-arm CT approach is superior to the angiographic
approach for the determination of vascular supply of specific liver
segments for dosimetry before radioembolization. Especially, for
unexperienced interventional radiologists or for a complex anatomy, C-arm CT improves individualized dosimetry concepts.

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P-355
Transrectal ultrasound-guided prostate fiducial marker
placement for image-guided radiotherapy in prostate cancer:
safety and efficacy based on a single-centre experience
C.M.Chu1, E.Dai1, D.Poon2, W.Tsang2, M.Kam2
1Department of Imaging and Interventional Radiology, Prince of
Wales Hospital, Hong Kong, Hong Kong PRC, 2Department of Clinical
Oncology, Prince of Wales Hospital, Hong Kong, Hong Kong PRC
Purpose: Use of fiducial markers to guide accurate prostate localisation during image-guided radiotherapy (IGRT) is now a standard
practice. We aimed to evaluate the technique, efficacy and safety of
TRUS-guided prostate fiducial marker placement at our institution.
Material and methods: Medical records of patients who underwent TRUS-guided prostate fiducial marker placement (20092015)
were reviewed. Three gold markers (IZI Medical) were placed, two
on the right apex and base and one on the left base. Post-procedure
US (all 133) and CT/MRI (78) were available to confirm marker positioning. Complications were recorded.
Results: In total, 133 men with mean age 70.5 years (range 5579),
mean PSA 10.8 (range 1.127.7), mean Gleason score 6.1 (range 57)
and clinical stage range T1bT3b underwent prostate fiducial marker
placement and then radiotherapy (RT). One patient was excluded
due to bony metastasis and another died of pneumonia before RT.
Eleven (8%) men had previously undergone TURP. Mean prostate
volume was 44.8 ml (range 10.6144.0). In total, 120 patients (92%)
underwent intensity-modulated radiotherapy. Eleven patients (8%)
underwent stereotactic body radiotherapy. All patients received
sedativeanalgesic premedication.
Malposition of 1 marker suspected based on US in 2 patients led to
an additional marker placement in 1 patient, but a subsequent MRI
confirmed all markers in situ in both patients. No patients required
additional prostate localisation during the period of RT.
Post-procedure culture-positive urinary-tract infection required
oral antibiotics in 1 patient (0.8%) and intravenous antibiotics in 6
patients (4.5%). Mild hematuria per rectal bleeding was observed
in 11 (8%) patients, and acute urinary retention was observed in 3
(2.3%) patients.
Conclusion: TRUS-guided prostate fiducial marker placement is
a safe and effective procedure, which facilitates accurate prostate
localisation for IGRT in the treatment of prostate cancer.

P-356
Detection of local tumorrecurrence by parenchymal blood
volume (PBV) mappingusing cone beam CT (DynaCT)after
transarterial chemoembolization of hepatocellular carcinoma
J.D.Kim, N.R.Kim, H.Y.Han, H.J.Kim, S.Y.Choi
Radiology, Eulji University Hospital, Daejeon, Korea
WITHDRAWN

P-357
Microwave ablation of hepatic lesions at challenging locations
V.D.VoChieu, F.Wacker, H.-J.Raatschen, K.I.Ringe
Department of Diagnostic and Interventional Radiology, Hannover
Medical School, Hannover, Germany
Purpose: To assess the feasibility and outcome of microwave ablation (MWA) of hepatic lesions at challenging locations.
Material and methods: In total, 67 patients referred for CT-guided
MWA were included in this retrospective IRB-approved study. A total
of 101 lesions (size 209 mm) were identified with either subcapsular (n=73) location or the necessity of a transpleural approach (n=43).
Technical success, outcome, and complications were evaluated on a

Abstract Book
per-lesion basis. Risk factors (tumor characteristics, coagulation status, and number of punctures and ablations) were analyzed using
univariate analysis (p<0.05 was deemed significant).
Results: In subcapsular locations, complications occurred in 14/73
lesions, including subcapsular hematoma in 11% (8/73) and pneumothorax in 8.2% (6/73) with majority of the cases falling into category A or B according to the SIR classification of complications by
outcome with only one case necessitating chest-tube placement.
Complications in lesions requiring a transpleural approach (23/43)
included pneumothorax in 39.5% (17/43) with 4 requiring chest-tube
placement and subcapsular hematoma in 14% (6/43). The number of
ablation positions per lesion and the thrombocyte count were significant risk (p<0.05) factors with regard to the occurrence of complications, while total ablation time, tumor entity, and lesion diameter were not. No significant effect on local tumor progression was
observed regarding subcapsular localization, transpleural approach,
or tumor diameter.
Conclusion: MWA of subcapsular lesions and subdiaphragmal
lesions requiring a transpleural approach is challenging and should
be performed with utmost care. As severe complications are rare,
CT-guided ablation of these challenging lesions seems to be feasible and safe.

P-358
Accuracy evaluation of microwave ablation with the Covidien
Emprint system in hepatocellular carcinoma: do expected
volumes correlate with in vivo results
S.Venkat1, T.Froud1, N.Salas2, A.Checkver1, G.Guerrero1,
R.Lencioni1, G.Narayanan1
1Radiology, University of Miami, Miami, FL, United States of America,
2Biomedical Engineering, University of Miami, Coral Gables, FL, United
States of America
Purpose: To compare the accuracy of expected results with that
of in vivo microwave ablation of HCC using the Covidien Emprint
system.
Material and methods: A retrospective review of an IRB approved
database of a single-center experience from June 2014 to September
2015 yielded 12 patients with hepatocellular carcinoma (HCC) having a total of 18 lesions, who underwent microwave ablation with
the Covidien Emprint system. The mean patient age was 67.0 (56.2
79.3) years with 2 women and 10 men. The volumes pre- and postablation were calculated using the volume of ellipsoid and recorded
along with 3-axis imaging measurements from immediate pre/post
procedure CECT. The expected volumes were derived from the manufacturers thermosphere chart. Imaging response was evaluated
using modified response evaluation criteria in solid tumors (mRECIST). Statistical analysis was performed using SPSS 22 and a paired
t-test.
Results: Pre-ablation lesion measurements averaged (AP ML
CC) 3.8 3.4 3.7 cm with an average volume of 40.9 cm3. Average
expected ablation zones were 4.4 4.1 4.3 cm with an average
volume of 42.2 cm3. Actual ablation zones averaged 4.6 3.9 4.2
with an average volume of 44.1 cm3. Dimension % difference is (AP,
ML, and CC) 12.4% (p=0.381), 13.2% (p=0.199), and 14.3% (p=.355),
respectively, with a volume % difference of 35.8% (p=.717).
Conclusion: Using the Covidien Emprint system demonstrated that
actual ablation zones were not significantly different from those
expected, resulting in predictable and reliable ablations. Given the
small sample size, a further study is warranted.

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P-359
Safety and efficacy of the Hansen Medical 6-Fr Magellan
catheter in robotically-assisted pelvic and visceral
embolization: comparison between two catheter designs
C.DelGiudice, O.Pellerin, G.Amouyal, C.Dan, M.R.Sapoval
Vascular and Oncological Interventional Radiology, Hpital Europen
Georges Pompidou, Universit Paris Descartes, Paris, France
Purpose: To evaluate the safety and efficacy of two designs of the
Hansen Medical 6-Fr Magellan catheter in performing roboticallyassisted pelvic and visceral embolization.
Material and methods: From April 2014 to June 2015, 35 patients
(22 female and 13 male; mean age 53.512.3 years) underwent
robotically-assisted pelvic or hepatic embolization using the Hansen
Medical 6-Fr Magellan catheter. The procedure types included 26
pelvic embolizations, 8 transarterial chemoembolizations (TACEs),
and 1 type II endoleak embolization.
Twenty-five procedures were performed using the first-generation
Hansen Medical 6-Fr Magellan catheter (group 1), and 10 procedures
were performed using the second-generation catheter (group 2).
Results: Technical success, robotic cannulation, and target embolization were achieved in 91.4% or 32 of 35 patients. Three patients
(group 1) required conversion to manual treatment due to inability to cannulate. All patients in group 2 achieved technical success.
No differences were observed in the set-up and preparation time to
assemble the system (7.92.2 min in group 1 vs. 82.3 min in group
2), fluoroscopy time (28.92.6 min in group 1 vs. 285.2 min in group
2), and procedure time (69.75.3 min in group 1 vs. 78.110.7 min
in group 2). Three minor adverse events occurred; all of them were
observed in group 1: 2 minor dissections and 1 hematoma.
Conclusion: The use of the Hansen Medical 6-Fr Magellan catheter in embolization is safe and effective. The second-generation 6-Fr
catheter, with an improved articulating distal section, reduced the
risk of vessel dissection, permitted faster interventions, and reduced
patient risk. Further experience is needed to demonstrate statistically significant results.

P-360
Double-combined treatment of intermediate-size HCC:
preliminary results in 31 patients
A.Vit1, S.Cannizzaro2, A.Pellegrin1, V.Gavrilovic1, P.Divis2,
M.Sponza1
1Interventional Radiology, University Hospital Santa Maria della
Misericordia, Udine, Italy, 2Institute of Diagnostic Radiology, University
of Udine, University Hospital Santa Maria della Misericordia, Udine,
Italy
Purpose: To assess hte efficacy and safety of double-combined
treatment performed during a single session (TACE+percutaneous
termoablation) in intermediate-size HCC.
Material and methods: Retrospective evaluation of 31 patients
(mean age 74.2 26/5 M/F) enrolled for HCC treatment in a single
center during 5 years (June 2009September 2014). All patients presented with intermediate-size HCC (35 cm), single lesion (mean size
36.2 5.3 mm sD), functional class Child A, no secondary lesions; not
suitable for surgical therapy.
The procedure was performed in a single session. The patient underwent segmental selective cTACE (lipiodol+doxorubicine) until stasis was obtained, percutaneous termoablation (RF 21 patients, 250
W MW 10 patients, mean power 57 W), ultrasound, and fluoroscopic
guidance, followed by additional TACE the total dose was up to 15
mL lipiodol and 50 mg doxorubicine.
Follow-up was performed with CT or MR at 1 month, 6 month, and
12 months complete response or local recurrence was defined as
the disappearance of any intratumoral arterial enhancement in the
target lesion at CT or MR.

SS/FC/HL/HTS/CM
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S277

Results: Five patients were excluded from the follow-up because 1

patient underwent liver transplantation 6 months after treatment
and 4 died within 1 year from treatment. Complete ablation was
reported at 1 month in 26/26 patients, while complete devascularization was reported at 6 months in 26/26 patients and at 12 months
in 23/26 patients.
Post-procedural complications were noticed in 2/31 patients: 1
major (transdiaphragmatic fistula) and 1 unnerelated (patient
deceased 4 days later because of bowel obstruction).
Conclusion: In this series, rates of complete ablation at 1 month
caused devascularization at 6 months and 12 months in most cases.
Complication rates were similar to those of the combined treatment
technique described in literature.

P-361
Comparison of microwave vs. radiofrequency ablation of HCC
when combined with DEB-TACE: progression-free and overall
survival analysis
R.J.Durrani1, D.M.Biederman1, J.S.Virk1, E.Dayan1, R.Patel2,
A.Fischman3, F.S.Nowakowski3, R.A.Lookstein2, E.Kim2
1Department of Vascular and Interventional Radiology, Icahn School
of Medicine at Mount Sinai, New York, NY, United States of America,
2Interventional Radiology, Mount Sinai Medical Center, New York, NY,
United States of America, 3Radiology and Surgery, Mount Sinai Medical
Center, New York, NY, United States of America
Purpose: To compare the efficacy and outcomes of chemoembolization combined with radiofrequency ablation (TACE-RFA) and chemoembolization combined with microwave ablation (TACE-MWA)
in the treatment of patients with unresectable hepatocellular carcinoma (HCC).
Material and methods: A retrospective review conducted from
4/2011 to 1/2014 identified a total of 197 patients treated with
TACE-MWA (Neuwave, WI) and 84 patients treated with TACERFA (Angiodynamics, NY). TACE was performed using LC Beads
(Biocompatibles, UK) loaded with doxorubicin in all cases. Patients
included in the study were ablation nave and had unresectable HCC
without metastatic disease. Outcomes analyzed included imaging
response (mRECIST), incidence of local recurrence, time-to-progression (TTP), and survival.
Results: A total of 168 patients met the inclusion criteria (TACE-RFA:
49, TACE-MWA: 119). The median (IQR) tumor size was 2.0 (1.32.5)
cm in the TACE-RFA group and 2.0 (1.32.4) cm in the TACE-MWA
group (p=0.9). The initial complete response rate was 82.5% for
TACE-MWA and 89.4% for TACE-RFA (p=0.3). Disease progression
occurred in 94 cases (MWA: 67; RFA: 27). Local tumor recurrence after
the initial complete response was observed in 20% of MWA (14/67)
and 48% of RFA cases (13/27) (p=0.01). The median (95% CI) TTP (m)
was 11.3 (7.717.3) in the TACE-MWA group and 15.9 (7.932.9) in the
TACE-RFA group (p=0.4). The mean survival (m) was 41.1 in the TACEMWA group and 37.4 in the TACE-RFA group (p=0.6).
Conclusion: There was no significant difference in the objective
response, TTP, or survival between the TACE-RFA and TACE-MWA
groups. A lower incidence of local tumor recurrence was observed in
the TACE-MWA group.

P-362
Evaluation of robot-assisted irreversible electroporation of
malignant hepatic tumors: first results
L.P.Beyer, C.Niessen, B.Pregler, C.Stroszczynski, P.Wiggermann
Department of Radiology, University Hospital Regensburg, Regensburg,
Germany
Purpose: To compare and evaluate the placement accuracy of
IRE electrodes, procedural time and ablation success using a new
CT-based robot-assisted approach and a CT fluoroscopy-guided
manual approach.

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Material and methods: We retrospectively analysed 34 IRE procedures in 33 patients (3 women, 30 men, mean age 61 years).
Seventeen IRE procedures were performed under robotic guidance, and the other 17 were performed under manual guidance. All
patients underwent 6-week follow-up examinations, including ultrasound, computed tomography and MR imaging.
Results: The mean deviation of the IRE electrodes compared with a
reference electrode, as measured by the last 3 cm, was significantly
reduced under robotic guidance (2.3 mm, range 0.04.0 mm, SD 1.0)
than under manual guidance (3.3 mm, range 0.26.2 mm, SD 1.2; p <
0,001). The total procedure time from the preinterventional planning
CT scan to the beginning of ablation was significantly lower under
robotic guidance (45.3 min, range 2864 min, SD 12.1) than under
manual guidance (81.3 min, range 48118 min, SD 22.1; p = 0,007).
Follow-up after 6 weeks showed complete ablation in all 17 (100%)
robot-assisted IRE cases and in 16 out of 17 (94.1%) manual IRE cases.
Conclusion: The robot-assisted approach for irreversible electroporation of malignant hepatic tumors is in the ascendancy over the
CT fluoroscopy-guided manual approach in terms of the parallelism
of the IRE electrodes and the procedural time. Complete ablation
succeeded in all cases, except for one in the manual-guided group.

P-363
Prospective evaluation of stereotactic percutaneous
irreversible electroporation of malignant hepatic tumors
L.P.Beyer, C.Niessen, B.Pregler, C.Stroszczynski, P.Wiggermann
Department of Radiology, University Hospital Regensburg, Regensburg,
Germany

Abstract Book
(n=35) and secondary (n=36) hepatic cancer were treated. Survival
analyses was performed according to the KaplanMeier method,
and proportional hazards were calculated after a mean follow-up of
19.9 months.
Results: The overall survival was 26.3 months. There were no significant differences between both groups regarding the underlying tumour. Patients with more than 2 lesions (median survival
12.4 months vs. 32.8 months) or lesions 3 cm (median survival
9.5 months vs. median not reached) showed a significantly shorter
survival.
Conclusion: Depending on tumour size (<3 cm) and the number of
lesions (<3), IRE showed promising results regarding overall survival.

P-365
Laparoscopic ultrasound-guided radiofrequency ablation of
hepatic tumors
M.-C.Chern1, C.-W.Lin2, T.-J.Tsai2
1Diagnostic Radiology, Sun Yat-Sen Cancer Center, Taipei, Taiwan,
2Department of Surgery, Sun Yat-Sen Cancer Center, Taipei, Taiwan
Purpose: To evaluate the safety and efficacy of laparoscopic ultrasound-guided radiofrequency ablation (LURFA) in hepatic tumors
that are difficult or impossible to be curatively treated with the percutaneous approach or in severe hepatic disease.
Material and methods: From April 2011 to December 2015, 56
patients with liver tumors (33 hepatocellular carcinamas and 23 metastatic colorectal cancers), which were not feasible to be treated by
percutaneous radiofrequency ablation or surgical resection, were
ablated by LURFA. Patients who underwent concurrent liver resection were excluded. Image modalities for the follow-up were CT
or MRI. Local recurrence was defined as radiographic evidence of
recurrent disease in direct contact with the prior ablation site.
Results: Eighty tumors with a mean diameter of 24 mm (1340 mm)
in 56 patients (1.4 lesions/patient) were successfully treated. Over
a median follow-up period of 24 months (range, 6 to 56.5 months),
KaplanMeier analysis demonstrated that the local recurrence-free
rate was 92.8% and the overall recurrence rate was 43.6%. One- and
3-year survival rates were 100% and 73.8%, respectively. The mean
hospital stay was 4 days (range 410 days). There were no >grade 2
adverse events in patients; only one patient had a liver abscess with
drainage (grade 3) (National Cancer Institute Common Terminology
Criteria for Adverse Events, Grade 15).
Conclusion: Laparoscopic ultrasound-guided radiofrequency ablation is a safe and effective treatment for hepatic tumors, especially
in difficult ablation areas. LURFA combines the advantage (assessing all segments of liver, protecting surrounding viscera and aggressive ablation) of a minimally invasive procedure and has a low local
recurrence rate.

Purpose: Evaluation of a CT-based 3-dimensional stereotactic guidance for planning and placement of electrodes during irreversible
electroporation (IRE) of malignant hepatic lesions.
Material and methods: This prospective study included 10 IRE procedures using 34 electrodes in 10 patients (all men, mean age 73
years). All electrodes were placed using the CT-based optical tracking system. All patients underwent follow-up examination after
6 weeks, including ultrasound, computed tomography, and MR
imaging.
Results: The mean planning time in the 3-dimensional CT dataset
for each patient was 14 minutes. Placement of the IRE electrodes
took 27 minutes on average. In 3 out of 10 cases, manual repositioning of 1 IRE probe after a verification scan was necessary. In the follow-up after 6 weeks, complete ablation without residual tumor was
observed in 9 cases. In the remaining case, only partial ablation was
achieved. No complications occurred.
Conclusion: CT-based 3-dimensional navigation systems allow a
fast and safe placement of electrodes for IRE of malignant hepatic
tumors. More studies comparing CT-based navigation systems and
manual CT guidance using fluoroscopy for procedure planning and
electrode placement are warranted to evaluate the efficacy of stereotactic guidance.

P-366

P-364

Surgical resection versus radiofrequency ablation plus drugeluting bead transcatheter arterial chemoembolisation in the
treatment of single large hepatocellular carcinoma

Impact of tumour size on long-term survival after irreversible

electroporation of malignant hepatic tumours
C.Niessen, L.P.Beyer, C.Stroszczynski, P.Wiggermann
Department of Radiology, University Hospital Regensburg, Regensburg,
Germany
Purpose: To evaluate the impact of tumour size on long-term survival after percutaneous irreversible electroporation (IRE) of primary
and secondary malignant hepatic cancer unsuitable for resection or
thermal ablation.
Material and methods: In this prospective single-centre study,
71 patients (57 men, 14 women, mean age 65 years) with primary

A.Posa1, R.Iezzi1, G.Coppola1, E.G.M.Antonuccio1, A.Gasbarrini2,

L.Bonomo1
1Department of Radiological Sciences, Institute of Radiology,
A. Gemelli Hospital - Catholic University, Rome, Italy, 2Department
of Internal Medicine, A. Gemelli Hospital - Catholic University, Rome,
Italy
Purpose: To compare hepatic resection (RES) and single-step combined therapy with radiofrequency ablation and drug-eluting bead
transarterial chemoembolisation (RFA + TACE) in patients with single
hepatocellular carcinoma (HCC) of >3 cm and compensated cirrhosis. Primary endpoints were overall survival (OS) and tumour recurrence (TR) rates.

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Material and methods: This retrospective study involved 56 Child
Pugh A cirrhotic patients (25 RES, 33 RFA+TACE) with single HCC
observed between 2010 and 2014 in our centre. All the patients did
not show macroscopic vascular invasion and/or extrahepatic tumour
spreading before treatment. The treatment choice was made after
multidisciplinary evaluation. RFA+TACE was performed using a single-step procedure (RFA during balloon occlusion of the tumourfeeding artery, followed by TACE). Cumulative OS and TR rates were
analysed using the KaplanMeier method.
Results: The median follow-up period was 16.5 months. The median
HCC size was 4.5 cm in the RES group (range 37.4 cm) and 4 cm in
RFA+TACE group (range 36.8 cm). Demographic, clinical and laboratory parameters as well as treatment-related complications did
not significantly differ between groups. OS rates at 13 years were
91.8%75.2% in the RES group and 86.3%61.6% in the RFA+TACE
group. Overall TR rates at 13 years were significantly lower in
resected patients (RES 32.7%42.3%, RFA+TACE 43%74.7%). Both
3-year local tumour progression (RES 31.1%, RFA+TACE 74.6%) and
distant intrahepatic recurrence (RES 34.8%, RFA+TACE 77.0%) were
significantly higher in the RFA+TACE group.
Conclusion: RES seems to be the choice of treatment in compensated cirrhotic patients with single HCC of >3 cm. One-step combined RFA+TACE treatment is an effective alternative therapeutic option in patients not suitable for RES after multidisciplinary
evaluation.

P-367
Single-step treatment with combined radiofrequency and
embolization in hepatocellular carcinoma: 14-year prospective
study
J.Urbano, M.Cabrera-Gnzalez, A.Alonso-Burgos, L.Paul-Ferrer
Vascular & Interventional Radiology, Jimnez Daz Foundation
University Hospital, Madrid, Spain
Purpose: We show our results of combined treatment with radiofrequency and embolization in non-surgical HCC.
Material and methods: Institutional review board approval was
obtained, and all patients signed informed consent. Between July
2001 and January 2016, we prospectively included 154 consecutive patients with HCC for simultaneous combined treatment with
RF and embolization: 102 men and 52 women with an average age
of 67.4 years, range (4385). Patients ChildPugh was B-7 or less.
Tumor size ranged form 15 to 150 mm. For tumors < 3 cm, we combined RF and TAE. For recurrences of any size and for tumors > 3 cm,
we combined RF and TAQE. We do not rule out RF in any subdiaphragmatic, subcapsular or yuxtavascular tumor location. Response
was evaluated according mRECIST criteria. The survival curves were
constructed using the KaplanMeier method and compared using
the log-rank test. R program was used for statistical analysis.
Results: Complete response for <3 cm, 3 to 5 cm and > 5 cm tumors
was 100%, 79,6% and 42,9%, respectively. Distant recurrence was
36.4%. The median survival was 37 months. The 1-, 2-, 3-, 5-, 8-, 10and 14-year overall survival was 92%, 77%, 62%, 42%, 31%, 11% and
0%. Histopathological differentiation (p=0.0079), ChildPugh score
(p=0.0003), initial response (p=0.0161), tumor size (p= 0.0073) and
number of tumors (p=0.0122) were significant prognostic factors for
survival. Major complications were 6.9% and 0.88% mortality.
Conclusion: Single-step combined therapy increases the volume
and intensity of ablation, enabling a better response and fewer
recurrences. The association of embolization & radiofrequency is
safe. There is a trend toward survival improvement.

SS/FC/HL/HTS/CM
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P-368
Comparison of thermal ablation and partial nephrectomy
for the treatment of renal cell carcinoma in the surveillance,
epidemiology, and end results (SEER) database population
O.Mironov1, A.Jaberi1, J.R.Kachura2
1Department of Medical Imaging, University of Toronto - University
Health Network, Toronto, ON, Canada, 2Medical Imaging, Toronto
General Hospital, Toronto, ON, Canada
Purpose: The effectiveness of thermal ablation for small renal cell
carcinoma (RCC) compared to surgical resection continues to be
debated. The purpose of this study was to review data collected by
SEER to compare the effectiveness of thermal ablation (TA) with that
of surgical resection (SR) for the treatment of small RCC.
Material and methods: SEER data was searched for records of
patients with a histological diagnosis of (4 cm) RCC who underwent either partial nephrectomy or TA. Tumor size and patient age
were compared between groups using the MannWhitney U test.
Comparison of survival was made using log-rank test. Cox regression was used to adjust for age at diagnosis.
Results: In total, 383 patients underwent TA and 4057 underwent SR. TA patients were on average significantly older (69.911.4
vs. 58.712.7 years; p<0.001). Mean tumor size was 2.5 cm for both
groups (p=0.819). Median follow-up was 55.81.7 months for the TA
group and 51.70.5 months for the SR group.
Univariate analysis demonstrated a significant difference in
observed survival (SR 98.20.5 vs. TA 83.82.3 months; p<0.001)
and disease specific survival (SR 105.90.2 vs. TA 103.41.2 months;
p=0.001). After adjusting for age, there was no significant difference
in observed survival (TA hazard ratio 5.047; 95% CI 0.82131.032;
p=0.089) or disease specific survival (TA hazard ratio 0.405; 95% CI
0.001117.592; p=0.755).
Conclusion: Older patients are more likely to undergo TA than SR.
There is no significant difference in age-adjusted observed or disease-specific survival between partial nephrectomy and TA for
<=4cm RCCs.

P-369
Toward personalized radioembolization with glass
microspheres: an examination of new Yttrium-90 glasses with
intrinsic radiopacity
X.F.Zhang1, M.Bligh2, F.Heelan1, J.Fraser1, E.Tonkopi2, G.Mawko2,
J.Clarke2, D.Liu3, R.J.Lewandowski4, S.C.Goodwin5, R.Abraham2,
D.Boyd6, S.Kehoe7
1Research and Development, ABK Biomedical Inc., Halifax, NS,
Canada, 2Diagnostic Imaging and Interventional Radiology, QE II
Health Sciences Centre/Dalhousie University, Halifax, NS, Canada,
3Interventional Radiology, Vancouver General Hospital, Vancouver,
BC, Canada, 4Interventional Radiology, Northwestern University,
Chicago, IL, United States of America, 5Department of Radiology, UCI
Medical Center, Orange, CA, United States of America, 6Department of
Applied Oral Sciences and School of Biomedical Engineering, Dalhousie
University, Halifax, NS, Canada, 7Research and Development / Applied
Oral Sciences, ABK Biomedical Inc. / Dalhousie University, Halifax, NS,
Canada
Purpose: To establish compositionproperty relationships (durability, cytotoxicity to healthy tissue, CT radiopacity and neutron activation reaction products) for novel Y-90 microspheres.
Material and methods: Yttriumstrontiumgalliumsilicate (YSGS)
oxide glass microspheres were evaluated using experimental
design. Chemical durability and cytotoxicity were determined via
the extracts derived (0.2 g/mL) in physiological medium between
1 and 21 days. Ionic concentrations (Y, Sr, and Ga) were ascertained
via inductively coupled plasma atomic emission spectroscopy

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(Perkin Elmer Optima7300). CT radiopacity was evaluated at 70 kVp

(Siemens Definition AS+ Scanner). Radioisotope profiles were determined via neutron activation under production conditions (1 g mass
with thermal neutron flux value of 2 1014n/cm2s over 24, 72, and
168 h). Exposure rates from radionuclidic activation products were
calculated to determine potential cumulative doses to the public.
Composition was subsequently modulated to maximize durability
and CT radiopacity whilst minimizing cytotoxicity and radioactive
reaction products.
Results: Durability was verified with Y, Sr, and Ga ion release not
exceeding 2.1830.133 ppm, 1.990.079 ppm, and 4.8530.270
ppm, respectively. Reducing compositional interactions between
Y2O3 and Ga2O3enhanced compatibility to normal tissue by 70%.
CT radiopacity from 13,664516 HU to 17,835355 HU was observed
by primarily enhancing SrCO3and Y2O3. Radionuclidic purity (RNP)
of >95% Y-90 was reached c.5 days post-irradiation with acceptable
public dose levels from Ga-72 and Sr-85 reaction products. A bestin-class (BIC) composition that satisfied the pre-determined design
criterion was subsequently determined.
Conclusion: A BIC Y-90 glass microsphere with significant radiopacity and durability, which also exhibits acceptable public radiation
exposure for outpatient therapy, has been identified in this work.

P-370
Differences in patient characteristics and long-term
outcomes between European and Asian patients treated with
radiofrequency ablation for hepatocellular carcinoma
M.C.Burgmans1, C.W.Too2, M.Fiocco3, A.Kerbert4, J.Schaapman1,
M.Coenraad4, A.R.vanErkel1, B.S.Tan2
1Radiology, Leiden University Medical Center, Leiden, Netherlands,
2Radiology, Singapore General Hospital, Singapore, Singapore,
3Statistics, Leiden University Medical Center, Leiden, Netherlands,
4Hepatology, Leiden University Medical Center, Leiden, Netherlands
Purpose: To compare patient characteristics and long-term outcomes after RFA for unresectable HCC between Asian and European
cohorts.
Material and methods: Retrospective analysis of 279 patients
(mean 64.8 12.1 years; 208 males) treated with RFA because of
newly diagnosed HCC in tertiary referral centers at Singapore and
the Netherlands. Median follow-up was 28.2 months (quartile: 13.1
40.5 months). Cumulative incidences of recurrence and death were
analyzed using a competing risk model.
Results: Age was significantly higher in the Asian cohort: 66.5 years
versus 60.1 years (p < 0.0001). The most common underlying liver
disease was chronic hepatitis B in the Asian cohort (48.0%) and alcoholic liver cirrhosis in the European cohort (54.4%) (p < 0.001). Asian
patients had less advanced disease: 35.5%, 55.0%, and 3.0%, respectively, had BCLC 0, A, and B; among the European patients, 21.5%,
58.2%, and 15.2%, respectively, had BCLC 0, A, and B (p = 0.01). The
cumulative incidence of recurrence in the Asian cohort at 1, 2, 3, and
5 years was 37.0%, 56.4%, 62.3%, and 67.7%, respectively, and that
in the European cohort was 32.6%, 47.2%, 49.7%, and 53.4%, respectively (p = 0.474). At 1, 2, 3, and 5 years the cumulative incidence of
death in the Asian cohort was 2.0%, 3.9%, 4.9%, and 4.9%, respectively, and that in the European cohort was 7.7%, 9.2%, 14.1%, and
21.0%, respectively (p = 0.155).
Conclusion: Similar short-term treatment outcomes are achieved
with RFA in HCC patients among southeast Asian and northern
European populations. Long-term recurrence and death rates differ between the cohorts as a result of differences in baseline patient
characteristics and selection. Our study provides insight relevant to
the design of future international studies.

Abstract Book

P-371
Safety of Y90 radioembolization after prior hemihepatectomy
M.Zimmermann, M.Liebl, M.F.Schulze-Hagen, F.Pedersoli,
P.Isfort, C.Kuhl, P.Bruners
Department of Diagnostic and Interventional Radiology, RWTH Aachen
University Hospital, Aachen, Germany
Purpose: To evaluate the safety of selective internal radiation therapy (SIRT) after prior (extended) hemihepatectomy.
Material and methods: In this single-center retrospective study, 12
patients who underwent SIRT for treatment of hepatic malignancies
after prior (extended) right (7/12) or left (5/12) hemihepatectomy
were reviewed. Six patients received lobar radioembolization, i.e.,
the whole liver remnant was treated during a single session, whereas
the remaining six patients were treated with segmental radioembolization during two to three sessions at 12-month intervals.
Patient data were analyzed with regard to the signs of progressive
hepatic dysfunction (increase in serum bilirubin, AST, ALT, and INR
and decrease in serum albumin and progressive development of
ascites) during a minimum follow-up period of 1 month after SIRT.
Results: Eleven out of 12 patients did not show any signs of hepatic
dysfunction following SIRT of the remnant liver.
One patient (1/12) developed signs of radioembolization-induced
liver dysfunction (REILD) 3 months after SIRT, with total serum bilirubin levels of 20 mg/dl and progressive ascites in the absence of
tumor progression. The cumulative administered radiation dose in
this patient was 2.8 Gbq (distributed over 2 therapy sessions), which
by far exceeded the average administered radiation dose among all
patients (1.65 Gbq).
Conclusion: SIRT after prior hemihepatectomy can generally be
considered as safe; however, the radiation dose needs to be carefully
considered to prevent overdosing due to the reduced volume of the
remnant liver.

P-372
The benefits of a new method of chemoembolization for
pancreatic cancer
E.Khayrutdinov, A.Arablinskiy, V.Tsurkan
Interventional Radiology, Botkin Hospital, Moscow, Russian Federation
Purpose: The main purpose of this study was to evaluate the efficacy, safety, and benefits of a new method of chemoembolization
for pancreatic cancer.
Material and methods: A new method of oidized oil chemoembolization for pancreatic cancer was developed. The methods description is as follows. Consecutive catheterization of the celiac artery
and proximal segment of the gastroduodenal artery was followed by
conduction of the coronary wire into the right gastroepiploic artery.
Position and inflation of the balloon catheter were distal to the place
of the origin of the arteries that supply the pancreatic tumor. When
the blood flow in the right gastroepiploic artery stopped, we started
chemoembolization through the diagnostic catheter located in the
proximal segment of the gastroduodenal artery. At the end of the
procedure, the balloon catheter was deflated and removed.
Thirty patients were enrolled in our study: 14 underwent the new
method and 16 underwent the standard method. Clinical characteristics of the patients were comparable between the two groups.
Results: Embolization procedures were successfully performed in all
patients. The duration of the procedure (36.3 and 63.4 min, p<0.05)
and radiation exposure (0.41 and 0.78 mZv, p<0.05) were significantly lower in the new method group. There were no complications
in both groups. The mean procedural cost in the new method group
was 3.5 times lower than that in the standard method group.

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Conclusion: The new method of chemoembolization for pancreatic
cancer is effective and safe. Its use promotes reduction of the procedure duration, radiation exposure, and procedural cost.

P-373
Repeated transarterial chemoembolization with degradable
starch microspheres (DSMs-TACE) of unresectable
hepatocellular carcinoma: a prospective pilot study
F.Chegai, S.Merolla, A.Orlacchio
Diagnostic and Molecular Imaging, Radiation Therapy and
Interventional Radiology, University Hospital Policlinico Tor Vergata,
Rome, Italy
Purpose: To evaluate tumor response rates using modified response
evaluation criteria in solid tumors (mRecist) and safety after transarterial chemoembolization (TACE) performed using degradable
starch microspheres (DSMs) for unresectable hepatocellular carcinoma (HCC) treatment.
Material and methods: We prospectively enroled 70 HCC cirrhotic patients (47 male, mean age 66.3 years) to be treated with
repeated DSMs-TACE procedures, performed at 46 week intervals
on the basis of mRecist response and patient tolerance. Lobar technique was used in case of multiple (>3) HCCs in the same lobe, and
when possible, the segmental or subsegmental approach was followed using microcatheter. A different combination of DSMs (225
450 mg EmboCept S) and Doxorubicin (50150 mg on the basis of
body surface 75 mg/m2) was injected. Clinical and biochemical evaluations were performed before and after each procedure. Treatment
response was assessed by computed tomography (CT) or magnetic
resonance imaging (MRI) 46 weeks following each procedure.
Results: A total of 198 DSMs-TACE procedures were performed (2.82
per patient). Complete response (CR) was observed in 20.8%, 37.5%,
and 58.3% patients after one, two, and three procedures, respectively. At the end of each treatment, 80% patients experienced at
least a partial response. At the end of the repeated procedures, no
differences between mono- or bi-lobar disease were observed in CR
(64.2% vs. 50%; p=ns). In most cases, treatment discontinuation was
due to worsening liver function.
Conclusion: DSM-TACE was safe and effective. CR rates were similar between patients with mono- or bi-lobar disease, indicating the
possibility of performing repeated procedures in a safe and effective
way in both types of patients.

P-374
Safety and efficacy of percutaneous renal ablation using a
high-power microwave system
D.K.Filippiadis, G.Velonakis, A.Mazioti, S.Spiliopoulos,
K.Malagari, A.D.Kelekis, N.L.Kelekis
2nd Radiology Department, University General Hospital Attikon,
Athens, Greece
Purpose: Small- to medium-sized renal masses are increasingly
imaged as incidental findings and require a treatment strategy
that preserves renal function and minimizes procedural morbidity. Percutaneous ablation is an expanding, minimally invasive
approach. We prospectively evaluated the safety and efficacy of
microwave ablation in the kidneys using a high-power microwave
system.
Material and methods: We prospectively evaluated 40 patients
undergoing percutaneous microwave ablation for lesion in the kidney with imaging characteristics on the CT and MRI resembling the
renal cell carcinoma using a high power microwave system (AMICA
SYSTEM, HS Rome Italy). Biopsy was performed on the same session with ablation using an 18-G semi-automatic soft tissue biopsy

SS/FC/HL/HTS/CM
Posters

S281

needle. In 1/40 cases, the biopsy specimen revealed inflammatory

myofibroblastic tumor, whilst in the rest 39/40 cases, renal cell carcinoma was biopsy proven. Patient and tumor characteristics, microwave technique, complications, and pattern of recurrence were evaluated. IRB approval was obtained.
Results: Technical success of 97% was achieved for microwave ablation. Average lesion size was 3.1 cm (2.04.3 cm). The 3-year overall survival was 95% (38/40). Local recurrence of 9% was observed.
Recurrences occurred early after ablation (within 12 months) and
delayed (beyond 12 months) with similar frequency. Minor complications, including hematomas, requiring nothing but observation
occurred in 6% of the cases.
Conclusion: Using a high-power microwave system for percutaneous renal ablation is a safe and efficacious policy for the treatment of
small- to medium-sized renal masses. Local recurrence occurs with
similar frequency irrespective of the time frame.

P-375
The relationships between baseline liver function and
perfusion before and after yttrium-90 radioembolization
E.J.Keller1, N.Chatterjee1, T.Carroll1, R.Salem2, A.NemcekJr.2,
R.J.Lewandowski2, J.D.Collins2
1Radiology, Northwestern University, Chicago, IL, United States of
America, 2Interventional Radiology, Northwestern University, Chicago,
IL, United States of America
Purpose: To investigate the relationship between serologic markers and regional liver perfusion before and after targeted yttrium-90
radioembolization (RAE) for hepatocellular carcinoma.
Material and methods: Thirteen prospectively recruited patients
(6711 years, 8 men) with hepatocellular carcinoma and no history
of liver-directed therapy, transjugular intrahepatic shunt placement,
or portal vein thrombosis underwent perfusion imaging using contrast-enhanced MR angiography at 1.5T immediately before and
after targeted Y90 RAE (21 segments treated). Embolized (tumor/
non-tumor) and remote (non-embolized) liver parenchymal perfusion were normalized to patients arterial input functions. Patients
blood counts, chemistries, and alpha-fetoprotein levels (AFPs)
were measured on the day of treatment. Serologic markers were
compared to pre- and post-treatment perfusion via correlation
coefficients.
Results: Average treatment volume and dose were 374234 mL
and 200122 Gy, respectively. Pre-treatment perfusion moderately
correlated with serologic markers of better liver function (low bilirubin, high albumin, and low INR) and less hypersplenism (higher
platelet and leukocyte counts) (r=0.3555, p<0.05). Correlations
between liver function and perfusion were lost (p>0.05) post-treatment whereas markers of hypersplenism remained moderately correlated with perfusion. Changes in embolized liver perfusion did not
exhibit significant relationships with patients lab values, and larger
increases in remote liver perfusion exhibited modest but significant correlations with worse baseline liver function and higher AFPs
(r=0.320.42, p<0.05).
Conclusion: Patients with worse pre-treatment liver function
tended to have less baseline tumor and non-tumor hepatic perfusion as well as larger increases in untreated liver perfusion following
Y90 RAE. Baseline serologic markers of liver function may predict the
effects of Y90 RAE on hepatic perfusion.

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haemoptysis (8.3%), pneumonia (2.1%), pleural effusion (2.1%) and
persistent chest pain (2.1%) were the other complications observed.
Conclusion: CT-guided RFA and MWA of soft-tissue sarcoma lung
metastases is a safe and effective minimally-invasive treatment
option for patients with sarcoma lung metastases. Appropriate
patient selection will maximize the clinical benefit and avoid unnecessary operations.

P-376
Are lung microwave ablations really unpredictable? In vivo
swine tumor-mimic model-based algorithm
L.Tselikas1, C.Teriitehau2, J.Adam3, K.Doassans1, B.Ba2,
G.Gravel2, T.deBare4, F.Deschamps4
1Interventional Radiology, IGR, Villejuif, France, 2Interventional
Radiology, Gustave Roussy, Villejuif, France, 3Pathology, Gustave
Roussy, Villejuif, France, 4Department of Radiology, Gustave Roussy
Cancer Campus, Villejuif, France

P-378

Purpose: To evaluate the size of ablation in the lungs using various

microwave treatment protocols.
Material and methods: All experiments were approved by an institutional care and use committee.
A total of 43 tumor-mimic models measuring 10, 20, or 30 mm were
created in 11 pigs using contrast-enriched thigh muscle injected into
the lungs of the same animal. Tumors were ablated under fluoroscopic and 3D-CBCT guidance using a single microwave antenna.
Continuous and pulse modes were used, keeping treatment duration the same and overall energy deposit equivalent for each tumor
size.
The ablation zones were measured using post-procedural CBCT and
on pathology.
Results: Post-ablation zones measured independently by two radiologists were significantly correlated with macroscopic results: r =
0.75 and 0.74 (p<0.0001) (interobsever correlation r = 0.9).
For 1, 2, and 3 cm tumor-mimic models, mean maximal and transverse ablation diameters were 3.60.3 2.560.45 cm, 4.140.53
2.930.31 cm, and 4.770.29 3.60.28 cm, respectively, using the
continuous mode and 30.17 2.140.19 cm, 3.990.43 2.960.44
cm, and 4.560.41 3.420.49 cm, respectively, using the pulse
mode.
No death occurred during treatment, and 3 pigs presented a pneumothorax requiring chest-tube placement.
Conclusion: Microwave ablation in the lungs is safe and reproducible, and the ablation zones can be evaluated using CBCT imaging.

P-377
CT-guided ablation of soft-tissue sarcoma lung metastases:
safety and oncological outcomes in a comprehensive cancer
centre
N.I.Fotiadis1, T.Oliver2, J.Suntharanathan1, C.Benson2, R.Jones2,
A.Miah2
1Interventional Radiology, The Royal Marsden Hospital, London, United
Kingdom, 2Sarcoma Unit, The Royal Marsden Hospital, London, United
Kingdom
Purpose: To present our results after radiofrequency ablation (RFA)
and microwave ablation (MWA) of soft-tissue sarcoma lung metastases at the largest sarcoma unit in UK.
Material and methods: Between September 2007 and October
2015, 33 consecutive patients (16 men and 17 women), median age
53 years (1783 years), with metastatic soft-tissue sarcoma and a
maximum of six lung lesions were treated with percutaneous ablation. Primary endpoints of the study were local tumour control and
progression-free survival (PFS), and secondary endpoints were complications and overall survival.
Results: A total of 78 metastases, mean size 14.1 mm (3.239 mm),
were treated over 48 ablation sessions (including 10 MWA sessions).
Over a median clinical and imaging follow-up of 21 months (range
368 months), the local control rate was 84.1% and the median
PFS was 9 months (95% CI 517 months). The overall survival was
37 months (95% CI 2968 months). There were 13 pneumothoraces (27.1%) and only six required treatment, three chest-drain insertions (6.1%), two aspirations (4.2%) and one thoracotomy. Transient

Validation of the risk-prediction model STATE score and

START strategy to guide TACE treatment in patients with
hepatocellular carcinoma
A.Mhringer-Kunz1, M.B.Pitton1, C.Dber1, R.Kloeckner1,
I.Schmidtmann2, S.Koch3, P.R.Galle4, A.Weinmann4
1Diagnostic and Interventional Radiology, University Medical Center of
the Johannes Gutenberg University Mainz, Mainz, Germany, 2Institute
of Medical Biostatistics, Epidemiology and Informatics, Johannes
Gutenberg University Mainz, Mainz, Germany, 3Clinical Registry Unit
(CRU), University Medical Center of the Johannes Gutenberg University
Mainz, Mainz, Germany, 4Department of Internal Medicine, University
Medical Center of the Johannes Gutenberg University Mainz, Mainz,
Germany
Purpose: TACE is the standard of care for inoperable patients with
intermediate stage HCC according to BCLC. However, not every
BCLC-B patient is equally suitable for TACE. Several scoring systems
to guide patients treatment regimen for TACE have been introduced. Nonetheless, none of these systems have managed to enter
clinical practice yet. Accordingly, the purpose of this study was to
externally validate the recently published STATE score and sequential use of the STATE and ART scores (START) strategy.
Material and methods: In total, 933 HCC patients underwent TACE
at our institution from January 2000 to September 2015. All variables
needed to calculate the STATE score and to implement the START
strategy (STATE: serum albumin, up-to-seven criteria and CRP level;
START: increase of AST level, increase of ChildPugh score and radiologic tumor response) were determined. Overall survival was calculated, and multivariate analysis was performed. Furthermore, STATE
score and START strategy were validated using Harrells C-index and
integrated Brier score (IBS).
Results: In 229 patients, the STATE score could be calculated. Low
and high STATE scores predicted median survivals of 20.2 and 16.0
months. Harrells C-index was 0.556 and IBS was 0.132. In the STATE
score, independent predictors of survival were up-to-seven criteria
and serum albumin level (all p<0.05). In 196 patients, additionally,
the ART score could be calculated. Combining the STATE and ART
scores resulted in a Harrells C-index of 0.588 and IBS of 0.130.
Conclusion: The STATE score helps determine the suitability for initial TACE. Additionally, the sequential use of the ART score (START
strategy) may indicate whether TACE treatment should be continued. However, neither STATE score nor START strategy alone provide
sufficient certainty for clear-cut clinical decisions.

P-379
Local recurrence rate of ultraselective transcatheter arterial
chemoembolization (TACE) for hepatocellular carcinoma (HCC)
D.Abo, Y.Sakuhara, T.Soyama, R.Morita, K.Kudo
Diagnostic and Interventional Radiology, Hokkaido University Hospital,
Sapporo, Japan
Purpose: To examine the local recurrence rate (LRR) of ultraselective
transcatheter arterial chemoembolization (TACE) for HCC.
Material and methods: In total, 139 HCCs in 72 patients (55 men,
17 women) with an average age of 68 years treated with ultraselective TACE between August 2012 and July 2014 were retrospectively

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examined. The LRR was estimated according to 1) portal vein (PV)

visualization during TACE [the PV could be visualized in the whole
of the embolized area (grade 2), the PV could only be visualized in
a section near the tumor (grade 1), and the PV was not visualized
(grade 0)] and 2) the CT findings obtained immediately after TACE
(the tumor was embolized with a safety margin (grade A), the tumor
was embolized without a margin in parts (grade B), and no tumor
was embolized (grade C)].
Results: The 139 tumors were classified as follows: grade 2, 78
(56.1%); grade 1, 58 (41.7%); and grade 0, 3 (2.1%) and grade A, 63
(45.3%); grade B, 64 (46.4%); and grade C, 12 (8.6%). The overall LRR
at 12 months was 23.4%. The LRR for the grade 2, 1, and 0 groups
were 19.5%, 27.0%, and not evaluated, respectively, and those for
the grade A, B, and C groups were 9.2%, 26.6%, and not evaluated,
respectively, at 12 months. The LRR of each grade were significantly
different (P=0.0058 and P<0.0001, respectively).
Conclusion: The local recurrence rate was significantly lower in
cases involving a greater degree of portal vein visualization and
embolization with a safety margin.

multitined electrodes. Response evaluation was done clinically and

using CEMRI/CECT after 4 weeks of assessment of the tumor size.
Improvement in the quality of life was also assessed pre- and postprocedure. Quality of life was objectively evaluated using the EORTC
QLQ C30 version 1.0. Range of movement pre- and postprocedure
were documented in cases involving the joints. Pain score was
assessed using the visual analog scale (VAS).
Results: The most important was significant improvement in the
range of movements and overall quality. The decrease in the tumor
size post-radiofrequency ablation was graded as 0%25%, 26%
50%, 51%75%, or 76%100%. Radiofrequency ablation proved to
be a good modality for treatment of fibromatosis.
Conclusion: Radiofrequency ablation of recurrent fibromatosis is
potentially safe and effective, especially in recurrent lesions and in
patients where complete surgical excision is difficult to achieve.

P-380

I.H.Sever1, I.N.Akpinar1, R.Ergelen1, F.Gunduz2, M.Sucu1,

D.Tuney1
1Radiology, Marmara University, Istanbul, Turkey, 2Gastroenterology,
Marmara University, Istanbul, Turkey

Y-90 microsphere radioembolization (TARE) of unresectable

HCC: how safe is it in case of portal vein thrombosis?
F.Somma, R.DAngelo, F.Fiore
Interventional Radiology, National Cancer Institute, Naples, Italy
Purpose: Assessment of safety and effectiveness of transarterial
radioembolization (TARE) using Y-90 microspheres in case of unresectable HCC not responsive to other locoregional treatments.
Material and methods: Between January 2005 and January 2013,
91 TARE were performed in 71 patients with unresectable HCC and
23 in those with portal vein thrombosis (PVT). Before treatment,
patients were studied with multi-detector computed tomography
(MDCT) and angiography. Some patients underwent the embolization of the gastroduodenal artery using microcoils. Shunting study
was performed with an injection of TC-99MAA through a 3-F microcatheter. Proton pump inhibitors (PPI) were administered to avoid
gastritis and ulcers.
Results: The average dose administered was 1.7 GBq. Postradioembolization syndrome was found in some patients. No other
side-effect was observed. mRECIST criteria were used to evaluate
the response. At least partial response was found in 71% of patient
three months after the procedure and in 91% at nine months. Mean
survival of patients with PVT was similar to those without thrombosis. Moreover, a regression of PVT was registered in more than half
patients.
Conclusion: Among the locoregional treatments of HCC, TARE is a
safe and effective technique, even in patients with PVT. PVT could
represent a persuasive indication for this treatment in intermediate
advanced HCC.

P-381
Role of radiofrequency ablation in fibromatosis
K.B.Gala1, S.S.Kulkarni1, N.S.Shetty1, A.M.Polnaya1, R.S.Chivate1,
V.N.Bakare2, P.Patel2, A.Puri2, A.Gulia2, S.Banavali2
1Interventional Radiology, Tata Memorial Hospital, Mumbai, India,
2Radiodiagnosis, Tata Memorial Hospital, Mumbai, India
Purpose: To evaluate the safety and effectiveness of RFA in recurrent fibromatosis.
Material and methods: Retrospective evaluation of 30 patients
who had undergone radiofrequency ablation of recurrent fibromatosis was conducted from January 2008 to December 2015. In all,
83 sessions were conducted. All patients underwent preprocedure
CE MRI/CECT. Radiofrequency ablation was done using monopolar

P-382
Percutaneous thermal ablation therapies in treatment of
hepatocellular carcinoma: short mid-term follow-up results

Purpose: Evaluation of the local therapeutic effectiveness of imaging-guided percutaneous thermal ablation therapies and their short
mid-term radiologic and clinical outcomes and comparison of the
therapeutic effectiveness between the MWA and RFA methods.
Material and methods: We retrospectively browsed the clinical,
radiologic, pathologic and demographic parameters of the patients
who had undergone RF or MW treatment due to HCC between
January 2012 and January 2015. Twelve females (30%) and 28 males
(70%) who were followed up for at least 6 months were included. We
evaluated the risk factors that were considered to affect the prognosis by means of log-rank (MantelCox) analysis. Complication
rates, ablative effectiveness and local progression-free and disease-free survival rates for 6-month and 1-year periods were calculated by means of the KaplanMeier test for each group separately.
The results of the two groups were compared by means of the Chisquare test.
Results: The 6-month, 1-year and 2-year survival rates for thermal ablation were 84.6%, 78.7% and 65%, respectively, for general, 76.3%, 55.2% and 33% for disease free and 78.9%, 76.2% and
37.3%, respectively, for local progression free. Size and number of
lesions were the only parameters effective for all type of survival
rates. In addition, ChildPugh classification, AFP level and gender
were found to affect just general, disease-free and local pregressionfree survival rates, respectively. No statistically significant difference
was found in the complications and ablative effectiveness as well as
6-month and 1-year general, disease-free and progression-free survival rates between RF and MW.
Conclusion: RFA and MWA methods have similar complication rates,
tumor ablation efficiency and survival rates for treatment in HCC
patients.

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Conclusion: RFA of subcapsular and nonsubcapsular HCC without
creating artificial ascites were comparable with regard to clinical
success and local and distant recurrences; however, the number of
minor complications was more in the subcapsular group. Therefore,
subcapsular lesions can be safely ablated without creating artificial
ascites.

P-383
Histologic subtype is an independent predictor of local
recurrence after ablation of primary lung adenocarcinoma
E.Ziv, S.Gao, J.P.Erinjeri, H.Yarmohammadi, F.E.Boas, W.Shady,
E.N.Petre, C.T.Sofocleous, S.B.Solomon
Radiology, Memorial Sloan Kettering Cancer Center, New York, NY,
United States of America

P-385

Purpose: To determine the association between histologic subtype of lung adenocarcinoma and local recurrence after lung thermal ablation.
Material and methods: We performed a retrospective review of our
clinical database to identify patients who underwent thermal ablation for lung adenocarcinoma between 2008 and 2015 and whose
tumors had available analysis of the histologic subtype. Specimens
that could not be verified as from the same site as the ablation were
excluded. Time to local recurrence was the primary endpoint and
was evaluated using competing risks regression. Clinical, technical,
and imaging covariates were evaluated as potential predictors of the
cumulative incidence of recurrence using univariate and multivariate analyses with clustered data.
Results: We identified a total of 39 patients with 42 tumors with
available histologic subtyping. The median tumor size was 188
mm. Of the 42 ablated tumors, 11 (26%) had a micropapillary component, 6 (14%) had a solid component, and 14 (33%) had micropapillary and/or solid components. Univariate analysis showed significant increased risk of local recurrence for solid (SHR=3.3, p=0.02),
micropapillary (SHR=4.1, p=0.008), and solid and/or micropapillary
component (SHR=6.0, p=0.002). On multivariate analysis, solid and/
or micropapillary subtype was the only independent predictor of
increased local recurrence after thermal ablation (SHR=6.1, p=0.03).
The 1-year, 2-year, and 3-year cumulative incidence or recurrence
was 35%, 51% and 59%, respectively, in patients with micropapillary and/or solid histologic subtype compared to 8%, 12%, and 17%,
respectively, in other histologic subtypes.
Conclusion: Micropapillary and/or solid histologic subtypes are
independent predictors of local recurrence after thermal ablation.

P-384
Efficacy and safety of radiofrequency ablation of subcapsular
hepatocellular carcinoma without creating artificial ascites: a
single-center experience
A.K.Yadav, R.Bansal, A.Gupta
Interventional Radiology, Sir Ganga Ram Hospital, Delhi, India
Purpose: Pupose of our study is to compare clinical success, complications, and local and distant recurrences of subcapsular and
nonsubcapsular hepatocellular carcinoma (HCC) treated with ultrasound-guided radiofrequency ablation (RFA) without creating artificial ascites.
Material and methods: Retrospective data was obtained from the
hospital records (Medical report department) for the period of 2
years (July 201012), including 37 cases comprising 12 subcapsular
(Group A) and 25 nonsubcapsular (Group B) lesions. Inclusion criteria were single lesion less than 5 cm in size, child A or B status, and
no evidence of vascular involvement or extra-hepatic disease. After
the procedure, follow-ups were performed at 1, 3, 6, and 12 months.
Clinical success, complications, and local and distant recurrences
were evaluated in both groups.
Results: Minor complication rates were 42% (5/12) in Group A and
8% (2/25) in Group B. Major complication was only in Group B (4%,
1/25), local recurrence after 3 and 12 months was 8% (1/12) and 42%
(5/12) and 12% (3/25) and 24% (6/25) and distant recurrence after 3
and 12 months were 8% (1/12) and 42% (5/12) and 20% (5/25) and
48% (12/25) in Groups A and B, respectively.

Hybrid DynaCT-guided hook-wire localization of pulmonary

lesions prior to surgical resection in the same hybrid operating
theatre
C.M.Chu1, E.Dai1, C.Ng2, R.Lau2, R.Wong2, S.C.-H.Yu3
1Department of Imaging and Interventional Radiology, Prince of
Wales Hospital, Hong Kong, Hong Kong PRC, 2Department of Surgery,
Prince of Wales Hospital, Hong Kong, Hong Kong PRC, 3Imaging and
Interventional Radiology, Chinese University of Hong Kong, Hong Kong
PRC, Hong Kong
Purpose: Hybrid DynaCT guided hookwire localization of pulmonary lesions immediately prior to surgical resection by radiologist in
same hybrid operating theatre is a new one-stop technique, which
our centre is the worlds first in performing such procedure. We aim
to compare safety & efficacy of this new technique with conventional MSCT guided hookwire procedure.
Material and methods: Retrospective case-control study performed in a university-based hospital from Feb 2014 to Jan 2016. 18
patients with lung lesion who underwent Hybrid DynaCT-guided
hookwire localization utilizing Siemens Artis Zeego system compared against 10 age and sex matched controls who underwent conventional MSCT guided hookwire localization. All cases performed
under local anesthesia.
Results: Mean lesion size was significantly smaller in DynaCT
group compared with MSCT group (5.961.92mm vs 8.423.30mm,
p=0.02). All interventions met primary endpoint of satisfactory
hookwire positioning by DynaCT/MSCT guidance. No cases of
hookwire dislodgement in both groups. DynaCT procedure associated with significantly shorter transfer times (38.2816.95min vs
98.735.24min, p<0.001) and a trend towards lower pneumothorax rate (22% vs 50%, p=0.13). DynaCT group had higher estimated
effective dose (24.6222.48 vs 8.263.88, p=0.01) and longer procedure time (55.3919.01min vs 23.309.99min, p<0.001) than MSCT
group. Lesion size inversely correlated with procedural time (r=0.50, p=0.01). Smaller lesion size (<5mm) associated with higher estimated effective dose (p=0.03); suggesting smaller target lesion size
may contribute
Conclusion: Hybrid DynaCT guided hookwire localization of pulmonary lesions immediately prior to surgical resection in same hybrid
operative theatre is a pioneer one-stop technique; which is associated with shorter interdepartmental transfer time & lower postprocedure pneumothorax rate when compared with conventional
MSCT procedure.

P-386
Ambulatory percutaneous lung biopsy with early discharge
and Heimlich valve management of iatrogenic pneumothorax
A.Saini1, A.Tavare1, D.Creer2, S.Hare1
1Radiology, Barnet General Hospital, Barnet, Hertfordshire, United
Kingdom, 2Medicine, Barnet General Hospital, Barnet, Hertfordshire,
United Kingdom
Purpose: To determine if an early discharge radiology-led percutaneous lung biopsy (PLB) service, incorporating ambulatory outpatient Heimlich valve chest drain (HVCD) to treat pneumothorax, is
safe and cost effective.

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Material and methods: A prospective study of 489 outpatient
image-guided PLBs, performed between March 2011 and March
2015, was conducted. Patients were discharged at 30 minutes if no
pneumothorax was present; repeat 60-minute CXR was performed
if a small asymptomatic pneumothorax was noted. If stable, patients
were discharged. In enlarging or symptomatic pneumothorax,
patients were discharged with HVCD in situ. Data on pneumothorax rates, numbers of patients requiring HVCD and failed early discharge were collated. A retrospective blinded pulmonary function
test (PFT) analysis was also performed.
Results: Four hundred eighty-nine PLBs were performed with
diagnostic accuracy of 97.8%, and 402 (82.2%) patients were discharged at 30 minutes. Eighty-seven patients developed pneumothorax (17.8%); 35 patients with a stable, asymptomatic pneumothorax were discharged at 60 minutes, and 52 patients required HVCD,
with 5/52 proceeding to PLB with drain in-situ: 38/52 (73.1%) had
drain removal at 24 hours and 14/52 (26.9%) at 48 hours. Four of 489
patients were admitted for social issues.
A blinded retrospective review of PFT data, available in 209/489
patients, revealed 28 with FEV<1l (range 0.39-0.99), of which 12 had
FEV1< 35% predicted. 22/28 (78.6%) were discharged at 30 minutes;
6/28 patients (21.4%) developed post-PLB pneumothorax, with 3
(10.7%) requiring outpatient HVCD for 24 hours.
Conclusion: This study demonstrates that early discharge PLB, facilitated by use of ambulatory HVCD, is safe, cost effective and expeditious, even in patients with poor lung function.

P-387
Bowel and abdominal organ displacement techniques for liver
ablation procedures
N.Kwok1, R.Arellano2
1School of Medicine, Tufts University School of Medicine, Boston, MA,
United States of America, 2Radiology, Massachusetts General Hospital,
Boston, MA, United States of America
Purpose: To review the bowel and abdominal organ displacement techniques as adjunct maneuvers for computed tomographyguided percutaneous thermal ablation of liver tumors.
Material and methods: An institutional database was queried
using the keywords hydrodissection, artificial ascites, and balloon to identify liver ablation procedures in which bowel displacement techniques were performed. We secondarily filtered the results
to exclude any procedures using displacement techniques intended
to create separation of the liver from the diaphragm or peritoneum.
The resulting records were reviewed to assess technique, technical
successes and failures of the displacement, and ablation-related success and complications.
Results: Between December 2002 and September 2015, 25 patients
with 25 liver tumors met the inclusion criteria. The most frequent
tumor encountered in these cases was hepatocellular carcinoma
(n=13). Among the bowel displacement techniques employed, 3
cases utilized an angioplasty balloon, while the remaining used
hydrodissection. The success rate was 19/25 (76%). The average time
to perform liver ablation procedures with displacement attempts
was similar to liver ablation procedures without displacement
attempts (2 h 43 min vs 2 h 45 min). There were no bowel displacement or ablation-related complications.
Conclusion: Bowel and abdominal organ displacement during liver
ablation procedures is safe and can be effective in minimizing the
risk of non-target organ injury. Organ displacement entails minimal additional risk, adds little time to procedure time, and can be
deployed with equipment readily available in the Interventional
Radiology suite. Such techniques allow continuation of a procedure
that would otherwise be unsafe for the adjacent organs.

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P-388
Combination of navigational radiofrequency ablation device,
ultrahigh viscosity cement vertebral augmentation and
stereotactic radiotherapy for the treatment of spine metastasis
J.-B.Zerlauth1, L.Schiappacasse2, J.Bourhis2, R.Meuli3
1Interventional Neuroradiology, CHUV, Lausanne, Switzerland,
2Radiotherapy, CHUV, Lausanne, Switzerland, 3Radiology, CHUV,
Lausanne, Switzerland
Purpose: To evaluate the safety and clinical benefits of spine metastasis treatment by combining radiofrequency ablation with a navigational device, vertebroplasty and stereotactic radiotherapy.
Material and methods: Fifteen patients with 17 spine metastasis were retrospectively included from December 2014 to February
2016. All patients were treated with both radiofrequency with the
STAR system and high-viscosity cement augmentation during the
same procedure. In addition, stereotactic body radiotherapy was
performed. A whole-spine MRI examination was done before and
after the percutaneous treatment (1, 3, 6 and 12 months); local control was defined as the absence of tumoral progression within the
targeted area. Clinical evaluation was performed by recording pain
score with the numerical rating scale and pain medications.
Results: Seventeen vertebral metastases were treated, from T4 to
S1; 35% of tumours involved epiduro-foraminal spaces and posterior arch of the vertebrae. The median pre-procedure pain score was
6 (range 0-9). The mean worst pain score dramatically decreased at
both 1 month (median 1.47) and 3 months (median 0.9). No postprocedural clinical complication occurred. Two cases of disc leakage
of cement were described without any clinical relevance. MRI followup examinations showed 88.3% local disease control at 1 month,
88.3% at 3 months and 82.3% at 6 months.
Conclusion: Locally ablative intent treatment of oligometastatic
spine disease can be feasibly performed by increasing tumoricidal
dose delivery and avoiding radiation-induced vertebral fractures.

P-389
CT-guided ablation for lung malignancy: 8-year data and
outcomes
S.R.Virdee, N.Kibriya, J.Evans
Interventional Radiology, Royal Liverpool University Hospital, Liverpool,
United Kingdom
Purpose: Radiofrequency and microwave ablations have been utilised in the treatment pulmonary malignancies. A retrospective
study of CT-guided ablations of pulmonary malignancies was performed to evaluate their efficacy and outcome.
Material and methods: A retrospective study was performed on
patients diagnosed with either primary or secondary lung malignancy who underwent treatment with CT-guided radiofrequency or
microwave ablation over an 8-year period. Review of standardised
interval follow-up imaging was undertaken and the outcomes were
recorded. Patient demographics and disease status were recorded
using the mRECIST criteria. Statistical analysis of the data was
performed.
Results: In total, 107 ablations were performed on 76 patients (43
male, 33 female). Majority of the patients had lung malignancies due
to primary lung carcinomas or colorectal metastases. Of these procedures, 85 were microwave ablations and the remaining 22 were
radiofrequency ablations. Targeted lesion sizes ranged from 3 mm to
66 mm. Overall, 47 (44%) cases resulted in procedural complications,
of which 40 were pneumothoraces. Twenty-six pneumothoraces
required intercostal drains. Average follow-up time was 9.5 months,
and the longest follow-up time was 73 months. At 1 month, 91.2%
of cases demonstrated stable disease with no evidence of residual

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tumour at the ablation site. At the 3 month follow-up, this decreased

to 85.3%; at 6 months, to 82.2%; and at 12 months, to 77.8%.
Conclusion: Microwave and radiofrequency ablations have proven
to be a safe and effective technique in the treatment of primary and
metastatic lung tumors.

P-390
Safety and efficacy of closure devices in patients with
coagulation disorder who underwent DEB TACE
B.DeFina1, M.A.Perin1, N.Wolosker1, F.Nasser1, B.B.Affonso1,
F.L.Galastri1, R.N.Cavalcante1, J.M.D.MottaLealFilho1, L.G.M.Valle1,
A.A.P.D.Azevedo2
1Radiologia Vascular Intervencionista, Hospital Israelita Albert Einstein,
So Paulo, Brazil, 2Interventional Radiology, Hospital Israelita Albert
Einstein, So Paulo, Brazil
Purpose: Patients with chronic coagulation disorders have greater
potential to develop complications after procedures that require
arterial access. This study aims to assess the effectiveness and benefits of using Perclose ProGlide closure devices in high-risk patients.
Material and methods: We performed a single-institutional, prospective study in cirrhotic patients with hepatocellular carcinoma
subjected to doxorubicin drug-eluting beads transarterial chemoembolization (DEB TACE). All the procedures were performed
with femoral artery puncture followed by the usage of the Perclose
ProGlide device. Based on the platelet count (PC) and international
normalized ratio (INR), these patients were divided into PC <= 50
10E3/mcL and INR >= 1.5 and PC > 50 10E3/mcL and INR < 1.5. No
platelets or blood products were infused before the procedures.
Complications in the access site were identified.
Results: A total of 579 DEB TACE procedures were evaluated. These
included 107 procedures in patients with PC <= 50 10E3/mcL and 80
procedures in patients with INR >= 1.5. Hemorrhagic complications
related to punctured sites, such as pseudoaneurysm and hematomas, were noticed. The group with PC <= 50 10E3/mcL showed
complications in 1.9% of procedures and the group with INR >= 1.5
showed complications in 2.5% of procedures. The statistical analysis
of complications between each group and patients without laboratorial alteration demonstrated no difference.
Conclusion: The Perclose ProGlide vascular closure device has been
demonstrated to be effective and safe in patients with thrombocytopenia and coagulopathy and is indicated to prevent hemorrhagic
complications and avoid preprocedural transfusions.

P-391
Transarterial chemoembolization (TACE) for hepatocellullar
carcinoma after balloon-occluded retrograde transvenous
obliteration (BRTO)
J.H.Kim, Y.H.Kim, C.S.Kim, Y.H.D.Kim, S.H.Jeong, S.H.Kim
Radiology, Keimyung University Dongsan Medical Center, Daegu, Korea
Learning Objectives: To retrospectively evaluate the safety and
efficacy of transarterial chemoembolization (TACE) in patients with
HCC after balloon-occluded retrograde transvenous obliteration
(BRTO).
Background: Liver cirrhosis and HCC are highly prevalent in Korea
because there are many patients with viral hepatitis.
Clinical Findings/Procedure: Sixteen patients underwent TACE
for HCC after BRTO from 2004 to 2015. Among the 16 patients, 6
patients had already undergone TACE for HCC before BRTO. The
change in laboratory parameters and in the Child-Pugh scores of
each pre- and post-procedure was analyzed using the Wilcoxon
signed-rank test and the TOST (two one-sided t-test) equivalence
test. Tumor response was evaluated by modified RECIST, and overall

Abstract Book
survival rate after TACE was calculated by the Kaplan-Meier method.
After BRTO, all patients showed improvement in their Child-Pugh
scores (p=0.027), total bilirubin (p=0.014), albumin (0.001), and PT
(p=0.011) according to the Wilcoxon signed rank test. All patients
who received TACE after BRTO showed a slightly decreased hepatic
function. However, the change in hepatic function was clinically
insignificant, and a comparison between the pre- and post-TACE
using the TOST equivalence test showed no statistically significant
difference (p<0.05) in Child-Pugh scores and all laboratory parameters. Complete tumor response was achieved in 9 patients, partial response in 6 patients, and progressive disease in 1 patient after
TACE. The 1-, 2-, and 3-year overall survival rate was 73.7%, 30.6%,
and 20.4%, retrospectively.
Conclusion: As it is generally known, BRTO improves the metabolic
activity of the liver. Therefore, TACE is a safe and effective treatment
for HCC in patients who have undergone BRTO.

P-392
Pictorial review of suboptimal enhancement and failure of CT
arterial portogram using a hybrid CT-angiography system
A.Bangaragiri, T.A.J.Urlings, N.K.K.Venkatanarasimha, S.Leong,
A.Gogna, C.W.Too, A.Patel, J.M.Chan, C.G.Padre, H.G.R.Lo,
F.G.Irani, B.S.Tan, K.-H.Tay, K.Damodharan
DDR, SGH, Singapore, Singapore
Learning Objectives:
1. To identify the factors contributing to variable enhancement of
liver or failure of CT arterial portography(CTAP).
2. Imaging illustration of the factors causing poor / non
enhancement of the liver during CTAP.
Background: A retrospective review of the CTAP images which
were acquired using our hybrid CT-angiography system, as part of
our routine planning study prior to Y90 radio-embolisation therapy
or trans-arterial chemo embolization (TACE) was performed to identify cases with suboptimal or poor liver enhancement. The images
from these cases were individually reviewed to determine the factors leading to the sub-optimal study.
Clinical Findings/Procedure: CTAP was performed in the Toshiba
hybrid CT-angiography suite. Twelve studies were documented as
variable enhancement or technical failures. Two cases were due to
early acquisition or poor cardiac output. Portal vein thrombus causing variable enhancement was seen in three patients. Liver cirrhosis and porto-systemic shunting were attributed to non-homogeneous enhancement in seven patients. Causes of variable enhancement included impaired portal vein perfusion from mass effect, laminar flow in portal vein and focal fatty infiltration. Causes of technical
failures included catheter position, portal hypertension and operator error.
Conclusion: Variable enhancement and technical failures are common occurrence during CTAP, and it is useful to be aware of the
causes of variable hepatic enhancement to allow for accurate
interpretation.

P-393
Agitated saline sonography: a simple technique for
intraprocedural feeder identification during transcatheter
arterial chemoembolization of hepatocellular carcinoma
K.P.BellamPremnath1, B.Ray2
1Department of Radiology, Rajagiri Hospital, Aluva, India, 2Radiology,
Aster Medcity Hospital, Ernakulam, India
WITHDRAWN

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P-394
Drainage outflow from hypervascular hepatocellular
carcinoma: what you need to know and why it is important in
transcatheter arterial chemoembolization (TACE)
T.Minami1, O.Matsui1, S.Miyayama2, A.Kitao1, N.Terayama3,
S.Kobayashi4, W.Koda1, K.Kozaka5, D.Inoue1, K.Yoshida1,
N.Yoneda1, T.Matsubara1, T.Gabata1
1Radiology, Kanazawa University Hospital, Kanazawa, Japan,
2Radiology, Fukuiken Saiseikai Hospital, Fukui, Japan, 3Radiology,
Takaoka City Hospital, Takaoka, Japan, 4Radiology, Kanazawa
University School of Medicine, Kanazawa, Japan, 5Radiology,
Kanazawa University Graduate School of Medical Science, Kanazawa,
Japan
Learning Objectives: The learning objectives of this Presentation is
1. To understand the microangioarchitecture of the liver and
hemodynamics of HCC analyzed by CT during hepatic arteriography (CTHA) as compared with histology.
2. To discuss with special reference to their importance in interventional therapy.
Background: Understanding the microangioarchitecture and
hemodynamics of the liver and tumor is inevitable for precise imaging diagnosis and effective interventional therapy.
Clinical Findings/Procedure: Analysis by correlating CT findings
during arterioportography (CTAP) and CTHA findings with pathology revealed the multi-step changes in the drainage vessels of
the tumor during hepatocarcinogenesis. Drainage outflow from a
hypervascular HCC can be observed in CTHA as a coronal enhancement. This blood overflow area is the first pathway of metastasis of
HCC and is known as microsatellite or daughter nodule. Complete
treatment of HCC means complete necrosis of whole nodules and
their surrounding drainage area. In superselective TACE, lipiodol,
a liquid embolic material that can enter the drainage area through
the peribiliary vascular plexus and lead to complete necrosis of the
tumor and its surrounding tissues, is used.
Conclusion: Drainage outflow from a hypervascular HCC means the
first pathway of metastasis of HCC, known as microsatellite nodule.
From the viewpoint of blood flow in hypervascular HCC, lipiodol is
efficacious not only as an embolus but also as a drug delivery agent.

P-395
Irreversible electroporation for medium-size pancreatic
adenocarcinoma
K.-W. Huang
Centre of Mini-Invasive Interventional Oncology, National Taiwan
University Hospital, Taipei, Taiwan
Learning Objectives: The clinical study assessed the efficacy and
safety of ultrasound-guided IRE combined with early TS-1 treatment
in patients for 3-5cm localized advanced pancreatic adenocarcinoma (LAPC).
Background: Irreversible electroporation (IRE) is a local tumor treatment. Thin needles are placed percutaneously around the tumor
under ultrasound guidance.
Short pulses of direct current sent through the tissue irreversibly increase cell membrane permeability, leading to cell death.
We report a clinical study assessing the efficacy and safety of ultrasound-guided surgical IRE combined with early TS-1 treatment in
patients for a 35-cm localized advanced pancreatic adenocarcinoma (LAPC).
Clinical Findings/Procedure: Methods: Eight patients (4 males)
with LAPC judged unsuitable for surgery were treated with IRE and
then with oral TS-1 treatment one day after the operation. IRE procedure was performed using a laparotomic approach under ultrasound guidance.

SS/FC/HL/HTS/CM
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S287

Results: No serious treatment-related adverse events were observed.

There was no 30-day mortality. Twelve months after the treatment,
all patients survived and 3 patients had no signs of local or distant
recurrence on a contrast-enhanced computed tomography image.
Disease-free survival was 10.5 months.
Conclusion: IRE for medium-size LAPC can be safely performed percutaneously under ultrasound guidance, and immediate TS-1 treatment after operation seemed to be tolerable with promising initial
results regarding efficacy.

P-396
Parenchymal blood volume (PBV) determined by C-arm
computed tomography: one-stop-shop transarterial
chemoembolization of hepatocellular carcinoma
R.Syha, K.Nikolaou, D.Ketelsen
Diagnostic and Interventional Radiology, Eberhard-Karls-University,
Tbingen, Germany
Learning Objectives: Applications of parenchymal blood volume
(PBV) C-arm computed tomography (CT) acquisitions during transarterial chemoembolization with drug eluting beads (DEB TACE):
treatment planning, complications management, and response
monitoring.
Background: C-arm CT has been increasingly used during TACE for
procedural planning and treatment response evaluation. PBV, which
is based on a principle similar to that of volume perfusion computed
tomography (VPCT), allows further quantitative analysis of tumor
blood volume (/100 ml) that has potential in prediction of the treatment outcome.
Clinical Findings/Procedure: Robotic angiographic suites enable
straightforward dual-phase C-arm CT acquisitions, including nonenhanced and contrast-enhanced runs, in the steady state of liver
perfusion. This allows the processing of 3D intra-arterial PBV of
tumor lesions and non-affected liver parenchyma. A further anatomical 3D reconstruction of the contrast-enhanced phase facilitates
locating the tumor lesions and feeding vessels for treatment planning. Rates of lesion detection, particularly small lesions, are comparable to those on cross-sectional imaging and superior to those on
conventional angiography. Quantification of blood volume is comparable to VPCT. In post-interventional scans, tumor devascularization in terms of reduction of PBV allows a quantitative real-time
approach to response monitoring. Intra-tumoral staining of contrast media in the non-enhanced run indicates the distribution of
DEB. Reduction of PBV and contrast media staining outside treated
lesions can be used for the detection of possible treatment-related
complications such as cholecystitis and pancreatitis.
Conclusion: PBV C-arm CT is a novel technique that allows intra-procedural real-time 3D treatment planning, complication management, and response monitoring during DEB TACE of hepatocellular
carcinoma in terms of a one-stop-shop procedure.

