SS/FC/HL/HTS/CM

CIRSE 2014

Glasgow, UK

September 13-17

CIRSE 2014

ABSTRACTS & AUTHOR INDEX 4 PART 1:

4 PART 2: 4 PART 3: 4 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/s00270-014-0940-z

Cardiovascular and Interventional Radiological Society of Europe

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Glasgow, UK

September 13-17

CIRSE 2014 PART 1

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

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Fundamental Course Basic principles of carotid artery intervention

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101.2 How to perform a typical carotid artery stenting procedure F. Fanelli Vascular and Interventional Radiology Unit, “Sapienza” University of Rome, Rome, Italy

101.1 Indications for carotid artery stenting - patient triage T.J. Cleveland Radiology, Sheffield Vascular Institute; Northern General Hospital, Sheffield, United Kingdom Learning Objectives 1. To understand the clinical indications for CAS 2. To understand the technical, clinical and anatomical indications and limitations for CAS 3. To understand the evidence guiding patient selection for CAS Carotid artery angioplasty and subsequent stenting is no longer a new procedure. We have >15 years of experience with the CAVATAS Trial being published in 2001, following which stenting became a norm at the carotid bifurcation. We have large randomized trials of carotid artery stenting (CAS) vs carotid endarterectomy (CEA), making CAS one of the most investigated endovascular procedures. Yet, there is considerable controversy. It is important to consider why interventions in the carotid artery are indicated. This is a procedure largely directed at stroke prevention. We know that an individual with a symptomatic carotid artery stenosis runs a high risk of recurrent stroke, particularly, in the short-term. In contrast, a person with an asymptomatic carotid stenosis carries a much lower risk, but nevertheless may benefit from intervention, particularly if subjected to a high-risk procedure such as cardiac surgery. It is also important to remember that the carotid artery originates in the upper chest and extends into the brain. The common carotid artery bifurcation is an area where diseases are more prevalent. It is now clear that once a carotid artery stent has been implanted, the risk of recurrent stroke is very similar for CAS and CEA. Like all procedures, the peri-procedural complication rate is dependent upon a number of factors, including case selection and operator experience. It is fairly consistent across trials that minor strokes associated with CAS are more frequent than that with CEA (major stroke and death being largely equivalent). A majority of these equalize with time. In contrast, CEA has an increased risk of cranial neurological damage and significant bleeding. Some groups are at a high risk of CEA, and others are at a high risk for CAS. Those patients who are at a high risk of stroke and CEA, if are suitable for CAS, the balance may lie with CAS. However, those who are not suitable for CAS will be better served by CEA. Patients with diseases far from the carotid bifurcation may be best served by CAS or a combination approach. People who have asymptomatic carotid stenoses are at a lower risk of stroke require an even safer treatment or they will not accrue benefit by risking a treatment. So far, CAS within the intra-cranial portion of ICA have not been shown to benefit from stenting.

Learning Objectives 1. To learn how and when to select embolic protection devices 2. To learn how to select and place stents 3. To learn which angiographic imaging is necessary for the procedure One of the most critical steps in carotid artery stenting is the ability to gain access to the common carotid artery. Different techniques such as direct approach, telescopic approach, and telescopic approach with the coaxial technique can be used. The selection is correlated with the anatomy of the aortic arch and technical skills of the operator. Cerebral protection devices play a fundamental role in the prevention of distal embolization. They must be selected on the basis of the patient’s anatomical characteristics and plaque morphology. The three types of cerebral protection devices available are distal occlusion balloons, filters, and proximal protection systems. In filter systems, the flow is maintained during the procedure, and emboli are captured and removed together with the device by retraction of the system. Proximal protection systems provide cerebral protection with no device, advancing through the stenosis on the basis of the inflation of an occlusion balloon at the level of the common carotid artery and at the origin of the external carotid artery, causing the inversion of the flow or the complete stop of the flow within the internal carotid artery. These systems take advantage of the vascular anastomosis of the circle of Willis. The procedure is entirely performed under protection, but the complete flow occlusion is not well tolerated by 6–10% of the patients. Self-expanding stents are nowadays the only devices that can be within the carotid territory. Balloon-expandable stents are avoided because having ICA at a superficial location, the risk of a stent crush - which may lead to cerebral flow impairment - is too high. Stent selection must be made in accordance with the anatomical and morphological characteristics of the carotid arteries and with the plaque morphology. In patients with tortuous anatomy of ICA, nitinol stents should be preferred because they are softer than stainless steel stents and are able to maintain the arterial curve. Post dilatation of the stent is the most critical step of the CAS procedure and requires careful attention because it is at this stage that embolic events are most likely to develop. The risk of embolization is correlated to the fact that while the stent is being dilated, the plaque suffers a squeeze and can slide beyond the stent meshes and migrate into the intra-cerebral circle. Before balloon dilation, 1 mg of atropine must be administered in order to reduce bradycardia and hypotension correlated to the stimulation of the carotid baroceptors (carotid sinus reflex). References 1. Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK. Society for Vascular Surgery. Updated Society for Vascular Surgery Guidelines for Management of Extracranial Carotid Disease: Executive Summary. J Vasc Surg. 2011;54:832-6. 2. Verzini F, De Rango P, Parlani G, Panuccio G, Cao P. Carotid Artery Stenting: Technical Issues and Role of Operators’ Experience. Perspect Vasc Surg Endovasc Ther. 2008;20:247-57. 3. Müller-Hülsbeck S, Jahnke T, Liess C, et al. Comparison of Various Cerebral Protection Devices Used for Carotid Artery Stent Placement: An In Vitro Experiment. J Vasc Interv Radiol. 2003;14:613-20.

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101.3 Tips and tricks for difficult carotid artery stenting procedures M. Szczerbo-Trojanowska Department of Interventional Radiology, Medical University of Lublin, Lublin, Poland Learning Objectives 1. To learn how to deal with difficult anatomy 2. To learn adjunctive manoeuvres in difficult cases 3. To learn how to avoid technical failure Carotid artery stenting (CAS) is a challenging procedure with a number of potential pitfalls, which can affect the outcomes. The patient condition, type of aortic arch, and carotid lesion characteristics are the most important factors determining successful carotid stenting. Difficulties can occur at every stage of CAS starting from vascular access. There are anatomical conditions in which femoral approach for CAS is very difficult or impossible. In these cases, a retrograde access from the upper extremity or an open cervical entry into the common carotid artery can be utilized. Catheterization of the aortic arch and common carotid artery (CCA) is responsible for most technical failures in carotid stenting due to anatomical geometry. The most difficult type 3 arch requires complex reverse curves catheters to navigate. Generally, a more tortuous aortic arch, more stiff guidewire, flexible sheath, and a longer length of guidewire in the CCA is required. During the procedure, it is essential to watch the image monitor to follow the position of the sheath and to avoid prolapse into the aortic arch, after its successful placement in the CCA. Tortuosity is a challenge in passing the catheter through the internal carotid artery (ICA). Difficulty increases when tortuosity is combined with stenosis, calcifications, and the ulceration of the sclerotic plaque. Tortuous carotids create problem in catheterizing primarily due to buckling of the introducer sheath back into the aorta. To navigate very tight narrowing or severe tortuosity of ICA, a “buddy” wire, a stiff guide, or the coaxial double-guiding catheter technique can be used. Critically tight ICA lesions may need a gentle predilatation with a 2-mm balloon for an advancement of the neuroprotection device. Filters can occasionally create arterial spasm, particularly in the region of their deployment, which can be treated with an injection of nimodipine (200 μm) or nitroglycerin (100 μm) into the carotid artery. After stent placement, debris from carotid plaque may be trapped within the filter causing cessation of flow in ICA. In such cases, aspiration is used to evacuate the standing column of blood and embolic debris. The removal of the filter also may be challenging. An external pressure or turning the head toward the contralateral side or advancement of the 6-F sheath into the stent may help in accomplishing the procedure. It is worth to remember that a failure in completing CAS is accepted but complication causing a stroke is not.

101.4 Managing procedural complications E. Brountzos 2nd Dept of Radiology, University of Athens, Athens, Greece Learning Objectives 1. To know which complications may occur 2. To learn how to recognise and avoid complications 3. To learn how to manage complications Complications of carotid artery stenting (CAS) include the following: • Spasm of the internal carotid artery: it follows the deployment of an embolic protection device and spontaneously resolves following its removal. Intra-arterial administration of 100–400 μg nitroglycerin is sometimes required.

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• Transient sinus bradycardia or asystole: they are common physiological responses to balloon dilatation of carotid bifurcation lesions. Intravenous atropine may be required. • Persistent hypotension: it occurs in 4%–11% CAS procedures. Hemodynamic monitoring for 24 h is essential. It responds to intravenous hydration and vasopressors. • Cerebral embolization: risk factors are - soft plaque; fresh thrombus; inadequate antiplatelet pretreatment; aggressive manipulation of guide wires, balloons, and stents, and prolonged and aggressive attempts to catheterize atherosclerotic, tortuous arteries. With clinical suspicion, intracranial DSA and recanalization of occluded arteries are mandatory measures. • Intracranial hemorrhage: it is a life-threatening complication. It occurs in approximately 0.3% CAS procedures. A sudden loss of consciousness preceded by severe headaches in the absence of intracranial vessel occlusion should be considered as a complication; the procedure should stop and anticoagulation should be reversed. Risk factors include: excessive anticoagulation, poorly controlled hypertension, and CAS in the presence of a recent (3 cm in diameter and the presence of large (≥3 mm) abutting vessels result in a 50% drop in the rate of complete tumor eradication. Is a standard RFA still the best technique for tumor ablation in 2014? Several novel thermal and non-thermal techniques for tumor ablation, including microwave ablation and irreversible electroporation, seem to offer potential advantages over RFA and are currently undergoing clinical investigation. Advances in ablation systems and devices are highly warranted. However, progress in image guidance and monitoring is also a key to success. To be able to compete with surgical resection, image-guided ablation needs to offer a more accurate prediction of the procedure outcome in each patient. The variability in outcomes needs to be minimized via a careful treatment planning. In addition, the outcome of the ablation procedure needs to be carefully documented by providing evidence that an “A0” treatment has been achieved.

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References 1. Lencioni R. Loco-regional treatment of hepatocellular carcinoma. Hepatology 2010; 52:762-773. 2. Lencioni R, Crocetti L. Loco-regional treatment of hepatocellular carcinoma. Radiology 2012;262:43-58.

902.1 T.F. Antonios Cardiovascular & Cell Sciences Research Institute, St. George’s, University of London, London, United Kingdom

Emerging ablation techniques P.L. Pereira Dept of Radiology, Minimally Invasive Therapies and Nuclearmedicine, SLK-Clinics GmbH, Ruprecht-Karls-University Heidelberg, Heilbronn, Germany Learning Objectives 1. To learn about underlying principles and differences among emerging technologies for ablation of HCC 2. To learn about pre-clinical experience with emerging technologies 3. To learn if the newly emerging technologies are ready to be implemented in clinical practice Image-guided percutaneous thermal techniques with radiofrequency ablation (RFA) is established as the first-line treatment in early-stage hepatocellular carcinoma (HCC) (1) or even as first-choice therapy in very early stage HCC if the patient is not a candidate for transplantation (2). Long-term survival of patients with HCC treated with RFA is similar to those treated with surgical resection, with lower morbidity and mortality. Regarding the large amount of studies reporting the efficacy of RFA for the treatment of larger HCC, RFA is currently the only technique that is recommended to treat HCC up to 5 cm in size, combined with transarterial chemoembolization for tumors larger than 3 cm (3). New technologies such as microwave ablation (MWA), high-intensity focused ultrasound (HIFU), and irreversible electroporation (IRE) are now explored in clinical settings to treat HCC (4). HIFU has already demonstrated its value as a bridging therapy for patients with HCC (5). HIFU ablation has shown to be a safe and effective method for unresectable HCCs with a survival benefit over TACE alone (6). IRE is a non-thermal ablation technique that induces tumor tissue destruction through bioelectrical injury. Preliminary results suggest that IRE is a safe and feasible modality for the local ablation of HCC, particularly if lesions are smaller than 3 cm (7). MWA has the advantage over RFA to be faster and less sensitive to the heat sink effect. MWA seems to be more effective in treating HCC of 3–5cm in size. Moreover, in a recent study comparing MWA with surgical resection in patients with solitary HCC up to 5 cm in size, MWA results in similar overall survival rates than resection. For solitary HCCs smaller than 3 cm, MWA was as effective as surgery (8). In conclusion, locoregional thermal therapies are a mainstay in the treatment of early and very early HCC. All thermal modalities may achieve excellent control and provide improved survival similar to surgery with better quality of life. The different techniques have advantages and drawbacks that should be prospectively analyzed. Therefore, more recent emerging technologies such as HIFU and IRE are not ready to be implemented in clinical practice. 1. Bruix J. Hepatology 2005. 2. Forner A. Lancet 2012. 3. http://www.awmf.org/leitlinien/detail/ll/032-053OL.html. 4. Pollak J. J Clin Gastroenterol 2014. 5. Mearini L. World J Gastroenterol 2013. 6. Cheung TT. Liver Int 2014. 7. Cheung Wl. Technol Cancer Res Treat 2013. 8. Shi J. J Gastroenterol Hepatol 2014.

Special Session Renal denervation Renal denervation: evidence before SYMPLICITY HTN-3

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References

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Learning Objectives 1. To learn the criteria for evaluating RDN 2. To learn the results of the current evidence 3. To understand the limitations of current research evidence Hypertension is the most important risk factor for cardiovascular diseases, including strokes, heart attacks, renal failure, and heart failure. Resistant hypertension (RH) is defined as uncontrolled blood pressure (BP) above target goal (>140/90 mmHg in non-diabetic patients and >130/80 mmHg in diabetic patients) despite the concurrent use of maximal tolerated doses of three or more different antihypertensive drugs, including a diuretic.1 Patients with RH are at higher risk for cardiovascular events. The causes of RH are varied and include non-concordance with antihypertensive medications; use of drugs that can increase BP such as non-steroidal anti-inflammatory drugs, steroids, cocaine, liquorice, and anti-angiogenic drugs; high salt diet; alcohol excess; obesity; and presence of secondary causes of hypertension such as hyperaldosteronism, renal artery stenosis, chronic kidney disease, and obstructive sleep apnoea. 2 Patients with RH have also been found to have increased sympathetic outflow. The sympathetic nervous system and in particular, sympathetic crosstalk between the kidneys and the brain, appears to play an important role in essential hypertension as demonstrated by elevated rates of renal norepinephrine spillover. 3 Furthermore, surgical sympathectomy has been used as a treatment for severe hypertension. 4 Recently, endovascular catheter ablation technology has allowed selective denervation of the human kidney using radiofrequency (RF) energy delivered via the renal artery lumen. 5 Renal sympathetic denervation is a novel endovascular catheter-based interventional procedure aimed at treating RH. Initial studies have shown significant improvement in BP control up to 36 months after the procedure. Symplicity I trial was the first in-human proof-of-concept study in 45 patients with RH.6 The baseline office BP was 177/101 mmHg while on a mean of 4.7 antihypertensive drugs. Six months after the RSD procedure, office BP was reduced by 22/11mmHg and by 27/17 mmHg at 1 year. Symplicity II was an international, multicenter, randomized but not blinded second study of the safety and effectiveness of renal sympathetic denervation (RSD) in patients with RH. Patients aged 18–85 years with a systolic BP ≥160 mmHg (≥150 mmHg in patients with type 2 diabetes) were included. RSD was performed in 52 patients, whereas antihypertensive medications were continued in 54 patients. BP improved significantly in the first month in the active RSD group, but BP reduction was much greater at 6 months (reduction by 32/12 mmHg), whereas in the control group, BP change was minimal (1/0 mmHg). BP reduction was significantly less in a smaller group of 20 patients who underwent ambulatory BP measurement (11/7 mmHg).7 Very recently, the results of the Symplicity III trial were published. 8 It was the first prospective, single-blind, randomized, sham-controlled trial. The primary efficacy endpoint was the change in office systolic BP at 6 months; a secondary efficacy endpoint was the change in mean 24-hour systolic ambulatory BP. A total of 535 patients underwent randomization. The study was negative as it did not show a significant reduction of office or ambulatory systolic BP in patients with RH 6 months after RSD compared with a sham control. However, there were several criticisms to the trial including the fact that the

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enrolled 360 patients in the RSD arm were treated by 140 interventionalists, out of which 120 interventionalists performed only one procedure each in the trial and that is the only RSD procedure they have done in their career. The Joint UK Societies (British Hypertension society, British Cardiovascular Society, British Cardiovascular Intervention Society, British Society of Interventional Radiology, and the Renal Association) recommend a temporary moratorium on RSD procedures for all cases as part of routine care in the NHS and private practice in the UK. Prospective randomized properly controlled trials are urgently needed to assess the future role of RSD in the treatment of RH. References

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tegy in resistant hypertension is justified by the pathophysiology of kidney function and by data from older studies on surgical sympathectomy which efficiently lowered blood pressure and mortality in patients with hypertension. The interruption of the renal sympathetic fibers by radiofrequency energy delivered via the renal arterial wall has been demonstrated to reduce renal and total body norepinephrine spillover and to lower the blood pressure in patients with resistant hypertension. However, despite promising results in several clinical trials, the technique failed to meet the primary efficacy end point in the recently published multicenter, randomized, sham-controlled Symplicity-HTN-3 study. Many factors potentially affecting the negative results have been discussed since then, one of them being ineffective ablation technique due to incomplete circumferential ablation or due to insufficient delivery of the radiofrequency power to the tissue. Since renal denervation has emerged as a promising strategy in treating resistant hypertension several other CE marked devices have released into the market. The devices differ by various factors which determine an adequate lesion formation like the form of energy used for tissue ablation, the power rate, the electrode-tissue interface temperature, the duration of the energy delivery, the size and number of the catheters active electrode(s) or the technology to achieve adequate tissue contact. Since there is a significant interplay between these variables each device has to provide a well-balanced ablation performance in order to achieve favourable results. However, while second generation devices have been optimized to guarantee a sufficient ablation procedure, there still is a significant lack of available data on the efficacy and safety of these devices compared to the data on the original single-electrode ablation catheter.

