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SS/FC/HL/HTS/CM

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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SS/FC/HL/HTS/CM

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

C RSE

S37

S38

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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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

S56

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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.

SS/FC/HL/HTS/CM

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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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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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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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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).

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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

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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.

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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.

C RSE

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.

C RSE

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.

C RSE

CIRSE 2016

SS/FC/HL/HTS/CM

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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.

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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.

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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.

C RSE

CIRSE 2016

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.

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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, Azien