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P-397
Role of n-butyl cyanoacrylate (glue) in vascular and
non-vascular procedures in interventional radiology
K.B.Gala1, S.S.Kulkarni2, N.S.Shetty2, A.M.Polnaya2, R.S.Chivate2,
J.Aiya2, V.N.Bakare3, P.Patel3, P.Kumar2, A.Patil2
1Radiology, Tata Hospital, Mumbai, India, 2Interventional Radiology,
Tata Memorial Hospital, Mumbai, India, 3Radiodiagnosis, Tata
Memorial Hospital, Mumbai, India
Learning Objectives:
1. To review the conventional endovascular uses of n-butyl cyanoacrylate (glue) in Interventional Radiology and supplement the
same with the corresponding imaging findings.
2. To highlight non-vascular locations where the use of glue has
proven to be beneficial in post operative patients thus obviating
the need of surgery.
Background: The role of cyanoacrylate glue has been well established in the management of conventional endovascular procedures
such as embolization of arteriovenous malformations (AVM), bleeding varices, angiodysplasias, etc. for a long time with good success
rate. Its property of rapid polymerization can also be utilized in various non-vascular locations, thus obviating the need for surgery on
many occasions.
Clinical Findings/Procedure:
1. A brief discussion regarding the chemical properties, mechanism
of action and tissue interactions of glue and a review of existing
literature pertaining to its uses in various specialties.
2. The current status of the use of cyanoacrylate glue in conventional endovascular procedures with an overview of the
technique, imaging features and the likely complications of the
procedure.
3. The use of glue in the following non-vascular procedures such
as portal vein embolization closure of bronchopleural fistula,
enterocutaneous fistula, post PTBD tract embolisation, etc. will be
discussed.
Conclusion: We hereby review our experience with n-butyl cyanoacrylate with special emphasis on its use in the unconventional nonvascular cases.

P-398
Role of lipiodol in vascular and non-vascular procedures in
interventional radiology
K.B.Gala1, S.S.Kulkarni2, N.S.Shetty2, A.M.Polnaya2, R.S.Chivate2,
P.Patel3, V.N.Bakare3, J.Aiya2, P.Kumar2
1Radiology, Tata Hospital, Mumbai, India, 2Interventional Radiology,
Tata Memorial Hospital, Mumbai, India, 3Radiodiagnosis, Tata
Memorial Hospital, Mumbai, India
Learning Objectives:
1. To review the conventional endovascular uses of lipidol in
Interventional Radiology and supplement the same with the
corresponding imaging findings.
2. To highlight non-vascular locations where the use of lipidol has
proven to be beneficial in postoperative patients thus obviating
the need of surgery.
Background: Lipiodol was previously used in hysterosalpingography but now it is widely used in vascular and non-vascular procedures. It is well established in the management of conventional
endovascular procedures such as embolization of arteriovenous
malformations (AVM), bleeding varices, angiodysplasias, lymphangiography, cTACE, and sclerotherapy of low-flow AV malformations. It
is also used in pre-RFA embolization of renal cell carcinoma, which
is the newer application. It is used in various non-vascular locations,
thus obviating the need for surgery on many occasions.

Abstract Book
Clinical Findings/Procedure:
1. A brief discussion regarding the chemical properties, mechanism
of action, and tissue interactions of lipiodol and a review of
existing literature pertaining to its uses in various specialties.
2. The current status of the use of lipiodol in conventional endovascular procedures with an overview of the technique, imaging
features, and the likely complications of the procedure.
3. The use of lipiodol in the following non-vascular procedures like
portal vein embolization closure of bronchopleural fistula, enterocutaneous fistula, post PTBD tract embolisation, lymphocele, etc.
will be discussed.
Conclusion: We hereby review our experience with lipiodol in vascular and non-vascular cases.

P-399
Techniques to avoid complications during percutaneous
cryoablation for renal cell carcinomas: all that we should know
K.Michimoto1, K.Shimizu1, Y.Kameoka1, J.Miki2, K.Kishimoto2,
S.Sadaoka1
1Department of Radiology, The Jikei University School of Medicine,
Kashiwa Hospital, Chiba, Japan, 2Urology, The Jikei University School of
Medicine, Kashiwa Hospital, Chiba, Japan
Learning Objectives: To learn about several technical tips to reduce
complications related to percutaneous cryoablation (PCA) of renal
tumors.
Background: PCA has gained an important role in the treatment of
renal cancers. Reported complication rate of PCA ranges from 6.0 to
12.9%, and bleeding or hematuria are the most common. Urothelial
injury, gastrointestinal injury, cholecystitis, pancreatitis, hypertensive crisis due to injury of the adrenal gland, nerve injury, skin burn,
and pneumothorax are also reported. We analyzed all techniques
used to avoid these complications of 140 consecutive procedures.
Clinical Findings/Procedure: By reviewing 140 procedures of PCA,
we evaluated the effectiveness and feasibility of each technique for
preventing complications. The following techniques will be demonstrated and discussed.
1. Patient positioning
- Which patient positioning is better to displace adjacent organs,
considering tumor location and skin-to-tumor distance.
2. Hydrodissection/carbodissection
- Which material is suitable to displace adjacent organ.
- Difference of distribution depending on materials.
- Effective puncture point.
3. Probe retraction technique.
- Feasibility and safety.
4. Transcatheter arterial embolization
- Suitable embolic materials.
- Techniques of superselective arterial embolization for preserving
renal function.
5. Ureteral stent placement
- Indication and effectiveness.
Conclusion: To utilize a variety of techniques allows safe ablation of
renal tumors.

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SS/FC/HL/HTS/CM
Posters

P-400

P-404

Microvascular plug (MVP) deployment in the venous outflow to

reduce the liverlung shunt prior to radioembolization

Transarterial chemoembolization for treatment of ACTHproducing neuroendocrine liver metastases

A.Masrani, J.Tasse, U.C.Turba, B.Arslan

Interventional Radiology, Rush University Medical Center, Chicago, IL,
United States of America

M.A.Shorikov1, O.N.Sergeeva2, D.Frantsev2, V.Panov2,

B.Dolgushin2
1Radiology, Radiotherapy and Medical Physics, Russian Medical
Academy of Postgraduate Education, Moscow, Russian Federation,
2Interventional Oncology, N.N. Blockhin Cancer Research Center,
Moscow, Russian Federation

A 44-year-old-man with HCC underwent a mapping procedure,

which showed liverlung shunt of 25.5% due to hepatic artery-tovein shunting. Using venous access, three MVPs were deployed into
two venous outflow branches by performing simultaneous angiograms. The shunt was reduced to 9%.

P-401

S289

A patient with liver metastasis of a pancreatic neuroendocrine

tumor demonstrating ectopic ACTH syndrome and reduction of
the spleen volume by 50% was treated by transarterial chemoembolization. The procedure resulted in tumor necrosis, symptomatic
improvement, splenic size reconstitution, and serum ACTH and cortisol level normalization.

Distal portal vein embolisation through a trans-splenic

access using microvascular plug (MVP) to reduce a high
hepatopulmonary shunt due to arterio-portal shunting and
hepatofugal flow

P-405

A.Masrani, U.C.Turba, B.Arslan

Interventional Radiology, Rush University Medical Center, Chicago, IL,
United States of America

A potential pitfall in emergency TAE for ruptured hepatic

lesion: extravasation from extra-hepatic feeding vessels in a
patient with previously untreated hepatic lesion

Attempt for bland embolisation failed to reduce 60.2% hepatopulmonary shunt in a patient with unresectable HCC. Utilising a transsplenic approach, MVPs were deployed in branches of the portal
vein where arterioportal shunt with hepatofugal flow was identified.
Shunt reduced to 14.7%.

T. Nishiyama
Department of Radiology, St. Luke's International Hospital, Tokyo,
Japan

P-402

We report three cases of spontaneous rupture of hepatic lesion

without a history of embolization that extravasated from an extrahepatic feeding vessel: right gastroepiploic artery, right intercostal
artery, and right inferior phrenic artery. The culprit artery was successfully embolized.

Treatment of esophagotracheal and esophagoaortic fistula

in an esophageal cancer patient with vascular plug, glue, and
aortic stent graft

P-406

J.M.Lee1, J.Ohm2
1Radiology, SoonChunHyang University Hospital, Bucheon, Korea,
2Radiology, Chungnam National University Hospital, Daejeon, Korea

A rare complication of DEB-TACE: gastric ulcer caused by

migration of the embolic agent through the adhesion between
superficial HCC and the stomach

We present the case of treatment of esophagotracheal and esophagoaortic fistula with vascular plug, glue, and stent graft in a 59-yearold man with esophageal cancer.

P-403
Successful treatment of growing hepatocellular carcinoma
(HCC) supplied by portal blood (PB) with transcatheter arterial
chemoembolization (TACE) via an arterio-portal shunt: a case
report
H.Tomimatsu, T.Taniguchi, N.Sakamoto, Y.Nakashima, T.Oda,
M.Nishioka, S.Noguchi, T.Kadoba, S.Noma
Radiology, Tenri Hospital, Tenri, Japan
PB supply to HCC is rare and difficult to treat with TACE. A 71-yearold man with multiple HCCs was treated with TACE. CTHA and CTAP
showed one growing lesion supplied by PB. This lesion was successfully treated by TACE via an arterio-portal shunt.

M.Hirata1, R.Watanabe2
1Radiology, Matsuyama Shimin Hospital, Matsuyama Ehime, Japan,
2Surgery, Matsuyama Shimin Hospital, Matsuyama Ehime, Japan
A 68-year-old woman with multiple HCCs was treated by DEB-TACE.
Nine days later, she had massive bleeding from a gastric ulcer caused
by nontarget embolization. Histologically, beads were thought to
have passed through the adhesion between superficial HCC and the
stomach.

P-407
Iatrogenic arterio-biliary fistula caused by repetitive
transcatheter arterial chemoembolization and arterial infusion
chemotherapy: threecase reports
R.Sato, T.Aramaki, E.Bekku, K.Yoza, M.Moriguchi
Division of Interventional Radiology, Shizuoka Cancer Center, Shizuoka,
Japan
Arterio-biliary fistula is a very rare complication of transcatheter arterial chemoembolization. Although the mechanisms remain
unclear, repetitive chemotherapy via fine vessels could have caused
this rare complication in the three cases we encountered, all of
which were successfully embolized
and remained asymptomatic
thereafter.

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Abstract Book

P-408

Others

Use of the Hansen Medical Magellan vascular robot in transarterial chemoembolisation of liver tumours

P-413

M.Scicchitano, J.Koukounaras, G.S.Goh, Y.Huynh

Radiology, Alfred Health, Melbourne, VIC, Australia

Embolizing lung radiofrequency ablation tracks

This is a case series using the Hansen Medical Magellan vascular

robot in trans-arterial chemoembolisation (TACE) of liver tumours,
which has not been described in the literature to date. Six patients
with difficult anatomy, some with prior unsuccessful TACE attempts,
were treated successfully.

P-409
Surgically assisted cryoablation with nerve protection for
extra-abdominal desmoid tumors: case reports
S.Grosfilley, P.E.Bize, A.Denys
Radiology, CHUV, Lausanne, Switzerland
We describe 3 cases of extraabdominal desmoid tumors treated by
combined open surgery with nerve dissection and insulation associated with peri-operative cryoablation, as radical surgical resection
would have resulted in limb function impairment and percutaneous
cryoablation was considered too dangerous.

P-410
How far could we go to ablate lung tumors?
J.Palussire1, A.Crombe1, V.Catena1, X.Buy1, F.Bonichon2
1Department of Radiology, Institut Bergoni, Bordeaux, France,
2Imaging Department, Institut Bergoni, Bordeaux, France
A patient presented with a follicular thyroid carcinoma. In 2006, lung
metastases were diagnosed, all radioiodine refractory. Between
2006 and 2016, 26 metastases have been treated with radiofrequency ablation over 11 sessions. For a slowly evolving disease,
repeated ablation is possible.

J.Izaaryene1, J.-M.Bartoli2, V.Vidal3, A.Jacquier2, J.-Y.Gaubert4

1Radiology, Hopital de la Timone, Marseille, France, 2Radiologie Adulte,
APHM CHU La Timone, Marseille, France, 3Service de Radiologie,
Hpital Timone Adultes, Marseille, France, 4Department of Adult
Radiology, CHU Timone 2, Marseille, France
Purpose: Pneumothorax is the most common complication after
percutaneous radiofrequency lung ablation. The chest tube is the
most frequent cause of lengthening the hospital stay.
Material and methods: We included prospectively 54 patients and
randomly divided them into 2 groups: 27 patients without embolization and 27 patients with embolization; in these patients, we
embolized the RFA tracks with gelatin torpedoes. The 2 groups were
comparable for different risk factors of pneumothorax (age, sex, history of ipsilateral thoracic surgery, and the distance between the
pleura and lesion).
Results: The number of pneumothorax was significantly (p = 0.008)
lower in the group with embolization, which included 14 pneumothoraces (51.9%), than in the group without embolization, which
included 23 pneumothoraces (85.2%). The volume of pneumothorax
was significantly less abundant (p = 0.019) in the group with embolization (average of 15.1%, standard deviation 13.8%) than in the
group without embolization (average of 28.7%, standard deviation
17.4%). The drainage was significantly lower (p = 0.011) in the group
with embolization (2 drainages or 14.3%) than in the group without embolization (13 drainages or 56.5%).
Conclusion: Embolization lung radiofrequency tracks with absorbable gelatin torpedoes significantly decreases the number and
abundance of pneumothorax and the number of chest tubes. This
method is simple and inexpensive; it is not intended to revolutionize
the practice of pulmonary RFA, but it can improve the patient comfort during hospitalization.

P-414

P-411
Successful embolization of massive life-threatening bleeding
following transoral giant glomus jugulare tumor biopsy
A.Tarkhanov1, E.Grebenev1, A.Dorofeev2, M.Kartashov1
1Radiology, Sverdlovsk Regional Oncology Center, Yekaterinburg,
Russian Federation, 2Surgery, Sverdlovsk Regional Oncology Center,
Yekaterinburg, Russian Federation
We report the case of a 33-year-old man with acute massive bleeding from a giant glomus jugulare tumor, which began during transoral biopsy. Bleeding was successfully managed with transarterial
embolization of the internal carotid artery.

P-412
Percutaneous cryoablation for stage T1b renal cell carcinoma
in a patient with a horseshoe kidney
H.Maeda1, K.Shimizu1, Y.Kameoka1, K.Michimoto1,
T.Yanagisawa2, K.Kishimoto2, S.Sadaoka1
1Department of Radiology, The Jikei University School of Medicine,
Kashiwa Hospital, Chiba, Japan, 2Department of Urology, The Jikei
University School of Medicine, Kashiwa Hospital, Chiba, Japan
This is the first case report of a percutaneous cryoablation for renal
cell carcinoma in a horseshoe kidney. A 42-mm tumor located at the
isthmus was adjacent to the inferior vena cava and the colon, but
was successfully treated without any complications.

Transarterial chemoembolization utilizing an expandable-tip

antireflux microcatheter: a multi-institution study of safety,
feasibility, and early outcomes
J.Titano1, A.Arepally2, T.Fischbeck 3, M.Katz3, A.Kim4, S.C.Rose5,
A.Fischman6
1Radiology, Icahn School of Medicine at Mount Sinai, New York,
NY, United States of America, 2Interventional Radiology, Piedmont
Healthcare, Atlanta, GA, United States of America, 3Interventional
Radiology, Keck School of Medicine of USC, Los Angeles, CA, United
States of America, 4Radiology, MedStar Georgetown University
Hospital, Washington, DC, United States of America, 5Radiology, UCSD
Health Sciences, San Diego, CA, United States of America, 6Radiology
and Surgery, Mount Sinai Medical Center, New York, NY, United States
of America
Purpose: We present a multi-center study of TACE utilizing
an expandable-tip antireflux microcatheter (ET-ARM) (Surefire
Precision; Surefire Medical, Westminster, CO) in hepatocellular carcinoma (HCC).
Material and methods: We retrospectively reviewed TACE performed using ET-ARM at 5 institutions between 06/2015 and
01/2016. Demographics and procedure characteristics included
age, sex, previous interventions, HCC etiology, performance status,
Child-Pugh class, BCLC stage, sorafenib therapy, laboratory values,
tumor size, and doxorubicin dose. Outcomes included CTCAEv4 toxicities, complications, and imaging response (mRECIST).

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CIRSE 2016
Results: A total of 41 HCC lesions in 32 patients (age 62 [9.3] years;
male 90.6%; HCV 46.9%; Child-Pugh A 68.8%; BCLC-A 56.3%; ECOG-0
81.3%) underwent TACE via ET-ARM. LC beads (BTG, London, UK) utilized in 80.5% of cases; median (IQR) doxorubicin dose was 50 (30
75) mg. Toxicities included grade 1/2 fatigue (6.3%), nausea (3%),
and ascites (3%). Baseline laboratory values included mean (standard deviation) total bilirubin 1.44 (0.82) mg/dL and AFP 101.5
(223.4) ng/dL. Laboratory toxicities included grade 1/2 bilirubin (52%) and grade 3/4 bilirubin (3%). Objective response rate was
91.9% with complete response in 67.6% of lesions. Minor complications included vessel spasm treated with nitroglycerin and portal
vein thrombus in treated lobe. No 30-day mortalities were observed.
Pre-treatment tumor diameter (p=0.012) and BCLC-A (p=0.013) were
predictive of mRECIST complete response.
Conclusion: TACE utilizing ET-ARM is safe and effective. In our multicenter cohort, BCLC-A and pre-treatment tumor diameter predicted mRECIST complete response. Doxorubicin dose did not predict imaging response. Further research is warranted to determine
if doxorubicin dose may be reduced utilizing ET-ARM with favorable
imaging response.

P-415
Lung shunt fraction in radioembolization: antireflux
microcatheter versus end-hole catheters
J.Titano1, A.Arepally2, A.Pasciak 3, A.Fischman4
1Radiology, Icahn School of Medicine at Mount Sinai, New York,
NY, United States of America, 2Interventional Radiology, Piedmont
Healthcare, Atlanta, GA, United States of America, 3Radiology,
Tennessee Graduate School of Medicine, Knoxville, TN, United States
of America, 4Department of Vascular and Interventional Radiology,
Icahn School of Medicine at Mount Sinai, New York, NY, United States
of America
Purpose: Radiation pneumonitis is a potential complication of
radioembolization (RE) in patients with a high lung shunt fraction
(LSF). Antireflux catheters (ARM) have been shown to increase tumor
Y-90 uptake; however, their effect on LSF has not been quantified.
We compared LSF following use of ARM (Surefire Infusion System,
Surefire Medical, Westminster, CO) to LSF using end-hole catheters.
Material and methods: To date, two randomized studies utilizing
ARM for RE have been completed. We performed a post-hoc analysis
of infusions performed with ARM and with end-hole catheters comparing LSF in each group. Procedure data included tumor pathology,
infusion catheter, and LSF. LSF was quantified using 99m-Tc MAA
scintigraphy. ARM and end-hole catheter infusion LSFs were compared in aggregate and stratified by tumor type.
Results: Forty-eight infusions were performed: 24 ARM and 24 endhole catheter. Tumor pathology was HCC in 58.3% of all cases. The
mean (standard deviation) LSF in the ARM group was 6.7% (6.3%)
and in the end-hole catheter group was 7.9% (7.7%). In aggregate,
there was no statistically significant difference between LSF measured in either group (p = 0.554). When stratified by tumor type, no
statistically significant differences were identified between ARM and
end-hole catheter LSFs in either the HCC subgroup (p = 0.274) or the
non-HCC subgroup (p = 0.699).
Conclusion: The use of an ARM had no measurable effect on LSF
in RE. Incidence of radiation pneumonitis is not expected to differ
when an ARM is used compared to a conventional microcatheter.

SS/FC/HL/HTS/CM
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S291

P-416
IR fellows professional identities and values across four
American medical centers
E.J.Keller1, S.A.Resnick1, S.O.Trerotola2, K.Valji3, M.S.Johnson4,
R.L.Vogelzang1
1Radiology, Northwestern University, Chicago, IL, United States of
America, 2Interventional Radiology, University of Pennsylvania
Medical Center, Philadelphia, PA, United States of America, 3Radiology,
University of Washington, Seattle, WA, United States of America,
4Section of Interventional Radiology, Indiana University Hospital,
Indianapolis, IN, United States of America
Purpose: To better understand what current interventional radiology (IR) fellows value about the field, their training, and their professional roles.
Material and methods: Sixteen fellows from 4 institutions, all
within the first months of training, were interviewed in a semi-structured format to facilitate a conversational tone. Fellows were asked
about a recent patient interaction, what led them to IR, their goals
during/after fellowship, what makes IR unique, and follow up questions for additional detail. An in-depth qualitative analysis of interview transcripts was then performed by two reviewers according to
the constructivist grounded theory, a well-validated method from
anthropology for investigating social processes.
Results: Fellows interest in IR tended to have migrated from either
diagnostic radiology or surgical fields. Reasons for pursuing IR came
from a desire to move away from aspects of the previous field of
interest toward perceived values of the opposite (radiology/surgery). These motivations tended to correlate with what they valued
most about IR, hoped to gain from their training, and hoped to do
after their fellowship. Common IR values included thinking on ones
feet, being hands-on, fixing problems, having to know it all, technical skill, and interpersonal skill. Descriptions of patient care were primarily limited to consent, the procedure, and brief follow up.
Conclusion: Even at the beginning of fellowship, IR fellows tend to
prioritize a blend of radiological and surgical values. The predominant absence of more clinical identities suggests that efforts to instill
and/or select for clinical values may be limited compared to fields
such as interventional cardiology.

P-417
Medical students understanding of interventional radiology
(IR): time for an undergraduate IR curriculum
Z.Alsafi1, V.Bhrugubanda2, S.Ramachandran2, A.Alsafi2,
M.S.Hamady2
1Medical School, UCL, London, United Kingdom, 2Radiology, Imperial
College Healthcare NHS, London, United Kingdom
Purpose: Interventional radiology (IR) is traditionally underrepresented in undergraduate medical curricula. Final-year medical students ought to be familiar with some common IR procedures in order to make adequate referrals and work-up patients
appropriately.
We evaluated the knowledge of final-year medical students on common IR procedures and compared it with their knowledge on other
specialties.
Material and methods: An 11-question, single-best-answer questionnaire assessing the knowledge on IR procedures and other minimally invasive non-IR procedures was administered to a group of
final-year medical students.
The questionnaires were marked, and the results were evaluated. A
paired two-tailed Students t-test was used to compare knowledge
across specialties. Graphpad Prism was used for statistical analysis.
Results: Fifty-one questionnaires were administered and returned.
Four students omitted answering one question each. One student

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answered all questions correctly. The median score was 6/11. The
best answered question was on coronary intervention followed by
neurosurgical procedures. The average score for IR procedures was
40% and that for non-IR procedures was 64% (P < 0.0001). While
most students had come across IR previously, 70% stated that they
would like further exposure.
We also accessed the undergraduate curricula of four London
Medical Schools; all four have a dedicated radiology curriculum, but
only one has a dedicated IR section.
Conclusion: Medical students lack of IR exposure translates into a
lack of appreciation of the role of the specialty. CIRSEs undergraduate curriculum can be adapted by individual medical schools to suit
their specific needs and bridge this knowledge gap.

P-418
Following a zero tolerance approach to inadequate patient
preparation for interventional radiology procedures:
implementation and early experience
R.D. White
Department of Clinical Radiology, University Hospital of Wales, Cardiff,
United Kingdom
Purpose: Initial audit of patient preparation for interventional radiology (IR) procedures in our centre showed 57% compliance, which
was considered unacceptably low. Inadequate preparation poses
significant and avoidable safety risks to patients (including knockon effects from prolonged inpatient stays due to cancelled or
postponed procedures). We initiated a Zero Acceptance for Poor
Patient Preparation (ZAPPP) approach with the aim of improving
compliance with preparation, with subsequent reaudits to assess
compliance.
Material and methods: A series of improvement measures were
taken, including taking pre-procedural instruction forms to the
ward for each patient, updating departmental guidelines, creating letters for ward staff and consultants responsible for inadequately prepared patients, updating patient information, and giving presentations to ward staff. Patient safety representatives were
consulted and medical director approval was granted to move to a
zero tolerance approach in inadequately prepared IR cases. After a
trial period (no patients cancelled unless absolutely unsafe to proceed and responsible medical/nursing staff informed and educated
them) and with specific exclusions from the policy (e.g. emergency/
urgent cases), ZAPPP officially went live. Number of cases which had
been inadequately prepared (and reasons for this) was subsequently
reaudited.
Results: There was an immediate and significant improvement in
compliance with patient preparation, rising from 57% pre-ZAPPP to
86% in the first month and >80% over the initial 9 months.
Conclusion: Implementing ZAPPP in IR is feasible, improves safety,
and has been greeted with positive feedback from clinical staff and
at board level. ZAPPP is an ongoing process with regular meetings,
and ways for further improving compliance are being sought and
implemented.

Abstract Book

P-419
A functional model for measuring competence in
interventional radiology: a national society of radiology
experience
P.ValdesSolis1, M.D.Ferrer-Puchol2, T.MorenoSnchez3,
F.Galindo4, J.L.delCura-Rodriguez5
1Radiology, Hospital Costa del Sol, Marbella, Spain, 2Radiology,
Hospital Universitario La Ribera, Alzira, Spain, 3Interventional
Radiology, Juan Ramon Jimnez Hospital, Huelva, Spain, 4Human
Resources, Hospital Costa del Sol, Marbella, Spain, 5Radiology, Hospital
Universitario de Basurto, Bilbao, Spain
Purpose: A national society of radiology has developed a new
model of competence measurement, based upon the functions of
radiologists. Its aim is to fulfill the requirements of any system aimed
at evaluating physician performance: formal, proactive, objective,
reproducible, fair, and responsible.
Material and methods: This model is based upon functions: we
defined what radiologists do and how they should do it. In order to
define functions, groups of experts worked in teams, directed by an
expert in competences. These functions were defined from the simplest to the most complex. The latest function is what we called element of competence, which can include in one or many procedures.
The elements of competence are grouped in three levels (I, II, and III)
according to their difficulty. Level I elements are those that any radiologist should be able to perform. Level III elements are the most
difficult ones. After designing the map of elements of competence,
we began to work in all of them. To achieve this, we worked online,
and designed a card for every element of competence. Each of these
cards includes: Title, Code, Procedures, Level, Quality requirements,
Evidences, Acquisition requirements, Maintenance of competence,
Grades, and References.
Results: The experts considered that radiologist have four main
functions: Acquire images, Diagnose, Treat, and Manage. From these
functions, the three resulted in 31 elements of competence in interventional radiology. All this material was published in a book. The
certification process is in progress.
Conclusion: We show a new model of evaluating competence in
interventional radiology.

P-420
Limitations reported in current interventional radiology
literature: a systematic review
M.Kuang1, W.Warnica1, M.Wang1, B.Davis1, H.R.Khosravi2,
M.Midia3
1Michael G. DeGroote School of Medicine, McMaster University,
Hamilton, ON, Canada, 2Medical Physics and Applied Radiation
Sciences, McMaster University, Hamilton, ON, Canada, 3Radiology,
McMaster University Medical Centre, Hamilton, ON, Canada
Purpose: To describe and summarize limitations reported in the current interventional radiology (IR) literature.
Material and methods: A MEDLINE database search was performed
to extract articles from Journal of Vascular and Interventional
Radiology and Cardiovascular and Interventional Radiology from
January 2013 to September 2015. Peer-reviewed original research
studies were included, and abstracts, basic science studies, case
reports, commentaries, conference proceedings, guidelines, and
reviews were excluded. In total, 626 articles were included and
assessed by four independent researchers. Reported limitations
were identified and categorized.
Results: In total, 953 limitations were identified and grouped into
18 categories, including retrospective nature of study (45.5%),
small sample size (42.0%), limited/lack of follow-up (20.4%), lack of
comparison/control group (18.2%), inconsistency and/or lack of

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standardization in protocol (18.1%), selection bias (14.9%), missing
data/records (13.9%), single institution (11.7%), nonrandomized trial
(11.5%), confounding factors not addressed (11.3%), technological
limitations (11.0%), lack of generalizability to the population at large
(8.9%), assumptions/over simplification (7.2%), no histopathological confirmation (5.3%), heterogeneous population (5.1%), outcome
not quantifiable/quantified (3.4%), non-blinded outcomes (2.6%),
and self-reported outcomes (2.1%), among others. On average, retrospective studies reported more limitations (3.15) than prospective
studies (2.50).
Conclusion: The top three limitations reported in the current IR literature include the retrospective nature of the study, small sample
size, and limited/lack of follow-up. Given this, using prospective data
repositories, collaboration across the IR community and establishment of standardized practice patterns could potentially improve
the quality of IR literature.

P-421
A survey of interventional radiology resources in Canada 2015State of the Nation
S.Modi, H.Baydoun, A.Gotra, K.Muchantef, L.-M.N.J.Boucher,
T.Cabrera, C.Torres, D.A.Valenti
Radiology, McGill University Health Center, Montreal, QC, Canada
Purpose: To assess the state of interventional radiology (IR)
resources in Canada and to establish if there have been significant
changes compared to a previous survey in 2011.
Material and methods: A web-based survey (using SurveyMonkey)
was sent to hospital sites providing IR in Canada. Findings were compared to the results of a survey sent in 2011.
Results: 76% (32/42) of responses were from tertiary hospitals.
Technologist needs are met according to 78%. Mean number of
technologists/room was 1.6 vs consensus requirement of 1.8. There
remains a gap in nurse numbers: 1 nurse (previously 0.9) per suite
(0.4-2) vs consensus requirement of 1.5. However, 66% felt that nursing numbers were adequate. 68% of centres have a radiology recovery room (RRR), which is an improvement compared to 2011 (32%).
At sites with RRR, 52% have inadequate beds, and 41% have inadequate nurses for beds. 71% of sites with no RRR facility do not have
access to adequate beds in hospitals. 78% of institutions provide oncall services, performing 0-15 cases/week. On-call nursing services
are under-resourced (45%-no nurse), whereas technologist staffing is adequate. Over 60% of sites need additional IR suites; 20%
increase from 2011. Responders perceived increases in DVT/venous
intervention, interventional oncology, and vascular work. Since 2011,
there have been improvements in availability of specialist equipment. 80% (previously 75%) have an ablation machine, and 60%
have a thrombectomy device (previously 33%).
Conclusion: Although there have been improvements, namely an
increase in the number of RRRs and specialist equipment (thrombectomy and ablation devices), the majority of resources are
unchanged. There remain shortages in nurses, particularly on-call.
The effects of these shortages are further exacerbated by the perception of an increase in demand for IR suites and expected workload increases. This survey highlights the ongoing struggles faced
by departments and a lack of significant improvement in 4 years.

SS/FC/HL/HTS/CM
Posters

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P-422
Comparison of percutaneous marking for small pulmonary
lesions using the dye emulsion versus a short hook wire before
video-assisted thoracoscopic surgery
K.Sawada1, M.Yabuta2, Y.Ishizaka1, A.Okumura1, T.Koyama1
1Diagnostic Radiology, Kurashiki Central Hospital, Okayama, Japan,
2Radiology, St. Lukes International Hospital, Tokyo, Japan
Purpose: To compare percutaneous marking using the dye emulsion (a mixture of diagnogreen, fat emulsion, and lipiodol) with
using a short hook wire before video-assisted thoracoscopic surgery
(VATS).
Material and methods: One hundred twelve patients (60 men, 52
women; mean age, 67.8 years) underwent percutaneous marking
using the dye emulsion for a small pulmonary lesion before VATS
between July 2010 and October 2014, and 86 patients (38 men, 48
women; mean age, 65.8 years) underwent percutaneous marking
using a short hook wire between September 2005 and September
2010. Primary endpoint was the incidence rate of pneumothorax.
Secondary endpoints were technical success rate, the rate of the
successful localization of target lesions during VATS, and the rate of
the successful localization of target lesions in resected specimens.
Results: There were no significant differences between percutaneous marking using the dye emulsion and using a short hook wire
with regard to technical success rate (95.5% vs 96.5%) and the rate
of the successful localization of target lesions during VATS (96.5%
vs 97.7%) and in resected specimens (100% vs 100%). The incidence
rate of pneumothorax using the dye emulsion was significantly
lower than that using a short hook wire (49.1% vs 65.1%, P<0.05).
Major complication such as air embolization was not noted in two
groups.
Conclusion: The incidence rate of pneumothorax after percutaneous marking using the dye emulsion prior to VATS was significantly
lower than that using a short hook wire.

P-423
Radiofrequency ablation of benign thyroid nodules: a
prospective multicenter study
S.L.Jung1, J.H.Baek 2, J.H.Lee2, J.Y.Sung3, K.S.Kim3, D.Lee3,
J.-H.Kim4, J.Sim5, S.M.Baek6, D.G.Na6, Y.K.Shong7
1Radiology, Seoul St. Marys Hospital, The Catholic University of Korea,
Seoul, Korea, 2Department of Radiology and Research Institute of
Radiology, University of Ulsan College of Medicine, Asan Medical
Center, Seoul, Korea, 3Radiology, Daerim St. Marys Hospital, Seoul,
Korea, 4Radiology, Seoul National University College of Medicine, Seoul,
Korea, 5Radiology, Withsim Clinic, Seoul, Korea, 6Radiology, Human
Medical Imaging & Intervention Center, Seoul, Korea, 7Department
of Endocrinology and Metabolism, University of Ulsan College of
Medicine, Asan Medical Center, Seoul, Korea
Purpose: To demonstrate the efficacy and safety of thyroid RF ablation for nonfunctioning thyroid nodules by trained radiologists with
unified protocol and similar devices.
Material and methods: All patients gave written informed consent
to participate in this prospective, multicenter, institutional review
boardapproved study. From May 2010 to December 2011, 360
nodules from 345 nodules from 345 patients (M:F = 43:302, mean
ageSD, 46.012.7 [range, 15-79] years) who met the eligibility criteria and gave written informed consent were enrolled. All operators performed RF ablation with a cool-tip RF system and two standard techniques (trans-isthmic approach and the moving shot technique). The primary outcome was volume reduction at the 12-month
follow-up. The therapeutic success, improvement of symptoms and
cosmetic problems, and complications were evaluated. Multiple linear regression analysis was used to identify factors independently
predictive of volume reduction.

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Results: Regarding the primary outcome, the volume reduction at

the 12-month follow-up was 80.313.7% (n=276; range, 38.7-100%).
The mean volume reduction at the 24-, 36-, 48-, 60-month follow-ups were 84.313.2% (n=198; range, 36.1-100%), 89.210.8%
(n=128; range, 45.5-100%), 91.98.4% (n=57; range, 69.9-100%),
and 95.34.3% (n=6; range, 88.5-100%), respectively. Our therapeutic success was 97.8% (270/276); mean symptom and cosmetic
scores showed significant improvement (P<0.001 and P<0.001,
respectively). Major complication rate was 1.0% (3/276). Solidity
and applied energy were independent factors predicting volume
reduction.
Conclusion: Trained radiologists using unified protocol and similar
devices can achieve effective and safe results for benign nonfunctioning thyroid nodules.

P-424
Radiofrequency ablation for benign thyroid nodules:
indications, treatment, and results
V.A.Solovov, A.A.Makhonin, M.O.Vozdvizhenskiy
Interventional Radiology, Samara Oncology Centre, Samara, Russian
Federation
Purpose: The aim of the study was to analyze the efficacy of radiofrequency ablation (RFA) for symptomatic and autonomously functioning benign thyroid nodules.
Material and methods: The analysis included the results of treatment of 350 patients with benign nodules of the thyroid gland,
received RFA at the Samara Oncology Center during 20142015. In
total, 140 (40%) patients had autonomously functioning thyroid
nodules and 210 (60%) patients had symptomatic ones. To exclude
malignant nodules, TIRADS and Bethesda systems were used.
Results: After RFA, nodule volume reduced by 72% after 6 months
and 81% after 12 months, and RFA was an effective method for treating nodule-related clinical problems and hot nodules. Cosmetic
results were excellent in 99% of patients. No serious complications
such as thyroiditis, voice change, and hematomas were observed.
Conclusion: RFA was effective and safe for treating benign thyroid
nodules with no serious complications, and it may be recommended
as an alternative to surgery.

P-425
One-year follow-up in patients treated with ultrasound-guided
percutaneous radiofrequency ablation of benign thyroid
nodules: therapeutic efficacy and safety of the technique
P.Rabuffi1, S.Vagnarelli1, A.Bruni1, D.Morosetti1, A.Spada2,
A.Santonati2, D.Bosco2, C.Ambrogi1
1Department of Interventional Radiology, Azienda Ospedaliera San
Giovanni Addolorata, Rome, Italy, 2Department of Endocrinology,
Azienda Ospedaliera San Giovanni Addolorata, Rome, Italy
WITHDRAWN

P-426
Acute effects of Shexiang Tongxin dropping pills in patients
with coronary slow flow phenomenon
S.Wang1, L.Chu1, Z.Xu1, G.Li2, C.Cui2, J.Chen1, N.Huangfu1
1Department of Cardiology, Ningbo Hospital of Zhengjiang University,
Ningbo First Hospital, Ningbo, China, 2Department of Cardiology, The
First Affiliated Hospital, Xian Jiaotong University College of Medicine,
Xian, China
Purpose: To investigate the acute effect of the traditional Chinese
medicine Shexiang Tongxin dropping pills (STDP) on patients with
coronary slow flow phenomenon (CSFP).

Abstract Book
Material and methods: In total, 22 patients with CSFP were
screened using corrected thrombolysis in myocardial infarction
(TIMI) frame counted (CTFC) on coronary angiography (CAG) (30
frames/second). CAG was performed 5 minutes after the sublingual administration of 4 pills of STDP. The acute coronary flow, blood
pressure and heart rate were determined prior to and after the
administration of STDP.
Results: There was a significant difference in blood flow frames and
CTFC between the two groups (P<0.05). CTFC values prior to and
after the administration of STDP were 48.0013.32 and 41.8015.38
for the left anterior descending artery (P<0.05), 59.004.69 and
50.009.04 for the left circumflex coronary artery (P<0.05) and
51.908.40 and 40.0910.46 for the right coronary artery (P<0.05),
respectively; the corresponding improvement rate was 12.92%,
15.25% and 22.76%, respectively. The overall average CTFC was
49.9810.01 and 40.4211.33 (P<0.05), respectively, prior to and after
the admnistration of STDP, with an improvement rate of 19.13%. No
significant differences were detected regarding the heart rate, blood
pressure, and renal as well as liver function before and after the
administration of STDP.
Conclusion: There is an obvious acute effect of STDP on patients
with CSFP. STDP can improve the coronary flow without influencing the blood pressure and heart rate, indicating its potential in the
treatment of myocardial ischemia.

P-427
Accurate and reliable wire position tracking without
fluoroscopy using a 3D navigation system for angiography in
the left renal artery: a phantom model study
T.Kariyasu1, K.Kuroki2, Y.Masuda1, S.Katase1, H.Tateishi1,
K.Soejima3, Y.Hosoi4, T.Ikezoe4, J.Shudo5, T.Iwamoto5, T.Nitatori1
1Department of Radiology, Kyorin University Faculty of Medicine,
Tokyo, Japan, 2Department of Medical Radiological Technology, Kyorin
University Faculty of Health Sciences, Tokyo, Japan, 3Department
of Cardiology, Kyorin University Faculty of Medicine, Tokyo, Japan,
4Department of Cardiovascular Surgery, Kyorin University Faculty of
Medicine, Tokyo, Japan, 5Department of Radiology, Kyorin University
Hospital, Tokyo, Japan
Purpose: A 3D electromagnetic cardiovascular navigation system
(MediGuide) was developed to minimise fluoroscopic exposure by
visualising the real-time location of catheters on pre-recorded cine
loops. However, MediGuideis now available only in electrophysiology (EP) catheterisation laboratories; no data are currently available
to assess the accuracy of the use of MediGuide as a vascular navigation platform for human trunk arteries. We performed a phantom
model experiment to ensure the exact and reproducible placement
of catheters in the left renal artery.
Material and methods: Human phantom: Endovascular evaluator
model (EVE) with water circulator, MediGuide enabled guidewire
and Artis Zee interventional system.
X-ray cine loop was recorded in three different fluoroscopic views
(RAO, LAO and AP). A guidewire was then introduced into the left
renal artery under the guidance of the MediGuide marker on the
recorded cine loops. No fluoroscopy was used. Location of the sensor detected by the MediGuidesystem was projected real time on
the pre-recorded cine loops and recorded as a movie file. The system accuracy was assessed by the frame-by-frame analysis of the
displacement between the projected sensor icon and their corresponding representation on fluoroscopic cine loops.
Results: The sensor-enabled guidewire could be visualised and
tracked without fluoroscopy. The mean displacement of the sensor
icon was 0.300.16 mm from the target. The system accuracy was
not affected by various C-arm angulations (RAO: 0.290.12 mm; LAO:
0.310.20 mm; AP: 0.290.15 mm).

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Conclusion: The MediGuide system is expected to be useful for
the angiography of the trunk of the body by accurately representing
catheter position without fluoroscopy.

P-428

SS/FC/HL/HTS/CM
Posters

S295

IL 4, p=0.57), although 3 cases of leg edema with wound infection

were seen in the PL group and none were seen in the IL group.
Conclusion: The technical and clinical success of TDEs performed
for traumatic chylous leaks with IL are similar to those performed for
the leaks with PL, while the total procedure time is reduced by 50
minutes on average. This supports the adoption of IL for TDEs.

Pediatric PICCs: when to give up

C.Kaufman, E.Reiner, D.Silin, B.Dillon
Department of Radiology and Biomedical Imaging, Yale New Haven
Hospital, New Haven, CT, United States of America
Purpose: To evaluate risk factors of difficult or failed PICC placement
in patients under 2 years old.
Material and methods: A single-institution retrospective review of
all peripherally inserted central catheters placed in patients 2 years
of age in interventional radiology (IR) from 1/1/2014 to 12/31/2015
was performed. Procedural images, dictations, and electronic medical records were reviewed for demographic information, prior central lines, type of anesthesia, procedure time, and fluoroscopy time.
Results: Thirty-three PICCs were placed in children 2 in IR during
the study period. Fourteen had easy PICC placement, 6 had difficult
but successful PICC placement, and 13 had failed upper extremity
PICC. Patient age <6 months did not correlate with longer procedure
time (p=0.491) or higher rate of failed procedures (p=0.2). The mean
procedure time for easy successful PICC placement was 25 minutes,
with a mean fluoroscopy time of 1.2 minutes, versus in the difficult/
failed PICCs the mean procedure time was 1 hour and 21 minutes,
with a mean fluoroscopy time of 2.6 minutes. This difference was
statistically significant with p=0.001 for the mean procedure time
and p=0.01 for the fluoroscopy time.
Conclusion: Patients with difficult or failed upper extremity PICCs
had significantly longer procedure and fluoroscopy time. This
exposes these young children to greater risk of complications from
radiation and anesthesia. Our results suggests that if an extremity
PICC is not successfully after 30 minutes, one should consider central
venous access via another approach.

P-429
Comparison of pedal and intranodal lymphangiography for
thoracic duct embolization (TDE) of traumatic chylous leaks
G.J.Nadolski1, Y.Dori2, J.Johnstone2, M.Itkin1
1Radiology, Hospital of the University of Pennsylvania, Philadelphia,
PA, United States of America, 2Cardiology, Childrens Hospital of
Philadelphia, Philadelphia, PA, United States of America
Purpose: Intranodal lymphangiography (IL) is a recently described
technique to perform TDE. This study compares outcomes between
IL and traditional pedal lymphangiography (PL) for TDE to treat traumatic chylous leaks.
Material and methods: Review of 177 patients (97 males, median
age 62 years) referred for TDE to treat traumatic chylous leak from
2002 to 2015 was performed. Records were reviewed for mechanism
and site of chylous leak, procedural time, and technical and clinical success. Patients were grouped by means of lymphangiography,
pedal (PL), or intranodal (IL).
Results: In total, 110 patients had TDEs with PL, while 67 patients
had TDEs with IL. Etiology and site of leak did not differ between
groups (p=0.74 and p=0.98, respectively). Median number of lymphangiograms and embolizations were 1 for both groups (p=0.1 and
p=0.56, respectively). TD cannulation was successful during the first
procedure in 87 PL (80%) compared to 55 IL (82%, p=0.7). The mean
total procedural time was 169 minutes (95% CI:154-185) for PL compared to 118 minutes (95% CI:103-133) for IL (p<0.001). Clinical success was achieved after 90 PL TDEs (82%) compared to 63 IL TDEs
(94%, p=0.042). Complications were similar in both groups (PL 10,

P-430
Microwave radiometry thermometry for the non-invasive
diagnosis of arterial vascular disease in patients with
suspected critical limb ischemia: a feasibility study
S.Spiliopoulos1, V.Theodosiadou2, P.M.Kitrou2, N.Barampoutis3,
K.N.Katsanos4, P.Davlouros3, D.Alexopoulos3, E.Siores5,
D.Karnabatidis2
12nd Radiology Department, Division of Interventional Radiology,
ATTIKO University Hospital, Athens, Greece, 2Department of
Interventional Radiology, University Hospital of Patras, Patras, Greece,
3Cardiology, Patras University Hospital, Patras, Greece, 4Interventional
Radiology, Guys and St. Thomas Hospitals, London, United Kingdom,
5Institute for Materials Research and Innovation, University of Bolton,
Bolton, United Kingdom
Purpose: Diagnosis of vascular involvement in diabetic foot disease remains challenging. We conducted a proof-of-concept study
to investigate the feasibility of microwave radiometry thermometry
(MWR) for the non-invasive diagnosis of critical limb ischemia (CLI).
Material and methods: This prospective study included 60 patients
equally divided into four groups (group N: normal patients; group
DN: diabetic patients with verified neuropathic ulcers without vascular involvement; group DC: diabetic patients with CLI; and group
NDC: non-diabetic CLI patients with CLI). Vascular disease was interrogated with diagnostic angiography. All patients underwent MWR
(RTM-01-RES; University of Bolton, UK) to record mean tissue temperatures in various pre-determined limb sites. Temperature measurements between study groups were compared using one-way
ANOVA and Dunn tests. Sensitivity and specificity of MWR as well as
the determination of a cut-off value for diagnosis of ischemic foot
disease were determined by ROC analysis.
Results: Temperatures recorded in vicinity to the foot ulcers of
diabetic CLI patients were similar to those recorded in vicinity to
the foot ulcers of non-diabetic CLI patients, but significantly lower
than those recorded in vicinity to the foot ulcers of patients with
solely neuropathic ulcers and patients without vascular involvement (group DC: 29.78oC2.13oC vs. group NDC: 29.18oC2.52oC vs.
group N: 32.98oC0.44oC vs. group DN: 33.38oC1.05oC; p<0.0001).
According to ROC analysis, the cut-off temperature value to diagnose ischemic foot disease was <32.3oC (area under the curve: 0.937;
95%CI: 0.861.00; p<0.001), with a sensitivity of 96.7% (95% CI: 82.8
99.9) and specificity of 84.0% (95% CI: 63.995.4).
Conclusion: MWR could be a very useful tool for the non-invasive
definitive diagnosis of arterial ischemic foot disease in patients with
suspected critical limb ischemia.

P-431
The implementation of the Exoseal vascular closure device for
transpopliteal artery puncture
.Balli, V.akir, R.Pekevik, S.Gr
Interventional Radiology, zmir Katip elebi University Atatrk Training
and Research Hospital, zmir, Turkey
Purpose: The purpose of this study is to assess the efficacy and
safety of using the Exoseal vascular closure device (VCD) for hemostasis in transpopliteal artery puncture.
Material and methods: The Exoseal VCD implementation, used
to achieve homeostasis in a transpopliteal approach in a total of

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37 procedures in 23 patients from May 2013 to February 2015 with

lower extremity arterial disease, was reviewed retrospectively. All
popliteal artery punctures were performed under ultrasonography
and fluoroscopy guidance in the prone position. After the procedure, the patients were monitored for 4-6 hours and evaluated with
ultrasonography in terms of puncture site complications. Follow-up
was performed in the first week, and then 1, 3, 6, and 9 months and 1
year after the treatment and annually thereafter.
Results: In one (3%) of 37 procedures, the Exoseal delivery shaft
was not placed properly due to inappropriate insertion angle of the
introducer sheath (>45). In one procedure, because of high blood
pressure, plug could not been deployed. Hemostasis was achieved
by manual compression in these two procedures. Minor hematoma
developed in one procedure. This patient was admitted to the interventional radiology ward for a day and evaluated for hematoma size
and distal blood flow with Doppler ultrasonography. In one procedure in the first week of follow-up, an arteriovenous fistula was
found, and this patient underwent reintervention.
Conclusion: The Exoseal VCD can be safely used for retrograde
puncture of the popliteal artery, with a high procedural success rate
(95%) and a low rate of access site complications (5%).

P-432
Interventional radiology (IR) procedural training using Thiel
cadaver simulation models: trainee survey
J.Anwar1, H.M.McLeod2, J.Robertson2, R.Duncan2, T.Wilkinson3,
M.Gueorguieva2, R.Bhat4, A.Barclay4, A.Melzer2, J.G.Houston1
1Clinical Radiology, Ninewells Hospital, Dundee, United Kingdom,
2Institute for Medical Science and Technology, University of Dundee,
Dundee, United Kingdom, 3Centre for Anatomy and Human
Identification, University of Dundee, Dundee, United Kingdom,
4Radiology, NHS Tayside, Dundee, United Kingdom
Learning Objectives:
1. To understand the potential for Thiel cadaveric models in IR
training.
2. To review trainee opinions of using these models in a range of IR
procedure courses.
Background: We have developed and used Thiel cadaver simulation models for interventional radiology training on courses hosted
by our institution. We assessed trainee experiences with Thiel
cadaver simulation models for a variety of interventional radiology
procedures: fluoroscopic liver intervention, CT-guided liver intervention and aorto-iliac intervention. Questionnaires assessed three
main themes: the degree of clinical/anatomical simulation provided
by Thiel cadavers compared with in vivo; how this model compares
to other simulation models for training and, finally, as to whether
trainees are uncomfortable using cadaveric models for training.
Clinical Findings/Procedure: In all, 57/59 attending trainees participated in the surveys; 47/56 (84%) agreed or strongly agreed that the
anatomy was realistic and comparable to in-vivo conditions, with
none disagreeing; 37/57 (65%) felt that operative tactility was comparable to in vivo conditions, with only 1 (2%) disagreeing; 46/57
(81%) felt that the cadaveric session successfully replicated the target clinical experience with only one (2%) disagreeing; 40/57 (70%)
agreed that the cadaveric model was superior to other teaching
models, although 4 (7%) disagreed; 11/57 (19%) were uncomfortable, 9 (16%) were unsure and 37 (65%) had no qualms with the use
of human cadavers for training purposes.
Conclusion: In this preliminary assessment of Thiel cadavers in IR
training, trainees reported excellent similarity with in vivo procedures (superior to existing teaching models) and utility as an alternative to animal or synthetic simulators.

Abstract Book

P-433
Diagnostic and interventional radiology in trauma to children:
from head to toe
J.Tisnado, G.Morano, M.Pasyk
Radiology, Virginia Commonwealth University, Richmond, VA, United
States of America
Learning Objectives: IR procedures are safe, easy, and effective,
and can be done without general anesthesia, to solve traumatic injuries in children.
Background: Trauma is the leading cause of death in children. The
incidence and severity of injuries due to trauma is increasing. We
have been taking care of trauma children for about five decades,
and therefore, we present our experience in the radiologic diagnosis and interventional radiologic management of trauma to children
from head to toe. We review conventional plain radiography, US, CT
and MRI for diagnosis and IR management.
Clinical Findings/Procedure: We present illustrative examples of
the most common injuries sustained by children in the head, neck,
chest, abdomen, pelvis and extremities (upper and lower). We briefly
review many IR procedures in trauma based on three main methods:
Embolisation with temporary and/or permanent particles, coils,
glue, etc.
Stent placement of self-expanding, balloon-expandable, covered
and uncovered stents.
Placement of balloon occlusion catheters in rare cases of injuries to
large vessels.
Conclusion: An IR, along with trauma and pediatric surgeons, is an
important member of the team dealing with traumatic injuries to
different organs and systems in children.

P-434
CT-guided pulmonary nodule microcoil localization technique,
misplacement errors, and complications: a pictorial essay
S.R. Alharbi
Radiology, King Saud University, Riyadh, Saudi Arabia
Learning Objectives:
1. To illustrate the technique of CT-guided pulmonary nodule
microcoil localization.
2. To be familiar with intraoperative fluoroscopic guided wedge
resection of pulmonary nodule post localization.
3. To describe various microcoil misplacement errors.
4. To demonstrate complications in microcoil placement.
Background: Fluoroscopy-guided video-assisted thoracoscopic
wedge resection is diagnostic and therapeutic of small pulmonary
nodules. Preoperative pulmonary nodule localization is required to
decrease the rate of conversion to thoracotomy. Various localization
techniques were described in the literature. Microcoil localization to
fluoroscopically guided video-assisted thoracoscopic wedge resection of small lung nodules increased its success rate.
Clinical Findings/Procedure: We describe in detail, with extensive illustrations, the technique of CT-guided pulmonary nodule
microcoil localization and intraoperative fluoroscopic guided wedge
resection of pulmonary nodule post localization. We describe and
illustrate 5 microcoil misplacement errors with explanation. We also
demonstrate 2 complications of microcoil placement.
Conclusion: CT-guided pulmonary nodule microcoil localization is
done preoperatively to fluoroscopy-guided video-assisted thoracoscopic surgical wedge resection. This exhibit will teach viewers the
microcoil localization technique, intraoperative fluoroscopic wedge
resection, various microcoil misplacement errors, and post-microcoil
localization complications.

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P-435
Novel imaging and interventional techniques of the lymphatic
circulation
M.Hsu1, M.Itkin2
1Department of Radiology, Hospital of the University of Pennsylvania,
Philadelphia, PA, United States of America, 2Department of Radiology,
University of Pennsylvania Medical Center, Philadelphia, PA, United
States of America
Learning Objectives:
1. Demonstrate the utility of novel imaging in lymphatic circulation evaluation, particularly intranodal lymphangiography (INL),
dynamic contrast enhanced magnetic resonance lymphangiography (DCMRL), and hepatic lymphangiography (HL).
2. Illustrate how lymphatic abnormalities contribute to the pathophysiology of various diseases.
3. Introduce novel lymphatic interventions, including thoracic duct
externalization, lymph node glue injection, thoracic duct stenting,
and transhepatic lymphatic embolization.
Background: The development of thoracic duct embolization for
treatment of traumatic chylothorax in 1995 pioneered the field of
lymphatic interventions. Innovative lymphatic imaging has recently
improved understanding of the lymphatic circulation and its role
in various diseases, including congenital lymphodysplasia, chylous
ascites, plastic bronchitis, protein-losing enteropathy, hepatic lymphorrhea, and congestive heart failure ascites. This enhanced knowledge of the lymphatic system, combined with improved intra-procedural lymphatic visualization, has facilitated the creation of new
interventional techniques.
Clinical Findings/Procedure: This case-based exhibit will provide imaging of congenital lymphodysplasia, chylous ascites, plastic bronchitis, and hepatic lymphorrhea using INL, DCMRL, and HL.
Key procedural steps in thoracic duct externalization for congenital
lymphodysplasia, lymph node glue injection for chylous ascites, thoracic duct stenting for plastic bronchitis, and transhepatic lymphatic
embolization for ascites will be presented with pertinent pre- and
post-procedural considerations. Finally, summary of outcomes will
be discussed.
Conclusion: Lymphatic interventions are a growing area of IR.
Knowledge of lymphatic abnormalities have improved with the use
of INL, DCMRL, and HL, which has led to development of novel treatments, including thoracic duct externalization for congenital lymphodysplasia, lymph node glue injection for chylous ascites, thoracic duct stenting for plastic bronchitis, and transhepatic lymphatic
embolization for ascites.

P-436
Efficacy and safety of minimally invasive treatment in patients
with benign parathyroid lesions
E.J.Ha1, J.H.Baek 2
1Department of Radiology, Ajou University School of Medicine, Suwon,
Korea, 2Department of Radiology and Research Institute of Radiology,
University of Ulsan College of Medicine, Asan Medical Center, Seoul,
Korea
Learning Objectives: To provide an up-to-date review of minimally
invasive treatment for benign parathyroid lesions focusing on the
efficacy and safety.
Background: Minimally invasive procedures such as percutaneous
ethanol, radiofrequency, laser, and microwave ablations for benign
parathyroid lesions have been introduced in recent years to avoid
the complications of traditional methods such as surgery. However,
the efficacy and safety of these procedures are not well known until
now.

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Clinical Findings/Procedure: This review will provide an introduction to the literature, principles, and advances of minimally invasive
treatments for benign parathyroid lesions, as well as a discussion on
its efficacy, complications, and future, based on current evidence.
Several clinical research papers evaluating the effect of these procedures on the alleviation of parathyroid lesions will be presented
to illuminate the important points, according to their indications
(parathyroid cyst, single parathyroid adenoma/hyperplasia, multiple
parathyroid hyperplasias, recurrent or persistent primary/secondary
hyperparathyroidism after surgery, and patients with multiple endocrine neoplasia type 1).
Conclusion: This educational review can help operators understand
the current evidence of minimally invasive treatment for benign
parathyroid lesions. Minimally invasive treatment may be an effective treatment option in patients with benign parathyroid lesions.

P-437
Comparison of different percutaneous accesses for treatment
of chylothorax
A.S.Jo, B.S.Majdalany
Department of Radiology, University of Michigan, Ann Arbor, MI, United
States of America
Learning Objectives: To discuss clinical indications, initial treatment algorithm, and different routes of percutaneous access of the
thoracic duct in treatment of high-output chylothorax.
Background: Percutaneous thoracic duct embolization is a wellestablished and minimally invasive treatment for chylothorax.
Traditionally, antegrade transabdominal access to the cisterna chyli
or lymphatic ducts is performed after transnodal lymphangiography. Recently, there has been an advent of retrograde access to the
upper thoracic duct via a transvenous route or via direct puncture
under ultrasound and/or fluoroscopic guidance in subjects without
accessible abdominal lymphatics.
Clinical Findings/Procedure: We will first briefly describe the clinical presentation and initial treatment algorithm of patients presenting with chylothorax. We will then review the most common anatomical presentation of cisterna chyli and its tributaries on transnodal lymphangiography. Lastly, we will describe how a traditional
antegrade access to the thoracic duct is performed and introduce
two novel retrograde options for accessing the upper thoracic duct.
Ideally, a lymphangiogram should depict a large cisterna chyli and
its tributaries, allowing an easy antegrade access. However, patients
may present with an inaccessible abdominal thoracic duct due to
severe disruption or anatomical variation. In these select cases, retrograde cannulation can be performed through venous access or
through direct puncture of the supraclavicular thoracic duct under
fluoroscopic and/or ultrasound guidance.
Conclusion: Understanding the normal and variant anatomy of the
central lymphatic system, initial treatment algorithm, and different
means of accessing the thoracic duct can help the operator perform
minimally invasive and potentially lifesaving embolization of the
thoracic duct during the treatment of high-output chylothorax.

P-438
Ultrasound-guided muscle injection of botulinum toxin A in
children: how we do it?
B.L.Connolly1, R.Gnannt1, D.Fehlings2, W.Mubarak1, D.A.Parra1
1Image Guided Therapy, The Hospital for Sick Children, Toronto,
ON, Canada, 2Child Development Program, Holland Bloorview Kids
Rehabilitation Hospital, Toronto, ON, Canada
Learning Objectives: To learn the technique of ultrasound guided
muscle injection of Botulinum Toxin A in children, and to highlight
practical tips and pitfalls for the interventionalist.

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Background: Intramuscular injections of botulinum toxin A is a

well-established procedure performed by developmental pediatricians, with or without ultrasound guidance, caring for children with
severe spasticity. It is an emerging role of pediatric interventionalists
to perform these injections in a controlled environment under general anesthesia/sedation using ultrasound guidance. We must know
sonographic muscular anatomy, useful landmarks, tips and tricks,
technical aspects and risks in performing this procedure safely. A
multidisciplinary team is imperative for the success and safety of this
undertaking.
Clinical Findings/Procedure: In the poster, we explain the preprocedural preparation, including clinical assessment, injection
planning and obtaining informed consent. Intra-procedurally, we
describe limb positioning and preparation on the procedure table,
with detailed images and explanation of the equipment used. As a
major goal of this poster, we illustrate muscle schematics with ultrasound correlation, stressing useful sonographic landmarks to direct
the interventionalist. Additionally, we provide insights into dosing
and neuromuscular mapping, technical tips and potential pitfalls,
which an interventional radiologist may encounter when performing this procedure. The post-procedural management wraps up our
educational poster.
Conclusion: Ultrasound-guided intramuscular injections of botulinum toxin A is a valuable and rewarding service that pediatric interventionalists can safely offer children with severe muscle spasticity.
Awareness of anatomy and technical pitfalls is important. A multidisciplinary team approach is imperative.

P-439
Anatomy, variants, and embryologic development of
the colonic vasculature: implications for the practicing
interventionalist
C.Schlager, R.C.Gaba, A.Lipnik, R.P.Lokken, J.T.Bui, C.E.Ray, Jr.
Radiology, University of Illinois, Chicago, IL, United States of America
Learning Objectives:
1. To become familiar with the development, normal distribution,
and most common anomalies of the colonic vascular supply.
2. To understand the implications for interventional radiologic (IR)
procedures arising from changes in the arterial distribution of the
colon.
3. To review the anatomy of the colonic venous drainage and its
implications for IR procedures.
Background: The colon demonstrates a highly variable vasculature.
This variability may arise from pathology (e.g., Leriche syndrome) or
anatomy (e.g., arc of Buehler) and has significant implications in the
performance of interventions. This educational poster will review
the most common and potentially important vascular patterns
encountered by the interventional radiologist.
Clinical Findings/Procedure: Both radiologic studies (angiography and cross-sectional imaging) and schematic diagrams will be
used to discuss common colonic vascular patterns. These patterns
include but are not limited to the arc of Riolan; the marginal artery
of Drummond; the arc of Buehler; aortic occlusive disease; the normal appearance of the vasa rectae and the level of collateralization
of these vessels; and iliac occlusive disease.
Conclusion: Understanding the vascular supply to the colon is vital
for practicing radiologists and has significant implications for interventions involving this distribution.

Abstract Book

P-440
Adrenal arterial embolisation: a case-based demonstration of
essential anatomical and technical considerations
P.S.Najran, D.Mullan, J.Bell
Radiology, The Christie Hospital NHS Foundation Trust, Manchester,
United Kingdom
Learning Objectives: A case-based demonstration of essential anatomical considerations when performing adrenal embolisation.
Background: Adrenal artery embolisation is a minimally invasive
method of managing acute haemorrhage. Indications are not limited to the acute setting, with applications being applied commonly
in oncology and adrenal hormonal suppression.
Knowledge of the complex adrenal arterial anatomy is essential.
The superior artery arising from the inferior phrenic, middle directly
from the aorta and inferior from the renal artery. For accurate interrogation of the vessels, direct cannulisation and angiogram are
required. Smaller-calibre vessels may limit the embolic agent used,
with coil embolisation becoming problematic, favouring an alternative agent such as particles and glue.
Clinical Findings/Procedure: We present a case of a 65-yearold male with haemorrhagic melanoma metastasis of the adrenal
glands.
Cross-sectional angiography revealed a large haematoma in the left
adrenal gland but no obvious contributing vessel. Aortic catheter
angiography again did not demonstrate the culprit vessel. However,
direct cannulation of the adrenal vessels demonstrated several
pseudoaneurysms originating from the superior adrenal artery,
which were occluded with microcoils.
Two days later, the patient presented with further haemorrhage of
the right adrenal artery. Again, no focus was identified on CT or aortic catheter angiography. Careful cannulisation of the adrenal vessel
revealed a small haemorrhagic focus from the inferior adrenal artery,
which was subsequently embolised.
Conclusion: Adrenal artery embolisation is a minimally invasive
method of managing an acute haemorrhage. This case demonstrates the importance of adrenal arterial anatomy with haemorrhagic foci identified only after careful interrogation of each adrenal
branch.

P-441
Arterial embolisation in priapism
B.Dorobat1, A.C.Carp1, A.Dimitriade1, Y.ElMekkaoui2, G.Iana2
1Department of Angiography and Endovascular Therapy, Bucharest
Emergency University Hospital, Bucharest, Romania, 2Radiology,
Bucharest Emergency University Hospital, Bucharest, Romania
Learning Objectives: We present our experience in the percutaneous management of high-flow priapism with transcatheter embolisation and gelfoam.
Background: High-flow priapism is defined as the state of painless
and permanent erection of the penis which generally develops by
perineal trauma. After differing initial management, all cases underwent arteriography.
Clinical Findings/Procedure: We report four cases of treatment
of arterial priapism by means of radiologic selective transcatheter
embolisation of the internal pudendal artery using an absorbable
gelatin sponge (Gelfoam). In three of the four patients, superselective pudendal and penile angiography demonstrated pathologic
arteriocavernous shunting.
Conclusion: When conservative measures are ineffective, the current treatment of choice for cases of fistula of the cavernous artery
is superselective embolisation of the artery. Prognosis is good with
high probability of preserving the erectile function.

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P-442
Perfused human Thiel-embalmed cadaveric hepatic model:
hi-fidelity teaching model for advanced interventional
radiology simulation training
H.M.McLeod1, B.Cox1, J.Robertson1, R.Duncan1, R.Eisma2,
M.Gueorguieva1, R.Bhat3, A.Barclay3, A.Melzer1, J.G.Houston4
1Institute for Medical Science and Technology, University of Dundee,
Dundee, United Kingdom, 2Centre for Anatomy and Human
Identification, University of Dundee, Dundee, United Kingdom,
3Radiology, NHS Tayside, Dundee, United Kingdom, 4Clinical Radiology,
Ninewells Hospital, Dundee, United Kingdom
Learning Objectives: The requirement for simulation based training within the field of interventional radiology (IR) is widely recognised. The objective of our research was to improve upon the known
limitations of static traditionally embalmed human cadaveric models currently used extensively for advanced surgical training.
Background: Thiel-embalmed human cadavers offer life-like tissue texture, tone and vascular patency. By exploiting these unique
characteristics, human cadaveric models with added function, i.e.
flow within the vasculature and respiratory motion, provide new
opportunities for hi-fidelity simulation training and assessment in
advanced endovascular interventional techniques.
Our research has developed techniques to introduce extracorporeal
flow into the hepatic vasculature and evaluate simulations of clinical
interventions upon this model applying and adapting clinical imaging modalities.
Clinical Findings/Procedure: Extracorporeal flow was introduced
both ante-grade and retro-grade into the portal vasculature via a
number of routes (portal vein, inferior vena cava and biliary tract).
The perfused hepatic system demonstrated improved texture and
tone over the non-perfused tissue. Fluoroscopic imaging with contrast, ultrasound and CT were used to conduct percutaneous interventions, such as biliary drainage and CT-guided ablation.
Additional complexity is introduced to the model by intubation and
mechanical ventilation to provide respiratory movement with MRI
being used to track and validate liver motion.
Conclusion: Thiel-embalmed human cadaveric hepatic model with
extracorporeal flow provides a life-like high fidelity model, offering a robust and novel simulation tool for advanced training in interventional radiology.

P-443
Landscape of medical errors in interventional radiology: entire
pathway of care
F.R.Rawf, C.D.Bicknell, A.W.Darzi, M.S.Hamady
Department of Surgery & Cancer, Imperial College London, London,
United Kingdom
Learning Objectives: To study the whole Interventional Radiology
(IR) pathway of care and describe medical errors that occur by using
a validated computerised error capture tool called FERERI (Failure
Estimation REcord in Radiology Interventions).
Background: Medical errors (ME) are a significant cause of adverse
events and procedural inefficiency. Half of these events are caused
by avoidable errors based on system factors and occur most commonly in surgical disciplines.
Clinical Findings/Procedure: This prospective observational
study was performed on 27 adult patients (14 males) referred to the
IR department at St Marys Hospital/Imperial College London. All
patients provided informed consent for their procedures. A WHO
checklist was followed in all cases. Only elective procedures, which
were purely performed by the IR team, were selected.

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Results: Eighty-eight percent of MEs occurred in the intraoperative

phase of the IR pathway, and about 83% of total errors were nontechnical. The most frequent errors were safety awareness (22.5%),
followed by communication errors (20.5%).
Conclusion: Preventable MEs are frequent across IR; while they
mostly occur in the intraoperative phase, they are commonly nontechnical in nature. Therefore, a robust intervention should be
implemented to address technical and non-technical errors across
the entire pathway.

P-444
Thoracic duct embolization with ethylene vinyl alcohol
copolymer (Onyx)
V.G.Helyar, N.Walker, T.Routledge, T.Sabharwal
Interventional Radiology, Guys and St Thomas NHS Foundation Trust,
London, United Kingdom
A male presented with recurrent chlyothorax in spite of multiple
failed surgical attempts at control. A thoracic duct leak was successfully embolized with Onyx following percutaneous puncture of the
cisterna chyli. Tips and tricks for succesful lymphatic embolization
are discussed.

P-445
Selective retrograde embolization of the chyle duct branch for
post-operative lymph leak
A.Masrani, U.C.Turba, B.Arslan
Interventional Radiology, Rush University Medical Center, Chicago, IL,
United States of America
A 57-year-old woman with post-operative chyle leak in the neck,
non-responsive to conservative management, underwent thoracic
duct embolization. Utilizing basilic vein access, the transected chyle
duct branch was catheterized and embolized using coils and Onyx.
The chyle leak stopped immediately afterward.

P-446
Treatment of a huge post-gastrectomy arterioportal fistula
with coil embolization using flow control with balloon
remodeling
M.Inagaki1, H.Kobayashi1, Y.Someya1, H.Nakai2, Y.Onishi1,
R.Yamashita3
1Department of Radiology, Otsu Red Cross Hospital, Otsu, Japan,
2Department of Radiology, Kyoto City Hospital, Kyoto, Japan,
3Department of Diagnostic Imaging and Nuclear Medicine, Kyoto
University Graduate School of Medicine, Kyoto, Japan
A 62-year-old man with a history of a gastrectomy presented with a
large arterioportal fistula and heart failure associated the fistula. Coil
embolization of the fistula using flow control with balloon remodeling was used to correct the abnormal blood flow.

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Abstract Book

P-447

P-451

Hypohepatia following living donor liver transplantation:

treatment by transcatheter embolization using a simulated
three-dimensional printing vascular model

Clinically successful Penumbra suction thrombectomy of

bilateral pulmonary emboli non-responsive to anticoagulation
A.Masrani, U.C.Turba, B.Arslan
Interventional Radiology, Rush University Medical Center, Chicago, IL,
United States of America

T.Kugiyama1, M.Koganemaru1, H.Horiuchi2, A.Kuhara1,

M.Nabeta3, N.Tanaka1, R.Iwamoto1, M.Kusumoto1, T.Abe1
1Radiology, Kurume University School of Medicine, Kurume, Japan,
2Surgery, Kurume University School of Medicine, Kurume, Japan,
3Emergency and Critical Care Medicine, Kurume University School of
Medicine, Kurume, Japan
We report a case in which the cause of hypohepatia was a stolen
portal vein flow to the inferior vena cava via the portacaval shunt
after liver transplantation; this was treated by transcatheter embolization with an Amplatzer vascular plug using a simulated threedimensional printing vascular model.

A patient with metastatic brain lesions and pulmonary emboli nonresponsive to 7 days of heparinization (unable to extubate) was
referred for pulmonary thrombectomy. Mechanical thrombectomy
was performed using the Penumbra system and resulted in clinical
improvement and extubation. Thrombus resolution was observed
on imaging.

P-452
A case of aorto-bilateral common iliac artery graft presenting
with an arterio-enteric fistula causing life-threatening lower GI
bleeding treated with a covered stent

P-448
Serum adrenal medullary hormones levels during
percutaneous cryoablation for adrenal metastasis from renal
cell carcinoma

S.R. Alharbi
Radiology, King Saud University, Riyadh, Saudi Arabia

Y.Kameoka1, K.Michimoto1, K.Shimizu1, J.Miki2, K.Kishimoto2,

S.Sadaoka1
1Department of Radiology, The Jikei University School of Medicine,
Kashiwa Hospital, Chiba, Japan, 2Department of Urology, The Jikei
University School of Medicine, Kashiwa Hospital, Chiba, Japan

A 57-year-old male, who was a known case of abdominal aortic

aneurysm, underwent aorto-bilateral common iliac artery graft.
He presented to the emergency room with life-threatening lower
GI bleeding due to an arterio-enteric fistula. This was successfully
treated with a covered stent.

Serum adrenal medullary hormones levels were measured during

percutaneous cryoablation for adrenal metastasis from renal cell
carcinoma. Maximum release of adrenal medullary hormones was
observed ten minutes after procedure, which is the duration of thaw
of an iceball.

P-453
Collateral venous pathway: a pitfall of adrenal venous
sampling (AVS) for accurate diagnosis and localization of
aldosterone-producing adenoma

M.AbdalKader, L.Coubeau, J.Lerut, P.P.Goffette

Radiology, Cliniques Universitaires Saint Luc, Woluwe Saint Lambert,
Belgium

K.Seiji1, H.Ota1, K.Omata2, M.Nezu2, Y.Ono2, Y.Iwakura2,

R.Morimoto2, M.Kudo2, F.Satoh3, K.Takase4
1Diagnostic Radiology, Tohoku University Hospital, Sendai, Miyagi,
Japan, 2Division of Nephrology, Endocrinology and Vascular Medicine,
Department of Medicine, Tohoku University Hospital, Sendai,
Miyagi, Japan, 3Division of Clinical Hypertension, Endocrinology and
Metabolism, Tohoku University Graduate School of Medicine, Sendai,
Miyagi, Japan, 4Diagnostic Radiology, Tohoku University Graduate
School of Medicine, Sendai, Miyagi, Japan

We describe an extremely rare life-threatening complication of percutaneous transhepatic portal vein procedure consisting of tension
hemothorax secondary to hepatic artery injury successfully managed by endovascular embolization. The possible explanation is
adhesions in the subphrenic space post-liver transplantation.

In rare cases, venous blood from adrenal adenoma drains into not
only the adrenal central vein but also the collateral pathways such
as the left inferior phrenic vein. To determine the lateralization of
aldosterone secretion correctly, we need to understand and identify
such collaterals.

P-450

P-454

Ultrasound-guided retrograde cannulation of the

supraclavicular thoracic duct for treatment of chylothorax

A rare case of cerebral air embolism caused by pulmonary

arteriovenous malformation after removing a central venous
catheter

P-449
Tension hemothorax, a life-threatening complication of
percutaneous transhepatic access: management and review of
literature

A.S.Jo, B.S.Majdalany
Department of Radiology, University of Michigan, Ann Arbor, MI, United
States of America
A novel approach to accessing the supraclavicular thoracic duct
under ultrasound and fluoroscopic guidance for treatment of chylothorax not amendable to antegrade catheterization via percutaneous transabdominal approach due to lack of accessible cisterna chyli
and lymphatic ducts.

T.Kugiyama1, M.Koganemaru1, A.Kuhara1, M.Nabeta2, N.Tanaka1,

R.Iwamoto1, M.Kusumoto1, T.Abe1
1Radiology, Kurume University School of Medicine, Kurume, Japan,
2Emergency and Critical Care Medicine, Kurume University, Kurume,
Japan
We report a rare case of paradoxical cerebral air embolism after
removing a central venous catheter. This patient had pulmonary
arteriovenous malformation (PAVM). Cerebral air embolism was
treated with hyperbaric-oxygen therapy, and transcatheter embolization was performed for PAVM.

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P-455
Percutaneous closure of a paravalvular leak (PVL) in a patient
with hemolytic anemia and complicated diabetic foot
M.Lewandowski1, A.Wojtarowicz1, M.Pelczarska1, R.Sabiniewicz 2,
J.Gorcy1
1Cardiology, Pomeranian Medical University, Szczecin, Poland,
2Pediatric Cardiology and Congenital Heart Diseases, Medical
University, Gdansk, Poland
WITHDRAWN

Peripheral vascular disease intervention

P-456
Endovenous radiofrequency-powered thermal ablation of the
marginal venous system
W.Uller, W.A.Wohlgemuth
Department of Radiology, University Medical Center Regensburg,
Regensburg, Germany
Purpose: Treatment of the marginal venous system is paramount
in reducing symptoms like venous thromboembolism and preventing complications related to venous insufficiency. The purpose of
this study was to demonstrate that endovenous radiofrequencypowered thermal ablation (RFA) of the marginal venous system in
patients with venous malformations is effective and safe.
Material and methods: A retrospective review of all patients with
venous malformations who underwent endovenous RFA for the
ectatic marginal vein from February 2014 to July 2015 was conducted. The marginal vein was percutaneously assessed under
ultrasound guidance. RFA was performed under fluoroscopy using
ClosureFast (Covidien). Technical success, complications and outcome were noted.
Results: In total, 19 pediatric and adult patients underwent RFA for
treatment of the marginal vein. In 15 cases, RFA was augmented with
ultrasound- and fluoroscopy-guided foam sclerotherapy. In two
patients, additional coils and one vascular plug were placed because
of the diameter of the vessel. Technical success defined as closure
of the marginal vein was noted in all patients. No complications
were noted. At the time of abstract submission, follow-up showed
encouraging results and was still ongoing.
Conclusion: Endovenous RFA is a safe and effective technique for
closure of the marginal vein in patients with venous malformations.

P-457
Retrograde transpedal revascularization of below-theknee arteries in patients with critical limb ischemia after an
unsuccessful antegrade transfemoral approach
J.P.Goltz1, F.Broos1, M.Planert1, M.Horn2, M.Wiedner2,
M.Kleemann2, J.Barkhausen1, E.Stahlberg1
1Department of Radiology and Nuclear Medicine, University Hospital
Schleswig-Holstein, Campus Lbeck, Lbeck, Germany, 2Clinic for
Surgery, University Hospital of Schleswig-Holstein, Campus Lbeck,
Lbeck, Germany
Purpose: To evaluate safety and the technical and clinical success of
endovascular below-the-knee (BTK) artery revascularization by a retrograde transpedal access after failed antegrade attempts.
Material and methods: We retrospectively identified 172 patients
with endovascular BTK revascularization between February 2014
and August 2015. In 16 of 172 patients (9.3%) (10 men, mean age
77.78.8 years), a transfemoral approach had failed and a transpedal
access had been attempted. Using ultrasound guidance, the dorsal

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pedal (n=13) or posterior tibial (n=3) artery was accessed using a

dedicated pedal access set. The procedure was completed in antegrade fashion after exit of the guidewire transfemorally by plain old
balloon angioplasty (POBA). Comorbidities, vessel diameter, and calcification at the access side were recorded. Outcomes analyzed were
technical success, procedural complications, procedure time, crossing (guidewire beyond lesion and intra-luminal) and procedural
(residual stenosis <30% after POBA) success, and limb salvage.
Results: Diabetes, coronary artery disease, and hypertension were
all present in 15 patients (93.8%), and renal impairment and previous amputations were seen in 7 (43.8%). Pedal access vessel calcification was present in 5/16 patients (31.3%). The mean diameter was 1.750.24 mm and the procedure time was 92.423 min.
Technical success was 100%. Retrograde crossing was successful in
12/16 patients (75.0%). Procedural success was observed in 10/16
patients (68.8%), and minor complications occurred in 2/16 patients
(12.5%). Limb salvage was 72.9%, and overall survival was 100% at 12
months. Major amputations after revascularization occurred in 2/16
patients (12.5%).
Conclusion: If an antegrade transfemoral approach to BTK lesions
fails, a retrograde transpedal/transtibial approach may nevertheless facilitate treatment. This approach appears to be safe and offers
high technical and acceptable clinical success rates.