1. Kumbhani DJ, Steg PG, Cannon CP, Eagle KA, Smith SC Jr, Crowley K, et al. Resistant hypertension: a frequent and ominous finding among hypertensive patients with atherothrombosis. Eur Heart J 2013;34:1204-14. 2. Calhoun DA, Jones D, Textor S, Goff DC, Murphy TP, Toto RD, et al. Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Circulation 2008;117:e510-26. 3. DiBona GF, Kopp UC. Neural control of renal function. Physiol Rev 1997;77:75-197. 4. Smithwick RH, Thompson JE. Splanchnicectomy for essential hypertension; results in 1,266 cases. J Am Med Assoc 1953;152:1501-4. 5. Schlaich MP, Sobotka PA, Krum H, Lambert E, Esler MD. Renal sympathetic-nerve ablation for uncontrolled hypertension. N Engl J Med 2009;361:932-4. 6. Krum H, Schlaich M, Whitbourn R, Sobotka PA, Sadowski J, Bartus K, et al. Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study. Lancet 2009;373:1275-81. 7. Symplicity HTNI, Esler MD, Krum H, Sobotka PA, Schlaich MP, Schmieder RE, et al. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Lancet 2010;376:1903-9. 8. Bhatt DL, Kandzari DE, O’Neill WW, D’Agostino R, Flack JM, Katzen BT, et al. A controlled trial of renal denervation for resistant hypertension. N Engl J Med 2014;370:1393-401.

1. Krum H, Schlaich M, Whitbourn R, et al. Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study. Lancet. 2009;373(9671):1275-81. 2. Esler MD, Krum H, Sobotka PA, Schlaich MP, Schmieder RE, Bohm M. Renal sympathetic denervation in patients with treatmentresistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Lancet. 2010;376(9756):1903-9. 3. Bhatt DL, Kandzari DE, O’Neill WW, et al. A controlled trial of renal denervation for resistant hypertension. The New England Journal of Medicine. 2014;370(15):1393-401.

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Renal denervation: SYMPLICITY HTN-3 evidence: overview

Renal denervation: beyond hypertension

M.J. Lee Radiology, Beaumont Hospital, Dublin, Ireland

J.G. Moss Department of Radiology, North Glasgow University Hospitals, Gartnavel General Hospital, Glasgow, United Kingdom

Learning Objectives 1. To learn about a sham trial versus non-sham trials 2. To learn about the results from simplicity 3RDN 3. To learn how to move forward with RDN No abstract available.

902.3 New devices, new opportunities? A. Schmid1, C. Ott2, R.E. Schmieder2, M. Uder1 1Radiology, University hospital of Erlangen, Erlangen, Germany, 2Nephrology and Hypertensiology, University hospital of Erlangen, Erlangen, Germany Learning Objectives 1. To learn which new devices are available 2. To learn how new RDN technology works 3. To learn what to expect from new technologies The principle of sympathetic nerve modulation as a therapeutic stra-

References

Learning Objectives 1. To learn why RDN still may have a role beyond hypertension 2. To learn which other pathologies might respond to RDN 3. To learn the available evidence for RDN beyond hypertension The sympathetic nervous system connects with most if not all organs of the body. Therefore, it seems likely that renal denervation (RDN) may have other effects in addition to blood pressure control. Although the data and evidence are still in their infancy, detectable changes have been reported in several clinical syndromes, which include the following. 1. heart failure 2. cardiac arrhythmias (e.g. atrial fibrillation) 3. chronic kidney disease 4. insulin resistance 5. sleep apnoea 6. polycystic ovarian syndrome 7. liver cirrhosis 8. loin pain haematuria syndrome

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However, in view of the contradictory results of the simplicity trials, more evidence is required before RDN can be recommended as standard care in these less well researched conditions. The evidence will be reviewed for the attendees.

Special Session Spine interventions 903.1 Osteoid osteoma and osteoblastoma A. Gangi Imagerie Interventionnelle, NHC, Strasbourg, France Learning Objectives 1. To learn how to treat benign bone tumours 2. To learn which ablation techniques can be used 3. To learn tips and tricks to increase success and limit complications No abstract available.

Abstract Book References 1. Zileli M et al. ABC of the spine. Eur Spine J. 2013 Mar; 22(3):593-601. 2. Guarnieri G, Ambrosanio G, Vassallo P, Granato F, Setola FR, Greco B, Izzo R, Muto M. Combined percutaneous and endovascular treatment of symptomatic aneurysmal bone cyst of the spine: clinical six months. Follow-up of six cases. Neuroradiol J. 2010 Mar; 23(1):74-84. 3. Amendola L et al. ABC of the mobile spine: the therapeutic role of embolization. Eur Spine J. 2013 Mar; 22(3):533-541. 4. Masala S, Muto M et al. Osteoporotic vertebral compression fractures augmentation by injectable partly resorbable ceramic bone substitute: a prospective non randomized trial. Neuroradiology 2011 Aug. 5. Guarnieri G, Vassallo P, Muto M, Muto. Percutaneous treatment of symptomatic aneurysmal bone cyst of L5 by percutaneous injection of osteoconductive material (Cerament). JNIS 2013.

903.3 Pre-operative embolisation A.G. Ryan Department of Radiology, Waterford Regional Teaching Hospital, Waterford City, Ireland

903.2 Aneurysmal bone cyst M. Muto Radiology, Cardarelli Hospital, Naples, Italy Learning Objectives 1. To learn how to confirm the diagnosis of ABC before treatment 2. To learn how to manage ABC 3. To learn tips and tricks to increase success and limit complications Aneurysmal bone cysts (ABC) are benign lesions of unknown origin and 30–50% are associated with condroblastoma, osteoblastoma, giant cell tumors, fibrous displasia, bone infarcts, or related to previous trauma history. ABC are vascularized cystic lesions with solid part due to the presence of collagen, and it is frequently possible to find multiloculate hemorrhagic cysts within this lesion. The entity of the arterial supply is not always the same case by case, and this can certainly influence the treatment strategy. ABC represent almost 1% of the primitive bone tumors; their most common location are long bones, spine, and iliac wings. Eighty percent of ABC are present in patients younger than 20 years of age as opposed to giant cell tumors. There is a mild predominance in females. Twenty percent of all ABC are located in spine, mainly at the cervical and thoracic levels. Pain and acute spinal cord compression with acute onset of motor and sensory deficits are the most frequent clinical symptoms, and the main problem is recurrence, which most frequently occurs after surgery. X-ray and CT imaging findings show the presence of a lytic lesion with thinning of cortical layer with internal septa, and MRI usually shows the presence of a pathologic mass with multiple blood levels within the lesion. Considering the risk of en block resection especially at the level of spine, the option of multiple mini-invasive treatments are available. The most frequent procedure performed in the recent years has been endovascular approach using microcatheter enabling a more distal injection of embolic agent such as glue or Onyx. This treatment reduces the arterial vascular supply but does not give any support for stability of the bone; for this reason, another option can be direct percutaneous injection of embolic agent. Recently, a new osteconductive material (Cerament Bone Support) has been used to improve the recalcification of the pathologic bone; this material is injected directly in the lesion through a small needle, leading to a good filling and the formation of new bone within 6 months after the treatment.

Learning Objectives 1. To learn the best indications for embolisation 2. To learn when to combine embolisation and ablation 3. To learn tips and tricks to increase success and limit complications Introduction Spinal tumours can result in instability, intractable pain and neurological compromise. In a metastatic setting, corpectomy and instrumental stabilisation are the treatments of choice to restore stability and relieve or prevent neural compression. Without pre-operative embolisation, operative resection of hypervascular tumours has to be abandoned occasionally because of haemorrhage1-2. First described by Benati in 19743, embolisation of arteries feeding spinal tumours is indicated to limit the potential massive blood loss reducing operative duration and mortality and ensuring optimal visualisation, thereby facilitating an adequate resection4. Additional resultant benefits include a reduced recurrence rate and a potentially prolonged survival (the latter is documented in hepatocellular carcinoma)5. With respect to reducing peri-operative blood loss, there is substantial evidence to support its efficacy4-16. Embolisation may also be performed in a palliative setting with curative intent for some benign primary tumours5. Patient selection Lesions with histologies known to produce hypervascular metastases respond more favourably (renal cell, thyroid, some sarcomas, hepatocellular carcinoma and germ cell and neuroendocrine metastases). Some typically hypovascular metastases, e.g. breast and prostate, may occasionally be hypervascular, and it is recommended that angiography (and embolisation if the tumor is hypervascular) should be performed regardless of the histology prior to a thoracolumbar corpectomy or vertebrectomy17. On pre-embolisation imaging, predictors of a positive outcome post-embolisation are purely lytic tumours, associated pathological fracture, rapid increase in size and/or progressive destruction9. Angiographic anatomy Critical to avoiding complications, specifically cord/brain ischaemia is a thorough knowledge of the arterial anatomy, its variants and the variations in flow patterns that may occur during the procedure. Vertebral supply In the cervical spine, there are four potentially different arterial supplies, namely the occipital arteries (C1 and 2), ascending cervical arteries (divisions of the thyrocervical trunk, typically supplying C3 and 4), deep cervical arteries (divisions of the costocervical trunk, typically supplying C5 and C6) and vertebral arteries (preferentially supplying C7).

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For skull base and C1/2 lesions, the ascending pharyngeal artery also needs to be examined, given its potential anastomoses with the occipital artery. In the high thoracic spine, the superior intercostal arteries (the right usually supplies T1–3, the left usually supplies T1–4) and supreme intercostal arteries (arising from the costocervical trunk) must be assessed. For thoracic and lumbar levels, a pair of segmental arteries arise at each vertebral body level, arising as separate origins in the thoracic and upper lumbar spine but usually from a common origin in the mid- and lower-lumbar spine. For lesions in the sacrum, the median sacral artery as well as the iliolumbar arteries (typically arising from the common iliac artery) and lateral sacral arteries (from the posterior division of the internal iliac arteries) need to be assessed. Radiculomedullary supply The spinal cord is supplied by a single anterior spinal artery (ASA) in the midline and paired posterolaterally with the posterior spinal arteries. ASA commences at the vertebrobasilar junction (from branches of one or both vertebral arteries) and extends to the filum terminale. Variants in appearance include calibre irregularity and ‘duplication’ (in the cervical region), focal discontinuity (thoracic) and further ‘duplication’ at the conus, the latter appearance arising from a ‘basket’ of anastomoses between ASA and the dorsal pial medullary arteries. The anterior and posterior spinal arteries are thinnest between T4 and T8, with usually only one radiculomedullary artery (T4 or 5) supplying ASA at this level, particularly resulting in the vulnerability of this section of the cord to radiculomedullary insult. ASA receives significant additional supply at locations where the oxygen demand is maximal, e.g. the sites of cord expansion at the origin of the brachial plexus in the cervical cord and in the conus at the lumbar plexus origin. This supplemental supply comes from the segmental arteries arising from the aorta, which divide at the level of the transverse process into ventroparietal and dorsospinal branches. The dorsospinal artery in turn divides at the level of the neural foramen into radicular and muscular branches. Each radicular branch divides into anterior and posterior radiculomedullary arteries running alongside the anterior and posterior nerve roots. Six to eight anterior radiculomedullary arteries have functional communications with ASA, and 11–16 posterior radiculomedullary arteries (radiculopial) communicate with the posterior spinal arteries. The radiculomedullary arteries supply, as their name suggests, the accompanying nerve roots and the cord in addition to the dura and bony wall of the spinal canal. Crucially, at the expansions, they can be the dominant supply to the cord. A variation, usually thoracic, is a common intersegmental trunk from which two adjacent segmental arteries arise. If this trunk is ‘complete’, each segmental artery gives rise to a dorsospinal branch; however, if the trunk is ‘incomplete’, one of the segmental arteries lacks a dorsospinal branch, which then arises directly from the aorta. When this is the case, the direct dorsospinal artery usually gives rise to a radiculospinal artery which in turn supplies the anterior spinal artery. The most frequently described (largest and thus most consistently identified) radiculomedullary artery is the artery of Adamkiewicz18, which in 75% of cases, is found between T9 and T12, arising three times more commonly on the left. This is seen in the midline and has the classic ‘hairpin’ appearance. This artery gives the most supply to ASA in the lower thoracic and upper lumbar levels. The cervical radiculomedullary artery (which has a ‘Y’, not hairpin, configuration) usually arises from the left vertebral artery (C5–6) but can arise from the right vertebral, from one of the anterior cervical arteries or in 10% of cases, from the deep cervical artery. In 15% of the cases where Adamkiewicz arises above T8, a separate conus artery is more likely to be visualised at L3 or above and rarely

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at L4. If Adamkiewicz arises in its typical location, the supplementary conus radiculomedullary artery is not always seen. A less frequently visualised radiculomedullary artery has a shared origin with the right bronchial artery from a T4 level intercostobronchial trunk, hence the risk associated with bronchial artery embolisation. In the majority of cases, the principal supply to a vertebral lesion is from the segmental artery of that level; however, the two levels above and below must also be interrogated to identify collateral supply via potentially rich anastomoses (which can account for greater than 50% of the supply to the vertebra compared with 30% from the named segmental artery alone) and to identify radiculomedullary branches. Familiarity with the normal appearance of vertebral enhancement (hemivertebral blush in the lower thoracic and lumbar regions, a complete vertebral blush in the upper thoracic region as a result of cross-filling anteriorly) aids in identifying abnormal enhancement patterns when present. The angiographer should be aware of common vascular variants (e.g. aplasia of a segmental artery) as well as be able to recognise those variants where radiculomedullary supply is affected (as described above). Embolisation The goal of embolisation is complete devascularisation of the tumour. As part of the pre-procedural workup, coagulopathies must be corrected as the embolisation procedure will fail in the absence of adequate clotting factors. Best results are achieved with general anaesthetic, which ensures optimal initial angiography to identify all target and non-target arteries and optimal guidance during embolisation. The choice of catheter will vary with operator preference but the thoracic and lumbar segmental arteries can be cannulated predictably with 4- or 5-French 0.038-inch lumen Mikaelsson catheters. The upper thoracic levels occasionally require a modified Cobra-type catheter. Five or six-French guiding catheters are recommended for providing stable access in the cervical spine and for lesions deriving supply from the internal iliac circulation. The segmental arteries at the level of the target lesion should be catheterised, and once access is stable, angiography performed to demonstrate the arteries supplying the tumour and the potential supply to the cord. Roadmapping and superselective microcatheters are routinely employed. Calibrated particles are the preferred embolic agents, given their reduced likelihood of clumping and consequent more predictable capillary distribution and lesser probability of microcatheter occlusion. Either polyvinyl alcohol or clear acrylic copolymer (trisacryl) microspheres can be used as in this setting; no clinical advantage has been identified with the use of either19. Three hundred- to five hundred-micron particles are most frequently used. Extra caution must be taken when using 100- to 300-micron particles as there is an increased risk of non-target embolisation through intralesional arteriovenous anastomoses. Particles less than 100 microns should be avoided because of potential passage into the systemic venous circulation. In order to protect tissues distal to the tumour circulation, the segmental artery distal to the takeoff of the tumour vessels is protectively coiled. This may also be described as ‘flow-redirection’ because this occlusion also encourages more antegrade flow of emboli into the tumour feeding artery20. As described above, the cervical spine has the most complex supply with the most dense anastamotic networks, resulting in an increased difficulty of achieving a complete embolisation and increased risk of non-target embolisation. Some of these anastomoses may only become apparent during embolisation as a result of altered flow dynamics, and thus, repeated meticulous monitoring angiography must be performed throughout the procedure. To ensure the completeness of embolisation, repeat angiography of the embolised branches is recommended as the particles ‘pack’

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distally and result in incomplete occlusion. Spasms may give rise to a false impression of occlusion. Proximal embolisation of feeding vessels (e.g. with coils of gelfoam) without microparticle embolisation is doomed to failure as rapid collateralisation occurs (within hours). For this same reason, larger embolic particles, e.g. greater than 700 microns should also be avoided. The more complete the embolisation, the greater the reduction in peri-operative blood loss21. Schmidt showed that the success of embolisation in a group of metastases was the only predictor for the extent of blood loss16. Although the use of liquid agents has been described in this setting [e.g. onyx and N-butyl cyanoacrylate (N-BCA)], data is very limited, and these are not first-line agents given their expense and the expertise required for their use. Direct puncture techniques for devascularisation, including cement osteoplasty and direct injection of N-BCA, have been described22-23. Clarencon reported two patients with spinal metastases in whom arterial embolisation was contraindicated because of an adjacent spinal artery. Onyx was injected by direct puncture without compromising the spinal artery and a satisfactory course24. Alcohol is discouraged as an agent in this setting, given its propensity to pass into radiculomedullary branches with resultant spinal cord infarction10; however, Sundaresan25 reported good results using alcohol in 17 patients with renal cell metastases. A superselective position and a slow infusion technique are mandatory. The sooner resection follows embolisation, the greater the reduction in peri-operative blood loss as with time, recanalisation and collateral establishment occurs. Surgery within 72 hours of the embolisation (optimally within 24 hours) decreases peri-operative blood loss10, 26, 27. Ammirati28 described direct puncture embolisation with N-butylcyanoacrylate of renal cell metastasis following transarterial embolisation with satisfactory results. Reports of pre-operative embolisation in benign lesions are limited. Sequential embolisation has been used to treat aneurysmal bone cysts (ABCs) and giant cell tumours. Pearl29 embolised two children with spinal ABCs by percutaneous injection of N-BCA and concluded that this technique was a technically simple and efficient adjunct to surgery and that direct injection may be undertaken when no acceptable target artery is identified for embolisation. In three cases, Trubenbach30 demonstrated that the radical resection of osteoblastomas was facilitated by pre-operative embolisation. Hai Bin Shi20 reported the use of pre-operative embolisation in small numbers of giant cell tumours, ABC and haemangioma. Complications In experienced hands, the risk of neurological complications is less than the usually quoted 2%. When a radiculomedullary artery arises directly from the segmental artery, this is usually considered an absolute contraindication to embolisation10; however, in centres with expertise in these techniques, test occlusion or target vessel provocation, and monitoring evoked potentials during embolisation to determine the risk of cord infarction, are used. Conclusions Pre-operative embolisation is safe and effective in the reduction of peri-operative blood loss. A meticulous technique and avoidance of radiculomedullary arterial embolisation prevents serious permanent neurological deficits. References 1. Heran MK. Preoperative embolisation of spinal metastatic disease: rationale and technical considerations. Semin Musculoskelet Radiol. 2011; 15(2): 135-42. 2. Ozkan E, Gupta S. Embolisation of spinal tumors: vascular anatomy, indications, and technique. Tech Vasc Interv Radiol. 2011; 14(3): 129-40.