P-458
Agitation thrombolysis and catheter-directed thrombolysis for
patients with massive pulmonary embolism
Y.Bi, X.-W.Han
Department of Interventional Radiology, The First Affiliated Hospital of
Zhengzhou University, Zhengzhou, China
Purpose: To retrospectively evaluate our clinical experience of agitation thrombolysis and catheter-directed thrombolysis (AT-CDT) in
the treatment of massive pulmonary embolism (PTE) patients.
Material and methods: A total of 37 PTE patients were treated
between October 2011 and January 2016; 29 cases of massive
PTE were treated by AT-CDT and 8 cases of non-massive PTE were
treated by catheter-directed thrombolysis (CDT). Clinical outcomes
and mortality were evaluated after treatment, and telephone follow-up was carried out after hospital discharge.
Results: AT-CDT was technically successful in 93.1% (27/29) patients,
with death in 2 cases because of respiratory failure and hematencephalon. Further, 82.8% (24/29) cases were clinically cured and
6.9% (2/29) cases were relieved during hospitalization. Death in 3
cases was due to respiratory failure caused by PTE and that in 2 cases
was due to diseases unrelated to PTE (lung carcinoma/ hemoptysis) during a 201524 days follow-up. For CDT, 7 cases were clinically
cured and 1 case was relieved, with no death. The survival rate of
AT-CDT for massive PTE was lower than that of CDT for non-massive
PTE, although there was no statistical significance.
Conclusion: AT-CDT may be a feasible and effective treatment for
patients with massive PTE, with a survival rate of 50.516.8% for
about 2 years.

P-459
Closure devices for iatrogenic thoraco-cervical vascular
injuries
G.Makris, R.Patel, M.W.Little, J.A.Sutcliffe, A.K.Allouni, M.Bratby,
R.Uberoi
Interventional Radiology, John Radcliffe Hospital, Oxford, United
Kingdom
Purpose: The unintentional arterial placement of a central venous
line can have catastrophic complications. Currently, the treatment
options include pull/compression, surgery, stent grafting or using a

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closure device (CD) to seal the arteriotomy. The purpose of this systematic review is to assess the available evidence regarding the use
of the various CDs for the management of iatrogenic thoraco-cervical arterial injuries (ITCAI).
Material and methods: PubMed, Scopus and Cochrane databases
were searched for clinical studies evaluating the short- and longterm clinical outcomes from the use of closure devices for the treatment of ITCAI.
Results: Twenty-six relevant case-series and case-reports were identified, with a total of 57 patients being studied. In the majority of the
studies, plug-based CDs were used (57%), followed by suture-based
devices (19%). The majority of studies reported good outcomes from
the use of closure devices in terms of achieving immediate haemostasis without any acute complications (98%). Long-term follow-up
data was only available in 6 studies, with only 1 case of carotid pseudoaneurysm being reported 1 month after the procedure. All other
cases (96%) had no long-term complications. Five studies conducted
direct or indirect comparisons between CDs and other treatments
(open surgery or stent grafting), suggesting no significant differences in safety or effectiveness.
Conclusion: The current data on the use of CDs for ITCAIs is supportive of their safety and effectiveness, with a number of significant limitations present. Further research is warranted on the safety
of this approach in order to identify those patients that are likely to
benefit from this treatment modality.

P-460
Usefulness and complications of the Crosser system in heavily
calcified below-the-knee arteries of hemodialysis patients
T. Sato
Radiology, Tsuchiya General Hospital, Hiroshima, Japan
Purpose: The number of PAD patients is increasing. About 300,000
people are hemodialyzed in Japan, and the peripheral artery of
these patients are often heavily calcified and obstructed. As no debulking devices except Crosser is reimbursed in Japan, we use the
Crosser catheter especially in the below-the-knee region. Here, we
report our experience of using Crosser in below-the-knee region.
Material and methods: Between September 2014 and July 2015,
81 CLI patients were treated by Crosser. Sixty one patients (75%)
were hemodialysis patients. Mean age was 71.1 years. Among these
patients, 102 below-the-knee arteries were treated. After guidewire
crossing of CTO or severe stenosis using microcatheter, Crosser was
used for destruction and debulking of the calcified plaque.
Results: Successful recanalization was obtained in 94 cases (92%).
No vessel perforation was observed. We experienced 3 cases of tip
or core wire separation of the Crosser catheter (6%) and 2 cases of
guidewire breakage (2%) during the procedure. In three cases, the
tip and wire fragments were retrieved retrogradely from the groin
by a gooseneck snare. In one case, the tip was retrieved antegradely
through distally inserted 4-F introducer. In the last case, we abandoned tip retrieval as it was located in a far distal portion.
Conclusion: Crosser is effective even in below-the-knee arteries of
dialysis patients. Some complications occurred in 5 cases. We have
to be prepared for these kinds of issues when using Crosser in heavily calcified lower extremity lesions.

Abstract Book

P-461
A novel perfusion angiography technique for the
interventional treatment of peripheral vascular disease
J.Hinrichs1, T.Murray2, M.Brehm3, M.Akin3, M.Wilhelmi4,
F.Wacker1, T.Rodt1
1Institute for Diagnostic and Interventional Radiology, Medizinische
Hochschule Hannover, Hannover, Germany, 2Dept. of Diagnostic and
Interventional Radiology, Beaumont Hospital, Dublin, Ireland, 3Clinic
for Cardiology, Hannover Medical School, Hannover, Germany, 4Clinic
for Thoracic surgery, Hannover Medical School, Hannover, Germany
Purpose: To evaluate a novel 2D-perfusion angiography (2D-PA)
technique allowing pro- and retrospective flow analysis based on a
proximal reference region of interest (ROI) and distal target ROI in
patients treated for peripheral vascular disease.
Material and methods: The 2D-PA technique allows quantifying
blood flow by post-processing of digital subtraction angiography
(DSA). This technique was performed before and after interventional
treatment (n=24; 13 PTAs, 11 stents), applying a proximal reference
ROI (arterial inflow) and target ROI distal to the treated lesion. Timeto-Peak (TTP), peak density (PD), and area under the curve (AUC)
were calculated. Ratios of the reference and the target ROI (TTPROI/
TTPREF, PDROI/PDRef, and AUCROI/AUCREF) were correlated to the
ankle brachial index (ABI) before and after treatment.
Results: The 2D-PA technique was feasible, allowing quantitative
flow analysis in all cases. A significant ABI increase was seen after
interventional treatment (0.690.18 vs. 0.990.29, p=0.0002). A correlating increase of 36% of PDROI/PDRef (0.720.44 vs. 0.980.43;
p=0.0007), a 17% decrease of TTPROI/TTPREF (1.520.48 vs.
1.260.42; p=0.006), and a 68% increase of AUCROI/AUCREF(0.690.5
vs. 1.170.6; p=0.0001) were detected.
Conclusion: The presented 2D-PA technique allows the quantitative assessment of arterial flow before and after interventional treatment. Furthermore, this technique has great potential for individual
therapeutic optimization and quantification of technical success for
scientific purposes.

P-462
Long-term patency of balloon-expandable covered kissing
iliac stents at the aortic bifurcation for the treatment of
atherosclerotic occlusive disease
M.Ugas1, R.Norby2, J.Patrie2, S.Sabri1
1Interventional Radiology, University of Virginia, Charlottesville,
VA, United States of America, 2Radiology, University of Virginia,
Charlottesville, VA, United States of America
Purpose: To review long term patency rates following the placement of balloon-expandable covered kissing iliac stents in the treatment of atherosclerotic occlusive disease at the aortic bifurcation.
Material and methods: A review of consecutive patients from a
single institution with atherosclerotic occlusive disease at the aortic bifurcation treated with balloon-expandable kissing stents performed between December 2004 and July 2010. Sixty five patients
were identified. Technical success was defined as having less than
30% residual stenosis of the target lesion. Clinical success was
defined as an improvement in Fontaine classification. All outcomes
were documented. Patency was considered lost if there was a drop
by more than 0.15 in ABI or stenosis or occlusion on imaging followup. Stent patency was analyzed using survival analysis with Kaplan
Meier log-rank test.
Results: All 65 patients received covered kissing iliac stents (37 men,
28 women; mean age, 63 years; age range, 3990 years). Technical
and clinical success was achieved in 100% of patients. Complications
occurred in 3 of 65 (4.6%) patients and included groin hematoma,
arterial closure device failure, and external iliac artery dissection.

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CIRSE 2016
The mean follow-up was 30 months ( range, 1100 months). Three
patients were lost to follow-up and 16/65 (25%) patients died during the follow-up period. Sustained improvement in clinical symptoms during the follow-up period was observed in 57/65 (88%)
patients. Primary patency at 1, 2, and 4 years were 93%, 85%, and
81%, respectively.
Conclusion: The use of covered balloon-expandable kissing stents
for the treatment of atherosclerotic occlusive disease at the aortic
bifurcation provides a durable therapeutic option.

P-463
A comparative study of percutaneous atherectomy for
femoropopliteal arterial occlusive disease: an experience of
160 patients
Y.Q. Gu
Vascular Surgery Dept, Xuanwu Hospital, Beijing, China

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Results: In total, 393 IP target vessels were successfully crossed in

201 limbs (mean age 73 years; male 69.8%; DM 64%). Median hospital stay was 6 days with a 30-day mortality of 2%. Median duplex follow-up was 16 months. AFS was 77% and 55% and F-MALE was 72%
and 64% at 1 and 2 years, respectively. Technical success per limb
(1vessel straight-in-line flow, stenosis <50%) was 94.0%, while technical success per target vessel (stenosis <50%) was 85.6%. Primary,
assisted-primary and secondary patency rates were 67%, 72% and
76% at 1 year and 49%, 54% and 60% at 2 years. F-TVR was 77% and
69% and LS was 95% and 89% at 1 and 2 years, respectively.
Multivariate Cox regression identified post-procedural dual-antiplatelet therapy (DAPT) as an independent predictor of AFS (P=.034)
and MALE (P=.002). Younger age (P<.001) and normal baseline eGFR
(P=.009) were significantly associated to better AFS.
Conclusion: Endovascular treatment of IP disease is safe and effective in patients with CLI. Post-procedural DAPT is a predictor for better AFS and F-MALE. AFS is significantly worse in elderly patients and
in those with low eGFR.

WITHDRAWN

P-464
Primary stenting of the superficial femoral artery in
intermittent claudication gives improved health-related
quality of life, ABI, and walking distance compared with
non-invasive treatment 6 month results of a prospective
randomized multicenter trial
H.Lindgren1, P.Qvarfordt2, M.kesson3, S.Bergman4,
A.Gottster5
1Interventional Radiology, Medical faculty/Clinical sciences,
Helsingborg, Sweden, 2Interventional Radiology Helsingborg, Lund
University/Vascular science Malmo, Helsingborg, Sweden, 3Department
of Clinical Sciences, Lund University, MedVASC AB, Malmo, Sweden,
4Primary Health Care Unit, Department of Public Health and
Community Medicine, Institute of Clinical Sciences, Lund University, The
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden,
5Vascular Centre, Skne University Hospital, Malm, Sweden
WITHDRAWN

P-465
Predictors of clinical outcome following endovascular
treatment of infrapopliteal disease in patients with critical
limb ischaemia
L.Biasi1, S.Patel1, I.Paraskevopoulos2, C.Gordon1, C.Adkin1,
T.Lea1, T.Donati1, A.Diamantopoulos2, K.N.Katsanos2, H.Zayed1
1Department of Vascular Surgery, Guys and St.Thomas NHS
Foundation Trust, London, United Kingdom, 2Department of
Interventional Radiology, Guys and St. Thomas NHS Foundation Trust,
London, United Kingdom
Purpose: The incidence of critical limb ischaemia (CLI) is steadily
rising among the aging population. This study sought to identify
the predictors of clinical outcome in a large cohort of consecutive
patients undergoing infrapopliteal (IP) endovascular interventions.
Material and methods: A prospectively maintained database of
consecutive patients undergoing percutaneous IP revascularisation for CLI (Rutherford 4-6) in our Institution between February
2012 and January 2014 was analysed. Patients demographics, cardiovascular risk factors, angiographic findings and follow-up results
were examined. The primary end points were amputation-free survival (AFS) and freedom from major adverse limb events (F-MALE)
at 1 and 2 years. Secondary endpoints were technical success, primary, assisted-primary and secondary patencies, freedom from target-vessel reintervention (F-TVR) and limb salvage (LS) rates based
on KaplanMeier analysis.

P-466
Lumivascular case series: OCT-guided CTO crossing followed
by OCT-guided atherectomy with 6-month MRA follow-up
A.Desai1, M.Brodmann2
1Anesthesiology, Stanford University, Redwood City, CA, United States
of America, 2MEDUK Graz, Division of Angiology, Graz, Austria
Purpose: To evaluate luminal patency of OCT-guided intervention
for peripheral arterial disease (PAD) at 6 months (30 patients/35
lesions) using MRA, ABI, and DUS.
Material and methods: Patients were evaluated with pre-operative MRA. CTOs were crossed using the OCT-guided Ocelot catheter
(Avinger, Inc.) for true lumen confirmation. Atherectomy was then
performed using the OCT-guided Pantheris catheter (Avinger, Inc.).
All tissues were retrieved for histologic evaluation. Patients were followed up upon discharge and at 6 months with MRA, ABI, and DUS.
Results: Pending promissory results for part of the cohort (available
for CIRSE 2016). Average lesion length treated, 9.5cm. Average CTO
lesion length, 11.4 cm. Standalone true lumen CTO crossing rate,
92.3% (12/13). Adjunctive stent rate, 14% (n=5), with average stent
length placed, 60 mm. Of the 9 patients who have completed follow-up through 6 months, 89% (n=8) have confirmed MRA luminal
patency. Pre-ABI average, 0.8, with average ABI at follow-up, 1.14.
Mean total fluoroscopy time was 14.7 min, and mean therapeutic fluoroscopy time was 5.3 min.
Conclusion: In this case series, OCT-guided therapies for CTO crossing and PAD therapy showed high efficacy, low adjunctive stent rate,
dramatically reduced total radiation, and favorable patency as measured by ABI, DUS, and MRA at 6 months. Further follow-up is necessary to determine the 12- and 24-month outcomes.

P-467
Transradial access for femoral artery intervention
Z.Ruzsa1, R.Bellavics2, B.Nemes1, F.Kuti2, E.M.Vgh1, K.Httl1,
B.Merkely1
1Cardiac and Vascular Center, Semmelweis University, Budapest,
Hungary, 2Invasive Cardiology, Bcs-Kiskun County Hospital,
Kecskemt, Hungary
Purpose: The purpose of this prospective register is to evaluate the
acute success and complication rate of the transradial access for
femoral artery intervention.
Material and methods: The clinical and angiographic data of 56
consecutive patients with symptomatic femoral artery stenosis
treated via transradial access using 6F sheathless guide between
2014 and 2015 were evaluated in a pilot registry. Stent implantation

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was done only in flow-limiting dissections and significant recoil.

Secondary access site was the popliteal or pedal artery. Primary endpoint: major adverse events (MAEs), clinical target lesion revascularisation (TLR) and rates of major and minor access site complications.
Secondary endpoints: angiographic outcome of the femoral artery
intervention, consumption of the angioplasty equipment, cross over
rate to femoral access site and hospitalisation in days. Transradial
cases were performed by two interventionalists skilled in transradial
technique and lower limb interventions.
Results: The radial artery puncture and the procedure were successful in all cases. The cross-over rate to femoral access site was 0%,
but in 2 patients (3.5%), secondary popliteal access was obtained.
The procedure was finished with good angiographic result in 54
cases (96.4%). In 24 patients, CTO recanalisation was performed
with 91.6% success rate. Balloon angioplasty was performed in all
cases, but additional stent implantation was necessary in 13 patients
(23.2%). Contrast consumption was 103.2 59.6 ml. Major access site
complications were not detected, but in one patient, asymptomatic
radial occlusion was observed (1.8%). Long-term MAEs was observed
in one patient (1.8%), and the half-year clinical TLR was 1.8%.
Conclusion: Femoral artery intervention can be safely and effectively performed using radial access with acceptable morbidity and
high technical success.

P-468
Beyond the acute ischemic stroke application of a
neurovascular aspiration device: thrombotic and embolic
complications in polidistrectual peripheral vessels successfully
managed with the Penumbra Max System
R.Gandini, S.Merolla, S.Abrignani, E.Pampana, F.Chegai, M.Muto
Diagnostic and Molecular Imaging, Radiation Therapy and
Interventional Radiology, University Hospital Policlinico Tor Vergata,
Rome, Italy
Purpose: The purpose of this study was to assess the safety and efficacy of the Penumbra thromboaspiration device in the management of thromboembolic events occurring in peripheral arteries, visceral arteries, and portal veins.
Material and methods: A mechanical thromboaspiration with
the Penumbra MAX system, traditionally used during acute ischemic stroke therapy, was performed in 23 cases (18 embolizations
occurred in BTK vessels during lower limb recanalization, 1 embolization of a right hepatic artery of a transplanted liver during an
angioplasty of the common hepatic artery, 1 acute thrombosis of a
common hepatic artery of a transplanted liver, 1 superior mesenteric
artery acute thrombosis, and 2 TIPS acute thrombosis). This system
involves a trackable catheter connected to a dedicated aspiration
pump (Penumbra MAX Pump, Penumbra, Inc.). Three, 4, and 5 MAX
and 64 ACE catheters were used.
Results: Technical success, defined as a full re-opening of treated
occluded vessels, was obtained in 21 cases (91%) without vessel dissection and/or perforation. In two cases, both in BTK arteries embolization, an effective thromboaspiration was not obtained, most
likely due to a distal microvascular thrombosis.
Conclusion: Our experience using the Penumbra system in the
peripheral vasculature demonstrates a safe, rapid, and effective
approach to manage thrombotic or embolic events involving different vascular districts. The Penumbra system catheters provide
a highly trackable and atraumatic solution to clot extraction in the
peripheral vasculature without risk of vessel dissection and/or perforation. Moreover, this solution does not require the use of adjunctive
devices or thrombolytic agents.

Abstract Book

P-469
Usefulness of laser Doppler tissue flowmeter monitoring
during endovascular therapy for peripheral artery disease
K.Takayama1, K.Myouchin1, K.Kichikawa2
1Radiology and Interventional Neuroradiology, Ishinkai Yao General
Hospital, Yao City, Japan, 2Radiology, Nara Medical University,
Kashihara, Nara, Japan
Purpose: Although skin perfusion (SP) pressure (SPP) is widely used
clinically to predict the probability of wound healing, it has not
been reported that laser Doppler tissue flowmeter (LDF) is useful
for assessing endpoint for endovascular therapy (EVT) for peripheral
artery disease (PAD) during the procedure. The aim of this study was
to determine whether LDF monitor during procedure is useful for
assessing the endpoint for EVT for PAD.
Material and methods: 112 limbs in 77 patients (54 men; age 48-97
years [mean 73.0 years] in whom SPP improved postoperatively
among 90 patients underwent successful EVT for PAD and intraoperative SP by LDF and SPP between January 2014 and November
2014. This study included 37 lesions in the iliac arteries, 60 lesions
in the superficial femoral arteries, and 18 lesions in the below-theknee arteries. SPP and SP were measured using the MV monitor
PLUS System (Nexis Corp, Fukuoka, Japan). Change of SP in dorsal
and plantar regions and correlation between SPP and SP in dorsal
and plantar regions were retrospectively assessed.
Results: SP in dorsal and plantar regions after EVT significantly improved in all cases, and there was a significantly positive correlation between SPP and SP in dorsal and plantar regions.
Asymptomatic distal embolization occurred in 2 patients (1.8%) during EVT. Both of cases were easily detected by LDF monitor, and
thrombolysis was performed immediately. No ischemic complication occurred in both cases due to thrombolysis.
Conclusion: LDF is useful for monitoring and assessing the endpoint of EVT for PAD.

P-470
Impact of patient and lesion characteristics on DEB PTA of the
femoro-popliteal artery: pooled analysis of three controlled
randomised trials
T.Albrecht1, A.Ukrow1, G.Tepe2, J.Ricke3, T.Zeller4, M.Werk 5,
U.Speck6
1Institut fr Radiologie und Interventionelle Therapie, Vivantes Klinikum Neuklln, Berlin, Germany, 2Department of Diagnostic and
Interventional Radiology, Medical Centre of Rosenheim, Rosenheim,
Germany, 3Radiology and Nuclear Medicine, University Hospital
Magdeburg, Magdeburg, Germany, 4Angiology, Herzzentrum Bad
Krozingen, Bad Krozingen, Germany, 5Radiology, Martin-LutherKrankenhaus, Berlin, Germany, 6Radiology, Charit, Berlin, Germany
WITHDRAWN

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CIRSE 2016

P-471
e-MISAGO: 1-year outcome data from the largest real world
nitinol stent registry
J.Ruef1, G.Schmid2, O.Andrs3, T.Fuss4, I.Kralj5, M.Wierzgon6
1Kardiologie/Angiologie, Kardiozentrum an der Klinik Rotes Kreuz,
Frankfurt, Germany, 2Radiology, Johanna-Etienne-Krankenhaus, Neuss,
Germany, 3Vascular Surgery, Hospital Universitari Dr. Josep Trueta De
Girona, Girona, Spain, 4Internal Medicin l, SRH Zentralklinikum Suhl,
Suhl, Germany, 5Interventional Radiology, Diakonissenkrankenhaus
Karlsruhe-Rppurr, Karlsruhe, Germany, 6Radiodiagnostics, TrinecPodles a.s, Trinec, Czech Republic
Purpose: To evaluate the long-term safety and efficacy of Misago RX
self-expanding nitinol stent when used for treatment of lower limb
atherosclerotic lesions in real-world practice.
Material and methods: e-MISAGO is a prospective, non-randomized, multi-centre registry conducted at 85 sites in 19 countries. All
adverse events are adjudicated independently. Primary safety and
efficacy endpoints match VIVA groups criteria.
Results: A total of 3331 patients (69.5% male, mean age 68.0 10.8
years) were included. Hypertension, smoking history, and diabetes
were present in 73.7%, 61.0%, and 37.6%, respectively. Critical limb
ischemia was present in 26.6% of the patients. Massive or moderate calcification was observed in 68.8% of lesions, chronic occlusions
were present in 24.7%, and TASC II C/D lesions in 28.8% of patients.
A total of 3992 Misago RX nitinol stents were placed in iliac arteries
(30.7%), femoropopliteal arteries (68.3%), and bypass grafts (1.0%).
The overall composite rate of death, amputation, and TLR at 12
months was 7.7% (death 3.0%; TLR 4.4%; and amputation 0.8%). The
overall primary patency rate at 1 year was 93.3%, ranging from 97.5%
in iliac arteries over 91.6% in femoro-popliteal arteries to 87.9% in
bypass grafts.
Conclusion: This large registry demonstrates that Misago RX nitinol stent is a valuable option in treating lower limb atherosclerotic
lesions in real-world practice.

P-472
Impact of lateral angiograms with a knee-joint bent after
popliteal artery stenting
M.Planert1, E.Stahlberg1, J.Loesaus1, M.Horn2, M.Kleemann2,
J.Barkhausen1, J.P.Goltz1
1Department of Radiology and Nuclear Medicine, University Hospital
Schleswig-Holstein, Campus Lbeck, Lbeck, Germany, 2Department
of Surgery, University Hospital of Schleswig-Holstein, Campus Lbeck,
Lbeck, Germany
Purpose: The purpose of this study was to evaluate the incidence of
functional stenosis after popliteal artery (PA) stenting using flexion
angiograms (FA) and its treatment.
Material and methods: Retrospectively, we identified 138 patients
who underwent PA intervention between October 2013 and May
2015; 84 of these patients underwent PA stenting. Of these 84
patients, 29 (16 men, 13 women, mean age 7310 years) had lateral
angiograms with the knee joint in a flexed position. Type of device
implanted, proximal landing zone (PLZ) (P1, P2 segment, distal SFA),
and angle of knee joint during FA were evaluated. Functional stenosis was defined as >50% lumen narrowing by visual estimation.
Results: Devices implanted included Supera stents (n=25),
Viabahnstent grafts (n=3), and a Tigrisstent (n=1). PLZ was within
P1 (n=8) and P2 segment (n=4), and distal SFA (n=17). Mean angle of
the knee joint was 7512.6. In 4/29 patients (13.8%), FA revealed relevant stenosis proximal to a Supera stent (PLZ P1: n=2, PLZ distal
SFA: n=2) and was treated by overlapping stent implantation.
Conclusion: Functional stenosis occurs in a considerable number of patients following PA stenting. Flexion angiograms should

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be performed especially if devices with a high radial force are utilized and proximal landing zones are located in P1 and distal SFA.
Additional stenting represents an option, although the need for it
has not been determined so far.

P-473
Decreased limb survival in diabetic patients with critical limb
ischemia compared with non-diabetic patients
M.Spreen1, H.Gremmels2, M.Teraa3, R.Sprengers4, M.Verhaar2,
R.StatiusvanEps5, J.-P.deVries6, W.P.T.M.Mali4, H.vanOverhagen1
1Radiology, HagaZiekenhuis, The Hague, Netherlands, 2Nephrology
& Hypertension, University Medical Center Utrecht, Utrecht,
Netherlands, 3Vascular Surgery, University Medical Center Utrecht,
Utrecht, Netherlands, 4Radiology, University Medical Center Utrecht,
Utrecht, Netherlands, 5Vascular Surgery, HagaZiekenhuis, The Hague,
Netherlands, 6Vascular Surgery, Sint Antonius Hospital, Nieuwegein,
Netherlands
Purpose: Diabetes mellitus (DM) was a common comorbidity in two
recently conducted trials of patients with critical limb ischemia (CLI),
namely, the PADI trial and JUVENTAS trial. In order to determine the
implications of DM for CLI we compared the clinical outcomes in diabetic versus non-diabetic subjects using the pooled data of these
trials.
Material and methods: Adult patients with CLI (Rutherford category 4) were selected from the PADI and JUVENTAS trial subjects.
Patients were considered diabetic when they were treated with oral
antidiabetic agents or insulin therapy at baseline. The observed
rates of major amputations and major events (i.e., major amputation or death) were compared between both groups. Hazard ratios
of diabetes for the risk of major amputation were calculated.
Results: Among our cohort of 281 patients, 138 patients (49.1%)
suffered from DM. The rate of major amputations was significantly
higher in the diabetic subgroup (p=0.015). Unadjusted and adjusted
hazard ratios of diabetes for the risk of major amputation were 1.87
[95% confidential interval (CI) 1.123.12; p=0.017] and 1.56 (95% CI
0.922.65; p=0.10). Other baseline factors with significant hazard
ratios were Rutherford category (HR 1.95; 95% CI 1.243.06; p=0.004)
and a high (>1.4) or immeasurable ABI (HR 2.78; 95% CI 1.375.64;
p=0.005).
Conclusion: Diabetic CLI patients are at a substantially higher risk of
major amputation when compared with non-diabetic CLI patients.
This higher risk is associated with a higher prevalence of high or
immeasurable baseline ABI in diabetic patients, indicating medial
calcification and more severe ischemia at baseline.

P-474
Elevated ankle brachial index is related to a high amputation
rate and cardiovascular comorbidity in patients with critical
limb ischemia
M.Spreen1, H.Gremmels2, M.Teraa3, R.Sprengers4, M.Verhaar2,
J.Wever5, J.A.Vos6, W.P.T.M.Mali4, H.vanOverhagen1
1Radiology, HagaZiekenhuis, The Hague, Netherlands, 2Nephrology
& Hypertension, University Medical Center Utrecht, Utrecht,
Netherlands, 3Vascular Surgery, University Medical Center Utrecht,
Utrecht, Netherlands, 4Radiology, University Medical Center Utrecht,
Utrecht, Netherlands, 5Vascular Surgery, HagaZiekenhuis, The
Hague, Netherlands, 6Interventional Radiology, St. Antonius Hospital,
Nieuwegein, Netherlands
Purpose: To assess the role of the anklebrachial index (ABI) regarding major amputation and amputation-free survival in patients with
critical limb ischemia (CLI) by pooling patient-level study data of two
recently conducted randomized controlled trials considering CLI,
the PADI and JUVENTAS trials.

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Material and methods: Adult patients with CLI (Rutherford category 4) were selected from the PADI and JUVENTAS subjects. We
distinguished three ABI categories: low ABI (<0.7), intermediate ABI
(0.71.4), and high ABI (>1.4/immeasurable). Observed rates of major
amputations and major events (i.e., major amputation/death) were
compared between these groups. Hazard ratios of high ABI for
the risk of major amputation and major amputation or death were
calculated.
Results: In total, 152 patients (54.1%) showed a low ABI at baseline,
96 patients (34.2%) an intermediate ABI, and 33 patients (11.7%) a
high ABI. Significantly more number of patients with high ABI had a
history of cardiovascular disease. Patients with a high ABI at baseline
showed a higher major amputation rate (52.1%) and lower amputation-free survival rate (5.0%) after 5 years compared with those with
an intermediate ABI (27.9% and 40.6%, respectively) and a low ABI
(22.7% and 45.9%, respectively) (p=0.001 and p<0.001). Unadjusted
and adjusted hazard ratios of high ABI for major amputation or
death were 2.79 (95% confidential interval (CI) 1.764.44; p<0.001)
and 2.66 (95% CI 1.574.51; p<0.001).
Conclusion: CLI patients with a high baseline ABI show more cardiovascular comorbidity than patients with low or intermediate ABI. A
high ABI in patients with CLI is an independent risk factor for major
amputation and reduced amputation-free survival.

P-475
Infra-popliteal bypass versus angioplasty in patients with
critical limb ischaemia compared using propensity score
analysis
S.Patel1, L.Biasi1, I.Paraskevopoulos2, J.Silickas1, T.Lea1,
A.Diamantopoulos2, K.N.Katsanos2, H.Zayed3
1Vascular Department, Guys and St.Thomas NHS Foundation Trust,
London, United Kingdom, 2Department of Interventional Radiology,
Guys and St.Thomas NHS Foundation Trust, London, United
Kingdom, 3Department of Vascular Surgery, Guys and St.Thomas NHS
Foundation Trust, London, United Kingdom
Purpose: Both infrapopliteal (IP) bypass surgery and endovascular
intervention have been shown to have good outcomes in patients
with critical limb ischaemia (CLI), though there are no randomised
trials to guide treatment choices. Our aim was to compare the outcomes of these treatments using propensity score (PS) matching in
order to reduce the effect of selection bias and confounding factors.
Material and methods: We compared outcomes in consecutive
patients undergoing IP bypass (BS) and IP angioplasty (EV) for CLI
(Rutherford 46) at a single institution following PS matching. The
end points were primary, assisted primary and secondary vessel
patency and amputation-free survival (AFS) at 12 months using the
KaplanMeier analysis.
Results: The initial cohort (n=279) differed significantly with respect
to the incidence of diabetes (P=.02), eGFR (P=.006), total lesion
length (P<.001) and Rutherford classification (P=.008). These factors were used to construct the PS model, which yielded a matched
cohort of 125 limbs. Primary patency (P=.014), assisted primary
patency (P=.003), secondary patency (P<.001) and AFS (P=.04) were
significantly better after BS than after EV. However, limb salvage was
similar (P=.16), and minor complications (P=.008) as well as length of
hospital stay (P=.001) were worse in the BS group.
Conclusion: Our data supports a pragmatic approach where
patients with a suitable vein conduit and acceptable operative risk
are considered for bypass, whereas in those with a higher operative
risk, an EV strategy is considered first.

Abstract Book

P-476
A comparison of clinical outcomes for diabetic and
non-diabetic patients following Misago Rx nitinol stent
implantation in the e-MISAGO registry
S.Mller-Hlsbeck1, K.Wahl2, I.Kralj3, L.Kindl4, U.Radtke5,
L.BagnaschinoBarco6
1Department of Diagnostic and Interventional Radiology /
Neuroradiology, Ev.-Luth. Diakonissenanstalt zu Flensburg, Flensburg,
Germany, 2Radiology, Oberlausitz-Kliniken gGmbH, Bautzen, Germany,
3Interventional Radiology, Diakonissenkrankenhaus Karlsruhe-Rppurr,
Karlsruhe, Germany, 4Radiology, Nemocnice Most, Most, Czech
Republic, 5Vascular/ Endovasculer Surgery, Luisenhospital Aachen,
Aachen, Germany, 6Angiology/ Vascular Surgery, Hospital Torrevieja
Salud, Torrevieja, Spain
Purpose: We aim to investigate the real-world outcomes of the
Misago Rx nitinol stent when used for treatment of atherosclerotic
lesions in the lower limb extremities in patients with or without diabetes mellitus (DM).
Material and methods: E-MISAGO is a prospective, non-randomized, multi-center registry conducted at 85 sites in 19 countries.
Primary safety and efficacy endpoints match VIVA groups criteria.
Of the 3235 patients, only 1247 diabetic patients (38.5%; mean age
69.59.7 years; 69.2% male) were eligible for this analysis.
Results: Diabetics had higher rate of concomitant hypertension (84.2% vs. 69.0%; p<0.0001), hyperlipidemia (58.2% vs. 42.8%;
p<0.0001), previous coronary artery disease (45.3% vs. 29.7%;
p<0.0001), and critical limb ischemia status (32.6% vs. 21.7%;
p<0.0001).
The prevalence of TASC II C or D lesions was similar in both groups;
however, massively calcified lesions and chronic total occlusion
(CTO) were significantly more common in diabetic patients (calcification 28.7% vs. 24.1%; CTO 26.4% vs. 23.3%).
The composite rate of death, amputation, and TLR was significantly
higher in diabetics at 12 months (DM vs. non-DM, 9.3% vs. 6.9%;
p=0.019). One-year primary patency showed no difference between
diabetics (93.0%) and non-diabetics (93.3%) overall (p=0.83) or stratified by lesion location.
Conclusion: Although patients with DM have a significantly higher
composite event rate, this data showed that DM does not have
a negative impact on patency at 1-year in patients treated with
Misago stents.

P-477
The impact of Misago Rx nitinol stenting on clinical outcomes
for the treatment in the bypass grafts from the e-MISAGO
registry
O.AndresNavarro1, S.Thebault2, M.Wierzgon3, I.Kralj4,
C.Paetzel5, M.Kaduk6
1Vascular Surgery, Hospital Universitari Dr.Josep Trueta De Girona,
Girona, Spain, 2Surgery, Clinique Ormeau-Pyrenees, Tarbes,
France, 3Radiodiagnostic, Trinec-Podles a.s, Trinec, Czech Republic,
4Interventional Radiology, Diakonissenkrankenhaus Karlsruhe-Rppurr,
Karlsruhe, Germany, 5Radiology, Klinikum Weiden, Weiden, Germany,
6Radiology/ Angiology, Dr. Drogula KH Dbeln, Dbeln, Germany
Purpose: To date, there is a lack of data on clinical outcomes following percutaneous peripheral revascularisation of a bypass graft
in the lower extremities. We investigated the safety and efficacy
of Misago stent implantation in the bypass grafts at the 12-month
follow-up.
Material and methods: E-MISAGO is a prospective, non-randomised, multi-centre registry. Primary safety and efficacy endpoint
match VIVA groups criteria.

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Of the 3331 patients enrolled in the registry, only 33 patients (mean
age 72.410.3 years; 66.7% male) at 15 sites underwent Misago Rx
nitinol stenting in the bypass grafts.
Results: Among this group, 74.3% had lesions in the femoro-popliteal bypass graft and 17.1% in the femoro-distal bypass graft.
Participants had a high prevalence of diabetes (51.5%), hypertension
(84.9%), hyperlipidaemia (42.4%) or previous coronary revascularisation (39.4%).
Critical limb ischaemia was present in 48.5% of the patients with
treated lesions, including new lesions, in-stent restenosis (ISR), restenosis post-angioplasty and thrombus-occluded artery. Massive
and moderate calcifications were observed in less than 20% of the
patients.
The mean lesion length was 65.880.8mm, and the mean reference
vessel diameter was 5.71.2mm. The composite rate of death, amputation or TLR was 15.2% at 1 year with the primary patency rate of
87.9%.
Conclusion: Despite the fact that bypass lesions are not frequently
observed, the results demonstrate that placement of the Misago
stent in the bypass graft is safe and effective in the lower extremities.

P-478
Do drug-eluting stents really work? A comparison of bare
metal and drug-eluting SFA stenting in a large UK tertiary
referral centre
G.H.Tse, J.Smith, D.Turner, S.D.Goode
Sheffield Vascular Institute, Northern General Hospital, Sheffield, United
Kingdom
Purpose: Randomised trials have shown promising results for
drug-eluting stents (DES) in the superficial femoral artery (SFA). We
reviewed our experience and compared results to published data
and our units historical outcomes with bare metal stents (BMS).
Material and methods: Data were collected for Zilver PTX (paclitaxel-coated) nitinol stents (Cook Medical) implanted into superficial
femoral (SFA) or popliteal arteries between July 2012 and April 2015
and for BMS implanted between April 2006 and December 2010.
Data were presented as meanSEM (range).
Results: A total of 248 patients were treated; 175 BMS procedures in
164 patients and 88 DES procedures in 84 patients (4 bilateral procedures), including 66 male and 18 female patients. For DES, the location of lesions treated included SFA (n=78) and SFA and popliteal
(n=10). Types of lesion treated: occlusion (63%), mix of occlusion and
stenotic disease segments (17%), stenosis (15%), in-stent re-occlusion (3%) and in-stent re-stenosis (2%). In DES cases, the occlusion
length was 15.80.98 cm (1-35). For DES, primary patency was 85%
at 6 months and 78% at 1 year, compared with historic BMS data of
63% patency at 1 year; this was significantly higher for DES (log rank
p<0.01).
Conclusion: We report the use of DES in a population with longlength femoropopliteal disease and high level of occlusive disease.
The change from BMS to DES has improved the outcomes in SFA disease despite the higher complexity of vascular diseases and demonstrates the benefits of DES in real world SFA stenting procedures
with complex lesions outside of an RCT.

SS/FC/HL/HTS/CM
Posters

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P-479
Alternative techniques for treatment of complex below-theknee arterial occlusions in diabetic patients with critical limb
ischemia
S.Merolla, D.Konda, S.Abrignani, F.Chegai, E.Pampana,
R.Gandini
Diagnostic and Molecular Imaging, Radiation Therapy and
Interventional Radiology, University Hospital Policlinico Tor Vergata,
Rome, Italy
Purpose: To describe alternative endovascular (EV) techniques, their
feasibility, and efficacy in limb salvage for the treatment of complex
below-the-knee (BTK) occlusions that could not be crossed with a
conventional antegrade access.
Material and methods: Between December 2007 and March
2015, 1725 patients (928 male) underwent EV treatment for critical limb ischemia. In 267 (15.4% [mean age 68.4 0.4 years]), antegrade approaches failed, and alternative approaches (plantar-topedal, trans-collateral, double approach) were used. Results were
compared with 56 patients treated between November 2002 and
November 2007 in whom conventional techniques were unsuccessful and unconventional techniques were not adopted. Follow-up
was performed at 1-6 months.
Results: TTechnical success was achieved in 258 (96.6%) patients.
Limb-salvage rates were 97.0% and 83.1% at 1- and 6-month follow-up, respectively. Thirty-three (12.4%) and 70 (26.2%) patients
underwent reintervention at 1- and 6-month follow-up, respectively. Transcutaneous oxygen tension increased at 1 month (44.7
1.1 vs. 15.7 0.8 mmHg; p < 0.001) and remained stable at followup. Forty-two (15.7%) patients required major amputation. Twentyseven (10.1%) patients died during follow-up. In our previous experience, PTA failure, amputation, and death rates were 10.5, 38.5, and
23.2%, respectively. Alternative techniques allowed a significant
decrease of major amputation and death rates (p = 0.0001 and p =
0.02, respectively).
Conclusion: The use of alternative techniques seems feasible in
case of a failed antegrade BTK revascularization attempt and could
minimize failure rates in the treatment of complex occlusions while
providing satisfying clinical success rates at 6 months.

P-480
An earlysingle-centre experience with the Phoenix
Atherectomy System in patients with heavily calcified femoropopliteal lesions
R.Gandini, F.Chegai, S.Merolla, M.Stefanini, S.Abrignani,
D.Konda, E.Pampana
Diagnostic and Molecular Imaging, Radiation Therapy and
Interventional Radiology, University Hospital Policlinico Tor Vergata,
Rome, Italy
Purpose: Heavily calcified lesions of the femoro-popliteal axis
remain one of the most challenging lesion subsets in peripheral
revascularisation and may limit endovascular approach. The Phoenix
Atherectomy System is an over-the-wire device with a front-cutting
element at its distal tip conceived to treat these types of lesions. The
purpose of our study was to evaluate the efficacy and safety of this
system in patients with heavily calcified femoro-popliteal lesions.
Material and methods: From January 2015 to June 2015, fifteen
patients with heavily calcified femoro-popliteal lesions causing
severe stenosis or occlusions were treated. We used Phoenix catheters (2.2 mm 6 Fr or 1.8 mm 5 Fr) when balloon catheter could not
pass through stenosis or occlusions due to the presence of a heavily
calcified lesion, although a 0.014-inch guide-wire was well advanced
through the lesions in an intraluminal fashion. Atherectomy with
Phoenix allowed both to debulk the extremely calcified plaques and

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to create a pilot channel through which the balloon catheter could

be advanced. After successful recanalisation, occluded arterial segments were treated conventionally with balloon angioplasty or
stents as appropriate.
Results: The mean lesion length was 5.1 cm (110 cm). The mean fluoroscopy time was 33.9 min. Technical success was achieved in 100%
of cases with a primary patency of 80% at the 6-month follow-up.
Only one complication was observed: SFA perforation, which was
was treated with a PTFE-covered stent. No case of distal embolisation was observed.
Conclusion: Recanalisation with the Phoenix Atherectomy System is
simple and safe, with a high technical success rate, and should be
considered an alternative technique of peripheral revascularisation.

P-481
Performance of Luminor drug-eluting balloon for
revascularization in chronic limb ischemia: a Spanish
prospective multicenter registry
V. Riambau
Vascular Surgery Division CardioVascular Institute, Hospital Clinic
University of Barcelona, Barcelona, Spain
Purpose: The primary objective was to analyze the performance
of Luminor 14 and 35 in terms of primary patency, defined as freedom from >50% restenosis in the target vessel with no re-intervention and freedom from serious adverse events such as death, amputation, and TLR during a minimum of 12-month follow-up period.
Material and methods: Luminor registry is an observational, prospective, multicenter study with single-arm treatment for stenotic or
occlusive lesions or in-stent stenosis of the femoropopliteal (FP) and
below-the-knee (BTK) vessels.
A total of 250 validated Rutherford 25 cases will be recruited during
a 15-month period following an intention to treat basis.
Results: Since Q3 2014, 143 cases with 165 lesions (81 CTO and 84
stenosis) have been included and monitored. These cases were
divided into 101 FP and 36 BTK vessels treated. Fourteen cases
combined both segments. Seven of them were in-stent stenosis. It
is important to emphasize that 72% of patients were classified as
Rutherford 4 or higher. Technical success was achieved in 99.7% of
the cases. Bailout stenting was necessary in 13 lesions (7.8%). The
30-day mortality was 1.4%. At the 6-month follow-up, mortality
was 9.4%; other medical complications were detected in 8 patients
(5.6%); 9 major amputations (8.3%) occurred and the TLR was 6.3%.
Freedom from TLR was 93.7%.
Conclusion: Interim and final results will be published in future
reports. Initial primary endpoints are encouraging, taking into
account the ischemic status severity of this cohort of patients.

P-482
Color-coded fluoroscopy in the determination of periinterventional stenosis grading in peripheral artery disease in
an angiographic suite: an in vitro phantom study of feasibility
and reproducibility
P.Ghibes1, G.Grzinger1, U.Grosse1, P.Martirosian2, F.Schick 2,
K.Nikolaou1, D.Ketelsen1, R.Syha1
1Diagnostic and Interventional Radiology, Eberhard-Karls-University,
Tbingen, Germany, 2Section on Experimental Radiology, EberhardKarls-University, Tbingen, Germany

Abstract Book
restrictions) and one reference model without stenosis (lumen
diameter 10 mm). The timedensity curve (TDC) and its area under
the curve (AUC) were analysed. Measurements were repeated three
times for the assessment of reproducibility. Changes in the AUC
between a reference ROI and three other ROIs proximal (ROI II) and
distal (ROI III and IV) to the stenosis were determined with different
integration times (1 s, 3 s, 5 s and 7 s).
Results: Color-coded fluoroscopy revealed reproducible results in
all investigated models. Differentiation between high-grade, middle-grade and low-grade stenoses was feasible using AUC and TDC.
During high-grade stenosis, the AUC in ROIs directly proximal to the
stenosis and distal to the stenosis decreased compared to the AUC
in the reference ROI (10.86%6.13% in ROI IV/7 s). During middleand low-grade stenoses, the effect turned around, and AUC in ROIs
directly proximal to the stenosis and distal to the stenosis increased
compared to the AUC in the reference ROI. An excellent correlation
to lumen restriction in mm was seen in ROIs behind the stenosis
using longer integration times (5 s, 7 s) (rho=0.9284 at 5 s).
Conclusion: High-grade, middle-grade and low-grade stenoses can
be differentiated using TDCs of color-coded fluoroscopy in terms
of AUCs in a reproducible way. High frame rates (30 images/s), long
integration times (5 s) and a dedicated post-processing software
are necessary.

P-483
Effectiveness of Supera stent placement in femoropopliteal
lesions in patients with a poor distal run-off
T.Zander, R.Herrera, E.Afanador, M.Valdes, M.Maynar
Endoluminal/-vascular Department, Hospiten Hospital Group, Santa
Cruz De Tenerife, Spain
Purpose: To assess the patency of Supera stent in the treatment
of complex femoropopliteal lesions in patients with one or no distal run-off.
Material and methods: During a period of 22 months, 17 patients
with femoropopliteal lesions were treated using a total of 21
Supera stents with only one or no distal run-off artery. Primary
patency, target lesion revascularization (TLR), and adverse events
were evaluated.
Results: Seventeen limbs of 17 patients (15 men) aged 74.848.1
years were included. Occlusion was present in 10 and long segment
stenosis in 7 with a mean lesion length of 181.2108.6 cm. Lesions
were classified as TASC A, B, C, and D in 2, 7, 4, and 4 limbs, respectively. Technical success was obtained in all patients with no major
procedure-related complications; in one case, distal migration of the
thrombus was observed after vessel preparation, which was successfully resolved by aspiration. Follow-up (FU) was 116 months (mean
6.1 months); two patients were lost during FU. Imaging-based studies to evaluate patency were available for 14/17 cases, and only clinical FU in 3/17 cases. Primary patency could be confirmed in 14 cases
(100%). Improvement or resolution of symptoms was experienced in
all cases. Minor amputation was necessary in 3 cases; however, these
patients presented with Rutherford 5. TLR at the time of FU was not
performed in any patient.
Conclusion: The placement of Supera stent in the femoropopliteal
lesions with one or none distal run-off vessels is safe and shows a
high primary patency rate at mid-term.

Purpose: The study evaluated the use of color-coded fluoroscopy

for treatment monitoring and stenose grading in peripheral artery
disease.
Material and methods: To evaluate the use of color-coded fluoroscopy, an in vitro flow phantom was assessed regarding the flow
behaviour of three stenosis models (80%, 60% and 40% diameter

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SS/FC/HL/HTS/CM
Posters

P-484

P-486

Preliminary angiographic and 6-month clinical results of the

CONSEQUENT trial

Percutaneous iliofemoral venous stenting to treat postthrombotic syndrome: long-term outcomes from a single
center experience

T.Albrecht1, D.R.Meyer2, S.Mller-Hlsbeck 3, I.Ott4, U.Redlich5,

J.Ricke6, M.W.Waliscewski7, T.Zeller8, G.Tepe9
1Institut fr Radiologie und Interventionelle Therapie, Vivantes Klinikum Neuklln, Berlin, Germany, 2Radiology, Hubertuskrankenhaus,
Berlin, Germany, 3Department of Diagnostic and Interventional
Radiology / Neuroradiology, Ev.-Luth. Diakonissenanstalt zu Flensburg,
Flensburg, Germany, 4Klinik fr Herz- und Kreislauferkrankungen,
Deutsches Herzzentrum Mnchen, Munich, Germany, 5Diagnostische
und Interventionen Radiologie, Klinikum Magdeburg, Magdeburg,
Germany, 6Radiology and Nuclear Medicine, University Hospital
Magdeburg, Magdeburg, Germany, 7Vascular Systems, B. Braun
Melsungen, Berlin, Germany, 8Angiology, Herzzentrum Bad
Krozingen, Bad Krozingen, Germany, 9Department of Diagnostic and
Interventional Radiology, Medical Centre of Rosenheim, Rosenheim,
Germany
WITHDRAWN

P-485
Endovascular treatment of arterial access site injuries with
N-butyl cyanoacrylate embolization
K.Akkan, H.Ozer, M.Yazol, E.T.Ilgit, B.nal
Department of Radiology, Gazi University, School of Medicine, Ankara,
Turkey
Purpose: To evaluate long-term results of endovascular treatment
of iatrogenic injuries at the arterial access site with N-butyl cyanoacrylate (n-BCA).
Material and methods: Endovascular treatment of iatrogenic injuries at the arterial access site with N-butyl cyanoacrylate (n-BCA)
was performed in 26 patients. In total, 21 patients had a pseudoaneurysm that could not be treated with guided manuel comression
and 5 patients had arteriovenous fistulas (AVFs). Sites of pseudoaneurysms included the common femoral artery (n=11), superficial
femoral artery (n=4), deep femoral artery (n=4) and brachial artery
(n = 2). AVFs were at the femoral artery (n=4) and brachial artery
(n = 1). All the embolization procedures were performed following
microcathterization of the neck of the pseudoaneurysm or feeding
artery of AVF. n-BCA was used as the embolic agent in all patients.
Stent-graft and n-BCA embolization were performed in 1 patient.
Balloon-assisted n-BCA embolization was performed in 5 patients.
Patient follow-up included clinical examination and evaluation for
potential parent artery obstruction with Doppler ultrasonography
or angiography in selected cases.
Results: Technical success was achieved in all 26 patients. None of
the patients developed parent artery obstruction.
Conclusion: n-BCA embolization was shown to be a safe and effective treatment method for iatrogenic vascular injuries at the access
site. It should be performed by experienced hands as a relatively
inexpensive procedure.

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C.DelGiudice1, G.Goudot2, L.Marzano3, P.Y.Laffy1, O.Pellerin1,

G.Amouyal1, T.Mirault2, E.Messas2, M.R.Sapoval1
1Vascular and Oncological Interventional Radiology, Hpital Europen
Georges Pompidou, Universit Paris Descartes, Paris, France, 2Vascular
Medicine, Hpital Europen Georges Pompidou, Universit Paris
Descartes, Paris, France, 3Radiology, Universit Sapienza, Rome, Italy
Purpose: To evaluate technical and long-term clinical outcomes of
iliofemoral venous stenting for post-thrombotic syndrome (PTS) .
Material and methods: From February 2007 to November 2015, 51
patients (27 female and 21 Male; mean age 40.313.7 years) underwent ilio-femoral venous stenting for symptomatic PTS. Technical
success, stent patency rates, and complications were recorded after
the interventions. Clinical improvement was evaluated by comparing the pre- and post-procedural Villalta scale.
Results: Percutaneous iliofemoral venous stenting was successful in
46 of 51 patients (91%) without major complications. The mean follow-up was 27.823 months. Cumulative primary stent patency rates
at 2 years were 82.3%. Six patients had an acute stent occlusion (48
h). The Villalta score decreased significantly compared with the preprocedural score (11.85.9 vs. 5.14.5, p<.01).
Conclusion: Endovascular stenting is a safe, effective, and feasible
method to treat the iliofemoral obstruction of PTS.

P-487
Off-label employment of StarClose vascular closure device for
antegrade puncture of the femoral artery in lower extremity
revascularization: two-year experience
P.Scalise, A.Grigolini, S.Vitali, V.Iodice, L.Giorgi, R.Cioni,
A.Lunardi
Diagnostic and Interventional Radiology, University of Pisa, Pisa, Italy
Purpose: To evaluate the safety and efficacy of the StarClose
Vascular Closure System (Abbott Vascular, Redwood City, CA) in
lower extremity revascularization after orthodromic femoral access.
Material and methods: From December 2013 to January 2016,
the StarClose vascular closure system was employed in a series of
80 patients who underwent lower limb interventions (percutaneous transluminal angioplasty and/or stenting) for peripheral arterial
disease.
In all these patients, ultrasound-guided 5-F sheath antegrade puncture of the common or superficial femoral artery was performed by
a highly experienced operator. Access site features included vessel
diameter of at least 4.5 mm and absence of atherosclerotic plaques
at the puncture site. All patients were clinically followed up, and a
Doppler US examination was performed 48 h after the procedure
to rule out potential iatrogenic complications at the arterial access,
such as pseudoaneurysm, arterial thrombosis or stenosis, hematoma, or arteriovenous fistula.
Results: StarClose was succesfully implanted in all the patients of
our series, with a procedural success rate of 100% (80/80).
In all patients, the artery was patent at the level of the access site
and iatrogenic vascular injuries did not occur in any cases. The time
required to reach complete hemostasis ranged between 5 and 30
seconds.
Conclusion: In our experience, StarClose is a safe and effective
device to be employed in case of antegrade puncture of the common or superficial femoral artery, allowing reduction in both incidence of vascular complications at the access site and the time to
reach complete hemostasis, with faster patient mobilization.

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P-488
Analgesic management and sedation in patients undergoing
PTA of lower limbs
M.SantlLetonja, R.Grkovski
Department of Radiology, Splosna bolnisnica Murska Sobota, Murska
Sobota, Slovenia
Purpose: Vascular interventional radiology has become a rapidly
growing field of medicine, increasing in number during the past
decades. Despite their minimally invasive nature, they can evoke
pain, discomfort, and anxiety among patients, effecting the implementation and outcome; thus, suitable analgesics and sedatives
should be considered.
Our objective was to compare patients using diclofenac and orphenadrine in combination with diazepam as premedication before
undergoing percutaneous transluminal angioplasty (PTA) of lower
limbs with those not using premedication for addressing patient
discomfort.
Material and methods: A total of 60 patients with no premedication were enroled for the PTA procedure from July to September
2015 and 68 patients with premedication were enroled from
October to December 2015. Diclofenac with orphenadrine in 250 ml
infusion and diazepam 5 mg tablet was used. Blood pressure, heart
rate, and breathing were monitored in every patient. Chronic renal
and liver diseases were an exclusion factor. A visual analog scale
(VAS) was used to evaluate patient pain, whereas anxiety and the
course of procedure itself were assessed by the performing interventional radiologist.
Results: Our study shows that median VAS in the group with premedication was 4 and in the group with no premedication was 6.
Also, a lower level of anxiety and a better course of the procedure
were observed in the performer of the first group.
Conclusion: We conclude that premedication with a combination of
diclofenac, orphenadrine, and diazepam decreases discomfort and
increases better course of treatment in patients undergoing PTA for
lower limbs.

P-489
The dual-layer micromesh design for the stenting of
thrombotic or ulcerated carotid artery stenotic lesions and
peripheral aneurysms
K.Akkan1, K.Karaman2, E.Ersoz1, A.M.Dkdk 3, E.T.Ilgit1, B.nal1
1Radiology, Gazi University School of Medicine, Ankara, Turkey,
2Radiology, Anadolu Medical Center, Istanbul, Turkey, 3Radiology,
Anadolu Saglik Merkezi, Kocaeli, Turkey
Purpose: To submit preliminary results of using new the dual-layer
micromesh (DLM) stent for the endovascular treatment of ulcerated or thrombotic carotid artery stenosis, dissection and peripheral
aneurysms.
Material and methods: DLM stent was implanted in 11 patients (7
men; mean age 61.8 years). Endovascular treatment with DLM stent
was performed for thrombotic or ulcerated carotid artery stenosis (n=5), iatrogenic common carotid artery dissection (n=1), renal
artery aneurysm (n=2), superior mesenteric artery aneurysm (n=1)
and vertebral artery V1 segment aneurysm (n=1).
Results: All the stents were deployed successfully without any
complication. Postprocedural angiographic control of the stented
carotid artery segments showed stasis of contrast material in the
ulcerated segment and no thrombotic component protrusion into
the lumen. Peripheral artery aneurysms showed reduced inflow
and late retention of contrast material in the aneurysm sac after
stenting. Catheter or computed tomography angiography control
at 1 month showed complete closure of the peripheral aneurysms

Abstract Book
and iatrogenic carotid artery dissection. Doppler ultrasonography
control of the carotid artery stenotic lesions at 1, 3 and 6 months
showed normal findings.
Conclusion: DLM stent seems to be effective and safe in the treatment of carotid artery dissections and thrombotic or ulcerated
carotid artery stenosis. This design also seems to be effective in the
treatment of pheripheral aneurysms because of its flow-diverting
capability.

P-490
Effectiveness of drug-eluting balloon angioplasty versus plain
balloon angioplasty for the treatment of in-stent re-stenosis in
patients with superficial femoral artery stents
M.A.K.Kabuli1, M.Abbas1, S.D.Goode2, D.Kusumawidjaja2
1Radiology, Northern General Hospital, Sheffield, United Kingdom,
2Vascular Radiology, Sheffield Vascular Institute, Sheffield, United
Kingdom
Learning Objectives: The purpose of this study was to investigate
the effectiveness of Drug Eluting Balloon Angioplasty Versus Plain
Balloon Angioplasty for the Treatment of In-stent Re-Stenosis in
Patient with Superficial Femoral Artery Stents.
Background: Percutaneous transluminal angioplasty and stenting
is now standard therapy for infrainguinal steno-occlusive disease.
SFA stents are hampered by high restenosis rates. The treatment of
InStent Restenosis with standard balloon angioplasty has been associated with poor long-term patency, often leading to further intervention for a significant portion of patients.
Clinical Findings/Procedure: This is a retrospective single-institution review of the outcomes of patients with ISR who underwent stenting for SFA occlusive disease between January 2006 and
December 2015. ISR is defined as peak systolic velocity ratio (PSVR)
of 2.5 or more on duplex ultrasonography. ISR treated with balloon
angioplasty were followed-up for a further year with duplex ultrasonography. We compared POBA data with those patients undergoing
DEB treatment.
Out of the 68 patients, 32 patients with ISR underwent POBA, achieving 95% technical success. There was an improvement to Rutherford
scores, but recurrence of ISR following angioplasty was high at 1
year (68%). The remaining 36 patients had DEB angioplasty. In addition to similar improvement of Rutherford scores and technical
success compared to POBA, the recurrence of ISR was significantly
lower, log rank p=0.001.
Conclusion: Plain balloon angioplasty for ISR following SFA stenting achieves high technical success rates and improves clinical outcomes, but is blighted by high recurrence rates at 1 year. Our data
suggests that drug-eluting balloon therapy for ISR significantly
improves the patency of the SFA stents compared to POBA.

P-491
Regional anaesthesia aiding peripheral vascular intervention
in patients with ischaemic rest pain
D.Vishwanath1, C.Murch2, G.Haldane3
1Interventional Radiology, Queen Elizabeth University Hospital,
Glasgow, United Kingdom, 2Interventional Radiology, Hairmyres
Hospital, East Kilbride, United Kingdom, 3Department of Anaesthesia,
Hairmyres Hospital, East Kilbride, United Kingdom
Learning Objectives: We introduce the sciatic nerve block as
regional anaesthesia for patients with ischaemic rest pain undergoing lower limb vascular interventional procedures. We discuss the
indications, technique, benefits and risks of this technique.
Background: Ischaemic rest pain is very debilitating to patients with
lower limb vascular disease. The patients are restless and often hold

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their limbs in a dependent position to aid flow, improving perfusion
and thereby alleviating the ischaemic pain. This ischaemic rest pain
is difficult to manage with oral analgesia and hence pose a distinct
challenge to peripheral vascular interventional radiological procedures performed under local anaesthesia. Some of these peripheral
interventions can last more than 2 hours, and these patients find it
impossible to lie still for this length of time. These patients have significant co-morbidities and pose a high risk for general anaesthesia.
In our experience, sciatic nerve block provides excellent regional
anaesthesia/analgesia in such patients, provides excellent conditions for the peripheral interventional procedures and avoids the
risks of general anaesthesia.
Clinical Findings/Procedure: Sciatic nerve block is performed
under ultrasound guidance. Longer-acting anaesthetics can be used,
which alleviates not just intra-operative discomfort but also reperfusion pain for up to 15 hours. This is ideal for both the patient and the
interventionist, and is easy to institute in any hospital setting.
Conclusion: Sciatic nerve block is a safe regional anaesthetic procedure which provides excellent regional anaesthesia and analgesia for a long duration in patients with ischaemic rest pain requiring
peripheral intervention.

P-492
Treatment of spontaneous dissection of the celiac artery
O.Ikeda1, Y.Tamura2, S.Inoue2, M.Eguchi3, Y.Yamashita3
1Diagnostic Radiology, Kumamoto University Graduate School of
Medical and Pharmaceutical Sciences, Kumamoto, Japan, 2Diagnostic
Radiology, Kumamoto University Hospital, Kumamoto, Japan,
3Diagnostic Radiology, Kumamoto University Graduate School of Life

Sciences, Kumamoto, Japan

Learning Objectives: We present three options for treating spontaneous isolated celiac artery dissection (SICAD).
Background: SICAD without associated aortic dissection and
median arcuate ligament syndrome is rare. Its natural course is
uncertain, and there is no consensus on the optimal strategy for its
management.
Clinical Findings/Procedure: Four SICAD patients underwent
transcatheter coil embolization (TCE). Treatment indications were
dissecting aneurysm >2 cm, enlargement of and/or blood flow in the
false lumen at follow-up, and protracted pancreatitis. Embolization
techniques were based on the entry and reentry position, reentry,
the extent of dissection, and the collateral circulation. In 2 patients
without reentry whose celiac artery dissociation site was identified, we placed self-expanding nitinol stents in the celiac artery and
packed the false lumen with metallic coils. One patient whose dissociation extended to splenic and hepatic arteries and whose splenic
dissecting aneurysm measured >2 cm was treated by coil embolization of the false lumen of the involved arteries and the true lumen of
the celiac and common hepatic artery. In another patient whose dissociation extended to the splenic artery, the distance from the aneurysmal dilation to the celiac artery orifice was treated by coil embolization of the true lumen of the splenic and celiac arteries and sealing the celiac artery orifice with a stent-graft cuff. There was neither
post-treatment visceral ischemia nor any complication.
Conclusion: TCE of spontaneous dissection of the celiac artery can
be safe and effective. If embolization of the celiac artery orifice is
impossible, stent-graft placement is effective.

SS/FC/HL/HTS/CM
Posters

S311

P-493
Leaving nothing behind: systematic review of the paclitaxelcoated PTA ballon angioplasty in the femoropopliteal segment
N.P.W.Eckardt, C.Klumb, U.Teichgrber, R.Aschenbach
Department of Radiology, University Jena, Jena, Germany
Learning Objectives: Our aim is to compare different endovascular revascularization methods for femoropopliteal lesions in a combined meta-analysis and systematic review containing both RCTs
and non-RCTs that had been published between 2000 and 2015.
We want to present evidence based data to prove the better outcome of drug coated ballon.
Background: Our method is to review the quality of the studies design, quality of the reported outcome and the performance.
Thirty-nine studies have been included (22 RCTs and 17 non-RCTs;
6800 patients).
We included 8 RCTs in the first meta-analysis, with 1292 patients.
Clinical Findings/Procedure: The overall outcome showed a superiority of DCB vs. POBA in terms of primary patency (6 months: 82.7%
vs. 54.3%; 12 months: 72.0% vs. 51.8%; and 24 months: 71.4% vs.
46.6%) and freedom from target lesion revascularization (6 months:
92.6% vs. 71.9%; 12 months: 90.0% vs. 73.3%; and 24 months: 85.7%
vs. 59.2%) up to 24 months. Only 1 study has published 56 months of
follow-up data, but sample size was small (n=24). Evidence on clinical outcome (e.g., Rutherford, WIQ, change of ABI) is little.
Conclusion: Studies also have a very heterogeneous study protocol,
and study populations, quality of studies, and reported outcomes
vary.
Some trials are still in progress, and we are looking forward to presenting our up-to-date results.

P-494
Deepen the knowledge behind retrograde punctures for
critical limb ischemia intervention: anatomical considerations
to achieve optimal retrograde puncture
S.Inui1, M.Yamamoto1, K.Yamada1, M.Horikawa2, K.Tanaka3,
T.Kaji1
1Radiology, National Defense Medical College, Tokorozawa, Japan,
2Dotter Interventional Institute, Oregon Health & Science University,
Portland, OR, United States of America, 3Cardiovascular Surgery,
National Defense Medical College, Tokorozawa, Japan
Learning Objectives:
1. To deepen the knowledge about relevant anatomical structures
for critical limb ischemia (CLI) intervention based on thorough
evaluation of contrast-enhanced computed tomography (CE-CT)
images and angiogram.
2. To summarize the optimal retrograde access methods to avoid
relevant structures for each target artery.
Background: Bi-directional approach has been widely accepted
particularly as bail-out strategy after unsuccessful antegrade
approach for recanalization of critical limb ischemia; however, multiple complication risks have also been reported for retrograde access,
including injury of adjacent structures, hemostasis failure, and compartment syndrome. We demonstrate optimal puncture methods
based on anatomical considerations behind retrograde puncture
sites through comprehensive evaluation of CE-CT and angiogram.
Clinical Findings/Procedure:
1. Brief summary of common target arteries and variations for CLI
interventions.
2. Possible complications based on anatomical features.
3. Optimal puncture methods depending on target arteries:
(a) Distal superficial femoral artery: puncturing vertically at the level
of the adductor hiatus.

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(b) Popliteal artery: puncturing 34 cm above the tibiofemoral joint

with a needle directed from medial to lateral.
(c) Below-the-knee arteries in general: puncturing at distal
two-thirds of the calf.
(d) Anterior tibial artery: puncturing on a virtual line orthogonal to
another line drawn along the posterior surfaces of the tibia and
fibula.
(e) Posterior tibial artery (PTA) and peroneal artery (PnA): needle
advancement touching the posteromedial side of the tibia with
angulated access from lateral to medial side of the target arteries.
Conclusion: We illustrate a theoretically safe and feasible retrograde puncture technique with comprehensive anatomical consideration. Deep knowledge behind puncture sites is a key to minimizing complication risks.

Abstract Book
often very expensive and have their own limitations and pitfalls.
Retrograde access via crural and popliteal approaches is increasingly
used for patients in whom other access attempts have failed or are
simply not feasible owing to their disease.
Clinical Findings/Procedure: In our institution, we attempted retrograde access via the crural and popliteal approaches in twelve
patients over the past 3 years. The procedures were successful in
eleven patients. The access failed in one patient. Following the procedure, one patient developed AV fistula and required no further
treatment. There was no loss of vessel in any patient.
Conclusion: In our cohort, retrograde access via crural and popliteal
approaches was a valuable and safe technique for revascularising
difficult peripheral arterial occlusive disease.

P-497

P-495
CTO revascularization: step-by-step SAFARI technique using a
snare
J.Ferreira1, P.F.Sousa2
1Angiologia e Cirurgia Vascular, Centro Hospitalar de Trs-os-Montes e
Alto Douro, Vila Real, Portugal, 2Radiologia, Centro Hospitalar de Trsos-Montes e Alto Douro, Vila Real, Portugal
Learning Objectives: To understand all the technical aspects
related to subintimal arterial flossing with antegrade-retrograde
intervention (SAFARI) using a snare for CTO revascularization.
Background: Endovascular revascularization is effective in chronic
total occlusion (CTO). Subintimal angioplasty should be tried when
intraluminal angioplasty is not feasible. Distal true lumen re-entry
is not always possible, and simultaneous retrograde and antegrade
approach may be used.
Clinical Findings/Procedure:
1) Antegrade access in a patent artery close to CTO and retrograde
access in the distal target artery under ultrasound guidance.
2) Intravenous administration of heparin (40 units/kg).
3) Subintimal tracking via antegrade and retrograde approach using
0.035 hydrophilic angled guidewires until the guidewires are
placed side by side; this was confirmed with AP and lateral views.
4) Insertion of a snare through one access and pulling back the wire
through the other access.
5) Angioplasty and stenting.
6) Sealing of access sites.
Conclusion: In CTO revascularization, it is not always possible to reenter the distal true lumen during subintimal angioplasty. Although
challenging, the SAFARI technique using a snare is an effective and
affordable approach compared with the techniques using more
expensive re-entry devices.

Direct percutaneous NBCA embolization of recurrent internal

iliac artery aneurysm with common iliac arterial balloon
occlusion to alter hemodynamics of the involved branches
Y.Ogawa1, H.Nishimaki2, K.Murakami1, K.Chiba2, Y.Sakurai2,
K.Fujiwara1, T.Miyairi2, Y.Nakajima1
1Radiology, St. Marianna University School of Medicine, Kawasaki,
Kanagawa, Japan, 2Cardiovascular Surgery, St. Marianna University
School of Medicine, Kawasaki, Kanagawa, Japan
A patient had internal iliac artery aneurysm (IIAA) after proximal
ligation. Direct percutaneous NBCA embolization of IIAA was performed with common iliac arterial balloon occlusion to alter hemodynamics of the involved branches. Sac and branches were completely embolized without complications.

P-498
A novel method for inferior epigastric artery false aneurysm
embolisation with thrombin: a case report
P.E. Smith
Radiology, Epworth Hospital, Melbourne, VIC, Australia
An 85-year-old female was referred to Radiology for embolisation
of a right inferior epigastric false aneurysm, secondary to iatrogenic
laceration during right hemicolectomy. Using ultrasound guidance,
thrombin was directly injected into the false aneurysm, and hemostasis was achieved.

P-499
Successful balloon-assisted n-butyl cyanoacrylate
embolization of puncture site bleeding
T.Ueda, S.Murata, F.Sugihara, D.Yasui, I.Miki, H.Saitou,
S.-N.Kumita
Radiology, Nippon Medical School, Tokyo, Japan

P-496
Retrograde crural and popliteal access and its role in
challenging peripheral arterial occlusions: a pictorial review

We performed transcatheter arterial embolizations using n-butyl

cyanoacrylate (NBCA) for two cases of active bleeding at puncture
site after endovascular treatment. We occluded the parent artery
using a balloon catheter during the embolizations in order to prevent migration of NBCA.

A.Alfahad, D.R.Shaw
Interventional Radiology, Leeds Teaching Hospitals, Leeds, United
Kingdom
Learning Objectives: Over the last three years we performed
twelve cases of retrograde access via crural and popliteal approach.
We aim to describe our experience of this technique, offering tips on
patient selection, procedural steps, pitfalls avoidance and imaging
options with illustrative cases.
Background: Chronic occlusion is present in up to 40% of patients
who undergo treatment for symptomatic peripheral vascular disease. Target vessel access and crossing can be a significant obstacle faced when treating this population. Re-entry devices have
been used for mitigating this limitation. However, such devices are

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SS/FC/HL/HTS/CM
Posters

P-500

Radiation safety

Inadvertent cannulation of the left subclavian artery during

central line placement: endovascular repair with covered stent

P-505

J.D.Vasani1, M.Hamblin2, R.Kane2

1Diagnostic Radiology, Presence Saint Francis Hospital, Evanston,
IL, United States of America, 2Interventional Radiology Department,
Presence Saint Francis Hospital, Evanston, IL, United States of America
An 80-year-old male with severe hypotension underwent inadvertent cannulation of the left subclavian artery. Initially undetected,
it was identified on follow-up chest x-ray, confirmed on CT, and followed by repair with covered stent. Various complications and alternative percutaneous repair techniques are also discussed here.

P-501
Intraprocedural foot embolization during SFA recanalization
for in-stent restenosis: plantar-to-pedal loop aspiration
thrombectomy technique using the Penumbra Max catheter
R.Gandini, S.Merolla, E.Pampana, F.Chegai, S.Abrignani
Diagnostic and Molecular Imaging, Radiation Therapy and
Interventional Radiology, University Hospital Policlinico Tor Vergata,
Rome, Italy
During an SFA angioplasty, occlusion of both tibial arteries occurred.
An effective distal recanalization was obtained with a 3 Max catheter, which was advanced using the loop technique through the posterior tibial artery up to the clot in the dorsalis pedis.

P-502
Recanalization and percutaneous transluminal angioplasty of
persistent sciatic artery occlusion
S.Breznik, B.Polanec
Radiology Department, UKC Maribor, Maribor, Slovenia
We present a case of successful endovascular recanalization of a persistent sciatic artery in a symptomatic claudicant 57-year-old female
patient. The variant anatomy was seen on pre-intervention CTA
but had been erroneously diagnosed as laterally positioned SFA in
another hospital.

P-503
Temporary aneurysm neck occlusion during thrombin injection
J.Ferreira, P.F.Sousa
Angiologia e Cirurgia Vascular; Radiologia, Centro Hospitalar de
Trs-os-Montes e Alto Douro, Vila Real, Portugal
An iatrogenic superficial femoral artery pseudoaneurysm measuring 6 x 5 cm with a 5 x 5 x 1-mm neck was corrected with thrombin injection. During the injection, the aneurysm neck was temporary occluded with a 5-mm balloon in order to avoid distal ischemia.

P-504
Retrograde tibial angioplasty for critical limb ischaemia of
forefoot amputation stump wound through dorsalis pedis
artery after a failed USG-guided pedal artery cannulation
S. Narasimhan
Vascular Surgery, Apollo Hospital, Bangalore, India
A non-healing, critically ischaemic, forefoot amputation stump
wound was successfully treated with retrograde anterior tibial artery
angioplasty through cannulation of stump wound via the exposed
dorsalis pedis artery using a 4-Fr sheath, standard tibial coaxial catheter, and guide wire.

S313

Prostate artery embolisation (PAE): radiation doses to patient

and operator
S.Mafeld1, S.Findlay1, F.Colgan1, R.Padgett2, K.Robson2, T.Page3,
P.Littler1, P.J.Haslam1
1Interventional Radiology, Freeman Hospital, Newcastle upon Tyne,
United Kingdom, 2Medical Physics, Freeman Hospital, Newcastle upon
Tyne, United Kingdom, 3Urology, Freeman Hospital, Newcastle upon
Tyne, United Kingdom
Purpose: Benign prostatic hyperplasia (BPH) is a common disease
with established medical and surgical interventions, including transurethral resection of the prostate (TURP). PAE has been suggested
as an effective and less invasive approach. PAE can be a technically
demanding procedure due to variant pelvic arterial anatomy and
need for superselective vessel catheterisation. This combination
can result in prolonged screening times and consequent high-radiation doses. Radiation dose is related to PAE according to the existing literature.
Material and methods: Radiation doses were monitored during 17
PAE cases. All cases were performed on a Siemens AG (Artis Zee) fluoroscopy suite capable of cone beam CT (DynaCT). Siemens inbuilt
patient radiation skin exposure monitoring was recorded. Operator
doses were monitored using a RaySafe i2 (Billdal, Sweden) active
dosimetry system.
Results: Mean system-recorded skin dose was 3,208 mGy, range
1,3686,369. The mean radiation DAP dose was 55,426 Gym2,
range 8,42789,053. Mean procedure time was 153.88 minutes
(range 90255) and mean screening time was 46.26 minutes (range
17.1296). Doses measured with the RaySafe in 14 cases were 115.694
Sv (range 21181) to the neck and 59.66 Sv (range 1.2416) to the
operators legs.
Conclusion: PAE can be a technically demanding procedure, resulting in prolonged radiation exposure to the patient and operator.
Awareness of PAE radiation doses is critical for effective radiation
safety.

P-506
Usefulness assessment through application of house-made
radiation protection devices in TACE
J.S.Kim, J.H.Shin
Radiology, Asan Medical Center, Seoul, Korea
Purpose: To evaluate the effectiveness of house-made radiation
protection devices in reducing radiation exposure to deterministic
organs such as the eyeballs, thyroid glands, and gonads in patients
undergoing transcatheter arterial chemoembolization (TACE).
Material and methods: From May 16, 2015 to October 30, 2016,
the house-made radiation shields made of 0.5 mm Pb were applied
to a RANDO phantom and 111 patients (men, 93) who underwent
TACE at our institution. To measure the difference in mean radiation
dose before and after radiation protection, glass dosimeters were
attached to the shields for eyeballs, thyroid glands, and gonads in
the phantom model and real patients.
Results: The phantom study demonstrated that the mean radiation dose decreased from 310.34 uGy to 48.4 uGy after protection for
eyeballs; thus, 84% of reduction in radiation exposure was reported.
Likewise, 63% and 73% of decrease in the radiation dose after protection were reported for the thyroid glands and gonads, respectively. In 111 patients, 88%, 69%, and 74% of reduction in radiation
exposure after protection was reported for the eyeballs, thyroid
glands, and gonads, respectively.

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Conclusion: This study revealed that the use of house-made radiation protection devices reduced radiation exposure to the deterministic organs by 69%88% in patients undergoing TACE. Therefore,
to minimize radiation exposure, developing radiation protection
devices and applying them to patients is expected to reduce the
potential adverse effects of irradiation.

P-507
Radiation dose structured reports: helping to improve patient
care in interventional practices
J.M.Fernandez-Soto1, E.Vano2, R.M.Sanchez1, J.I.Ten3
1Servicio de Fisica Medica, Hospital Clinico San Carlos (IdISSC), Madrid,
Spain, 2Radiology, Complutense University, Madrid, Spain, 3Servicio de
Radiodiagnostico, Hospital Clinico San Carlos (IdISSC), Madrid, Spain
Purpose: To present the functionalities and first results of an automatic patient dose registry based on DICOM radiation dose structured report (RDSR) for interventional radiology and cardiology (IC)
in a large university hospital.
Material and methods: An automatic patient dosimetry system
based on MPPS DICOM objects has been upgraded to manage
DICOM RDSR objects in five catheterization laboratories. The information contained in RDSRs is included in a database, and a webbased application allows auditing of the evolution of patient doses.
A graphical representation summarizes all information in a skin dose
map, where each radiation event is represented with a level of gray
proportional to the incident air kerma, a size proportional to the
radiation field at the surface of the patient, and a position that takes
into account the X-ray beam projection.
Results: During 2015, 3315 procedures were registered in the database. The system offers, in addition to the skin dose map, an easy
access to any procedure, the revision of all the radiation events and
their technical details. The automatic feeding of the database allows
the analysis of the trends for the different parameters registered:
kerma area product, cumulative skin dose, fluoroscopy time, number of series, and frames per procedure.
Conclusion: Evaluation of data contained in a DICOM RDSR is a complex task. A graphical representation of the skin dose map helps to
identity procedures where peak skin dose could be higher than the
trigger level for potential clinical follow-up. The approach is being
initially used for IC.