Abstract Book 3. Benati A, Dalle Ore G, Da Pian R, Bricolo A, Maschio A, Perini S. Transfemoral selective embolisation in the treatment of some cranial and vertebro-spinal vascular malformations and tumours. Preliminary results. J Neurosurg Sci. 1974; 18(4): 233-8. 4. Truumees E, Dodwad S-N, Kazmierczak C D. Preoperative embolization in the treatment of spinal metastasis. J Am Acad Orthop Surg. 2010; 18 (8): 449-53. 5. Tralhão J G, Kayal S, Dagher I, Sanhueza M, Vons C, Franco D. Resection of hepatocellular carcinoma: the effect of surgical margin and blood transfusion on long-term survival. Analysis of 209 consecutive patients. Hepatogastroenterology. 2007; 54 (76): 1200-6. 6. Jacobs W B, Perrin R G. Evaluation and treatment of spinal metastases: an overview. Neurosurg Focus. 2001; 11(6): e10. 7. Owen RJT. Embolization of musculoskeletal tumors. Radiol Clin North Am. 2008; 46(3): 535-43. vi 8. Heary R F, Bono C M. Metastatic spinal tumors. Neurosurg Focus. 2001; 11(6): e1. 9. Prabhu V C, Bilsky M H, Jambhekar K et al. Results of preoperative embolization for metastatic spinal neoplasms. J Neurosurg. 2003; 98 (Suppl 2): 156-64. 10. Jones K, Meyers P, Gobin P, Liu A-H. Embolization of spinal tumors. In: Operative Techniques in Neurosurgery. New York, NY: Elsevier Science; 2003: 156-62. 11. Shi H, Jin Z, Suh D C, Lee H K, Li L. Preoperative transarterial embolization of hypervascular vertebral tumor with permanent particles. Chin Med J (Engl). 2002; 115(11): 1683-6. 12. Reuter M, Heller M, Heise U, Beese M. Transcatheter embolization of tumors of the muscular and skeletal systems. Rofo. 1992; 156 (2): 182-8. 13. Gellad F E, Sadato N, Numaguchi Y, Levine A M. Vascular metastatic lesions of the spine: preoperative embolization. Radiology. 1990; 176(3): 683-6. 14. Nair S, Gobin YP, Leng LZ, Marcus JD, Bilsky M, Laufer I, Patsalides A. Preoperative embolisation of hypervascular thoracic, lumbar, and sacral spinal column tumors: technique and outcomes from a single center. Interv Neuroradiol. 2013; 19(3): 377-85. 15. Kato S, Murakami H, Minami T, Demura S, Yoshioka K, Matsui O, Tsuchiya H. Preoperative embolisation significantly decreases intraoperative blood loss during palliative surgery for spinal metastasis. Orthopedics. 2012; 35(9): e1389-95. 16. Schmidt R, Rupp-Heim G, Dammann F, Ulrich C, Nothwang J. Surgical therapy of vertebral metastases. Are there predictive parameters for intraoperative excessive blood loss despite preoperative embolisation? Tumori. 2011; 97(1): 66-73. 17. White A P, Kwon B K, Lindskog D M, Friedlaender G E, Grauer J N. Metastatic disease of the spine. J Am Acad Orthop Surg. 2006; 14 (11): 587-98. 18. Manjila S1, Haroon N, Parker B, Xavier AR, Guthikonda M, Rengachary SS. Albert Wojciech Adamkiewicz (1850-1921): unsung hero behind the eponymic artery. Neurosurg Focus. 2009; 26(1): E2. 19. 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(5): 495-502. 20. Hai Bin Shia, Dae Chul Suha, Ho Kyu Leea, Soo Mee Lima, Dae Hong Kima, Choong Gon Choia, Choon Sung Leea, Seung Chul Rhima. Preoperative transarterial embolisation of spinal tumor: embolisation techniques and results. AJNR Am J Neuroradiol. 1999; 20: 2009-15. 21. Sun S, Lang E V. Bone metastases from renal cell carcinoma: preoperative embolization. J Vasc Interv Radiol. 1998; 9(2): 263-9. 22. Schirmer C M, Malek A M, Kwan E S, Hoit D A, Weller S J. Preoperative embolization of hypervascular spinal metastases using percutaneous direct injection with n-butyl cyanoacrylate: technical case report. Neurosurgery. 2006; 59: E431-432 author reply E431-432.

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23. Liebig T, Henkes H, Kirsch M, Piotin M, Jans P, Kühne D. Preoperative devascularization of a circumferential osteogenic metastasis to the upper cervical spine by direct percutaneous needle puncture: a technical note. Neuroradiology. 2005; 47(9): 674-9. 24. Clarençon F, Di Maria F, Cormier E, Sourour NA, Enkaoua E, Sailhan F, Iosif C, Le Jean L, Chiras J. Onyx injection by direct puncture for the treatment of hypervascular spinal metastases close to the anterior spinal artery: initial experience. J Neurosurg Spine. 2013; 18(6): 606-10. 25. Sundaresan N, Choi IS, Hughes JEO, Sachdev VP, Berenstein A. Treatment of spinal metastases from kidney cancer by presurgical embolization and resection. J Neurosurg. 1990; 73: 548-54. 26. Berkefeld J, Scale D, Kirchner J, Heinrich T, Kollath J. Hypervascular spinal tumors: influence of the embolization technique on perioperative hemorrhage. AJNR Am J Neuroradiol. 1999; 20(5): 757-63. 27. Barton P P, Waneck R E, Karnel F J, Ritschl P, Kramer J, Lechner G L. Embolization of bone metastases. J Vasc Interv Radiol. 1996; 7(1): 81-8. 28. Ammirati M, Spiliopoulos K, Epstein CR, Gabriel J, Bourekas EC. Preoperative direct percutaneous embolisation of spinal metastasis from renal cell carcinoma. J Neurointerv Surg. 2011; 3(3): 297-9. 29. Pearl MS, Wolinsky JP, Gailloud P. Preoperative embolisation of primary spinal aneurysmal bone cysts by direct percutaneous intralesional injection of n-butyl-2-cyanoacrylate. J Vasc Interv Radiol. 2012; 23(6): 841-5. 30. Trübenbach J, Nägele T, Bauer T, Ernemann U. Preoperative embolisation of cervical spine osteoblastomas: report of three cases. AJNR Am J Neuroradiol. 2006; 27(9): 1910-2.

903.4 Aggressive haemangioma S.M. Tutton Department of Radiology, Medical College of Wisconsin, Milwaukee, WI, United States of America Learning Objectives 1. To learn how to recognise aggressive haemangioma 2. To learn how to treat aggressive haemangioma percutaneously 3. To learn tips and tricks to increase success and limit complications No abstract available.

Special Session Bleeding: hepato-spleno-GI tract 904.1 Embolisation and BRTO for gastric or ectopic varices: technique and results H. Kiyosue Radiology, Oita University hospital, Yufu, Japan Learning Objectives 1. To learn the indications for treatment 2. To learn the techniques for BRTO 3. To describe technical outcomes, clinical success and complications Since the introduction of balloon-occluded retrograde transvenous obliteration (B-RTO) for the treatment of gastric varices in the 90s, it has rapidly spread in Japan because of its reliability to control or prevent variceral bleeding. At present, B-RTO is becoming gradually popular in the world. The concept of B-RTO is to ablate whole gastric varices by filling a sclerosing agent retrogradely via the systemic

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draining vein. Once a sclerosing agent sufficiently fills and stagnates in whole varices, the varices are surely obliterated within 1 week. B-RTO is indicated for isolated gastric varices that have bled or are at a bleeding risk (large or growing varices, presence of red color sign). The presence of the catheterizable draining route such as gastrorenal shunt is essential for B-RTO. B-RTO has been recently applied for the treatment of ectopic varices or portosystemic encephalopathy as well. Although no contraindications have been described, indication for patients with refractory ascites and the main portal vein thrombosis should be carefully considered. Based on the published data, the technical success of B-RTO procedure and complete eradication of the gastric varices were seen in 90–100% and 80–100%, respectively. Rebleeding rate of ruptured varices after B-RTO is quite low (around 2%). Risk of serious complications is quite low (1.8%), but it includes fatal complications such as pulmonary embolism and SMV thrombosis. There are several technical variations and modifications of the B-RTO procedure, including methods of devascularization of collateral drainages, varying sclerosing agents, and balloon indwelling time (30 minutes to overnight). Recently, an alternative technique using AVP and gelatin sponge instead of balloon and sclerosant has also been described. In this presentation, these results and techniques regarding B-RTO will be reviewed with a presentation of illustrative cases. References 1. Kanagawa H, Mima S, Kouyama H, et al. Treatment of gastric fundal varices by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol 1996;11:51–58. 2. Hirota S, Matsumoto S, Tomita M, Sako M, Kono M. Retrograde transvenous obliteration of gastric varices. Radiology 1999;211:349–356. 3. Fukuda T, Hirota S, Sugiura K, et al. Long-term results of balloonoccluded retrograde transvenous obliteration for the treatment of gastric varices and hepatic encephalopathy. J Vasc Interv Radiol 2001;12:327–336. 4. Kiyosue H, Mori H, Matsumoto S, Yamada Y, Hori Y, Okino Y. Transcatheter obliteration of gastric varices. Part 2. Strategy and techniques based on hemodynamic features. Radiographics 2003;23:921–937. 5. Hiraga N, Aikata H, Takaki S, et al. The long-term outcome of patients with bleeding gastric varices after balloon-occluded retrograde transvenous obliteration. J Gastroenterol 2007;42:663– 672. 6. Akahoshi T, Hashizume M, Tomikawa M, et al. Long-term results of balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding and risky gastric varices: a 10-year experience. J Gastroenterol Hepatol 2008;23:1702–1709. 7. Gwon DI, Ko GY, Yoon HK, et al. Gastric varices and hepatic encephalopathy: treatment with vascular plug and gelatin sponge-assisted retrograde transvenous obliteration--a primary report. Radiology 2013;268:281–287.

904.2 Acute upper gastro-intestinal bleeding: from imaging to endovascular treatment R. Uberoi Radiology, John Radcliffe Hospital, Oxford, United Kingdom Learning Objectives 1. To teach imaging measures for acute gastro-intestinal bleeding 2. To learn the techniques for endovascular treatment 3. To describe technical outcomes, clinical success and complications Gastrointestinal haemorrhage is a serious and often life-threatening condition. It is important in the treatment decision-making strategy to differentiate between upper and lower GI haemorrhage. Haematemesis and malaena suggest upper GI bleeding and profuse

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bleeding from the rectum suggests lower GI bleeding; however, profuse upper GI bleeding can also result in this. Upper GI bleeds occur in 103 per 100,000 people, and the most common cause is peptic ulcer disease (50%). The vast majority of upper GI bleeds (>90%) can be diagnosed and treated endoscopically with a sensitivity and specificity of 92–98% and 30–100%, respectively. Lower GI haemorrhage occurs in around 25 per 100,000 people, most commonly associated with diverticular disease. Unlike upper GI endoscopy, colonoscopy has a much smaller role but is useful in the assessment of the colon and anal tract as 2–9% of bleeds result from piles. The vast majority will stop bleeding spontaneously, 35% will bleed again once and 50% a third time, with an overall mortality of 3.6%. Imaging is used when the bleeding site remains occult and helps to target interventions either for open surgery or interventional radiology. Traditionally, this has been performed using nuclear imaging, catheter-directed angiography and increasingly over the last 5–10 years, multislice CT. Nuclear scanning is more sensitive than catheter-directed angiography and will pick up bleed rates of 0.04– 0.5 ml/min vs 0.5–1 ml/min. However, anatomical localisation with radionuclide imaging can be insensitive with variable accuracy rates, whilst mesenteric angiography is invasive and requires highly skilled angiographers. Multi-detector CTA is a promising first-line modality for GI haemorrhage. It is time-efficient, sensitive and allows accurate diagnosis or exclusion of active GI haemorrhage, thus having a profound impact on the evaluation and subsequent treatment of patients who present with acute GI bleeding. There are an increasing number of studies that advocate the use of CTA in acute GI haemorrhage, as it is recognised as a useful diagnostic tool for fast and accurate detection and localisation of acute GI haemorrhage. A study first published by Ettore et al in 1997 found that helical CT angiography revealed the site of hemorrhage in 72% (13/18) of patients, and the diagnosis of bleeding site was confirmed at surgery in 11 of these 13 patients. Despite the small sample size, this study proved that helical CT angiography is easier and faster than conventional angiography for localising GI bleeding and is useful as a guide for subsequent selective angiography[4]. Subsequently, Yoon et al demonstrated an accuracy of 88.5% (22/26) for the detection of acute GI bleeding using multi-detector row CT. Wu et al and Anthony et al proposed that CT angiography should be used routinely for the investigation of patients who meet the criteria for acute GI haemorrhage because of its high accuracy and the ability to show the precise location and aetiology of bleeding, thereby directing management. Angiography in many centres, including our own, are limited to patients where a bleeding site has been identified on MSCT or the patient remains unstable despite a negative MSCT. However, the sensitivity rates of 63–90% and 40–86% are reported for upper and lower GI bleeds, respectively, with an overall accuracy of 43–87%. Various techniques can be employed to increase the detection rates for bleeding, including localiser clips placed at endoscopy, bowel paralysis using glucagon or buscopan and provocative angiography with heparin or vasodilators. Having identified the site of bleeding, patients are increasingly being treated by first-line interventional techniques where these are available for both upper and lower GI bleeding, and surgery is limited to patients who have failure of haemorrhage control despite attempted embolisation. With the development of microcatheter technology and a range of embolic materials such as coils, glue and amplatzer plugs, reported technical and clinical success rates are high for nonvariceal GI bleeding. In a recent review, reported rates in 228 patients showed technical success rates of 92–100% and clinical success rates of 51–83%. Major causes for failure were inability to selectively catheterise the bleeding branches and access vessel occlusion. Reported rebleeding rates are 9–47% following embolisation, rates for surgery were 0–35% and 30-day mortality rates were 3–27%. Predictors of rebleeding were reported to be coagulopathy, longer

Abstract Book time to angiography, massive transfusion, previous surgery, bleeding secondary to trauma, cancer bleeding and use of coils as the only embolic agent or multiorgan failure. On the whole, patients with GI bleeding are at high risk and complications are related to underlying conditions such as advanced age or comorbidities. In the upper GI tract, above the ligament of Treitz is generally considered very safe because of collateral supply to organs and bowel. But the risk of significant ischaemia or stricture may be increased when there has been previous upper abdominal surgery, radiotherapy or severe atherosclerosis and where there is extensive embolisation or when liquid agents such as glue or small particles are used. Lang reported a 16% (9/57 patients) incidence rate of duodenal strictures following TAE. If true bowel infarction occurs, surgical intervention will then be necessary. Interventional radiology plays a central role in the management of GI bleeding. Where bleeding is obscure, MSCT has now become the first-line imaging modality for patients to guide subsequent intervention. Many patients can also now be successfully treated with selective embolisation of the bleeding vessels and avoid major surgery. References 1. Van Dam J, Brugge WR. Endoscopy of the upper gastrointestinal tract, N Engl J Med 1999; 341:1738-48. 2. Longstreth GF. Epidemiology and outcome of patients hospitalised with acute lower gastrointestinal hemorrhage: a population based study. Am Gastroenterol 1997; 92:419-24. 3. Lefkoviz Z, Cappell MS, Lookstein R, Mitty HA, Gerard PS. Radiologic diagnosis and treatment of gastrointestinal hemorrhage and ischemia. Med Clin North Am 2002; 86:1357-99. 4. Lee EW, Laberge JM. Differential diagnosis of gastro-intestinal bleeding: Tech Vasc Inter Radiol; 2005:7:112-122. 5. S. Anthony, S. Milburn, R. Uberoi. Multi-detector CT: review of its use in acute GI haemorrhage. Clinical Radiology 2007; 62: 938-949. 6. Lian-Ming Wu, Jian-Rong Xu, Yan Yin, Xin-Hua Qu. Usefulness of CT angiography in diagnosing acute gastrointestinal bleeding: A meta-analysis. World Journal of Gastroenterology 2010; 16(31): 3957-3963. 7. Yoon W, Jeong YY, Shin SS, Lim HS. Acute massive gastrointestinal bleeding: detection and localization with arterial phase multi-detector row helical CT. Radiology 2006; 239(1):160-7. 8. Laing et al. Acute gastrointestinal bleeding: emerging role of multidetector CT angiography and review of current imaging techniques. Radiographics 2007:27:1055-1070. 9. Loffroy R, Guiu B, D’Athis P, et al. Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: predictors of early rebleeding. Clin Gastroenterol Hepatol 2009;7:515-523. 10. Loffroy R, Guiu B, Cercueil JP, et al. Refractory bleeding from gastroduodenal ulcers: arterial embolization in high-operativerisk patients. J Clin Gastroenterol 2008;42:361-367. 11. Poultsides GA, Kim CJ, Orlando R 3rd, Peros G, Hallisey MJ, Vignati PV. Angiographic embolization for gastroduodenal hemorrhage: safety, efficacy, and predictors of outcome. Arch Surg 2008;143:457-461. 12. Lang EK. Transcatheter embolization in management of haemorrhage from duodenal ulcer: long-term results and complications. Radiology 1992;182:703-707.