P-508
Measurements, analysis & comparison with calculations of
peak skin doses during common interventional radiology
fluoroscopy procedures
R. Suri
Interventional Radiology, University of Texas Health Sciences Center
San Antonio, San Antonio, TX, United States of America

Abstract Book
Results: For 5 TIPS patients, mean OSL PSDs were 23.3% lower than
RDLs. The OSL PSDs were higher than the calculated PSDs by 24.8%
(1), 26.3% (2), and 21.7% (3). For 12 TACE patients, mean OSL PSDs
exceeded the reference dose levels by 75.4%. The OSL PSDs were
higher than the calculated PSDs by 22.7% (1), 30.9% (2), and 27.7%
(3). For 4 MAA patients, mean OSL PSDs exceeded the reference
dose levels by 36.7%. The OSL PSDs were higher than the calculated
PSDs by 40.38% (1), 42.52% (2), and 38.91% (3).
Conclusion: OSL PSDs were higher than calculated PSD, most
closely correlated with calculations using height/weight for estimating patient thickness.

P-509
Advantages of using a realtime robotic tracking system for
CT-guided percutaneous cryoablation of renal tumors in terms
of success of treatment and radiation exposure
S.Quarchioni, F.Arrigoni, F.Bruno, A.LaMarra, S.Mariani,
L.Zugaro, A.Barile, C.Masciocchi
Department of Biotechnological and Applied Clinical Sciences,
University of LAquila, LAquila, Italy
Purpose: To evaluate the advantages of using a robotic tracking system for CT-guided percutaneous cryoablation of renal tumors in
terms of radiation exposure to the interventional radiologist (IR) and
success of the treatment.
Material and methods: From February 2014 to June 2015, we
treated 10 patients with solid contrast-enhancing renal tumor: inclusion criteria were a tumor size of <4 cm and patients with high surgical risk. Patients with coagulation disorder and lesion considered
unsuitable for treating by IRs and urologists were excluded. The procedures were performed with a robotic tracking system that starting from CT scans, reconstructs 3D virtual models of the patients
anatomy and allows to position the cryprobe inside the body with
a realtime navigation. Final position of the probe was, however, confirmed with Fluoro-CT before cryoablation. Two freezing cycles (10
minutes) separated by two warming cycles (5 minutes) were performed. All patients were slightly sedated.
Results: In 7 patients, Fluoro-CT confirmed good position of
the cryoprobe; in 1 patient, the cryprobe was repositioned with
Fluoro-CT due to an error of 3 mm. After treatment, all patients
showed complete devascularisation of the lesion in CT follow-up
at 1 and 6 months. A decreased size of the lesion was detected in
4 patients at 6 months. No major complications occurred. Radiation
dose to the IR was 0.
Conclusion: The robotic tracking system is an innovative medical
device that allows centering lesions with a high degree of precision
and following the trajectory of the cryoprobe realtime to avoid sensitive structures with a reduction of radiation dose to the IR.

P-510

Purpose: The purpose of this study is to measure the peak skin

doses for four routinely high-dose hepatic interventional procedures by using optically stimulated luminescence dosimeters (OSL).
This study compares the actual measurements of the peak skin dose
utilizing locally calibrated OSL dosimeters with the traditional medical physics calculations of peak skin dose.
Material and methods: Four OSLs per patient were affixed to the
patients back overlying the expected location of the liver, ensuring
that they were included in the fluoroscopic field of view. The highest dose was recorded as the OSL peak skin dose (OSL PSD), against
which other calculated measurements were compared. PSDs were
calculated using the displayed Cumulative air KERMA (per the Philips
Allura XPer FD 20 DICOM display). Patient thickness was assessed by
three separate methods: (1) using calipers; (2) estimated by kV and
SID (from DICOM); (3) estimated by height and weight.

CT angiography during long-term follow-up after endovascular

aneurysm repair (EVAR): combined dose reduction techniques
R.A.Rotzinger1, J.Kahn1, G.Bning1, P.Freyhardt1, D.M.Renz2,
B.Hamm1, F.Streitparth1
1Department of Radiology, Charit - Universittsmedizin Berlin, Berlin,
Germany, 2Institute of Diagnostic and Interventional Radiology,
Friedrich-Schiller-University, Jena, Germany
Purpose: Endovascular aneurysm repair (EVAR) requires lifelong surveillance by CT angiography (CTA). This is attended by a substantial accumulation of radiation exposure. Iterative reconstruction has
been introduced to attain dose reduction at lowered tube potential. This study evaluates adaptive statistical iterative reconstruction (ASIR) for follow-up after EVAR at different levels of tube voltage
concerning diagnostic quality and dose reduction potential.

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CIRSE 2016
Material and methods: In total, 100 CTAs in 67 patients with EVAR
were examined using 5 protocols: group A (n=40) as biphasic standard using filtered back projection (FBP) at 120 kV; groups B (n=40),
C (n=10), and D1 (n=5) as biphasic standards using ASIR at 120, 100,
and 80 kV, respectively; and group D2 (n=5) as monophasic standard using split-bolus ASIR protocol at 80kV. Image quality was
assessed quantitatively by calculating signal- and contrast-to-noise
ratios (SNRs, CNRs) and qualitatively by two experienced observers
(5-point Likert scale). CTDIvol (mGy), total DLP (mGy x cm), and effective doses (mSv) were determined.
Results: Applied doses in ASIR groups were significantly lower than
FBP standard (B: 37.4%, C: 48.6%, D1: 61.4%, and D2: 75%). Compared
to group A, SNRs and CNRs in group B were equal and in groups C
and D equal to partially inferior; however, none of the values were
decisive for diagnostic quality. Subjective image quality ratings in all
groups were good to excellent without impairments of diagnostic
confidence, with high inter-rater agreement.
Conclusion: ASIR contributes to significant dose reduction without
decisive impairments of image quality or diagnostic confidence in
CTA after EVAR. We recommend an adapted follow-up introducing
ASIR and combined low kV for EVAR surveillance.

P-511
Using the LIGHTSABER to reduce patient radiation dose during
fluoroscopy
M.K.Singh1, J.H.Shah2, M.Wallace-Severa1, A.Narkiewicz-Jodko1,
R.Koff1, A.Lee1, S.Braverman1, S.Hartzman1
1Radiology, Santa Barbara Cottage Hospital, Santa Barbara, CA, United
States of America, 2Radiology, Maimonides Medical Center, New York,
NY, United States of America
Learning Objectives: A structured approach is essential for optimizing fluoroscopic settings so that the overall dose to the patient
will have been reduced. At the conclusion of this exhibit one can
use this checklist to ensure they are taking the proper precautions
to reduce radiation dose to the patient. Concise, relevant physics
explanations accompany each topic. A short case based quiz concludes this exhibit to test your knowledge.
Background: Safety checklists have proven to be effective tools in
many areas of medicine. It is imperative that the operator and technologist quickly run through an on-the-go checklist when appropriate. While implementing these steps, it is also important to note that
there is a delicate balance between minimizing dose and optimizing quality.
Clinical Findings/Procedure: Through the mnemonic LIGHTSABER,
this exhibit explains considerations one should take during fluoroscopic examinations. Remembering to step Lightly by tapping intermittently on the fluoroscopy pedal; bring the Image Intensifier close
to the patient; turn the Grid off; use fluoroscopy Hold to review
anatomy and fluoro-save when possible; keep track of the Total
fluoroscopy Time; make sure the x-ray source is in optimal position and Spread the dose when appropriate; Align/collimate the
beam; understand how tube settings contribute to Beam properties
and how adjustments to the x-ray tube can be made; understand
how Electronic magnification affects dose; and know and avoid
Radiosensitive organs when possible.
Conclusion: By using the checklist/mnemonic LIGHTSABER, one can
ensure they have taken the necessary precautions to limit radiation
dose to the patient.

SS/FC/HL/HTS/CM
Posters

S315

P-512
Occupational exposures to ionizing radiation from
interventional cardiology: literature and practice review
A. Maschera
Cardiovascular Dept - Emodinamica - Ospedale dellAngelo, Azienda
ULSS12 Veneziana, Venezia, Italy
Learning Objectives: This paper, examines the existing scientific
evidence on the alarming incidence of cancer and other serious
adverse effects among medical professionals who perform interventional procedures. The paper focuses also on evidence about available protection systems and practical recommendations for interventional staff.
Background: Over the last decade, there has been a growing body
of evidence on the adverse health effects of occupational exposures
to ionizing radiation from interventional cardiology and vascular
procedures. International published data shows that there has been
an increasing focus on reducing patient exposure to radiation, but
less attention has been paid to lowering the risk for medical professionals who have cumulative exposure.
Clinical Findings/Procedure: Simple methods for reducing or minimizing occupational radiation dose include minimizing fluoroscopy time and number of acquired images; using available patient
dose reduction technologies; using good imaging-chain geometry;
collimating; avoiding high-scatter areas; using protective shielding;
using imaging equipment whose performance is controlled through
a quality assurance program; and wearing personal dosimeters so
that you know your dose.
Conclusion: Effective use of these methods requires both appropriate education and training in radiation protection for all interventional cardiology personnel and the availability of appropriate protective tools and equipment. Unfortunately, these tools may not
offer sufficient protection to the medical professional as high doses
accumulate.
A re-design of interventional laboratories with the awareness of
operators and skilled professionals as radiographers with the inclusion of new technologies could modernize, and transform, what
constitutes ALARA.

Renal and visceral artery intervention

P-513
Iatrogenic renal vascular injuries: what is the role of the
interventional radiologist?
F.Corvino1, M.Silvestre2, F.Giurazza3, A.Cervo4, A.Corvino1,
F.Maglione5
1Department of Advanced Biomedical Sciences, Diagnostic Imaging
Section, Federico II University, Naples, Italy, 2Diagnostica per Immagini
e Radioterapia, AOU Federico II, Naples, Italy, 3Radiology, Campus
Biomedico University of Rome, Rome, Italy, 4Radiology, AOU Federico
II, Naples, Italy, 5Vascular and Interventional Radiology, Cardarelli
Hospital, Naples, Italy
Purpose: To demonstrate the role of interventional radiology in the
treatment of iatrogenic renal vascular injuries using transcatheter
embolization by reviewing our 6-year experience.
Material and methods: Our retrospective analysis consists of a total
of 65 patients (38 M and 27 F) who underwent renal arterial embolization (RAE) for iatrogenic arterial kidney bleeding. Percutaneous
nephrostomy (n=26), nephron-sparing surgery (n=20), percutaneous
nephrolithotomy (n=10), surgical nephrectomy (n=6), and biopsy
(n=4) were the iatrogenic cause. Estimated glomerular filtration
rate (eGFR), renal function tests, hemoglobin, and hematocrit levels
before and after embolization were recorded and compared.

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Abstract Book

Results: Diagnostic renal angiography revealed 40 pseudoaneurysms, 21 arteriovenous fistulas, 4 actively bleeding vessels, and 2
arteriocalyceal fistulas. Embolization was performed with microcoils,
polyvinyl alcohol particles, embospheres, spongostan emulsion
and Glubran plus Lipiodol. The technical success rate was 100%.
No major complications requiring intensive care treatment were
encountered during or after the procedures. No patient required
emergency surgery or subsequent surgical treatment. No statistically significant differences in eGFR or renal function stage appeared
after RAE.
Conclusion: Percutaneous treatment can be proposed as a first-line
treatment in iatrogenic renal arterial injuries, resulting in a safe and
effective procedure without significant change in renal function.

Results: CO2gas was injected from the marginal artery in four cases
and from the vasa recta in five cases. Extravasation was revealed in
three cases for each. We could detect the bleeding site by injecting CO2 from vasa recta in two cases, in which extravasation was
not shown in a previous CT. The bleeding site was embolized with
microcoils in four cases and gelatin sponge in one case and was not
embolized in one case. All six cases showed no re-bleeding during
the mean follow-up period of 5 months (117 months). The adverse
events associated with CO2 injection included abdominal discomfort in three cases, nausea in two cases, and vomiting in one case.
Conclusion: CO2angiography was useful and safe in detecting the
bleeding point in the colonic diverticulum, even though extravasation was obscured on conventional angiography.

P-514

P-516

Iatrogenic bleeding: interventional radiology to the rescue

Cryptogenic hemoptysis: effectiveness of bronchial artery

embolization using n-butyl cyanoacrylate

A.K.Yadav, R.Bansal, A.Gupta

Interventional Radiology, Sir Ganga Ram Hospital, Delhi, India
Purpose: The main objectives of this study were to determine the
etiology of iatrogenic bleed and investigate the outcome of angioembolisation in the management of iatrogenic bleeding.
Material and methods: Thirty-five cases of iatrogenic bleeding
referred to the IR department from 2009 to 2014 were retrospectively reviewed. The technical success was evaluated on the basis
of the achievement of hemostasis and clinical success based on lab
parameters. There were 27 males and 8 females with a mean age of
51 years (range 1496 years). Patients who had laparoscopic cholecystectomy (n=9, 25%) and renal intervention (n=9, 25%) constituted
the largest group, while those who underwent complex gastrointestinal surgery such as the Whipple procedure constituted the second
largest group (n=6, 17%): GJ for blunt trauma (n=2, 5.7%), open cholecystectomy with HJ (n=3, 8.6%) and bowel resection (n=1, 2.8%).
Results: Technical success was achieved in 33 patients (94%).
Adequate hemostasis could not be achieved in 2 patients because
of inability to localize bleeding site. Clinical success was achieved in
28 patients (80%). Two patients (5.7%) who continued to bleed died
within 3 days following the procedure. Five patients (14.7%) died
within 30 days of the procedure. Among them, surgery was performed in 3 patients, and 2 were managed conservatively. Among
the 5 patients with clinical failure, 2 died of excessive blood loss,
while 3 died of sepsis/cardiac-related issues.
Conclusion: Iatrogenic bleeding can be successfully treated with
angioembolisation. High mortality is seen in patients who have
undergone complex gastrointestinal surgeries; these patients
should be treated vigorously. Patients who have undergone genitourinary surgical or medical procedures show better prognosis.

P-515
The usefulness of CO2 angiography in detecting active
bleeding from the colonic diverticulum
E.Sugihara, S.Kawamoto
Radiology, Osaka General Medical Center, Osaka, Japan

C.J.Yoon, C.H.Jeon, H.Lee, Y.-J.Kim, S.W.An, Y.N.Woo

Radiology, Seoul National University Bundang Hospital, Seongnam,
Korea
Purpose: This study aims to assess the safety and effectiveness of
BAE using n-butyl cyanoacrylate (NBCA) in patients with cryptogenic hemoptysis.
Material and methods: Between May 2003 and March 2014, 28
patients (mean age 45.0 years, mean cigarette consumption 19.1
pack years) who underwent BAE for cryptogenic hemoptysis (no
possible cause on bronchoscopy and chest CT) were enrolled in this
study. A retrospective review was conducted for the angiographic
findings of cryptogenic hemoptysis, technical and clinical success,
complications of BAE, and rate of recurrent hemoptysis.
Results: Selective bronchial arteriograms were abnormal in 19
patients (67.9%: hypertrophic bronchial arteries [n=18], parenchymal hypervascularity [n=15], and pulmonary vessel shunt [n=8]).
All abnormal bronchial arteries (right [n=10], left [n=3], and both
[n=6]) were successfully embolized with NBCA. Nine patients (32.1%)
showed normal angiographic findings, in whom the bronchial arteries were empirically embolized based on CT and/or bronchoscopic
lateralization (right [n=4], left [n=2], and both [n=3]). Hemoptysis
stopped within 24 hours in all patients. There was no procedurerelated complication. During the follow-up (range 6115 months,
median 34), 3 patients (10.7%) experienced recurrent hemoptysis
at 1, 5, and 11 months after initial BAE; these patients were treated
with repeated embolization (once for each patient). The estimated
hemoptysis-free survival rates were 92.8%, 89.3%, and 89.3% at 6,
12, and 24 months, respectively.
Conclusion: Bronchial arteries were angiographically abnormal in
a large proportion of patients with cryptogenic hemoptysis (67.9%).
BAE using NBCA is a safe and effective treatment in patients with
cryptogenic hemoptysis, including those with a normal bronchial
arteriogram.

P-517

Purpose: The purpose of this study was to evaluate the usefulness

and safety of CO2angiography in patients with active bleeding from
the colonic diverticulum.
Material and methods: Between April 2014 and December 2015,
21 cases in 17 patients underwent angiography for the hemorrhage of the colonic diverticulum. Extravasation had been previously detected on dynamic contrast-enhanced CT in 19 cases,
but active bleeding could not be detected in 13 cases on conventional angiography with iodinated contrast material. CO2angiography was applied in nine cases among the 13 cases. The detectability of colonic hemorrhage with CO2, the clinical course, and adverse
events were evaluated.

Proximal splenic embolization in a polytrauma patient: our

experience
A.Nivolli, D.Ivaldi, M.Arn, A.Barile, P.Gazzo
S.s.d. Interventional Radiology, Asl2 Savonese-Ospedale S. Corona,
Pietra Ligure, Italy
Purpose: In total, 32% of polytrauma patients have a spleen injury;
conservative treatment associated with proximal splenic artery
embolization has gained importance in recent years in hemodynamically stable patients. Here we present our experience of proximal
splenic artery embolization and aim to demonstrate the effectiveness of the procedure as a conservative treatment.

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CIRSE 2016
Material and methods: Between January 2007 and December 2015,
34 patients aged 2346 years were treated with proximal splenic
embolization. Lesions between II and III degree of AAST classification were treated in hemodynamically stable or borderline polytrauma patients. Embolization was performed by occlusion of the
medium splenic artery segment with Amplatzer Plug or POD or spirals. Patients were then subjected to strict clinical and instrumental
monitoring (blood chemistry exams every 6 h for 48/72 h, CEUS at 24
h, and CT with a contrast agent at 48 h and after 15 days).
Results: Embolization has had technical success of 100%.
The rate of minor complications was 17.6% (six cases with focal areas
of ischemia); major complications occurred in 11.7% of patients: two
cases of complete splenic infarcts, one case of splenic abscess, and
one case of rebleeding. All the patients with major complications
were treated with open surgery splenectomy 2/3 days after the
embolization.
Conclusion: Proximal splenic artery embolization in patients with
spleen lesions above Grade II (AAST) is associated with a reduction
of splenectomy. The results of our study, despite a low number of
cases, demonstrate that this procedure is able to significantly reduce
the number of splenectomy procedures in the polytrauma setting,
particularly in young-aged patients.

P-518
Tumor localization with a hook wire and selective arterial
embolization of renal tumor in a hybrid operating room at
the same time as laparoscopic partial nephrectomy: a new
approach in renal surgery
L.Besnier1, A.Bouvier1, P.Bigot2, P.Panayotopoulos2,
A.-R.Azzouzi2, C.Aub1
1Radiology Department, Angers University Hospital, Angers, France,
2Urology Department, Angers University Hospital, Angers, France
Purpose: Laparoscopic nephron-sparing surgery (LNSS) is the standard of care for tumors confined to the kidney. Superselective tumor
embolization (STE) allows limiting of operative bleeding without
renal ischemia. However, the surgical excision can be difficult due
to adherent perirenal fat or, in case of delayed surgery, due to the
occurrence of post-embolization perilesional edema.
We describe a new concept for the treatment of kidney tumors: in
a hybrid operating room, we performed STE at the same place and
time as LNSS.
Material and methods: We treated 13 patients with localized renal
tumors of moderate to high complexity RENAL score.
STE was performed in a hybrid operating room at the same time as
LNSS without dissection and clamping of the renal pedicle.
In addition, we used a percutaneous hook wire inserted into the
tumor under ultrasound guidance in 4 patients for immediate preoperative tumor localization.
A 3D renal arteriography was performed to precisely identify the
tumor vascularization and an endovascular guidance software was
used in order to limit radiation and iodine injection.
Results: Mean size of the tumor was 3.4 cm (28).
Mean blood loss was 137 137.4 mL.
Post-embolization control 3D arteriography confirmed preservation
of healthy renal parenchyma in all cases.
No postoperative complications occurred.
Mean hospital stay after the procedure was 3.8 1.7 days.
Conclusion: Combined approach, including simultaneous tumor
localization with a hook wire, STE, and LNSS, in a dedicated operating room is a new zero-ischemia method that reduces the difficulty of the surgery, limits injury to the kidney, and increases patient
safety.

SS/FC/HL/HTS/CM
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S317

P-519
Evaluation of effects of induced ischemia (arterial vs. venous)
on the extension of coagulation necrosis of RFA in the liver,
spleen, and kidneys
A.Rasekhi1, G.Shadmani1, K.Kazemi2, E.Zaree3, A.Monabati4
1Interventional Radiology, Shiraz University of Medical Science, Shiraz,
Iran, 2Transplant Surgery, Shiraz University of Medical Science, Shiraz,
Iran, 3General Surgery, Namazee Hospital, Shiraz, Iran, 4Pathology,
Shiraz University of Medical Science, Shiraz, Iran
Purpose: The combination of RFA with tissue-induced hypoperfusion (arterial vs. venous clumping and PVA selective microembolization) is associated with more extensive tissue burn (coagulation
necrosis) than that with only RFA. This combination may be associated with better results and a lower rate of tumor recurrence in
patients with HCC or other tumors.
Material and methods: Eleven dogs with nearly similar sizes were
selected. The study was conducted as follows:
Kidneys: (8 dogs) Right kidney: upper pole [1], RFA; lower pole [2],
RFA+renal artery clumping. Left kidney: upper pole, RFA [3]; lower
pole, RFA+renal artery PVA microembolization [4].
Liver: (10 dogs) RFA was performed in one hepatic lobe [5], and
in the other lobe, RFA+portal vein and hepatic clamping [6] were
performed.
Spleen: (8 dogs) RFA was performed in one pole [7], and
RFA+splenic aretery and vein clamping [8] were performed in the
other pole.
In three dogs, RFA+selective splenic artery clamping [9] was performed in one pole and RFA+selective splenic vein clamping was
performed in the other pole [10].
Beside gross measurment of the area of coagulation necrosis for
comparison, pathologic slides were prepared and coded and
reviewed by pathologists.
Results: The average extension of coagulative necrosis in different
methods are as follows:
1&3- 13.5x13.3 mm
2- 16x13.3 mm
4- 15x12.5 mm
5- 12.3x13.5 mm
6- 18.7x16.7 mm
7- 12.4x14.8 mm
8- 16x17 mm
9- 6x7 mm
10- 12.5x11.5 mm
Conclusion: Difficulty in treating moderate to large tumors is often
attributed to the powerful heat-sink effect. Considering the result of
previous studies about decreasing tumor blood flow to aid RF ablation in our study, we can conclude that in two flow-restricted organs,
better results are achieved by venous occlusion than with arterial
occlusion. This effect may be due to the importance of amount of
extracellular fluid for success of RFA.

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P-520
Long-term results of percutaneous endovascular treatment in
patients with mesenteric ischaemia: bypass postponement...
or renouncement?
T.Bulut1, R.Oosterhof-Berktas2, R.Geelkerken3, M.Brusse-Keizer4,
E.Stassen1, J.Kolkman5
1Radiology, Medisch Spectrum Twente, Enschede, Netherlands,
2Radiology, Medisch Spectrum Twente/ Martiniziekenhuis, Enschede/
Groningen, Netherlands, 3Vascular Surgery, Medisch Spectrum Twente,
Enschede, Netherlands, 4Medical School Twente, Medisch Spectrum
Twente, Enschede, Netherlands, 5Gastro-enterology, Medisch Spectrum
Twente, Enschede, Netherlands
Purpose: Over the past decade, primary stenting of the celiac (CA)
and superior mesenteric artery (SMA) has become an alternative
for open revascularization as treatment of mesenteric ischemia.
Institutes have presented favourable short-term outcomes after percutaneous antegrade mesenteric artery stenting (PMAS), but there is
a lack of data on long-term stent patency. This study focused on the
anatomical durability of PMAS in patients suffering from mesenteric
ischaemia.
Material and methods: One hundred and forty-one patients
treated by PMAS for acute, chronic and acute-on-chronic mesenteric ischaemia over an 8-year period were evaluated. All procedures were performed by dedicated interventional radiologists.
Anatomical success was assessed by duplex ultrasound and/or
CT-angiography. A stenosis 70% was considered as failure.
Results: Eighty-six CAs and 99 SMAs were treated in 141 patients.
Nine CAs (10%) and 30 SMAs (30%) were occluded at the time of
treatment. Median follow-up was 32 months (IQR 20-46). The overall primary patency rate at 12 and 60 months was 77.0% and 45.0%.
The overall primary-assisted patency rate was 90.3% and 69.8%. The
overall secondary patency was 98.3% and 93.6%.
Conclusion: PMAS has excellent long-term secondary patency
rate, comparable to published data on long-term patencies after
open revascularization. PMAS in patients with mesenteric ischaemia
should therefore not be considered as a postponement of an operative bypass, but a bridge to a possible next endovascular treatment.

P-521
Stent angioplasty of transplant renal artery stenosis
A.Massmann1, C.Marchal1, S.Seiler-Mussler2, M.Janssen3,
M.Stckle3, A.Buecker1
1Diagnostic and Interventional Radiology, Saarland University Medical
Center, Homburg, Germany, 2Nephrology, Saarland University Medical
Center, Homburg, Germany, 3Urology, Saarland University Medical
Center, Homburg, Germany
Purpose: Retrospective evaluation of stent angioplasty for treatment of transplant renal artery stenosis (TRAS).
Material and methods: During 2000-2015, 66 patients (male n=41;
mean agestandard deviation 54.815.1 years) with ultrasoundbased suspicion for TRAS were referred for catheter angiography.
Pre-/postinterventional blood pressure and renal function were
assessed.
Results: Angiography confirmed TRAS in 63 (95.5%) patients
219265 [1-891] days post transplantation.
Primary technical success (residual stenosis <25%) of stent-implantation was 100% (Palmaz Blue, Cordis n=62; Advanta V12, MaquetGetinge Atrium) n=1 for filiforme TRAS to avoid vessel-rupture).
No peri-procedural complications occurred.
During the 3511.1 [21-6] months of follow-up, improvement of all
target parameters was obvious:

Abstract Book
Reduction of blood-pressure systolic 13812 to 1375 mmHg
(p=0.0233) and diastolic 8712 to 779 mmHg (p=0.0524) and dosage reduction of antihypertensive medication (n=31 [1-5]) (p>0.1)
after 1 year.
Improvement of flow-acceleration of arterial anastomosis from
3.11.2 [1-6] to 1.30.4 [0.8-1.9] m/s (p=0.0089) and resistance index
from 0.640.09 [0.46-0.74] to 0.730.09 [0.6-0.85] (p=0.0195) after
one year.
Improvement of glomerular filtration rate after 1 week from 31.55.1
(23.2-39.1) to 38.47.2 (25.8-50.4) (p=0.0309).
Primary patency and transplant survival was 100% after 1 year.
Conclusion: Stent implantation for transplant renal artery stenosis
optimizes safely and efficiently arterial hypertension, hemodynamics, and renal excretion function.

P-522
Short- and long-term outcomes of percutaneous interventions
for transplant renal artery stenosis: a 10-year experience
A.Macdonald, M.W.Little, P.Boardman, R.Patel, M.Bratby,
A.J.Wigham, J.Phillips-Hughes, R.Uberoi, S.Anthony, C.R.Tapping
Radiology, Oxford University Hospitals Trust, Oxford, United Kingdom
Purpose: Interventions performed for transplant renal artery stenosis (TRAS) at our single transplant centre were evaluated for technical success, complications, and change in serum creatinine levels (as
a surrogate measure of transplant function).
Material and methods: Thirty consecutive interventions were performed in 24 patients with TRAS diagnosed using magnetic resonance angiography between 2006 and 2015. The procedure report,
subsequent imaging, and patient record were used to determine
technical success and identify complications. Clinical success was
assessed based on the pre-procedure, post-procedure and longterm creatinine values. Creatinine levels were correlated with
patient records to screen for confounding factors such as intercurrent illnesses.
Results: There were three technical failures: one due to high-grade
transplant renal arterial stenosis and two due to extreme tortuosity
of the feeding transplant artery. Three cases were complicated with
simple groin haematoma. The 30-day mortality rate was 0%.
Five patients required re-intervention following initial angioplasty
of the stenotic transplant renal artery due to persistently increased
creatinine levels. Of these, re-intervention cases, three underwent
repeat angioplasty, whilst two were stented; all cases subsequently
showed good clinical success. Six patients underwent primary stenting; none of these required re-intervention.
The mean short-term reduction in creatinine levels was 26% (95% CI
10, median follow-up 49 days) and the mean long-term reduction in
the levels was 25% (95% CI 17, median 983 days post-procedure).
Conclusion: Percutaneous intervention for TRAS is an effective and
safe procedure with a high technical success rate and minor complication rate. Significant and sustained improvements in serum creatinine were achieved. The use of a stent in the primary intervention
was associated with a lower rate of re-intervention.

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P-523
Assessing the effect of baseline manual dexterity and
playing computer-games on catheter-wire manipulation in
interventional radiology-nave medical students
Z.Alsafi1, Y.Hameed1, P.Amin1, S.Shamsad1, A.Alsafi2,
M.S.Hamady3
1Medical School, UCL, London, United Kingdom, 2Radiology, Imperial
College Healthcare NHS, London, United Kingdom, 3Radiology, St
Marys Hospital, London, United Kingdom
Purpose: We speculate that baseline hand-eye coordination affects
the operators catheter and wire manipulation in interventional radiology. Playing computer games has also been linked to improved
visuospatial awareness.
We set out to investigate the effect of playing computer games and
basic manual dexterity on catheter-wire manipulation in a mechanical aortic model.
Material and methods: Medical student volunteers filled in a preprocedure questionnaire assessing their exposure to computer
games. Their manual dexterity was measured using a smart-phone
game. They were then shown a video clip demonstrating renal
artery cannulation and were asked to reproduce this. All attempts
were recorded and timed. Two-tailed Student t-test was used to
compare continuous data, while Fishers exact test was used for categorical data.
Results: Fifty students (40 males and 10 females) aged 1822 took
part, of whom 46 successfully cannulated the right renal artery at an
average of 168 s (103301). There was no significant difference in the
dexterity app score or time to cannulate the renal artery between
males and females.
Students who played more than 10 h per week had better dexterity
scores than those who did not play computer games: 9.1 s vs 10.2 s
(p = 0.0237).
Four of 19 students who did not play computer games failed to cannulate the renal artery, while all those who played regularly completed the task; this was statistically significant (p = 0.0168).
Conclusion: Playing computer games regularly may improve manual dexterity and the ability to complete a basic IR task.

P-524
Variables predicting active extravasation and contrast-induced
nephropathy in conventional angiography for acute intraabdominal bleeding
Z.Haber, H.W.Charles, J.Weisstuch, S.Kovacs, A.R.Deipolyi
Radiology, Division of Vascular and Interventional Radiology, NYU
Langone Medical Center, New York, NY, United States of America
Purpose: To identify variables predicting active extravasation and
contrast-induced nephropathy (CIN) in angiography performed for
acute bleeding.
Material and methods: We retrospectively reviewed all conventional angiograms performed for acute bleeding (1/2013 to 6/2015),
including 75 angiograms (46 gastrointestinal; 29 other sources of
intra-abdominal bleeding cases) in 70 patients (26 women; 44 men)
with a mean age of 59 (range 21-92) years. We recorded demographic information, comorbidities, vital signs immediately preceding angiography, post-procedure complications, and change in
hematocrit (Hct) and fluids and blood products administered over
the 24 hours prior to angiography.
Results: Of 75 exams, 20 (27%) showed contrast extravasation.
Hct was the only independent predictor of contrast extravasation
(p=0.017). Patients with active extravasation had larger Hct than
those without extravasation (17% vs. 1%; p=0.01). CIN occurred
after 10 of 66 angiograms (15%), with GFR being the only independent predictor (p=0.03); 8% of patients with normal renal function

SS/FC/HL/HTS/CM
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S319

(GFR>60) developed CIN; 29% of patients with mild-moderate

impairment (GFR 30-60) developed CIN; and 67% of patients with
severe renal impairment (GFR<30) developed CIN after angiography.
Conclusion: Greater decrease in hematocrit over the 24 hours prior
to angiography for intra-abdominal bleeding is an independent predictor of active extravasation, whereas pre-existing renal impairment is the independent predictor of CIN. The potential benefit of
diagnosing active extravasation in patients with large hematocrit
declines can be weighed against the risk of renal impairment.

P-525
Percutaneous revascularization for renal artery stenosis:
outcome of renal function and blood pressure
J.MorenoNegrete, A.Sotomayor, M.Barrufet, F.M.Gmez,
J.Guitart, P.Bermudez, M.Burrel
Vascular Interventional Unit, Hospital Clnic Barcelona, Barcelona,
Spain
Purpose: The aim of the study was to retrospectively analyze the
outcome of patients who underwent endovascular treatment for
renal artery stenosis (RAS) at our institution.
Material and methods: We evaluated patients treated between
January 2008 and June 2011, who presented RAS associated with
renal insufficiency and/or arterial hypertension. Baseline characteristics and complications related to treatment were recorded. To assess
the results, blood pressure, creatinine levels, and number of antihypertensive drugs were collected at 3 and 6 months after treatment.
Results: In total, 48 patients were treated (40 males, 8 females), with
a median age of 64.7 years. Treatment was performed on 41 native
kidneys and 7 transplants; over 75% of patients showed >75% stenosis. At baseline, creatinine levels were >1.5 mg/dl in 40 patients and
22 patients showed blood pressure >140 mmHg (systolic) and >90
mmHg (diastolic). At the 6-month follow-up after treatment, creatinine levels were stabilized or dropped in 70% of cases and 23%
showed restoration of renal function. Bilateral stenosis performed
better with more than a four-fold reduction at 6 months compared
with unilateral stenosis. Among hypertensive patients, blood pressure dropped significantly (p<0.05) in 83% of cases, with normalization of values in 47%. In total, 50% of the patients lowered the number of antihypertensive drugs. There were no major complications
related to the procedure.
Conclusion: With appropriate selection criteria, the percutaneous renal artery revascularization showed good results for lowering
blood pressure and restoring renal function, with low complication
rates related to the procedure.

P-526
Endovascular treatment of hepatic artery hemorrhage after
pancreaticoduodenectomy and extended hepatectomy: what
should we do to decrease mortality and complications?
T.Hasegawa1, H.Ota2, T.Matsuura2, T.Sato2, K.Seiji2, F.Motoi3,
J.Yamauchi4, M.Unno3, K.Takase1
1Diagnostic Radiology, Tohoku University Graduate School of Medicine,
Sendai, Miyagi, Japan, 2Diagnostic Radiology, Tohoku University
Hospital, Sendai, Miyagi, Japan, 3Surgery, Tohoku University Graduate
School of Medicine, Sendai, Miyagi, Japan, 4Gastrointestinal Surgery,
Sendai Kousei Hospital, Sendai, Miyagi, Japan
Purpose: To evaluate risk factors predicting death and complications following endovascular treatment (EVT) as the customary
treatment for hepatic artery and gastroduodenal artery stump pseudoaneurysms after pancreaticoduodenectomy (PD) and extended
hepatectomy (HTX).
Material and methods: Between April 2004 and December
2014, 44 patients (mean age: 66.3 years; PD: 34; HTX: 10) with

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postoperative hemorrhage underwent urgent EVT. Prevention from

no flow through hepatic arteries by stents or side-holed catheter
grafts was stratified in cases without replaced hepatic arteries, if
technically available. Associations with mortality and hepatic complications after EVT were evaluated for difference in operative methods, EVT techniques, interval between surgery and EVT, presence
of portal vein stenosis, shock, coagulopathy at EVT onset, and postEVT angiographic findings.
Results: Hemorrhages were treated using microcoils in 31 (70%),
bare stent-assisted coiling in 5 (11%), catheter graft with coiling in 5
(11%), and covered stents in 3 (7%) patients. Mortality and hepatic
complications rates were 36.4% (n=16) and 34.1% (n=15), respectively. Hemorrhagic shock (n=18; OR: 42; 95% CI: 6.8, 259.4; p<0.0001)
and coagulopathy (n=14; OR: 39; 95% CI: 6.3, 243.1; p<0.0001) at EVT
onset were significantly associated with mortality. Coagulopathy at
EVT onset (adjusted OR [aOR]: 18.9; 95% CI: 3.3, 176.0; p<0.001) and
no visualization of hepatopetal flow through the hepatic arteries
(n=19; aOR: 12; 95% CI: 1.8, 136.2; p<0.01) were significantly associated with hepatic complications; there was no significant association among other variables.
Conclusion: EVT should be performed as soon as possible before
shock or coagulopathy appears. The visualization of hepatic arterial
flow decreases hepatic complications.

P-527
Endovascular intervention in high-grade renal trauma: a single
trauma center experience of the safety, efficacy, and clinical
outcomes
J.W.Kim1, S.S.Byun1, J.H.Kim1, J.H.Shin2, G.-Y.Ko2
1Radiology, Gachon University Gil Medical Center, Incheon, Korea,
2Radiology, Asan Medical Center, Seoul, Korea
Purpose: To report an experience with the endovascular intervention of high-grade renal trauma.
Material and methods: A retrospective review of high-grade renal
injury (grade III or higher) was performed in a single trauma institution. A total of 27 patients (male:female, 18:9; mean age, 39 years,
age range, 380 years) who underwent 28 endovascular interventions between 2005 and 2015 were included in the study. Medical
records, imaging studies, and procedure reports were reviewed to
assess the type of injury, angiographic findings, and procedure outcomes. Associated injuries were present in majority of patients.
Results: The mean time from injury to intervention was 10 hours
(range, 1.550 hours). All endovascular interventions were technically successful. The procedure efficacy was 96% (26/27); one patient
(4%) had a recurrent hemorrhage requiring a secondary intervention. Out of the 27 patients, 26 patients with grade III (n=10) or IV
(n=16) renal injury were treated with superselective transarterial
embolization. In the remaining one patient with grade V renal injury,
recanalization of the occluded renal artery with stent placement
was successfully achieved. Mean clinical follow-up was 22.5 months
(range, 3104 months). There was no procedure-related death. No
procedure-related or delayed onset of renal insufficiency occurred.
Three patients died within 30 days of intervention; all of them had
severe associated injuries, including head and intestinal injuries.
Conclusion: Endovascular intervention is a safe and effective
method for high-grade renal trauma.

Abstract Book

P-528
Endovascular treatment of visceral artery aneurysms (VAAs)
and pseudoaneurysms (VAPAs) in 100 patients: feasibility,
technical and clinical success, complications and clinical
outcome of covered stenting
P.Marra1, M.Venturini2, M.Colombo1, R.Chiesa1, A.DelMaschio1,
F.DeCobelli1
1Radiology, San Raffaele Hospital, Milan, Italy, 2Radiology, Vita-Salute
University, San Raffaele Hospital, Milan, Italy
Purpose: We retrospectively evaluated feasibility, technical aspects
and clinical outcome of covered stenting (CS), which is considered as
the first therapeutic option, in comparison with those of transcatheter embolization (TE).
Material and methods: We report 100 cases of VAAs or VAPAs
treated with CS or TE (coils) between 2000 and 2015 in our center.
In case of CS, a self-expandable Viabahn stent graft was preferentially used via transfemoral catheterization. Coronary stent-grafts
and transaxillary approach were considered as alternatives. Clinical
outcome for CS was measured in terms of VAA/VAPA exclusion and
stent patency at the clinical and imaging follow-ups.
Results: Hundred patients were submitted to endovascular treatment due to 52 VAAs and 48 VAPAs (31 splenic, 21 hepatic, 14 renal,
12 superior mesenteric, 11 gastroduodenal, 8 pancreaticoduodenal and 3 left gastric arteries). CS was feasible in 30 patients, while
70 patients underwent TE. Technical success was achieved in 29/30
(97%) CS procedures and in 67/70 (96%) TE procedures. Clinical success was obtained in 26/30 (87%) CS procedures and in 58/70 (83%)
TE procedures. No major complications were recorded with both
endovascular modalities. Based on the available clinical and imaging follow-up data, the VAA/VAPA exclusion and stent patency were:
both 29/30 at completion angiography; respectively 22/22 and
21/22 at 3-6 months and respectively 18/18 and 16/18 at more than
6 months. For 8 CS patients, aneurysm exclusion and stent patency
were confirmed after 3 years.
Conclusion: When feasible, CS should be considered as the firstchoice treatment showing high rates of technical and clinical success, with good clinical outcome in terms of aneurysm exclusion and
stent patency.

P-529
Endovascular management of renovascular hypertension in a
paediatric population: a 12-year single-centre experience
N.Thulasidasan, N.Karunanithy
Department of Interventional Radiology, Guys and St.Thomas NHS
Foundation Trust, London, United Kingdom
Purpose: To investigate the use of percutaneous transluminal
angioplasty (PTA) in the management of children with renovascular
hypertension at a single centre over a 12-year period, with a focus on
diagnostic the work-up and treatment outcomes.
Material and methods: The medical records of all children who
underwent digital subtraction angiography (DSA) to investigate
hypertension between May 2003 and April 2015 were reviewed.
Ultrasound (US) and magnetic resonance imaging (MRI) findings
were compared with DSA results. Clinical outcome was measured
by comparing the number of oral antihypertensive medications
required to achieve blood pressure control pre- and post-PTA.
Results: In total, 78 hypertensive children were investigated with
DSA, and the evidence of renovascular disease (RVD) was identified
in 28 children (35.9%). The work-up MRI angiography had a sensitivity of 85% for RVD compared to 44% for US Doppler. Eleven children (39.3%) with RVD had an underlying syndrome. NF1 was present in six children (21.4%) with RVD. Evidence of mid-aortic syndrome (MAS) was seen in five patients (17.6%). Twenty children were

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treated with PTA; of these, 15 (75%) were deemed fully treated based
on angiographic criteria, with four (20%) partially treated and one
(5%) not responding to PTA. Of those deemed fully treated, 66.7%
were successfully weaned-off all oral antihypertensive medications
post-PTA.
Conclusion: PTA is a safe and effective treatment for renovascular
hypertension. Of the 75% children who demonstrated good angiographic response to PTA, 66.7% were cured of hypertension.

P-530
Spontaneous abdominal haemorrhage secondary to Sutton
Kadir syndrome: a case series
E.Lake, N.Chalmers
Radiology Department, Manchester Royal Infirmary, Manchester,
United Kingdom
Learning Objectives:
1. Describe Sutton-Kadir syndrome, including the pathophysiological processes involved.
2. Explain patient presentation, typical imaging findings.
3. Present 4 cases of spontaneous haemorrhage secondary to
Sutton-Kadir syndrome.
3. Discuss endovascular and surgical management strategies for this
rare phenomenon.
Background: SuttonKadir syndrome refers to the development
of inferior pancreaticoduodenal artery aneurysm secondary to coeliac axis stenosis caused by the median arcuate ligament. Increased
retrograde flow in the pancreaticoduodenal vessels is thought to
be the causative factor in the development of these aneurysms.
Although a well-recognised phenomenon, examples of spontaneous haemorrhage remain very rare.
Clinical Findings/Procedure: We present 4 cases of spontaneous intra-abdominal haemorrhage in association with SuttonKadir
syndrome. All patients had a coeliac stenosis secondary to median
arcuate ligament syndrome and no other cause for the development of the pancreaticoduodenal aneurysm. Three patients were
managed with emergency embolisation, and one was managed
conservatively.
We explain typical imaging findings and discuss current endovascular and surgical management strategies.
Conclusion: Spontaneous haemorrhage secondary to SuttonKadir
syndrome is a very rare but distinct entity, usually requiring urgent
endovascular intervention. This is the largest known case series to
date.

SS/FC/HL/HTS/CM
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S321

discontinuity of Gerotas fascia are sensitive indicators for the need

for TAE for patients with renal trauma. When a discrepancy between
CT and angiography manifests, it is important to determine whether
it is due to the cessation of arterial bleeding or if vasospasm, the
physiologic response to hemodynamic instability, is masking the
vascular injury: is prophylactic embolization needed? A sound
understanding of potential variations of normal renal vasculature is
essential to master and may prevent treatment failure: presence of
the accessory renal artery, renal capsular artery, etc. Angiographic
interpretation is also a potential source of problems. Transarterial
embolization can be used even in kidneys with congenital malformations such as horseshoe kidney.
Conclusion: Interventional radiology has a pivotal role in the diagnosis, management, and treatment of renal trauma. Renal injury
may be a life-threatening event, but if handled correctly, it can be
managed safely without the need for nephrectomy in most cases.
Transarterial embolization is an alternative treatment option to control renal bleeding.

P-532
Coil embolization for renal aneurysm in a patient with Leriche
syndrome: usefulness of the dual-microcatheter technique and
triple-coaxial system
Y.Furuta, M.Shimohira, T.Hashizume, T.Kawai, K.Suzuki, K.Ohta,
Y.Sawada, K.Nakayama, H.Nishikawa, Y.Shibamoto
Department of Radiology, Nagoya City University Graduate School of
Medical Sciences, Nagoya, Japan
A patient with Leriche syndrome and left subclavian artery stenosis
had a renal aneurysm. Coil embolization was successfully performed
via the right brachial artery using the dual-microcatheter technique
to prevent coil migration and the triple coaxial system to prevent
kick-back of the microcatheter.

P-533
Concomitant transarterial and transvenous coil embolization
for a large aneurysmal-type renal arteriovenous fistula
K.Nakayama1, M.Shimohira1, T.Hashizume1, T.Kawai1, K.Ohta1,
K.Suzuki1, Y.Sawada1, Y.Furuta2, Y.Shibamoto2
1Department of Radiology, Nagoya City University Graduate School of
Medical Sciences, Nagoya, Japan, 2Radiology, Nagoya City University
Graduate School of Medical Sciences, Aichi, Japan

Special considerations for embolization in patients with blunt

renal trauma

A 74-year-old woman had a large aneurysmal-type renal arteriovenous fistula. Coil embolization was performed via both the feeding
artery and draining vein concomitantly, with balloon occlusion of
the feeding artery to prevent coil migration, pulmonary embolism,
and rupture during procedure.

J.W.Kim1, J.H.Kim1, S.S.Byun1, D.I.Gwon2, G.-Y.Ko2

1Radiology, Gachon University Gil Medical Center, Incheon, Korea,
2Radiology, Asan Medical Center, Seoul, Korea

P-534

P-531

Learning Objectives: To learn radiographic predictors of need for

angiography and embolization after traumatic renal injury
To know pitfalls for the interventionist in the management of blunt
renal trauma
Background: Although the incidence of renal trauma is lower compared with other solid organ injuries regardless of the mechanism,
these injuries can be associated with life-threatening complications of which renal hemorrhage is the most acute and dramatic.
Therefore, although there is no unified consensus for the management of renal injury, higher-grade renal injuries typically receive
intervention.
Clinical Findings/Procedure: Contrast extravasation, the
extent of hematoma, long perirenal hematoma rim distance, and

Stent-assisted coil embolization with a jailed catheter and

trans-cell techniques for a broad-necked saccular aneurysm of
the proximal renal artery: a case report
M.Inoue, M.Tamura, S.Nakatsuka, S.Oguro, M.Jinzaki
Diagnostic Radiology, Keio University, School of Medicine, Tokyo, Japan
We describe the coiling of a broad-necked saccular aneurysm of
the proximal renal artery. A microcatheter was placed in the aneurysm, followed by stent deployment. Then, another microcatheter
was inserted through the stent struts. Coil embolization with a jailed
catheter and trans-cell techniques was achieved.

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P-535

P-539

Selective bilateral renal artery embolization with acrylic

microsphere particles in focal segmental glomerulosclerosis

Early renal allograft venous thrombosis: is thrombolytic

treatment effective?

N.Dogan1, O.F.Nas2, B.Canver3, K.Ozturk 2, G.Gokalp2

1Radiology Clinic, Private Bahar Hospital, Bursa, Turkey, 2Department
of Radiology, Uludag University Faculty of Medicine, Bursa, Turkey,
3Nephrology Clinic, Bursa State Hospital, Bursa, Turkey

A.Pastor, C.Nieto, J.M.Martinez, M.Pons

Interventional Radiology, Son Espases Hospital, Palma De Mallorca,
Spain

We present a case of selective bilateral renal artery embolization

with acrylic microsphere particles, which is an alternative to surgery
in a young patient with end-stage kidney failure and resistant proteinuria secondary to primary focal segmental glomerulosclerosis.

We present a case of iliofemoral deep venous thrombosis involving

the renal allograft two months after the transplant. The salvage of
the kidney was achieved with catheter-directed local thrombolysis.
A year later, the patient remains asymptomatic with stable renal
function.

P-536

P-540

Embolization for spontaneous adrenal hemorrhage

Thrombolysis of a superior mesentery artery graft stent

thrombosis using an AngioJet thrombectomy system

T.Gentsu, T.Okada, N.Katayama, R.Tani, E.Ueshima, Y.Koide,

K.Sofue, M.Yamaguchi, K.Sugimoto
Department of Radiology and Center for Endovascular Therapy, Kobe
University Hospital, Kobe, Japan

H.Baydoun, A.Gotra, L.-M.N.J.Boucher, D.A.Valenti

Radiology, McGill University Health Center, Montreal, QC, Canada

We report a case of spontaneous right adrenal hemorrhage in a

60-year-old man complaining of acute low back pain. Embolization
of the right inferior adrenal artery pseudoaneurysm with glue and
coils was successfully performed.

A 58-year-old woman with stage III metastatic pancreatic cancer

having had a Whipples with superior mesenteric artery reconstruction 2 years prior presented with graft occlusion needing stenting.
Three weeks later, the stent thrombosed and successful thrombolysis was achieved with an AngioJet device.

P-537

P-541

Application of Y-stent-assisted coil embolisation technique in

the treatment of broad-neck visceral artery aneurysms

Renal artery entrapment by hypertrophic diaphragmatic crus

in a 17-year-old athlete with hypertension: a case report and
literature review

B.Barry, G.Parker, D.Robinson, S.Dubenec, C.Rogan

Radiology Department, Royal Prince Alfred Hospital, Sydney, NSW,
Australia

Y.Someya1, R.Yamashita2, H.Kobayashi1, M.Inagaki1, Y.Onishi1

1Department of Radiology, Otsu Red Cross Hospital, Otsu, Japan,
2Department of Diagnostic Imaging and Nuclear Medicine, Kyoto

The case report will focus on the use on Y-stent-assisted coil embolisation technique, traditionally used in the treatment of broad neck
intracranial aneurysms, for treating both renal and splenic artery
broad-neck aneurysms.

University Graduate School of Medicine, Kyoto, Japan

P-538

A 17-year-old male athlete with hypertension was suspected of having high-positioned right renal artery ostium entrapped by hypertrophic diaphragmatic crus based on ultrasonography and CT. Renal
arteriography in inspiration and expiration, including translesional
pressure gradient measurement, confirmed the diagnosis.

Stent-graft placement for hepatic artery

pseudoaneurysmwithin one month after living donor liver
transplantation

P-542

U.R.Kang1, G.-C.Kim2, Y.H.Kim3, C.S.Kim3, S.H.Jeong3

1Radiology, Daegu Catholic University Medical Center, Daegu, Korea,
2Radiology, Kyungpook National University & Hospital, Jung Gu,
Daegu, Korea, 3Radiology, Keimyung University School of Medicine,

Endovascular treatment of an iatrogenic SMA pseudoaneurysm

using a flow-diverter stent
K.Karaman, A.M.Dkdk, O.Karadeniz
Radiology, Anadolu Saglik Merkezi, Kocaeli, Turkey

Dongsan Medical Center, Daegu, Korea

A 56-year-old man with alcoholic liver cirrhosis underwent living
donor liver transplantation. At 14 days after transplantation, a pseudoaneurysm of the proper hepatic artery was noticed on CT scan.
Complete exclusion of the pseudoaneurysm using balloon-expandable coronary stent graft was achieved.

This case report describes our preliminary experience with a patient

with an iatrogenic (post-embolectomy) superior mesenteric artery
pseudoaneurysm that was treated with the Roadsaver double layer
micromesh stent.

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SS/FC/HL/HTS/CM
Posters

S323

P-543

P-547

Hybrid procedures for penetrating trauma combining

emergency abdominal surgery and interventional radiology:
2 cases

Repermeabilization of the celiac trunk with stent allowing

Whipple surgery in a patient considered unresectable due to
celiac trunk stenosis

Y.Kawahara, S.Kijima, A.Ugajin, Y.Koyashiki, H.Fujii, H.Kanazawa,

T.Sasaki, H.Nakamura, H.Sugimoto
Department of Radiology, Jichi Medical University Hospital, Shimotukeshi, Tochigi, Japan

C.J.GonzalezNieto, J.V.MndezMontero, M.LeyvaVsquezCaicedo, J.E.ArmijoAstrain

Radiology Department, Hospital Clinico San Carlos, Madrid, Spain

We introduce 2 cases of severe knife injuries of multiple organs. We

selected hybrid procedures combining emergency operation and
interventional radiology using C-arm angiographic imaging system
in the operation room.
The procedures were effective to treat multiple injuries at the same
time.

A 75-year-old female had pancreatic carcinoma that was considered unresectable due to subocclusive stenosis of the celiac trunk.
Repermeabilization of the celiac trunk with a stent that re-stablished
antegrade flow of hepatic artery was performed. Later, the tumor
was successfully resected.

P-548

P-544

Splenic artery embolisation for treatment of small-for-size

liver remnant following resection

Recurrent aberrant aneurysm shortly after initial aneurysm

embolization in cases of suspected segmental arterial
mediolysis (SAM)

M.A.Gelabert1, J.Codina2, S.Lpez-Ben3, M.Casellas3, V.Cuba2,

A.CodinaBarreras4, S.Pedraza2
1Radiology, Hospital Dr. Josep Trueta, Girona, Spain, 2IDI - Radiologia,
Hospital Dr Josep Trueta Girona, Girona, Spain, 3Department of
Surgery, Hospital Dr Josep Trueta, Girona, Spain, 4Hepatobiliary
Surgery, Hospital Dr. Josep Trueta, Girona, Spain

T.Hasegawa1, K.Seiji2, H.Ota2, T.Matsuura2, K.Takase1

1Diagnostic Radiology, Tohoku University Graduate School of Medicine,
Sendai, Miyagi, Japan, 2Diagnostic Radiology, Tohoku University
Hospital, Sendai, Miyagi, Japan
We present two cases of new aberrant aneurysms forming rapidly in
opposing pancreatic arcades 27 hours and 8 days, respectively, after
initial coil embolization of the arcade pseudoaneurysms. SAM coexisting with median arcuate ligament syndrome possibly triggered
these ectopic recurrences.

P-545
Retrograde stenting of the celiac trunk via the superior
mesenteric artery
F.Pedersoli, P.Isfort, M.Zimmermann, M.F.Schulze-Hagen,
M.Liebl, P.Bruners, C.Kuhl
Department of Diagnostic and Interventional Radiology, RWTH Aachen
University Hospital, Aachen, Germany
A 72-year-old woman presented with complete closure of the celiac
trunk, which was successfully recanalized and stented through a retrograde approach via the superior mesenteric and then via the gastroduodenal artery, with a combined transbrachial and transfemoral access.

P-546
Emergency endovascular treatment for idiopathic dissection of
the superior mesenteric artery (SMA): a report of two cases
S.Kasuya1, H.Kikuchi2, T.Sonokawa1, M.Tanami1, R.Ishikawa1,
T.Nakatsuka1, N.Kitamura1, M.Odashima1, T.Inaoka1, J.Toda3,
H.Terada1
1Radiology, Toho University Sakura Medical Center, Chiba, Japan,
2Internal Medicine, Toho University Sakura Medical Center, Chiba,
Japan, 3Diagnostic Imaging and Interventional Radiology, Tokyo
Womens Medical University Yachiyo Medical Center, Chiba, Japan
We describe two middle-aged male patients with idiopathic dissection of SMA rescued by emergency endovascular treatment. One
was treated with endovascular stenting for localized dissection at
the SMA orifice, and the other was treated with coil embolization for
severe SMA dissection.

Post-hepatectomy liver failure is a major cause of death after liver

resection. We describe a patient who developed clinical evidence
of hyperbilirubinaemia due to hepatic insufficiency after right lobe
hepatectomy. It was successfully treated by embolisation of the
splenic artery.

TIPS and portal vein intervention

P-549
Overnight balloon-occluded retrograde transvenous
obliteration for gastric varices: value of the next-day CT
H.-C.Kim, M.Lee, M.Kim
Radiology, Seoul National University Hospital, Seoul, Korea
Purpose: To investigate the role of the next-day CT after overnight
balloon-occluded retrograde transvenous obliteration (BRTO) for
gastric varices.
Material and methods: From June 2007 to June 2015, 126 patients
(male: female, 92: 35; mean age, 61.34 10.45 years; range, 3392
years) who received overnight BRTO for gastric varices were
included in this study. Next-day CT was obtained before removal of
the balloon catheter. For evaluation of usefulness of the next-day CT
after BRTO, the next-day CT and then follow-up CT were retrospectively reviewed by two radiologists in consensus.
Results: The next-day CT revealed incomplete obliteration of the
gastric varices in 16 of 126 patients (12.7%), 11 of whom had additional obliteration of gastric varices in effect. Of these 11 patients, all
patients who had available follow-up CT (n=7) showed no residual
gastric varies (median follow-up duration, 985 days; range 71934
days). By contrast, one of 16 patients who had incomplete thrombosis of gastric varies could not have additional obliteration of gastric
varices due to presumed occlusion of gastrorenal shunt by sclerosing agent. This patient eventually had residual varices on follow-up
CT.
Conclusion: The next-day CT is a useful diagnostic method of evaluation for residual gastric varices after overnight BRTO and help
patients have further additional injection of the sclerosing agent
in case of incomplete obliteration before removal of the balloon
catheter.

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P-550
Factors predicting hypertrophy of the future liver remnant
after preoperative percutaneous transhepatic portal vein
embolization with ethanol
Y.Sakuhara, D.Abo, T.Soyama, R.Morita, T.Kimura, K.Kudo
Diagnostic and Interventional Radiology, Hokkaido University Hospital,
Sapporo, Japan
Purpose: The purpose of this study was to evaluate the predictive
factors related to FLR hypertrophy after percutaneous transhepatic
portal vein embolization (PTPE) with ethanol.
Material and methods: We retrospectively reviewed 143 patients
who underwent PVE with ethanol before major hepatectomy. Ten
patients underwent additional PVE because of recanalization of
embolized vessels and insufficient hypertrophy. FLR hypertrophy
and the ratio of FLR to the total estimated liver volume (FLR/TELV
ratio) were assessed by comparing the volumetric data obtained
from computed tomography (CT) images before and after PVE.
Postprocedure FLR data of 4 patients was excluded because extrahepatic disease was detected on CT images after PTPE in 2, and
additional transileocolic PVE was performed after PTPE failed in 2.
The nonparametric matched pairs test was applied for bivariate and
multivariate data (gender, age, amount of injected ethanol, leukocyte count, platelet count, total bilirubin level, and transaminase
level) regarding FLR hypertrophy. P values less than .05 were considered to indicate significant differences.
Results: The mean FLR increased from 419 cm3 to 542 cm3 after
PTPE and the mean increase in the FLR/TELV ratio was 33.6% in the
remaining 139 patients. The mean increase in the FLR/TELV ratio was
10.7%. FLR hypertrophy was inversely related to the preliminary FLR
(P < .0001) and FLR/TELV ratio (P < .0001). No other factors were significantly related to the increases in FLR or FLR/TELV ratio.
Conclusion: FLR hypertrophy after PTPE with ethanol is inversely
related to the size of FLR and the FLR/TELV ratio before PTPE.

P-551
Curative treatment option for hepatocellular carcinoma
(HCC) patients beyond the Barcelona criteria: sequential
embolization before hepatectomy
P.Pajor1, I.Duds2, A.Zsirka-Klein1, D.Brdos1, L.Harsnyi1,
P.Kupcsulik1, O.Hahn1
11st Dept. of Surgery, Semmelweis University, Budapest, Hungary,
2Department of Radiology, Semmelweis University, Budapest, Hungary
Purpose: Partial hepatectomy and liver transplantation are the
curative treatment options with the best long-term survival for
HCC patients. Only a few patients can benefit from transplantation.
Sufficient future liver remnant (FLR) is the only criterion of partial
hepatectomy. Small FLR can hypertrophy after portal vein embolization (PVE). Twenty percent of PVE patients cannot undergo hepatectomy because of tumor progression during the hypertrophy period
of 4-6 weeks.
The aim of this study was to prevent tumor progression with
sequential embolization (TAE+PVE) before hepatectomy.
Material and methods: Fifteen HCC patients received sequential
embolization between 2010 and 2015 at our institute. Two weeks
before PVE of the tumorous liver lobe, TAE (transarterial embolization) was performed. Before the embolizations and 8 weeks after
PVE CT-volumetry and 99mTc-Mebrofenin SPECT/CT were performed
to measure FLR volume and function. Resectability and 90-day morbidity and mortality rates (Clavien-Dindo score) were also measured.
Results: In 86% (13/15) of the patients, the tumor became resectable; in 2, hepatectomy was still not possible because of insufficient
FLR hypertrophy. Two patients had minimal tumor progression (did
not influence hepatectomy), 5 patients had stable disease, and 8

Abstract Book
patients had tumor regression before surgery. Median FLR volume
and FLR function 8 weeks after TAE+PVE were 41% and 46%, respectively. Morbidity and mortality rates after hepatectomy were 33.4%
(5/15) and 6.6% (1/15), respectively. During the 24 months of followup, 53% (8/15) of the patients were tumor-free.
Conclusion: With the help of sequential embolization, tumor progression after PVE can be prevented and more HCC patients can be
candidates for curative liver resection.

P-552
Hepatocellular carcinoma with portal vein tumor thrombus
and its treatment with transarterial chemoembolization
combined with computed tomography-guided125iodine
implantation: a retrospective controlled study
H.-T. Hu
Department of Radiology and Research Institute of Radiology,
Henan Cancer Hospital / The Affiliated Cancer Hospital of Zhengzhou
University, Zhengzhou, Henan Province, China
Purpose: We conducted a retrospective controlled study to evaluate
the safety and efficacy of TACE combined with CT-guided 125iodine
implantation in patients with HCC and portal vein tumor thrombus.
Material and methods: The medical records of consecutive
patients with HCC and PVTT who received TACE with 125iodine or
TACE alone between January 2010 and December 2011 were retrospectively evaluated. In the TACE with125iodine group, 125iodine
implantation was performed 47 days after the first TACE session. Outcomes of the groups were compared using the t-test and
KaplanMeier method based on the repeated TACE procedure, PVTT
responses, and median survival.
Results: Fifty patients received TACE with125iodine and 50 received
TACE alone. TACE with 125iodine showed a significant survival benefit compared to TACE alone in patients with PVTT (median survival,
13.1 vs. 6.0 months; P<0.01). Moreover, the PVTT control rate was
significantly higher in the TACE with 125iodine group (78% vs. 18%;
P<0.01). On multivariate analysis, TACE with 125iodine treatment was
an independent prognostic factor for overall survival. The bilirubin
level increased at 4 weeks but was recovered at 8 weeks, with no difference from baseline. 125Iodine seed implantation-related adverse
events occurred in 9 patients, including pneumothorax with collapsed lung (<30% of the ipsilateral lung), minor subcapsular hemorrhage of the liver, and seed flotation to the normal liver parenchyma. There were no serious complications related to 125iodine
seed implantation.
Conclusion: TACE with 125iodine therapy may be effective for
patients with advanced HCC who developed a tumor thrombus in
the first-order portal vein branches. In patients with unresectable
HCC who develop PVTT, TACE with125iodine treatment may prolong
survival with minimal influence on the quality of life.

P-553
PV malignant thrombus percutaneous recanalization by
endoportal RFA and stenting the rationale, technique and
early results
M.Mizandari1, N.Habib2, T.Azrumelashvili1
1Diagnostic and Interventional Radiology, Tbilisi State Medical
University, High Technology Medical Center - University Hospital,
Tbilisi, Georgia, 2Surgery & Oncology, Imperial College, London, United
Kingdom
Purpose: The novel technique of PV thrombus recanalization is
presented.
Material and methods: Fourteen patients underwent percutaneous endoportal RF treatment attempts. The PV tributary was
accessed under US guidance; a 5-Fr diameter guiding catheter was

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used to conduct the guidewire across the blocked segment, and
portography was performed. A 15-Watt power was applied for 2
minutes using a bipolar endoluminal RF device (Habib EndoHPB,
EMcision Ltd., London, UK) placed in the PV blocked segment
according the guidewire. The number of RF application sessions
depended on the tumour thrombus extent shown on portography. After RF application, a self-expanding 14-mm diameter vascular
stent was positioned, and PV patency restoration was documented
by final portography. The procedure was completed by procedure
track RF ablation and/or coil embolisation.
Results: The procedure was completed in 10 (71.4%) cases. In 3
(21.5%) cases, we could not conduct the wire across the thrombus,
and in 1 (7.1%) case, the thrombus was traversed by the wire but we
failed to conduct the RF device and the procedure was completed
by stenting. The PV obstructed segment showed restored blood
flow in all completed cases, as documented by post-procedure portography and follow-up Doppler and CT studies. This resulted in
liver function improvement in 6 (60.0%) of procedural success cases.
Recanalized PV patency varied from 3 weeks to 22 months. In 3
cases, patients underwent successful TACE after PV recanalization.
Conclusion: PV thrombus percutaneous recanalization by endoportal RFA with subsequent stenting is an effective technique and
should be suggested as a possible treatment option for HCC patients
with PVT.

P-554
Endovascular treatment of symptomatic BuddChiari
syndrome: in favor of early TIPS
K.L.C.Rosenqvist1, R.Sheikhi2, L.-G.Eriksson1, R.Rajani3,
F.Rorsman2, P.Sangfelt2, R.Nyman1
1Department of Radiology, Oncology and Radiation Science,
Institution of Surgical Sciences, Uppsala, Sweden, 2Department of
Gastroenterology and Hepatology, Institution of Internal Medicine,
Uppsala, Sweden, 3Department of Gastroenterology, Institution of
Internal Medicine Karolinska Sjukhuset, Stockholm, Sweden
Purpose: To evaluate the efficiency and safety of liver vein angioplasty and early transjugular intrahepatic portosystemic shunts
(TIPS) in symptomatic patients with BuddChiari syndrome (BCS)
and compare with the results of less interventional treatment in similar BCS patients in an earlier national study.
Material and methods: A retrospective study of the 14 symptomatic patients with BCS treated with endovascular methods in our
hospital during 2003-2015. Comparisons were made with a national
epidemiology study of medical, and sporadically endovascular,
intervention in symptomatic BCS patients in 1986-2003.
Results: Five of the 14 patients had primary liver vein angioplasty,
4 followed by TIPS, and 9 had primary TIPS. The technical success
rate of the TIPS procedure was 100%, and polytetrafluoroethylenecovered stents were used in all patients. According to prognostic indices, the risk of TIPS dysfunction, liver transplant, and death
was high in most patients, but only one patient died and one had
a liver transplant. Primary TIPS patency at 1- and 2-years was 85 and
67%, respectively. Overall 1- and 5-year transplantation-free survival was 100 and 93% compared with 47 and 28%, respectively,
in 1986 to 2003. Three patients had episodes of de novo hepatic
encephalopathy.
Conclusion: There is an obvious improvement in transplantationfree survival with TIPS than with medical treatment only. TIPS seems
to be a safe and effective method of treatment for symptomatic
BCS. TIPS should be considered early in patients with insufficient
response to medical treatment.

SS/FC/HL/HTS/CM
Posters

S325

P-555
Impact of transjugular intrahepatic portosystemic shunting on
liver transplantation: a single-center experience
R.Gandini, F.Chegai, A.Lacch, S.Merolla, E.Pampana
Diagnostic and Molecular Imaging, Radiation Therapy and
Interventional Radiology, University Hospital Policlinico Tor Vergata,
Rome, Italy
Purpose: To assess the impact of the transjugular intrahepatic portosystemic shunt (TIPS) on liver transplantation.
Material and methods: From 2008 to 2014, 16 patients were transplanted after TIPS insertion and were compared with 20 matched
patients transplanted without prior TIPS. The TIPS group consisted
of 16 patients (mean age 55 10 years). All patients in this group
have performed the TIPS procedure for the following indications:
refractory ascites in 7 (43.75%), refractory ascites + portal thrombosis in 4 (25%), and gastro-esophageal bleeding in 5 (31.25%). The
control group consisted of 20 patients (mean age 55 8 years), with
a pre-transplant MELD score between 11 and 37 (23 5 medium).
Results: Time of transplant-free survival was longer in the TIPS
group compared to the control group. At the time of transplant,
no stent was occluded or misplaced. Stent removal was difficult in
2 cases (12.5%), but complete extraction was always achieved even
when there was an extensive vein-wall encapsulation. Patients
who undergo TIPS did not improve in their MELD score but had an
increased transplant-free survival time (P=0.048) due to the resolution of portal hypertension complications. No significant difference
was noted among the intraoperative parameters: collateral venous
circulation, intraoperative portocaval anastomosis, transfusions,
and total operative time. The survival rate of the TIPS group at 18
months was 56% against 50% in the control group. The analysis of
the survival curves did not show statistically significant differences
(P=0.87).
Conclusion: TIPS can prove to be a safe bridge for LT, increasing the
transplant-free survival time of end-stage cirrhotic patients.

P-556
Transfemoral transcaval core-needle liver biopsy and portal
pressure measurement: a single-center experience with the
first 100 cases
C.Shabrang, J.Cho, D.Krausz, Y.Golowa, M.Jagust, J.Cynamon
Department of Radiology, Division of Vascular and Interventional
Radiology, Montefiore Medical Center/Albert Einstein College of
Medicine, New York, NY, United States of America
Purpose: To review the safety and feasibility of transfemoral transcaval (TFTC) liver biopsies and portal pressure measurements performed at a single center.
Material and methods: Retrospective chart review was performed
on 96 consecutive patients who underwent 100 TFTC core-needle liver biopsies (63.0% male, mean age 52.8 15.0 years) from
February 1, 2014 to February 5, 2016. Core-needle liver biopsies were
performed directly through the inferior vena cava (IVC) using a technique previously described.
Results: Technical success was 97% (n=97). Overall histologic success was 95% (n = 95). All biopsies were performed from the right
common femoral vein. Portal venous pressure measurements were
requested in 92 cases, and all were successfully obtained. An IVC
filter was present in 3.0% of cases (n = 3), and TFTC biopsies were
successful in two of three. Moreover, 2.0% of cases overall required
elective conversion, including conversion to percutaneous liver
biopsy due to megacava (n=1) or to transjugular liver biopsy (TJLB)
due to an IVC filter (n=1). Major complications (2.0%) included selflimiting fever (n=1) and septic shock, which resolved with medical

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management (n=1). Minor compilations (4.0%) included abdominal

pain (n= 1), hemoglobin decrease (n=1), femoral access site bleeding (n=1), and small sub-hepatic hematoma (n=1).
Conclusion: TFTC core-needle liver biopsies are a safe and feasible
alternative to traditional TJLB.

P-557
Polytetrafluoroethylene (e-PTFE)-covered transjugular
intrahepatic portosystemic shunt (TIPS) after liver
transplantation: a single-center experience
L.Maruzzelli1, M.DAmico2, I.Petridis1, F.Tuzzolino1, R.Miraglia1,
A.Luca1
1Diagnostic and Therapeutic Services, Mediterranean Institute for
Transplantation and Advanced Specialized Therapies (IsMeTT),
Palermo, Italy, 2Radiology, University of Palermo, Palermo, Italy
Purpose: To retrospectively evaluate the outcome of e-PTFE-covered TIPS in adult liver transplant (LT) recipients with portal hypertension as the complication at our center.
Material and methods: Between November 1999 and November
2014, 857 LTs have been performed at our center. Thirty five (4%)
of these 857 patients underwent TIPS using e-PTFE-covered stents
after LT. These 35 patients (males 26, age 56 13 years) were followed up until the last clinical evaluation, redo LT, or death.
Results: TIPS indications included refractory ascites (n=24, 69%),
variceal bleeding (n=4, 11%), massive portal vein thrombosis (n=4,
11%), and others (n=3, 9%). Three patients underwent partial LT. PreTIPS liver histology was available in 27 patients, of which 22 showed
recurrence of cirrhosis, 2 showed regenerative nodule hyperplasia,
1 showed chronic rejection, 1 showed veno-occlusive disease, and
1 showed Budd-Chiari recurrence. Median time from LT to TIPS was
26.9 months (IQR 41.2). TIPS was technically successful in all patients;
in 4 patients, the combined transjugular/percutaneous approach
was necessary. Two coaxial stents were necessary in 10 patients
(28%). The mean portosystemic pressure gradient was reduced from
156.7 to 72.5 mmHg (p<0.05). Two patients (5%) showed peri-procedural bleeding (1 requiring blood transfusions). TIPS revision was
required in 10 patients (28%). Four patients (11%) underwent redo
LT. At 1, 6, 12, and 60 months, the grafts and patients survival rates
were 84%-88%, 74%-77%, 61%-66%, and 21%-27%, respectively.
Conclusion: e-PTFE-covered TIPS is a challenging but feasible procedure in LT recipients with a relatively low complication rate; it can
improve grafts and patients survival rate in LT recipients with portal
hypertension as the complication.

P-558
Transjugular portosystemic shunt (TIPS) in cirrhotic patients
with portal vein thrombosis
S.LombardoGalera, J.J.EspejoHerrero, M.E.PerezMontilla,
L.J.ZureraTendero
Radiologia Intervencionista, Hospital Universitario Reina Sofa,
Cordoba, Spain

Abstract Book
Results: TIPS was implanted in 21 patients. Four patients were
excluded from the follow-up (2 were lost during the follow-up and 2
died at 2 and 6 months after TIPS placement). The average transhepatic gradient prior to TIPS placement was 17.8 (1036) mmHg, and
the average transhepatic gradient after TIPS implantation was 9.47
(222) mmHg. The average primary patency in months of follow-up
was 21 months and 23 months of secondary patency. There were
only 2 cases of TIPS dysfunction at 6 and 49 months, 2 occlusions at
7 and 40 months, and 1 occlusion at 2 days after implantation; these
concerns were resolved by placing coaxial prostheses. Currently, all
TIPS are permeable, and only 2 patients underwent transplantation.
Conclusion: The high permeability of TIPS in cases of portal vein
thrombosis is excellent.

P-559
Portal vein stent placement with or without varix embolization
for the management of jejunal variceal bleeding in patients
with previous hepatopancreatobiliary surgery
D.J.Shim, J.H.Shin, Y.Kim, K.Han, E.T.Kim, W.S.Choi, E.Jang
Radiology, Asan Medical Center, Seoul, Korea
Purpose: To evaluate the safety and efficacy of portal vein stent
placement with the addition of variceal embolization for the management of jejunal variceal bleeding in patients with previous hepatopancreatobiliary surgery.
Material and methods: Between January 2000 and June 2015, portal vein stent placement was attempted in 477 patients. Twenty-two
of these (63 10 years) with jejunal variceal bleeding considered to
be caused by portal-vein obstruction after surgery were included
in this study. Computed tomography (CT) findings before and after
treatment and the rates of technical and clinical success, complications, and clinical outcomes were retrospectively evaluated.
Results: Stent placement was successful in 19 of 22 patients.
Additional variceal embolization was performed in 5 cases. Clinical
success, defined as the cessation of bleeding without recurrence
within 1 month, was achieved in 18 of 19 patients with technical success. One patient developed recurrent bleeding 4 days after stent
placement and was successfully treated with additional variceal
embolization. There were no procedure-related complications. A
regression of the jejunal varices was noted in 14 of 19 patients on
follow-up CT scan. During the follow-up period (258 days, range
7-1196), stent occlusion and recurrent bleeding occurred in 6 and 4
patients, respectively, among the 19 patients who achieved technical success. Statistical analyses revealed no significant differences in
stent patency between benign and malignant strictures.
Conclusion: Percutaneous, transhepatic, portal-vein stent placement with or without jejunal variceal embolization appears to be
a safe and effective treatment for jejunal variceal bleeding after
surgery.

P-560

Purpose: Portal vein thrombosis worsens the prognosis of cirrhotic

patients. The aim of our study was to evaluate the effects of the performance of a transjugular portosystemic shunt (TIPS) in cirrhotic
patients with upper gastrointestinal bleeding (UGB) for gastroesophageal varices (VGE) and portal vein thrombosis (PVT).
Material and methods: A retrospective study from January 2006 to
February 2016 was performed, including 21 patients with UGB and
PVT (8 acute, 8 chronic with cavernomatosis, and 5 chronic without
cavernomatosis). The average age was years: 15 men and 6 women.
Transhepatic gradient was analyzed before and after TIPS placement
and permeability follow-up with Dopplers ultrasound.

Parallel stent-technique for reduction of transjugular

intrahepatic portosystemic stent-shunt in patients with
hepaticencephalopathy and as bridging in acute liver failure:
technical feasibility and clinical outcome in six patients
T.L.Gockner1, K.-H.Weiss2, H.U.Kauczor3, B.A.Radeleff3
1Diagnostic and Interventional Radiology, University Hospital Mainz,
Mainz, Germany, 2Internal Medicine IV, University Hospital Heidelberg,
Heidelberg, Germany, 3Diagnostic and Interventional Radiology,
University Hospital Heidelberg, Heidelberg, Germany
Purpose: To evaluate technical feasibility and clinical outcome of
parallel stent-technique for TIPSS modification.
Material and methods: Six patients (3 males; mean age 60 years)
underwent a TIPSS reduction using parallel stent-technique. The

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technique was initially developed by Holden et al. and was modified
by insert another stent in the TIPSS tract against an inflated 5-mm
balloon. After removal of the balloon, the new TIPSS tract shows an
hourglass configuration and an increased portal-systemic pressure
gradient (PSG). The procedure was performed because of hepatic
encephalopathy (HE) (n=5) and acute liver failure (n=1). Clinical follow-up was performed before and after TIPSS reduction. During
angiography, PSG before and after implantation of stent graft, additional balloon-dilatation, variceal embolisation as well as success
were recorded. Also, 30-d mortality and 6-month survival were
recorded.
Results: Technical and hemodynamic success were 100%. Before
TIPSS reduction, mean PSG was 5.7 mmHg (3-12). Performing TIPSS
reduction PSG was increased by mean 8.7 mmHg (2-16) with a final
mean PSG of 14.3 mmHg (7-21). In 2 patients, an additional balloon
dilatation was performed to modify PSG. Variceal embolisation after
TIPSS reduction was performed in 1 patient. Two patients died in the
first 30 days because of multiorgan failure and sepsis. Four patients
survived for at least 6 months. In these patients, HE dropped to
grade 0 (n=2) or 0-1 (n=2).
Conclusion: Parallel stent-technique is an effective and safe option
to increase PSG in patients with refractory or severe HE by an adjustable partial closure of TIPSS. In individual cases the technique is possible for bridging in acute liver failure.

P-561
Transsplenic approach for portal intervention in the presence
of massive portal vein thrombosis and massive ascites
D.Yasui, S.Murata, T.Ueda, H.Yamaguchi, F.Sugihara, I.Miki,
H.Saitou, S.-I.Kumita
Radiology, Nippon Medical School, Tokyo, Japan
Purpose: To evaluate the feasibility and safety of the transsplenic
approach for portal intervention when the transhepatic approach
cannot be applied.
Material and methods: Transsplenic approach was applied for the
treatment of portal vein thrombosis in 2 cases and rectal variceal
rupture in 1 case. Transhepatic approach was thought to be inappropriate because of massive portal vein thrombosis and massive ascites; therefore, transsplenic approach was selected. Successful access
to the portal vein, clinical success of the treatment, and adverse
events were evaluated.
Results: Splenic vein was punctured percutaneously under ultrasonographic guidance using a 21-G fine needle system. Access to the
portal vein was established and scheduled procedure was accomplished in all cases. Thrombolysis, percutaneous angioplasty, and
stent deployment were performed for the cases of portal vein
thrombosis. Reconstruction of hepatopetal flow was obtained in
one case; however, clinical success was not obtained in the other
case due to end-stage cirrhosis. Sclerotherapy using ethanolamine
oleate was successfully performed in the case of rectal varices via
the inferior mesenteric vein, and cessation of rectal hemorrhage
was obtained. Amplatzer vascular plug II or IV and microcoils were
placed as an anchor in the distal end of the splenic vein, and the
puncture tract was subsequently embolized using gelatin sponge
sheet and cyanoacrylate. No adverse event that required additional
intervention, including post-procedural bleeding, was observed.
Conclusion: Transsplenic approach can be a safe and effective alternative for transhepatic approach in the presence of massive portal
vein thrombosis and massive ascites.

SS/FC/HL/HTS/CM
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P-562
Long-term outcomes of endovascular intervention for portal
vein inflow disturbance after liver transplantation
H.D. Jung
Radiology, Hallym University Sacred Heart Hospital, Anyang-si,
Gyeonggi-do, Korea
Purpose: We retrospectively evaluated long-term outcomes of percutaneous transhepatic balloon angioplasty with or without stent
placement for portal vein stenosis or thrombosis after liver transplantation (LT).
Material and methods: Between January 2004 and December 2014,
1294 patients underwent LT (living donor: 889, deceased donor:
405); 54 patients (43 men, 11 women; mean age, 57.7 years) were
confirmed to have portal vein stenosis or thrombosis on follow-up
computed tomography or ultrasonography. All patients with portal
vein stenosis underwent percutaneous transhepatic interventions,
including direct portography with manometry and balloon angioplasty, with or without stent placement. Technical and clinical success, laboratory and manometry findings, patency, and major complications were evaluated. Follow-up after the initial balloon angioplasty ranged from 14 days to 110.6 months (mean, 38.2 months).
Results: The technical success rate was 98.1%, and clinical success
was achieved in 90.7% of patients. Forty-eight patients experienced
a significantly improved pressure gradient across the stenosis after
percutaneous transhepatic balloon angioplasty with or without
stent placement; the mean pressure gradient decreased from 11.2
mmHg to 2.04 mmHg. At 1, 3, 6, and 12 months and at the last follow-up after balloon angioplasty with or without stent placement,
clinical success rates were 98.1%, 96.2%, 94.3%, 94.3%, and 92.5%,
respectively. One major complication following balloon angioplasty
with stent placement, namely, abrupt removal of the vascular sheath
with tract bleeding was noted.
Conclusion: Percutaneous transhepatic balloon angioplasty with or
without stent placement is a safe and effective treatment with longterm patency for portal vein stenosis after LT.

P-563
Portal vein embolisation: North Brisbane (Australia)
experience
K.Seow, N.Kienzle
Interventional Radiology, The Royal Brisbane and Women Hospital,
Herston, QLD, Australia
Learning Objectives: To determine the safety and efficacy of portal vein embolisation (PVE) as an adjunctive therapy to curative liver
resection.
Background: The liver has a great capacity to regenerate after
injury. Regeneration is facilitated by intra- and extra-hepatic growth
factors, which are transported primarily by portal veins.
The incidence of liver malignancy is increasing. Surgery is the curative treatment. However, large-volume liver resection increases the
risk of post-operative liver insufficiency, before the liver remnant has
a chance to increase its volume.
Causes of post-operative liver insufficiency are multifactorial.
Post-operative liver size, known as future liver remnant (FLR), is a
strong independent predictor for post-operative insufficiency and
complications.
Studies suggest that pre-operative PVE improves surgical outcomes by increasing FLR, avoiding portal hypertension and preventing post-operative liver insufficiency. PVE is also linked to improved
post-operative biliary excretion, albumin uptake and liver function
tests (LFTs).

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Clinical Findings/Procedure: Retrospective study: PVE patients at

the Royal Brisbane and Womens Hospital and the Wesley Hospital
from 2008 to 2015. Thirty patients were included.
Data collected: demographics, indication for PVE, medical history
known to reduce hepatic reserves (cirrhosis, diabetes), FLR, LFTs, PVE
approach, embolisation agent and procedural complications.
End outcome: High safety profile, with 1 case of major complication
(cholangitis). Significant improvement to FLR with high rate of progression to surgery 90% (27/30).
Conclusion: PVE is a safe and effective method to increase FLR,
allowing for curative liver resection with reduced risk of post-operative liver failure.

P-564
Ectopic varices: anatomical classification, hemodynamic
classification, and management by balloon-occluded
retrograde and antegrade transvenous obliteration (B-RTO
and B-ATO)
T.Matsubara1, T.Minami1, S.Kobayashi2, W.Koda1, K.Kozaka3,
T.Ogi1, D.Inoue1, A.Kitao1, K.Yoshida1, N.Yoneda1, T.Gabata1
1Radiology, Kanazawa University Hospital, Kanazawa, Japan,
2Radiology, Kanazawa University School of Medicine, Kanazawa,
Japan, 3Radiology, Kanazawa University Graduate School of Medical
Science, Kanazawa, Japan
Learning Objectives: Varices due to portalhypertension can occur
throughout the gastrointestinal tract. These include esophageal,
gastric, duodenal, mesenteric, small bowel, large bowel, and internal
hemorrhoids.The learning objectives of this Presentation is
1. To understand anatomy classification of various varices
2. To understand hemodynamics classification of various varices
3. To discuss technical aspects of BRTO and BATO for gastric and
ectopic varices.
Background: Patients with portal hypertension-related variceal
bleeding require a multi-disciplinary approach that includes gastroenterologists, diagnostic radiologists, and interventional radiologists. For the past 20 years, B-RTO has become a standard procedure in Japan. Nowadays, we treat not only gastric varices but also
other various varices such as ectopic varices using B-RTO and B-ATO
procedures.
Clinical Findings/Procedure: Ectopic varices are complex and
highly variable entities that are not fully understood.
In this presentation, we describe the following:
1. Anatomic and hemodynamic classification of gastric varices,
duodenal varices, jejunoileal varices, colonic varices, gall bladder
varices, and stomal varices.
2. Typical management strategies involving B-RTO and B-ATO procedures.
Conclusion: There are various procedures for the management of
gastric and ectopic varices. Anatomical and hemodynamic understanding is important for appropriate treatment using balloonoccluded procedure.

Abstract Book

P-565
Embolization of a coronary varix through recanalized
paraumbilical vein in a cirrhotic patient
C.H.Kang1, S.B.Yang2, H.J.Kim3, W.-H.Lee4, J.M.Lee5
1Radiology, Gangneung Asan Hospital, Gangneung, Korea, 2Radiology,
SoonChunHyang University Hospital, Gumi, Korea, 3Radiology, Daejeon
Hankoo Hospital, Daejeon, Korea, 4Radiology, SoonChunHyang
University Hospital, Cheonan, Korea, 5Radiology, SoonChunHyang
University Hospital, Bucheon, Korea
A 51-year-old male was referred because of life-threatening
hematemesis. He was diagnosed with rupture of coronary varix and
liver cirrhosis. However, he had massive ascites and low platelet
count. Endoscopic approach failed, and we successfully performed
embolization of the varix through recanalized paraumbilical vein
using coils and histoacryl.

P-566
Vascular plug for partial TIPS occlusion
L.Paul-Ferrer, A.Alonso-Burgos, M.Cabrera-Gnzalez, J.Urbano
Vascular & Interventional Radiology, Fundacion Jimenez Diaz, Madrid,
Spain
A 59-year-old male patient required TIPS reduction for management of refractory hepatic encephalopathy. Partial occlusion was
achieved using simultaneous deployment of a Nitinol vascular plug
and a non-covered stent into the TIPS prosthesis. Clinical and haemodynamic outcomes were satisfactory.

P-567
Arterial embolization of a post-traumatic extrahepatic
arterioportal fistula
P.Tarazov1, A.Polikarpov2
1Angio/Interventional Radiology, Russian Scientific Center of Radiology
and Surgical Technologies, St. Petersburg, Russian Federation,
2Interventional Radiology, Russian Scientific Center of Radiology and
Surgical Technologies, St. Petersburg, Russian Federation
A male patient was admitted with suspected liver cirrhosis and
recurrent variceal bleeding and was treated with endoscopic ligation and splenectomy. Several years before, he had survived an
abdominal gun-shot injury. Angiographically detected high-flow fistula between the splenic artery and vein remnants was successfully
embolized.

P-568
Use of an Amplatzer vascular plug for the treatment of an
aneurysmal intrahepatic portosystemic shunt in an adult
F.Petrocelli, A.Utili, G.Salsano, G.Bovio, F.Camerano, C.Ferro
Radiology, San Martino University Hospital, Genoa, Italy
A 74-year-old woman with HCV-related liver cirrhosis presented with
pulmonary hypertension and several episodes of encephalopathy.
CT revealed an aneurysmal porto-venous shunt between the right
portal branch and the middle hepatic vein, which was successfully
treated using an Amplatzer vascular plug.

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SS/FC/HL/HTS/CM
Posters

S329

P-569

P-573

Severe cholangitis post-portal vein embolisation: lessons to be

learned

Direct intrahepatic portocaval shunt (DIPS) utilizing femoral

access only for acute esophageal bleeding varices

K.Seow, N.Kienzle
Interventional Radiology, The Royal Brisbane and Women Hospital,
Herston, QLD, Australia

A.Masrani, J.Tasse, U.C.Turba, B.Arslan

Interventional Radiology, Rush University Medical Center, Chicago, IL,
United States of America

Coliform colonisation of the biliary tract occurred after insertion of

an internal-external drain. With subsequent portal vein embolisation, patient suffered severe cholangitis, requiring prolonged antibiotic treatment, which delayed curative liver resection.
Lesson learned: insert an external biliary drain instead of an internalexternal drain.

A patient with acute variceal bleeding was referred for TIPS. Due to
bilateral total occlusions of the brachiocephalic veins, a portocaval
shunt was created utilizing femoral access, puncturing the left portal vein from IVC under IVUS and fluoroscopy. The occluded main
portal vein was also recanalized.

P-570
Obliteration of mesocaval shunt with detachable coils and
cyanoacrylate from the inlet to the outlet of the tract through
a balloon catheter in a patient with hepatic encephalopathy
J.Toda1, T.Kimura1, S.Kasuya2, H.Terada2, Y.Hirayama3
1Diagnostic Imaging and Interventional Radiology, Tokyo Womens
Medical University Yachiyo Medical Center, Chiba, Japan, 2Radiology,
Toho University Sakura Medical Center, Chiba, Japan, 3Nephrology,
Hirayama Hospital, Chiba, Japan
A 67-year-old male with Childs B chronic liver disease (NASH) was
referred to our department due to severe hepatic encephalopathy.
Contrast-enhanced CT revealed major shunt between SMV and IVC.
Successful transvenous obliteration was performed with detachable
coils and cyanoacrylate.

P-571
Double balloon-occluded retrograde transvenous obliteration
(BRTO) using a pull-through technique for the treatment of
duodenal varices with two draining veins
Y.Koide, T.Okada, T.Gentsu, R.Tani, N.Katayama, E.Ueshima,
K.Sofue, M.Yamaguchi, K.Sugimoto
Department of Radiology and Center for Endovascular Therapy, Kobe
University Hospital, Kobe, Japan
Two draining veins join the inferior vena cava, but catheterization of
one was difficult. A pull-through technique from one draining vein
to another was used to deliver the balloon catheters to each vein,
and BRTO was successfully performed.

P-572
Dual-access, antegrade and retrograde, embolization of large
gastric fundal varices
J.E.ArmijoAstrain1, M.LeyvaVsquez-Caicedo2,
C.J.GonzalezNieto2, J.V.MndezMontero2
1Radiology, Hospital Clinico San Carlos, Madrid, Spain, 2Vascular and
Interventional Radiology, Hospital Universitario Clnico San Carlos,
Madrid, Spain
Despite having a TIPS, our patient had giant gastric fundal varices. We performed an embolization with cyanoacrylate through an
antegrade transTIPS access. However, prior coil embolization of the
back door through the renal vein was needed to avoid pulmonary
embolism.

P-574
Percutaneous treatment of a complex case of PD stone
obstruction-induced pancreatitis complicated with diabetes,
peripancreatic hematoma, and PV thrombosis
M.Mizandari, T.Azrumelashvili
Diagnostic and Interventional Radiology, Tbilisi State Medical
University, High Technology Medical Center - University Hospital,
Tbilisi, Georgia
Percutaneous peripancreatic hematoma and dilated PD transgastric drainage along with PV thrombus recanalization by stent were
performed, leading to peripancreatic fluid collection elimination,
pancreato-gastric fistula formation, and PV flow restoration; this
resulted in pancreatitis elimination, liver function preservation, and
improved blood sugar control.

P-575
Interventional management of a difficult case of recurrent
umbilical caput bleeding
V.Jain, A.H.Khandelwal, S.S.Baijal, D.Jain, A.K.Kapoor
Radiology, Medanta, the Medicity, Gurgaon, India
WITHDRAWN

P-576
Stent placement for portal vein stenosis
E.Shibata, N.Okura, T.Hidemasa, J.Sato, K.Ohtomo
Radiology, The University of Tokyo Hospital, Tokyo, Japan
We use stents for portal vein stenosis when the percutaneous transluminal balloon angioplasty for stenosis alone is not sufficient. We
review cases of stent placement for portal vein stenosis and show
the patency after the treatment.

P-577
Rheolytic mechanical thrombectomy for occluded TIPSS
P.Kumar, S.Srinivasan
Interventional Radiology, Aintree University Hospital, Liverpool, United
Kingdom
TIPSS occlusion is an uncommon outcome since the advent of covered stent grafts. We present a case of an occluded TIPSS, which
was successfully recanalised using rheolytic mechanical thrombectomy followed by relining of the shunt to improve flow and
haemodynamics.

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Abstract Book

P-578

P-582

Iatrogenic injury of the superior mesenteric vein

Successful transjugular intrahepatic portosystemic shunts with

embolization in the treatment of bleeding esophageal varices
refractory to endoscopic management: anatomical change of
esophageal varices after gastrectomy

A.Pastor, C.Nieto, M.Sastre, J.Pueyo, J.M.Martinez, B.Rodriguez

Interventional Radiology, Son Espases Hospital, Palma De Mallorca,
Spain
We present the case of an accidental tear of the superior mesenteric
vein during a surgical procedure. We performed successful stent
recanalization of the SMV, avoiding large intestinal resection.

Y.J.Kang1, H.O.Kim2, N.Y.Yim2, B.C.Lee2, J.K.Kim2

1Diagnostic Radiology, Chonnam National University Hwasun Hospital,
Jeollanam-do, Korea, 2Diagnostic Radiology, Chonnam National
University Hospital, Gwangju, Korea
A 76-year-old man had massive hematochezia. CT confirmed esophageal varices draining into the omental vein due to total gastrectomy. Transjugular intrahepatic portosystemic shunts with coil
embolization was performed successfully. We conclude that TIPS
with embolization is an effective treatment for esophageal varices.

P-579
Two cases of bleeding small intestinal varices successfully
treated by balloon-occluded retrograde transvenous
obliteration (B-RTO) using n-butyl-2-cyanoacrylate
K.Masuda1, S.Takenaga1, H.Ashida2, K.Enoki2
1Radiology, The Jikei University Katsushika Medical Center, Tokyo,
Japan, 2Radiology, Jikei Medical University Hospital, Tokyo, Japan

P-583

Bleeding small intestinal varices are difficult to manage. We report

two cases of small intestinal variceal bleeding that were successfully treated by balloon-occluded retrograde transvenous
obliteration (B-RTO) via the right inferior epigastric vein using
n-butyl-2-cyanoacrylate.

P-580
Portal stenting for post-operative portal thrombosis due to a
kink at the portal trunk
Y.Kodama1, Y.Sakurai1, Y.Yoshino2, Y.Ambo3
1Radiology, Teine Keijinkai Medical Center, Sapporo, Japan, 2Radiology,
Teine Keijinkai Hospital, Sapporo, Japan, 3Surgery, Teine Keijinkai

Transsplenic gastric fundal varices embolization and multiple

splenic arteries embolization to manage untreatable gastric
bleeding in a patient with chronic splenic vein occlusion
R.Gandini, S.Merolla, E.Pampana, F.Chegai, S.Abrignani
Diagnostic and Molecular Imaging, Radiation Therapy and
Interventional Radiology, University Hospital Policlinico Tor Vergata,
Rome, Italy
In order to manage untreatable gastric fundal variceal bleeding, a
direct transsplenic gastric fundal variceal embolization combined
with partial splenic artery embolization was safely and effectively
performed in a patient with left portal hypertension due to chronic
splenic vein occlusion.

Hospital, Sapporo, Japan

P-584

A patient who had undergone right hepatectomy for advanced

gall bladder carcinoma developed extensive portal thrombosis.
Thrombolysis was performed but was ineffective. The kink at the
distal of portal trunk was considered as the origin of the thrombosis. Portal stenting was performed, which resolved the thrombosis.

Transjugular thrombolysis followed by TIPSfor an acute portal

venous thrombosis
Y.Takeuchi1, N.Hayashi2, Y.Ichijo2, H.Shirasu3, T.Nishimura4
1Radiology, North Medical Center, Kyoto, Japan, 2Radiology, Kyoto
Prefectural University of Medicine, Kyoto, Japan, 3Gastroenterology,
Fukuchiyama City Hospital, Fukuchiyama, Japan, 4Hepatology, North

P-581

Medical Center, Kyoto, Japan

A case of successful recanalization and stent placement for

chronic portal vein obstruction after pylorus-preserving
pancreatoduodenectomy

Acute portal venous thrombosis led to anorexia and jaundice in

a 62-year-old woman with alcoholic cirrhosis. Transhepatic portal
venous thrombectomy and 96-hour urokinase infusion through a
transjugular portal venous catheter followed by TIPS stent insertion
was successful in relieving her symptoms.

H.Kondo1, Y.Tanahashi1, M.Osawa1, T.Yamamoto1, M.Inoue2,

M.Yamamoto3, S.Onozawa4, S.Furui1
1Radiology, Teikyo University School of Medicine, Tokyo, Japan,
2Diagnostic Radiology, Keio University, School of Medicine, Tokyo,
Japan, 3Radiology, National Defense Medical College, Tokorozawa,
Japan, 4Radiology, Nippon Medical School, Tokyo, Japan

P-585
Complex endovascular treatment of a malignant
portomesenteric vein occlusion

A 47-year-old man had portal vein occlusion nine years after PPPD
for a mass-forming pancreatitis. The PV occlusion was penetrated
using a TIPS needle, and stent placement was performed via a transileocolic approach assisted with the AcuNav ultrasound catheter.

T. Kljuevek
Clinical Institute of Radiology, UMC Ljubljana, Ljubljana, Slovenia
A 47-year-old man was admitted to the intensive-care unit because
of haemorrhagic shock due to gastrointestinal bleeding after an
unsuccessful endoscopic treatment. CT showed PNET with portomesenteric thrombosis and liver metastasis. TIPS was performed
together with recanalization and stent-graft placement in the portomesenteric vein.

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SS/FC/HL/HTS/CM
Posters

S331

P-586

Urinary tract intervention

Venous graft thrombosis and perforation following modified

Whipple procedure: endovascular management and review of
literature

P-589

M.AbdalKader1, C.Bourdeaux2, P.P.Goffette3

1Interventional Radiology, Cliniques Universitaires Saint Luc,
Brussels, Belgium, 2Chirurgie et Transplantation Abdominale,
Cliniques Universitaires Saint Luc, Brussels, Belgium, 3Radiologie
Interventionnelle et Vasculaire Neuroangiographie Thrapeutique,
Cliniques Universitaires Saint Luc UCL, Brussels, Belgium

M.Patel1, D.Jilani1, O.Ahmed2, T.G.VanHa1, J.M.Lorenz1, J.A.Leef1

1Radiology, University of Chicago, Chicago, IL, United States of America,
2Department of Radiology, Rush University, Chicago, IL, United States

65 year-old patient with pancreatic carcinoma and porto-mesenteric confluence invasion underwent Whipple procedure with vascular reconstruction, the postoperative course was complicated
by venous graft thrombosis and perforation successfully managed
by thrombectomy and stenting. This is the first report of such a
complication.

P-587
Two cases of rectal varices treated with balloon-occluded
antegrade transvenous sclerotherapy
N.Seino1, S.Sai1, N.Hosaka1, Y.Ohgiya1, R.Abe1, N.Mizobuchi1,
M.Honda2, T.Gokan1, M.Hasegawa3
1Radiology, Showa University, Shinagawa City, Japan, 2Radiology,
Totsuka Kyoritsu Dai-ni Hospital, Yokohama, Japan, 3Radiology, Showa
University Koto Toyosu Hospital, Koto City, Japan
We report two cases of patients who underwent balloon-occluded
antegrade transvenous sclerotherapy with different puncture routes
for the treatment of rectal varices. One of the routes was percutaneous transhepatic puncture. The other route was percutaneous direct
puncture of the superior rectal vein.

P-588
Successful trans-splenic recanalization of a completely
occluded main portal vein in a pediatric liver transplant
patient
A.S.Jo, R.Srinivasa
Department of Radiology, University of Michigan, Ann Arbor, MI, United
States of America
Successful trans-splenic recanalization of the main portal vein in a
pediatric liver transplant patient with complete occlusion of the
main portal vein from the splenomesenteric confluence to the transplant anastomosis.

P-588a
Portal biliopathy
U.G.Rossi1, P.Torcia1, P.Rigamonti1, F.Petrocelli2, M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Radiology, San Martino University Hospital, Genoa, Italy
We describe the case of a 38-year-old female who developed jaundice and portal hypertension due to portal cavernoma formation.
The patient was treated with biliary drainage and TIPS. Follow-up at
48 months was uneventful.

Factors influencing success of percutaneous renal access by

radiology for subsequent percutaneous nephrolithotomy

of America
Purpose: To identify variables affecting outcomes and complications from percutaneous nephrostomy placement prior to percutaneous nephrolithotomy (PCNL).
Material and methods: A total of 121 percutaneous nephrostomies placed in 106 patients by Interventional Radiology at a single
institution between 2005 and 2014 were included in a retrospective
review. Patient factors, stone characteristics, and technical variables
were recorded in addition to stone free survival, complications, and
length of hospital stay.
Results: All significant stones were removed in 114 (94.2%) cases.
A single PNCL was sufficient for stonefree success in 102 (84.3%)
cases, ancillary procedures were required in 18 (14.9%) cases, and
percutaneous access was deemed insufficient in only 5 (4.1%) cases.
Total complication rate was 13.2% with only 2 (1.7%) accessrelated
complications. Average hospital stay was 2.4 nights.
Larger nephrostomy catheters placed initially for percutaneous
access were associated with reduced need for ancillary procedures
(p=0.015) and also with smaller decreases in hematocrit during PCNL
(p=0.029). Larger total stone burden was associated with increased
need for ancillary procedures (p=0.013) and lower overall stone
free success (p=0.048). Percutaneous access was more likely to be
insufficient (p=0.004), and ancillary procedures were more likely to
be required (p=0.002) in patients with higher BMI. Multiple factors
were associated with increased hospital stay included patient anemia (p=0.012), coagulopathy (p<0.001), and prior genitourinary surgery or anomaly (p=0.021).
Conclusion: Larger nephrostomy catheters tend to be associated
with reduced need for ancillary procedures and smaller decreases in
hematocrit from PCNL. Otherwise, factors affecting stonefree success, complications, and length of hospital stay from PCNL are primarily patient or stone related.

P-590
Percutaneous nephrostomy placement for urosepsis: is it that
urgent?
T.G.Tullius, M.Patel, J.A.Leef, J.M.Lorenz, T.G.VanHa
Department of Radiology, University of Chicago, Chicago, IL, United
States of America
Purpose: The primary goal is to determine whether shorter time to
nephrostomy placement affects length of hospitalization or mortality in patients with urosepsis. The secondary goals include success
rates and procedure complications.
Material and methods: A retrospective, institutional review boardapproved study of percutaneous nephrostomies (PCN) for urosepsis by interventional radiology at a single institution over a 10-year
period. Forty-eight PCN were placed in 36 patients (60.4% female,
average age 63.5 years). Patient and procedural variables included
time between admission and PCN placement, length of hospital stay
post-PCN placement, survival data, and complications.
Results: Average time to PCN placement was 3.3 days after admission. Average length of hospital stay post-PCN placement was 8.0
days. ICU admission occurred in 41.7%. Emergency after-hours
placement was performed in 47.9% of cases. Hydronephrosis

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occurred in 91.7% of cases with moderate or severe hydronephrosis

in 77.1%. Urolithiasis occurred in 31.3%. Total complication rate was
12.5%. Placement failure was 8.3%. Death within 30 days of placement occurred in 4.2%.
Time from admission to PCN was associated with neither decreased
length of stay post-procedure (p=0.624) nor mortality (p=0.689).
Factors associated with increased mortality included respiratory rate
(p=0.030) and serum potassium (p=0.039). Older patients (p<0.001)
and patients with lower mean arterial pressure (p=0.03) were more
likely to require ICU admission. No factors were associated with an
increased risk of procedural complication or access failure.
Conclusion: Shorter time from admission to PCN placement in
patients with urosepsis was not associated with decreased length of
stay, requirement for intensive care, or decreased mortality. Factors
affecting mortality were primarily related to patient condition.

P-591
Fluoroscopy-guided transurethral exchange of the double-J
ureteral stent in women
T.-S.Seo1, M.G.Song1, Y.H.Kim2, S.B.Cho2, H.H.Chung3, S.H.Lee3
1Radiology, Korea University Guro Hospital, Seoul, Korea, 2Radiology,
Korea University Anam Hospital, Seoul, Korea, 3Radiology, Korea
University Ansan Hospital, Ansan, Korea
Purpose: To evaluate the technical feasibility and safety of fluoroscopy-guided transurethral exchange of the double-J ureteral stent
(DJUS) in women.
Material and methods: Between January 2008 and January 2016,
we performed 36 sessions of fluoroscopy-guided transurethral
exchange of 50 DJUSs in 25 women with ureteral obstruction due
to malignancy. Nineteen patients underwent a single session, and
6 patients underwent repeated sessions. Twenty-two procedures
were for bilateral ureters, and 14 procedures were for unilateral ureter. Six DJUSs with blind proximal end had been placed under cystoscopic guidance by a urologist before we exchanged. We extracted
old DJUSs with a goose-neck snare and inserted DJUSs with 68 F
diameter and 24 or 26 cm length over the guidewire. We evaluated
the success rate, procedure time, and complications.
Results: We exchanged 49 stents (98%) successfully. Exchange of
the DJUS with a blind proximal end was successful in 5 of 6 stents
(83%) by the modified method. The DJUSs had been placed for
mean 111.2 days before removal. Mean procedure time was 15.0
minutes (range: 931 minutes) for unilateral DJUS and 25.2 minutes
(range: 1441 minutes) for bilateral DJUS. All patients complained
of mild discomfort, which was controlled by analgesics during the
procedure, and showed mild hematuria, which improved spontaneously within a few days, without major complications.
Conclusion: Fluoroscopy-guided transurethral exchange of the
DJUS in women seems to be feasible and safe, and the DJUS with
a blind proximal end also could be exchanged by the modified
method without cystoscopic assistance.

P-592
Self-expanding stents for treating ureteral strictures and
fistulae
J.R.TorrecillaGarca-Ripoll1, J.M.DazRomero1,
M.UdaondoCascante2, A.HermosnPea2,
F.J.TruebaArguiarena2, S.MartnMartn1, J.R.CortiasGonzlez1
1Urology, H.C.U. Valladolid, Valladolid, Spain, 2Radiology, H.C.U.
Valladolid, Valladolid, Spain

Abstract Book
Material and methods: From January 2009 to December 2015, we
studied the evolution of 32 ureteric metallic self-expanding stents
made of nitinol with an internal PTFE lining. They were implanted
with a retrograde approach, under spinal block and sedation,
guided by fluoroscopy.
Results: Thirty-four stents were placed in 26 patients (13 female and
13 male). Mean age was 62.47 years (range: 2588). Four patients
(19%) presented with fistulae, and twenty-two (81%) with stenotic
lesions. The etiology was benign in 19, while in 7 patients, malignancy was involved. Five stents were localized in the right side,
6 in the left side, and 8 in the graft. Patients were discharged in a
mean of 3 days (range: 111). The mean follow-up was 13.75 months
(range: 146). Main complications were migration 16%; encrustation
6% (with obstruction in 3%); internal epithelial growth 3%; and urinary tract infections 3%. Patients tolerated the stents well with minimal discomfort. In 69% of the cases, the main problem was solved
without need of further intervention.
Conclusion: Metallic stents are a promising, safe, and effective
treatment option for the minimally invasive management of both
benign and malignant ureteral strictures and fistulae.

P-593
Endourologic treatment of ureteral stenosis in children: our
experience
M.E.PerezMontilla, S.LombardoGalera, J.J.EspejoHerrero,
L.J.ZureraTendero
Interventional Radiology Unit, Hospital Reina Sofia, Cordoba, Spain
Purpose: We describe our experience with balloon dilatation in the
treatment of ureteral stenosis in children and the usefulness of this
procedure.
Material and methods: In total, 33 patients were treated for ureteral stenosis with endourological balloon dilatation from 2010 to
2015. The diagnostic protocol included ultrasound, cystogram and
diuretic renography MAG-III. The dilatation was performed by a retrograde approach, or if it failed, an anterograde approach was used.
The dilatation was performed with a balloon (37 mm). Then, a double-J stent was positioned. Patients underwent clinical review at
1, 3, 6 and 12 months as well as renal ultrasound examination and
diuretic renography MAG III.
Results: In total, 33 children (mean age 30 months) were treated (27
males, 82%). Ureteral stenosis was detected in the prenatal phase
(n=25). The stenosis was located in 68%: ureteropelvis junction
(n=26) and ureterovesical junction (n=12). The retrograde approach
was used in 78% patients and anterograde approach in 22%. The dilatation diameter was 37 mm; when the balloons notch did not disappear, we used a cutting balloon (n=5). The mean surgical time was
130 minutes. There were no intraoperative complications. The double-J stent was removed after a mean time of 2.5 months. In 85%
children, diminution of the renal pelvis diameter and improvement
in the obstructive pattern were observed.Of the other 3, 1 required
a second balloon dilatation within 10 months, while 2 required it
within 6 months after pyeloplasty was performed. Post-operatory
complications were urinary tract infection (6), double-J stent
obstruction (2), urinoma (1) and pyelonephritis (1).
Conclusion: Balloon dilatation is a valid and safe option in the treatment of ureteral stenosis, with a short hospital stay and good results
during follow-up.

Purpose: The use of metallic stents permits surpassing of structural

defects in the ureter wall. We present our experience in the use of
self-expanding nitinol stents covered with polytetrafluoroethylene
(PTFE) for solving ureteric strictures or fistulae.

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P-594
Small renal masses and percutaneous biopsy: where are we?
A.Paladini1, G.Pizzi2, G.Vallati2, D.BeomonteZobel1, F.M.Danza3
1Radiology, Universit Cattolica del Sacro Cuore, Policlinico
Universitario A. Gemelli, Rome, Italy, 2Interventional Radiology,
IFO Istituto Regina Elena National Cancer Institute, Rome, Italy,
3Bioimmagini e Scienze Radiologiche, Universit Cattolica del Sacro
Cuore, Rome, Italy
Learning Objectives: To describe the most recent indications of
this procedure and discuss materials and methods so as to perform
the procedure in the right way to reduce the incidence of risks and
complications.
Background: Patients with renal tumors often undergo surgery
without a histological diagnosis. This attitude is unusual for all other
body cancers in which a preoperative diagnosis is always obtained.
Moreover, many authors have described an incidence of benign
lesions after surgical enucleation to be between 20% and 30%. What
is emerging from the literature is that renal parenchymal tumors are
very different as far as histology is concerned. For this reason, it is
essential to discuss the use of pre-treatment biopsies of small renal
masses (SRM). This concept is even more important nowadays with
small lesions because there are no official diagnostic guidelines. In
addition, a correct diagnosis of the disease would allow conservative
treatment or a minimally invasive procedure (RFA, microwave, cryo,
and HIFU).
Clinical Findings/Procedure: In this poster, we will analyze the different types of sampling (laid down and turned on one side, prone,
and supine), types of needles (cutting needles, pinching needles,
and suction needles), and complications (seeding, bleeding, and
other complications).
Conclusion: Percutaneous biopsy of SRM is a very accurate, sensitive, and highly specific method for establishing a precise diagnosis,
identifying the nature of the mass, and affecting the clinical history
of the patient.
Due to the significant percentage of benign lesions, the introduction of this technique in the diagnostic protocol of SRM will avoid
unnecessary surgery in many patients.

P-595
Covered self-expanding metallic stents for recurrent ureteric
stenosis in renal transplant patients
A.Gotra1, H.Baydoun1, P.DelliFraine1, A.Bessissow1, S.Modi2,
M.Schmidt1, L.-M.N.J.Boucher1, D.A.Valenti1
1Radiology, McGill University Health Center, Montreal, QC, Canada,
2Radiology, University Hospital Southampton, Southampton, United
Kingdom
Learning Objectives:
1. Describe the most common locations and causes of ureteric
obstruction following renal transplantation.
2. Describe currently available surgical and IR treatment options for
recurrent ureteric stenosis.
3. Discuss metallic stent options and placement techniques.
Background: Ureteric obstruction is the most common complication following renal transplantation (313%). The UVJ is the most frequent location of stenosis, usually due to ureteral ischemia. The type
of ureteral anastomosis (ureteroneocystostomy, ureteroureterostomy or ureteropyelostomy) leads to variability in the incidence and
location of stenosis. Treatment options for recurrent stenosis include
surgery, which is technically challenging and associated with variable rates of organ loss. Current IR treatment options include percutaneous nephrostomy insertion, balloon dilatation and double J
stent insertion.

SS/FC/HL/HTS/CM
Posters

S333

Clinical Findings/Procedure: At our institution, patients with

ureteric stenosis causing renal transplant dysfunction are initially treated with percutaneous nephrostomy followed by ureteroplasty (6-mm balloon) and DJ insertion (6 Fr). If obstruction reoccurs, a nephrostomy tube is re-inserted followed by repeat ureteroplasty (6-mm balloon) and DJ insertion (8 Fr). Persistent/recurrent strictures may be treated with retrievable covered self-expanding metallic stents. Ideal stent characteristics for such treatment
include: high radial force, polytetrafluoroethylene covering to prevent ingrowth, covered mid portion, uncovered distal and proximal
portions to aid anchoring and prevent migration and irregular outer
layer to increase friction. Retrieval options include standard hook
retrieval devices and antegrade/retrograde stent mobilisation using
balloons.
Conclusion: Covered self-expanding metal stent insertion represents an effective treatment option for recurrent/refractory strictures in transplant ureters. This may represent a safer and more costeffective treatment when compared to surgical conduit.

P-596
Prostate artery embolization with CO2 for giant prostatic
hyperplasia
I.M. Kably
Radiology, University of Miami, Miami, FL, United States of America
A 62-year-old male with urinary retention and intractable hematuria
and a prostate size of 724 mL was successfully treated with PAE and
CO2as the contrast agent. This is the highest prostate volume successfully treated with PAE in the medical literature.

P-597
Positive antegrade ureteric transluminal biopsy using a biliary
biopsy forceps kit
G.Aruede1, P.Ignotus1, C.Wetton1, J.Donohue2, A.Shaw1
1Interventional Radiology, Maidstone and Tunbridge Wells Hospitals,
Kent, United Kingdom, 2Urology, Maidstone and Tunbridge Wells
Hospitals, Kent, United Kingdom
An elderly female with a history of breast cancer presented with an
obstructing stricture of the distal left ureter. Retrograde ureteroscopic biopsy and stenting were unsuccessful. Antegrade ureteric
transluminal biopsy and stenting were successfully performed, with
histology confirming metastatic breast carcinoma.

P-598
Difficult removal of a covered metallic ureteric stent in a renal
transplant patient using a retrograde approach
A.Gotra, H.Baydoun, M.Schmidt, P.DelliFraine, A.Bessissow,
L.-M.N.J.Boucher, D.A.Valenti
Radiology, McGill University Health Center, Montreal, QC, Canada
A 74-year-old male presented for removal of a metallic ureteric stent.
A hook-retrieval device and antegrade approach with Mustang balloon failed to mobilize the stent. A retrograde approach using a
Mustang balloon allowed extraction of the stent via the penis.

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Abstract Book

P-599

P-601

Dedicated renal tract closure: a step towards single-step renal

intervention

Outcome of endovascular treatment (BRTO/PTO) for visceral

varices due to portal hypertension in one institute

S.D.Goode, F.Sakhinia, F.Lee

Sheffield Vascular Institute, Northern General Hospital, Sheffield, United
Kingdom

Y.Baba, T.Fuji, M.Ishikawa, K.Kajiwara, W.Fukumoto, K.Awai

Diagnostic Radiology, Graduate School of Biomedical Sciences,
Hiroshima University, Hiroshima, Japan

Currently, most renal interventions for antegrade ureteric stents are

performed as a 2-step procedure. We propose and present a case
of single-step antegrade ureteric stent insertion method utilising a
dedicated renal tract closure embolisation technique.

Purpose: To investigate outcome and poor prognostic factors associated with endovascular treatment (BRTO/PTO) in patients with visceral varices due to portal hypertension.
Material and methods: From September 2008 to August 2015, 47
patients (28 males, 19 females; mean age 65) were diagnosed with
visceral varices due to portal hypertension in our institute. The sites
of visceral varices were the stomach in 40 patients, duodenum in
4 patients, and rectum in 3 patients. The endpoint was defined as
death associated with varices rupture. Statistical analysis was performed between the endpoint and prognostic factors including
patient background or information, blood sample data, ChildPugh
score and MELD score. Univariate analysis was performed with a log
rank test by the KaplanMeier method, and multivariate analysis
was performed with the Cox hazard regression model.
Results: Average follow-up period was 691 days. Univariate analysis showed a statistically significant difference in poor prognostic
factors, including age (72; P=0.0013), CRP (1.4; P=0.0074 ), red cell
blood counts (210 x 104/L; P=0.0013), PT time (70%; P=0.0013),
total bilirubin value (1.7 mg/dl; P=0.0154), serum albumin value
(2.2 g/dl; P=0.0145), Child-Pugh score (10; P=0.0002), and ChildPugh classification (P=0.0009). In multivariate analysis, there was a
statistically significant difference for the following poor prognostic
factors: red cell blood counts (hazard ratio 0.05, P=0.0208) and total
bilirubin value (hazard ratios 13.16, P=0.0480).
Conclusion: Our results indicate that red cell blood counts and total
bilirubin value are the prognostic factors most strongly associated
with death from visceral varices rupture.

Venous intervention and IVC filters

P-600
Percutaneous embolization in pelvic congestive syndrome:
long-term results
M.D.Ferrer-Puchol1, R.RamiroGandia2, M.LeonDonoso3,
E.EstebanHernndez1, P.FariasAlijo3, G.Sempere-Campello2
1Interventional Radiology, Hospital Universitario de la Ribera, Alzira,
Spain, 2Radiology, Hospital Universitario de la Ribera, Alzira, Spain,
3Vascular Surgery, Hospital Universitario de la Ribera, Alzira, Spain
Purpose:
1. To demonstrate a relationship between pelvic congestive
syndrome (PCS) and presence of ovarian and iliac venous incompetence.
2. To know the relation between PCS and other factors.
3. To analyse the short-term and long-term clinical effects of embolization.
Material and methods: We studied 100 women referred to the
Vascular Radiology Unit from the Vascular Surgery Department for
clinical suspicion of pelvic congestion syndrome. We evaluated pelvic pain, pelvic heaviness and dyspareunia using a visual analogue
scale (VAS) before and after embolization. All patients underwent
a selective venography of ovarian and iliac veins. The patients in
whom venous incompetence was confirmed underwent embolization in the same procedure.
Clinical results were evaluated before embolization, 2 months and 2
years later, and Students t test for dependent samples was used to
compare the mean values.
The relationship between PCS with age, multi-parity and obesity
was studied.
Results: Mean values of VAS in all patients demonstrated pelvic pain: 7.7, pelvic heaviness: 7.6 and dyspareunia: 6.7. In 58 of the
100 patients, embolization was performed, after signs of pelvic
venous incompetence were found. Embolization was successful in
all patients. Relation between PCS and the studied factors was not
demonstrated.
According to the VAS score, a significant relief of symptoms was confirmed 2 months later and became more evident at 2 years (p < 0.00).
Conclusion: In patients with PCS, the percutaneous embolization of
insufficient pelvic veins achieves clinical improvement in long term.

P-602
Embolization for erectile dysfunction due to venous leakage
R.Aschenbach, U.Teichgrber, T.Franiel
Diagnostic and Interventional Radiology, University Hospital Jena,
Jena, Germany
Purpose: To evaluate the impact of endovascular embolization in
men with erectile impotence due to veno-occlusive dysfunction.
Among other factors like hypogonadism, diabetes mellitus, drugs
related to opioids, alcohol, tobacco, and several psychological factors, veno-occlusive dysfunction is one of the vascular factors causing ED, leading to impotence. Endovascular embolization for venoocclusive dysfunction in erectile impotence is a safe and effective
therapeutic option with low a complication rate and high technical
and clinical success rates.
Material and methods: We retrospectively evaluated 33 patients
with a history of erectile impotence due to veno-oclusive dysfunction confirmed by pharmacocavernosometry and cavernosography.
All underwent endovascular embolization intead of the transfemoral approach.
Results: All procedures were performed without any major or minor
events. Complication rate was 0%. Technical success was achieved
in 31/33 patients. Two patients failed because of anatomical reasons.
Overall clinical success was achieved in 29/33 patients. In total, 4/33
patients showed no change in the ED severity score.
Conclusion: Endovascular embolization for veno-occlusive dysfunction in erectile impotence is a safe and effective therapeutic option
with a low complication rate and high technical and clinical success
rates.

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Posters

S335

P-603

P-605

Intraplug coil delivery for fast closure of giant arteriovenous

fistula aneurysm in dialyzed patients: case series and literature
review

Investigation on proper locations and shapes of port-catheter

implantation to prevent port-catheter dysfunction

R.Gandini, F.Chegai, S.Merolla, D.Konda, E.Pampana

Diagnostic and Molecular Imaging, Radiation Therapy and
Interventional Radiology, University Hospital Policlinico Tor Vergata,
Rome, Italy
Purpose: To evaluate the efficacy and safety of intraplug coil delivery for the fast closure of giant arteriovenous fistula aneurysm in
dialyzed patients.
Material and methods: Between April 2011 and September 2014, 9
patients with AVF aneurysm were treated at our department. These
patients had different clinical symptoms (4 with steal syndrome
and 5 with both cardiac abnormalities and steal syndrome). Preprocedural arteriography was performed to assess the patency of
the vessels of the upper limb. Diagnostic fistulography was obtained
to detect any retrograde or collateral flow besides the main outflow
vein and outline the anatomy. The site of embolization was identified and measured using both modalities. To avoid the risk of migration, AVP was deployed at the narrowest point of AVFs, exploiting
the maximum diameter of the plug. To obtain a fast closure and to
improve the thrombogenicity of the AVP, we decided to directly
prick the plug percutaneously with a 20-G spinal needle. Spindle has
been extracted and replaced by a 0.020 wide Penumbra coil.
Results: No procedure-related complications were observed. No
radiologic or clinical signs of distal ischemia or perfusion defects
were seen. Occlusion was confirmed at 4 weeks by diagnostic contrast fistulography and 3 months by US in all cases. All patients
showed quick improvement of initial symptoms, and during the follow-up, the patients showed complete remission of initial symptoms. No cases of plug migration were observed.
Conclusion: Our preliminary results suggest that an endovascular
approach is a feasible and safe technique for the treatment of AVF
giant aneurysm when open surgery is contraindicated.

P-604
Techniques of adrenal venous sampling in cases with double
inferior vena cava
K.Endo, S.Morita, S.Suzaki, H.Yamazaki, Y.Nishina, S.Sakai
Department of Diagnostic Imaging and Nuclear Medicine, Tokyo
Womens Medical University Hospital, Tokyo, Japan
Purpose: To review the techniques of adrenal venous sampling
(AVS) in patients with double inferior vena cava (IVC).
Material and methods: We retrospectively reviewed the techniques of selecting the adrenal veins in 6 patients with double IVC.
The right adrenal vein (RAV) and common trunk of the left adrenal vein (LAV) as well as the left inferior phrenic vein were selected
using catheters specialized to select RAV and LAV, which were commonly used in Japan.
Results: For LAV, the common trunks were selected by turning the tips of the LAV catheters in the left IVC through the left
renal veins (n=3) and in the interiliac communicating vein (n=1),
and by advancing the LAV catheters into the left IVC without turning the tips through the interiliac communicating vein (n = 1), and
from the sheath placed in the left femoral vein (n=1). Subsequently,
LAVs in all patients were selected using microcatheters. RAVs in all
patients were selected using the RAV catheters without any unusual
technique.
Conclusion: For AVS in patients with double IVC, several techniques
are feasible for selecting LAV, while no special technique is required
for selecting RAV.

K.Matsunari, H.Fujisawa, T.Kushihashi

Radiology, Showa University Northern Yokohama, Kanagawa, Japan
Purpose: We experienced 16 cases of port-catheter dysfunction in
102 cases of power-injectable port-catheter implantation using a
right internal jugular vein approach from January 2012 to December
2015.
The purpose of this study was to evaluate differences of locations
and shapes of the port-catheter implantation in two groups: G-I,
port-catheter dysfunction cases (n=16) and G-II, non-dysfunction
cases (n=86).
Material and methods: The average age of 102 patients (males
59, females 43) was 67.0 years (range 4090). Under the same conditions, we compared angles of ascending and descending catheters, heights of catheter bending point, upward length from the
right clavicle and catheter tip positions (downward length from the
tracheal bifurcation) with chest DSA images at the time of the portcatheter implantation with arms relaxed to the side.
Results: With respect to age and sex, there were no statistically significant differences between G-I and G-II. Significant differences
were observed in heights and angles of catheters (p<0.05). The
median angles were 62.2 in G-I and 80 in G-II. The median heights
were 3.3 cm in G-I and 2.2 cm in G-II. The median catheter tip positions were 3.6 cm in G-I and 4.6 cm in G-II.
Conclusion: In our study, to keep proper locations and shapes of
port-catheter implantation to prevent port-catheter dysfunction,
the angles of ascending and descending catheters were over 80
and heights of catheter bending point were 2.2 cm or below.

P-606
IVC filter retrieval rates and reasons for non-retrieval
S.Sayeed1, C.J.Hammond2
1Vascular Radiology, Leeds General Infirmary, Leeds, United Kingdom,
2Vascular Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, United
Kingdom
Purpose: To reaudit IVC filter [IVCF] retrieval rates and assess reasons for IVCF non-retrieval.
Material and methods: A retrospective review of all patients with
temporary IVCF inserted in 2010, 2011, and 2012 was conducted.
Information was collated from radiology databases.
Results: A previous IVCF retrieval audit (2009) demonstrated a
retrieval rate of 33.7%.
In the current audit, 134 patients underwent temporary IVCF insertion. Of which, 102 (76%) had retrieval requested [66 on the day of
the procedure (by the inserting radiologist) and 33 on a later date].
Three requests were undated.
In total, 74 patients (55%) underwent attempted retrieval, of which
66 (49%) were successful. There were 2 failed retrievals and 6
patients with contraindications to retrieval (large volume trapped
thrombus). Median filter dwelling time was 43 days.
In total, 60 patients did not undergo retrieval. Of these, 18 died
(median 20 days post insertion), 10 were deemed too unwell to
undergo retrieval by the referring clinical team, 7 declined retrieval,
5 showed risks of retrieval attempt outweighing its benefits (usually tilted filters in the elderly), and 5 showed contraindications to
retrieval on interval CT. In 15, no reason was apparent.
Of patients undergoing temporary IVCF insertion, retrieval was
either attempted or was not indicated in 89% despite an overall
retrieval rate of only 49%.

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Conclusion: Despite changes in process since the last IVCF retrieval

audit (2009), the crude retrieval rate remains low. However, we identified a large cohort of patients in whom IVCF retrieval was not
appropriate. Crude retrieval rates are insensitive to this.

P-607
Isolated pharmacomechanical thrombectomy in Paget
Schroetter syndrome
J.M.Krkkinen1, T.Riekkinen1, E.Sihvo2, J.Turtiainen3, P.Saari4,
K.Mkinen1, H.I.Manninen4
1Heart Center, Kuopio University Hospital, Kuopio, Finland, 2Surgery,
Central Finland Central Hospital, Jyvskyl, Finland, 3Surgery, North
Karelia Central Hospital, Kuopio, Finland, 4Clinical Radiology, Kuopio
Univ. Hospital, Kuopio, Finland
Purpose: To evaluate the feasibility of isolated pharmacomechanical thrombectomy (IPMT) in the treatment of PagetSchroetter syndrome (PSS), followed by the thoracoscopic or open surgical decompression of the subclavian vein.
Material and methods: Twenty two of 27 consecutive patients with
PSS received IPMT using the Trellis-8 Peripheral Infusion System
(Covidien) between 2010 and 2014. Subsequent surgery was performed in 18 of the patients; nine patients were treated with thoracoscopic resection, seven patients with subclavicular resection, two
patients with transaxillary first-rib resection, and four patients with
IPMT and anticoagulation. Technical success, complications, and
2-month patency were registered.
Results: IPMT was successful in 95% of patients; one patient with
unsatisfactory lysis received further catheter-directed thrombolysis,
which, however, did not improve the result. The mean endovascular
procedure time was 105 33 minutes (range 70200 minutes), and
the required median amount of thrombolytic agent was 500,000 IU
(range 250,0001,000,000 IU). Adjunctive balloon venoplasty and
aspiration were used in 82% and 32% of patients, respectively. One
patient had an intimal tear of the subclavian vein that was identified and repaired during surgery. There were no other complications related to the endovascular procedure. At 2 months, 15 of 18
patients with follow-up imaging available had patent subclavian
vein and all except one of the 22 patients were asymptomatic.
Conclusion: IPMT is a safe and effective method for early thrombus
removal in PSS.

P-608
A new technique for venous insufficiency treatment: vein
sealing system
O. Rodoplu
Cardiovascular Surgery, Bilecik Government Hospital, Bilecik, Turkey
Purpose: Vein sealing system (Variclose) is a new technique for
venous insufficiency treatment and for closing venous reflux. The
aim of this study is showing advantages or disadvantages of this
new technique.
Material and methods: We operated 300 patients between June
2014 and July 2015 at the Uludag university medicine school hospital and Bilecik government hospital. In all, 55% of the patients
were women and 45% of the patients were men. In total, 25% of the
patients were at high risk (with diabetes mellitus, coronary artery
disease, etc.) and 75% of the patients showed isolated venous insufficiency [grade 34 venous reflux and dilated incompetent saphenous vein (>4 mm)].
Results: We did not need general or spinal anesthesia. Variclose
eliminates the necessity of tumescent anesthesia in thermal endovenous ablation methods. We did not see any numbness or skin
and nerve damage complications caused by the thermal ablation
methods. We did not need surgery room conditions. Patients could

Abstract Book

immediately return their work and daily routines. deep vein thrombosis did not occur. Surface tissue infections occured in 1% of the
patients, particularly due to morbid obesity and diabetes mellitus.
After the operations, we controlled saphenous veins. In all, 98% of
saphenous veins were closed. The patients were controlled after
3-6-9-12 months by venous Doppler ultrasonography, and 2% recanalization seemed at the patients control ultrasonographies.
Conclusion: As a new technique, the vein sealing system provides
advantages such as ease of use, shortening of the procedure time,
performance in outpatient conditions, eliminating the necessity
of tumescent anesthesia in thermal ablation, and prevention from
complications (nerve damage, hematoma, rush, burn, etc.) in thermal ablation.

P-609
Comparing early results for the treatment of acute and
subacute iliofemoral deep vein thrombosis with rotational
thrombectomy catheter and only medical treatment
O. Rodoplu
Cardiovascular Surgery, Bilecik Government Hospital, Bilecik, Turkey
Purpose: In our study, we aimed to compare early outcomes in
patients who were treated with pharmacomechanical thrombectomy by endovascular intervention due to acute/subacute iliofemoral deep vein thrombosis (Group 1) and who were treated with only
medical treatment (Group 2).
Material and methods: Between September 2014 and May 2015,
20 patients (12 males, 8 females; mean age 54.6 24.5 years; Group
1) treated with pharmacomechanical thrombectomy by endovascular intervention due to acute/subacute iliofemoral deep vein thrombosis were retrospectively reviewed and compared with 20 patients
(11 males, 9 females; mean age 53.4 23.5 years; Group 2) who were
treated with only medical treatment.
Results: At the 12-month follow-up, the average complaint score
was 2.15 out of 10 in Group 1 and 4.35 out of 10 in Group 2. In Group
1, Venous Doppler USG showed near complete patency of iliac and
femoral veins in 90% of the patients. In Group 2, Venous Doppler
USG showed near complete patency of iliac and femoral veins in
40% of the patients. None of the Group 1 patients showed pulmonary thromboembolism. In Group 2, 3 patients showed pulmonary
thromboembolism.
Conclusion: Early use of endovenous pharmacomechanic thrombectomy performed by Reya-Venocat rotational thrombectomy
catheter, a new method of acute and subacute DVT treatment, is a
convenient method according to its efficiency and reliability. During
medium and long terms, the process of endovenous pharmacomechanic thrombectomy can be seen as a promising alternative treatment because it avoids the development of post-thrombotic syndrome and pulmonary thromboembolism and provides a sufficient
venous system.

P-610
A comparison between Denali and Cook IVC filters: should a
difficult filter retrieval alter practice?
A.Baheti1, D.Nicholson1, J.Patrie1, A.Uflacker2, A.W.Park 3,
S.Sabri2, J.R.Stone1, Z.J.Haskal1, J.F.Angle1, L.Wilkins1
1Interventional Radiology, University of Virginia, Charlottesville,
VA, United States of America, 2Radiology, University of Virginia,
Charlottesville, VA, United States of America, 3Radiology, University of
Virginia Hospital, Charlottesville, VA, United States of America
Purpose: IVC filter placement and retrieval has become a routine
and is a mainstay in care of patients with absolute or relative contraindications to anticoagulation. Removal of some traditional filters (Cook Gunther Tulip) may be complicated due to the tilting or

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penetration of a strut. We sought to evaluate whether perceived

ease of retrieval of self-straightening filters (Bard Denali) justifies
changes in clinical practice.
Material and methods: Retrospective chart review of all patients in
a tertiary care center undergoing successful (n=468) or unsuccessful (n=7) IVC filter removal of a Tulip or Denali filter over a 3-year time
period. Study endpoints included removal technique; procedure
cost; and procedure, fluoroscopy, and sedation times.
Results: When comparing the two devices, successful IVC filter
removal did not demonstrate age or gender predilection. Patients
with Tulip filters had a longer mean filter dwell time (p=0.039). Tulip
filters required slightly longer median fluoroscopy times (difference
0.6 min, p<0.001) and lead to a slight increase in the cost to retrieve
(difference $105, p=0.004). Room time and advanced filter removal
techniques did not differ between devices. One patient with Denali
filter had a technically unsuccessful removal compared with six
patients with Tulip filters (p=0.176).
Conclusion: Denali filter removal requires slightly less resources
than Tulip filter removal; however, our cohort had a longer mean
dwell time for successful Tulip filter removal than the cohorts
included in previous studies (5.8 months); this is a known complicating factor during filter removal. This data suggests that given the
prevalence of advanced filter retrieval techniques, the potential for
perceived ease of removal should not determine filter choice.

P-611
Geometric changes of the Crux inferior vena cava filter within
varying caval diameters
R.Sincic, V.Kumar, K.Lobo, J.M.Jefferson, M.B.Conrad, S.Nanavati,
D.McCoy, M.Saeed, S.Hetts, M.Wilson
Radiology and Biomedical Imaging, University of California, San
Francisco, CA, United States of America
Purpose: To determine how the geometric shape of Crux inferior
vena cava (IVC) filters change when deployed within varying IVC
diameters.
Material and methods: An analytical model predicting dependence of Crux IVC filter length on inferior vena cava diameter was
created by assuming the Crux filter takes the shape of two cylindrical
helices fixed at their two ends (caudal and cranial), confined to one
complete turn, with a fixed arc length of 11.5 cm measured as the
undeployed filter in sheath. Two variables account for filter shape
changes (axial length and radial diameter).
Fluoroscopic images were obtained of filters deployed in IVC phantoms made from acrylic tubing with inner diameters between 18 and
28 mm. X-ray alignment marks were machined into the phantoms, to
ensure X-ray beam was orthogonal to deployed filters. Physiologic
conditions were produced by flowing bovine blood heated to 37C
at 0.5 L/min through IVC phantoms during filter deployment.
Results: Filters shortened after deployment with increased IVC
phantom diameters, shortening up to 60% at the maximum IVC
phantom diameter recommended for use by the manufacturer (28
mm). Non-linear regression analysis of Crux filter lengths deployed
in bovine blood flowing within IVC phantoms of different diameters fit the analytical model with a root mean square error (RMSE) =
0.42 compared to the linear regression model that produced RMSE
= 0.52.
Conclusion: Post-deployment filter lengths decreased with increasing IVC phantom diameters, and this dependence is predicted by
our analytical model. Predictions of filter length changes may aid filter selection for certain anatomies such as short narrow IVCs.

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P-612
Caval penetration by retrievable and non-retrievable IVC
filter: a retrospective study conducted in 3 community-based
hospitals of North Chicago
J.D.Vasani, M.Hamblin
Interventional Radiology Department, Presence Saint Francis Hospital,
Evanston, IL, United States of America
Purpose: To evaluate the prevalence and patterns of penetration of
IVC filters (IVCF)
Material and methods: After IRB approval,a retrospective review
of CT scans performed on patients with IVCFs implanted between
January 2012 and January 2015 was performed. SPSS software was
used for statistical analysis.
Results: A total of 316 IVCF were implanted, of which 116 subjects
had follow-up CT imaging. Among these, 69 (57.8%) had non-retrievable (NR) filters [Greenfield titanium (18), Venatech (18), and Trapease
(31)], while 49 (42.2%) had retrievable (R) filters [Optease (7), Bard (1),
Celect (33), and Tulip (8)]. Number of follow-up CTs were variable
(range 1-5, median 1), while mean follow-up duration was 152.82
days (median 52d). Average age of the sample was 71.02 15.39
years, and the sex ratio (M:F) was 65:51.
Thirty-two (27.6%) subjects demonstrated penetration of at least 1
strut outside the IVC wall with a mean (SD) 2.5 1.8 and with mean
(SD) penetration distance of 5.86 1.7 mm. Among patients with
penetration, 78.15% (24/32) had (R) filters, which showed statistical
significance when compared with (NR) filters (p < 0.001). Statistical
significance (p < 0.000) was noted when penetration was compared
to the manufacturer: Celect and Tulip filters showed maximum penetration. Penetration of adjacent organs occurred in 20 (62.5%) subjects (29 IVCF limbs) involving the duodenum, intervertebral disc,
aorta, and psoas muscle. Celect filters showed highest rate of organ
penetration of 75.8%, where 1 patient had a large post-procedure
retroperitoneal hematoma. Only 6 of 49 (12%) retrievable filters were
successfully removed.
Conclusion: Retrievable filters more often penetrates the IVC wall
when compared to non-retrievable filters. IVC wall penetration as a
complication of IVCF is asymptomatic; however, organ penetration
has a controversial outcome. Delayed/non-retrieval of IVCF increases
risks for penetration and other complications.

P-613
Retrievable inferior vena cava filters for pulmonary embolism
prevention: long-term clinical and CT follow-up after retrieval
A.Laborda1, J.A.GuirolaOrtz2, V.MayoralCampos2, C.Lahuerta1,
J.BoschMelguizo3, M.A.deGregorio3
1GITMI, University of Zaragoza, Zaragoza, Spain, 2Radiology, Hospital
Clnico Universitario Lozano Blesa, Zaragoza, Spain, 3Interventional
Radiology, University of Zaragoza, Zaragoza, Spain
Purpose: To study long-term adverse events, complications and
anatomical modifications after the bearing and retrieval of inferior
vena cava filters (IVCF) for pulmonary embolism (PE) prevention.
Material and methods: This retrospective study included 158 IVCF
placed from April 2007 to January 2014 with intention of retrieval.
All patients were telephonically located and scheduled for IR
inquiry. They were asked about symptoms related to recurrent PE,
DVT and postphlebitic syndrome. An abdominal CT was performed
in patients who gave their consent to evaluate IVC alterations. We
recorded any adverse event observed during implantation, dwell
time, recovery, 1-year follow-up and the current inquiry.
Results: Of 158 patients, 4 could not be located, 1 refused inquiry,
and 15 had died (4 pulmonary embolism and 11 non-PE related
cause). Of the 138 patients (76 male, 62 female), 125 of 138 filters were recovered at first attempt. Nine filters were impossible

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to retrieve (tilting and inclusion of the hook in the wall). Main indications for filter placement were DVT and massive/submassive PE
(49.10%), PE and acute bleeding (21.24%) and recurrent PE (16.9%).
Two types of filters were used: Gunther Tulip (63.40%) and Celect
(36.60%). Most minor complications appeared in the pre-retrieval
CT (11 tilting; 14 apparent penetration > 3 mm, 3 intrafilter thrombus). Mean dwell time was 98.32 days (range 30-2160). Mean followup was 51.37 (range 35-79).
Conclusion: The deployment and recovery of GT and Celect filters
for prophylaxis of PE is a safe procedure. Recovery is simple and
achieved in most cases. A well-indicated retrieval does not increase
the number of cases with DVT or PE.

P-614
The role that an IR department plays in association with PE
mortality
J.A.GuirolaOrtz1, A.Laborda2, V.MayoralCampos1, C.Lahuerta2,
W.T.Kuo3, M.A.deGregorio4
1Radiology, Hospital Clnico Universitario Lozano Blesa, Zaragoza,
Spain, 2GITMI, University of Zaragoza, Zaragoza, Spain, 3Vascular and
Interventional Radiology, Stanford University, Stanford, CA, United
States of America, 4Interventional Radiology, University of Zaragoza,
Zaragoza, Spain
Purpose: To determine the role that an interventional radiology (IR)
department plays in the diagnosis and treatment of acute pulmonary embolism (PE) and its correlation to mortality in a 5-year retrospective study in a single specialised centre.
Material and methods: From 2010 to 2014, 722 patients were diagnosed with PE. All relevant patient data were gathered using electronic medical records, analysing the medical history, PE diagnostic
method and treatment, dividing the patients in two groups, patients
who underwent angiographic diagnosis and treatment (direct
and mechanical thrombolysis, with/without IVCF placement) and
patients treated with only anticoagulant therapy. All the data were
statistically compared between alive and deceased patients, as a
case-control study, calculating the risk and protective factors.
Results: Of the 722, 610 were alive and 112 dead. Mean hospital stay
before death was 9.1310.39 days. Neoplastic history was the main
risk factor for mortality (OR 1.9; 99% CI 1.07-3.49). A history of DVT
(OR 0.31; 99% IC, 0.13-0.76) or a previous PE (OR 0.005; 99% IC, 0.0010.02) were protecting factors, probably due to a quicker diagnosis.
Referral to the IR department for angiography and treatment prevented mortality in PE (OR 0.29; 99% CI 0.09-0.88), meaning a higher
possibility of survival (1.2-10.6% higher) for patients that underwent
IR treatment. Filter placement did not have influence on the final
outcome.
Conclusion: IR plays an important role in the diagnosis and treatment of PE patients, reducing about 72% of mortality risk in patients
who were referred to the IR unit compared to those who stayed in
the ICU.

P-615
Device-specific complication rates in retrievable inferior vena
cava filters: a systematic review and meta-analysis
M.F.Errea1, R.J.Lewandowski1, J.Karp1, R.Ryu2, K.R.Desai1
1Radiology, Northwestern University, Chicago, IL, United States of
America, 2Radiology, University of Colorado, Aurora, CO, United States
of America
Purpose: Despite the rapid growth in placement of retrievable inferior vena cava filters (rIVCF), accurate estimates of complication rates
of these devices are lacking. Utilizing extracted data, we aimed to
estimate device-specific complication rates and, in this respect,
identify differences between commonly encountered rIVCF.

Abstract Book

Material and methods: The MEDLINE, CENTRAL, and ClinicalTrials.

gov databases were searched for publications and unpublished trials describing complications in rIVCF that included clinical and imaging follow-up. Data regarding filter fracture, migration, filter thrombosis, and lower extremity deep venous thrombosis (DVT) were
pooled using a random-effects model. Serial pairwise comparisons
were performed and corrected using the Holm-Bonferroni method.
Statistical significance was accepted at p<0.05.
Results: Fifty-seven studies examining 7199 filters (9 devices: Crux,
Option, OptEase, Gunther Tulip, Celect, ALN, Denali, Recovery, and
G2) were analyzed. Recovery filters fractured most frequently (7.8%,
95% CI 4.7-12.6; p<0.01); Celect filters penetrated the caval wall most
frequently (37.3%, 95% CI 17.6-62.3; p<0.01); G2 filters migrated most
frequently (13.3%, 95% CI 6.1-26.6; p<0.05); and Option and Denali
filters were associated with recurrent DVT more frequently (12.1%,
95% CI 5.2-25.8; p<0.05 and 13%, 95% CI 8.3-18.7; p<0.05) than other
devices. No difference in DVT was observed between Option and
Denali devices (p=1). The rates of filter thrombus precluding retrieval
were not significantly different among the devices.
Conclusion: There are significant differences in the types of complications encountered most frequently with specific rIVCFs.
Establishment of device-specific complication profiles fosters an
individualized approach to device utilization and retrieval planning;
such information is crucial in preventing adverse events and improving patient outcomes.

P-616
Endovascular treatment of iliofemoral deep vein thrombosis
in pregnancy by using ultrasound-guided percutaneous
aspiration thrombectomy
M.Gedikoglu1, L.Oguzkurt2
1Radiology, Baskent University School of Medicine, Adana, Turkey,
2Radiology, Koc University, Istanbul, Turkey
Purpose: The purpose of this article was to describe percutaneous
aspiration thrombectomy under ultrasound guidance in pregnant
patients with iliofemoral deep vein thrombosis.
Material and methods: Nine consecutive pregnant patients with
acute and subacute iliofemoral deep vein thrombosis underwent
percutaneous aspiration thrombectomy under ultrasound guidance. Aspiration thrombectomy by using large-bore guiding catheters was performed to achieve thrombus removal and uninterrupted
venous flow on color Doppler ultrasonography. Balloon venoplasty
or Fogarty balloon embolectomy was used, if needed. The treatment was considered successful if there was adequate venous
patency and symptomatic relief.
Results: Complete or significant thrombus removal and uninterrupted venous flow were achieved in all patients at the first intervention. Two patients (22.2%) had a recurrence of thrombosis in the
first post-intervention week; one of them required a second intervention, and the other patient who had high levels of inflammatory markers was not subjected to further intervention. Two patients
who had resistance to the advancement of the guiding catheter
were treated with balloon venoplasty. The Fogarty balloon embolectomy catheter was used in one patient to remove ball-like subacute thrombus. Complete leg pain relief was rapidly achieved in 8
patients (88.8%), but minimal swelling remained around the ankle.
No procedure-related complications or clinically detectable pulmonary embolism were observed during or after the intervention.
Conclusion: Endovascular treatment with ultrasound-guided percutaneous aspiration thrombectomy can be routinely used as a safe
and effective way to remove thrombus from deep veins in pregnant
women with acute and subacute iliofemoral deep vein thrombosis.

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P-617
Cardiac arrhythmias in children with peripherally inserted
central catheters (PICCs)
B.L.Connolly1, S.Dhillon2, O.Shearkhani3, R.Hamilton4
1Image Guided Therapy, The Hospital for Sick Children, Toronto, ON,
Canada, 2Dept of Cardiology, IWK Health Centre, Dalhousie University,
Halifax, NS, Canada, 3Faculty of Medicine, University of Toronto,
Toronto, ON, Canada, 4Department of Cardiology, The Hospital for Sick
Children, Toronto, ON, Canada
Purpose: To analyze the prevalence, types, timing, and management of cardiac arrhythmias associated with PICCs in children.
Material and methods: A retrospective review of 3180 PICCs
placed in children (neonate to 18 years) between January 2009 and
June 2013 to identify arrhythmias that occurred during or postPICC insertion. Data sources included radiology reports, M&M
reviews, Vascular and ECG databases, cardiology consults, and medical records. Case:control (1:1) comparison of patient with/without
arrhythmias was performed to identify risk factors.
Results: In 4.5 years, 38 patients (21 men, 17 women) developed
arrhythmias associated with PICCs, 7 during and 31 post-procedure.
Procedural arrhythmias included self-resolving sinus tachycardia
(n=2) and SVT (n=5) that responded to ice (n=3), adenosine (n=2), or
both (n=1). Potential risk factors included electrolyte abnormalities
(n=1), dilated cardiomyopathy (n=1), and prior arrhythmia (n=1).
Post-procedural arrhythmias occurred in 31 patients (1%) between
1 week and 3 months after insertion (mean 9 days); 74% were
atrial arrhythmias, and 26% were ventricular. Potential risk factors
included underlying cardiac disease (17/31) and prior arrhythmias
(12/31). No significant difference was found in demographic/clinical factors between cases and controls, e.g., age, weight, dwell time,
diagnosis, prior inotropes/arrhythmias. Central tip of PICCs was significantly deeper among cases than among controls (rib 6.3 v. 5.34,
p=0.004; number of vertebrae below carina 2.04 v. 1.38, p=0.008).
Management included anti-arrhythmic agents (17/31), PICC manipulation (13/31), and others (ablation, cardioversion, pacing) (6/31).
PICC adjustment was effective in 5/13, but arrhythmia recurred in
8/13. Long-term anti-arrhythmic drugs were required in 9.
Conclusion: PICC-related arrhythmias are uncommon. The tip
position tended to be lower in cases than in controls. Multiple
approaches to management are needed.

P-618
Adrenal vein sampling with and without cone beam CT
acquisitions: outcome in a low-volume center
K.I.Ringe1, F.Wacker1, C.Terkamp2, B.C.Meyer1
1Department of Diagnostic and Interventional Radiology,
Hannover Medical School, Hannover, Germany, 2Department of
Gastroenterology, Hepatology and Endocrinology, Hannover Medical
School, Hannover, Germany
Purpose: To evaluate and compare the outcome of adrenal vein
sampling (AVS) with and without additional cone beam CT (CBCT)
acquisitions.
Material and methods: Fifty patients (19 females, 31 males; median
age 52 years) referred for AVS were included in this retrospective
IRB-approved study. Diagnostic tools included fluoroscopy, CBCT,
and online cortisol measurements. Patients were divided into group
1 before (n=15) and group 2 after (n=35) CBCT became available in
our department. In group 2, CBCT acquisitions were performed at
the discretion of the performing radiologist (subgroup 2a; n=21);
in the remaining 14 patients, no CBCT was acquired (subgroup 2b).
Fluoroscopy time, dose-area product (DAP), and technical success
rates were calculated and compared separately for the right and left

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S339

adrenal vein (Mann-Whitney test, Fisher exact test). Selectivity, lateralization, and contralateral suppression indexes were calculated
based on the blood samples.
Results: Overall fluoroscopy time (mean, group 1 and 2: 44:55 and
27:33min) and DAP (mean, group 1 and 2: 8316 and 5203 Gycm2)
were significantly lower after CBCT availability (p=0.0004 and
p=0.0177); success rates for the right and left renal vein were similar (right 60% and 66%; left 87% and 77%). At subgroup analysis (2a
vs. 2b), implementation of CBCT increased technical success rates for
the right and left adrenal vein (right 76% vs. 50%; left 81% vs. 71%;
p>0.05). However, CBCT acquisitions resulted in a marked increase of
the DAP (mean 7358 Gycm2).
Conclusion: CBCT is a useful additional tool in the radiologists
armamentarium for AVS, but scans should be acquired cautiously at
the radiologists discretion and only if needed.

P-619
Thrombolysis and endovascular treatment of acute iliofemoral
DVT: a 5-year single-center retrospective experience
S. Habib
Radiology Department, Nottingham University Hospitals-QMC,
Nottingham, United Kingdom
Purpose: To review our learning-curve progression in the treatment
of IFDVT and suggest guidelines for future management.
Material and methods: A retrospective review of 69 patients who
presented with acute IFDVT (34 males) with a mean age of 62 years
(2286) since 2010. In total, 55 patients (79%) were identified to have
MayThurner syndrome. Forty patients were treated with combined
AngioJet pharmacomechanical thrombectomy (PMT) and catheter-directed thrombolysis (CDT), while 16 and 13 patients underwent only PMT and CDT, respectively. Three patients had phlegmasia cerula dolens; two failed to respond to treatment and died from
multi-organ failure.
Results: Primary success rate in clearing IFDVT was 89%. Of those
treated with PMT+CDT, only 4 (10%) failed to show thrombus clearance compared to 6% and 7% of those treated with only PMT and
CDT, respectively. Persistent common femoral vein DVT had a detrimental effects on short- and long-term patencies. There was a steep
evolution in choosing the type of stents, starting from self-expanding nitinol stents to Wall stents and recently Veniti stents. In total, 34
patients with left and two with right IFDVT were stented. Stent radial
force had an impact on venous patency. There were no immediate
complications. We are currently collecting the long-term patency
data to be presented at the time of the conference.
Conclusion: There is a continuous learning curve in treating IFDVT.
PMT is a safe endovascular treatment with a primary success rate
of around 90%. Recent advances in stent design and mechanical
thrombectomy technology are promising for the successful management of DVT in future.

P-620
Carbon dioxide cavography for IVC filter retrieval: a safety and
efficacy study
S.A.Gupta1, K.R.Desai1, S.Desai1, R.Ryu2, R.J.Lewandowski1
1Radiology, Northwestern University, Chicago, IL, United States of
America, 2Radiology, University of Colorado, Aurora, CO, United States
of America
Purpose: Iodinated contrast venography is performed prior to inferior vena cava filter (IVCF) retrieval. It is associated with nephrotoxicity allergic reactions. This study evaluated the efficacy/safety of
carbon dioxide (CO2) venography for IVCF retrieval.

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Material and methods: We included consecutive patients (2008

2014) who underwent CO2 venography for IVCF retrieval. We
recorded demographics, indication for IVCF retrieval/CO2 usage,
venography findings, pre-/post-retrieval creatinine levels, and complications. We compared creatinine levels using two-tailed t-test;
p<0.05 was considered statistically significant.
Results: In total, 82 IVCF retrieval attempts were made: 77 when
filtration was no longer indicated, 2 in exchange for new IVCF, 2
for previously unsuccessful attempts, and 1 for IVCF complication. Median device dwell time was 47 days (range 9254). CO2was
employed for renal insufficiency (n=58) and contrast allergy (n=24).
Venography detected filter thrombus in 9.8% of the cases (n=8).
Three filters with large (>30% filter volume) thrombus were left in
place for continued anticoagulation, 2 were later retrieved, and
1 was lost to follow-up. Five filters with small (<30% filter volume)
thrombus were removed. Of 74 filters with no thrombus, 73 were
removed; 1 failed retrieval and was lost to follow-up. Filter retrieval
success rate was 95% (n=78). No complications occurred. Pre-/postprocedural Cr was not significantly different in 66 patients, in whom
both values were known (1.59 pre, 1.65 post, p=0.82).
Conclusion: CO2is a safe/effective venography agent prior to IVCF
retrieval. Our series demonstrates a similar rate of thrombus detection with CO2relative to previously published series with iodinated
contrast without risks of allergic reaction or nephrotoxicity.

P-621
A multicenter evaluation of the Celect Platinum IVC filter
R.G.McWilliams1, I.Wilson2, R.Allison2, T.Chan1,
R.Lakshminarayan3, J.A.McCann-Brown4, G.J.Robinson3
1Interventional Radiology, Royal Liverpool University Hospital,
Liverpool, United Kingdom, 2Department of Radiology, University
Hospital Southampton NHS Trust, Southampton, United Kingdom,
3Radiology Department, Hull Royal Infirmary, Hull, United Kingdom,
4Incorporated, Cook Research, West Lafayette, IN, United States of
America
WITHDRAWN

P-622
Perforations associated with peripherally inserted central
catheters (PICCs) in neonates
B.L.Connolly1, A.Sertic2, K.-S.Lee3
1Image Guided Therapy, The Hospital for Sick Children, Toronto, ON,
Canada, 2Faculty of Medicine, University College Dublin, Dublin,
Ireland, 3Neonatology, The Hospital for Sick Children, Toronto, ON,
Canada

Abstract Book
Cases trended towards the younger age and lower birth weight and
weight at insertion than controls. No significant differences were
observed in size and number of lumens between cases and controls.
Average PICC level was higher (at T2.4) among pleural effusions and
lower among pericardial effusions (at T5.9) than among controls (at
T5). One or more high-risk drugs were infused in 6/14 (43%) of cases
compared to 10/28 (36%) controls. Infusion volumes were similar.
Conclusion: PICC perforations are rare in neonates. Risk factors may
include younger age, lower birth weight, polyurethane catheters,
and high-risk infusates.