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904.3 Acute lower gastro-intestinal bleeding: from imaging to endovascular treatment L. Defreyne Department of Vascular and Interventional Radiology, University of Ghent, Ghent, Belgium Learning Objectives 1. To teach imaging measures for acute gastro-intestinal bleeding 2. To learn the techniques for endovascular treatment 3. To describe technical outcomes, clinical success and complications No abstract available.

904.4 Spleen trauma management: when and how to embolise P.E. Bize Radiology, Centre Hospitalier Universitaire Vaudois de Lausanne, Lausanne, Switzerland Learning Objectives 1. To teach imaging measures in splenic trauma and indications for treatment 2. To learn the techniques for trauma treatment 3. To describe technical outcomes, clinical success and complications Severity of splenic trauma is graded according to the AAST score. Non-operative management (NOM) has become the rule for lower grade splenic injuries. However, the overall rate of NOM failure is 10% and in case of secondary bleeding, the mortality is rate is 3–5%. Even though there is no absolute correlation between the severity grade and the risk of secondary bleeding from splenic trauma, higher grades tend to have poorer prognosis. We recommend that in adults every grade ≥3 should be treated with proximal splenic artery embolization (SAE). The major independent risk factor for secondary bleeding is the presence of vascular lesions such as pseudoaneurysm or arterio-venous fistula on arterial phase CT. These lesions should then be actively sought for in every case of splenic trauma, not only at admission but also 72 hours after admission. We also recommend that any patient with active bleeding on the admission CT scan should be treated with proximal SAE irrespecitve of the severity grade of the lesion. Proximal SAE is also an option in selected hypovolemic patients particularly when they respond favourably to fluid resuscitation. SAE has a very limited rate of complication such as splenic infarct or abscesses and allows preservation of the splenic function. Due to very good evolution of a vast majority of splenic trauma in children, the role of SAE is limited to those with active bleeding or vascular lesions at risk on follow-up CT.

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Special Session Acute stroke: diagnostic and therapeutic concepts 905.1 “One-stop shop” angio stroke imaging: benefits A. Dörfler, T. Engelhorn Department of Neuroradiology, University Erlangen-Nuremberg, Erlangen, Germany Learning Objectives 1. To understand the ‘’one-stop shop’’ concept 2. To learn about technical background 3. To understand the potential impact of this concept The management of acute ischemic stroke is rapidly developing. Clinical data suggest that interventional stroke treatment may provide superior clinical outcomes compared with intravenous thrombolytic therapy alone. Besides the careful neurological assessment, brain imaging is of major importance. The goals of an imaging evaluation for acute stroke are to establish a diagnosis as early as possible to obtain accurate information about intracranial vasculature and brain perfusion to select the appropriate therapy. At least brain CT imaging - ideally multimodal MRI using perfusion imaging and various types of cerebral angiography - should be available 24/7 with imaging priority for stroke patients. Since “time is brain,” any possible delays in stroke management should be minimized at every step. Regarding an optimized stroke workflow, new flat-detector angiography might here provide an alternative multimodal imaging modality for acute stroke with the potential to speed up stroke management. Originally aimed at improving standard radiography by providing higher absorption efficiency, flat-panel detector technology has meanwhile got widely accepted for neuroangiographic imaging. Especially flat-panel detector CT (FD-CT) which uses rotational C-arm mounted flat-panel detector technology is capable of volumetric imaging with a high spatial resolution. In combination with intravenous contrast administration, FD-CT provides cross-sectional imaging of the brain, highresolution imaging of the cerebral vasculature, and whole-brain perfusion imaging in one setting as a “one-stop shop” angio stroke imaging. The ability to assess cerebral perfusion and vasculature within the angiographic suite and interventional setting may significantly improve the management of ischemic stroke patients. This presentation addresses the concept, technical background, and potential clinical impacts of this innovative approach of multifunctional stroke imaging within the angio suite for acute stroke diagnosis and treatment, respectively. References 1. Struffert T, Deuerling-Zheng Y, Engelhorn T, Kloska S, Gölitz P, Köhrmann M, Schwab S, Strother CM, Dörfler A. Feasibility of cerebral blood volume mapping by Flat Detector Computed Tomography in the Angio Suite: first experience in patients with acute middle cerebral artery occlusions. Am J Neuroradiol. 2012;33:618-625.

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905.2 Direct thromboaspiration/adapt technique A.S. Turk Department of Radiology, Medical University of South Carolina, Charleston, SC, United States of America Learning Objectives 1. To understand the direct aspiration technique 2. To learn about technical details of the procedure 3. To learn the clinical results and impact of the technique Early and efficient revascularization of large cerebral vessel occlusions has been shown to correlate with improved outcomes in selected patients with acute ischemic stroke. Aspiration thrombectomy using the Penumbra system, while an effective technique for achieving revascularization, has yielded only modest clinical results. Stent retrievers have been shown to also be effective for vessel recanalization, with similar clinical outcomes. Recent advances in catheter technology have included very large, easily trackable, aspiration thrombectomy catheters that can now more easily and reliably navigate the cerebrovasculature. A novel technique using this newest generation of large-bore aspiration catheters as a first approach for thrombectomy has recently been reported to be a fast, safe, simple and effective method that has facilitated our approach to acute ischemic stroke thrombectomy. In the minority of cases in which aspiration alone is unsuccessful in achieving complete revascularization, the platform is versatile, allowing rapid incorporation of adjunctive devices (such as stent retrievers). The purpose of this talk is to discuss the initial experience with stroke cases that were undergoing a direct aspiration first pass technique (ADAPT) with a large-bore aspiration catheter as the primary method for vessel recanalization. References 1. Turk AS, Spiotta A, Frei D, et al. Initial clinical experience with the ADAPT technique: A direct aspiration first pass technique for stroke thrombectomy. J Neurointerv Surg. 2013 doi: 10.1136/ neurintsurg-2013-010713 [published Online First: Epub Date]. 2. Turk AS, Frei D, Fiorella D, et al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014. doi: 10.1136/neurintsurg-2014-011125 [Epub ahead of print].

905.3 Direct distal thromboaspiration combined with stent retrievers G. Gal Department of Radiology, Odense University Hospital, Odense, Denmark Learning Objectives 1. To understand the concept of combined use of direct aspiration and stent retrievers 2. To learn the technical tricks of the technique 3. To learn the potential impact of the technique With the advent of the ADAPT technique, the approach to intraarterial thrombectomy has significantly changed. In my experience, it has been the method of choice ever since I used the 5Max catheter for the first time, with unexpected ease of navigation and excellent angiographic results. Since we practically always start the management of the ischemic stroke with i.v. thrombolysis, due to the time-consuming transport of the patients from many remote referring hospitals, several thrombi in the smaller vessels are already lysed when the patients reach our angiographic unit, with improved neurological status. For that reason, the need of stentrievers has been continuously diminishing following the introduction of the ADAPT, since all thrombi proximal to and in the circle of Willis as well as in the M1, A1, and P1

Abstract Book segments are within easy reach for the 5Max or – better yet – for the ACE catheter, that is a further development of the 5Max, with somewhat larger ID and even softer distal part, which sometimes can be navigated into the larger M2 branches. The use of different adjunctive devices, such as long sheaths, microcatheters, and microguidewires of suitable sizes, from different manufacturers will be reviewed and analyzed, along with the stentrievers compatible with them, even if the need of the latter is declining. Since the audience is expected to consist mainly of general radiologists, I’ll highlight step by step the technical details of the procedure, which is already well known in the INR community. Finally, I’ll also take up the question of when to stop in order to not harm the patient – a question that is particularly important for those with less experience with the intracranial vessels, the importance of the careful analysis of the collateral circulation of the affected branch, and the major neurological functions depending on the different vascular territories of the brain.

905.4 New generation stent retrievers: any improvement? A. Bonafé, C. Riquelme Bareiro, V. Costalat, P. Machi, O. Eker Neuroradiologie, Hopital gui de Chauliac, Montpellier, France Learning Objectives 1. To learn about new generation stent retrievers 2. To understand the technical differences of new retrievers 3. To learn the improvements in new generation stent-retrievers The clinical progression of acute ischemic stroke (AIS) is strongly correlated with early recanalization. Patients with occlusion of large arteries and those with scores of high clinical severity (NIHSS score > 12) are unlikely to benefit from thrombolytic therapy (rt-PA) and those in which the fibrinolytic treatment failed are potential candidates for mechanical revascularization techniques. Mechanical systems used for revascularization either act as thromboaspiration or mechanical removal of by clots by non-implantable stents. Multiple single-center retrospective studies have shown the value of these techniques. Prospective trials and one randomized controlled trial evaluating the contribution of thrombectomy in combination with intravenous thrombolysis (SWIFT-PRIME STUDY) are underway. SOLITAIRE FR (Covidien), REVIVE SE (Codman), and TREVO PROVUE (Styker) stentrievers have demonstrated higher recanalization rate than the first-generation devices (Merci, Penumbra) with low complications rates. The combination of clot retrieval and direct aspiration through a large bore catheter (ADAPT technique) claimed even better recanalization rate (95% TICI 2b-3). Thrombectomy has acceptable results in terms of efficacy and safety for the treatment of patients with AIS and is an attractive therapeutic option for patients out of time or contraindicated to fibrinolytic therapy. Keywords:  Acute ischemic stroke, Thrombectomy, rt-PA, Neurointervention References 1. J Neurointerv Surg. 2014;6(4):260-4. doi: 10.1136/ neurintsurg-2014-011125. Epub 2014 Feb 25. 2. Stroke. 2013;44(10):2802-7. doi: 10.1161/STROKEAHA.113.001232. Epub 2013 Aug 1. 3. Stroke. 2011;42:1929-35.

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Fundamental Course Basic principles of intermediate-advanced HCC management

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Learning Objectives 1. To learn what is needed to perform a successful conventional chemoembolisation (skills, equipment, devices) 2. To learn when to choose conventional chemoembolisation over chemoembolisation with drug-eluting beads 3. To learn about the historical and recent results of conventional chemoembolisation in HCC In 2002, conventional TACE has been demonstrated to be superior to supportive care in 2 RCTs (1, 2), and since then no other treatment have been demonstrated superior or equivalent in phase 3 study. Conventional TACE has been developed in the early 80s in Japan to target HCC. The drug (single agent or a combination of several agents) is emulsified with lipiodol to take advantage of its selectivity for tumoral artery, which is responsible for a preferential lipiodol uptake by the tumor (3, 4). When used for TACE in an animal model, lipophilic anticancer drug has demonstrated a concentration of chemotherapy within tumor tissue that can be up to 100 times higher that that obtained after systemic chemotherapy (5). After injecting the lipiodol drug mixture, a complementary embolization is delivered to stop the arterial flow in order to increase dwell time of the drug with the tumor and to combine the drug cytotoxicity with ischemia that has been demonstrated to increase drug uptake by causing failure of transmembrane pumps (6). When injected in the hepatic artery, a combination of lipiodol, doxorubicin, and embolization has demonstrated a pharmacokinetic benefit over drug plus lipiodol or doxorubicin alone (7, 8). Such drug vectorization by lipiodol is better obtained when water in oil emulsion is used (7). Lipiodol has the unique advantage of allowing drug vectorization from the hepatic artery through the peribiliary plexus to the distal portal branches, that allows treating small satellite nodules around the main HCC. Increase in such portal passage of lipiodol has been reported to be related with an absence of local recurrence after TACE (9). More recently, drug-eluting beads have demonstrated interesting ability in loading and delivering doxorubicin after intraarterial injection with a high drug concentration in tumors and low systemic passage (10, 11), even if complete release of the drug from the beads is questioned (12). No specific targeting of the tumor by the beads has been demonstrated. Beads are responsible for toxicity to healthy liver parenchyma (13). Conventional TACE is the standard of care for intermediate HCC. Its efficacy has improved along the recent years from a response rate of 27% and 35% and a 2-year OS of 31% and 63% in a randomized control study published in 2002 for Lo and Llovet, respectively (1, 2) to a response rate of 73% and a 2-year OS of 75% in a recent prospective study (14).

Clinical management of the intermediate-advanced HCC patient J.-L. Raoul, G. Piana Medical Oncology, Paoli-Calmettes Institute, Marseille, France Learning Objectives 1. To learn about epidemiology of intermediate and advanced HCC 2. To learn how to select patients for IO procedures among intermediate and advanced HCC patients 3. To learn about the role and future prospects of systemic therapy in advanced HCC Treatment of hepatocellular carcinoma (HCC) is difficult and based on 3 major factors: performance status (PS), severity of liver cirrhosis, and tumor extension. It must be decided in a tumor board meeting. Following BCLC, intermediate-stage patients had a multinodular tumor, a compensated liver cirrhosis (Child–Pugh A or B) and an excellent PS (0) but no extrahepatic spread or venous thrombosis (even segmental). Advanced stages are defined by the presence of extrahepatic spread, venous thrombosis, PS 1 or 2, and compensated cirrhosis. The treatment of choice for intermediate-stage tumors is transarterial chemoembolization (TACE) or drug-eluding beads injection and for advanced-stage tumors is systemic therapy and sorafenib (until 2014). However, this algorithm do not apply for all patients and the position of radioembolization must be clarified. For example, we have clear contraindications for TACE among intermediate-stage patients (huge or infiltrative tumors, renal insufficiency, Child–Pugh B8 or above, hepatofugal flowetc). In contrast, TACE can be proposed to some advanced-stage patients with a single or a few nodules easy to treat by superselective TACE despite having PS 1 or 2. But if the first line of treatment is intra-arterial, it is important to know which patients can receive a second session and those requiring to shift to systemic treatment. Some new scores are currently tested to determine patients who will not benefit from a second session. Radioembolization is promising and studies seem to demonstrate that its efficacy is the same as TACE. However, no randomized trial designed to compare its efficacy on survival is currently planned. But this treatment seems to be better tolerated than TACE and can be performed even in case of portal vein thrombosis. Some randomized trials are currently ongoing to compare radioembolization with sorafenib in advanced cases with liver-only HCC. The addition of sorafenib or other antiangiogenic drug to TACE is logical, but the initial results are disappointing, and therefore, new data are required. In conclusion, cross-talks between interventional radiologists and hepatologists or medical oncologists are mandatory in some specific cases and at each stage of the therapeutic treatment in order to provide the patient with a better treatment. References 1. Raoul JL, Sangro B, Forner A, et al. Cancer Treat Rev 2010. 2. Lammer J, Malagari K, Vogl T, et al. Cardiovasc Interv Radiol 2009. 3. Salem R, Lewandowski R, Kulik L, et al. Gastroenterology 2011.

Conventional chemoembolisation T. de Baère Image Guided Therapy, Gustave Roussy, Villejuif, France

1001.3 Chemoembolisation with drug-eluting beads J.-F.H. Geschwind Vascular and Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America Learning Objectives 1. To learn what is needed to perform a successful chemoembolisation with drug-eluting beads (skills, equipment, devices) 2. To learn when to choose chemoembolisation with drug-eluting beads over conventional chemoembolisation 3. To learn the results of chemoembolisation with drug-eluting beads No abstract available.