P-623
Sclerotherapy and vein gluing combined as a single procedure
for saphenous veins
J.C. Ragg
Interventional Radiology, Angioclinic Vein Centers, Berlin, Germany
Purpose: Current vein gluing methods (VenaSeal, VariClose) use
larger amounts of aggressive and hardly resorbable cyanoacrylate;
the effects depend on manual compression. These drawbacks could
be overcome by a modality that combines pointwise gluing and
catheter sclerotherapy (ScleroGlue project).
Material and methods: In total, 18 patients (11 females, 7 males,
4269 years) with GSV insufficiency and 824 mm (mean: 9.4
mm) underwent combined sclerotherapy (aethoxysklerol 1%, 1+4
with air) and gluing using a double catheter access, including the
VariClose gluing system (Biolas Inc.). Auxiliary-associated targets
(refluxive side branches > 6 mm , n = 22, and perforator veins > 6
mm , n = 12) were included. First, sclerofoam was applied via catheter A (2.3 mm); then, cyanoacrylate glue was injected during the
spasm phase of the target vein, while withdrawing this second catheter B (1.6 mm). No manual compression was applied. There were
no external compression media (stockings, bandages) allowed after
treatment.
Results: All cases (18/18) showed immediate saphenous occlusion
and elimination of reflux. All auxiliary targets (34/34) were successfully reached by microfoam and occluded. The amount of glue used
for saphenous veins was 1033 mg (mean: 19.7 mg)/cm vein. The
procedural time from the first puncture to patient mobilization was
1223 min. (mean: 16.5).
Conclusion: The ScleroGlue method seems to provide reliable
denaturation and effective GSV gluing, achieved without any external compression and with low quantities of glue. The procedure is
very fast and requires no anesthesia, except at the puncture site.
Further studies will involve non-acrylate glues.

P-624

Purpose: To identify possible clinical associations and risk factors

for neonatal vascular perforations associated with PICCs, a potential
life-threatening complication.
Material and methods: A retrospective single-center case series
of PICCs placed between 2004 and 2014 in a quaternary hospitals
NICU. Study design: case:control, 1:2 ratio, matched by date and gestational age. PICCs were placed by NICU and IR. Demographics, catheter details, infusion details (medications & volumes), and management were analyzed.
Results: Of 3454 PICCs, 14 cases of perforation were identified (0.4%
incidence), which occurred on a mean 5.5 days (range 1-40 days)
post-insertion. Perforations caused pleural effusions (n=5), pericardial effusions (n=5), pleural & pericardial effusions (n=2), or chest
wall edema (n=2). Cases were managed by catheter removal (n=12)
or PICC pull-back (n=2). Majority of PICCs were polyurethane [13/14
(93%) cases v. 20/28 (71%) controls], and the remainder were silicone.
None died from their perforation. Incidence did not differ between
PICCs placed by NICU or IR.

Outcome and histological analysis of explanted inferior vena

cava filters
T.Annweiler1, L.Bertoletti2, F.G.Barral3
1Radiology, Saint-Etienne University Hospital, Saint Priest En Jarez,
France, 2Thrombosis Research Group, Saint-Etienne University Hospital,
Saint Priest En Jarez, France, 3Interventional Radiology, CHU SaintEtienne Hospital Nord, Saint-Etienne, France
Purpose: Our study aimed to determine i) whether the presence of
thrombi within the optional cellar filters (CF) was associated with the
occurence of thromboembolic events within 3 months after removal
and ii) whether a high tilt was associated with the presence of vascular wall fragments, the occurence of thromboembolic events after
removal, and an extended fluoroscopy time.
Material and methods: Retrospective single-center study on CFs
removed with histological examination during 20102014 at the
Saint-Etienne University Hospital, France. The presence of thrombi
and vascular wall fragments within the CF upon withdrawal,

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CIRSE 2016

epidemiological data, treatment, and the onset of thromboembolic

events were sought by reviewing the patient records and by consulting their family physicians.
Results: Eighty-five participants were included. In total, 69 exhibited
a thrombus within CF and 75 had vascular wall fragments. The mean
tilt was 10.24.7, and the mean fluoroscopy time was 704971 s.
Four patients experienced a thromboembolic event within 3 months
after CF removal. No association was found between the presence
of a thrombus within CF and the onset of thromboembolic events.
The tilt was associated with the presence of vascular wall fragments
(OR=6.0, p=0.016) but neither with the onset of thromboembolic
events (OR=1.2, p=0.867) nor with the fluoroscopy time (=50.3,
p=0.850). No deaths from hemorrhage were observed.
Conclusion: The onset of thromboembolic events within 3 months
after CF removal was associated neither with the presence of thrombus nor with the tilt. An increased tilt was associated with a greater
risk of vascular wall fragments, which justifies a careful radiological
technique in order to prevent high tilts.

P-625
Establishing standard venous anatomy references for Angel
Catheter insertion to guide the final position of the catheter
filter
M.R.Akhtar1, J.KyawTun2, J.Saeed2, J.-Y.Chun3, O.S.Jaffer2,
N.Bunker3, T.Fotheringham2
1Interventional Radiology, Barts Health NHS Trust, London, United
Kingdom, 2Department of Interventional Radiology, The Royal
London Hospital, Barts Health NHS Trust, London, United Kingdom,
3Department of Radiology, Royal London Hospital, London, United
Kingdom
Purpose: To establish standard venous anatomy references for
Angel Catheter (AC) insertion.
Material and methods: A retrospective review of all AC insertions
from 2013 to 2015 was conducted at a Level 1 UK-based trauma
centre.
ACs are inserted without image guidance and their filter position is
assessed through post-procedure radiographs. Filter position with
respect to the renal veins (RV) was reviewed on the subsequent CT/
pelvic venogram.
The following measurements were obtained from admission trauma
CT scans using curved multiplanar reconstruction:
-Right/Left RV to mid-inguinal ligament
-Mid-sternoclavicular joint to pubic symphysis
Results: In total, 35 ACs were placed in polytrauma patients (26
male, mean age of 37 2.9 years) over 2 years. Seven patients did not
have trauma CT and thus were excluded from the study.
Of the remaining 28 patients, filters in 8 patients were suboptimally
placed on post-procedure radiographs: 1 filter was at the common
iliac vein confluence (subsequently repositioned) and 7 filters were
placed over the origin of the renal veins without complicating renal
vein thrombosis. The length from the right RV to the mid-inguinal
ligament was 23.330.7 cm (mean 25.9 2.0 cm). The length from
the left RV to the mid-inguinal ligament was 23.332.5 cm (mean
27.5 2.1 cm). The length from the mid-sternoclavicular joint to the
pubic symphysis (torso length) was 49.759.3 cm (mean 54.5 3.1
cm).
Thus, ACs should be inserted to a length of 25.9 2 cm using a right
femoral approach or 27.5 2.1 cm using a left femoral approach in
an average patient with a torso length of 54.5 3.1 cm.
Conclusion: Angel Catheters are inserted blind with demonstrable risk of malposition and risk of renal vein thrombosis. Therefore,
standard anatomy reference values are important in guiding length
of catheter insertion.

SS/FC/HL/HTS/CM
Posters

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P-626
Two-year outcome after MOCA
C. Teichert
Interventional Radiology, University Medicine of Rostock, Rostock,
Germany
Purpose: Comparison of the efficacy, safety, and primary and secondary technical successes of the endovenous non-thermal, tumescensless mechanochemical ablation of varicose veins with the subjective outcomes using different scoring systems.
Material and methods: MOCA is a tumescentless method combining mechanical intima injury with chemical irritation due to a liquid
sclerosant. In 2014, 67 endovenous ablations of the GSV (66 pts) and
the SSV (1 pt) were performed. In the follow-up (before and after 1
day, 6 weeks, 6 months, 12 months, and 24 months), patient satisfaction and improvement in the quality of life were determined using
TLQ-CVI. PDI was also used. Clinical examination was based on CEAP
and rVCSS supported by duplex ultrasound.
Results: In total, 40 patients were treated and completed the follow-up. The primary technical success was 95%. Two patients with
primary treatment failure were treated through a second intervention. After 1 and 2 years, 90% of the treated veins completely disappeared. Secondary varicosis occurred in 2 elder patients with an
open proximal segment. No severe adverse events and no severe
complications were observed. Mild side effects like slight local pain,
skin changes, local thrombophlebitis (8/40, 20%), and hematoma
(7/40, 18%) without need for further systemic or local treatment
appeared. Clinical improvement was proven in 100% of the treated
pts, independent of the technical success; the improvement was
observed in all used clinical and subjective scoring systems.
Conclusion: MOCA is a safe treatment for GSV and SSV insufficiency
with a high technical success, no severe adverse events, and only
minor side effects; it improves the quality of life.

P-627
Peripherally inserted central catheter in paediatric population
A.Fohlen1, F.Villedieu2, J.J.Parienti3, J.-P.Pelage1
1Department of Radiology, University Hospital and Medical Center,
Caen, France, 2Department of PICU, University Hospital and Medical
Center, Caen, France, 3Department of Statistic and Research, University
Hospital and Medical Center, Caen, France
Purpose: To assess feasibility, safety and morbidity of PICC placement in a global paediatric population.
Material and methods: A retrospective study of all consecutive
paediatric PICCs placed in our centre during a 48-month period. Risk
factors for complications were analysed.
Results: A total of 92 PICCs were inserted in 76 patients (39 girls
(51%)). Technical success was 98%. Mean patient age was 9.17 6.16
years (range, 0-18). Medical units represented 62%, surgical units
22% and intensive care units 16%. PICC were placed for digestive diseases in 24%, pulmonary infections in 21%, orthopaedic diseases in
17%, meningo-encephalitis in 14% and in oncology in 12% of cases.
Antibiotics (47%) and nutrition (41%) were the most frequent medications injected. Vein diameter was 3.32 1.18 mm (range, 0.67.8). Completion of therapy was achieved in 78% of PICCs. Thirtytwo children (35%) were treated at home. Average catheter life was
22.86 24.48 days (range, 0-192). Nine (9%) were removed for complications. Suspicion of sepsis (7%) and accidental displacement (3%)
were the most common reasons for catheter removal. Overall complication rate was 9.03 for 1000 catheter-days, with an infection rate
of 1.9 for 1000 catheter-days. No predictive factor for complications
was found. No correlation was found between the rate of complications and the following parameters: procedure duration, diameter of
the punctured vein, catheter length, duration of insertion, age and
BMI.

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Conclusion: PICC is safe for prolonged intravenous therapy in neonates and children. The incidence of complications is low 8.56 for
1000 catheter-days. No predictive factor for complication was found.

P-628
Magnetic resonance venogram (MRV) using the blood-pool
contrast agent gadofosveset trisodium versus gadolinium:
comparison of image quality and vessel identification and
application to venous interventions

Abstract Book
Conclusion: In this educational poster, various important things
related to IPSS, ASVS, and AVS will be provided. Also, representative cases from authors institution will be provided. Readers could
deepen their understanding about venous sampling. The teaching
points of this educational exhibit are as follows: 1) to understand the
anatomic and physiologic knowledge involved in IPSS, ASVS, and
AVS; 2) to review technical tips that can help interventionist to do
successful procedure with accurate results; and 3) to know how to
interpret the result of each procedure.

H.Ferral, S.Regalado, M.Alonzo

Radiology, NorthShore University HealthSystem, Evanston, IL, United
States of America

P-630

Purpose: Awareness of chronic disabling venous disorders has

increased. The need for optimal, non-invasive methods for the precise diagnosis of chronic venous conditions has become essential to
plan intervention. The purpose of this study is to compare the imaging and diagnostic quality of MRV studies done with gadolinium versus gadofosveset.
Material and methods: This is an IRB-approved retrospective study.
All MRVs performed at our institution between July 1, 2009 and
August 30, 2015 were reviewed. A total of 25 MRVs were performed:
14 were performed using gadofosveset and 11 gadolinium. MRV
images were reviewed in a blinded fashion by two radiologists with
experience in MRV. The quality of the images was classified as optimal, adequate, and suboptimal. The interpretation of the MRV was
classified as diagnostic or non-diagnostic. Results were analyzed
with the chi-square method.
Results: There was a high degree of agreement in the interpretation of the MRVs by both evaluators. There was discrepancy in 1/25
studies reviewed (4%). All MRVs were considered to be diagnostic by
reader # 1 regardless of the contrast material used. Reader # 2 considered one of the studies suboptimal for diagnosis, and this was an
MRV performed with gadolinium. According to our results, image
quality was not different between gadolinium and gadofosveset.
Conclusion: Our study showed that MRV is useful in the diagnosis
of chronic venous disorders. No differences in the quality of images
and diagnostic information were identified between MRVs performed using gadolinium and gadofosveset.

G.Morano1, M.Pasyk1, J.Tisnado2, J.Tisnado1

1Radiology, Virginia Commonwealth University, Richmond, VA, United
States of America, 2Radiology, Memorial Sloan Kettering Cancer Center,
New York, NY, United States of America

P-629

Inadvertent puncture of central arteries during central venous

catheterization: the spectrum of iatrogenic complications

Revisited diagnostic interventional endocrinology: IPSS, AVS,

and ASVS

G.Morano, M.Pasyk, J.Tisnado

Radiology, Virginia Commonwealth University, Richmond, VA, United
States of America

The role of interventional radiology in venous blood sampling

revisited

N.Y.Yim, Y.J.Kang, H.O.Kim, B.C.Lee, H.D.Jung, J.K.Kim

Diagnostic Radiology, Chonnam National University Hospital,
Gwangju, Korea
Learning Objectives: The objective of this exhibit is to present
basic knowledge and practical tips about inferior petrosal sinus
sampling (IPSS), arterial stimulation venous sampling (ASVS), and
adrenal venous sampling (AVS).
Background: Diagnostic interventional procedures, including IPSS,
ASVS, and AVS, has played a pivotal role in widening understanding about endocrinologic diseases, in terms of functional and anatomical aspects. However, poor angiographic understanding about
vasculature around deep-seated endocrine organs, lack of knowledge for result interpretation, and lack of skill for venous sampling
lead to these procedures being overlooked, even by interventional
radiologist.
Clinical Findings/Procedure:
1) Physiologic and anatomic background for IPSS, ASVS, and AVS.
2) Technical tips and angiographic findings for accurate sampling
and better procedure.
3) Interpretation of results, clinical application, and representative
case presentation.

Learning Objectives: The value of venous blood sampling in nondiagnostic imaging.

Background: Venous blood sampling (VBS) was a routine procedure to localize endocrine tumors before noninvasive imaging.
Lately, the need of VBS decreased. With newer CT scanners, small
tumors (<5 mm) are found, and young IRs do not learn VBS procedures. Some physicians are unaware of these obsolete but important IR procedures.
Clinical Findings/Procedure: The VBS procedures reviewed are as
follows: inferior petrosal sinus VBS and sinography, cavernous sinus
VBS and sinography, VBS and venography of neck, chest and mediastinal veins, percutaneous catheterization of the portal vein for
VBS, adrenal gland VBS and venography, right hepatic vein VBS during arterial stimulation with Ca2+, gonadal VBS and venography, and
renal vein and IVC VBS.
Conclusion: VBS accurately localizes endocrine tumors in patients
with clinical and laboratory evidence of endocrine tumor(s) where
imaging is nondiagnostic. VBS is simple, safe, and easy and should
be reviewed during the training of young IRs.

P-631

Learning Objectives: Management of iatrogenic puncture of arteries during central venous catheterizations.
Background: Central venous catheter placement (CVCP) is a routine procedure in this era of aggressive medical care, and its indications are well accepted in most institutions. In many instances, CVCP
is delegated to the least experienced operators such as nurses, medical students, interns, and residents. We have accumulated a vast
experience in the diagnosis and management of inadvertent catheterization of arteries. We manage the varied spectrum of mishaps
with placement of stents of different types and configurations and/
or embolization, or both, using non-invasive imaging modalities.
Here we provide advice as to avoid these uncommon mishaps, most
of them serious enough to result in catastrophic consequences.
Clinical Findings/Procedure: We have accumulated a spectrum
of placements and misplacements occurring during CVCP in which
the arteries carotid, subclavian, innominate, brachial and others
rather than the veins, were entered.
We have managed most of these unfortunate situations with endovascular procedures: stenting and/or embolization or both of punctures and/or tracts. Most catheters in the wrong locations (arterial

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CIRSE 2016

rather than venous) can be removed and managed by IR. No associated complications have occurred during the IR management of
these potentially serious misadventures.
Conclusion: Inadvertent placement of catheters in arteries rather
than in veins are uncommon complications of CVCP but seen with
increased frequency in this era of aggressive medical care and lack
of expertise of the operators. Therefore, the IR must be ready to
manage these complications using different tricks of the trade:
usually stenting and/or embolization or both.

P-632
Understanding the radiology and biochemistry of adrenal
venous sampling
R. Chung
Department of Diagnostic Radiology, Khoo Teck Puat Hospital,
Singapore, Singapore
Learning Objectives: With sample clinical vignettes, the reader will:
1. Understand the role of diagnostic and interventional radiology in
PA.
2. Appreciate techniques for successful adrenal venous sampling
(AVS).
3. Avoid pitfalls during sampling.
4. Interpret the biochemical results and apply this to planned clinical
management.
Background: Primary hyperaldosteronism (PA) is the most frequent
secondary form of hypertension, and it carries a significant risk of
damage to cardiorenal systems. Radiology plays a pivotal role in the
identification and management stratification of this patient cohort.
Clinical Findings/Procedure: Adrenal venous sampling (AVS)
technique:
Under continuous synthetic ACTH infusion, samples are acquired
sequentially from the adrenal veins and IVC. The left adrenal vein,
forming a common trunk with the inferior phrenic vein, is relatively easy to find given its insertion into the ipsilateral renal vein.
The short and small right adrenal vein, with its variable insertion site
into the IVC, often makes it a technically difficult cannulation target
and, as a result, has a lower reported technical success rate. Gentle
venography may demonstrate 1 of the 5 characteristic appearances
as described by Daunt. Differentiation from hepatic radicle cannulation with dense tissue staining is also illustrated.
Biochemical interpretation:
The selectivity index is used to confirm biochemical success of AVS
cannulation. The lateralization index then differentiates between
bilateral and unilateral aldosterone secretion, dictating subsequent
medical versus surgical management.
Conclusion: Diagnostic and interventional radiology plays a critical
role in PA. Result interpretation beyond radiology affords a better
appreciation of the expected patient management pathway.

P-633
Superior vena cava syndrome: from the diagnosis to the
treatment algorithm
P.Torcia1, U.G.Rossi1, P.Rigamonti1, G.Mauri2, A.M.Ierardi3,
G.Carrafiello4, M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Radiology, IRCCS Policlinico San Donato, San Donato
Milanese, Italy, 3Radiology, Uninsubria, Ospedale di Circolo, Varese,
Italy, 4Department of Radiology, University of Insubria, Varese, Italy
Learning Objectives: To describe clinical and radiological classification in patients with superior vena cava (SVC) syndrome with the
aim to determine a correct treatment algorithm.
Background: SVC syndrome is caused by impaired venous return
due to compression/obstruction of the SVC. Clinical signs and

SS/FC/HL/HTS/CM
Posters

S343

symptoms may include orthopnoea, oedema of the upper body,

respiratory distress, convulsions and coma. Which patients require
urgent intervention and which patients require little specific treatment for SVC syndrome can be not well defined. Definition of the
management is very important for the spectrum of possible interventions: from radiotherapy and chemotherapy to thrombolytic and
SVC stenting.
Clinical Findings/Procedure: The purpose of this poster is to illustrate SVC syndrome: (i) physiopathology, (ii) clinical and radiological
classification and (iii) treatment algorithm.
Conclusion: A correct clinical and radiological grading of patients
with SVC syndrome could provide a correct assessment of these
patients. These patients can benefit from the spectrum of interventional radiology procedures.

P-634
Interventional radiology in central venous stenosis in dialysis
patients: why, when and how
P.Torcia1, P.Rigamonti1, U.G.Rossi1, M.Gallieni2, G.Mauri3,
A.M.Ierardi4, G.Carrafiello5, M.Cariati1
1Radiology and Interventional Radiology, San Carlo Borromeo Hospital,
Milan, Italy, 2Nephrology, San Carlo Borromeo Hospital, Milan, Italy,
3Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy,
4Radiology, Uninsubria, Ospedale di Circolo, Varese, Italy, 5Department
of Radiology, University of Insubria, Varese, Italy
Learning Objectives: To describe radiological classification and
indications of angioplasty and stenting in haemodialysis patients
with central venous stenosis or thrombosis.
Background: Haemodialysis patients are at particular risk for the
development of central venous stenosis or thrombosis. Central
venous stenosis or occlusion is associated with functional impairment of haemodialysis. In these cases, angioplasty or stenting (in
stenosis or occlusion refractory to angioplasty) is the first-line treatment, but restenosis or early stent failure may occur.
Clinical Findings/Procedure: The aim of this poster is to illustrate
central venous stenosis/occlusion: a) physiopathology, b) classifications, c) diagnostic imaging and d) possible interventional radiology
therapies.
Conclusion: Clinical and imaging grading of haemodialysis patients
with central venous disease provides a correct assessment of these
patients. These patients can benefit from the spectrum of interventional radiology procedures.

P-635
Managing the dysfunctional central venous catheter
V.Rachapalli1, N.Kundaragi1, D.Thiruchunapalli2, S.Inuganti2,
S.Chappiidi3, M.Uthappa1
1Interventional Radiology, BGS Global Hospital, Bangalore,
India, 2Interventional Radiology, Global Hospital, Chennai, India,
3Interventional Radiology, Global Hospital, Hyderabad, India
Learning Objectives: Upon review of this poster the reader 1. Should be able to identify the various causes of a dysfunctional
central venous catheter
2. Should know the various interventional radiology techniques that
can be used to salvage dysfunctional catheters
Background: Venous catheters are increasingly used in clinical
practice. Their use ranges from administration of medications to
monitoring in critically ill patients. However, they are prone to dysfunction. Not all catheters can be removed or exchanged in the
event of malfunction. The objective of this abstract is to educate the
readers on the various techniques that can be used to salvage a dysfunctional/malfunctioning venous catheter. This requires the appropriate cause to be identified and prompt treatment to be initiated in
order to reduce patient morbidity.

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Clinical Findings/Procedure: We present multiple cases identified from our clinical practice. There were a multitude of reasons accounting for this, the most common being catheter occlusion. Other causes include misplaced catheters, migrated tips and
fractured catheters. Their treatment options are discussed. We will
be discussing various methods to unblock catheters, including
mechanical and pharmacological techniques. Use of various devices
and their roles will be highlighted. Measures to prevent future catheter malfunction, such as catheter flushing techniques, will be discussed. In addition, management of other causes of venous catheter malfunction will be discussed. The case will be richly illustrated.
Conclusion: Dysfunctional catheters are not uncommon in clinical practice. It is important for an interventional radiologist to identify and appropriately manage them to increase their longevity and
reduce patient morbidity.

P-636

Abstract Book

for frequently associated pathology, and to provide relevant information regarding vascular or surgical procedures.
Clinical Findings/Procedure: Embryologic errors in the thorax can
originate a left-sided superior VC or a superior VC duplication. The
anomalies of the inferior VC (IVC) include the left-sided IVC, which
typically ends at the left renal vein and the IVC duplication, generally
in the infrarenal segment; the azygos continuation of the IVC; the
circumaortic and retroaortic left renal veins; the circumcaval ureter,
in which the proximal ureter courses posterior to the IVC; absence of
the infrarenal IVC or the entire IVC. Sometimes, more than one type
is present in the same patient.
Conclusion: Congenital anomalies of the VC are not that rare CT
findings and can have major clinical implications. The radiologist
needs to be aware of these anomalies to correctly recognize them
and the associated pathology, as well as to provide relevant information regarding planning of vascular intervention or surgery.

Pictorial essay of inferior vena cava filter complications

P-638

T.B.Kinney, H.Aryafar, J.Minocha, A.Picel

Department of Radiology, UCSD Medical Center, San Diego, CA, United
States of America

The role of interventional management for lumbosacral

radiculopathy due to epidural venous engorgement related to
pelvic venous outflow impediment

Learning Objectives: The object of this poster is to present a comprehensive collection of IVC filter complications.
Background: Varying indications for filters are partially explained
by recommendations from different clinical specialties. Retrievable
filters were developed after the PREPIC 1 trial. Design changes allow
ease of retrieval but have altered complications, including migration, perforation, and fractures. Despite retrievability, many studies
reveal low retrieval rates. The FDA in 2010 issued recommendations
to retrieve all filters when no longer clinically indicated.
Clinical Findings/Procedure: This pictorial essay will display several IVC filter complications. Adherence to guidelines is encouraged.
Pre-insertion planning review helps device selection and successful insertion. Intra-procedural checks mitigate insertion errors. Filter
registries increase retrievals. A wide variety of complications may
occur with filters, including recurrent thromboembolism, migration, perforation, fracture, and thrombosis. The process of IVC filter retrieval itself can involve possible complications. Lastly, some
patients may unfortunately develop recurrent venous thromboembolism after filter retrieval.
Conclusion: IVC filter complications can occur and may manifest in
a wide variety of manners as illustrated in this poster. As the technology continues to advance, improved performance characteristics are expected. Clearly, more prospective IVC filter studies are
urgently needed to help better apply these tools for the patients
optimized protection and help determine when, and in whom, filter
retrievals are best warranted.

P-637
Where is the vena cava? Depicting congenital vena cava
anomalies
A.I.S.Ferreira, M.Ramalho, J.Leito, I.Tvora
Radiology, CHLN Santa Maria Hospital, Lisbon, Portugal
Learning Objectives: The authors aim to review the spectrum of
vena cava (VC) congenital anomalies, by means of original schematic
illustrations and computed tomography studies, with particular
emphasis to embryologic development errors and imaging findings.
Background: The embryogenesis of the VC involves the formation
of several anastomoses between paired embryonic veins. When this
complex process does not go according to the plan, different variations may be seen in the venous drainage of the thorax, abdomen,
and pelvis. This knowledge is essential to recognize them in crosssectional imaging studies, thus avoiding diagnostic pitfalls, to look

W.Hsu1, T.-C.Tsai1, L.-S.Lin2, T.-C.Chang2

1Surgery, Taipei Medical University-WanFang Hospital, Taipei, Taiwan,
2Neurosurgery, Taipei Medical University Hospital, Taipei, Taiwan
Learning Objectives: Neurological symptoms of lower extremity
presenting in patients could be due to vascular origin for which the
patho-etiology should be investigated.
Background: Pelvic venous outflow impediment is most commonly
due to idiopathic iliac vein compression at left iliocaval junction due
to permissible anatomical variation. The clinical manifestation of
this disorder is mainly swelling and soreness of legs, primarily on the
left side. This is known as MayThurner syndrome since 1957. Other
authors, Cockett et al, reported a case series with more serious clinical symptomatology and coined the term iliac compression syndrome (ICS). These have never mentioned neurological symptoms
related to ICS.
Clinical Findings/Procedure: Between Mar 2008 and Dec 2014, we
followed up 325 cases of ICS, which were all verified by an imagining study. Among them, 25 patients presented with lumbosacral
radiculopathy with various degrees of motor and sensory dysfunction. Neurological study showed radiculopathy in all patients. IVDSA
with MDCT and reformation revealed remarkable epidural venous
engorgement (EVE) in the lower lumbar spine. All patients underwent percutaneous intraluminal balloon dilatation and placement
of stents.
Conclusion: Technical success rate was 100% in all 325 cases. In all,
775 stents were deployed. Clinical symptoms of leg swelling and
pain improved dramatically within a short time. For the group with
neurological symptoms, the symptoms improved progressively over
a period of 112 weeks. The neurological symptoms of motor or sensory deficit in the lower extremity may be attributed to a vascular
origin. Using interventional technique to solve the venous outflow
obstruction may avoid spine decompression surgery.

P-639
Pulmonary embolism: what the past tells us for the future
T. Heller
Interventional Radiology, University Medicine of Rostock, Rostock,
Germany
Learning Objectives: Between the first, unsuccessful performed
surgical thrombectomy in a patient with pulmonary embolism (PE)
in 1908 by F. Trendelenburg no substantial change of the treatment
regime took place although different minimal invasive approaches

C RSE

CIRSE 2016

has been developed. In this presentation we introduce the ratio, the

mechanism of action, the effectiveness and the advantage of the
currently available endovascular devices
Background: F. Trendelenburg postulated the immediate clot
removal as the only treatment option in the case of severe PE. The
first successful operation was performed by Kirschner in 1924. Since
then, the open operation has been the standard treatment of PE
to present. As an alternative to open surgery, embolectomy can
be performed with an endovascular approach, first introduced by
Greenfield in 1969. Recent reports have demonstrated that modified
angiographic catheters and devices can successfully break up and
remove emboli in patients with massive PE.
Clinical Findings/Procedure: Balloon angioplasty and pigtail rotational catheter are well known and widely used in combination
with local thrombolysis. In the last decades, new devices such as
the pharmacomechanical thrombectomy (AngioJet, EKOS) and the
thrombectomy with high suction power (Aspirex, Indigo, Angiovac)
were developed, but all of them had the drawback of missing multicenter randomized clinical trials (RCT). So they are not present in
the actual guidelines. Only the EKOS got the FDA approval for therapy of PE.
Conclusion: At present, different endovascular treatment options
for PE are available, most of them highly effective but not proven in
RCTs.

P-640
Aberrant drainage of the left testicular vein into the left
subcostal vein and left renal vein presenting a challenge
during varicocele embolization
N.B.Mani, M.D.Darcy, A.Allaei
Division of Interventional Radiology, Mallinckrodt Institute of
Radiology, Washington University in St. Louis School of Medicine, St.
Louis, MO, United States of America
Testicular veins exhibit various variations, including the number,
course, and drainage pattern. We encountered a rare case of drainage of the left testicular vein into the left subcostal vein and the
left renal vein. Angiography, embryology, and embolization are
discussed.

P-641
Transvenous retrohepatic inferior vena cava sarcoma biopsy
M.GonzlezLeyte, A.AlvarezLuque, M.EchenagusiaBoyra,
G.Rodriguez-Rosales, E.CallejaCartn, J.M.JimenezPerez
Interventional Radiology, Hospital General Universitario Gregorio
Maran, Madrid, Spain
We report a 54-year-old female with an inferior vena cava sarcoma
in whom pathologic tumor diagnosis was achieved on endoluminal
biopsy by a transvenous femoral access an alternative route that
must be taken into consideration.

P-642
Innominate vein repair after central line misplacement
L.DiazDorronsoro, R.ZaragozanoGuillen
Interventional Radiology, Hospital General Universitario Miguel Servet,
Zaragoza, Spain
We describe the case of a patient with cardiac failure who had an
11-French introducer perforating the left internal jugular vein into
the mediastinum. We describe a modified technique that we used
for embolization.

SS/FC/HL/HTS/CM
Posters

S345

P-643
Emergency endovascular repair for iatrogenic common iliac
vein injury during/after anterior lumbar interbody fusion
S.Fuwa1, S.Hase2, T.Nakagawa2, J.-I.Nishimura2
1Department of Radiology, Tokyo Metropolitan Bokutoh Hospital,
Tokyo, Japan, 2Department of Interventional Radiology, Kawasaki
Saiwai Hospital, Kawasaki-city, Kanagawa, Japan
Vascular injury during anterior lumbar interbody fusion (ALIF) is a
well-documented occurrence and could have fatal consequences.
We report here two cases of common iliac vein injury during and
after ALIF that were successfully treated by stent-graft placement.

P-644
Recanalising the SVC: time for new tools
A.Alsafi, R.H.Thomas, M.S.Hamady
Radiology, Imperial College Healthcare NHS, London, United Kingdom
A 24-year-old patient with cystic fibrosis requiring multiple indwelling central venous lines over the years developed symptomatic SVC
obstruction. We describe the use of an ultrasound-guided re-entry
device (Pioneer) to rencanalise & stent his SVC after conventional
techniques failed.

P-645
Interventional bullet retrieval from the right ventricle
P.Kisza, A.Mojtahedi, S.Contractor
Division of Interventional Radiology, Department of Radiology, Rutgers,
New Jersey Medical School, UH, Newark, NJ, United States of America
Bullet embolization to the right ventricle is a rare event.
Endovascular treatment is feasible. We present a case of successful removal, describe the technical issues, and review the available
literature.

P-646
Successful endovascular treatment for severe multiple
arteriovenous thrombosis caused by heparin-induced
thrombocytopenia
R.Usui1, K.Idoguchi1, M.Narita1, S.Nakao1, Y.Mizushima2
1Division of Endovascular Therapy, Rinku General Medical Center,
Senshu Trauma and Critical Care Center, Osaka, Japan, 2Senshu
Trauma and Critical Care Center, Rinku General Medical Center, Osaka,
Japan
A 41-year-old man developed life-threatening multiple arteriovenous thromboses due to heparin-induced thrombocytopenia in the
bilateral iliac arteries, superior vena cava, brachiocephalic vein, and
other vessels. He was treated with continuous transcatheter thrombolysis and repeated transcatheter thrombectomy without any
complications.

P-647
Percutaneous treatment of IVC obstruction due to postresection kinking associated with IVC thrombosis
T.G.VanHa, R.Navuluri, B.S.Funaki
Radiology, University of Chicago, Chicago, IL, United States of America
A patient presented with IVC thrombosis after liver resection
for colorectal metastasis due to twisting and kinking of the IVC.
Treatment involved thrombectomy with the AngioVac device followed by stenting of the kinked area using a Z-stent.

S346

CIRSE

P-648
Retrieval of an inverted Option filter malpositioned in the
renal vein
O.Ahmed, A.Masrani, S.Madassery, J.Soni, J.Tasse, D.Heussner,
C.Turba, B.Arslan
Interventional Radiology, Rush University Medical Center, Chicago, IL,
United States of America
A 44-year-old female underwent maldeployment of an inverted
Option filter into the right renal vein at an outside institution. A
snare was used to engage the upside-down filter apex and positioned cephalad to collapse the filter legs and remove it intact.

P-649
Vena cava filter migration due to a pericatheter fibrin sheath
J.R.Fortuo, J.Guitart, A.Alguersuari, E.CriadoParedes, J.F.FalcoFages
Interventional Radiology, Corporacin Sanitaria Parc Tauli, Sabadell,
Spain
We present the case of a migrated inferior vena cava filter into the
right ventricle. We used a preexisting femoral line with an unnoticed
fibrin sheath to deploy the filter.

P-650
Endovascular treatment of an iliac vein injury using stent graft
S. Narasimhan
Vascular Surgery, Apollo Hospital, Bangalore, India
Right atrial canulation for ASD repair through the femoral vein
caused illiac vein injury with shock. Angiography showed bleeding from confluence of the common iliac veins due to unrecognized
MayThurners syndrome. Balloon tamponade with placement of
kissing iliac covered stents avoided major surgery.

P-651
Acute pulmonary embolism complicating upper extremity
thrombolysis with CLEANER, a rotational thrombectomy device
N.B.Mani, A.J.Gunn, R.Ramaswamy, M.D.Darcy
Division of Interventional Radiology, Mallinckrodt Institute of
Radiology, Washington University in St. Louis School of Medicine, St.
Louis, MO, United States of America
We present a case of acute pulmonary embolism causing acute cardiorespiratory arrest following the use of CLEANER (a rotational
thrombectomy device) while attempting to clear thrombus during
an upper extremity lysis in a patient with history of non-small cell
lung cancer.

C RSE

Abstract Book

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A
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Bilia
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S347

Barcelona, Spain

September 10-14

CIRSE 2016
PART 4

Author Index

List of all abstract authors with

presentation numbers
Please note that bold numbers
indicate presenting authors and
P-numbers stand for poster
presentations.

Cardiovascular and Interventional Radiological Society of Europe

C RSE

S348

A
Aaltonen, E.
Abadal, J.M.
Abbas, M.
AbdalKader, M.
Abdelaziz, O.
Abe, R.

706.6
P-113
P-490
P-449, P-586
P-229
P-12, P-256, P-274,
P-587
Abe, T.
P-150, P-177, P-349,
P-447, P-454
Abernethy, W.
3106.3
Abid, R.
P-172
Abisi, S.
3106.5
Abo, D.
P-379, P-550
Abraham, R.
P-369
Abrignani, S.
P-3, P-280, P-468,
P-479, P-480, P-501,
P-583
Abt, D.
104.1
Abtin, F.
2306.4
Abualruz, A.
2307.2
Abuawad, C.
607.1
Accardo, C.
1508.4
Adam, A.
2902.3
Adam, G.
1509.1
Adam, J.
P-376
Adams, G.L.
3005.6
Adkin, C.
P-465
Afanador, E.
P-483
Affonso, B.B.
P-390
Aftab, K.
P-315
Aguilar Gutierrez, J.A.
P-232
Agust, A.
1508.2, P-97
Ahmad, W.
P-315
Ahmed, B.M.
P-216
Ahmed, F.
P-92
Ahmed, O.
1507.6, P-589, P-648
Aiya, J.
P-397, P-398
kesson, M.
P-464
Akhan, O.
1704.4
Akhtar, M.R.
P-625
Akin, M.
P-461
Akinwande, O.
1508.6, 3105.3
Akkan, K.
P-46, P-485, P-489
Akpinar, I.N.
P-382
Al Ghaithi, H.A.
P-93
Al Hajeri, M.
P-93
Al Rawahi, T.
P-93
Al Salmi, I.S.
P-93
Alammari, S.
P-119, P-123
Alanazi, T.
P-123
Albrecht, T.
P-470, P-484
Alchanan, R.
P-183
Alcorn, D.J.
P-320
Aldrighetti, L.
1509.6
Alegre Castellanos, A.
P-269
Alexopoulos, D.
P-430
Alexopoulou, E.
P-79
Alfahad, A.
P-8, P-496
Alguersuari, A.
P-649
Alharbi, A.
P-123
Alharbi, S.R.
P-175, P-434, P-452
Al-Hazmi, T.
P-107, P-271
Aliberti, C.
P-305

CIRSE

Abstract Book

Al-Khatib, A.
Allaei, A.
Allan, R.
Allison, R.
Allouni, A.K.
Almeida, M.Q.
Almoaiqel, M.

P-331
P-640
P-264
P-621
P-459
P-89
P-107, P-116, P-243,
P-271
Almokdad, O.
2307.2
AlMolani, F.
P-348
AlMuhaish, M.
P-348
Almuzrakchi, A.
2307.2
AlNammi, A.
P-348
Alonso-Burgos, A. P-22, P-95, P-117, P-133,
P-236, P-367, P-566
Alonzo, M.
P-628
Al-Roubaie, M.
P-115
Alsafi, A.
P-189, P-417, P-523,
P-644
Alsafi, Z.
P-189, P-417, P-523
AlSafran, Z.
P-348
Alshehri, S.
P-107, P-119, P-271
Al-Toki, M.A.
P-116, P-243
Alvarez, M.J.
P-113
Alvarez Luque, A. P-138, P-162, P-166,
P-641
Alvez, M.
P-168
Alvi, A.R.J.
P-37
Alzaabi, S.
P-348
Amabile, C.
P-207
Amaral, J.
P-103
Ambo, Y.
P-580
Ambrogi, C.
P-218, P-425
Ambrosino, P.
1508.4, P-311, P-312,
P-313
Ameli-Renani, S.
2207.3
Amemiya, S.
P-215
Amin, P.
P-523
Amin, S.
P-153
Amouyal, G.
707.2, 1702.2, 2704.2,
P-359, P-486
An, S.W.
P-141, P-516
Ananthakrishnan, G.
P-149
Andersen, I.R.
P-317
Anderson, V.
708.6, P-308
Andersson, T.
2601.4
Andic, C.
P-114
Andraina, T.
607.5
Andrs, O.
P-471
Andres Navarro, O. P-477
Angle, J.F.
P-610
Ankum, W.M.
3005.4
Annweiler, T.
P-624
Anochi, F.A.
P-281
Anthony, S.
P-522
Antoniou, G.
2307.1
Antonuccio, E.G.M. 2307.4, P-366
Anwar, J.
2206.6, P-432
Anzidei, M.
P-206
Aoki, A.
P-12
Aoki, M.
P-143
Apitzsch, J.C.
P-55
Aquerreta Beola, J.D.
P-76
Arabi, M.
P-107, P-119, P-123,
P-271

C RSE

Arablinskiy, A.
Arai, Yasua.
Arai, Yasun.
Aramaki, T.
Arbet, M.J.
Ardisson, V.
Arellano, R.
Arepally, A.
Argiro, R.
Aris, F.
Arizono, S.
Armijo Astrain, J.E.

P-299, P-372
P-96, P-226
P-226
P-63, P-96, P-298, P-407
607.5
P-303
P-387
3105.3, P-414, P-415
1508.5, P-335
P-271
P-310
P-47, P-170, P-279, P-547,
P-572
Arn, M.
P-517
Arrigoni, F.
1506.5, P-81, P-87,
P-509
Arsava, E.M.
2501.1
Arslan, B.
1507.6, P-18, P-400,
P-401, P-445, P-451,
P-573, P-648
Aruede, G.
P-597
Aryafar, H.
P-636
Asakura, K.
P-298
Ascanio, S.
P-222
Ascenti, G.
708.3
Aschenbach, R.
P-257, P-493, P-602
Ashida, H.
P-109, P-579
Ashokan, A.
1508.1
Atiiga, P.
P-320
Atwell, T.D.
P-68
Aub, C.
P-518
Awad, A.S.
P-300
Awai, K.
P-260, P-601
Aytac, I.I.K.
P-124
Azama, K.
P-148
Azevedo, A.A.P.D. P-390
Azoulay, D.
1509.3
Azrumelashvili, T. P-27, P-221, P-553, P-574
Azzeroni, R.
P-137
Azzouzi, A.-R.
P-518

B
Ba, B.
P-376
Baba, A.
P-278
Baba, Y.
P-260, P-601
Babaei Jandaghi, A. 1407.4
Babatola, F.
607.2
Babu, S.
P-99
Bachellier, P.
2502.1
Baek, J.H.
102.2, P-423, P-436
Baek, S.M.
P-423
Bagla, S.
2306.4, P-67
Bagnall, A.
708.4
Bagnaschino Barco, L.
P-476
Baheti, A.
P-610
Baijal, S.S.
P-575
Baird, A.
P-153
Bakare, V.N.
P-381, P-397, P-398
Balboa Arregui, O. P-224
Balderi, A.
104.4, P-146
Bale, R.
705.6, 901.4
Balestra, F.
P-45
Balestrieri, L.
P-336
Ballah, D.
P-270
Ballhausen, H.
P-73

Balli, .
Banavali, S.
Bangaragiri, A.
Bansal, R.
Bao, G.
Barah, A.
Baralis, I.
Barampoutis, N.
Barbe, L.
Barbosa, F.
Barclay, A.
Brdos, D.
Barile, A.

P-431
P-381
P-392
P-384, P-514
2207.5
2307.2
104.4, P-146
P-430
P-209
707.6, 2304.4
P-432, P-442
P-551
1506.5, P-81, P-509,
P-517
Barkhausen, J.
P-457, P-472
Barral, F.G.
P-624
Barral, P.-A.
P-6
Barrufet, M.
P-268, P-525
Barry, B.
P-537
Bartal, G.
103.1, 1901.1
Bartoli, J.-M.
3105.1, P-6, P-339, P-413
Barzakova, E.
P-98
Bascal, Z.
2305.1
Bashaeb, K.O.
2307.1
Bashiti, R.
P-94
Baydoun, H.
P-421, P-540, P-595,
P-598
Bazille, C.
P-340
Beam, S.
P-51
Bechade, D.
2306.5
Beck, P.
708.5, P-219
Bdouet, L.
705.4, 1508.3, 2207.1
Beilvert, A.
705.4, 1508.3, 2207.1
Bekku, E.
P-63, P-298, P-407
Bell, J.
607.2, P-440
Bellam Premnath, K.P.
P-393
Bellavics, R.
P-467
Belli, A.-M.
204.1, 2207.3
Benenati, J.F.
3005.6
Bengel, F.
P-265
Benito, A.
705.2
Benson, C.
P-377
Beomonte Zobel, B. 1407.1, 1407.2
Beomonte Zobel, D.
P-594
Berger, H.
P-112
Bergman, S.
P-464
Berjano, E.
P-97
Berlis, A.
3104.3
Bermudez, P.
P-268, P-525
Bernard, P.
2207.6
Bertoletti, L.
P-624
Besnier, L.
P-518
Besselink, M.G.H. 2306.6
Bessissow, A.
P-595, P-598
Beton, O.
3105.4
Bettinger, D.
1509.2
Beumer, M.
P-327
Beyer, L.P.
P-318, P-344, P-362,
P-363, P-364
Bezerra, C.H.N.
P-239
Bezzi, M.
1101.2, 1508.5, P-206,
P-335
Bhat, R.
2206.6, P-432, P-442
Bhrugubanda, V. P-417
Bi, Y.
P-458

S349

SS/FC/HL/HTS/CM
Author Index

CIRSE 2015
2016

Biard, J.M.
Biasi, L.
Bibin, J.
Bicknell, C.D.
Biederman, D.M.
Bigot, P.
Bilbao, J.I.
Bilbey, N.
Bilhim, T.
Billot, N.
Binkert, C.A.
Bisceglie, P.
Bize, P.E.
Blessing, E.
Bley, T.
Bligh, M.
Bloom, A.I.
Boardman, P.
Boas, F.E.
Boatta, E.
Boccalatte, L.
Bocciardi, A.
Bogetti, C.
Bolgen, C.
Bolger, M.P.
Bonda, J.M.
Bongiovanni, S.
Bonichon, F.
Bning, G.
Bonk, F.
Bonnefoy, O.
Bonomo, G.
Bonomo, L.
Bonomo, S.
Borges, F.
Borgmeyer, S.
Boscarato, P.
Bosch Melguizo, J.
Bosco, D.
Bose, P.
Botero, V.
Bouchard, L.
Boucher, L.-M.N.J.

2207.6
P-7, P-465, P-475
1509.1
P-443
P-361
P-518
607.3, 705.2, 1701.4
P-338
901.2
2704.2
1802.3
1507.5
P-319, P-409
903.3
P-318
P-369
P-212
P-522
P-383
P-352
607.1
707.6
P-193
P-114
P-108
P-76
104.4, P-146
P-410
P-510
P-327
P-347
P-343
2307.4, P-366
P-296
P-40
P-112
P-25, P-277
P-613
P-425
708.4
P-31
706.3
P-121, P-421, P-540,
P-595, P-598
Bourdeau, I.
706.3
Bourdeaux, C.
P-586
Bourgeois, A.
P-94
Bourhis, J.
P-388
Bouvier, A.
P-518
Bouziane, T.
P-84
Bovio, G.
P-48, P-163, P-227,
P-253, P-568
Boyd, D.
P-369
Bozorgchami, H.
P-285
Bozzi, A.
P-280
Brambillasca, P.M. 2304.4
Braren, R.F.
P-304
Brat, H.
P-84
Bratby, M.
P-459, P-522
Braunschweig, M. 1509.1
Braverman, S.
P-511
Bredt, C.
P-322
Breen, D.J.
P-320
Brehaut, G.
P-255
Brehm, M.
P-461
Breinl, J.
2306.2
Brennan, D.
P-196

Breznik, S.
Brigato, C.
Briguglio, J.
Brinton, T.J.
Brodmann, M.
Broos, F.
Brountzos, E.
Brouwer, P.A.
Browne, R.
Bruners, P.
Bruni, A.
Brning, R.D.
Bruno, F.
Brusse-Keizer, M.
Bruyas, A.
Bryant, T.J.
Buecker, A.
Buendia, L.A.
Buhk, J.-H.
Bui, J.T.
Bukata, S.V.
Bulut, T.
Bungay, P.M.
Bunker, N.
Burdo, F.
Burgard, C.A.
Burgmans, M.C.
Burrel, M.
Busch, O.R.C.
Busto, G.
Butt, M.W.
Buy, X.
Byun, S.S.

P-502
1408.2
3106.3
1408.3
1408.3, 3005.3, P-466
P-457
1506.2, P-80, P-111
2102.3
P-60
P-98, P-371, P-545
P-218, P-425
P-327
P-87, P-509
P-520
P-209
707.1, 707.5, 2207.2,
P-135, P-145, P-258
707.3, 904.5, 1407.6,
2503.4, P-521
P-89
1509.1
P-439
3105.5
P-520
708.1
P-625
1508.2, P-97, P-324
P-53
902.1, P-329, P-370
3301.4, P-268, P-525
2306.6
1508.4
708.1
1001.2, 2306.4, 2306.5,
P-65, P-88, P-410
P-267, P-527, P-531

C
Cabrera, T.
P-421
Cabrera-Gnzalez, M.
P-22, P-95, P-117, P-133,
P-236, P-367, P-566
Cacace, L.
1508.4
akir, V.
P-431
Calareso, G.
P-350
Calcagni, F.
P-207
Calcara, G.
1507.5
Calleja Cartn, E. P-138, P-162, P-166,
P-641
Callstrom, M.R.
2306.4, 2504.2, P-67,
P-68
Camacho Oviedo, J.A.
P-113
Camerano, F.
P-48, P-163, P-227,
P-253, P-568
Cancellieri, R.
P-69, P-70
Candelari, R.
P-25, P-277
Candeo, A.
1408.2
Cannavale, A.
707.1, 2207.2, 2603.2,
P-135, P-258
Cannizzaro, S.
P-291, P-360
Cano, V.M.
607.1
Canver, B.
P-535
Cao, G.
P-321
Cappelli, A.
P-222
Caracoche, M.
P-91

S350

Caradu, C.
Carandina, R.
Caravita, T.
Carducci, S.
Carey, J.D.
Cariati, M.

Carli, D.
Carlsson, T.
Carmo, M.
Carnevale, F.C.
Carp, A.C.
Carr, J.C.
Carrafiello, G.

Carrillo, M.
Carroll, T.
Carteret, T.
Casale, A.
Casarrubea, G.
Cascella, T.
Cascio, S.
Casellas, M.
Cassarino, S.
Castellano, V.
Castellvi, Q.
Castriota, F.
Casula, E.
Catalano, C.
Catalano, V.
Catena, V.
Caudrelier, J.

Cavaglia, E.
Cavalcante, R.N.
Cazzato, R.L.

Celdran, A.
Celia, A.
ern, M.
Cervera Araez, A.
ervinka, D.
Cervo, A.
Chagnon, M.
Chalmers, N.
Chan, J.M.
Chan, T.
Chang, I.S.
Chang, T.-C.
Chapot, R.
Chappiidi, S.
Charles, H.W.
Chatterjee, N.
Chavan, A.
Chavan, V.

CIRSE

2206.3
P-305
P-66
P-87
P-51
2305.4, P-1, P-2, P-9,
P-10, P-11, P-39, P-43,
P-50, P-58, P-125, P-152,
P-181, P-192, P-230,
P-231, P-234, P-251,
P-272, P-273, P-588a,
P-633, P-634
1506.1
P-255
P-181, P-192
104.2
P-281, P-441
P-263
1704.1, 2305.4, P-1, P-2,
P-9, P-39, P-50, P-58,
P-230, P-231, P-234,
P-251, P-272, P-273,
P-633, P-634
607.3
P-375
1506.3
P-350
P-336
P-350
P-64
P-548
P-207
P-95
P-324
3104.6
P-232
1508.5, P-206, P-335
P-305
1001.2, 2306.5, P-65,
P-88, P-410
1506.4, 2504.3, P-49,
P-62, P-208, P-352,
P-353
P-147
P-390
1506.4, 2504.3, P-49,
P-62, P-208, P-352,
P-353
P-95
P-336
101.3
P-268
607.5
P-147, P-513
706.3
P-530
P-118, P-392
P-621
P-101
P-638
2601.1
P-235, P-635
706.6, 2207.5, P-54,
P-524
P-375
1302.2
2307.2

Abstract Book

Chawla, A.
Checkver, A.
Chegai, F.

P-99
P-358
P-3, P-280, P-293, P-373,
P-468, P-479, P-480,
P-501, P-555, P-583,
P-603
Chen, C.-M.
2304.6, P-187
Chen, J.
P-426
Chen, J.X.
P-337
Chern, M.-C.
P-365
Cheskin, L.
3105.3
Cheung, W.
P-204
Chevallier, P.
1509.5
Chiaradia, M.
1509.3
Chiba, K.
P-197, P-497
Chiesa, R.
P-528
Chikada, M.
P-197
Chiras, J.
P-71, P-86
Chivate, R.S.
P-85, P-134, P-381,
P-397, P-398
Cho, J.
P-556
Cho, S.B.
P-591
Choi, B.G.
P-140
P-356
Choi, S.Y.
Choi, W.S.
P-559
Choi, Y.H.
P-248
Chomy, F.
1001.2, P-347
Chrisman, H.B.
2207.4
Christeas, N.
1507.2
Chu, C.M.
P-355, P-385
Chu, L.
P-426
Chu, S.-Y.
2304.6, P-187
Chun, H.J.
P-140
Chun, J.-Y.
P-625
Chun, S.-Y.
706.5
Chung, H.H.
P-591
Chung, R.
P-99, P-632
Ciaccia, M.
P-336
Ciampi Dopazo, J.J. P-323
Ciardullo, M.
P-29
Ciccarelli, O.
P-142
Cicero, C.
P-336
ilda, B.M.
1507.3
Cioni, R.
1001.1, P-207, P-487
Ciostek, P.
P-290
Cirelli, C.
1508.5, P-335
Citone, M.
P-254
Clarenon, F.
P-71, P-86
Clark, W.A.
2604.3
Clarke, J.
P-369
Clment, O.
2704.2
Cleveland, T.J.
2206.4, 3005.5
Codina, J.
P-548
Codina Barreras, A. P-548
Coenraad, M.
P-370
Cohen, D.J.
3005.3, 3106.3
Cohn, D.
P-212
Colgan, F.
P-331, P-505
Colic, M.
P-17, P-294
Collin, N.
P-255
Collins, J.D.
2207.4, P-263, P-375
Colombo, M.
P-528
Congedo, M.T.
2307.4
Coniglio, G.
1507.5, P-296
Connolly, B.
P-33, P-103
Connolly, B.L.
P-438, P-617, P-622
Connolly, S.
1506.6

C RSE

Conrad, M.B.
P-270, P-611
Contractor, S.
P-645
Cooper, C.J.
3106.3
Coppola, G.
2307.4, P-366
Corbin, N.
705.3
Cormier, E.
P-71, P-86
Cornalba, G.
P-45, P-137
Cornelis, F.
1506.3
Cornelissen, S.
1507.4
Corona, M.
1508.5
Corradini, S.G.
1508.5, P-335
Corti, R.
2305.5, P-122
Cortias Gonzlez, J.R.
P-592
Corvino, A.
P-147, P-513
Corvino, F.
P-147, P-513
Coschiera, P.
P-305
Costache, V.
2304.3
Coubeau, L.
P-449
Courtney, K.
P-82
ven, I.
P-287
Cox, B.
P-442
Creer, D.
P-386
Cremonesi, A.
3104.6
Crespo Picazo, J.L. P-100
Criado Paredes, E. P-649
P-193
Cristoferi, M.
Crocetti, L.
1001.1, P-207
Crombe, A.
P-410
Crowe, P.M.
204.2
Crowley-Matoka, M.
2207.4
Cuba, V.
P-548
Cuesta Prez, J.
P-323
Cui, C.
P-426
Cui, Y.
P-321
Cutlip, D.
3106.3
Cvetic, V.Z.
P-17, P-294
Cynamon, J.
P-556
Czuczman, P.
2305.1

D
Dababou, S.
DAgostino, R.
Dai, E.
Dake, M.D.
DAlessio, A.
Dallatana, R.
Daly, K.
Damascelli, B.
DAmico, M.
Damodharan, K.
DAngelo, R.
Danza, F.M.
Dappen, R.
Darcy, M.D.
Darzi, A.W.
Das, M.
Das, R.
Dasgupta, N.
Davey, P.
Davies, C.
Davis, B.
Davlouros, P.
Dayan, E.

P-206
3106.3
P-355, P-385
1302.3, 3005.2
2306.3
P-10, P-11, P-181, P-192
P-194
2306.3
2307.6, P-557
P-118, P-392
P-309, P-380
P-594
P-351
304.2, P-83, P-640,
P-651
P-443
303.3, 2307.3
2207.3
P-83
708.4
P-184
P-420
P-430
P-361

Dan, C.
De Bare, T.

707.2, P-359
901.1, 1004.2, 1506.3,
2306.4, 2901.1, P-347,
P-376
De Bruijn, A.M.
3005.4
De Cobelli, F.
1509.6, P-528
De Concilio, B.
P-336
De Crescenzo, F.
1408.5, P-3
De Fabritiis, P.
P-66
De Febis, E.
2304.4
De Fina, B.
P-390
Defreyne, L.
P-32
De Graaf, R.
203.1, 2307.3
De Gregorio, M.A. P-286, P-613, P-614
De Haan, M.W.
2307.3
Deipolyi, A.R.
706.6, 2207.5, P-54,
P-524
De Jong, K.P.
P-223
Del Cura-Rodriguez, J.L.
P-419
Del Giudice, C.
707.2, 1702.2, 2704.2,
P-359, P-486
Del Maschio, A.
1509.6, P-528
Delassus, P.
2304.5
Delgado Almandoz, J.E.
3104.1
Delgado Escudero, J.
P-269
Della Sala, S.
1407.2
Della Vigna, P.
P-343
Delli Fraine, P.
P-595, P-598
De Marco, F.
P-314
De Masi-Jacquier, M.
P-6
De Mathelin, M.
705.3, P-209
De Nardi, P.
P-240
De Nunzio, M.
708.1
Denys, A.
1004.4, 1509.5, 2305.1,
P-319, P-409
Depaoli, A.
P-193
Derbel, H.
1509.3
De Rooij, T.
2306.6
Desai, A.
3106.6, P-466
Desai, K.R.
P-615, P-620
Desai, S.
P-620
De Santibanes, E. 607.1, P-29
De Santibanes, M. P-29
Deschamps, F.
1506.3, 2306.4, P-376
Desgranges, P.
2206.5
Deux, J.F.
2206.5
De Vries, J.
2604.2
De Vries, J.-P.
P-473
Dhillon, P.S.
708.1
Dhillon, S.
P-617
Dhondt, E.
P-32
Di Costanzo, G.
P-228
Diamantopoulos, A.
3106.5, P-238, P-465,
P-475
Diaz Dorronsoro, L. P-642
Diaz-Cartelle, J.
3005.1
Daz Romero, J.M. P-592
Diaz-Sandoval, L.J. 1408.2
Diethrich, E.B.
2304.3, 2304.5
Diez-Miranda, I.
607.4, 2305.6, P-38
Dijkgraaf, M.G.
2306.6
Dillon, B.
P-428

S351

SS/FC/HL/HTS/CM
Author Index

CIRSE 2015
2016

Dimitriade, A.
Divis, P.
Do, T.D.
Doassans, K.
Dobrowolski, T.
Dogan, A.
Dogan, N.
Dkdk, A.M.
Dolgushin, B.
Dollinger, M.
Domitrovic, L.A.
Donati, T.
Donners, R.
DOnofrio, A.
Donohue, J.
Dori, Y.
Dorobat, B.
Dorofeev, A.
Douglas, P.
Doviner, V.
Dreher, M.
Drescher, P.
Dubenec, S.
Dber, C.
Ducasse, E.
Duds, I.
Duddy, M.J.
Duignan, J.
Duka, E.
Duman, E.
Duncan, R.
Dupont, B.
Dupuy, D.E.
Duran, R.
Durrani, R.J.
Durst, M.
Duvoux, C.
Dwel, S.
Dworkin, L.
Dyer, J.
Dyer Hartnett, S.

P-281, P-441
P-291, P-360
705.1
P-376
2206.1
P-285
P-124, P-535
P-489, P-542
P-404
P-318
P-224
P-7, P-465
P-213
1408.5
P-597
P-259, P-429
P-281, P-441
P-411
P-64
P-212
P-308
1408.4
P-537
P-297, P-345, P-378
2206.3
P-551
P-14
P-196
2305.4, P-1, P-2, P-50
P-287
P-432, P-442
P-340
2306.4
P-319
P-361
P-304
1509.3
P-304
3106.3
P-135, P-145, P-258
2305.6, P-38

E
Ebeid, W.A.
P-72
Echenagusia Boyra, M.
P-138, P-162, P-166,
P-641
Echevarria, J.
P-323
Eckardt, N.P.W.
P-493
Egge, J.
P-139
Eguchi, M.
P-158, P-492
Eichler, K.
P-205
Eiken, P.W.
2306.4
Eisma, R.
P-442
Eker, H.E.
P-114
El Bosraty, H.
P-300
Eldergasch, O.
1302.2
El-Haddad, G.
P-337
Elhelali, A.
2304.3, 2304.5
El Idrissi, R.
707.4
Ellis, S.
P-204
El Mekkaoui, Y.
P-441
Elodie, B.
705.3, P-208
Elsayad, M.
P-37
Elwood, C.
P-242
Endo, K.
P-604

Endo, M.
P-298
Enescu, I.
P-352
Engelhorn, T.
2102.2
England, A.
2206.2
Enoki, K.
P-109, P-579
Erasmus, H.-P.
P-206
Erdoan, C.
P-124
Ergelen, R.
P-382
Eriksson, L.-G.
P-554
Erinjeri, J.P.
P-334, P-383
Erpenbach, S.
P-244
Errea, M.F.
P-615
Ersoz, E.
P-489
Escal, L.
1509.5
Espaa, A.
P-76
Espejo Herrero, J.J. P-120, P-558, P-593
Esperon, A.
P-168
Esteban Hernndez, E.
P-61, P-600
Ettl, J.
P-112
Evans, J.
P-56, P-389

F
Faiella, E.
1407.1, 1407.2, 1703.2
Falahatkar, S.
1407.4
Falco-Fages, J.F.
P-649
Fanelli, F.
903.1, 1508.5, 2603.2
Fanelli, G.
P-193
Farias Alijo, P.
P-600
Farrelly, C.
606.6
Fasoli, F.
P-66, P-69, P-70
Fehlings, D.
P-438
Feldman, D.
P-54
Felicioli, A.
P-305
Fernndez Martnez, A.M.
P-224
Fernndez Rey, C. P-24
Fernandez-Soto, J.M.
P-507
Ferral, H.
P-628
Ferreira, A.I.S.
P-637
Ferreira, J.
P-495, P-503
Ferrer-Puchol, M.D. P-61, P-419, P-600
Ferro, C.
P-48, P-163, P-227,
P-253, P-568
Fichetti, M.
P-25, P-277
Fidelman, N.
P-337
Filippiadis, D.K.
1506.2, 2504.1, P-79,
P-80, P-111, P-374
Findlay, M.P.
2306.1
Findlay, S.
P-505
Fiocco, M.
P-370
Fiore, F.
P-309, P-380
Fiorentini, G.
P-305
Fiorina, I.
P-122
Firanescu, C.E.
2604.2
Fischbach, R.
1509.1
Fischbeck, T.
P-414
Fischman, A.
904.6, 3105.3, P-361,
P-414, P-415
Fisher, R.
2206.2
Flechsig, P.
705.1
Flood, K.
P-185
Fo, R.
P-343
Fohlen, A.
2307.5, P-339, P-340,
P-627

S352

Fonck, M.
Fontana, F.
Fortuo, J.R.
Fotheringham, T.
Fotiadis, N.I.
Fournier, D.
Fragoso, M.C.B.V.
Francica, G.
Franiel, T.
Frantsev, D.
Fraser, J.
Fratantoni, M.E.
Frauenfelder, G.
Freitas, R.M.C.
Freyhardt, P.
Friedman, M.
Friedman, T.
Fries, P.
Fristachi, R.
Froud, T.
Fuji, T.
Fujii, H.
Fujii, K.
Fujimori, M.
Fujisawa, H.
Fujiwara, K.
Fukuda, T.
Fukumoto, W.
Fumarola, E.
Fumarola, E.M.
Funaki, B.S.
Furui, S.
Furuta, A.
Furuta, Y.
Fuss, T.
Fuwa, S.

CIRSE

2306.5
P-1
P-649
P-625
P-377
P-84
P-89
P-220
P-257, P-602
P-404
P-369
607.1, P-29
1407.1, 1407.2
P-89
P-213, P-510
1506.6
2305.2
1407.6
1508.4
P-358
P-260, P-601
P-543
P-19, P-246
P-328
P-605
P-497
P-155
P-260, P-601
P-45
P-137
304.4, P-647
P-165, P-245, P-247,
P-581
P-310
P-301, P-532, P-533
P-471
P-15, P-130, P-643

G
Gaba, R.C.
Gabata, T.
Gabbani, G.
Gade, T.
Gl, G.
Gala, K.B.

P-105, P-439
P-394, P-564
P-254
P-261
3104.3
P-85, P-134, P-381,
P-397, P-398
Galastri, F.L.
P-390
Galfano, A.
707.6
Galindo, F.
P-419
Galle, P.R.
P-297, P-345, P-378
Gallieni, M.
P-634
Gallo, P.
1508.4, P-311, P-312,
P-313, P-314
Glvez Gonzalez, E. P-113
Ganaha, F.
P-148
Gandini, R.
1408.5, P-3, P-280,
P-293, P-468, P-479,
P-480, P-501, P-555,
P-583, P-603
Gangi, A.
202.3, 705.3, 1101.1,
1506.4, 2504.3, P-49,
P-62, P-208, P-209,
P-352, P-353
Gao, Q.
3106.3
Gao, S.
P-383
Garca, J.
P-40

Abstract Book

Garcia, M.J.
Garca-Barqun, P.
Garca Marcos, R.
Garca Prraga, D.
Garcia Revillo, J.
Garca Surez, A.
Garin, E.
Garner, A.M.
Garnon, J.

P-179
607.3, P-76
P-100
P-100
P-120, P-269
P-323
P-303
3005.5
1506.4, 2504.3, P-49,
P-62, P-208, P-209,
P-352, P-353
Garrido Collado, M.A.
P-269
Gasbarrini, A.
P-366
Gatta, E.
P-25
Gatzweiler, C.
606.4
Gaubert, J.-Y.
P-347, P-413
Gaudry, M.
P-6
Gavrilovic, V.
P-291, P-360
Gazzetti, M.
2603.2
Gazzo, P.
P-517
Geboes, K.
P-32
Gebski, V.
2306.1
Gedikoglu, M.
P-114, P-616
Geelkerken, R.
P-520
Geisel, D.
2306.2
Geiskopf, F.
P-209
Geisler, B.P.
3005.5
Geist, V.
3106.1
Gelabert, M.A.
P-548
Generalov, M.I.
P-13
Gentsu, T.
P-90, P-536, P-571
George, J.
3106.4
Gerasia, R.
2307.6
Geschwind, J.-F.H. 708.6, P-308
Ghariq, E.
P-329
Ghibes, P.
P-482
Ghodadra, A.
P-214
Ghouri, M.A.
P-128
P-220
Giardiello, C.
Gibbs, P.
2306.1
Gibbs, R.G.J.
P-191
Gilbert, P.
706.3
Gillams, A.
1001.3
Gimeno Peribez, M.J.
P-286
Gioppo, A.
P-137
Giordano, A.V.
P-87
Giordano, G.
P-296
Giorgi, L.
P-487
Giori, A.
P-240
Giroux, M.-F.
706.3
Giuffrida, S.
1507.5
Giurazza, F.
1407.1, P-147, P-513
Given, M.F.
P-196
Gkoutzios, P.
3106.5
Glaser, S.
P-304
Gnannt, R.
P-33, P-103, P-438
Gnutzmann, D.
705.1
Gockner, T.L.
705.1, P-560
Goffette, P.P.
2207.6, P-142, P-449,
P-586
Gogna, A.
P-118, P-392
Goh, G.S.
P-408
Gokalp, G.
P-295, P-535
Gokan, T.
P-12, P-256, P-274, P-587
Golfieri, R.
P-222

C RSE

Golowa, Y.
P-556
Goltz, J.P.
P-457, P-472
Gomaa, M.B.
2307.2
Gomes, A.S.
3105.5
Gmez, F.M.
P-100, P-268, P-525
Gomez, J.
P-232
Gomez Campos, D. P-117, P-133
Gonalves, B.
101.4, 2704.1
Gong, B.
P-338
Gonzalez Aguirre, A.J.
P-334
Gonzlez-Ayora, S. P-95
Gonzlez Costero, R.
P-323
Gonzlez De Garay, M.
P-323
Gonzalez-Junyent, C.
607.4, 2305.6, P-38
Gonzlez Leyte, M. P-138, P-162, P-166,
P-641
Gonzalez Nieto, C.J. P-547, P-572
Gonzlez Nieto, J. P-47, P-170, P-279
Gonzalez Toranzo, R.S.
P-91
Goode, S.D.
2206.4, P-478, P-490,
P-599
Goodwin, S.
P-64
Goodwin, S.C.
P-369
P-455
Gorcy, J.
Gordon, A.C.
P-56
Gordon, C.
P-465
Goshima, S.
P-165, P-180, P-245,
P-247, P-252
Goto, H.
P-178
Gotra, A.
P-421, P-540, P-595,
P-598
Gottster, A.
P-464
Goubergrits, L.
2304.2
Gouda, A.H.
3104.4
Goudot, G.
P-486
Graif, A.
P-179
Gramenzi, A.
P-222
Grant-Casey, J.
P-217
Grasso, R.F.
1407.1, 1407.2, 1703.2
Gravas, S.A.
2701.1, 2701.2
Gravel, G.
P-376
Greben, C.
P-115
Grebenev, E.
P-411
Greco, F.G.
P-350
Greco, G.
P-350
Greenhalgh, R.M. 1302.1
Gremmels, H.
P-473, P-474
Grey, D.
2305.1
Grigolini, A.
P-487
Grigoriadis, S.
P-80, P-111
Grilli, C.J.
P-179
Grimm, M.-O.
P-257
Gringeri, C.
P-304
Grkovski, R.
P-488
Groenwald, M.
2305.2
Grosfilley, S.
P-409
Gro, C.
P-304
Grosse, U.
P-482
Gross-Goupil, M. P-88
Grosso, M.
104.4, P-146
Grover, G.
P-191
Grzinger, G.
P-354, P-482

Gruber-Rouh, T.
Grunwald, I.Q.
Gu, Y.Q.
Guarise, A.
Guazzaroni, M.
Guenther, E.
Gueorguieva, M.
Guerrero, G.
Guevara, C.
Guirola Ortz, J.A.
Guitart, J.
Guiu, B.
Gulia, A.
Gummalla, K.M.
Gunduz, F.
Gunn, A.J.
Gnther, R.W.
Guo, J.-H.
Guo, Y.
Gupta, A.
Gupta, A.K.
Gupta, S.A.
Gr, S.
Gurevitch, V.
Guy, R.
Guzaia, N.
Guzaiz, N.
Guzelmansur, I.
Gwon, D.I.

P-325
2501.3, 2601.3
P-463
P-336
P-66, P-69, P-70
707.4
P-432, P-442
P-358
P-83
P-286, P-613, P-614
P-525, P-649
1509.5, P-339
P-381
P-41
P-382
P-651
2306.2, P-213
P-74
3105.2, P-346
P-384, P-514
3104.4
P-620
P-431
P-5
P-217
P-116
P-243
P-114
P-531

H
Ha, E.J.
Haase, A.
Haber, Z.
Habib, N.
Habib, S.
Habibzadeh, H.
Hacikurt, K.
Hacking, N.

Haft, J.
Hahn, O.
Haider, S.
Hajdu, S.D.
Hakyemez, B.
Haldane, G.
Halena, G.
Halkier, B.
Hamady, M.S.

Hamblin, M.
Hameed, Y.
Hamilton, R.
Hamm, B.
Hammond, C.J.
Hamour, N.
Hampson, C.O.
Hamza, K.R.
Han, H.Y.
Han, K.
Han, X.-W.
Hansrani, M.
Hao, C.
Hao, Z.J.

S353

SS/FC/HL/HTS/CM
Author Index

CIRSE 2015
2016

P-436
P-304
P-524
P-27, P-221, P-553
P-619
1407.4
P-124
707.1, 707.5, 2207.2,
2701.3, P-135, P-145,
P-258
P-275
P-551
P-34
P-319
P-124, P-295
P-491
1408.1
P-338
1702.3, P-189, P-191,
P-417, P-443, P-523,
P-644
P-500, P-612
P-523
P-617
2306.2, P-213, P-510
P-185, P-606
P-348
1408.4
P-172
P-356
P-559
P-282, P-458
P-128
P-321
P-249

Hara, T.
Haraguchi, T.
Hare, S.
Harris, M.R.
Harsnyi, L.
Hartzman, S.
Hase, S.
Hasegawa, M.
Hasegawa, T.

P-198, P-307
P-226
P-386
P-135, P-145, P-258
P-551
P-511
P-15, P-130, P-643
P-587
P-164, P-178, P-328,
P-526, P-544
Hashizume, T.
P-131, P-144, P-301,
P-532, P-533
Haskal, Z.J.
303.2, P-610
Haslam, P.J.
P-320, P-505
Hatopp, A.
P-244
Hausegger, K.A.
2601.2, 3106.2
Hayashi, N.
P-584
He, S.-C.
P-74
Healey, T.
2306.4
Heelan, F.
P-369
Heerink, W.J.
P-223
Hehenkamp, W.J.K. 3005.4
Hehr, T.H.
3104.1
Heianna, J.
P-148
Heidarzadeh, A.
1407.4
Heinemann, V.
2306.1
Heinz, M.
606.2, 606.3
Helali, A.
P-186
Held, S.
P-351
Heller, T.
P-639
Helmberger, T.K. 3201.2, P-330
Helyar, V.G.
P-238, P-444
Hennemuth, A.
2304.2
Hennessy, M.
P-106
Henrich, W.
3106.3
Henroteaux, D.
1507.4
Herget, E.
708.5, P-219
Herlihy, D.
P-196
Hermann, M.D.
P-59
Hermosn Pea, A. P-592
Hernandez Morales, D.
607.4, 2305.6, P-38
Herrera, R.
P-483
Hetts, S.
P-611
Heuss, L.T.
1101.4
Heussner, D.
P-648
Heye, S.
1507.4
Hidemasa, T.
P-215, P-576
Hillen, T.
1506.6
Himeno, Y.
P-226
Hinrichs, J.
P-265, P-461
Hirasawa, S.
P-143
Hirata, M.
P-57, P-406
Hirayama, Y.
P-570
Hoeper, M.M.
P-265
Hoff, A.O.
P-89
Hoffer, E.K.
P-34
Hoffmann, R.-T.
606.4
Hofmockel, T.
606.4
Hohenstein, E.
P-344
Holden, A.
903.4, 1408.3
Holden, R.
2305.1
Holgun, A.J.
P-31
Holly, B.
3105.3
Honda, M.
P-587
Hong, H.P.
P-35, P-288
Hong, K.
3105.3

Hongo, N.
Hopkins, J.
Horikawa, M.
Horiuchi, H.
Horn, M.
Hosaka, N.
Hosoi, Y.
Houston, J.G.
Hsu, M.
Hsu, M.-Y.
Hsu, W.
Hu, H.-T.
Hu, J.
Hu, L.
Huang, K.-W.
Huang, L.
Huangfu, N.
Hubinont, C.
Huespe, P.
Hung, C.-F.
Hunt, S.
Huppert, P.E.
Husty, J.
Httl, K.
Huynh, Y.
Hwang, J.H.
Hynes, N.
Hyon, S.H.

P-190
P-14
P-104, P-285, P-494
P-447
P-457, P-472
P-12, P-256, P-274,
P-587
P-427
2206.6, P-432, P-442
P-435
2304.6
P-638
P-552
P-321
2207.5
P-395
2304.1
P-426
2207.6
607.1
2304.6
P-261
1802.2, 3201.3, P-330
607.5
P-292, P-467
P-408
P-101
2304.3, 2304.5, P-186
607.1, P-29

I
Iana, G.
Iazzolino, L.
Icasuriaga, A.
Ichihashi, S.
Ichijo, Y.
Ichikawa, T.
Idoguchi, K.
Ierardi, A.M.

Iezzi, R.
Ignotus, P.
Ihaya, T.
Ikeda, N.
Ikeda, O.
Ikezoe, T.
Ilgit, E.T.
Illindala, U.
Illing, R.
Imai, Y.
Imamine, R.
Inaba, Y.
Inagaki, M.
Inaoka, T.
Iarrairaegui, M.
Inchingolo, R.
Inoue, D.
Inoue, M.
Inoue, S.
Inoue, Y.
Inuganti, S.

P-281, P-441
2206.2
P-168
705.5, P-188, P-211
P-584
P-198
P-4, P-159, P-160,
P-161, P-646
1704.1, 2305.4, P-1, P-2,
P-9, P-39, P-50, P-58,
P-231, P-234, P-251,
P-272, P-273, P-633,
P-634
2307.4, 3301.2, P-366
P-242, P-597
P-326
P-157
P-158, P-492
P-427
P-46, P-485, P-489
1408.3
P-320
P-198
P-310
P-96
P-446, P-541
P-546
705.2
P-228
P-394, P-564
P-36, P-132, P-156,
P-534, P-581
P-278, P-492
P-19, P-246
P-235, P-635

S354

Inui, S.
Iodice, V.
Iovino, V.
Iqbal, A.
Iraha, Y.
Irani, F.G.
Isenburg, J.C.
Isfort, P.
Ishiguti, T.
Ishikawa, M.
Ishikawa, R.
Ishizaka, Y.
Islam, S.
Ismail, A.
Isoda, H.
Itkin, M.
Ito, N.
Ito, T.
Ivaldi, D.
Ivanov, A.S.
Ivorra, A.
Iwakoshi, S.
Iwakura, Y.
Iwamoto, R.
Iwamoto, T.
Iwanowski, J.
Izaaryene, J.