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1001.4 Radioembolisation J.I. Bilbao Dept. of Radiology, Clinica Universidad de Navarra, Pamplona, Spain Learning Objectives 1. To learn how to select patients with HCC for radioembolisation 2. To learn what the results are for radioembolisation in advanced HCC patients 3. To learn if there is a role for radioembolisation in intermediatestage HCC patients The therapeutic rationale for radioembolization (RE) is the direct application of radiation from within the tumor. The particles used in this method have a null embolic effect; therefore, they can be used in at least those patients to whom any endovascular tumoral treatment is considered beneficial. There are many studies involving a large number of cases successfully treated by RE in early (BCLC A), intermediate (BCLC B), and advanced (BCLC C) tumors. Several studies have been published regarding BCLC C tumors with complete portal tumoral thrombosis treated with one RE procedure and providing a 10-month survival. For cases with partial portal thrombosis, survival was >12 months (higher than those obtained with systemic treatment). In both clinical criteria, therapeutic techniques based on embolization/ischemia should not be applied because of a high complication risk. The patient group with BCLC B is large and heterogeneous, thereby fitting the possibility of subgroups according to the tumor stage (multiple bilateral nodules etc), the clinical status (ECOG), or the hepatic functional reserve (Child–Pugh). The BCLC early B TACE, as RE, gives good results. However, this is not so evident in other HCC “B” in which the size of the predominant tumor or the presence of bilateral multinodularity, a factor based on ischemia, can lead to serious complications. Therefore, the indication for RE in BCLC B and C is based on data obtained from studies that included cases in whom TACE was contraindicated or ineffective or in which RE was selected as the first choice and as an alternative to TACE. A unique fact that characterizes RE and provides a great therapeutic value lies in its intense ablative effect so that it can be applied as an alternative to surgery (“segmentectomy radiation”). In addition, RE is, along with portal embolization, the only endovascular therapeutic method that demonstrates an intense contralateral hepatic regeneration effect, thus providing new possibilities for patients with initially non-surgical HCC.

Special Session Controversy Controversies in BTK treatment 1003.1 Distal embolic protection devices are reasonable: Pro S. Müller-Hülsbeck Radiology and Neuroradiology, Diako Flensburg, Flensburg, Germany Distal embolization of plaque or thrombus may cause organ ischemia following percutaneous peripheral interventions. The incidence and clinical significance of particulate embolization during percutaneous superficial femoral artery (SFA) and below-the-knee (BTK) intervention can be monitored using continuous Doppler ultrasound. The rate and timing of embolization at various phases of intervention such as guidewire crossing, balloon angioplasty, stent deployment, and others like directional atherectomy will definitely vary.

Abstract Book Lam et al evaluated 60 patients who underwent SFA intervention (PTA, PTA with stenting, atherectomy, and excimer laser). A 4-MHz Doppler probe was used for continuous monitoring, and distal embolization was registered as embolic signals (ES). ES were quantitatively assessed during critical portions of the procedure including guidewire crossing, balloon angioplasty, stent deployment and/ or atherectomy. ES were recorded at each step of SFA intervention, and the frequency was greatest during stent deployment. Despite the frequency of these events, only one patient angiographically and clinically developed significant embolization. Based on their findings, the authors do not support the routine use of protection devices during percutaneous SFA intervention (1). Similar findings are reported by Shrikhande et al. In 2137 lesions treated in 1029 patients, distal embolization (DE) is a rare event that occurs more often with thrombectomy and atherectomy devices. Moreover, in-stent and complex native lesions are at a higher risk for DE. DE is typically reversible with endovascular techniques and has no effects on patency rates and limb salvage (2). Keeping these two publications in mind, one has to question whether it is worth to use an embolic protection device. Using a protection device during femoropopliteal interventions has the potential to prevent migration of debris, which may be important for high-risk patients with limited distal run-off. The PRO-RATA study included 30 patients suitable for PTA. Macroscopic debris was found in 27/30 filters of all distal protection devices used in all 29 patients. Debris particle size ranged from 90 to 2000 μm (1200 ± 640) (3). Same findings were reported in the PROTECT registry. Macroembolization is very frequent in patients undergoing lower extremity interventions, particularly, with atherectomy (4). Clinical data have shown that the application of an embolic protection device in the lower limb arteries is safe. Prospective and, ideally, randomized trial data are warranted to justify the increased use of filters in lower extremity interventions, despite the obvious benefits that these devices provide. However, the clinical relevance of distal embolization in the lower extremity remains unquantified (5). References 1. Lam RC, Shah S, Faries PL, McKinsey JF, Kent KC, Morrissey NJ. Incidence and clinical significance of distal embolization during percutaneous interventions involving the superficial femoral artery. J Vasc Surg. 2007 Dec;46:1155-59. 2. Shrikhande GV, Khan SZ, Hussain HG, Dayal R, McKinsey JF, Morrissey N. Lesion types and device characteristics that predict distal embolization during percutaneous lower extremity interventions. J Vasc Surg. 2011 Feb;53(2):347-52. 3. Müller-Hülsbeck S, Hümme TH, Philipp Schäfer J, Charalambous N, Paulsen F, Heller M, Jahnke T. Final results of the protected superficial femoral artery trial using the FilterWire EZ system. Cardiovasc Intervent Radiol. 2010 Dec;33(6):1120-7. 4. Shammas NW1, Dippel EJ, Coiner D, Shammas GA, Jerin M, Kumar A. Preventing lower extremity distal embolization using embolic filter protection: results of the PROTECT registry. J Endovasc Ther. 2008 Jun;15(3):270-6. 5. Müller-Hülsbeck S1, Schäfer PJ, Hümme TH, Charalambous N, Elhöft H, Heller M, Jahnke T. Embolic protection devices for peripheral application: wasteful or useful? J Endovasc Ther. 2009 Feb;16(1):I163-9.

1003.2 Distal embolic protection devices are reasonable: Con D.F. Ettles Radiology, Hull Royal Infirmary, Hull, United Kingdom The theory and concept of using devices to prevent distal embolisation during the angioplasty of below-the-knee vessels has many attractions. The incidence of embolisation during arterial

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intervention is known to be relatively high and the possible sequelae of macroemboli in diseased and small diameter crural vessels is potentially catastrophic. Any technological advance or procedural refinement that could make below-the-knee intervention safer or more effective needs careful consideration. Nevertheless, the proposal that distal embolic protection devices should be routinely used in all such cases is fundamentally flawed and cannot yet be recommended. Why is this? As stated above, we know from experimental and clinical studies that distal embolisation is a frequent and predictable consequence of arterial intervention. This should not be a surprise to those of us who routinely undertake vascular interventional procedures. Doppler ultrasound can demonstrate the showers of emboli related to balloon inflation and deflation, and the results of experimental studies can confirm the capture of atherosclerotic debris in filters retrieved from vessels distal to the intervention site. However, the relationship between this information and the occurrence of clinically significant embolisation is poorly understood. Even in patients with precarious distal runoff, the incidence of clinically significant embolic complications following below-the-knee intervention is extremely low and also difficult to predict. Inevitably, a small proportion of below-the-knee interventions will result in a sudden onset of pain and sensory or motor loss that results from this event, but a variety of techniques including immediate thrombolysis, mechanical retrieval and even simple adjunctive angioplasty can effectively restore the distal circulation in many cases. Failing that, surgical exploration performed in a timely manner, often under local anaesthesia, will effectively resolve the situation. The use of distal embolic protection devices has its foundations in coronary and carotid interventional practice. Justifiable concerns regarding the potential effects of embolisation into these highstakes vascular territories has driven the search for an optimal antiembolisation strategy. Has this been justified? Contradictory evidence exists within the published literature and has not mandated a uniform approach for the use of embolic protection devices in such patients. Certainly, there have been numerous articles published advocating the use of protection devices in lower limb intervention, but these have in the main come from the USA where cardiologists familiar with such technology appear keen to push forward its use into peripheral arterial intervention. In the UK and Europe, where a more objective approach to new developments in interventional treatment and their potential contribution to improved patient care underpins clinical practice, there has been a significantly less enthusiastic uptake of this technology. This is a perfectly reasonable stance given the large body of clinical experience and the lack of high-level evidence for the use of embolic protection devices. However, there is no good randomised controlled study to support the routine use of distal embolic protection devices in below-theknee interventions. The most effective interventional procedures are those completed using the minimum number of steps and within a short and defined duration. Given our knowledge regarding the low incidence of symptomatic distal embolisation during BTK interventions, the addition of a further stage to deliver a distal protection device into hostile and high-risk territories may itself introduce additional risks. Complications related to the delivery and retrieval of such devices are well documented. Most below-the-knee interventions can be completed using 0.035 or 0.018 systems without the need to add the complication of using lower profile systems. This can be a particularly important consideration when treating heavily calcified or long segment crural disease. We live in an increasingly cost-aware health culture, and there is currently no convincing data to indicate improved cost-effectiveness in relation to the use of BTK protection devices or support a strategy involving the routine use of such devices. It is doubtful whether the results of further evaluation will alter this conclusion. Whether or not the selective use of distal embolic protection may be justifiable in

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certain situations or selected patient groups requires a much fuller evaluation. Possible scenarios such as intervention in patients with single-vessel runoff or those being treated for acute limb ischaemia are obvious examples. Until such information is available, it is reasonable to suggest that as far as BTK intervention is concerned, this remains an expensive technology awaiting an application. References 1. Mendes BC, Oderich GS, Fleming WD, et al. Clinical significance of embolic events in patients undergoing endovascular femoropopliteal interventions with or without embolic protection devices. J Vasc Surg 2014;59:359-367. 2. Muller-Hulsbeck S, Schafer PJ, Humme TH, et al. Embolic protection devices for peripheral application: wasteful or useful? J Endovasc Ther 2009;16:I163-I169. 3. Rogers JH, Laird JR. Overview of new technologies for lower extremity revascularisation. Circulation 2007;116:2072-2085.

1003.3 Drug-eluting stents in all short BTK lesions: Pro H. van Overhagen Radiology, Haga Teaching Hospital, The Hague, Netherlands Infrapopliteal arterial occlusive disease is a leading source of critical limb ischemia. The clinical goal of infrapopliteal treatment is to obtain relief from ischemic rest pain, facilitate healing of ulcer or gangrene, prevent limb loss or limit the extent of amputation, and permit wound healing after amputation. The technical goal of endovascular treatment is to create 1–3 patent crural vessels with unobstructed inflow and outflow into the foot in combination with appropriate distal run-off. For years, percutaneous transluminal angioplasty (PTA) has been the primary technique in the endovascular treatment of infrapopliteal occlusive disease. The technical success rates of infrapopliteal PTA are high, but patency rates during follow-up may be disappointing. In the short-term, this may be due to intimal hyperplasia and in the long-term, due to progressive vascular disease. Reocclusion of blood vessels may cause clinical deterioration and eventually lead to major amputation. Amputation itself is associated with significant morbidity, mortality, and only a limited revalidation. Thus, efforts have been made to suppress intimal hyperplasia and increase patency. There are no trials that show improved results from bare-metal stents versus PTA of crural vessels and, use of bare-metal stents is generally limited as a bail-out technique to treat flow-limiting dissections or treat early restenosis. Drug-eluting stents (DES) have been successfully used in coronary vessels to address the problem of intimal hyperplasia and seem to be beneficial in obtaining patency in crural vessels. While some trials are still being analyzed, in the DESTINY trial, 140 patients with CLI were randomized to either a bare-metal stent or an everolimus-eluting stent. Primary patency, defined as absence of >50% restenosis at 12 months was significantly higher after treatment with the everolimus-eluting stents versus bare-metal stents (85% versus 54%). In the ACHILLES trial, 200 patients were randomized to infrapopliteal sirolimus-eluting stenting or PTA. At 1-year follow-up, there were lower restenosis rates (22.4% versus 41.9%) and greater vessel patency (75% versus 57.1%) for sirolimus-eluting stents versus PTA, respectively. Finally, in a recent systematic review of infrapopliteal drugeluting stents, DES showed higher patency rates (80% versus 58.5%) and improved wound healing at one year than those with control treatments. Therefore, the conclusion was that DES inhibit vascular restenosis and improve primary patency and wound healing. References 1. Van Overhagen H, Spiliopoulos S, Tsetis D. Below-the-knee interventions. Cardiovasc Intervent Radiol 2013; 36: 302-311.

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2. Katsanos K, Spiliopoulos S, Diamantopoulos A, Karnabatidis D, Sabharwal T, Siablis D. Systematic review of infrapopliteal drugeluting stents: a meta-analysis of randomized controlled trials. Cardiovasc Intervent Radiol 2013; 36: 645-658. 3. Scheinert D, Katsanos K, Zeller T et al. A prospective randomized multicenter comparison of balloon angioplasty and infrapopliteal stenting with the sirolimus-eluting stent in patients with ischemic peripheral arterial disease: 1-year result of the ACHILLES trial. J Am Coll Cardiol 2012; 60: 2290-2295. 4. Bosiers M, Scheinert D, Peeters P et al. Randomized comparison of everolimus-eluting versus bare-metal stents in patients with critical limb ischemia and infrapopliteal arterial occlusive disease. J Vasc Surg 2012; 55: 390-399.

1003.4 Drug-eluting stents in all short BTK lesions: Con T. Rand Dept. of Radiology, KH Hietzing, Vienna, Austria The concept of using drug-eluting stents (DES) in below-the-knee (BTK) arteries seems a good idea and reflects the strategies of treatment above the knee, namely to overcome the major limitations of bare-metal stents, such as neointimal hyperplasia and in-stent restenosis. The idea was that antiproliferative drugs, such as paxlitaxel and sirolimus, could be released from the stent struts and inhibit hyperplasia. At a first glance, infrapopliteal vessels seem just to differ in their diameters from other DES indications. However, there are definitely several other major factors, which totally differ for BTK indications and use DES for focal infrapopiteal lesions more than questionable. General indications for infrapopliteal endovascular treatment, the nature of disease, and the lack of evidence speak a clear language. General indications for BTK endovascular procedures are critical ischemia, mainly representing Rutherford stage 3 and 4. Vessel disease in such stages is represented by long diffuse occlusions of multiple vessels and generally do not reflect solitary focal lesions. Therefore, major guidelines state that PTA with optional bailout stenting should remain the preferred strategy in treating CLI patients. Further, even more than a decade after the introduction of DES, there are only a few and relatively small studies for their use in BTK, and their methodological quality is inconsistent. Achilles, Destiny, and Yukon indicate focal success only if spot results are considered. With a general and practical view, such as the number of patients that need to be treated for one single success, these results varied. The number of patients needed to treat to succeed in one patient is 4,8 for vessel restenosis, for TLR its 8,3 for wound healing 6 patients, and for TLR it is even 8,3 patients. For limb amputation the absolute risk difference is just 4%. These numbers have to be multiplied with the individual number of focal stenosis, in all these patients needed to be treated. The sum then resembles the number of stents that might be necessary, if a consequent stent concept would be followed. Even if roughly estimated the numbers of stents needed are absolutely unimaginable and unrealistic. Other present meta-analysis define the quality of evidence for BTK studies as very inconsistent. Regarding DES versus BS, most trials show very low-to-moderate quality of evidence for equal efficacy between strategies. Several clinical outcomes, such as wound healing, changes in Rutherford classification, amputation, death, and TLR were similar for the DES and PTA strategy between 2- and 48-month follow-up. None of the included trials considered newer generation drugcoated balloons. In conclusion, most investigations and reports about endovascular BTK treatment still do not reflect the biological nature of the disease,

Abstract Book and therefore, do not reach practical acceptance for a general use to treat all focal lesions in infrapopliteal arteries with DES. Although DES definitely play a role as a bail-out procedure, the main question, if the individual interventionalist would indeed stent all focal lesions in infrapopliteal arteries with DEB, is clearly answered in negative. References 1. Drug-eluting stents for revascularization of infrapopliteal arteries: updated meta-analysis of randomized trials. Fusaro M et al; JACC. 2013:1284-93. 2. Randomized trials for endovascular treatment of infrainguinal arterial disease. Systematic reviews and meta-analysis. Jen S, et al; Eur J Vasc Endovasc Surg. 2014, in press. 3. 1-year results from the ACHILLES trial. Scheinert et al. J Am Coll Cardiol. 2012;60:2290-95. 4. Sirolimus eluting stents for treatment of infrapopliteal arteries reduce clinical event rate compared to bare-metal stents. Rastan et al; J Am Coll Cardiol. 2012;60:587-91. 5. Sirolimus eluting stents vs bare metal stents for the treatment of focal lesions in infrapopliteal arteries. Rastan et al. Eur Heart J. 2011;32:2274-81. 6. Randomized comparison of everolimus-eluting versus bare metal stents in patients with CLI and infrapopliteal arterial occlusive disease. Bosieres et al. J Vasc Surg. 2012;55:390-98.

1003.5 The angiosome concept: Pro M. Brodmann MEDUK Graz, Division of Angiology, Graz, Austria Below-the-knee disease with a clinical presentation of critical limb ischemia is associated with a high rate of limb loss due to minor and major amputations. Over the past years, especially with the improvement of endovascular techniques, the limb salvage rate improved to a certain extent. The main problem is to find a way to optimize blood flow to the critical limb area. Different concepts exist on how this can be achieved, i.e., by treating as many vessels as can be reopened by an endovascular procedure, by targeting the two main BTK vessels, or in an outstanding situation, by treating the inflow of collaterals to achieve as much blood flow to the foot as possible. Derived from plastic surgery for the purpose of healing of flaps, the angiosome concept has been developed. An angiosome is an anatomic unit of tissue (comprising skin, subcutaneous tissue, fascia, muscle, and bone) fed by a source artery and drained by specific veins. The whole body can be divided into 40 angiosomes, whereas the foot comprises six. The posterior tibial artery feeds three, while the anterior and the peroneal arteries feed two angiosomes. The angiosome treatment concept of BTK disease refers to the concept in cardiology where reversible ischemic areas are discriminated and respective vessels leading to these areas are treated in a distinctive way. For peripheral arterial occlusive vessel disease, such reversible ischemic areas may be open wounds at the foot level. A proof for this concept may be the fact that ischemic heel ulcerations perfused by the dorsalis pedis artery are able to heal in approximately 86.5% cases.