CIRSE

P-494
P-487
P-314
P-315
P-148
P-118, P-392
P-51
P-98, P-371, P-545
P-75
P-260, P-601
P-546
P-182, P-422
2207.3
P-300
P-310
P-259, P-429, P-435
P-36, P-110
P-63
P-517
P-13
P-324
P-188
P-453
P-447, P-454
P-427
2206.1
P-413

J
Jaberi, A.
P-368
Jackson, R.
P-331
Jacquier, A.
P-6, P-413
Jae, H.J.
1803.2
Jaff, M.R.
3005.3
Jaffer, O.S.
P-625
Jagust, M.
P-556
Jain, D.
P-575
Jain, V.
P-575
Jairath, V.
P-217
Jakobs, T.F.
P-322
Jamerson, K.
3106.3
James, K.
706.1
Jang, E.
P-559
Jang, J.Y.
1509.4
Janich, M.
P-304
Janssen, M.
P-521
Jaschke, W.
103.4
Jefferson, J.M.
P-611
Jegonday, M.-A.
2307.5, P-340
Jennings, J.
1506.6
Jeon, C.H.
P-141, P-516
Jeon, U.B.
1509.4
Jeon, Y.S.
P-102
Jeong, S.H.
P-250, P-391, P-538
Jesse, M.
P-92
Jeukens, C.R.
2307.3
Ji, X.
P-321
Jia, Z.
P-262
Jiaping, L.
P-26
Jilani, D.
P-589
Jimenez Perez, J.M. P-138, P-162, P-166,
P-641
Jinzaki, M.
P-36, P-132, P-156, P-534
Jo, A.S.
P-23, P-275, P-437,
P-450, P-588
Jockenhoevel, S. 705.5, P-211

John, J.
Johnson, M.S.
Johnstone, J.
Jones, R.
Joshi, H.
Jung, H.D.
Jung, S.L.

Abstract Book

2305.1
P-416
P-429
P-377
P-183
P-562, P-629
P-423

K
Kaabneh, A.
Kably, I.M.
Kabuli, M.A.K.
Kachura, J.R.
Kadoba, T.
Kaduk, M.
Kahn, J.
Kaireit, T.
Kaissis, G.
Kaji, T.
Kajita, K.
Kajiwara, K.
Kalish, Y.
Kaltenbach, B.
Kam, M.
Kamei, N.
Kameoka, Y.
Kamo, M.
Kamper, L.
Kanazawa, H.
Kane, R.
Kang, C.H.
Kang, H.-Y.
Kang, U.R.
Kang, Y.J.
Kapoor, A.K.
Kara, L.
Karadeniz, O.
Karaman, K.
Kariyasu, T.
Krkkinen, J.M.
Karnabatidis, D.
Karouki, M.
Karp, J.
Karska, K.
Kartashov, M.
Karunanithy, N.
Karunyam, B.
Kasem, M.A.O.
Kasuya, S.
Katase, S.
Katayama, M.
Katayama, N.
Katsanos, K.N.

Katz, M.
Kauczor, H.U.
Kaufman, C.
Kaufman, J.A.
Kavanagh, E.P.
Kavnoudias, H.
Kawada, H.
Kawahara, Y.
Kawai, N.

P-128
P-42, P-596
P-490
P-368
P-16, P-276, P-403
P-477
P-510
P-265
P-304
P-104, P-494
P-180
P-260, P-601
P-212
P-205
P-355
P-190
P-399, P-412, P-448
P-176
303.1
P-543
P-500
P-44, P-199, P-565
P-77
P-250, P-538
P-582, P-629
P-575
1407.3
P-542
P-489, P-542
P-427
P-607
1507.2, P-430
2206.2
P-615
P-302
P-411
P-529
2207.2
P-300
P-546, P-570
P-427
P-278
P-90, P-536, P-571
1507.2, 3005.5, 3106.5,
P-7, P-238, P-430, P-465,
P-475
P-414
705.1, P-560
P-428
2703.2, 3202.1, P-285
2304.3, 2304.5, P-186
P-201, P-204
P-165, P-180, P-245,
P-247, P-252
P-543
P-180, P-252

C RSE

Kawai, T.
Kawamoto, S.
Kay, D.
Kayan, Y.
Kazemi, K.
Kee, S.
Kehoe, S.
Keirse, K.F.
Kelekis, A.D.
Kelekis, N.L.
Keller, E.J.
Kelly, I.P.
Kelm, M.
Kemeny, N.E.
Kenny, L.M.
Kerbert, A.
Kessel, D.O.
Ketelsen, D.
Kettenbach, J.
Khaja, M.
Khandelwal, A.H.
Khankan, A.
Khawar, S.
Khayrutdinov, E.
Khira, H.G.
Khosla, A.
Khosravi, H.R.
Khubulava, G.
Kibriya, N.
Kichikawa, K.
Kienzle, N.
Kiezle, N.
Kijima, S.
Kikuchi, H.
Kilpatrick, H.
Kim, A.
Kim, C.S.
Kim, E.
Kim, E.H.
Kim, E.T.
Kim, G.
Kim, G.-C.
Kim, G.M.
Kim, H.
Kim, H.-C.
Kim, H.J.
Kim, H.O.
Kim, J.D.
Kim, J.H.
Kim, J.-H.
Kim, J.K.
Kim, J.S.
Kim, J.W.
Kim, K.S.
Kim, M.
Kim, M.D.
Kim, N.R.
Kim, S.H.
Kim, Y.
Kim, Y.H.

P-131, P-301, P-532,

P-533
P-515
P-320
3104.1
P-519
606.5
P-369
3005.1
1506.2, 2504.1, P-79,
P-80, P-111, P-374
1506.2, P-79, P-80, P-111,
P-374
2207.4, P-263, P-375,
P-416
P-82
2304.2
P-334
202.4
P-370
P-185
P-354, P-396, P-482
902.4, 1407.3, 1407.5
P-23, P-275
P-575
P-107, P-243, P-271
P-315
P-299, P-372
P-72
P-28
P-420
P-5
P-389
3005.2, 3104.5, P-188,
P-211, P-469
P-569
P-563
P-543
P-546
2305.1
P-414
P-250, P-391, P-538
P-361
P-140
P-559
P-216
P-538
P-136
P-44
P-136, P-203, P-549
P-356, P-565
P-582, P-629
P-356
P-250, P-391, P-527,
P-531
P-423
P-582, P-629
P-506
P-267, P-527, P-531
P-423
P-549
P-216
P-356
P-250, P-391
P-559
P-250, P-391, P-538,
P-591

Kim, Y.H.D.
Kim, Y.-J.
Kimbiris, G.
Kimura, T.
Kind, M.
Kindl, L.
Kinney, T.B.
Kinoshita, R.
Kint, J.F.
Kirk, J.E.
Kishimoto, K.
Kisza, P.
Kitagawa, A.
Kitamura, N.
Kitao, A.
Kitrou, P.M.
Kiyosue, H.
Klapp Oliger, M.
Kleemann, M.
Klein, N.
Kljuevek, T.
Kloeckner, R.
Klumb, C.
Klumpen, H.J.
Ko, G.-Y.
Ko, P.-J.
Kobashi, Y.
Kobayashi, H.
Kobayashi, S.
Kobeiter, H.
Koch, G.

Koch, J.-A.
Koch, P.
Koch, S.
Kcher, M.
Koda, W.
Kodama, H.
Kodama, Y.
Koehler, M.
Koelemay, M.J.W.
Koff, R.
Koganemaru, M.
Koide, Y.
Koizumi, J.
Kok, H.K.
Kolkman, J.
Komisar, O.
Komori, K.
Konda, D.
Kondo, H.
Konstantos, C.
Koops, A.
Korkmaz, M.
Kosanke, Y.
Kseolu, K..F.
Kothary, N.
Koukounaras, J.
Kovacs, S.
Kovatcheva, R.
Kowoll, A.
Koyama, T.

S355

SS/FC/HL/HTS/CM
Author Index

CIRSE 2015
2016

P-250, P-391
P-141, P-516
P-179
P-550, P-570
P-65
P-476
P-636
P-148
P-329
708.1
P-399, P-412, P-448
P-645
P-75
P-546
P-394, P-564
1507.2, P-430
P-190
P-244
P-457, P-472
707.4
P-585
P-297, P-345, P-378
P-493
P-329
P-527, P-531
2304.6, P-187
P-278
P-446, P-541
P-394, P-564
104.3, 1509.3, 2206.5,
P-339
1506.4, 2504.3, P-49,
P-62, P-208, P-352,
P-353
P-351
P-318
P-297, P-345, P-378
1803.1
P-394, P-564
P-334
P-580
P-112
2503.1
P-511
P-150, P-177, P-349,
P-447, P-454
P-90, P-536, P-571
P-198, P-307
P-126, P-196
P-520
P-129
3005.2
P-3, P-280, P-479, P-480,
P-603
P-165, P-180, P-245,
P-247, P-252, P-581
P-79
1509.1
P-124
P-304
1507.3
P-337
P-408
706.6, P-524
102.3
3104.3
P-182, P-422

Koyama, Y.
Koyashiki, Y.
Koyasu, H.
Kozaka, K.
Kozhevnikov, D.
Kozlov, A.
Kraitchman, D.L.
Kralj, I.
Krausz, D.
Krautschneider, W.
Krebs, H.
Krishnan, P.
Krishnasamy, V.
Krger, K.
Kuang, M.
Kubo, S.
Kudo, K.
Kudo, M.
Kuehne, T.
Kugiyama, T.

P-143
P-543
P-180, P-252
P-394, P-564
P-5
P-332
3105.3
P-471, P-476, P-477
P-556
1509.1
2306.4
3005.3
708.6, P-306, P-308
P-344
P-420
P-237
P-379, P-550
P-453
2304.2
P-150, P-177, P-447,
P-454
Kuhara, A.
P-150, P-177, P-349,
P-447, P-454
Kuhelj, D.
1702.4
Kuhl, C.
P-98, P-371, P-545
Kulik, L.
P-263
Kulkarni, S.S.
P-85, P-134, P-381,
P-397, P-398
Kumar, P.
P-153, P-397, P-398,
P-577
Kumar, V.
P-270, P-611
Kumita, S.-I.
P-167, P-561
Kumita, S.-N.
P-333, P-499
Kundaragi, N.
P-235, P-635
Kuo, W.T.
P-614
Kupcsulik, P.
P-551
Kurokawa, S.
3104.5
Kuroki, K.
P-427
Kurup, A.N.
P-68
Kurz, P.
P-244
Kushihashi, T.
P-605
Kusumawidjaja, D. 2206.4, P-490
Kusumoto, M.
P-349, P-447, P-454
Kuti, F.
P-467
Kwok, N.
P-387
Kwon, J.H.
P-216
Kwon, S.H.
P-233
Kyaw Tun, J.
P-625

L
La Fougre, C.
P-354
La Marra, A.
P-509
Laasch, H.-U.
607.2
Labarre, D.
705.4, 1508.3, 2207.1
Laborda, A.
P-286, P-613, P-614
Lacch, A.
P-555
Lacroix, A.
706.3
Laenen, A.
1507.4
Laffy, P.Y.
P-486
Lagan, F.
P-336
Lahuerta, C.
P-613, P-614
Laiolo, E.
P-241
Laird, J.R.
3005.3
Lake, E.
P-149, P-530
Lakshminarayan, R. P-621
Lammer, J.
1301.1, 1408.6

Lanciego, C.
Lang, W.
Langenbach, M.
Langleib, M.
Laniado, M.
Lanocita, R.
Lapuyade, B.
Laterre, P.
Latich, I.
Lau, R.
Laurent, A.
Laurent, F.
Laurinkiene, J.
Lawler, L.P.
Layton, K.F.
Le Jeune, P.
Le Pennec, V.
Lea, T.
Lease, J.L.
Leati, G.
LeBlanc, K.
Lederer, W.
Lee, A.
Lee, B.C.
Lee, D.
Lee, D.Y.
Lee, E.W.
Lee, F.
Lee, H.
Lee, H.G.
Lee, J.H.
Lee, J.M.

P-323
606.2, 606.3
P-325
P-40, P-168, P-169
606.4
P-350
1506.3
P-142
2305.2
P-385
705.4, 1508.3, 2207.1
P-347
P-82
P-108
2604.1
2704.2
2307.5
P-465, P-475
3104.1
2305.5, P-122
606.5
705.6
1506.6, P-511
P-582, P-629
P-423
P-216
606.5
P-599
P-141, P-516
P-140
P-423
P-44, P-154, P-199,
P-402, P-565
Lee, K.H.
P-35
Lee, K.-S.
P-622
Lee, M.
P-549
Lee, M.J.
202.1, P-126
Lee, S.H.
P-591
Lee, S.-H.
P-77
Lee, W.-H.
P-44, P-199, P-565
Lee, Y.-H.
2304.6
Leef, J.A.
P-589, P-590
Lehrman, E.
P-270
Leigh, R.
P-219
Leito, J.
P-637
Lencioni, R.
3301.1, P-306, P-358
Lenhart, L.
3105.2, P-346
Lenton, J.
P-185
Leon Donoso, M. P-600
Leong, S.
P-118, P-392
Len Rafael, J.
P-100
Lepareur, N.
P-303
Lerario, A.M.
P-89
Lerut, J.
P-449
Leung, D.
P-179
Levy, E.
708.6, P-306, P-308
Lewandowski, M. P-455
Lewandowski, R.J. 1701.2, P-263, P-369,
P-375, P-615, P-620
Lewis, A.
708.6, 2305.1, P-306,
P-308
Leyva Vsquez-Caicedo, M.
P-47, P-170, P-279,
P-547, P-572
Li, G.
P-426
Li, J.
P-321
Li, S.
3105.2, P-346

S356

Li, T.-F.
P-282
Li, X.
P-321
Li, Y.-J.
P-289
Lichtenberg, M.
3106.1
Liebl, M.
P-98, P-371, P-545
Lin, C.-W.
P-365
Lin, L.-S.
P-638
Lin, S.
P-321
Lin, S.-Y.
2304.6
Lindgren, H.
P-464
Lindsay, R.
P-121
Lipnik, A.
P-439
Little, M.W.
P-459, P-522
Littler, P.
P-331, P-505
Liu, D.
P-369
Liu, J.
P-94
Llanos Jimnez, L. P-323
Llavata, A.
P-61
Lo, H.G.R.
P-118, P-392
Lo, T.
3104.3
Lobo, K.
P-611
Loehr, C.
3104.3
Loesaus, J.
P-472
Loffroy, R.
304.3
Lohle, P.N.M.
204.3, 1506.1, 2604.2
Lokken, R.P.
P-439
Lombardi, P.
P-115
Lombardo Galera, S.
P-120, P-558, P-593
Lonjedo, E.
P-232
Lookstein, R.A.
3302.4, P-361
Loose, R.W.R.
1901.2
Lopes, P.
101.4, 2704.1
Lpez-Ben, S.
P-548
Lopez-Carreira, L. P-323
Lorenz, J.M.
P-589, P-590
Lottes, A.E.
3005.2
Lourenco, P.
P-338
Lu, W.
P-30
Lubrano, J.
P-340
Luca, A.
2307.6, P-557
Lucatelli, P.
1508.5, P-335
Lueg, C.
P-112
Luigiano, C.
P-45
Luki, B.
P-17, P-294
Lunardi, A.
P-487
Lunardi, G.
P-193
Lundon, V.
2304.3, P-186
Luppi, G.
1407.1, 1407.2

M
Ma, J.
P-282
Macdonald, A.
P-522
Macfarlane, C.
708.6, P-308
Macher-Gppinger, S.
705.1
Maclean, D.F.W.
P-135, P-145, P-258
Madassery, S.
1507.6, P-648
Madhavan, M.
P-93
Madoff, D.C.
2306.4
Madrid, J.M.
P-76
Maeda, H.
P-412
Maestri, M.
2305.5
Mafeld, S.
708.4, P-331, P-505
Maglione, F.
P-147, P-513
Magnani, R.
P-239

CIRSE

Abstract Book

Magnano San Lio, V.

P-296
Maher, B.
707.1, 2207.2, P-135,
P-258
Mahnken, A.H.
705.5, 1101.3, P-55
Mhringer-Kunz, A. P-345, P-378
Mailli, L.
2207.3
Majdalany, B.S.
P-437, P-450
Majeed, O.
P-315
Makhonin, A.A.
P-424
Mkinen, K.
P-607
Makino, W.
P-148
Makris, G.
P-459
Malagari, K.
1004.3, P-374
Maleux, G.
1507.4, 2703.4
Malfa, P.
1507.5
Mali, W.P.T.M.
P-473, P-474
Mancini, A.
P-81
Mancini, M.
P-137
Mani, N.B.
P-214, P-640, P-651
Manninen, H.I.
P-607
Manzi, M.G.
1408.2
Manzoor, K.
1508.1
Marcello, R.
1703.1
Marchal, C.
P-521
Marchian, A.V.
P-350
Marcia, S.
P-78
Mariani, S.
P-509
Marini, S.
P-78
Marino, M.A.
708.3
Markl, M.
P-263
Marotti, N.
P-241
Marquardt, S.
P-316
Marra, P.
1509.6, P-240, P-528
Marrocchio, C.
P-206
Mart-Bonmat, L. P-100
Martin, R.C.G.
1508.6, 2306.6
Martinez, J.M.
P-539, P-578
Martinez Higueros, C.L.
P-24, P-195
Martnez Rodrigo, J.
P-100
Martn Martn, S. P-592
Martirosian, P.
P-482
Maruta, K.
P-12
Maruzzelli, L.
2307.6, P-557
Marzano, L.
P-486
Marzio, A.
P-336
Maschera, A.
P-512
Masciocchi, C.
1506.5, P-81, P-87, P-509
Masrani, A.
1507.6, P-18, P-400,
P-401, P-445, P-451,
P-573, P-648
Massaro, J.
3106.3
Massmann, A.
707.3, 1407.6, 2603.4,
P-521
Masso Romero, J. 3104.3
Masuda, K.
P-579
Masuda, Y.
P-427
Masulovic, D.
P-17
Mathew, A.
2206.4
Mathias, N.
P-127
Matkaselk, I.
3104.2, P-283
Matsubara, T.
P-394, P-564
Matsui, O.
P-394
Matsumoto, A.H. 3106.3
Matsumoto, S.
P-190

C RSE

Matsumura, T.
Matsunari, K.
Matsuo, M.

P-173
P-605
P-165, P-180, P-245,
P-247, P-252
Matsushita, N.
P-328
Matsuura, T.
P-526, P-544
Mattle, H.
2102.1
Matusnaga, K.
P-246
Mauri, G.
P-9, P-43, P-58, P-125,
P-231, P-234, P-272,
P-343, P-633, P-634
Mawko, G.
P-369
Mayes, A.
2307.1
Maynar, M.
P-483
Mayoral Campos, V. P-286, P-613, P-614
Maystrenko, D.N. P-13
Mazioti, A.
1506.2, P-111, P-374
Mazza, E.
P-254
Mazza, O.
P-29
McCafferty, I.J.
1703.4, P-320
McCann-Brown, J.A.
706.4, P-621
McCaslin, J.
708.4
McCormack, F.
P-259
McCoy, D.
P-611
McGarry, M.
P-179
Mclaughlin, V.
P-275
McLeod, H.M.
2206.6, P-432, P-442
McNulty, N.J.
P-34
McPherson, S.J.
P-8, P-185
McWilliam, S.
1506.6
McWilliams, R.G. 2206.2, P-621
Medhi, G.
3104.4
Mege, D.
3105.1
Meier, R.
P-112
Meijerink, M.R.
102.4
Mela, P.
705.5, P-211
Melchiorre, F.
P-45, P-137, P-240
Meloni, T.
P-193
Melzer, A.
2206.6, P-432, P-442
Mendez, S.
P-323
Mndez Montero, J.V.
P-47, P-170, P-279, P-547,
P-572
Mendona, B.B.
P-89
Menzel, M.
P-304
Mergeani, A.
P-281
Merino-Casabiel, X. 607.4
Merkely, B.
P-292, P-467
Merolla, S.
1408.5, P-3, P-280,
P-293, P-373, P-468,
P-479, P-480, P-501,
P-555, P-583, P-603
Messas, E.
P-486
Metz, D.C.
P-337
Metzger, C.
3005.3, 3106.3
Meuli, R.
P-388
Meunier, C.
P-347
Meyer, B.C.
P-265, P-618
Meyer, D.R.
P-484
Miah, A.
P-377
Miazga, M.
P-302
Micari, A.
3005.3, 3104.6
Michimoto, K.
P-399, P-412, P-448
Micieli, C.
P-2, P-50
Midia, M.
P-420
Midy, D.
2206.3

Migliorisi, C.
Mikhail, A.
Miki, I.

707.6, 2304.4
P-308
P-167, P-333, P-499,
P-561
Miki, J.
P-399, P-448
Milad, M.P.
2207.4
Milburn, S.
P-128
Miligkos, D.
2207.2
Miller, C.
P-185
Millor, M.
607.3
Milner, A.M.
3104.1
Mimura, H.
P-226
Minami, T.
P-394, P-564
Mincarelli, C.
P-25, P-277
Mine, T.
P-333
Mingjian, L.
P-26
Minocha, J.
P-636
Miotti, D.
2306.3
Miraglia, R.
2307.6, P-557
Mirault, T.
P-486
Mironov, O.
P-368
Mirzaee, H.
2304.2
Miyairi, T.
P-197, P-497
Miyayama, S.
P-394
Miyazaki, M.
P-143
Mizandari, M.
P-27, P-221, P-225,
P-553, P-574
Mizobuchi, N.
P-12, P-256, P-274, P-587
Mizushima, Y.
P-4, P-159, P-160, P-161,
P-646
Mochizuki, T.
P-171
Modestino, F.
P-222
Modi, S.
707.5, P-135, P-145,
P-258, P-421, P-595
Moelker, A.
P-329
Mogami, T.
P-278
Mohr, P.
P-327
Moine, L.
705.4, 1508.3, 2207.1
Moineddin, R.
P-103
Mojtahedi, A.
P-645
Mokry, T.
705.1
Mollaiyan, A.
1509.2
Monabati, A.
P-519
Mondaini, F.
P-254
Monfardini, L.
P-343
Montagne, J.
607.1
Montana, A.
P-296
Monteleone, P.A. 3105.5
Moon, M.H.
P-248
Moon, S.-Y.
P-77
Moore, W.
2306.4
Moramarco, L.P.
2305.5, P-122
Moran, T.H.
3105.3
Morano, G.
P-433, P-630, P-631
Morelli, F.
P-45, P-137, P-240
Moreno, A.
3104.3
Moreno, F.L.
P-91
Moreno Negrete, J. P-525
Moreno Snchez, T. P-419
Mori, H.
P-190
Moriarty, H.K.
P-82
Moriguchi, M.
P-63, P-298, P-407
Morimoto, R.
P-453
Morin, J.
2206.3
Morita, R.
P-379, P-550
Morita, S.
P-604
Moriya, T.
P-157

S357

SS/FC/HL/HTS/CM
Author Index

CIRSE 2015
2016

P-218, P-425
Morosetti, D.
Morosi, C.
P-350
Morris, J.M.
P-68
Morris, L.
2304.5, P-186
Mortensen, F.V.
P-317
Mortensen, N.
P-217
Mosconi, C.
P-222
Mostafa, M.
P-229
Motoi, F.
P-526
Motta Leal Filho, J.M.D.
P-390
Moyse, N.
P-331
Mubarak, W.
P-438
Muchantef, K.
P-421
Mueller, H.
1407.5
Mulazzani, L.
P-305
Mulder, M.
3104.1
Mullan, D.
607.2, P-440
Mller-Hlsbeck, S. 2603.3, 3005.1, 3106.2,
P-476, P-484
Munetomo, Y.
P-278
Muoz Ruiz-Canela, J.J.
P-323
Murakami, K.
P-197, P-497
Murata, K.
P-200
Murata, S.
P-167, P-333, P-499,
P-561
Murayama, S.
P-148
Murch, C.
P-491
Murphy, M.
P-217
Murphy, T.P.
3106.3
Murray, T.
P-461
Mustafa, S.A.R.
P-56
Muto, M.
P-3, P-468
Myouchin, K.
3104.5, P-469
Myrcha, P.
P-290

N
Na, D.G.
Naaisa, F.
Nabeta, M.

P-423
P-255
P-150, P-177, P-349,
P-447, P-454
Nacarino Mejias, V. P-323
Nadolski, G.J.
P-261, P-429
Nagai, T.
P-301
Nagayama, H.
P-155
Naguib, N.N.
P-325
Naiki, T.
P-301
Nair, S.
1508.1
Najran, P.S.
607.2, P-440
Nakagawa, T.
P-15, P-130, P-643
Nakai, H.
P-446
Nakajima, K.
P-328
Nakajima, Y.
P-12, P-226, P-497
Nakamura, H.
P-543
Nakamura, M.
3005.2, P-173
Nakamura, T.
P-173
Nakano, R.
P-200
Nakao, S.
P-4, P-159, P-160, P-161,
P-646
Nakashima, Y.
P-16, P-276, P-403
Nakasone, Y.
P-158
Nakatsuka, A.
P-328
Nakatsuka, S.
P-36, P-132, P-156,
P-534
Nakatsuka, T.
P-546

Nakayama, K.
Nanavati, S.
Nani, R.
Nanto, S.
Napoli, A.
Narasimhan, S.
Narayanan, G.
Nardella, M.
Narita, M.

P-301, P-532, P-533

P-270, P-611
P-350
3005.2
2504.4, P-206
P-504, P-650
P-42, P-306, P-358
P-228
P-4, P-159, P-160, P-161,
P-646
Narkiewicz-Jodko, A.
P-511
Nas, O.F.
P-124, P-295, P-535
Nassef, A.A.
P-72
Nasser, F.
P-390
Nasto, A.
1508.4, P-311, P-312,
P-313, P-314
Natrella, M.
P-193
Navuluri, R.
P-647
Neal II, R.E.
P-204
Negussie, A.
P-308
Neill, M.
706.6
Nemcek Jr., A.
P-375
Nemes, B.
P-292, P-467
Nerla, R.
3104.6
Nesbit, G.
P-285
Nesbitt, C.
708.4, P-128
Nestola, M.
P-228
Neto, J.E.B.
P-89
Neugebauer, M.
2304.2
Nezu, M.
P-453
Ng, C.
P-385
Ni, J.Y.
P-202
Niazi, I.
P-315
Nichelatti, M.
P-137
Nicholson, D.
P-610
Nie, C.-H.
2305.3
Niehaus, K.
P-327
Nielsen, D.T.
P-317
Niessen, C.
P-318, P-344, P-362,
P-363, P-364
Nieto, C.
P-539, P-578
Niklas, C.
707.3
Nikolaou, K.
P-354, P-396, P-482
Nishikawa, H.
P-532
Nishimaki, H.
P-19, P-197, P-246,
P-497
Nishimura, J.-I.
P-15, P-130, P-197, P-643
Nishimura, T.
P-584
Nishina, Y.
P-604
Nishioka, M.
P-16, P-276, P-403
Nishiyama, T.
P-405
Nitatori, T.
P-427
Nitta, N.
P-200
Nivolli, A.
P-517
Nobuhara, M.
P-16
Noda, Y.
P-180, P-252
Noguchi, S.
P-16, P-276, P-403
Noma, S.
P-16, P-403
Norby, R.
P-462
Nordmeyer, H.
2601.1
Nordmeyer, S.
2304.2
Nour-Eldin, N.-E.A. P-205, P-325
Novacic, K.
P-37
Nowakowski, F.S. P-361
Nozawa, Y.
P-278
Numminen, H.
3104.2, P-283

S358

Nunes, T.F.
Nyman, R.

CIRSE

P-239
P-554

O
Oakland, K.
OBrien, C.
Oda, T.
Odashima, M.
ODwyer, E.
Ogasawara, G.
Ogawa, T.
Ogawa, Y.
Ogi, T.
OGrady, E.A.
Oguro, S.
Oguzkurt, L.
Oh, J.H.
Oh, J.S.
Ohgiya, Y.
Ohki, T.
Ohm, J.

P-217
P-60
P-16, P-276, P-403
P-546
P-60
P-246
P-326
P-197, P-497
P-564
P-153
P-36, P-132, P-156, P-534
203.2, P-616
P-233
P-140
P-587
3005.2
P-44, P-154, P-199,
P-402
Ohta, K.
P-131, P-144, P-301,
P-532, P-533
Ohtomo, K.
P-215, P-576
Oji, K.
P-190
Okada, T.
P-90, P-536, P-571
Okumura, A.
P-182, P-422
Okuno, S.H.
P-68
Okuno, Y.
1703.3
Okura, N.
P-576
Oldhafer, K.J.
P-327
Oleschuk, A.N.
P-13
Oliva, V.L.
706.3
Oliver, T.
P-377
Ollikainen, J.
3104.2
Olsson, K.M.
P-265
Omar, A.
2307.2
Omata, K.
P-453
nal, B.
P-46, P-485, P-489
Onaran, M.
P-46
Onishi, Y.
P-446, P-541
Ono, H.
P-197
Ono, S.
P-198
Ono, Y.
P-453
Onozawa, S.
P-167, P-333, P-581
Oosterhof-Berktas, R.
P-520
Ordi i Camprubi, Q. 607.4, 2305.6, P-38
OReilly, M.K.
606.6, P-108
Orlacchio, A.
P-373
Orlov, A.E.
P-342
Orsi, F.
2502.4, P-343
Osawa, M.
P-165, P-245, P-247,
P-581
Oshima, K.
P-143
Osuga, K.
P-96
OSullivan, G.J.
203.3, 706.4
OSullivan, M.
P-60
Oszkinis, G.
1408.1
Ota, H.
P-164, P-178, P-453,
P-526, P-544
Ota, S.
P-200
Ott, I.
P-484
Oudkerk, M.
P-223
Ozer, H.
P-485

Ozturk, K.

Abstract Book

P-295, P-535

P
Paci, E.
Padgett, R.
Padre, C.G.
Paetzel, C.
Page, T.
Pajor, P.
Paladini, A.
Palena, L.M.
Palialexis, K.
Palla, C.
Palussire, J.

P-25, P-277
P-505
P-392
P-477
P-505
P-551
P-594
1408.2
P-79
2504.4
1001.2, 2306.4, 2306.5,
P-65, P-88, P-347, P-410
Pampana, E.
1408.5, P-3, P-280,
P-293, P-468, P-479,
P-480, P-501, P-555,
P-583, P-603
Pan, T.
P-74
Panayotopoulos, P. P-518
Panbude, S.
P-85
Pancione, L.
P-37
Pnek, J.
607.5
Panov, V.
P-404
Papadimatos, P.
1507.2
Papadouris, D.
2306.4
Paprottka, P.M.
P-52
Paquet, F.
P-121
Pramo, M.
607.3, 705.2
Paraskevopoulos, I. 3106.5, P-465, P-475
Parienti, J.J.
P-627
Park, A.W.
P-610
Park, J.
P-54
Park, J.H.
1509.4
Park, S.I.
P-216
Park, S.W.
P-101
Parker, G.
P-537
Parra, D.A.
P-33, P-103, P-438
Parra-Farias, C.
607.4, 2305.6, P-38
Pascale, F.
1508.3
Pasciak, A.
P-415
Pasqua, S.
2306.3
Pastor, A.
P-539, P-578
Pasyk, M.
P-433, P-630, P-631
Patan, D.
1507.5
Patel, A.
P-118, P-392
Patel, B.
P-115
Patel, J.V.
P-185
Patel, M.
P-589, P-590
Patel, P.
P-54, P-381, P-397, P-398
Patel, R.
2704.3, 3105.3, P-179,
P-361, P-459, P-522
Patel, S.
P-7, P-465, P-475
Patelli, G.
2306.3
Patil, A.
P-397
Patrie, J.
P-462, P-610
Ptz, T.
P-73
Paudel, K.
3105.3
Paul-Ferrer, L.
P-22, P-95, P-117, P-133,
P-236, P-367, P-566
Paulis, L.
2307.3
Paulo, G.
1901.3
Pavlovskij, A.
P-332
Peano, E.
P-146
Peck, R.
607.6

C RSE

Pedersoli, F.
P-98, P-371, P-545
Pedicini, V.
P-43, P-125, P-230, P-272
Pedraza, S.
P-548
Pedrazzini, F.
104.4, P-146
Peeters, M.
2306.1
Pegorer, M.
2304.4
Peir de las Heras, J.
P-323
Pekevik, R.
P-431
Pekolj, J.
607.1, P-29
Pelage, J.-P.
2307.5, P-339, P-340,
P-627
P-455
Pelczarska, M.
Pellegrin, A.
P-291, P-360
Pellegrini, P.
P-336
Pellerin, O.
707.2, 1702.2, 2704.2,
3202.4, P-359, P-486
Pelliccione, F.
P-137
Pea Baranda, B. P-323
Pencina, K.
3106.3
Penderkar, H.S.
3104.4
Penegor, S.A.
P-51
Peperhove, M.
P-316
Pereda Rodriguez, J.
P-24
Peregrin, J.H.
303.4
Pereira, P.L.
202.2, 705.1, 2902.2,
3301.3, P-330, P-344
Perera, A.
P-191
Pereyra, S.
P-40
Perez, J.T.
2306.5
Perez Cajaraville, J.J.
P-76
Perez Lafuente, M. 607.4, 2305.6, P-38
Perez Montilla, M.E. P-120, P-558, P-593
Perin, M.A.
P-390
Perrault, F.
706.3
Perreault, P.
706.3
Peschillo, S.
3104.3
Petersen, B.D.
P-285
Petit, A.
1509.3
Petre, E.N.
P-334, P-383
Petridis, I.
P-557
Petrillo, G.
P-296
Petrocelli, F.
P-9, P-48, P-152, P-163,
P-227, P-231, P-253,
P-568, P-588a
Phillips-Hughes, J. 1704.3, P-522
Piacentino, F.
P-1
Picel, A.
P-636
Pienimki, J.-P.
3104.2, P-283
Pieraccini, M.
P-241
Pierredon, M.-A.
1509.5
Pietzsch, J.B.
3005.5
Piffaretti, G.
P-1, P-2
Pinzani, A.
P-336
Piquet, P.
P-6
Piras, E.
P-78
Pittarello, F.
P-336
Pitton, M.B.
P-297, P-345, P-378
Pizzi, G.
P-594
Planert, M.
P-457, P-472
Pleban, E.
2206.1
Pluntke, S.
P-351
Polanec, B.
P-502
Polikarpov, A.
P-332, P-567
Pollak, J.
2305.2

Pollock, G.
Polnaya, A.M.

708.1
P-85, P-134, P-381,
P-397, P-398
Pons, M.
P-539
Pook, L.M.
P-51
Poon, D.
P-355
Porcherot, S.
706.1
Poretti, D.
P-125, P-230, P-234,
P-272
Posa, A.
2307.4, P-366
Posada, M.
904.1
Pourghorban, R.
1407.4
Prasad, C.
3104.4
Pregler, B.
P-362, P-363
Preusser, T.
P-73
Prevoo, W.
901.3
Priest, R.
P-285
Prino, A.
2306.3
Pritchard, W.
708.6
Protto, S.M.
3104.2, P-283, P-284
Pu, J.
2304.1
Pua, B.
2306.4
Puckridge, P.
P-264
Pueyo, J.
P-578
Puippe, G.
1802.4
Pulpeiro Ros, J.R. P-323
Punamiya, S.
2703.3, P-41
Puppala, S.
P-185
Puri, A.
P-381
Puthukudiyil, N.K. 1508.1
Putzer, D.
705.6
Pyra, K.
P-302

Q
Qanadli, S.D.
Quarchioni, S.
Quaretti, P.
Quencer, K.B.
Quesada, R.
Qvarfordt, P.

3202.3
P-87, P-509
2305.5, P-122
2305.2
1508.2, P-97
P-464

R
Raatschen, H.-J.
Rabinovitz, M.
Rabuffi, P.
Rachapalli, V.
Radaelli, A.
Radeleff, B.A.
Radosa, C.G.
Radosa, J.C.
Radosevic, A.
Radtke, U.
Ragg, J.C.
Ragozzino, A.
Railton, N.
Rajan, D.K.
Rajani, R.
Ramachandran, S.
Ramalho, M.
Ramaswamy, R.
Ramiro Gandia, R.
Ramos, J.
Rampoldi, A.G.

S359

SS/FC/HL/HTS/CM
Author Index

CIRSE 2015
2016

P-357
P-214
P-218, P-425
P-235, P-635
708.6, P-308
705.1, P-330, P-560
606.4
606.4
1508.2, P-97, P-324
P-476
706.2, P-210, P-623
P-220
P-320
606.1
P-554
P-417
P-637
P-651
P-61, P-600
1509.5
707.6, 2304.4

Rao, P.P.

705.3, 1506.4, P-49,

P-62, P-208, P-209,
P-352, P-353
P-193
Rapellino, A.
Rasekhi, A.
P-519
Rasmussen, F.
P-317
Raspanti, C.
P-254
Ratcliff, C.
P-128
Rathmann, N.
103.2
Ratnam, L.
2207.3
Ratti, F.
1509.6
Raudsepp, T.
P-194
Ravenda, P.
P-343
Ravi, R.
P-153
Rawf, F.R.
P-443
Ray, A.F.
707.5
Ray, B.
P-393
Ray, Jr., C.E.
P-105, P-439
Ray, S.
706.1
Redlich, U.
P-484
Redondo Olmedilla, M.
P-269
Reekers, J.A.
2503.3, 3005.4
Reeves, H.
P-331
Refai, M.
P-277
Regalado, S.
P-628
Regi, J.M.
2206.4
Regus, S.
606.2, 606.3
Rehman, I.
P-315
Reiner, E.
P-428
Reiser, M.F.
P-52, P-53
Renaud, P.
P-209
Renc, O.
2703.1
Renz, D.M.
P-510
Renzulli, M.
P-222
Renzullo, M.
P-121
Reppas, L.
1506.2, P-80, P-111
Resnick, S.A.
P-416
Rho, M.H.
P-35, P-288
Riambau, V.
P-481
Richter, G.M.
P-244, P-330
Ricke, J.
2306.1, P-470, P-484
Ricoeur, A.
P-209
Ridouani, F.
1509.3, 2206.5
Rieder, C.
P-73
Rieger, J.
P-322
Riekkinen, T.
P-607
Rigamonti, P.
P-9, P-10, P-11, P-39,
P-43, P-58, P-125, P-152,
P-181, P-192, P-230,
P-231, P-234, P-251,
P-272, P-273, P-588a,
P-633, P-634
Rilling, W.S.
1701.3
Rimon, U.
P-129
Ringe, K.I.
P-357, P-618
Rinnenthal, J.
P-213
Rivolta, N.
P-2
Robertson, I.
P-106, P-194
Robertson, J.
2206.6, P-432, P-442
Robinson, D.
P-537
Robinson, G.J.
3202.2, P-621
Robinson, S.I.
P-68
Robson, K.
P-505
Roek, M.
3302.3
Rodoplu, O.
P-608, P-609
Rodriguez, A.
P-40

Rodriguez, B.
P-578
Rodrguez-Fraile, M.
705.2
Rodriguez-Rosales, G.
P-138, P-162, P-166,
P-641
Rodriguez-Takeuchi, S.Y.
P-31
Rodt, T.
P-316, P-461
Rogan, C.
P-537
Rolland, Y.
P-303
P-205
Roman, A.
Roman, T.
P-302
Romani, F.
2304.4
Romano, F.
P-220
Rongen, L.
705.5
Roohani, P.
3104.1
Roosen, L.J.
1507.1
Rorsman, F.
P-554
Rosati, M.
P-25, P-277
Rose, P.S.
P-68
Rose, S.C.
P-337, P-414
Rosenqvist, K.L.C. P-554
Rossi, U.G.
2305.4, P-1, P-2, P-9,
P-10, P-11, P-39, P-43,
P-50, P-58, P-125,
P-152, P-181, P-192,
P-230, P-231, P-234,
P-251, P-272, P-273,
P-588a, P-633, P-634
Rssle, M.
1509.2
Rotzinger, R.A.
P-510
Routledge, T.
P-444
Rovati, M.
P-240
Roy, I.N.
708.2
Rubinsky, B.
707.4
Rubis Passonia, G. P-39, P-230
Rudarakanchana, N.
P-191
Ruef, J.
P-471
Ruers, T.
3201.4
Ruffino, M.A.
3104.6
Ruiz, A.
P-232
Ruiz Santiago, F.
2604.4
Rund, L.
P-105
Russo, C.
2304.4
Ruzsa, Z.
P-292, P-467
Ryan, A.G.
P-82
Ryan, D.T.
606.6
Ryan, E.
P-126
Ryu, R.
P-615, P-620

S
Saar, M.
Saari, P.
Saba, L.
Sabharwal, T.
Sabiniewicz, R.
Sabri, S.
Sadaoka, S.
Saeed, J.
Saeed, M.
Saguchi, T.
Saha, P.
Sai, S.
Sailer, A.M.H.

707.3
P-607
P-78
3201.1, P-444
P-455
P-462, P-610
P-399, P-412, P-448
P-625
P-611
P-157
P-7
P-12, P-256, P-274, P-587
2307.3

S360

Saini, A.
Saini, J.
Saito, F.
Saito, K.
Saitou, H.
Sakaguchi, S.
Sakai, S.
Sakakibara, H.
Sakamoto, A.
Sakamoto, N.
Sakhinia, F.
Sakuhara, Y.
Sakurai, Y.
Salas, N.
Salcedo, G.
Salem, R.
Sallemi, C.
Salman, R.
Salsano, G.

P-386
3104.4
P-15
P-157
P-167, P-499, P-561
P-188
P-604
P-164, P-178
P-333
P-16, P-276, P-403
607.6, 2206.4, P-599
P-379, P-550
P-197, P-497, P-580
P-358
904.1
P-263, P-337, P-375
1509.6
P-243
P-48, P-163, P-227,
P-253, P-568
Salvador, J.
P-232
Samper Wamba, J.D.
P-224
Sanal, B.
P-124
Sanchez, J.
1508.2, P-97
Sanchez, P.
P-324
Sanchez, R.M.
P-507
Sanchez Corral, J. P-323
Sanchez-Claria, R. P-29
Sangfelt, P.
P-554
Santa Mara, E.
705.2
Santl Letonja, M. P-488
Santonati, A.
P-425
Santoni, M.
707.1, 2603.2
Santonocito, S.
1507.5, P-296
Santoro, G.
P-7
Santos Martn, E.G. 1701.1, 3105.6, P-214
Santuari, D.
P-10, P-11, P-181, P-192
Sapoval, M.R.
707.2, 1702.2, 2704.2,
3106.1, P-359, P-486
Sarti, D.
P-305
Sasaki, T.
P-543
Sastre, M.
P-578
Sato, J.
P-576
Sato, R.
P-63, P-298, P-407
Sato, T.
P-164, P-460, P-526
Satoh, F.
P-453
Sattler, T.
P-322
Sauguet, A.
3106.1
Sawada, K.
P-182, P-422
Sawada, Y.
P-301, P-532, P-533
Sawaia, R.N.
P-89
Saxon, R.R.
3005.6
Sayeed, S.
P-606
Sayre, J.W.
3105.5
Sbarzaglia, P.
3104.6
Scaglione, M.
P-220
Scalise, P.
P-487
Schaapman, J.
P-370
Schaefer, J.P.
2704.4
Schatka, I.
P-265
Scheinert, D.
1408.3, 3005.3, 3106.1
Schembri, V.
1509.5
Schiappacasse, L. P-388
Schick, F.
P-482
Schima, W.
1704.2
Schlager, C.
P-439

CIRSE

Abstract Book

Schlett, C.
705.1, P-244
Schmid, A.
606.2, 606.3
Schmid, G.
P-471
Schmidt, M.
P-595, P-598
Schmidtmann, I.
P-297, P-345, P-378
Schmit, G.D.
P-68
Schmitt, C.
P-351
Schmitz, J.J.
P-68
Schmitz-Rode, T. 705.5, P-211
Schmuck, B
1302.2
Schneider, G.K.
707.3, 1407.6
Schneider, P.
3005.3
Schnell, S.
P-263
Schnorr, J.
2306.2, P-213
Scholz, J.M.
3104.1
Schook, L.
P-105
Schrder, D.
1509.1
Schrder, H.
3106.2
Schroe, H.
3005.1
Schullian, P.
705.6
Schulte, R.
P-304
Schulze-Hagen, M.F.
P-98, P-371, P-545
Schumann, C.
2304.2, P-73
Schurink, G.W.
2307.3
Schtze, J.
P-213
Schwaiger, M.
P-304
P-52
Schwarz, J.B.
Schwind, R.
P-105
Schwindt, A.G.
3106.6
Scicchitano, M.
P-408
Scott, J.
P-185
Scully, N.
P-242
Secco, S.
707.6
Segarra Medrano, A.
607.4, 2305.6, P-38
Seiji, K.
P-164, P-178, P-453,
P-526, P-544
Seiler-Mussler, S. P-521
Seino, N.
P-12, P-256, P-274,
P-587
Sekiguchi, T.
P-198, P-307
Sempere-Campello, G.
P-61, P-600
Sempoux, C.
P-319
Sen, .
P-46
Seo, T.-S.
P-591
Seow, K.
P-563, P-569
Seppnen, J.
3104.2, P-283
Sergeeva, O.N.
P-404
Sertic, A.
P-622
Servais, E.
705.4, 1508.3, 2207.1
Setacci, C.
3104.6
Settembrini, A.
P-10
Sever, I.H.
P-382
Sewall, L.E.
3005.6
Shabrang, C.
P-556
Shadmani, G.
P-519
Shady, W.
P-383
Shah, A.H.
P-14
Shah, J.H.
P-511
Shaida, N.
P-174
Shamsad, S.
P-523
Shanmugasundaram, P.
1508.1
Shapiro, J.
3106.3
Sharma, K.
708.6, P-306, P-308

C RSE

Sharma, N.K.
Shaw, A.
Shaw, D.R.
Shearkhani, O.
Sheikhi, R.
Shelkov, G.
Shetty, N.S.
Shi, H.
Shibamoto, Y.
Shibata, E.
Shibata, T.
Shibuya, K.
Shim, D.J.
Shim, J.J.
Shimizu, K.
Shimizu, T.
Shimohira, M.
Shimura, S.
Shin, E.J.
Shin, J.H.
Shin, M.
Shin, W.
Shinmoto, H.
Shinozuka, K.
Shirasu, H.
Shong, Y.K.
Shorikov, M.A.
Shrivastava, V.
Shudo, J.
Shui, S.
Shuto, R.
Sideris, A.
Sidhu, A.
Sieders, G.
Sielezneff, I.
Siemer, S.
Sievert, H.
Sihvo, E.
Silickas, J.
Silin, D.
Silipigni, S.
Sillanp, N.
Silvestre, M.
Sim, J.
Sincic, R.
Singh, M.K.
Siniscalchi, A.
Siores, E.
Siracusano, S.
Smaldone, F.
Smith, J.
Smith, P.E.
So, Y.H.
Soejima, K.
Sofia, C.
Sofocleous, C.T.
Sofue, K.
Sojka, M.
Solcia, M.
Solomon, S.B.
Solouki, M.
Solovov, V.A.

2306.1
P-238, P-242, P-597
P-185, P-496
P-617
P-554
P-5
P-85, P-134, P-381,
P-397, P-398
P-118
P-131, P-144, P-301,
P-532, P-533
P-215, P-576
P-310
P-143
P-559
P-20, P-21
P-399, P-412, P-448
P-178
P-131, P-144, P-301,
P-532, P-533
P-198
3105.3
706.5, P-506, P-527,
P-559
P-216
P-216
P-104
P-310
P-584
P-423
P-404
P-183
P-427
P-282
P-190
P-54
606.1, P-94
P-223
3105.1
707.3
3106.1
P-607
P-475
P-428
708.3
3104.2, P-283, P-284
P-147, P-513
P-423
P-611
P-511
P-66
P-430
P-336
P-81
P-478
P-498
P-248
P-427
708.3
1001.4, P-334, P-383
P-90, P-536, P-571
P-302
707.6, 2304.4
2306.4, P-334, P-383
P-223
P-342, P-424

Somasundaram, V.H.
1508.1
Someya, Y.
P-446, P-541
Somma, F.
P-309, P-380
Sommer, C.M.
705.1, P-244
Sone, M.
P-96, P-226
Song, M.G.
P-591
Soni, J.
1507.6, P-648
Sonoda, A.
P-200
Sonokawa, T.
P-546
Sortino, D.
104.4, P-146
Sotomayor, A.
P-268, P-525
Soulen, M.C.
P-261, P-337
Soulez, G.
706.3
Sourouni, S.
1507.2
Sousa, M.J.
101.4, 2704.1
Sousa, P.F.
P-495, P-503
Soyama, T.
P-379, P-550
Spada, A.
P-425
Spark, I.
P-264
Speck, U.
P-470
Spies, J.B.
204.4
Spiking, J.
P-242
Spiliopoulos, S.
1507.2, P-374, P-430
Spinelli, A.
P-78
Spinelli, M.
707.6
Spink, C.
1509.1
Sponza, M.
P-291, P-360
Spreafico, C.
P-350
Spreen, M.
P-473, P-474
Sprengers, R.
P-473, P-474
Squarza, E.
P-168, P-169
Squirrell, C.
708.1
Srinivasa, R.
P-588
Srinivasan, S.
P-153, P-577
Stacul, F.
102.1, P-336
Stahl, M.
P-351
Stahlberg, E.
P-457, P-472
Stahnke, S.
3106.2
Stampfl, U.
705.1
Stang, A.
P-327
Stankovic, Z.
P-263
Stashek, K.
P-337
Stassen, E.
P-520
Statius van Eps, R. P-473
Stavrou, G.A.
P-327
Stechele, M.
2306.2
Steele, K.
3105.3
Stefanini, M.
1408.5, P-293, P-480
Stefanov, F.
2304.3, P-186
Steffes, M.
3106.3
Stehling, M.
707.4
Stenzl, A.
2701.4
Stimpson, A.L.
P-184
Stckle, M.
707.3, P-521
Stoeckle, E.
P-65
Stolzenburg, N.
2306.2, P-213
Stone, J.R.
P-610
Stracke, C.P.
2601.1
Streitparth, F.
2306.2, P-213, P-510
Strobl, F.F.
P-52
Stroszczynski, C. P-318, P-330, P-344,
P-362, P-363, P-364
Strumberg, D.
P-351
Su, I.-H.
2304.6
Suarez Anzorena Rosasco, F.J.
P-91

S361

SS/FC/HL/HTS/CM
Author Index

CIRSE 2015
2016

Sucu, M.
Suga, T.
Sugawara, H.
Sugihara, E.
Sugihara, F.

P-382
P-16
P-246
P-515
P-167, P-333, P-499,
P-561
Sugimoto, H.
P-543
Sugimoto, K.
P-90, P-536, P-571
Sugino, Y.
P-328
Sugrue, G.
606.6, P-108
Suh, R.D.
2306.4
Sullo, A.
P-314
Sultan, M.
2304.3
Sultan, S.
2304.3, 2304.5, P-186
Sultato, E.
1408.2
Sun, J.-H.
2305.3
Sun, S.
3105.2, P-346
Sung, C.K.
P-248
Sung, J.Y.
P-423
Suntharanathan, J. P-377
Suri, R.
P-151, P-508
Sutcliffe, J.A.
P-459
Suyama, Y.
P-36
Suzaki, S.
P-604
Suzuki, K.
P-131, P-301, P-532,
P-533
Svetlikov, A.V.
P-5
Svobodova, I.
607.5
Swaelens, C.
2206.2
Swanberg, J.
P-266
Syed, I.
P-37
Syed, M.
P-94
Syha, R.
P-354, P-396, P-482
Symanski, J.
1506.6
Szczerbo-Trojanowska, M.
P-302
Sze, D.Y.
P-337
Szopinski, P.
1408.1, 2206.1

T
Tacher, V.
Tacke, J.
Takagi, H.
Takaki, H.
Takase, K.
Takasugi, S.
Takayama, K.
Takenaga, S.
Takeuchi, Y.
Takkenberg, R.B.
Talamo, M.
Tamura, M.
Tamura, Y.
Tan, A.
Tan, B.S.
Tan, H.-Y.
Tanahashi, Y.
Tanaka, H.
Tanaka, K.
Tanaka, N.
Tanaka, T.
Tanami, M.
Tancray, Y.

1509.3, 2206.5
1408.6, 3106.2
P-164
P-328
P-164, P-178, P-453,
P-526, P-544
P-326
3104.5, P-469
P-579
P-584
P-329
1508.4
P-36, P-132, P-156, P-534
P-492
P-64, P-127
P-118, P-370, P-392
P-264
P-165, P-180, P-245,
P-247, P-252, P-581
P-171
P-494
P-150, P-177, P-349,
P-447, P-454
2502.2
P-546
2307.5

Tani, R.
Taniguchi, T.
Tapping, C.R.
Tarantino, F.P.
Tarantino, L.

P-90, P-536, P-571

P-16, P-276, P-403
P-522
P-207
1508.4, P-311, P-312,
P-313, P-314
Tarantino, P.
1508.4, P-311, P-312,
P-313
Tarazov, P.
P-332, P-567
Tarkhanov, A.
P-411
Tarrel, R.M.
3104.1
Tarulli, M.
P-34
Tasse, J.
1507.6, P-400, P-573,
P-648
Tasu, J.-P.
P-339
Tateishi, H.
P-427
Tavare, A.
P-386
Tvora, I.
P-637
Tay, K.-H.
P-118, P-392
Teichert, C.
P-626
Teichgrber, U.
903.2, P-257, P-493,
P-602
Teigen, C.
3005.6
Tejero, C.
P-286
Teleki, B.
P-292
Ten, J.I.
P-507
Teng, G.-J.
P-74
Tepe, G.
1408.3, 3005.3, P-470,
P-484
Teperman, L.
P-54
Teraa, M.
P-473, P-474
Terada, H.
P-546, P-570
Terayama, N.
P-394
Teriitehau, C.
P-376
Terkamp, C.
P-618
Tesdal, I.K.
P-139
Textor, S.C.
3106.3
Thakor, A.
P-103
Thebault, S.
P-477
Thenint, M.-A.
P-49, P-208, P-352,
P-353
Theodosiadou, V. P-430
Therasse, E.
706.3
Thiounn, N.
707.2
Thiruchunapalli, D. P-235, P-635
Thomas, M.
P-128
Thomas, R.H.
P-644
Thomas, R.P.
1302.2
Thomas, S.M.
2206.4
Thomson, J.
P-8
Thomson, K.R.
P-201, P-204
Thulasidasan, N.
P-529
Thurley, P.D.
708.1
Tich, V.
2306.3
Tilocca, C.
P-296
Tirado, J.
P-115
Tisnado, Jaime
P-433, P-630, P-631
Tisnado, Jamie
P-630
Titano, J.
P-414, P-415
Tobe, S.
3106.3
Toda, J.
P-546, P-570
Togashi, K.
P-310
Tokue, H.
P-143
Tokuuye, K.
P-157
Tomas, M.
P-22
Tomimatsu, H.
P-16, P-276, P-403
Tomozawa, Y.
P-200

S362

Tonkopi, E.
Too, C.W.
Toomay, S.
Toporek, G.
Torcia, P.

P-369
P-118, P-370, P-392
P-28
1407.3
2305.4, P-1, P-2, P-9,
P-10, P-11, P-39, P-43,
P-50, P-58, P-125, P-152,
P-181, P-192, P-230,
P-231, P-234, P-251,
P-272, P-273, P-588a,
P-633, P-634
Torella, F.
2206.2
Toro, J.S.
P-31
Torrecilla Garca-Ripoll, J.R.
P-592
Torreggiani, W.
P-60
Torres, C.
P-421
Torresi, M.
P-122
Torsello, G.
1408.3
Tosoratti, N.
P-207
Tradi, F.
3105.1
Trerotola, S.O.
P-416
Troxler, M.
P-8
Trueba Arguiarena, F.J.
P-592
Trujillo, M.
P-97
Trumm, C.G.
P-52, P-53
Trupp, S.
P-257
Tsai, T.-C.
P-638
Tsai, T.-J.
P-365
Tsang, W.
P-355
Tse, G.H.
P-478
Tselikas, L.
103.3, 902.3, 1506.3,
P-376
Tseng, J.-H.
2304.6
Tsetis, D.K.
101.2
Tsoumakidou, G. 1506.4, 2504.3, P-49,
P-62, P-208, P-352,
P-353
Tsuda, T.
P-171
Tsurkan, V.
P-299, P-372
Tsushima, Y.
P-143
Tullius, T.G.
P-590
Tuney, D.
P-382
Turba, C.
P-648
Turba, U.C.
1507.6, P-18, P-400,
P-401, P-445, P-451,
P-573
Turner, D.
2206.4, P-478
Turtiainen, J.
P-607
Tuttle, K.
3106.3
Tuzzolino, F.
P-557

U
Ubbink, D.T.
Uberoi, R.

2503.2
101.1, 3302.2, P-217,
P-459, P-522
Udaondo Cascante, M.
P-592
Uder, M.
606.2, 606.3
Ueda, T.
P-167, P-333, P-499,
P-561
Ueshima, E.
P-90, P-536, P-571
Uflacker, A.
P-610
Ugajin, A.
P-543
Ugas, M.
P-462

CIRSE

Ukrow, A.
Uller, W.
Ulmer, H.
Unni, A.K.K.
Unno, M.
Uraki, J.
Urbani, M.
Urbano, J.

Urlings, T.A.J.
Usui, R.
Uthappa, M.
Utili, A.

Abstract Book

P-470
P-456
705.6
1508.1
P-526
P-328
P-336
304.1, P-22, P-95,
P-117, P-133, P-236,
P-323, P-367, P-566
P-118, P-392
P-4, P-159, P-160, P-161,
P-646
P-235, P-635
P-48, P-163, P-227,
P-253, P-568

V
Vagnarelli, S.
Vaiani, M.
Valdes, M.
Valdes Solis, P.
Valdivia Ruiz, J.
Vlek, V.
Valenti, D.A.

P-218, P-425
P-350
P-483
P-419
P-224
607.5
P-121, P-421, P-540,
P-595, P-598
Valji, K.
P-416
Vallabhaneni, S.R. 708.2
Vallati, G.
P-594
Valle, L.G.M.
P-390
Van Buskirk, M.
2306.1
Vance, A.Z.
P-179
Vance, L.
P-94
Van Cutsem, E.
2902.1
van Delden, O.M. 2306.6, P-329
Vandenabeele, L. P-32
Van Den Bergh, F. P-32
van der Bom, M.
708.6, P-308
van der Leij, C.
2307.3
Vander Mijnsbrugge, W.
1507.4
van Erkel, A.R.
P-370
Van Ha, T.G.
P-589, P-590, P-647
van Hazel, G.A.
2306.1
van Hooft, J.E.
2306.6
van Laarhoven, H.W.
2306.6
Vanlangenhove, P. P-32
van Lienden, K.P. 2306.6, 2502.3
Vano, E.
1901.4, P-507
van Overhagen, H. P-473, P-474
van Zwam, W.H.
2307.3, 2501.4
Vappou, J.
705.3
Varano, G.M.
1004.1, P-343
Vari, A.
1101.2, 1101.5
Varma, R.
P-214
Varrassi, M.
P-87
Vasan, A.
3105.5
Vasani, J.D.
P-500, P-612
Vaswani, D.
1506.6
Vavra, P.
904.3
Vecchietti, F.
P-66, P-69, P-70
Vedantham, S.
3302.1
Vgh, E.M.
P-292, P-467
Velez, E.
P-270
Vella, A.
P-137

C RSE

Vellody, R.
Velonakis, G.

P-59
1506.2, P-79, P-80,
P-374
Venkat, S.
P-306, P-358
Venkatanarasimha, N.K.K.
P-118, P-392
Venturini, M.
1509.6, P-240, P-528
Verbeeck, N.
1507.4
Vercelli, R.
707.6, 2304.4
Vergoossen, L.
2307.3
Verhaar, M.
P-473, P-474
Vermassen, F.E.
1302.4
Vidal, V.
904.4, 3105.1, P-413
Villa, C.
P-91
Villedieu, F.
P-627
Vinay, C.
P-146
Viniol, S.
P-55
Virdee, S.R.
P-389
Virk, J.S.
P-361
Virmani, R.
2603.1
Vishwanath, D.
P-491
Vit, A.
P-291, P-360
Vitali, S.
P-487
Vivas, I.
607.3
Vliegenthart, R.
P-223
Vo Chieu, V.D.
P-357
Vogel, A.
P-316
Vogel, J.A.
2306.6
Vogelzang, R.L.
2207.4, P-416
Vogl, T.J.
P-205, P-325
von Sedewitz, C.U. P-327
Vorontsov, I.
P-299
Vorwald, P.
904.1
Vos, J.A.
203.4, P-474
Vozdvizhenskiy, M.O.
P-342, P-424
Vyhmeister, R.
1506.6

W
Wach, B.
Wacker, F.

705.3, P-209
P-265, P-316, P-357,
P-461, P-618
Wada, T.
3104.5
Wadhwani, A.
708.5, P-219
Wah, T.M.
P-320
Wahl, K.
P-476
Waliscewski, M.W. P-484
Walker, N.
P-444
Walker, P.
P-185
Wallace, A.N.
1506.6
Wallace-Severa, M. P-511
Wang, M.
P-420
Wang, S.
3105.2, P-346, P-426
Wang, X.
P-321
Wang, Y.
P-26
Wanhainen, A.
P-266
Ward, E.
P-60
Warnica, W.
P-420
Watanabe, R.
P-57, P-406
Watanabe, S.
P-200
Weber, J.
2501.2, 3104.3
Weber, S.
1407.3
Weber, W.
3104.3
Wei, C.
P-26
Wei, W.-S.
P-289
Weinmann, A.
P-297, P-345, P-378

Weisbrod, A.J.
Weiss, C.R.
Weiss, K.-H.
Weiss, N.
Weisstuch, J.
Wenzhe, F.
Werk, M.
Werncke, T.
Werner, M.
Wetton, C.
Wever, J.
White, R.D.
White, S.B.
Whomsley, R.
Widlan, F.
Widmann, G.
Wiedermann, F.
Wiedner, M.
Wierzgon, M.
Wiggermann, P.

P-68
904.2, 3105.3
P-560
606.4
P-524
P-26
P-470
P-265
1408.3
P-242, P-597
P-474
P-56, P-418
P-337
2305.1
P-212
705.6
705.6
P-457
P-471, P-477
P-318, P-344, P-362,
P-363, P-364
Wigham, A.J.
P-522
Wildberger, J.E.
2307.3
Wildenberg, J.
P-261
Wildgruber, M.
P-112
Wileyto, E.P.
P-337
Wilhelmi, M.
P-461
Wilkins, L.
P-610
Wilkinson, T.
2206.6, P-432
Willfort-Ehringer, A. 3106.1
Williams, D.
P-23, P-275
Williams, R.
708.4
Willis, S.
708.6, P-308
Wilmink, J.W.
2306.6
Wilson, I.
P-621
Wilson, M.
P-270, P-611
Wittebole, X.
P-142
Wittgenstein, H.
2306.2
Woehrle, N.
P-322
Wohlgemuth, W.A. 1803.3, P-456
Wojtal, K.
P-302
Wojtarowicz, A.
P-455
Wolf, F.
1408.3, 1802.1, P-211
Wolosker, N.
P-390
Won, J.H.
P-20, P-21
Won, J.Y.
P-216
Wong, R.
P-385
Woo, Y.N.
P-141, P-516
Wood, A.M.
P-56
Wood, B.J.
708.6, P-306, P-308
Woodhams, R.
P-19, P-246
Woodrum, D.A.
2306.4
Wrns, M.A.
P-297
Wright, C.
P-242
Wu, W.
2304.1

X
Xi, Y.
Xing, B.
Xu, L.F.
Xu, Z.

P-28
P-321
P-202
P-426

Y
Yabuta, M.
Yadav, A.K.

S363

SS/FC/HL/HTS/CM
Author Index

CIRSE 2015
2016

P-182, P-237, P-422

P-384, P-514

Yagihashi, K.
Yaltrk, E.
Yamada, K.
Yamada, M.
Yamaguchi, H.
Yamaguchi, M.
Yamakado, K.
Yamamoto, M.
Yamamoto, T.

P-176
P-46
P-104, P-494
P-160
P-167, P-333, P-561
P-90, P-536, P-571
P-328
P-104, P-494, P-581
P-75, P-165, P-245,
P-247, P-581
Yamamoto, Y.
P-237
Yamanaka, T.
P-328
Yamane, T.
P-19, P-246
Yamanishi, T.
P-341
Yamashina, A.
P-157
Yamashita, J.
P-157
Yamashita, R.
P-446, P-541
Yamashita, Y.
P-158, P-492
Yamauchi, J.
P-526
Yamazaki, H.
P-604
Yamazaki, M.
P-15
Yamazoe, S.
P-278
Yanagisawa, T.
P-412
Yang, S.B.
P-199, P-565
Yang, Z.-Q.
P-262
Yannes, M.P.
3105.6
Yao, S.
P-200
Yarmohammadi, H. 2306.4, P-337, P-383
Yasui, D.
P-167, P-333, P-499,
P-561
Yasui, T.
P-301
Yazol, M.
P-46, P-485
Yldrm, E.
P-287
Yildiz, A.
P-124
Yilmaz, M.B.
3105.4
Yim, N.Y.
P-582, P-629
Ying Qiang, Z.
P-26
Yokoi, H.
3005.2
Yoneda, N.
P-394, P-564
Yoon, C.J.
P-141, P-516
Yoshida, K.
P-394, P-564
Yoshino, Y.
P-580
You, K.
2206.5
Young, M.L.
3104.1
Yoza, K.
P-63, P-298, P-407
Yrizarry, J.
P-42
Yu, E.M.M.
P-201, P-204
Yu, S.C.-H.
P-385
Yu, W.
P-26
Yunaiyama, D.
P-157

Z
Zalog, P.
1408.4
Zampino, M.
P-343
Zander, T.
P-483
Zangos, S.
P-205
Zapf, S.
707.4
Zaragozano Guillen, R.
P-642
Zaree, E.
P-519
Zarek, M.
P-212
Zayed, H.
3005.5, 3106.5, P-7,
P-465, P-475
Zech, C.J.
902.2
Zeile, M.
P-327
Zelek, K.
1803.4

Zeller, T.

1408.3, 3005.1, 3005.3,

P-470, P-484
Zerlauth, J.-B.
P-388
Zhang, L.
P-289
Zhang, X.F.
P-369
Zhang, Y.-L.
2305.3
Zhemchugov, A.
P-5
Zhong, J.
P-320
Zhou, G.-H.
2305.3
Zhu, H.-D.
P-74
Zhu, X.
P-321
Zimmermann, M. P-98, P-371, P-545
Ziv, E.
P-383
Zsirka-Klein, A.
P-551
Zugaro, L.
1506.5, P-81, P-509
Zurera Tendero, L.J. P-120, P-558, P-593
Zutshi, A.
P-93
Zymvragoudakis, V. 3106.5

IDEAS
2

S e p t e m b e r 11-13
B a r c e l o n a / S p a i n

ABSTRACTS &
AUTHOR INDEX

S367 PART 1:
S385 PART 2:

Lecture Sessions
Hot Topic Lectures
Author Index

Online Publication Number:

10.1007/s00270-016-1405-3

C RSE

Cardiovascular and Interventional Radiological Society of Europe

IDEAS
2

S e p t e m b e r 11-13
B arcelona/Sp ain

PART 1
Abstracts of
Lecture Sessions
Hot Topic Lectures
sorted by presentation
numbers

C RSE

Cardiovascular and Interventional Radiological Society of Europe

S368

CIRSE

Lecture Session
Thoracic dissections

Abstract Book

905.2
Ancilliary techniques in complicated type B dissections
D.M.Williams
Radiology, Frankel Cardiovascular Center University of Michigan, Ann
Arbor, MI, United States of America

905.1
Do we need a new classification for type B dissection?
M.D.Dake
Cardiothoracic Surgery, Stanford University, Stanford, CA, United States
of America
Learning Objectives
1. To learn about existing classification of type B dissection
2. To learn about shortcomings in the existing classification
3. To learn about the different components that led to a proposal
for a new classification
The role of imaging in a new classification system for aortic dissection DISSECT
Classification systems for aortic dissection provide important guides
to clinical decision making, but the relevance of traditional categorization schemes is being questioned in an era when endovascular techniques are assuming a growing role in the management of
this frequently complex and catastrophic event. In recognition of
the expanding range of interventional therapies now used as alternatives to conventional treatment approaches, the Working Group
on Aortic Diseases of the DEFINE Project developed a categorization
system that features the specific anatomic and clinical manifestations of the disease process that are most relevant to contemporary
decision making.
The DISSECT classification system is a mnemonic-based approach
to the evaluation of aortic dissection. It guides clinicians through an
assessment of 6 critical characteristics that facilitate optimal communication of the most salient details that currently influence the
selection of a therapeutic option, including the findings that are key
when considering an endovascular procedure but are not taken into
account by the DeBakey or Stanford categorization schemes. The
6 features of aortic dissection include: Duration of disease, Intimal
tear location, Size of the dissected aorta, Segmental Extent of aortic
involvement, Complications of the dissection, and Thrombus within
the aortic false lumen.
In current clinical practice, endovascular therapy is increasingly considered as an alternative to medical management or open surgical
repair of aortic dissection. The use of a new system for categorization of aortic dissection, DISSECT, addresses the shortcomings of
well-known established schemes devised over 40 years ago before
the introduction of endovascular techniques. It will serve as a guide
to support a critical analysis of contemporary therapeutic options
and inform management decisions based on specific features of the
disease process.
References
1. Dake MD, Thompson M, van Sambeek M, Vermassen F, Morales
JP. DISSECT: a new mnemonic-based approach to the categorization of aortic dissection. EUR J VASC ENDOVASC SURG 2013;
46:175-190.
2. Dake MD. An algorithmic strategy for the evaluation and
management of type B dissections. ENDOVASC TODAY 2014;
13:42-52.
3. Dake M. Timing of TEVAR treatment: when should treatment
occur in acute, initially uncomplicated type B aortic dissection?
ENDOVASC TODAY EUR 2015; 4:4-6.

Learning Objectives
1. To learn about the treatment algorithm for type B dissections
2. To learn about the shortcomings of TEVAR in type B dissections
3. To learn about additional techniques to solve remaining issues
after TEVAR in type B dissections
Fenestration, stenting, and thrombolysis constitute essential tools at
any center treating a substantial number of complicated aortic dissections, which primarily include type B and repaired type A dissections. Complications of dissection include the leaking false lumen,
where endografts have an indispensable role, and malperfusion,
which for the purpose of the interventionalist should be understood
as arterial obstruction. This talk will briefly review the pathophysiology of arterial obstruction in aortic dissection based on anatomy
(dynamic versus static obstruction), physiology (transient, intermittent, and fixed dynamic obstruction), and thrombosis (true versus
false lumen). The complementary roles of fenestration, stenting, and
thrombolysis will then be illustrated with case examples.

905.3
Update on fenestrated and branched grafts in post-dissection
aneurysms
W.Ritter
Radiology, Klinikum Nrnberg Sd, Nuremberg, Germany
Learning Objectives
1. To learn about the definition and indication to treat in chronic
dissections
2. To learn about the technical difficulties with planning of fenestrated/branched stent grafts in post-dissection aneurysms
3. To learn about complications of fenestrated/branched stent
grafts in post-dissection aneurysms
Approximately 20% to 30% of patients suffering from an uncomplicated acute type B dissection will develop a secondary thoracic
(TAA) or thoracoabdominal (TAAA) aneurysm. The goal in the treatment of a post-dissection aneurysm is to exclude the aneurysm from
blood flow and pressure. In case of TAAA formation, a fenestrated/
branched endovascular repair (F/Br-EVAR) is mandated.
Our experience in the treatment of post-dissection aneurysms with
F/Br-EVAR includes 34 patients (29 male, mean age 64.8 9.9 years)
treated from October 2010 to December 2015. All cases were technically successful, but in one case, a retroperitoneal approach was
needed for renal artery catheterization. Two (5.9%) patients died
postoperatively within 30 days: one due to multiple organ failure
and one due to cardiac decompensation. Perioperative spinal cord
ischemia (SCI) occurred in 5 (14.7%) patients. One (2.9%) patient suffered paraplegia with significant improvement prior to discharge,
and four (11.7%) patients suffered transient paraparesis with complete recovery prior to discharge. One (2.9%) patient developed late
(6 months) SCI with urinary incontinence and lower limb weakness
due to regression of a type II endoleak. Mean follow-up (FU) was
18.5 months (range 166 months). One late death was graft related
and occurred 26 months postoperatively due to an aortoesophageal fistula. Five target vessel occlusions were noticed (3 renal arteries, 1 superior mesenteric artery, and 1 celiac trunk) during FU. In
one case, an iliac-renal bypass was performed. One patient with
known occlusion of the other renal artery became dialysis dependent. The remaining three cases were asymptomatic and did not
require treatment. Endoleaks were diagnosed in 17 (50%) patients
during FU. These included 6 (17.6%) type Ib endoleaks from a target

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2016

vessel. Four (11.7%) patients had distal type Ib endoleaks from dissected iliac arteries. Six (17.6%) patients had type II endoleaks. One
(2.9%) patient had a type III endoleak. Reintervention was required
in 10 (29.4%) patients. Six (17.6%) patients were treated for type Ib
endoleak with stent-graft extension into the target vessel or with
re-flairing of the existing stent graft. Other reinterventions included
one iliac-branched device for distal type Ib endoleak, one stentgraft extension to the external iliac artery with embolization of the
internal iliac for type Ib endoleak, one coil embolization of a type II
endoleak, and one implantation of a bridging stent graft for the LRA
for type III endoleak. Aneurysm sac regression during FU was significant (p=0.007) from 66.5 6.5 mm to 57.4 9.5 mm, with a false
lumen thrombosis rate of 78% for patients who completed 6 months
of FU.
F/Br-TEVAR is a feasible option to achieve complete exclusion of
a post-dissection TAAA. Early and mid-term FU seem promising.
Despite the higher need for reintervention, F/Br-EVAR leads to favorable aneurysm remodeling with aneurysm shrinking and high rates
of complete false lumen thrombosis.

905.4
Complications of stent-grafting
C.Nienaber
Cardiology and Aortic Centre, Imperial College, The Royal Brompton &
Harefield NHS Trust, London, United Kingdom
Learning Objectives
1. To learn about the technical principles of TEVAR in thoracic
dissections
2. To learn about complications and how to avoid them
3. To learn about the treatment of complications after TEVAR in
thoracic dissections
No abstract available.

905.5
TEVAR for type B dissection - percutaneous approach: pro
L.B.Lnn
Dept. of Radiology and Dept. of Vascular Surgery, Copenhagen
University National Hospital, Copenhagen, Denmark
The endovascular world has dramatically changed since the
Seldinger technique was introduced in the 1950s. The development has been in several areas. There are ever-improving new closure devices put on the market and, above all, refined endovascular tools that make it possible to achieve hemostasis even after using
large bore sheaths, leaving the ancient manual compression behind.
Thoracic endovascular aortic repair (TEVAR) is increasingly applied in
the treatment of aortic dissections and aneurysms.
The choice of vascular access point depends on the anatomy, the
degree of peripheral artery disease, and the type of percutaneous
procedure. Key to the success of the procedures is optimal preoperative imaging. The computed tomography angiography (CTA) data
provides an opportunity to understand the predictors of vascular
complications and is also useful for patient selection, aortic morphology assessment, access artery patency evaluation, endograft
type selection, and endograft surveillance.
Access to the femoral artery can be achieved with the following:
a. surgical femoral cut down
b. true percutaneous access suture techniques, without any open
surgical component
c. femoral fascial closure, by which the cribriform fascia at the common femoral artery is sutured
d. surgiclose technique, which exposes only the anterior wall of the
common femoral artery

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Type B dissection is a challenging procedure that requires individualized treatment concepts. In order to decrease the incidence of
groin complications, a percutaneous femoral approach or miniinvasive technique should initially be the choice for all endovascular aortic procedures, with a low threshold to convert to traditional
cut-down technique when complications such as bleeding, stenosis, ischemia, or femoral artery injury occur. A total percutaneous
approach in type B aortic dissections reduces hospital stay, complications, and mortality.
References
1. De Backer O, Arnous S, Sandholt B, Brooks M, Biasco L, Franzen
O, Lnn L, Bech B, Sndergaard L. Safety and efficacy of using
the Viabahn endoprosthesis for percutaneous treatment of
vascular access complications after transfemoral aortic valve
implantation. Am J Cardiol. 2015 Apr;115(8):1123-9.
2. Larzon T, Roos H, Gruber G, Henrikson O, Magnuson A,
Falkenberg M, Lnn L, Norgren L. Editors choice. A randomized
controlled trial of the fascia suture technique compared with
a suture-mediated closure device for femoral arterial closure
after endovascular aortic repair. Eur J Vasc Endovasc Surg. 2015
Feb;49(2):166-73.
3. Larzon T, Lonn L, van Den Berg J. How to avoid and manage
groin complications after endovascular repair. Prevention and
Management of Vascular Complications. EVC 2012: M.Jacobs Ed.
Torino Edizioni Minerva Medica Chapter 5, p33-40.

905.6
TEVAR for type B dissection percutaneous approach: con
V.Riambau, S.Pasquadibisceglie
Vascular Surgery Division CardioVascular Institute, Hospital Clinic
University of Barcelona, Barcelona, Spain
Despite the continuous progress in the endovascular treatment of
aortic pathology, vascular access complications are frequent due to
the necessity of large femoral introducer sheaths. Currently, there
are three different techniques to achieve femoral access: surgical
cut down with handmade suture, modified open technique with fascia suture, and the use of suture-mediated closure devices (pTEVAR).
pTEVAR for type B dissection is an attractive solution but has some
general and dissection-related limitations that should be taken into
account.
An electronic search of English literature in Medline PubMed was
performed using the following keywords and their combinations related to the aim of the topic: TEVAR dissection B percutaneous, dissection B TEVAR (between 2010 and 2016), percutaneous TEVAR, percutaneous dissection B, dissection B access,
TEVAR access, percutaneous thoracic endograft, and percutaneous endograft. We considered both case reports with one or more
patients and retrospective and prospective studies. All the articles
were included in the three categories of relevance with respect to
the principal topic (relevance A, B, and C).
Forty-nine articles were considered in this systematic review. No
articles were found for the category of relevance A, nine for category B, and four for category C; the remaining 36 articles were considered poor for relevance and not directly included. We identified
the following limitations of pTEVAR: older age of the patient, arterial
hypertension, severe atherosclerotic and calcified vascular accesses,
dissection involving the common femoral artery and thoracoabdominal repair with higher risk of spinal cord ischemia, and necessity for temporal retrograde iliolumbar perfusion taking out the
large introducer systems.
This systematic review of literature and our own experience on
pTEVAR for type B dissection illustrate how pTEVAR is an attractive
approach with some limitations that should be taken into account.

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Hot Topic Symposium

Aortic emergencies
1302.1
Death and secondary aortic rupture risk 15 years after EVAR or
open repair
R.M.Greenhalgh
Vascular Surgery Research Group, Imperial College, London, United
Kingdom
No abstract available.

1302.2
Acute TEVAR for ruptured aneurysm and dissection
A.Chavan, B.Schmuck , O.Eldergasch, R.P.Thomas
Institut fr Diagnostische & Interventionelle Radiologie, Klinikum
Oldenburg gGmbH, Oldenburg, Germany
Ruptured aneurysms and dissections involving the ascending aorta
or the aortic arch are still a domain of open surgery (1-3). As opposed
to this, pathology involving the descending thoracic aorta is increasingly being endoluminally treated (4-8).
With the interventionalists becoming increasingly familiar with the
Perclose technique under local anesthesia, thoracic endovascular
aneurysm repair for rupture (rTEVAR) has acquired a new dimension
as the patient is spared the acute hemodynamic changes that may
be associated with performing the procedure under general anesthesia, especially as permissive hypotension has proved to effectively reduce blood loss (9). Furthermore, early institution of CSF
drainage reduces morbidity by limiting the incidence of post-procedural paraplegia (10).
As compared to open repair for ruptured descending thoracic aortic
aneurysms, rTEVAR is associated with a lower morbidity and mortality and shows equivalent late outcomes (5,11). In experienced hands,
rTEVAR has a procedural success rate of about 95%. Procedurerelated complications, including stroke and paraplegia, occur in
about 11% to 15% of the patients. The results reflect the commencement of a paradigm shift in the approach to treat this formidable
surgical challenge. Unlike the open surgical approach centered primarily around the surgical team, rTEVAR requires a cohesive team
effort that spans several disciplines. In addition, the surgical team
should be prepared to perform debranching procedures such as
carotid-subclavian or celiac artery bypass, which are not commonly
performed otherwise (12).
In ruptured type B dissections, the primary aim of entry closure is
to cut off direct blood flow to the ruptured false lumen and thus
achieve hemodynamic stability, ultimately preventing mortality and
major cardiac, cerebral, visceral, and renal complications. Trimarchi
and colleagues consider rTEVAR to be a suitable bridging procedure
to elective open repair at a later stage (13). However, this is a topic
of debate in the petticoat era, with proximal entry closure being
followed by bare metal stenting of the distal true lumen to initiate
complete aortic remodeling (14-15).
However, to ensure consistently good results with rTEVAR, certain
organizational requirements and infrastructures are mandatory
in a clinical setting of severe chest pain, hemorrhagic pleural effusion, and/or hemoptysis. These include a round-the-clock immediate access to a multi-slice CT, a constant 24/7 availability of an experienced endovascular team, an adequate stock of appropriate catheters, guidewires, endografts, and bare metal stents, as well as the
availability of a hybrid OR (12,13,16).

Abstract Book
References
1. Borst HG, Heinemann MK, Stone CD (eds.) (1996): Surgical
treatment of aortic dissection. Churchill Livingstone, New York.
2. Karck M, Chavan A, Hagl C, Friedrich H, Galanski M, Haverich
A: The frozen elephant trunk technique: a new treatment for
thoracic aortic aneurysms. J Thorac Cardiovasc Surg 2003; 125:
1550-3.
3. Chavan A, Karck M, Hagl C, Winterhalter M, Baus S, Galanski M,
Haverich A: Hybrid endograft for one-step treatment of multisegment disease of the thoracic aorta. J Vasc Interv Radiol 2005;
16: 823-9.
4. Semba CP, Kato N, Kee ST, Lee GK, Mitchell RS, Miller DC, Dake
MD: Acute rupture of the descending thoracic aorta: repair with
use of endovascular stent-grafts. J Vasc Interv Radiol 1997; 8:
337-42.
5. Patel HJ, Williams DM, Upchurch GR, Dasika NL, Deeb GM: A
comparative analysis of open and endovascular repair for the
descending thoracic aorta. J Vasc Surg 2009; 50: 1265-70.
6. Dake MD, Kato N, Mitchell RS, Semba CP, Razavi MK, Shimono T,
Hirano T, Takeda K, Yada I, Miller DC: Endovascular stent-graft
placement for the treatment of acute aortic dissection. N Engl J
Med 1999; 340: 1546-52.
7. Morgan R, Loosemore T, Belli AM: Endovascular repair of
contained rupture of the thoracic aorta. Cardiovasc Intervent
Radiol 2002; 25: 291-4.
8. Hausegger KA, Tiesenhausen K, Schedlbauer P, Oberwalder P,
Tauss J, Rigler B: Treatment of acute aortic type B dissection with
stent-grafts. Cardiovasc Intervent Radiol 2001; 24: 306-12.
9. van der Vliet JA, van Aalst DL, Schultze Kool LJ, Wever JJ,
Blankensteijn JD: Hypotensive hemostasis (permissive
hypotension) for ruptured abdominal aortic aneurysm: are we
really in control? Vascular 2007; 15: 197-200.
10. Jonker FHW, Verhagen HJM, Lin PH, Heijmen RH, Trimarchi S,
Lee WA, Moll FL, Athamneh H, Muhs BE: Outcomes of endovascular repair of ruptured descending thoracic aortic aneurysms.
Circulation 2010; 121: 2718-23.
11. Jonker FH, Trimarchi S, Verhagen HJ, Moll FL, Sumpio BE, Muhs
BE: Meta-analysis of open versus endovascular repair for
ruptured descending thoracic aortic aneurysm. J Vasc Surg 2010;
51: 1026-32.
12. Coselli JS, Gopaldas RR: Ruptured Thoracic Aneurysms. To stent
or not to stent? Circulation 2010; 121: 2705-7.
13. Trimarchi S, Segreti S, Grassi V, Lomazzi C, de Vincentiis C,
Rampoldi V: Emergent treatment of aortic rupture in acute type
B dissection. Ann Cardiothorac Surg 2014; 3: 319-24.
14. Nienaber CA, Kische S, Zeller T, Rehders TC, Schneider H,
Lorenzen B, Bnger C, Ince H: Provisional extension to induce
complete attachment after stent-graft placement in type B
aortic dissection: the PETTICOAT concept. J Endovasc Ther 2006;
13: 738-46.
15. Melissano G, Bertoglio L, Rinaldi E, Civilini E, Tshomba Y,
Kahlberg A, Agricola E, Chiesa R: Volume changes in aortic true
and false lumen after the PETTICOAT procedure for type B
aortic dissection. J Vasc Surg 2012; 55: 641-51.
16. Willigendael EM, Cuypers PW, Teijink JA, van Sambeek MR:
Systematic approach to ruptured abdominal aortic aneurysm
in the endovascular era: intention-to-treat eEVAR protocol. J
Cardiovasc Surg 2012; 53: 77-82.

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LS/HTS

1302.3

1302.4

Traumatic rupture of the thoracic aorta

Intramural haematoma and penetrating ulcer

M.D.Dake
Falk Cardiovascular Research Center, Stanford University School of
Medicine, Stanford, CA, United States of America

F.E.Vermassen
Department of Vascular Surgery, University Hospital Ghent, Ghent,
Belgium

Endovascular therapy has revolutionized the treatment of blunt

traumatic thoracic aortic injuries. With an increased access to highresolution CT scanning, more of these injuries are being diagnosed
and treated. This talk will focus on blunt aortic injury and its management, including classification and triage, timing of repair, and
current status of endovascular repair.
Blunt thoracic aortic injury typically occurs as a result of sudden
deceleration with multi-directional forces being applied to the aortic arch and descending thoracic aorta, most commonly at the site
of the ligamentum arteriosum. The severity of damage to the aorta
can vary from an intimal tear to pseudoaneurysm formation or even
aortic rupture. The frequencies of thoracic aortic rupture is 0.3% in
pedestrian injuries (n=5,838), 0.1% in high-level fall injuries (n=1,613),
and 1.4% in pelvic fractures (n=1,450).
Given the mode of injury, aortic damage is associated with multiple
other injuries; patients commonly experience long bone and pelvic
fractures, pulmonary contusions, and blunt head trauma. These injuries can complicate a traditional open aortic repair making it a very
high-risk procedure because of the need for thoracotomy and single
lung ventilation. The use of endovascular repair in these cases may
provide a safer alternative.
Since the first published clinical series of endovascular repair in 1997,
the mortality and frequency of paraplegia have markedly decreased
with endovascular repair versus those with open surgical repair. In
general, most large meta-analyses in the medical literature associate
one-third to one-half the mortality rate and one-sixth to one-fourth
the frequency of paraplegia with endovascular repair.
Technical tips and the results of clinical trials of endovascular repair
will be reviewed, including the risks and complications associated
with endograft use.
References
1. Kato N, Dake MD, Miller DC, Semba CP, Mitchell RS, Razavi MK,
Kee ST. Traumatic thoracic aortic aneurysm: treatment with
endovascular stent-grafts. RADIOLOGY 1997;205:657-662.
2. Chung J, Owen R, Turnbull R, Chyczij H, Winkelaar G, Gibney
N. Endovascular repair in traumatic thoracic aortic injuries:
comparison with open surgical repair. J VASC INTERV RADIOL
2008;19:478-486.
3. Go MR, Barbato JE, Dillavoum ED, Gupta N, Rhee RY, Makaroun
MS, Cho JS. Thoracic endovascular aortic repair for traumatic
aortic transection. J VASC SURG 2007;46:928-933.
4. Midgley PI, MacKenzie KS, Corriveau MM, Obrand DI, Abraham
CZ, Fata P, Steinmetz OK. Blunt thoracic aortic injury: a single
institution comparison of open and endovascular management.
J VASC SURG 2007;46:662-668.
5. Marcheix B, Dambrin C, Boldu JP, Arnaud C, Hollington L, Cron
C, Mugniot A, Soula P, Bennaceur M, Chabbert V, Otal P, Cerene
A, Rousseau H. Endovascular repair of traumatic rupture of the
aortic isthmus: midterm results. J THOR CARDIOVASC SURG
2006;132:1037-1042.
6. Lin PH, Bush RL, Zhou W, Peden EK, Lumsden AB. Endovascular
treatment of traumatic thoracic aortic injury should this be the
new standard? J VASC SURG 2006;43:A22-A29.

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No abstract available.

Lecture Session
Arch and ascending thoracic aorta
1406.1
Update on surgical techniques and outcomes
A.L.Nobre
Cirurgia Cardiotorcica, Hospital Santa Maria Lisboa, Lisbon, Portugal
Learning Objectives
1. To learn which patients are fit enough for open surgery
2. To learn which cerebral protection technique reduces the stroke
risk
3. To learn how to perform an elephant trunk
No abstract available.

1406.2
Overview of endovascular techniques in the arch
H.Rousseau1, B.Saint-Lebes2, O.Meyrignac1, F.Mokrane1
1Dept. of Radiology, CHU Rangueil, Toulouse, France, 2Vascular Surgery
Unit, CHU Rangueil, Toulouse, France
Learning Objectives
1. Tips to perform CHIMPS in the arch
2. To learn which preoperative imaging is required
3. To learn what the current anatomical challenges are
Although there has been progress in surgical technique, anesthetization, and intensive care management, the conventional surgical
repair of aortic arch pathology is still a challenging and invasive procedure. Recently, endovascular repair has been accomplished using
both hybrid and near-total endovascular techniques. Exclusion of
the lesion, maintenance of cerebral perfusion, and avoidance of the
emboli are the primary intraoperative objectives. However, aortic
arch anatomy presents complex spatial geometry with curvatures
and three-dimensional angulations, challenging the apposition
of endovascular devices. Moreover, stent grafts in the aortic arch
are subject to great dynamic strain, high blood flow, and pulsatile
movement, which may cause migration, fractures, or disconnection
of the device components.
Hybrid repair
In hybrid repair, supra-aortic debranching is performed to provide
an appropriate landing zone for the stent graft and preserve perfusion to the supra-aortic trunks, followed by stent graft deployment
into the ascending and transverse aortic arch, without the need for
cardiopulmonary bypass or hypothermic circulatory arrest.
Chimney or snorkel grafts
Chimney or snorkel grafts have even been proposed to extend the
proximal fixation zone. They have the advantage of using standard,
off-the-shelf materials and being technically less demanding. Until
more patients and longer follow-ups are available, chimney grafts
should only be considered in emergency patients who are poor candidates for open repair or show inadvertent coverage of the supraaortic trunks.

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Fenestrated and branched stent grafts

Most fenestrated and branched stent grafts are currently in early
feasibility trials, and their safety and efficacy have not yet been
demonstrated.
In situ fenestration techniques and custom-made fenestrated stent
grafts have been reported to accomplish revascularization without
performing extra-anatomic bypass. However, data demonstrating
efficacy are sparse and limited to case reports and series.
The Mono Branch Arch systems: The Valiant Mona LSA thoracic stent
graft system (Medtronic) and the Conformable Gore TAG thoracic
branch endoprosthesis (Gore & Associates) have been designed to
circumvent the need to revascularize LSA with a bypass. The entire
procedure may be performed through a single femoral access site.
If results prove promising, it is conceivable that this same technology could be used in future to treat more proximal arch aneurysms,
especially blunt aortic trauma and type B aortic dissection.
The Double Branch Arch systems (Bolton Medical and Cook Medical)
are composed of a proximal stent graft placed at the level of the
ascending aorta (zone 0) with two parallel tunnels to preserve blood
flow to arch vessels, which in general are the innominate and left
common carotid arteries.
Discussion
There is clearly a role for near-total minimally invasive aortic arch
aneurysm repair, especially in patients deemed unfit for open repair
because of either anatomic or physiological reasons. Whether
results can match traditional open repair in high-volume centers
remains to be answered in future trials.
References
1. Bavaria J, Vallabhajosyula P, Moeller P, Szeto W, Desai N,
Pochettino A. Hybrid approaches in the treatment of aortic arch
aneurysms: postoperative and midterm outcomes. J Thorac
Cardiovasc Surg. 2013;145(3 suppl):S85-90.
2. Cao P, De Rango P, Czerny M, Evangelista A, Fattori R, Nienaber C,
Rousseau H, Schepens M. Systematic review of clinical outcomes
in hybrid procedures for aortic arch dissections and other arch
diseases. J Thorac Cardiovasc Surg. 2012;144(6):1286-1300.
3. Lindblad B, Bin Jabr A, Holst J, Malina M. Chimney grafts in aortic
stent grafting: hazardous or useful technique? Systematic review
of current data. Eur J Vasc Endovasc Surg. 2015;50(6):722-731.
4. Ben Abdallah I, El Batti S, Sapoval M, Abou Rjeili M, Fabiani JN,
Julia P, Alsac JM. Proximal scallop in thoracic endovascular aortic
aneurysm repair to overcome neck issues in the arch. Eur J Vasc
Endovasc Surg. 2016;51(3):343-349.
5. Haulon S, Greenberg RK, Spear R, Eagleton M, Abraham C,
Lioupis C, Verhoeven E, Ivancev K, Klbel T, Stanley B, Resch T,
Desgranges P, Maurel B, Roeder B, Chuter T, Mastracci T. Global
experience with an inner branched arch endograft. J Thorac
Cardiovasc Surg. 2014;148(4):1709-1716.
6. Tse LW, Lindsay TF, Roche-Nagle G, Oreopoulos GD, Ouzounian
M, Tan KT. Radiofrequency in situ fenestration for aortic arch
vessels during thoracic endovascular repair. J Endovasc Ther.
2015;22(1):116-121.

1406.3
Stroke: the big enemy
M.P.Jenkins
Vascular Surgery, Imperial College Healthcare NHS Trust, St Marys
Hospital, London, United Kingdom
Learning Objectives
1. Should shaggy aortas be contra indicated for any treatment?
2. To learn which cerebral monitoring should be performed
3. To learn how to deal with post-operative stroke
The brain is extremely sensitive to both hypoperfusion and embolic
complications, and stroke remains one of the most devastating
complications in both open and endovascular treatment for arch

Abstract Book
pathology. The risk associated with intervention depends on the
atheroma burden that can be subjectively assessed using CTA.
Montgomerys transoesophageal echo classification1 is often cited
as a more objective grading (from I describing normal or mild intimal thickening to V describing a mobile atheromatous lesion), but
this is open to subjective interpretation.
Unlike the descending thoracic aorta (wherein TEVAR has predominated in the last decade), open surgery remains the gold standard
both within the ascending aorta and aortic arch. Despite refinement
of techniques for cerebral protection, outcomes from the highest
volume centres continue to record major stroke rates of 4%12%2-4.
Not surprisingly, much study time has been invested into determining the causes and treatment for peri-operative stroke5.
In an effort to reduce the morbidity associated with open aortic arch
surgery, a technique mandating circulatory arrest, less invasive strategies have been investigated. Combining extra-anatomical bypass
and endovascular stenting has allowed more frail patients to be
treated but not with any reduction in stroke risk6. The use of chimneys and parallel grafts has also been attempted within the arch,
but again no consistent reduction in stroke rate has been observed7.
The most recent registry data, however, has shown a commendably
low stroke rate of 2%, but this group includes aortic dissection and
PAU patients in addition to atherosclerotic aneurysms patients8.
Numerous series have shown that the more proximal is the intervention, the higher is the stroke risk.
More recently, a number of industry partners have developed
branched endovascular devices for use within the aortic arch. The
experience is not sufficiently mature to comment on durability, and
so far, case selection and learning curve constraints have implied
that the comparison with open and hybrid surgery is probably
unfair9.
What is clear is that whether the arch is compressed with a surgical
clamp or instrumented with a stiff wire, embolic risk is inevitable,
and no amount of statin medication can eradicate this risk. From an
endovascular embolic perspective, two main risk periods, stiff wire
placement and stent deployment, have already been established.
From a hypoperfusion perspective, some lessons are already clear
from more distal TEVAR use; one of the lessons is that the revascularisation of the left subclavian artery reduces the risk of both stroke
and paralysis in patients at risk. Therefore, strategies to protect the
brain from the inevitable potential insult are necessary. Diffusion
weighted MRI technology has allowed the burden of silent microembolisation to be visualised; this has led to the concept that fullblown clinical strokes probably represent the tip of the iceberg of
the cerebral insult. In a way similar to the carotid filters being used in
CAS, clinical pilots are now being undertaken using embolic shields
in the arch at the time of stent deployment. It is too early to decide
how beneficial this method will ultimately be, but it is a potentially
promising advance in an area where there has been little success to
date.
From a practical perspective, intra-operative monitoring using transcranial Doppler confers little benefit. Although useful as a research
tool, it merely detects emboli after they have occurred; therefore, it
is of limited use in preventing adverse clinical sequelae; it can perhaps only warn to stop the ongoing manoeuver. Once emboli have
left the arch, any deficit is related to whether the carotid or vertebral territory is affected. The only therapeutic options are then supportive with maintenance of adequate oxygenation, blood pressure
and anti-platelet medication with early physiotherapy for any physical impairment. Therefore, a shaggy aortic arch remains a contraindication for most forms of treatment as the considerable stroke risk
probably outweighs the treatment benefit with the current technology. In conclusion, the arch remains a hostile environment for both
open and endovascular treatment and stroke is still the big enemy.

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References
1. Montgomery DH, Ververis J, McGorisk G, et al. Natural history of
severe atheromatous disease of the thoracic aorta: a transesophageal echocardiographic study. J Am Coll Cardiol. 1996;27:95101.
2. Sundt TM 3rd, Orszulak TA, Cook DJ, et al. Improving results of
open arch replacement. Ann Thorac Surg. 2008;86:787-796.
3. Tian DH, Wan B, Di Eusanio M, et al. A systematic review and
meta-analysis on the safety and efficacy of the frozen elephant
trunk technique in aortic arch surgery. Ann Cardiothorac Surg.
2013;2:581-591.
4. Minakawa M, Fukuda I, Yamauchi S, et al. Early and long-term
outcome of total arch replacement using selective cerebral
perfusion. Ann Thorac Surg. 2010;90:72-77.
5. Okada T, Shimamoto M, Yamazaki F, et al. Insights of stroke in
aortic arch surgery: identification of significant risk factors and
surgical implication. Gen Thorac Cardiovasc Surg. 2012;60:268274.
6. Antoniou GA, Mireskandari M, Bicknell CD, et al. Hybrid repair
of the aortic arch in patients with extensive aortic disease. Eur J
Vasc Endovasc Surg. 2010;40:715-721.
7. Moulakakis KG, Mylonas SN, Markatis F, et al. A systematic review
and meta-analysis of hybrid aortic arch replacement. Ann
Cardiothorac Surg. 2013;2:247-260.
8. Bosiers MJ, Donas KP, Mangialardi N, et al. European Multicenter
Registry for the Performance of the Chimney/Snorkel Technique
in the Treatment of Aortic Arch Pathologic Conditions. Ann
Thorac Surg. 2016 Jan 12. doi: 10.1016/j.athoracsur.2015.10.112.
9. Haulon S, Greenberg RK, Spear R, et al. Global experience with
an inner branched arch endograft. J Thorac Cardiovasc Surg.
2014;148:1709-1716.

1406.4
Stent graft in the ascending aorta: where are we?
T.Klbel
Klinik und Poliklinik fr Gefmedizin, Universitres Herzzentrum
Hamburg (UHZ), Hamburg, Germany
Learning Objectives
1. Should acute type A dissections undergo endografting?
2. Tips for transapical or supraaortic insertion of endografts
3. Rapid pacing or IVC occlusion to lower cardiac output?
Acute type A aortic dissections (TAADs) bear a significant risk of
mortality and constitute a surgical emergency. Furthermore, given
the complexity and vitality of the regional anatomy, surgical intervention is technically demanding and prone to complications, with
a mortality rate of 7%30% in various centers. Recently, there has
been an impetus on developing safer, less morbid interventions for
acute TAADs. Owing to its successful adoption as the intervention of
choice for abdominal aortic aneurysms and complicated type B aortic dissections, endovascular therapy appears to be suited for implementation in the treatment of TAAD. As no prospective randomized controlled trials examining the role of endovascular therapy for
TAADs exist, practice must be guided by experience reported in retrospective studies, case series, and case reports. The presentation
will describe and analyze current endovascular treatment options in
the ascending aorta, including embolization of false aneurysms and
stent-graft treatment for TAADs.

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1406.5
When to use a total endovascular approach for arch management
S.Haulon
Vascular Surgery, Hpital Cardiologique, CHRU Lille, Lille, France
Open surgery for aneurysms involving the aortic arch remains the
gold standard for patients with limited comorbidities. The need
for sternotomy, cardiopulmonary bypass, and deep hypothermic
circulatory arrest represents a significant physiological burden.
Endovascular techniques have been applied to the aortic arch in
order to offer treatment to patients at high risk for open surgery. The
hybrid arch repair combines an open procedure to secure a proximal
landing zone with concomitant endovascular stent graft placement
in the aortic arch. Although this technique is considered to be minimally invasive, by avoiding aortic cross-clamping and hypothermic circulatory arrest, the morbi-mortality rate remains high. Clear
evidence to show superiority of hybrid repair techniques over open
repair technique is lacking.
Continued development and evolution of endografts have allowed
for the application of total endovascular repair of complex aortic aneurysms involving the visceral segment with fenestrated and
branched stent grafts. Good initial results with this later generation
of endografts have broadened their use to the aortic arch in highrisk patients. Nevertheless, the aortic arch poses unique challenges
relating to the potential neurologic complications, the inherent arterial angulations, the high blood flow, the pulsated movement of the
aorta in this area, and the proximity of the aortic valve and coronary
arteries.
Total endovascular arch repair using branched arch endografts,
although technically challenging, may lower the morbidity associated with arch aneurysm repair in selected high-risk patients. Our
presentation will review early evidence for the use of branched
endograft technology to treat aortic arch aneurysms. The technique
used by our team for the deployment of branched endografts in the
aortic arch will be thoroughly described.

1406.6
When to use a hybrid approach for arch management
S.Trimarchi
Cardiovascular Dept., IRCCS Policlinico San Donato, San Donato
Milanese, Italy
No abstract available.

Lecture Session
Endoleaks/complications
1505.1
Hypogastric preservation with EVAR: a must for most
F.Verzini
Unit of Vascular and Endovascular Surgery, Ospedale S. Maria della
Misericordia, Universit degli Studi di Perugia, Perugia, Italy
Learning Objectives
1. To learn the different options for the management of the
hypogastric artery
2. To learn when to revascularise the hypogastric artery
3. To learn the complications correlated with the exclusion of the
hypogastric artery
Preserving pelvic perfusion during endovascular aortoiliac aneurysm repair (EVAR) is advocated to minimize the risk of ischemic

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complications that may occur in up to 40%45% of acute unilateral internal iliac artery (IIA) occlusions with a possible increase in
the proportions after bilateral occlusion. The clinical sequelae may
vary from relatively benign hip and buttock claudication to severe
and life-threatening colonic infarction, paraplegia, vasculogenic
impotence, or sacral necrosis. Although IIA occlusions can often be
asymptomatic, it is not possible to predict those in whom buttock
ischemia may be clinically significant with respect to those who will
develop colon or spinal cord ischemia. Iliac branch grafts (IBGs) have
emerged in the last decade as a method to preserve IIA flow during
EVAR in patients with abdominal aortic aneurysm (AAA) with extensive involvement of the iliac artery. In the last few years, there has
been an increasing report on larger series of IBG even from multiple
centers, while pivotal trials are under way in the U.S.A. to investigate
current models of IBG. With the availability of multiple publications,
today there is evidence to better understand the feasibility and the
occurrence of early and late complications with commercially available IBG. The rate of technical success with current IBG is reported
to be high, with rates ranging from 86% to 100% in the most recent
series published after 2009. This demonstrates the feasibility of IBG
use in a selected group of patients at experienced centers. The main
reason for technical failures was complex anatomy, which suggests
that careful assessment and patient selection are paramount to preclude technical failure. Narrow lumen of the common iliac artery or
thrombus, severe kinking of the external iliac artery, narrow or stenotic internal iliac ostium, and wide angle of the IIA branches are
found as common sources of technical failure. IBG and iliac occlusions, endoleak, disconnection/migration, and loss of integrity have
been reported as late complications. However, IBD patency in the
major reported series is ranging between 81% and 91%, with freedom from reintervention within 80% at a maximum follow-up of
5 years. Today, IBG can be performed with a high rate of technical
success. Mid-term and late patency rates are encouraging, with low
rates of late failure. The most advanced models available may help in
broadening the spectrum of use in patients at high risk for open surgery or IIA occlusion, rendering the iliac branch endografting a standard of care in suitable anatomies.

1505.2
Is aortic neck dilatation a problem?

Abstract Book
for BES was 4.8 years and that for SES was 4.6 years. The annual
post-implant rate of infrarenal neck diameter increase was fivefold
greater in the SES group (1.1 mm/year) than in the BES group (0.22
mm/year).
The current post-EVAR computed tomography (CT) scan protocols may underestimate the influence of neck dilatation on the
loss of apposition between the endograft and neck. Therefore, we
developed a new software to determine this apposition surface
and changes during follow-up post-EVAR. The apposition surface
between the endograft and infrarenal neck was calculated at the
first post-EVAR CT scan and all other available CT scans in a group
of 41 patients with late type IA endoleaks. Almost 40% of patients
with type IA endoleak during FU suffered from substantial neck dilatation, which can be defined as an independent risk factor for late
endograft failure.
We can conclude that aortic neck dilatation post-EVAR will occur in
most patients, particularly with the use of SES. The average growth
rate is around 1 mm/year and may lead to type IA endoleaks and
migration in a substantial proportion of patients. Careful determination of the apposition surface between the endograft and aortic
neck is warranted to determine neck expansion and to prevent complete loss of seal.
References
1. Oberhuber A, Buecken M, Hoffmann M, et al. Comparison of
aortic neck dilatation after open and endovascular repair of
abdominal aortic aneurysm. J Vasc Surg 2012;55:929-34.
2. Monahan TS, Chuter TAM, Reilly LM, et al. Long-term follow-up
of neck expansion after EVAR. J Vasc Surg 2010;52:303-7.
3. Savlovskis J, Krievins D, De Vries JPPM, et al. Aortic neck
enlargement after endovascular aneurysm repair using balloonexpandable versus self-expanding endografts. J Vasc Surg
2015;62:541-9.

1505.3
Prediction and prevention of type II endoleak
G.M.Richter
Director Clinics for Diagnostic and Interventional Radiology, Klinikum
Stuttgart, Stuttgart, Germany
Learning Objectives
1. To learn the different causes of type II endoleaks
2. To learn how to treat type II endoleaks
3. To learn how to prevent a type II endoleak

J.P.P.M.deVries
Vascular Surgery, Sint Antonius Hospital, Nieuwegein, Netherlands
Learning Objectives
1. To discuss the complications correlated to the dilatation of the
proximal neck
2. To learn the morphological changes in the aortic proximal neck
3. To learn the different strategies to manage the dilatation of the
proximal neck
Long-term success of endovascular aortic aneurysm repair (EVAR)
depends on adequate seal between the endograft and infrarenal
aortic neck. Post-EVAR neck dilatation may increase the risk of loss of
apposition and type IA endoleaks. It has been proven that after both
open and endovascular repair of abdominal aortic aneurysms (AAA),
the (remaining) infrarenal neck will dilate in a substantial proportion
of patients.[1]
In several recent publications, the effect of aortic neck dilatation
has been described. Monahan et al. evaluated the influence of longterm neck expansion in 46 patients treated with a Zenith endograft.
[2] After a mean follow-up of 59 months, the median neck expansion
rate was 5.3 mm. However, no late type IA endoleaks were observed.
Recently, we evaluated eventual differences in aortic neck dilatation
after EVAR using balloon-expandable (BES) versus self-expanding
(SES) endografts.[3] A comparison was made between 49 patients
treated with the Nellix endosystem (BES) and 56 patients treated
with the Endurant II endograft (SES). The mean follow-up duration

No abstract available.

1505.4
Iliac limb occlusion: how to prevent, how to manage
E.Brountzos
2nd Dept. of Radiology, University of Athens, Athens, Greece
Learning Objectives
1. To learn the clinical presentations of iliac limb occlusion
2. To learn the different therapeutic options to manage an iliac
limb occlusion
3. To learn the tips and tricks in the prevention of limb occlusion
Iliac limb occlusion is a well-documented complication of endovascular aortic aneurysm repair (EVAR); it occurs in 2.6% to 7.4% of the
cases and represents the third most common cause of hospital readmission following EVAR. [1, 2] Various anatomical and graft-related
factors have been correlated with limb occlusion. In comparison
with supported grafts, first-generation unsupported grafts were 15
times more likely to require intervention because of kinking; other
device-related causes requiring intervention include limb migration and dislocation. [3, 4] Anatomical factors related to iliac limb

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occlusion include distal landing zone on the external iliac artery,

external iliac artery diameter being <10 mm, calcified and narrowed
aortic bifurcation, kinking, twisting or stenosis of the iliac limb, stenosis or angulation of the proximal common iliac artery, graft infolding, tortuous iliac artery, excessive limb oversizing, and compromised runoff. [5, 6] Limb occlusion usually occurs within the first 90
days post-intervention; however, its late occurrence has also often
been reported. [1] Patient presentation varies from asymptomatic
incidental findings during surveillance to mild, moderate, or severe
claudication and more advanced ischemic symptoms such as rest
pain and acute limb ischemia. [4, 6] Prevention strategies include
rigorous evaluation of completion angiography, including oblique
views and removal of stiff wires and long sheaths to allow tortuous
iliac arteries to return to their natural anatomic position and reveal
limb kink, as well as aggressive pre-emptive stenting of limb graft
kinking to avoid thrombosis. Pullback pressure measurement to
detect hemodynamically significant stenosis and intravascular ultrasound (IVUS) to detect graft infolding have also been proposed. [1]
Treatment options include conservative management in case of mild
symptomatology and open surgical procedures (surgical thrombectomy angioplasty/stenting/extra-anatomic bypass) or endovascular procedures (catheter-directed thrombolysis and stenting and
endovascular thrombectomy and stenting/covered stenting) in case
of more severe ischemic symptoms. Both open surgical and endovascular methods yield satisfactory outcomes. [1-6]
References
1. Woody JD, Makaroun MS. Endovascular graft limb occlusion.
Semin Vasc Surg. 2004; 17(4):262-7.
2. Mantas GK, Antonopoulos CN, Sfyroeras GS, et al. Factors predisposing to endograft limb occlusion after endovascular aortic
repair. Eur J Vasc Endovasc Surg. 2015; 49(1):39-44.
3. Baum RA, Shetty SK, Carpenter JP, et al. Limb kinking in
supported and unsupported abdominal aortic stent-grafts. J
Vasc Interv Radiol. 2000; 11(9):1165-71.
4. Maleux G, Koolen M, Heye S, Nevelsteen A. Limb occlusion
after endovascular repair of abdominal aortic aneurysms with
supported endografts. J Vasc Interv Radiol. 2008; 19(10):1409-12.
5. Faure EM, Becquemin JP, Cochennec F; ENGAGE collaborators. Predictive factors for limb occlusions after endovascular
aneurysm repair. J Vasc Surg. 2015; 61(5):1138-45.e2.
6. Carroccio A, Faries PL, Morrissey NJ, et al. Predicting iliac limb
occlusions after bifurcated aortic stent grafting: anatomic and
device-related causes. J Vasc Surg. 2002; 36(4):679-84.

1505.5
Endovascular management of type I endoleaks
J.F.Benenati
Peripheral Vascular Laboratory, Baptist Cardiac and Vascular Institute,
Miami, FL, United States of America
Type I endoleaks are often observed at the time of the initial procedure but they may also be identified at the time of follow-up imaging studies. They represent the most dangerous type of endoleaks
and almost without exception mandate repair.
It may usually be difficult to determine whether the leak identified
is truly a type I leak or is a type II or type III leak. Excellent imaging
and good imaging protocols are necessary to distinguish between
the different types of endoleaks. It is also possible to have both type
I and type II endoleaks at the same time.
When a type I leak is identified during the endovascular repair
or during follow-up, it can be fixed in the majority of the cases.
Management of type I leaks at the time of endovascular repair
includes the following:
adding an endograft component such as a cuff
deploying a balloon expandable stent across the leak site
using a balloon on the initial endograft

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using snorkel-type techniques

fenestration of mesenteric vessels or renal arteries to extend fabric across the leak
Endovascular repair options are often less expensive and less invasive than surgical repair options. Additionally, once the endograft is
in place, surgical repair may be more complicated. An endovascular
approach should be considered as the primary therapy for patients
with type I leaks. Only when endovascular repair fails or there is no
endovascular option should surgical repair be considered as the first
choice of therapy.
References
1. Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial
comparing conventional and endovascular repair of abdominal
aortic aneurysms. N Engl J Med. 2004;351(16):1607-1618.
2. Chaikof EL, Blankensteijn JD, Harris PL, et al. Reporting
standards for endovascular aortic aneurysm repair. J Vasc Surg.
2002;35(5):1048-1060.
3. Buth J, Harris PL, van Marrewijk C, Fransen G. The significance
and management of different types of endoleaks. Semin Vasc
Surg. 2003;16(2):95-102.
4. Choi SY, Lee DY, Lee KH, et al. Treatment of type I endoleaks after
endovascular aneurysm repair of infrarenal abdominal aortic
aneurysm: Usefulness of N-butyl cyanoacrylate embolization
in cases of failed secondary endovascular intervention. J Vasc
Interv Radiol. 2011;22(2):155-162.
5. Maldonado TS, Rosen RJ, Rockman CB, et al. Initial successful
management of type I endoleak after endovascular aortic
aneurysm repair with n-butyl cyanoacrylate adhesive. J Vasc
Surg. 2003;38(4):664-670.
6. Day CP, Buckenham TM, Laing AD. Embolization of proximal type
I endoleak using n-butyl cyanoacrylate after endovascular repair
of the thoracic aorta: Two case reports. J Vasc Interv Radiol.
2011;22(1):105-107.
7. Lee JT, Ullery BW, Zarins CK, Olcott C 4th, Harris EJ Jr, Dalman RL.
EVAR deployment in anatomically challenging necks outside the
IFU. Eur J Vasc Endovasc Surg. 2013;46(1):65-73.
8. Moulakakis KG, Mylonas SN, Avgerinos E, et al. The chimney graft
technique for preserving visceral vessels during endovascular
treatment of aortic pathologies. J Vasc Surg. 2012;55(5):14971503.
9. Byrne J, Mehta M, Dominguez I, et al. Does Palmaz XL Stent
deployment for type 1 endoleak during elective or emergency
endovascular aneurysm repair predict poor outcome? A multivariate analysis of 1470 patients. Ann Vasc Surg. 2013;27(4):401411.

1505.6
Surgical management of type I endoleaks
R.G.J.Gibbs
Division of Vascular Medicine and Vascular Surgery, St Marys Hospital,
Imperial College NHS Trust, London, United Kingdom
No abstract available.

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Lecture Session
Abdominal aorta 1

Abstract Book

1705.3
Contrast-free EVAR: when and how
F.Fanelli
Interventional Radiology Unit, Department of Radiological Sciences,
Sapienza University of Rome, Rome, Italy

1705.1
Four-year results of the comparative French trial of fenestrated
and branched graft versus open surgery
J.-P.Becquemin
Service de Chirurgie Vasculaire & Endocrinienne, CHU Henri Mondor,
Crteil, France
Learning Objectives
1. To learn about patient outcomes from the comparative f-EVAR
trials
2. To learn which patients are best suited for f-EVAR and b-EVAR vs.
open repair
No abstract available.

1705.2
The PERICLES registry
K.P.Donas1, G.Torsello2, F.J.Veith3
1Vascular Surgery, St. Franziskus Hospital Mnster, Mnster, Germany,
2Center for Vascular and Endovascular Surgery, University Hospital,
Mnster, Germany, 3Vascular Surgery, New York University Medical
Center, New York, NY, United States of America
Learning Objectives
1. To learn what the PERICLES registry is
2. To learn about the outcomes of the PERICLES registry
The aim of the performance of the chimney technique for the treatment of complex aortic pathologies (PERICLES) registry was to provide the latest pooled evidence about chimney grafts in pararenal
pathologic processes and to evaluate if the sceptisicm about the
grafts is justified.
Overall, data of 517 patients (398 of whom were treated at European
vascular centres and 119 at US centres) who underwent chimney
EVAR between 2008 and 2014 were reviewed. The mean number of
chimney grafts placed was 1.7 per patient (overall 898 target aortic
branch vessels).
In total, 49.2% of the chimney grafts were balloon-expandable covered stents and 39.6% were self-expanding covered stents. Primary
chimney graft patency was 94.1%. The mean aortic aneurysm diameter was significantly decreased to 61.219.7 mm from 65.916.5
mm, p.001.
The technical success was 97.1%. The mean new neck/seal length
after placement of the chimney grafts increased from 4.87.4 mm to
21.112.7 mm. Persistent type IA endoleak rate was 2.9%. The 30-day
mortality rate for the elective cases was 3.7%.
The present global experience with the chimney/snorkel graft
underlines the complementary role of parallel grafts and supports
wider usage and further evaluation. Based on the mid-term results,
it seems that the widespread scepticism is not justified.
References
1. Collected world experience about the performance of the
snorkel/chimney endovascular technique in the treatment of
complex aortic pathologies: the PERICLES registry. Donas KP, Lee
JT, Lachat M, Torsello G, Veith FJ on behalf of the PERICLES investigators. Annals of Surgery 2015;262(3):546-53.

Learning Objectives
1. To learn how to perform totally contrast-free EVAR
2. To learn when to perform totally contrast-free EVAR
Up to 30% of patients undergoing elective endovascular repair of
abdominal aorta (EVAR) suffer from pre-existing chronic renal insufficiency (CRI).
This particular group of patients is at risk of developing contrastinduced nephropathy (CIN). The incidence of CIN annually rises
by 5%8% and is associated with extended hospitalization and
increased number of medical resources.
New techniques have been experienced in order to perform EVAR
with a low dose of the contrast medium or totally without it.
Intraoperative ultrasound enables to reduce or to completely eliminate the amount of contrast media.
For example, carbon dioxide being a radio-opaque agent has
been used during angiography and contrast-enhanced ultrasound
(CEUS) with microbubbles and has proved to be feasible for EVAR in
patients with contraindications to contrast media.
Using intra-operative Doppler ultrasound, contrast media can be
completely abolished during EVAR procedures.
Intravascular ultrasound (IVUS) allows an accurate and safe deployment of the stent-graft, performing EVAR without any contrast
medium. However, these techniques are not always available and
not yet widely used because all of them lack the diagnostic sensitivity necessary for detecting endoleaks. Pulsed Doppler ultrasound
permits additional assessment of in-stent flow characteristics. The
technique is useful in detecting iliac limb stenosis and endograft
kinking during the procedure. IVUS is able to visualize not only the
aortic morphology but also the origin of the renal arteries and can
accurately evaluate the aortic diameters.
In addition, IVUS has the advantage of assessing the correct wall
apposition of the stent-graft, the absence of kinking or tortuosity,
and the patency of the stent-graft inner lumen.
References
1. Hoshina K, Kato M, Miyahara T, et al. A retrospective study of
intravascular ultrasound use in patients undergoing endovascular aneurysm repair: its usefulness and a description of the
procedure. Eur J Vasc Endovasc Surg 2010;40:559-63.
2. von Segesser LK, Marty B, Ruchat P, et al. Routine use of intravascular ultrasound for endovascular aneurysm repair: angiography
is not necessary. Eur J Vasc Endovasc Surg 2002;40:537-42.
3. Kopp R, Zrn W, Weidenhagen R, et al. First experience using
intraoperative contrast-enhanced ultrasound during endovascular aneurysm repair for infrarenal aortic aneurysms. J VascSurg
2010;51:1103-10.
4. Clevert DA, Kopp R. Contrast-enhanced ultrasound for endovascular grafting in infrarenal abdominal aortic aneurysm in a
single patient with risk factors for the use of iodinated contrast. J
Vasc Interv Radiol. 2008;19:1241-5.
5. Park B, Mavanur, A. Drezner AD, et al. Clinical impact of chronic
renal insufficiency on endovascular aneurysm repair. Vasc
Endovascular Surg. 2007;40:437-45.

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1705.4

1705.5

3D printing for complex EVAR

Standard EVAR outside IFU yes

A.Hoffman
Department of Vascular Surgery and Transplantation, Rambam
Medical Centre, Haifa, Israel

J.P.P.M.deVries
Vascular Surgery, Sint Antonius Hospital, Nieuwegein, Netherlands

Learning Objectives
1. To learn what 3D printing can achieve
2. To learn how 3D printing can help EVAR
Complex abdominal aortic aneurysm (AAA) may present treatment
challenges for endovascular repair (EVAR) when the spatial complexity, position, size, angulation, neck geometry, and variability of the
important branches are unusual. Accurate pre-operative planning is
especially mandatory when branching or fenestrations are contemplated. Although the current imaging modalities of CTA, MRA, and
three-dimensional (3D) US enable a good understanding of effective
treatment planning for most patients, there are still cases in which
the feasibility of EVAR remains doubtful.
3D printing is an advanced technology that allows the preparation
of handy physical models made of various plastic materials obtained
from many types of computer files like DICOM, CT, MRI, and 3D photos. The advances in 3D technology, with its widespread availability
have led to 3D printing becoming useful in many areas of medicine.
Specifically, in cardiovascular medicine and surgery, 3D modeling
techniques have been used by device manufacturers and companies
to test their devices in vitro.
Since this technology allows better appreciation of complex anatomical and pathologic conditions, we hypothesized that for some
of our patients with complex aneurysmal anatomy, the use of actual
3D models as an additional imaging tool may improve accuracy of
pre-operative treatment planning.
To prepare for 3D print models of complex AAAs, we used the
standard CTA files from a CD disk or from the PACS of the relevant
patients. A representative series was chosen, and volume rendering
was done to construct a computerized 3D model by readily available
programs like Philips IntelliSpace Portal, Syngovia of Siemens, and
the public InVesalius program. These programs allow concentration
on the area of interest, deletion of unnecessary image details, and
exporting the final model as a 3D printable file (.STL or .OBG). These
files were then loaded onto our institutional desktop 3D printer
(Objet30 Pro, Stratasys) and modeled either as full solid models or
as a hollow shell only. The models may be printed in reduced dimensions or as actual 1:1 size for accurate planning. We further enhanced
the 3D models by the post-printing addition of different colors for
normal versus aneurysmal segments of the arterial tree.
These enhanced 3D solid models allowed visual and tactile inspection for a better appreciation of the geometry of complex aneurysms. Color enhancement of these models added another dimension of comprehension even for experienced surgeons and invasive
radiologists and allowed more accurate measurements of branch
positions, distances, and angles in space when tortuosity was
severe. Endovascular use of covered stents as branches and embolization techniques could be easily preoperatively envisioned. The
hollow 3D printed shells allowed us, in some cases, to preoperatively
practice under fluoroscopic guidance with real EVAR devices.
We conclude that enhanced, in-house, 3D printed models are a new
powerful tool for preoperative endovascular treatment planning of
complex AAAs.

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Off-label use of abdominal aortic endografts depends on patients

risk factors for open repair, physicians and institutions experience
of endovascular aortic repair (EVAR), and the forgiving nature of the
endograft itself. One of the problems regarding the instructions
for use (IFU) of endografts is that they will be frequently outdated
because of the evolution and revision of endografts.
It is questionable whether the treatment of patients with off-label
use of endografts will increase short-term and long-term failure
rates. A few recent publications did not show any adverse effects
of the off-label use of modern endografts.[1],[2],[3] Beckerman et al.
evaluated the computed tomography (CT) data of 566 EVAR patients
who underwent repair between 2003 and 2014.[4] Despite the fact
that most patients had been treated outside IFU, there was no difference in outcomes with respect to all-cause mortality and aneurysmrelated mortality. Moreover, there was no association between IFU
adherence and late-onset rupture or need for re-intervention.
Thus, it is important to re-evaluate the current parameters defined
as hostile neck characteristics and IFU. One of these parameters is
infrarenal angulation. It may be discussed whether angulation is the
best way to describe the course of the endograft in the aortic neck.
We introduce a new parameter, curvature, to determine the true
course of an endograft along the aortic neck. Curvature, instead of
angulation, is an independent risk factor for the occurrence of early
type IA endoleaks during EVAR.[5]
We can conclude that more EVAR patients are treated outside endograft IFU. Re-evaluation of outdated IFU is warranted, and although
off-label use should not promoted, it seems to be benign in terms of
the risk for short-term and long-term failures.
References
1. Torsello G, Troisi N, Donas KP, et al. Evaluation of the Endurant
stent graft under IFU vs off-label conditions for EVAR. J Vasc Surg
2011;54:300-6.
2. Van Keulen JW, De Vries JPPM, Dekker H, et al. One-year multicenter results of 100 AAA patients treated with the Endurant
stentgraft. J Vasc Surg 2011;54:609-15.
3. Walker J, Tucker LY, Goodney P, et al. Adherence to EVAR device
instructions for use guidelines has no impact on outcomes. J
Vasc Surg 2015;61:1151-9.
4. Beckerman WE, Tadros RO, Faries PL, et al. No major difference in
outcomes of EVAR stent grafts placed outside of IFU. J Vasc Surg
2016, in press.
5. Schuurmann RC, Ouriel K, Muhs BE, et al . Aortic curvature as
a predictor of intraoperative type IA endoleak. J Vasc Surg
2016;63:596-602.

1705.6
Standard EVAR outside IFU no
J.Lammer
Cardiovascular and Interventional Radiology, Medical University
Vienna, Austria, Vienna, Austria
Commercially available stent grafts for the treatment of abdominal aortic aneurysms have been developed for treatment within the
anatomic criteria of use. The instructions for use (IFU) usually include
the following criteria: aortic neck angle 60, aortic neck length 10
mm, and aortic diameter at the lowest renal artery 32 mm. Before
the CE mark and FDA approval, they are tested for these criteria.
When within these IFU criteria, the devices have demonstrated to be
safe and effective. Type I endoleaks and migration were observed
in 2% patients at discharge and in 5% patients within 5 years of

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follow-up. Freedom from rupture was reported in 100% patients

within 5 years of follow-up. Schantzer et al. have demonstrated in a
large retrospective analysis that the use of devices not within the IFU
criteria results in a significantly higher percentage of aneurysm sack
growth in comparison to treatment with devices within the IFU criteria (1). The independent predictors of AAA sac enlargement were
endoleak, age >80 years, aortic neck diameter >28 mm, aortic neck
angle >60, and common iliac artery diameter >20 mm. Recently, the
use of chimney and snorkel stent grafts has opened the possibility
to treat AAAs with standard EVAR devices not within the IFU criteria.
However, the rate of type I endoleaks was reported between 10%
and 14% at discharge (2). The rate of chimney/snorkel occlusion was
4%5%.
Rates of sack enlargement, reintervention, renal failure, and aneurysm related mortality should be reported 5 years after chimney/
snorkel therapy of patients treated with EVAR devices not within the
IFU criteria. Patients should be informed about the potential risks
and outcome when treated with such devices.
References
1. Schanzer A, et al. Predictors of abdominal aortic aneurysm
sac enlargement after endovascular repair. Circulation. 2011
Jun;123(24):2848-55.
2. Lindblad B, et al. Chimney grafts in aortic stent grafting:
hazardous or useful technique? Systematic review of current
data. Eur J Vasc Endovasc Surg. 2015 Dec;50(6):722-31.

inflammatory response can still occur. Type IV TAAA has significantly

lower postoperative risks compared to Type I to III TAAA. Measures
to reduce spinal cord ischemia include cerebrospinal fluid drainage,
distal aortic perfusion, reimplantation of intercostal and/or lumbar
arteries, and perioperative assessment of spinal cord function using
motor evoked potential monitoring. Adequate MAP of 80 mmHg has
to be postoperatively maintained. Open TAAA repair should be performed in highly specialized centers, which report lower complication and mortality rates. Overall rates for death and major complications should be less than 10%. Adequate staff support and hospital and surgeon volumes significantly influence postoperative survival. Open or endovascular repair should be considered for patients
at low to moderate surgical risk. Difficult anatomy is not an issue
for open repair. Patients with connective tissue disorder are best
treated by durable open repair. Aiming for durable results, good
risk patients are best treated by open repair. These facts support
the need for aortic centers where the entire spectrum of treatment
options is provided under one umbrella and where indications seek
for technology and not vice versa.

Lecture Session
Thoraco-abdominal aortic disease

Learning Objectives
1. To learn the technical aspects of endovascular procedures in
case of TAAA
2. To learn how to prevent technical complications of endovascular
treatment
3. To learn how to preserve patency of the visceral branches
Thoracoabdominal aortic aneurysm (TAAA) repair continues to represent a clinical and technical challenge. Conventional open repair
still carries appreciable morbidity and mortality rates even in highvolume and experienced centres. Despite improvement in perioperative care and various surgical adjuncts, cardiopulmonary, renal and
neurological complications such as spinal cord ischaemia are common problems after open repair.
The endovascular treatment of infrarenal aortic aneurysms has
gained widespread acceptance and has revolutionised the field of
vascular surgery over the last decade. More recently, ingenious technical and material developments in endovascular technology have
enabled the manufacture of custom-made endografts to treat even
more challenging cases. These devices allow the treatment of aneurysmal segments of the thoracoabdominal aorta, while preserving blood flow to the visceral arteries via fenestrations, branches or
a combination of the two. Although there is still a lot to be learnt
about these new procedures, encouraging results in terms of feasibility and safety have been reported. Nevertheless, patients undergoing these procedures, most of whom have been refused open surgery, remain vulnerable in the postoperative period and are particularly at risk of spinal cord ischemia and acute renal failure. This presentation will describe our single-institution experience with the
endovascular treatment of >300 consecutive patients presenting
with complex thoracoabdominal aneurysmal disease.

2205.1
Role of surgery in 2016
J.Schmidli
Cardiovascular Surgery, Bern University Hospital, Bern, Switzerland
Learning Objectives
1. To learn the technical aspects of surgical procedures for TAAA
2. To learn indications and contra-indications for surgical procedures
3. To learn how to prevent surgical complications
In 2016, classical thoracoabdominal replacement is experiencing
a revival as endovascular failure has resulted in an increased need
for early or late conversion. Especially, in pathologies where endovascular therapy was used as a trade-off to treat an underlying disease and where current technology still does not meet the needs
and probably will not in future, open surgery has its role in the treatment of thoracoabdominal aortic disease. Preoperative risk analysis is essential and forms a part of the decision making, especially in
comorbid patients. A preoperative consensus from the anesthetist,
cardiologist, ICU specialist, and surgeon is extremely useful in order
to optimally treat the patient and to conduct him across the surgery
and first few postoperative days. General consensus exists regarding
surgical repair of TAAA for low and moderate surgical risk patients
with TAAA larger than 60 mm in maximal diameter, rapid growth
of more than 10 mm per year, or symptoms. Compromised cardiac
function, severe COPD, and preoperative renal failure are strong predictors of adverse outcome. Therefore, preoperative cardiac and
pulmonary assessments are essential and mandatory. Preoperative
inspiratory muscle training and moderate conditional training are
helpful. Type I to III TAAA cases according to the modified Crawford
classification are associated with different complications such as
MOF, paraplegia, renal and visceral ischemia, and death. Short extracorporeal circulation time and continuous distal aortic and selective
visceral perfusion are keys to success. Mild systemic hypothermia
using left heart bypass seems to be the most established technique.
Despite these protective measures, mucosal damage and systemic

2205.2
Technical challenges in endovascular TAAA procedures
S.Haulon
Vascular Surgery, Hpital Cardiologique, CHRU Lille, Lille, France

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2016

2205.3
Sandwich grafts: how far can we go?
T.Pfammatter
Institute of Diagnostic and Interventional Radiology, University
Hospital Zurich, Zurich, Switzerland
Learning Objectives
1. To learn technical aspects of sandwich grafts
2. To learn when to use sandwich grafts
3. To analyse the initial data of sandwich graft technique
The treatment of a thoracoabdominal aortic aneurysm (TAAA) is
challenging owing to the need to maintain flow in the renal and visceral arteries taking-off from an extensively degenerated tortuous
aorta. In this environment, planning, branch cannulation and stentgraft placement becomes complex. Two totally endovascular versatile techniques, modular branched aortic stent-graft placement and
the sandwich procedure, have recently been introduced to rapidly
treat patients who would not have been timely treated by endovascular means because of the delay in obtaining customized branched
devices.
The sandwich stent graft is a technique in which the parallel renovisceral stent grafts are centrally anchored between tubular aortic stent grafts, excluding the aneurysm, while their distal ends land
in the aortic branch vessel (1). The use of the off-the-shelf tubular aortic and peripheral pieces of different lengths, diameters and
manners (i.e. parallel grafts in chimney or periscope configuration)
overcomes most individual anatomical hurdles. General anesthesia
is preferred as the procedures tend to be lengthy and the patients
are generally elderly. In addition to bilateral femoral accesses, one
or two left axillary/subclavian arterial accesses are needed. In majority of the cases, all accesses can be percutaneous when adopting the
preclosing technique. The descending and the bifurcated abdominal aortic stent grafts, abutting the origin of the celiac axis and
accordingly, the most caudal renal artery are deployed first. The next
step will typically be the transfemoral deployment of the renal stent
grafts (periscope/snorkel) and the transaxillary introduction of the
visceral stent grafts (chimney). Finally, the transfemoral placement
of an oversized (20%30%) bridging aortic tubular stent graft at the
thoracoabdominal junction is performed.
The sandwich technique has been performed for aneurysms due to
aortic degeneration or chronic dissection. The timing ranged from
urgent to elective treatment. Previous aortic arch debranching, stenosed or occluded left subclavian arteries and extremely kinked
aorta may preclude the successful transluminal rebranching of the
renovisceral arteries. The technical success of the sandwich procedure was around 90% (1, 2). Failures were due to inability of renal
artery cannulation. Primary type I and III endoleaks (gutter leaks)
occurred in up to 21% of the patients. However, spontaneous leak
thrombosis was noted in many instances in the following weeks.
Endoleaks were more frequent when more than two parallel grafts
were needed. At 30 days, an all-cause mortality rate of up to 20% has
been reported. In the largest clinical study (n=32), there was just one
case of paraplegia and two patients permanently required hemodialysis (2). Mid-term follow-up data suggest the sandwich technique
is a durable technique suited even for urgent thoracoabdominal
aortic aneurysm repair (1-4).
References
1. Lobato AC, Camacho-Lobato L. A new technique to enhance
endovascular thoracoabdominal aortic aneurysm therapy--the
sandwich procedure. Semin Vasc Surg. 2012;25(3):153-60.
2. Schwierz E, Kolvenbach RR, Yoshida R, Yoshida W, Alpaslan A,
Karmeli R. Experience with the sandwich technique in endovascular thoracoabdominal aortic aneurysm repair. J Vasc Surg.
2014;59(6):1562-9.

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3. Bin Jabr A, Lindblad B, Dias N, Resch T, Malina M. Efficacy

and durability of the chimney graft technique in urgent and
complex thoracic endovascular aortic repair. J Vasc Surg.
2015;61(4):886-94.
4. Pecoraro F, Veith FJ, Puippe G, Amman-Vesti B, Bettex D, Rancic
Z, Pfammatter T, Lachat M. Mid- and longer-term follow up of
chimney and/or periscope grafts and risk factors for failure. Eur J
Vasc Endovasc Surg. 2016;51(5):664-73.

2205.4
Incidence and prevention of spinal cord ischaemia in TAAA
branched grafting
E.S.Debus
Klinik und Poliklinik fr Gefmedizin, Universittsklinikum HamburgEppendorf, Hamburg, Germany
Learning Objectives
1. To learn the pathophysiology of spinal cord ischaemia
2. To learn how to prevent spinal cord ischaemia
3. To learn about spinal cord ischaemia management
No abstract available.

2205.5
Hybrid repair is the best option
R.G.J.Gibbs
Division of Vascular Medicine and Vascular Surgery, St Marys Hospital,
Imperial College NHS Trust, London, United Kingdom
No abstract available.

2205.6
Total endovascular repair is the best option
R.A.Morgan
Department of Radiology, St. Georges Hospital, London, United
Kingdom
No abstract available.

Lecture Session
Abdominal aorta 2
2505.1
Tips and tricks for obtaining supraceliac aortic control for rAAA
F.J.Veith
Surgery, NYU Langone Medical Center, New York, NY, United States of
America
Learning Objectives
1. To learn when and how supraceliac aortic control is applied
2. Technical tips for interventions during aortic control
3. To learn about complications during aortic control
Endovascular aneurysm repair (EVAR) is being increasingly used to
treat ruptured abdominal aortic aneurysms (RAAAs). Approximately
25% of RAAAs suffer complete circulatory collapse before or during
the procedure. Their survival depends on obtaining and maintaining supraceliac balloon control until the endograft is fully deployed.
This is accomplished with a sheath-supported compliant balloon inserted via the groin contralateral to the side to be used for
insertion of the endograft main body. After the main body is fully
deployed, a second balloon is placed within the endograft and the

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first balloon is removed so that extension limbs can be placed at the

contralateral side. A third balloon can be placed via the contralateral
side and ipsilateral extensions can be deployed as necessary.
This technique of supraceliac balloon control is important to achieve
good outcomes with RAAAs. In addition to minimizing blood loss,
this technique minimizes visceral ischemia and maintains aortic control until the aneurysm rupture site is fully excluded.

2505.2
Update on fenestrated stent grafts
G.M.Richter
Director Clinics for Diagnostic and Interventional Radiology, Klinikum
Stuttgart, Stuttgart, Germany
Learning Objectives
1. To learn about indications
2. To learn about devices
3. To learn about mid-term results
No abstract available.

2505.3
Potential of inner branched grafts
E.Verhoeven1, A.Katsargyris1, W.Ritter2
1Department of Vascular and Endovascular Surgery, Paracelsus Medical
University, Nuremberg, Germany, 2Institut fr Diagnostische und
Interventionelle Radiologie KNS, Klinikum Nrnberg Sd, Nuremberg,
Germany
Learning Objectives
1. To learn about indications
2. To learn about technique
3. To learn about limitations and when not to use
The evolution of fenestrated and branched endovascular techniques
is enjoying increasing widespread. Technical feasibility and durability have been demonstrated in many presentations and publications. Our personal experience now includes 1000 fenestrated and
branched cases. The experience has grown over the years not only
in terms of more complex cases but also in terms of the number of
cases per year. This has been made possible by the technical evolution of both stent grafts and ancillary products as well as further
technical refinements. More complex anatomies and thereby more
patients can now be offered an endovascular solution.
To address target vessels in complex abdominal (AAA) and thoracoabdominal (TAAA) aortic aneurysms, two solutions have been
proposed: fenestrations (=holes in the graft) and directional side
branches. In general, fenestrations work well for target vessels that
have a close to 90-degree take-off from the aorta and when the
main graft at the level of the target vessel is appositioned to the
wall or there is only a short gap to be bridged. Nowadays, a balloonexpandable covered stent is routinely used to seal the fenestration
and to maintain perfusion to the target vessel. The Achilles heel of
fenestrations is the stability and durability of the seal between the
nitinol ring of the fenestration and the covered stent, especially
when there is a longer gap to bridge. Exact positioning of the graft
with alignment of the fenestrations to the target vessels is mandatory, and catheterization can be tedious. Directional branches work
well when target vessels have a steep take-off angle and when there
is a larger gap to be bridged, which is often the case in TAAA. Other
advantages of directional branches include better seal and fixation
for the bridging stent-graft and less critical positioning of the branch
with regard to the target vessel. Disadvantages include the required
cranial approach (subclavian, axillary, or brachial) to catheterize the
branches and target vessels and the stiffness of available bridging

Abstract Book
stent grafts. Because most side branches are directed downwards,
the bridging stent-grafts have to accommodate an angle of up to
90 degrees, especially for the renal arteries. In most branched stent
grafts, the diameter of the main graft is tapering down above the
level of the branches in order to create room for the branches. This
means that the sealing zone needs to be achieved far above the
branches.
Most complex AAAs are treated with fenestrated grafts. This is not
only because of the anatomical configuration of the target vessels
but also because using branched grafts would mean starting much
higher in the descending thoracic aorta, leading to a TAAA repair
and thereby increasing the risk of paraplegia. For TAAA, we prefer
a tailored approach choosing the ideal configuration for each individual target vessel. This has resulted in the use of many stent grafts
incorporating both branches and fenestrations.
Recently, inner branches as a additional option for visceral arteries were discussed. The idea is not new as it was already proposed
by Cook for the first time in 2004. This idea resulted in the iliac
branched device and later in the use of inner branches in the Cook
arch branched device. Together with Cook, it was decided to carefully evaluate the option of inner branches for the visceral arteries.
Inner branches have a cylindrical part inside the main graft and are
connected to the wall via a basket-type bag. In the Cook device, the
basket is diamond-shaped because of the support by the Z-stents.
The obvious advantages could be summarized by giving an extra
option for the target vessels that are not particularly well suited for
either fenestrations or directional branches. One example is the target vessel that presents with a steep take-off in conjunction with a
smaller diameter of the aorta (no room for a directional branch).
With the inner branches, there is no need to taper the main graft,
which provides more wall contact and sealing at the level of the target vessel and obviates the need for a higher start of the main graft.
Another advantage is given by the support of the basket that automatically directs the catheter and the wire into the direction of the
target vessel and facilitates catheterization. The basket also provides
support to the bridging stent-graft; this reduces the risk of migration
and disconnection as well as kinking.
Besides the technical advantages, there may be a greater advantage
of the off-the-shelf fenestrated/inner branch grafts for all complex
AAAs. The diamond-shaped openings of the inner branches are relatively wide and allow for a lot of flexibility in positioning (Figure
3b). In our opinion, a graft composed of a double-width scallop for
the celiac artery, an 8-mm fenestration for the superior mesenteric
artery, and two inner branches for the renal arteries could become
a valuable off-the-shelf solution for many relatively acute pararenal
aneurysms.
Finally, the use of the flexible Viabahn should be considered again.
The main reason for not using the very flexible covered Viabahn
stent was given by the difficult and unprecise deployment in a cavity and the lack of appropriate lengths. With the inner branches, a
covered stent length of 5 cm is often adequate, and the deployment
of a Viabahn in the inner branch is supported by the basket, again
resulting in a precise positioning of the Viabahn.
Inner branches are not available yet, but we have been allowed to
cautiously evaluate the concept in specific anatomies where the
inner branch technology is considered to be beneficial. The early
experience in different anatomies has proven to work very well, with
easy catheterization of the target vessels. However, there are manufacturing limitations as the Z-stent cannot be bent around an inner
branch as in a fenestration. In addition, the visibility of the outline of
the baskets is not as good as in standard fenestrations and branches,
where markers clearly line out the edges. Therefore, the use of four
inner branches can bring new challenges with the deployment of
the graft. Finally, all the inner branches can be fitted with indwelling wires, but the snaring position of these wires should be decided
upfront in the descending aorta to avoid clashes.

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In conclusion, the inner branch technology offers another valuable
option, which enables the manufacturing of a more fitting custommade graft and may also become part of an easier and more applicable off-the-shelf graft for most complex AAAs.

2505.4
The ongoing Achilles heel of EVAR: how to counter it
G.Maleux
Department of Radiology, University Hospitals Leuven, Leuven, Belgium
Learning Objectives
1. To determine weaknesses of EVAR
2. To learn how to prevent EVAR weaknesses
3. To acquire knowledge on improving EVAR outcomes
No abstract available.

2505.5
Conventional stent grafts are superior to new concepts: pro
E.S.Debus
Klinik und Poliklinik fr Gefmedizin, Universittsklinikum HamburgEppendorf, Hamburg, Germany

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prospective studies. All the articles were included in three categories of relevance with respect to the principal topic (relevance A, B,
and C). The clinical experience of more than 15 years in endovascular
aortic repair of our center was further considered in order to better
explain tips and tricks for each alternative vascular access.
Forty articles were considered in this systematic review. Eight articles were considered poor for relevance and not directly included.
We identified the following alternatives to the trans-femoral access:
direct iliac artery exposure, open retroperitoneal iliac conduit or
totally laparoscopic iliac conduit, abdominal aortic conduit, a variable series of endoconduit techniques, direct access to the descending thoracic aorta through a sixth/seventh interspace thoracotomy
or to the ascending aorta through a third/fourth thoracotomy, transapical access, innominate artery access with partial upper sternotomy, carotid, subclavian and axillary exposure with interposition of a
prosthetic conduit and, transvenous (transcaval) approach. The preoperative image assessment is a crucial step to evaluate the suitability of the procedure and to reduce access-related complications.
Despite continuous advances in TEVAR devices, difficult iliofemoral
access remains a significant problem that can be managed with different alternatives in order to improve results.

2903.2
Endograft sizing for type B dissection

No abstract available.

2505.6
Conventional stent grafts are superior to new concepts: con
R.A.Morgan
Department of Radiology, St. Georges Hospital, London, United
Kingdom
No abstract available.

Lecture Session
Tips and tricks
2903.1
Access route for thoracic stent-grafting
V.Riambau, S.Pasquadibisceglie
Vascular Surgery Division CardioVascular Institute, Hospital Clinic
University of Barcelona, Barcelona, Spain
Learning Objectives
1. Tips to negotiate challenging femoral and iliac vessels during
TEVAR
2. To learn what the role of percutaneous femoral access is
3. To learn how to deal with and avoid access route complications
The endovascular repair of this pathological condition (TEVAR) has
evolved during the past 20 years to become the predominant technique in most of repairs of thoracic aortic pathology. Despite the
continuous progress in thoracic stent grafting, vascular access complications are frequent due to the necessity of large femoral introducer sheaths (1825 F) as well as anatomical limitations (iliac calcification and angulation and severe multiple stenosis or occlusion).
TEVAR today should overcome these limitations, reducing the introducer size and using creative alternative accesses.
An electronic research of English literature in Medline PubMed was
performed using the following keywords and their combinations
related to the aim of the topic: thoracic endograft access, thoracic aortic aneurysm access, and TEVAR access. We considered
both case reports with one or more patients and retrospective and

J.C.vandenBerg
Interventional Radiology, Ospedale Regionale di Lugano, Sede Civico,
Lugano, Switzerland
Learning Objectives
1. To learn which imaging modalities and image post-processing
are best suited for correct endograft sizing
2. To learn how to choose the correct endograft diameters
3. To learn how to determine the most appropriate endograft
length and the necessity for distal endograft extension
The sizing related to TEVAR for type B dissection will be discussed in
this paper. The roles of CT angiography, MR angiography and intravascular ultrasound will be dealt with. The differences with respect
to the sizing related to thoracic aortic aneurysms and the influence
of stent-graft oversizing on device-related complications after thoracic endovascular aortic repair will be demonstrated.

2903.3
Identification and navigation in the true lumen in aortic dissection
R.G.McWilliams
Dept. of Radiology, Royal Liverpool University Hospital, Liverpool,
United Kingdom
Learning Objectives
1. To learn how pre-procedural imaging assists in keeping to the
true lumen during intervention
2. To learn how to gain access to the true lumen in dissections
extending into the iliacs and femorals
3. To learn which difficulties to expect in negotiating severely
narrowed and/or thrombosed true lumina
Modern imaging reviewed at a workstation allows for straightforward identification of the true and false lumina in aortic dissection. CT scanning with or without ECG-gating is the most common
modality used for diagnosis and treatment planning.
There are many artefacts which mimic aortic dissection which must
first be considered and eliminated. True aortic dissection has CT features which distinguish the true lumen from the false lumen. The
true lumen is most easily determined by its continuity with an undissected segment of aorta.

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The smaller lumen is usually the true lumen. If there is calcification in

the intimal flap then this faces the true lumen.
The false lumen displays the beak sign and less commonly aortic
cobwebs are seen at CT. Intraluminal thrombus is more commonly
seen in the false lumen.
Where one lumen wraps around the other lumen then the inner
lumen is the true lumen. Secondary dissection can create more than
two lumina.
The true lumen normally supplies the coeliac trunk, SMA and right
renal artery. The false lumen normally supplies the left renal artery.
Successful navigation through the true lumen requires that the
operator begins in the true lumen and progresses to the undissected proximal aorta via the true lumen. Femoral artery access is
nearly always in the true lumen as dissection rarely extends to the
common femoral artery. Pre-operative imaging should extend to
the groins as uncommonly there may be dissection at this level.
Knowledge of the pre-operative CT scan will identify the lower limit
of dissection and the operator must take steps to avoid passing into
the false lumen as the catheter and wire are advanced.
Stent graft deployment in the false lumen is a risk if steps are not
taken to avoid it and this complication is reported in the literature
and may be under-reported (Follis et al). The key to avoiding this
complication is careful progression of the wire and catheter during
endovascular repair. Sequential angiograms as the catheter is progressed will confirm that the catheter remains in the true lumen and
the angiographic anatomy and wire position should be studied in
relation to the expected position from the pre-operative CT scan.
If the intervention is performed in a modern hybrid theatre then
3D-overlay of the CT dataset can be used to confirm that the wire is
in the true lumen. Further confirmation may be obtained with transoesophageal echocardiography. Intravascular ultrasound is another
option.
References
1. Aortic dissection: CT features that distinguish true lumen
from false lumen. LePage MA, Quint LE, Sonnad SS et al. AJR
2001;177:207-211.
2. Multidetector CT of aortic dissection: a pictorial review.
McMahon MA, Squirrell CA. Radiographics 2010; 30:445-460.
3. Acute aortic syndromes: pathology and imaging. P Littler, W De
Monye, M Murphy et al. Imaging 21(2009):131-141.
4. Endovascular graft deployment in the false lumen of type
B dissection. Follis F, Filippone G, Stabile A et al. Interactive
Cardiovascular and Thoracic Surgery 10 (2010) 597-599.

2903.4
Post-stent graft infection and fistulas
J.-P.Beregi
Radiology, CHU Caremeau, Nimes, France
Learning Objectives
1. To learn how frequent infections and fistulas following stentgrafting are
2. To learn how to deal with these complications
3. To learn how to prevent these complications
Stentgraft infection is rare (prevalence < 1%). Management is difficult, and no strict guidelines are published. Case reports or review
of the literature can help in the management of such complications.
Abdominal stent-graft infections were more frequently reported
than thoracic stent-graft infections, but this fact should be compared considering the total number of stent-graft implantations
in the world. Staphylococcus species, Streptococcus species and
Escherichia coli were the most commonly isolated microorganisms.
Risk factors of infected stentgrafts are elderly patients, sex (more
men), immune deficiency (primary or secondary to corticosteroid
therapy or neoplasm) patients, procedural environment, secondary

Abstract Book
procedures and emergency treatment. Antibiotic prophylaxis is
mandatory with cephalosporin or penicillin therapy.
Diagnosis of infection is based on clinical symptoms, imaging and
microbial cultures (1/3 negatives). Infected stent grafts have been
shown to present roughly 1/3 as chronic disease, 1/3 as severe acute
sepsis and 1/3 as aortoenteric fistula. CT angiography is the gold
standard technique for diagnosis, but nuclear medicine imaging is
sometimes necessary for chronic disease.
The following two main options could be performed: conservative treatment with antibiotic therapy or surgical replacement of
the stentgraft. Surgical replacement is recommended when active
gastrointestinal bleeding, pseudoaneurysm or extensive perigraft
purulence involving adjacent organs are present. When there is
no immediate danger to the patients life (majority of cases), conservative management is started with proper antimicrobial therapy. Additional procedures such as drainage, sac irrigation or surgical debridement could be performed. Decision to remove the stent
graft is difficult in fragile patients and often requires a case-by-case
evaluation.
Whatever is the treatment, long-term antibiotic therapy is always
required in all cases, with close monitoring of the C-reactive protein
levels. Mortality remains high, irrespective of the treatment. Among
patients treated for endograft infection without explantation, those
with aortoenteric fistula had the worst outcome.
References
1. Moulakakis KG et al; Outcome after preservation of infected
abdominal aortic endografts. J Endovasc Ther 2014;21:448-55.
2. Setacci C et al; How to diagnose and manage infected
endografts after endovascular aneurysm repair. Aorta
2014;6:255-64.
3. De Donato G et al; Prosthesis infection: prevention and
treatment. J Cardiovasc Surg 2014;55:779-92.
4. Laser A et al; Graft infection after endovascular abdominal aortic
aneurysm. J Vasc Surg 2011;54:58-63.

2903.5
Value of procedure rehearsal of EVAR procedures
L.Desender, F.E.Vermassen
Department of Thoracic and Vascular Surgery, Ghent University
Hospital, Ghent, Belgium
Learning Objectives
1. To learn which possible complications could be circumvented by
procedure rehearsal
2. Does procedure rehearsal have an impact on procedure time
and endograft expense?
3. To illustrate the various options for procedure rehearsal
Evolutions in virtual-reality simulation enable patient-specific
rehearsal (PsR) of endovascular aneurysm repairs (EVARs). This
allows the interventionalist and his team to practice and evaluate
the real case on patient-specific anatomy, try different approaches
and endovascular equipment and thus optimise the treatment plan.
We conducted a multicentre, randomised controlled trial to assess
the effect of PsR on procedural errors and technical performance.
Patients with an infrarenal aortic or iliac aneurysm suitable for
EVAR with the Gore C3 Excluder (W.L. Gore & Assoc, Sunnyvale,
California, USA) or Endurant (Medtronic Vascular, Santa Rosa,
California, USA) were recruited at six vascular centres across Europe.
Cases were randomly assigned to preoperative PsR or to the control
group. Primary outcome measures were errors during the real procedure and technical operative metrics (total endovascular and fluoroscopy time, contrast volume, number of angiograms and radiation
dose). Secondary outcomes were technical and human factor skills,
deviation of treatment plan and technical and initial clinical success
rates.

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CIRSE 2015
2016

Hundred patients were recruited between September 2012 and

June 2014. Procedures were performed by teams with different
EVAR experience. There was a 26% (95% confidence interval (CI):
9%40%; p=0.004) reduction in minor errors, a 76% (95% CI: 30%
92%; p=0.009) reduction in major errors and a 27% (95% CI: 8.2%
42%, p=0.007) reduction in errors causing procedural delay in the
PsR group. The number of angiograms performed to visualise proximal and distal landing zones was 23% (95% CI: 8%36%; p=0.005)
and 21% (95% CI: 7%32%; p=0.004) lower, respectively, in the PsR
group. Technical (p=0.79) and human (p=0.65) factor skills and primary technical (p=0.80) and initial clinical (p=0.20) success rates
were similar in both groups. In 44/50 (88%) cases, the lead interventionalist changed his treatment plan after PsR.
PsR prior to EVAR can be used in different hospital settings by
diverse teams with various EVAR experiences. It reduces perioperative errors as well as the number of angiograms to deploy the stent
graft, thereby reducing delays. Ultimately, it may improve patient
safety and procedural efficiency.

2903.6
How to simplify FEVAR
M.S.Hamady
Radiology, St Marys Hospital, London, United Kingdom
Learning Objectives
1. To learn about the current status of off-the-shelf fenestrated
endografts
2. Can FEVAR be performed percutaneously under local anaesthesia?
3. Tips for correct endograft placement and rapid catheterisation
of the branch vessels
No abstract available.

SS/FC/HL/HTS/CM
LS/HTS

S383

S384

CIRSE

Abstract Book

CIRSE 2015
2016

S385

SS/FC/HL/HTS/CM
Author Index

IDEAS
2

S e p t e m b e r 11-13
B arcelona/Sp ain

PART 2
Author Index
List of all abstract authors
with presentation numbers
Please note that bold numbers
indicate presenting authors.

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S386

CIRSE

B
Becquemin, J.-P.
Benenati, J.F.
Beregi, J.-P.
Brountzos, E.

P
1705.1
1505.5
2903.4
1505.4

1302.2

D
Dake, M.D.
Debus, E.S.
Desender, L.
De Vries, J.P.P.M.
Donas, K.P.

905.1, 1302.3
2205.4, 2505.5
2903.5
1505.2, 1705.5
1705.2

E
Eldergasch, O.

Saint-Lebes, B.
Schmidli, J.
Schmuck, B.

Thomas, R.P.
Torsello, G.
Trimarchi, S.

1705.3

1505.6, 2205.5
1302.1

H
Hamady, M.S.
Haulon, S.
Hoffman, A.

905.6, 2903.1
1505.3, 2505.2
905.3, 2505.3
1406.2

1302.2

G
Gibbs, R.G.J.
Greenhalgh, R.M.

Riambau, V.
Richter, G.M.
Ritter, W.
Rousseau, H.

1406.2
2205.1
1302.2

F
Fanelli, F.

Pasquadibisceglie, S.
905.6, 2903.1
Pfammatter, T.
2205.3

C
Chavan, A.

Abstract Book

2903.6
1406.5, 2205.2
1705.4

1302.2
1705.2
1406.6

van den Berg, J.C.

Veith, F.J.
Verhoeven, E.
Vermassen, F.E.
Verzini, F.

2903.2
1705.2, 2505.1
2505.3
1302.4, 2903.5
1505.1

W
Williams, D.M.

905.2

J
Jenkins, M.P.

1406.3

K
Katsargyris, A.
Klbel, T.

2505.3
1406.4

L
Lammer, J.
Lnn, L.B.

1705.6
905.5

M
Maleux, G.
McWilliams, R.G.
Meyrignac, O.
Mokrane, F.
Morgan, R.A.

2505.4
2903.3
1406.2
1406.2
2205.6

N
Nienaber, C.
Nobre, A.L.

905.4
1406.1

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