1003.6 The angiosome concept: Con K.A. Hausegger Radiology, General Hospital Klagenfurt, Klagenfurt, Austria The angiosome concept has been introduced by the plastic surgeon for better understanding of perfusion patterns when surgical reconstruction of soft tissues defects is planed (1). Soon this concept has been also implemented into the concept of revascularization of with critical limb ischemia (CLI) (2). It has been shown that

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direct arterial revascularization of an angiosome with ulceration reveals an increased healing rate compared to indirect revascularization via collateral flow (3). However, it has been also shown the architecture of the angiosome is highly variable (4), which may be problematic during surgery, where no direct vascular visualization is possible. However, during endovascular procedures the best possible display of the vascular anatomy of the treated territory can be achieved. Therefore, the vascular intervention is rather driven by the angioanatomic situation then by a theoretical angiosome concept. Furthermore, it may be desirable to revascularize a distinct arterial segment; however, this may be simply impossible due to the severity of the disease. It has been proven that the most important factor for limb salvage in patients with CLI is the number of patent arteries post-PTA (5). The angiosome concept is helpful to estimate the clinical effect of the revascularization procedure (direct vs. indirect revascularization); however, the goal of the intervention should be to recanalize as many crural arteries as possible. References 1. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg 1998;102:599. 2. Ida O, Nanto S, Uematsu M et al. Importance of the angiosome concept for endovascular therapy in patients with critical limb ischemia. Catheter Cardiovasc Intervent 2010;75:830. 3. Lejay A, Georg Y, Tartaglia E et al. Long term outcomes of direct and indirect below the knee open revascularization based on the angiosome concept in diabetic patients with critical limb ischemia. Ann Vasc Surg. 2014 May;28(4):983-9. 4. Nagase T, Sanada H, Takehara K et al. Variations of plantar thermographic patters in normal controls and non-ulcer diabetic patients: novel classification using the angiosome concept. J Plast Reconstr Aesthet Surg 2011;64:860. 5. Peregrin J, Koznar B, Kovac L et al. PTA of infrapopliteal arteries: long term clinical follow-up and analysis of factos influencing clinical outcome. Cardiovasc Intervent Radiol 2010;33:720.

Special Session Treatment options for BPH 1004.1 Non-IR treatment options: surgical and medical M. Harris Urology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom Learning Objectives 1. To understand clinical assessment and indications for treatment for BPH 2. To learn the non-endovascular options, including medical and surgery 3. To describe the outcomes of non-endovascular techniques No abstract available.

1004.2 Prostate artery embolisation: indications and results F.C. Carnevale Interventional Radiology, University of Sao Paulo Medical School, São Paulo, Brazil Learning Objectives 1. To understand adequate patient selection 2. To learn correct patient assessment for PAE 3. To describe outcomes including clinical success and complications

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Prostatic artery embolization (PAE) has emerged as an alternative to surgical treatments for benign prostatic hyperplasia (BPH). Patient selection and refined technique are essential for good results. BPH can be treated safely by PAE with low rates of side effects, and thereby reducing prostate volume with clinical improvement in lower urinary tract symptoms (LUTS) and quality of life (QoL) without urinary incontinence, ejaculatory disorders, or erectile dysfunction. A multidisciplinary approach is essential for understanding the disease, to select a good candidate, and to achieve better results. Patient Selection A multidisciplinary team of interventional radiologists, diagnostic radiologists, and urologists should be involved in patient selection and follow-up. Any patient who has LUTS [International Prostate Symptom Score (IPSS) over 7] and is refractory to or intolerant to selective alpha-blockers or/and 5 alpha-reductase can be a candidate for PAE. The prostate size for PAE should be >30 grams. Patients with prostate size ranging from 30 to 90 grams are candidates for transurethral resection of the prostate or laser treatment. Open surgery is usually performed for patients with >90 grams. IPSS (evaluated as mild, moderate, and severe) and the International Index of Erectile Function (IIEF; evaluated as severe, moderate, mild-to-moderate, mild, and no dysfunction) are used as assessment tools by our medical team. Patients with malignancy and any other cause of voiding dysfunction are excluded. To assess a baseline QoL index, patients complete a questionnaire that includes the question, “If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?” The answers range from terrible, unhappy, mostly dissatisfied, mixed, mostly satisfied, pleased, and delighted. Before intervention, the urologist orders digital rectal examination (DRE), prostate specific antigen (PSA), and prostate biopsy, if concern is indicated. Prostate biopsy is an urologist personal decision. As a general recommendation, the following patients should undergo prostate biopsy with a minimum of 12 cores and have a negative histopathology report prior to treatment by PAE: a) patients with DRE findings suspicious for prostate cancer, b) patients with baseline PSA levels of >10 ng/mL, and c) patients with baseline PSA levels of >2.5 ng/mL and 8) was observed in 14/104 (13.5%) patients in a mean duration of 14.7-month (range, 3–36 months) follow-up. Recurrence (12/14 patients; 85.7%) were related to prostate volume of 30%. Overall clinical improvement in LUTS assessed by IPSS, QoL, and urodynamic data is achieved without urinary incontinence, ejaculatory disorders, or erectile dysfunction. Nevertheless, a multidisciplinary approach with urologists, diagnostic radiologists, and interventional radiologists is essential. References 1. AUA Practice Guidelines Committee. AUA guideline on management of benign prostatic hyperplasia. I. Diagnosis and treatment recommendations. J Urol 2003; 170:530-547. 2. Carnevale FC, Antunes AA, da Motta Leal Filho JM et al. Prostatic artery embolization as a primary treatment for benign prostatic hyperplasia: preliminar results in two patients. Cardiovasc Intervent Radiol 2010; 33:355-361. 3. Schafer W, Abrams P, Liao LM, et al. Good urodynamic practices: uroflowmetry, filling cystometry, and pressureflow studies. Neurourol Urodyn 2002; 21:261-74. 4. Carnevale FC, da Motta-Leal-Filho JM, Antunes AA et al. Quality of life and clinical symptoms improvement support prostatic artery embolization for patients with acute urinary retention due to benign prostatic hyperplasia. J Vasc Interv Radiol 2013; 24(4):535-42.

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5. Antunes AA, Carnevale FC, da Motta-Leal-Filho JM, et al. Clinical, laboratorial and urodynamic findings of prostatic artery embolization for the treatment of urinary retention related to benign prostatic hyperplasia: a prospective single center pilot study. Cardiovasc Intervent Radiol 2013; 36(4):978-86. 6. Camara-Lopes G, Mattedi R, Antunes AA, Carnevale FC, Cerri GG, Srougi M, Alves VA, Leite KR. The histology of prostate tissue following prostatic artery embolization for the treatment of benign prostatic hyperplasia. Int Braz J Urol 2013; 39(2):222-7. 7. Frenk NE, Baroni RH, Gonçalves OMG, Carnevale FC, Antunes AA, Srougi M, Cerri GG. MRI findings after prostatic artery embolization for treatment of benign hyperplasia. AJR Am J Roentgenol 2014 [In press]. 8. National Cancer Institute, Common Terminology Criteria for Adverse Events (CTCAE). Version 4.0 Published: May 28, 2009 (V4.03: June 14, 2010) U.S. Department of Health and Human Services National Institute of Health (NIH) Publication n° 09-5410http://evs.nci.nih.gov/Ftp1/CTCAE/Abont.html.

1004.3 Prostate artery embolisation: technique M.A. de Gregorio1, M. Sanchez Ballestin2 Radiology, Clinico Universitario Zaragoza, Zaragoza, Spain, 2GITMI, University of Zaragoza, Zaragoza, Spain 1Interventional

Learning Objectives 1. To learn about basic equipment including selective catheters, guidewires and embolic agents 2. Technique for super-selective embolisation 3. To learn how to overcome procedural difficulties Prostatic artery embolization (PAE) is a new and promising alternative treatment for benign prostatic hyperplasia (BPH). PAE is, in general, technically challenging and often time-consuming. The small diameter, difficult identification, tortuosity, atherosclerosis, and anatomical variations of the prostatic arteries in elderly patients make selective catherization difficult, demanding trained interventional radiologists. In our experience, the most important factor to avoid potential complications and reduce X-ray exposure is a clear identification of the prostatic arteries. With that aim, we use the PROVISO technique described by Carnevale in 2008. Prior to the procedure, a Foley catheter is placed in the bladder and its balloon is filled with a mixture of 50% iodinated contrast medium and 50% normal saline solution. This measure provides a good orientation to the prostate site and related structures in the pelvis during the intervention and helps to avoid non-target embolization. PAE is performed under local anaesthesia and a 400 mg single dose of ciprofloxacin is administered before the procedure. The procedure begins with pelvic angiography using a power injection at the 10 mL/s for 2 sec for a total volume of 20 mL to vascular roadmap. A 4- or 5-Fr glide cobra catheter is then placed in the contralateral internal iliac artery, and a digital subtraction arteriogram is performed with the injection of contrast medium at 4 mL/s for a total volume of 12 mL in the 25º–55º ipsilateral oblique projection. A 5-Fr contralateral hydrophilic introducer provided the necessary support for selective catheterization in the presence of advanced atherosclerotic vessels. A Waltman loop is formed using the initial hydrophilic glide cobra catheter to catheterize the ipsilateral internal iliac artery. In some cases with technical difficulty, Simmons I or II catheter is used. In some special difficult cases, contralateral artery puncture was performed. The contralateral oblique view is most useful for the identification of the five anterior branches of the internal iliac artery. The prostate arteries are usually seen anterior to and immediately below the Foley balloon. Proviso, which stands for internal pudendal, middle rectal, obturator, vesical, and inferior and superior gluteal arteries, help in identifying the branches of the anterior division of the internal iliac artery.

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The inferior vesical artery is the main branch supplying the prostate gland. It usually arises as the second or third branch of the anterior trunk of the internal iliac artery. Generally, one main prostatic artery is found on each side. Moreover, in some patients, the main prostatic artery and any additional prostatic branches arise from the superior vesical, internal pudendal, obturator, or middle rectal arteries. The inferior vesical artery can be catheterized from the same ipsilateral oblique perspective using the microcatheter under the vascular roadmap, and DSA is performed with the manual injection of 2–3 mL contrast medium in the oblique and posterior–anterior views. The arteriograms in these projections are very important to identify the prostatic branches, thus avoiding non-target embolization, collaterals, and shunts. After reviewing both projections, the catheter is advanced into IVA at the ostium of the prostatic arteries, and flow-directed embolization is performed. The use of small diameter hydrophilic microcatheters is mandatory in the catheterization of the prostatic arteries due to the small calibre of the vessel and their tendency to spasm. We use microcatheters of 200 cases per 100,000 person-years [1] [2]. Thoracic aortic diseases mainly comprises 6 entities: true thoracic aortic aneurysm (TAA), traumatic aortic rupture (TAI), aortic dissection, intramural hematoma (IMH), penetrating aortic ulcer (PAU), and false aneurysm, with a significant overlap of these diseases. All these entities can occur either as an acute aortic syndrome (AAS) or as chronic forms of the diseases. Recent guidelines, consensus documents, and overview articles have summarized the current knowledge and made recommendations regarding the management of thoracic aortic diseases [2, 3]. Whereas, patients with AAS involving the ascending aorta are to be treated by surgery and those with diseases of the descending thoracic aorta are usually treated medically; only in the event of complications, these patients become candidates for surgery or increasingly, for treatment with thoracic endovascular aortic repair (TEVAR) [3]. Most data on TEVAR originates from registries, with only very limited information derived from randomized controlled clinical trials. Therefore, it is necessary to get as much information as possible from other databases. Nevertheless, TEVAR has evolved into a safe and effective therapy for different aortic pathology resulting in promising long-term results. [4] True Thoracic Aortic Aneurysms A meta-analysis [5], including 17 studies, involved 517 patients treated with OR and 538 patients treated with TEVAR, all as elective cases. The authors found that in the endovascular cohort of patients, a lower 30-day mortality rate (0%–8% vs 1%–18%, p < 0.0001) and a better paraplegia rate (0%–13% vs 0%–7%, p < 0.0007). No significant difference were described in terms of early stroke rate, more common in the TEVAR group (0%–10% vs 0%–7%) or in terms of major reintervention rate at 48 months, more frequent in the OR group (8.4% vs 7%). Likewise, a further meta-analysis reported similar results regarding the treatment of ruptured TAAs [6]. It included 28 studies, involving 81 patients who underwent OR and 143 patients treated by TEVAR. Early mortality rate (18.9% vs 33% p < 0.016) and myocardial

Abstract Book infarction rate (3.5% vs 11.1% p < 0.047) were significantly lower in the TEVAR group. Paraplegia rate (3.1% vs 5.5% p < 0.05) and stroke rate (4.1% vs 10.2% p < 0.05) were also reduced after TEVAR, although no significant difference was found. The number of major intervention was also increased in the endovascular patients, but such a difference was not significant (9% vs 2.3%). Traumatic Thoracic Aortic Injury (TAI) A recently published review, including 7768 patients enrolled for TAI, found a significantly reduced mortality rate for TEVAR when compared with OR (9% vs 19%; p < 0.01) [7]. In the same study, no significant difference in the event rate across the two groups was noted for stroke, whilst the risk of developing spinal cord ischemia (SCI) and end-stage renal disease (ESRD) were higher in OR (9% vs 3%; p = 0.01 for SCI and 8% vs 5%; p = 0.01 for ESRD). OR was also associated with an increased risk of graft and systemic infection, whilst endovascular repair was associated with an increased need for secondary procedures (5.4%; p = 0.07), mostly due to endoleak (60%), followed by stent collapse (11%). An advantage in terms of survival as well as decreased incidence of paraplegia in TEVAR when compared with OR was also found in other systematic reviews [8] [9]. Altogether, available data indicate that TEVAR, in suitable anatomies, should be the preferred treatment option in TAI. Dissections and Intramural Hematoma About 15%–20% patients presented with complications and required intervention. These complications included ischemia of visceral organs, kidneys, spinal cord or the lower limbs, renal failure, paraplegia/paraparesis, periaortic hematoma, and uncontrolled pain/hypertension and required emergency intervention. Altogether, there is increasing evidence that TEVAR has a substantial advantage in early mortality over open surgery in patients with complicated type B dissection. The aim of endovascular stent-graft therapy is to cover the primary entry tear to reduce the pressure in the false lumen. This can prevent the extension of the dissection and may lead to thrombosis in the false lumen with aortic remodeling and stabilization. Visceral ischemia, (impeding) rupture, persistent refractory pain, and uncontrollable hypertension are all indications for TEVAR. There are three meta-analyses available which report the short- and mid-term result in complicated type B dissection treated with TEVAR [10] [11] [12]. Technical success ranged between 95% and 99%, hospital mortality 2.6%–9.8%, and neurological complications 0.6%– 3.1%. Patients treated with TEVAR had a better outcome compared with open surgery (mortality of 9.3% vs 33.9%). Other studies confirmed these findings with in-hospital mortality of 4%, 40%, and 33% in TEVAR, open surgery, and medically treated patients, respectively. Recent studies showed a 5-year survival up to 80%. There is only one randomized controlled trial ADSORB (a European study on medical management vs TAG device + medical management for acute uncomplicated type B dissection), but definitive results are not available. The 1-year results of the trial showed more frequent false lumen thrombosis and aortic remodeling in those patients with type B aortic dissection treated with TEVAR compared with those managed medically [13]. Chronic Type B Aortic Dissections Classically, aortic dissection is defined as acute within 14 days from onset and chronic after that duration. This temporal classification is based on the fact that 70% deaths due to aortic dissection occurs within the first 2 weeks from the onset and the risk of dissectionrelated death remains high in the first 3 months. In recent years, it has been suggested that a separate category of dissection, termed subacute (between 2 weeks and 6 months after the initial dissection) should be included to recognize the potential of endograft stimulated aortic remodeling within this time period. When type B aortic dissection in uncomplicated, there is still a debate for the endovascular approach and the timing of implantation. During the chronic phase, medical therapy and repeated

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imaging are essential to identify patients who require intervention. In patients with chronic dissection, aortic-related complications may occur in 20%–50% patients. Overall, it is estimated that approximately 20%–40% patients with chronic type B aortic dissection develop enlargement of the false lumen that warrants treatment, and approximately 25% descending thoracic or thoracoabdominal aneurysm are associated with aortic dissection. Apart from aneurysmal degeneration, aortic-related complications include repeat dissection, retrograde dissection, and the rupture of the false lumen. A recent systematic review detailed the 567 pooled cases of TEVAR [14]. In this review, the early (30-day or in-hospital) mortality was 3.2%, the incidence of stroke was 0.82%, and spinal cord injury occurred in 0.43%. Based on the results of stent graft for uncomplicated type B aortic dissection in selected centers, a randomized trial (INSTEAD) comparing medical treatment and TEVAR was started 6 years ago to evaluate TEVAR for subacute uncomplicated type B aortic dissection in the prevention of long-term complications such as aortic aneurysm or survival benefit [15]. Results at 2 years did not show benefit for the invasive approach because of the early complication in that group, despite the benefit of aortic remodeling. However, 5-year results show the opposite [16]. Finally, an interdisciplinary expert consensus on the management of type B aortic dissection reviewed literature and provided proposal for strategies for the management of type B aortic dissection [3]. Looking at their proposals, TEVAR is indicated in the first 15 days if acute complicated type B dissection. If uncomplicated, close follow-up is mandatory to evaluate aortic dissection from 2 to 6 weeks (subacute phase). During that period, TEVAR is indicated if total aortic diameter is >55 mm or total aortic diameter increases by >4 mm or if recurrent symptoms or signs are in the favor of eminent rupture. Other criteria could be used to recommend stent graft insertion when the false lumen diameter is >22 mm, a large proximal entry tear, or a partial false lumen thrombosis. Finally, endovascular repair of the thoracic aorta results in an excellent mid-term protection from aortic-related mortality, regardless of presenting pathology. [17] References 1. Hagan PG, Nienaber CA, Isselbacher EM, et al.: The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000; 283(7): 897-903. 2. Hiratzka LF, Bakris GL, Beckman JA, et al.: 2010 ACCF/AHA/AATS/ ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/ American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation 2010; 121(13): e266-369. 3. Fattori R, Cao P, De Rango P, et al.: Interdisciplinary expert consensus document on management of type B aortic dissection. J Am Coll Cardiol 2013; 61(16): 1661-78. 4. Patterson B, Holt P, Nienaber C, Cambria R, Fairman R, Thompson M: Aortic pathology determines midterm outcome after endovascular repair of the thoracic aorta: report from the Medtronic Thoracic Endovascular Registry (MOTHER) database. Circulation 2013; 127(1): 24-32. 5. Jonker FH, Verhagen HJ, Lin PH, et al.: Outcomes of endovascular repair of ruptured descending thoracic aortic aneurysms. Circulation 2010; 121(25): 2718-23.

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6. Patel HJ, Williams DM, Upchurch GR, Jr., Dasika NL, Deeb GM: A comparative analysis of open and endovascular repair for the ruptured descending thoracic aorta. J Vasc Surg 2009; 50(6): 1265-70. 7. Murad MH, Rizvi AZ, Malgor R, et al.: Comparative effectiveness of the treatments for thoracic aortic transection [corrected]. J Vasc Surg 2011; 53(1): 193-199 e1-21. 8. Karmy-Jones R, Ferrigno L, Teso D, Long WB 3rd, Shackford S: Endovascular repair compared with operative repair of traumatic rupture of the thoracic aorta: a nonsystematic review and a plea for trauma-specific reporting guidelines. J Trauma 2011; 71(4): 1059-72. 9. Hoffer EK, Forauer AR, Silas AM, Gemery JM: Endovascular stentgraft or open surgical repair for blunt thoracic aortic trauma: systematic review. J Vasc Interv Radiol 2008; 19(8): 1153-64. 10. Eggebrecht H, Nienaber CA, Neuhauser M, et al.: Endovascular stent-graft placement in aortic dissection: a meta-analysis. Eur Heart J 2006; 27(4): 489-98. 11. Parker JD, Golledge J: Outcome of endovascular treatment of acute type B aortic dissection. Ann Thorac Surg 2008; 86(5): 1707-12. 12. Xiong J, Jiang B, Guo W, Wang SM, Tong XY: Endovascular stent graft placement in patients with type B aortic dissection: a metaanalysis in China. J Thorac Cardiovasc Surg 2009; 138(4): 865-72. 13. Brunkwall J, Lammer J, Verhoeven E, Taylor P: ADSORB: a study on the efficacy of endovascular grafting in uncomplicated acute dissection of the descending aorta. Eur J Vasc Endovasc Surg 2012; 44(1): 31-6. 14. Thrumurthy SG, Karthikesalingam A, Patterson BO, et al.: A systematic review of mid-term outcomes of thoracic endovascular repair (TEVAR) of chronic type B aortic dissection. Eur J Vasc Endovasc Surg 2011; 42(5): 632-47. 15. Nienaber CA, Rousseau H, Eggebrecht H, et al.: Randomized comparison of strategies for type B aortic dissection: the INvestigation of STEnt Grafts in Aortic Dissection (INSTEAD) trial. Circulation 2009; 120(25): 2519-28. 16. Nienaber CA, Kische S, Rousseau H, et al.: Endovascular repair of type B aortic dissection: long-term results of the randomized investigation of stent grafts in aortic dissection trial. Circ Cardiovasc Interv 2013; 6(4): 407-16. 17. Wiedemann D, Mahr S, Vadehra A, et al.: Thoracic endovascular aortic repair in 300 patients: long-term results. Ann Thorac Surg 2013; 95(5): 1577-83.

1702.3 Femoro-popliteal segment E. Atar Radiology Department, Rabin Medical Center Hasharon Hospital, Petah Tikva, Israel Learning Objectives 1. To learn about the latest trial results 2. To learn which patients benefit most from drug-eluting devices 3. To learn about adjunctive medical therapy Until recently, the major limitation of endovascular treatment in the femoropopliteal segment was the high incidence of restenosis. This was due to the forces from different directions that these vessels faced during regular activities and the use of older equipment. Various endovascular options from different accesses are available today to treat stenoses and occlusions at the superficial femoral and popliteal arteries. The technological improvements in the tools for interventions and the data from the trials, as summarized in the TASC1 and TASC 2 recommendations have made percutaneous intervention the best option in the majority of pathologies in these vessels in all 4 TASC levels.

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The tools for treatment available today include balloons with longer sizes and better technology, bare-metal stents from various metals and designs, covered stents, drug-eluting stents, and drug-eluting balloons. Several chronic total occlusion devices are also available today, providing promising results, and together with subintimal angioplasty and re-entry devices, more options are available to the operator. Moreover, treatment can be performed from both directions of the pathology under ultrasound guidance while using new micropuncture kits. Data from recent trials are published frequently reporting better long-term patency results. Adjunctive medical therapy, although this option is less studied, plays an important role in the duration of the treated vessel patency, as in other locations. Nevertheless, there is always a need for improvement, and the operators must be updated with trial results for patients’ better treatment.

1702.4 Infrapopliteal segment S. Sharma1, S. Kumar2 1Dept of Cardiac Radiology, All India Institute of Medical Sciences, Delhi, India, 2Cardiac Radiology, All India Institute of Medical Sciences, Delhi, India Learning Objectives 1. To learn about the latest trial results 2. To learn which patients benefit most from drug-eluting devices 3. To learn about adjunctive medical therapy The management of advanced obstructive infrapopliteal disease poses challenges due to unfavorable image morphology characterized by diffused, multifocal, and multi-segment occlusive lesions with poor or absent distal run-off vessels. Below-the-knee (BTK) disease is not the same as above knee disease and often presents with critical limb ischemia (CLI). Patients frequently have comorbidities, such as diabetes and renal failure. Both intima and media are diseased with an involvement of smaller arteries. The disease frequently involves long segments, has heavily calcified arteries, and additional proximal femoropopliteal disease. There are no TASC guidelines for BTK lesions. Leg ulcers may have multifactorial etiologies, including neuropathy, infection, venous insufficiency, and arterial insufficiency. These patients require a multispecialty higher level of care. Further, minor amputations are not regarded as treatment failure. Many a times, vascular interventions are performed to lower the level of amputation. The occurrence of restenosis is difficult to evaluate due to a variety of issues, including lack of uniform angiographic follow-up, heavy calcification precluding optimal duplex ultrasound and CT angiography, low eGFR if present precluding MR angiography, and inability to perform anklebrachial pressure index due to the presence of ulcers or its unreliability due to diffuse occlusive disease. Long-term patency rates also do not have a linear relationship with clinical outcomes. Wound or ulcer healing relate better to the outcome, and limb salvage rates are better than patency rates for predicting the outcome of endovascular revascularization. Short-term patency, resulting in pulsatile blood flow to ischemic ulcers, promotes repair mechanisms and tissue salvage. Treatment strategies include medical management, wound care, and endovascular and surgical revascularization. Endovascular procedures include balloon angioplasty [including drug-eluting balloons (DEB)], stenting [bare-metal stent (BMS) and with coatings such as carbon and pharmacologic agents (DES)], and therapeutic angiogenesis. In suitable patients with severe limb ischemia with a life expectancy of >2 years and a usable vein, bypass surgery was advocated (BASIL trail) for infrainguinal lesions1. Bypass had better patency rates than endovascular techniques but with no significant difference in limb salvage rate. In patients with 40 mm of at least 1 BTK vessel with distal runoff, and with >1-year life expectancy were included. Binary in-segment restenosis at a 1-year angiographic or ultrasonographic follow-up was the primary endpoint. Clinically driven target lesion revascularization, major amputation, and target vessel occlusion were included as secondary endpoints. In all, 132 patients with 158 infrapopliteal lesions were enrolled. The mean length of treated segments was 129 ± 83 mm in the DEB group compared with 131 ± 79 mm in the PTA group (P = 0.7). Binary restenosis, assessed by angiography in >90% patients, occurred in 20/74 lesions (27%) in the DEB group compared with 55/74 lesions (74%) in the PTA group (P < 0.001); target lesion revascularization was observed in 12 patients (18%) versus 29 (43%; P = 0.002) lesions and target vessel occlusion in 12 (17%) versus 41 (55%; P < 0.001). Only 1 major amputation occurred in the PTA group (P = 0.9). DEB compared with PTA significantly reduced 1-year restenosis rates and improved target lesion revascularization with lower target vessel occlusion in treatment of BTK lesions in diabetic patients with CLI. Further, IN.PACT DEEP trial is a 2:1 randomized controlled trial designed to assess the efficacy and safety of infrapopliteal arterial revascularization between IN.PACT Amphirion paclitaxel drug-eluting balloon (IA-DEB) and standard balloon angioplasty (PTA) in patients with CLI. Altogether, 358 patients at 13 European centers were enrolled. It will assess the overall impact on infrapopliteal artery patency, limb salvage, wound healing, pain control, quality of life, and patient mobility; 1-year results should be shortly available. Moreover, the use of DES has shown good results. The proven efficacy of DES in the treatment of coronary artery disease gave rise to the notion that they may have a better patency compared with BMS in small infrapopliteal vessels. YUKON BTX trial8 was a prospective, randomized, multicenter, double-blind trial comparing sirolimuseluting stents (SES) with BMS for the treatment of focal infrapopliteal

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lesions. One hundred and sixty one patients with a mean target lesion length of 31 ± 9 mm were treated. Eighty two patients were randomized to the SES group and 79 to the BMS group; 76.5% patients in the SES group and 79.7% in the BMS group reached 1-year follow-up. The 1-year primary patency rate was 80.6% versus 55.6%. The secondary 1-year patency was 91.9% versus 71.4%. There was no statistically significant difference in limb salvage rate or mortality. SES achieved significantly higher primary and secondary patency rates as compared with BMS for focal infrapopliteal arterial lesions. Follow-up at 2 years showed that long-term eventfree survival, amputation rates, and clinical status were significantly improved by DES compared with BMS. DESTINY trial, another multicenter, randomized controlled study, suggested that the treatment of infrapopliteal lesions with everolimus-eluting stents reduced restenosis and the need for reintervention compared with BMS. ACHILLES trial is a multicenter European RCT comparing the role of sirolimus-eluting stent versus PTA in 200 patients with intermittent claudication or CLI. It showed the superiority of DES over PTA in terms of clinical endpoint at 1-year follow up. There is level 1 evidence for the use of olimus-eluting stents for short/focal infrapopliteal lesions and improved patency of DES versus BMS or PTA for short/focal lesions9,10. Infrapopliteal DES inhibits restenosis, reduces repeat procedures and improves event-free survival. Gene and stem cell therapy may emerge as a new frontier in the treatment of infrapopliteal disease in no-option CLI patients. Therapeutic angiogenesis aims to treat ischemic tissues by delivering recombinant proteins, genes, or cells to promote neoangiogenesis11. Despite the fact that preclinical studies showed promising results for both these forms of treatment, there have been concerns regarding the safety, side effects, protein efficacy, and gene transfer studies12. These have led to the development of cell-based therapies as alternative approaches to induce vascular regeneration and to improve the function of damaged tissue. Therapeutic angiogenesis using stem cells has the potential to rewrite treatment algorithms in suitable patients. Stem cells from embryonic tissue have pluripotent potential and may provide potent clinical outcomes but have serious ethical issues and potential danger of differentiation into unfavorable cell types. Hence, most clinical experience is based on the use of adult stem cells usually derived from bone marrow peripheral blood and adipose tissue. Most trials have shown varying degrees of benefit in terms of relief of symptoms, improvement in indices such as ankle brachial pressure index, transcutaneous oxygen pressure measurements, and collateral number and density among others. This is despite the fact that the type of cells used (peripheral blood or bone marrow-derived) may not be best in terms of efficacy or CD34 count, the doses used may well be suboptimal, best route of administration (intra-arterial, intramuscular or other) has yet not been identified. In addition, optimal outcome measures and optimal duration when the outcome is most visible has not been defined. Outcomes of this therapy may be improved by the application of imaging technologies that allow the investigators to track the location, engraftment, and the survival of administered cell population. Despite these limitations, most studies have shown substantial improvement in clinical outcomes13. There is some evidence that patients with Buergers’ disease may respond better to this therapy than those with atherosclerosis as the underlying cause. Although proof with large randomized trials for both the above therapies is still lacking, they have shown the ability to improve perfusion with arteriogenesis, angiogenesis, and vasculogenesis. Further research will define the role of this strategy in suitable patients. There is a paucity of long-term follow-up data in terms of randomized studies comparing the different endovascular options to treat BTK obstructive arterial disease. Limited data suggests an emerging role for cell based therapies to induce therapeutic angiogenesis in no-option patients with CLI. In selected patients with short life expectancy, PTA alone can have good results for limb salvage at 1-year follow-up. The use of BMS is largely restricted as bail-out for

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want of adequate randomized data. Newer devices including DEB and DES have shown promising results. These outcomes need to be validated through large randomized trials before an optimal treatment algorithm for the BTK disease can be identified. References 1. Bradbury AW. Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial: Analysis of amputation free and overall survival by treatment received. J Vasc Surg 2010; 51: 18S-31S. 2. Schmidt A, Ulrich M, Winker B: Angiographic patency and clinical outcome after balloon-angioplasty for extensive infrapopliteal arterial disease. Catheter Cardiovasc Interv 2010; 76: 1047-54. 3. Romiti M, Albers M, Brochado-Neto F.C, et al: Meta analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg 2008; 47: 975-81. 4. Rand T, Lammer J, Rabbia C, Maynar M, Zander T, Jahnke T, Müller-Hülsbeck S, Scheinert D, Manninen HI: Percutaneous transluminal angioplasty versus turbostatic carbon-coated stents in infrapopliteal arteries: InPeria II trial. Radiology 2011; 261(2): 634-42. 5. Rocha-Singh K: Interim results from the VIVA I: Xcell Trial. Endovascular Today 2009; 3: 57-59. 6. Waksman R, Pakala R: Drug-Eluting Balloon The Comeback Kid? Circ Cardiovasc Interv 2009; 2: 352-58. 7. Listro F, et al: Drug-eluting Balloon in Peripheral Intervention for Below The Knee Angioplasty Evaluation (DEBATE-BTK): A Randomized Trial in Diabetic Patients with Critical Limb Ischemia. Circulation 2013; 128(6): 615-21. 8. Rastan A, et al: Sirolimus-eluting stents for treatment of infrapopliteal arteries reduce clinical event rate compared to baremetal stents: long-term results from a randomized trial. J AM Coll Cardiol 2012; 60(7): 587-91. 9. George A, Nicholas C, Kavitha K, Stavros A, Andrew S, Ferdinand S, John S, and David M: Meta-analysis of outcomes of endovascular treatment of infrapopliteal occlusive disease with drugeluting stents. J Endovasc Ther 2013; 20(2): 131-44. 10. Katsanos K, Spiliopoulos S, Krokidis M, Karnabatidis D, Siablis D: Does below-the-knee placement of drug-eluting stents improve clinical outcomes? J Cardiovasc Surg (Torino) 2012; 53(2): 195-203. 11. Zachary I, Morgan RD: Therapeutic angiogenesis for cardiovascular disease: biological context, challenges, prospects. Heart 2011; 97(3): 181-89. 12. Gupta R, Tongers J, Losordo W: Human studies of angiogenic gene therapy. Cir Res 2009; 105: 724-6. 13. De Haro J, Acin F, Lopez-Quintana A, Florez A, Martinez-Aguilar E, Varela C: Meta-analysis of randomized, controlled clinical trials in angiogenesis: gene and cell therapy in peripheral arterial disease. Heart Vessels 2009; 24(5): 321-8.

Special Session Pancreatitis 1703.1 State-of-the-art imaging and staging/grading systems T.L. Bollen Department of Radiology, St. Antonius Hospital, Nieuwegein, Netherlands Learning Objectives 1. To become familiar with the imaging modalities for the pancreas 2. To learn the imaging semiology of pancreatitis 3. To learn the staging of the pancreatitis Introduction: Acute pancreatitis is a relatively common and potentially life-threatening disease. It is the third most common gastrointestinal disorder requiring acute hospitalization in the United States with

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annual costs exceeding $2 billion.(1,2) Approximately 20% of patients develop severe acute pancreatitis elicited by a sustained systemic inflammatory response syndrome (SIRS), which precedes the development of (multi)organ failure or death. Severe acute pancreatitis is associated with a mortality of 15–30%, whereas the mortality of mild acute pancreatitis is only 0–1%.(3,4) Organ failure is the most important determinant for mortality in acute pancreatitis.(4,5) However, in around 30% of patients with necrotizing pancreatitis, secondary infection of necrosis occurs mainly between the second and fourth week after the onset of the disease.(4) If left untreated, the mortality of infected necrosis approaches 100%.(3) In most western countries, gallstones are the cause of pancreatitis in approximately 50% of patients and alcohol in 20%. In about 20% of cases, the cause remains unknown (idiopathic). The remaining 10% constitutes a rather large group of possible causes of acute pancreatitis, including hypercalcemia, hypertriglyceridemia, medications, and hereditary causes.(6) The clinical diagnosis of acute pancreatitis requires two of the following three conditions: 1) characteristic abdominal pain suggestive of acute pancreatitis, 2) serum amylase and/or lipase three or more times the upper limit of normal, and 3) characteristic findings of acute pancreatitis on contrast-enhanced computed tomography (CECT), MR imaging, or transabdominal ultrasonography (US).(3) Usually, the first two criteria are present and CECT is not required for diagnosis. It takes at least 72–96 hours of the disease for a CECT scan to demonstrate clinically relevant morphologic changes like intra- and/or peripancreatic necrosis or peripancreatic collections. Severe acute pancreatitis runs a biphasic clinical course with concomitant peaks in mortality. The first phase (i.e., 1–2 weeks after the onset of symptoms) is characterized by SIRS. Organ failure in the SIRS phase is usually not related to infection but rather a direct result of severe systemic inflammation. Half of the deaths occur during this phase due to (multi)organ failure. The second phase (i.e., after 1–2 weeks) is characterized by a counteractive antiinflammatory response syndrome (CARS). Organ failure in the CARS phase is related to infections such as infected necrosis. The second peak in mortality is largely attributed to infection of necrosis in particular when accompanied by organ failure.(7) Diagnostic imaging: Imaging modalities commonly used for the diagnosis and severity assessment of acute pancreatitis include US, CECT, and MRI. Ultrasound: In the initial phase of acute pancreatitis, US is primarily used for the assessment of biliary stones and biliary obstruction, thereby enabling to elucidate the etiology of pancreatitis. US may also be used for the characterization of pancreatic collections by differentiating fluid from nonliquid material. Furthermore, US can serve as an imaging guide during diagnostic or therapeutic interventions. The major disadvantage of US is the limited visibility in a large proportion of patients with severe acute pancreatitis. Computed tomography: CECT is at present the best imaging technique to evaluate patients suspected of having acute pancreatitis. A monophasic CT protocol after intravenous contrast administration is usually sufficient for the diagnosis and severity assessment of acute pancreatitis. Typically, scans are performed during the pancreatic phase (delay of 40–50 seconds) or portal venous phase (delay 60–70 seconds). Dual-phase studies are recommended in case of hemorrhage, ischemia, or suspicion of a pseudoaneurysm. CECT establishes the diagnosis of acute pancreatitis or may provide an alternative diagnosis. CECT is also beneficial for staging the morphologic severity of acute pancreatitis. However, CECT obtained within the first 72 hours after the onset of symptoms may fail to show major morphologic changes in patients with clinically severe acute pancreatitis; in particular, the presence or true extent of parenchymal necrosis may go unrecognized on early CT. A follow-up CECT obtained 5–7 days later would be required to better determine the morphologic severity of disease. CECT is also useful for the follow-up and evaluation of local and other pancreatic complications and for guidance of interventional procedures. The major disadvantage of CECT is the limited capability of differentiating fluid from nonliquid material in peripancreatic collections.(8)

Abstract Book Magnetic resonance imaging: MRI has gained a more prominent role in the assessment of acute pancreatitis. The presence and extent of pancreatic necrosis and peripancreatic collections can be evaluated with equal accuracy compared with CECT.(9) In fact, MRI is better in detecting mild acute pancreatitis.(10) Due to its inherent tissue contrast resolution capability, MRI is also superior to CECT in determining whether the collections contain fluid or nonliquid material. Hence, MRI has been shown to accurately predict the drainability of collections.(11) In addition, it can detect pancreatic duct disruption using an MRCP sequence. In approximately 30% of patients with severe acute pancreatitis, disruption of the pancreatic duct was reported.(12) Recognizing pancreatic duct disruption has therapeutic implications because early diagnosis of ductal leakage demands a more definitive therapy (e.g., transpapillary stent placement). The major disadvantages of MRI include the longer scanning time (which can pose a problem for very ill patients), motion artifacts, the need for specialized MRI-compatible monitoring equipment in critically ill patients, and high costs if routinely used. Moreover, the sensitivity of MRI in detecting gas bubbles is inferior to CECT, whereas imageguided percutaneous intervention is easier to perform with CT. Therefore, at present, MRI is mainly used as a problem-solving tool in acute pancreatitis. Classification of acute pancreatitis: The 1992 Atlanta Symposium defined acute pancreatitis and classified pancreatic complications on the basis of clinical criteria.(13) Better understanding of the pathophysiology of acute pancreatitis, improved diagnostic imaging, and the development of minimally invasive radiologic, endoscopic, and operative techniques for the management of local complications have made it necessary to revise the 1992 Atlanta Classification (Atlanta Classification 2012).(14) Acute pancreatitis basically has two different morphologic forms: interstitial edematous pancreatitis and necrotizing pancreatitis. In interstitial pancreatitis, the pancreas enhance normally on CECT with or without surrounding peripancreatic inflammatory changes or fluid. The hallmark of necrotizing pancreatitis is the presence of tissue necrosis either of the pancreatic parenchyma (depicted as areas of nonenhancement of the pancreas), the peripancreatic tissues (manifested as heterogeneous areas surrounding the pancreas), or both. Clinically, the severity of acute pancreatitis is defined according to 3 degrees of severity - mild, moderately severe, and severe acute pancreatitis - depending on the presence of organ failure and local and/ or systemic complications.(14) In practice, the morphologic severity and clinical severity frequently overlap (i.e., patients with interstitial pancreatitis have clinically mild disease, and conversely, most patients with necrotizing pancreatitis will sustain clinically severe acute pancreatitis). However, this premise does not always hold true. Therefore, it is important to realize that clinical severity prevails over morphologic severity. Peripancreatic collections that may occur in acute pancreatitis include acute peripancreatic fluid collection (APFC) and pseudocyst in interstitial pancreatitis and acute necrotic collection (ANC) and walled-off necrosis (WON) in necrotizing pancreatitis. The primary determinants that differentiate each peripancreatic collection are its content (fluid only in APFC and pseudocyst; fluid and necrotic material in ANC and WON) and degree of encapsulation (none or partial wall in APFC and ANC; complete encapsulation in pseudocyst and WON).(14) The adoption of the Revised Atlanta Classification 2012 should allow for the standardization of interinstitutional data and provide a framework for more accurate and precise communication between clinicians. Staging of acute pancreatitis: Early severity stratification of acute pancreatitis is deemed important for several reasons. The identification of patients with the highest morbidity and mortality is critical because these patients may benefit most from timely transfer to the intensive care unit or tertiary referral centers for supportive treatment or for targeted therapy (i.e., endoscopic intervention

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or enteral feeding). In addition, stratification is essential for reliable interinstitutional comparison of new methods of therapy and for inclusion of patients in randomized trials.(3) Scoring systems related to CT are the most studied imaging tests in acute pancreatitis.(15) Since the introduction of CT for the diagnosis and severity assessment of acute pancreatitis in the eighties, many imaging-based systems have been developed. Determinants of most radiologic scoring systems include pancreatic changes, peripancreatic features, and extrapancreatic features. The severity assessment of AP by CT can be done using unenhanced (Schröder index, Balthazar grade, Pancreatic size index, MOP score, Retroperitoneal extension grade, and EPIC score) or CECT studies (CT Severity Index and Modified CT Severity Index). Of all radiologic staging systems available, the CT severity index (CTSI) is the most studied.(16) CTSI combines the Balthazar grade (0–4 points) with the extent of pancreatic necrosis (0–6 points) on a 10-point severity scale. The calculated CTSI can then be subdivided in three categories (CTSI 0–3, 4–6, and 7–10; corresponding to predicted mild, moderate, and severe disease, respectively) that have subsequent increases in morbidity and mortality. All reports on the discriminatory power of radiologic scoring systems (including CTSI) show a positive correlation between the scoring system studied and patient outcome. A recent study compared 7 of the 8 available CT prognostic scoring systems on the day of admission.(17) This study did not detect significant differences between the studied CT scoring systems in predicting clinical severity or mortality (AUC ranging between 0.72–0.88 and 0.70–0.81, respectively). Moreover, CT scoring systems did not perform better than commonly used clinical scoring systems.(17) In the presentation, the limitations of clinical and radiologic scoring systems for severity stratification will be outlined. Importantly, scoring systems (radiologic and biochemical systems alike) do not correlate with the risk of particular extrapancreatic complications (e.g., abdominal compartment syndrome, bowel ischemia or perforation or arterial pseudoaneurysm). Therefore, they fail to provide detailed information that impacts patient management on an individual basis. Current evidence suggests that there is no role for radiologic scoring systems for prediction purposes early in the disease process (i.e., at admission). Also, given the high costs associated with acute pancreatitis (1), the radiation burden of (serial) CT (18,19) and the lack of correlation between imaging utilization and patient outcome (19,20), the initial evaluation of a patient presenting with acute pancreatitis is best performed based on clinical assessment and biochemical scoring systems that better correlate with organ failure and systemic complications dominating the clinical picture in the first weeks after the initial attack. Performing CT on admission (or within the first days after admission) is unlikely to affect patient management unless a severe complication (like hemorrhage or bowel ischemia) is suspected or in case of a diagnostic dilemma. The decision about when to perform MDCT depends, therefore, on the overall clinical presentation. Unquestionably, the impact of CT is greater in the later phase of the disease process in patients who have predicted severe acute pancreatitis by clinical assessment or who fail to improve clinically despite conservative therapy when local complications (most commonly infection of parenchymal and peripancreatic tissues) predominantly dictate clinical management. Imaging-based predictive systems are useful for identifying groups of patients at risk for local complications or having severe disease rather than providing specific information that changes clinical management on an individual basis. However, there are several individual CT features that may significantly impact patient management. Among these are the presence of significant necrosis (more than 30%), especially in case of central gland necrosis (associated with increased need for intervention); imaging signs of infected necrosis (requiring empirical antibiotics or some kind of radiologic, endoscopic, or surgical intervention); massive hemorrhage or detection of an arterial pseudoaneurysm (indication for angiographic coiling

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or surgery); deep vein thrombosis (indication for anticoagulation); cholecystitis (amenable for percutaneous drainage); bowel ischemia or perforation (indication for surgery); and features of the abdominal compartment syndrome (requiring percutaneous drainage of ascites or surgery). The conveyance of these specific CT findings to clinicians caring for these challenging patients will have more clinical impact on patient management than providing any radiologic score. References 1. Fagenholz PJ, Fernandez-del Castillo C, Harris NS, Pelletier AJ, Camargo CA. Direct medical costs of acute pancreatitis hospitalizations in the United States. Pancreas 2007;35(4):302-7. 2. Shaheen NJ, Hansen RA, Morgan DR, Gangarosa LM, Ringel Y, Thiny MT et al. The burden of gastrointestinal and liver diseases, 2006. Am J Gastroenterol 2006;101(9):2128-38. 3. Banks PA, Freeman ML. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006;101(10):2379-400. 4. Besselink MG, Van Santvoort HC, Boermeester MA, Nieuwenhuijs VB, van Goor H, Dejong CH et al. Timing and impact of infections in acute pancreatitis. Br J Surg 2009;96(3):267-73. 5. Petrov MS, Shanbhag S, Chakraborty M, Phillips AR, Windsor JA. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology 2010;139(3):813-20. 6. Frossard JL, Steer ML,Pastor CM. Acute pancreatitis. Lancet 2008;371(9607):143-52. 7. Werner J, Feuerbach S, Uhl W, Buchler MW. Management of acute pancreatitis: from surgery to interventional intensive care. Gut 2005;54(3):426-36. 8. Bollen TL, van Santvoort HC, Besselink MG, van Es HW, Gooszen HG, van Leeuwen MS. Update on acute pancreatitis: ultrasound, computed tomography, and magnetic resonance imaging features. Semin Ultrasound CT MR 2007;28(5):371-83. 9. Arvanitakis M, Delhaye M, De Maertelaere V, Bali M, Winant C, Coppens E et al. Computed tomography and magnetic resonance imaging in the assessment of acute pancreatitis. Gastroenterology 2004;126(3):715-23. 10. Amano Y, Oishi T, Takahashi M, Kumazaki T. Nonenhanced magnetic resonance imaging of mild acute pancreatitis. Abdom Imaging 2001;26(1):59-63. 11. Morgan DE, Baron TH, Smith JK, Robbin ML, Kenney PJ. Pancreatic fluid collections prior to intervention: evaluation with MR imaging compared with CT and US. Radiology 1997;203(3):773-78. 12. Lau ST, Simchuk EJ, Kozarek RA, Traverso LW. A pancreatic ductal leak should be sought to direct treatment in patients with acute pancreatitis. Am J Surg 2001;181(5):411-15. 13. Bradley EL III. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992. Arch Surg 1993;128(5):586-90. 14. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013 Jan;62(1):102-11. 15. Delrue LJ, De Waele JJ, Duyck PO. Acute pancreatitis: radiologic scores in predicting severity and outcome. Abdom Imaging 2010;35:349-61. 16. Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990;174:331-6. 17. Bollen TL, Singh VK, Maurer R, Repas K, van Es HW, Banks PA, 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(4):612-9.

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18. Smith-Bindman R, Lipson J, Marcus R, Kim KP, Mahesh M, Gould R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med 2009;169:2078-86. 19. Mortele KJ, Ip IK, Wu BU, Conwell DL, Banks PA, Khorasani R. Acute pancreatitis: imaging utilization practices in an urban teaching hospital-analysis of trends with assessment of independent predictors in correlation with patient outcomes. Radiology 2011;258:174-81. 20. Spanier BW, Nio Y, van der Hulst RW, Tuynman HA, Dijkgraaf MG, Bruno MJ. Practice and yield of early CT scan in acute pancreatitis: a Dutch observational multicenter study. Pancreatology 2010;10(2-3):222-8.

1703.2 Endoscopic and surgical treatment options D.F. Martin Dept. of Radiology, Wythenshawe Hospital, Manchester, United Kingdom Learning Objectives 1. To learn the best indication of endoscopic interventions 2. To learn surgical indications 3. To understand the results and complications Irrespective of its etiology, acute pancreatitis is a variable condition ranging from mild interstitial oedematous pancreatitis to severe necrotising pancreatitis. The disease normally has two phases; the first is an acute inflammatory response, which may be accompanied by organ failure but not normally by intra-abdominal complications, which require intervention. In this phase of the disease, endoscopic intervention with ERCP to remove gallstones or stent the bile duct is indicated by patients who have jaundice or cholangitis as well as acute pancreatitis. It is now generally agreed that ERCP is not indicated outside of these situations. The presence of acute pancreatitis in patients with gallbladder stones and without jaundice or cholangitis does not indicate the need for ERCP as in the vast majority of these patients, the offending stone has already passed by the time of presentation. Patients with mild interstitial oedematous pancreatitis recover after the acute inflammatory phase, but patients with necrotising pancreatitis, particularly, those with a large percentage of necrosis may go on to develop complications, which require endoscopic or surgical intervention. Acute Peripancreatic Fluid Collection Acute fluid collection in non-necrotic pancreatitis is an expected event; it is rarely ever infected and does not require intervention. Pancreatic Pseudocyst Pancreatic pseudocysts are the endpoints of persistent peripancreatic fluid collections and by definition do not contain necrotic material. Pseudocysts may be symptomatic because of their size causing pain, gastric outlet obstruction or biliary obstruction. As most pseudocysts resolve spontaneously, a period of observation is wise before intervention is initiated. A persistent, enlarging or symptomatic pseudocyst can be managed endoscopically by EUS-guided pseudocyst drainage either incising the posterior wall of the stomach or the medial wall of the duodenum, whichever gives better access. Most endoscopists place plastic pigtail stents to provide drainage but covered metal stents are also available, which are easily placed and provide very rapid, low-maintenance drainage. Many endoscopists insert stents and simply allow the stents to be discharged spontaneously as the pseudocyst diminishes in size. Others undertake the maintenance of stents, removing and replacing these until the pseudocyst is resolved. Complications most commonly involve pseudocyst infection or haemorrhage. Surgical options for the management of pseudocysts include open cystogastrostomy or laparascopic cystogastrostomy, the main indication for these procedures being failed endoscopic drainage.

Abstract Book Acute Necrotic Collection Acute collections associated with pancreatic necrosis most commonly occur in or around the pancreatic bed but can occur elsewhere in the abdomen or in the mediastinum. These can develop into walled-off necrotic collections if left. The most significant cause of mortality during this second phase of acute pancreatitis is related to infection of a walled-off necrotic collection and constant clinical and biochemical monitoring is essential to recognise this complication, which then requires urgent drainage. This can be done percutaneously, endoscopically or surgically or even using a combination of approaches. The endoscopic approach is the same as for a pancreatic pseudocyst, but the insertion of a large diameter covered metal stent is probably preferable in providing a better drainage. These large bore stents also have the possible benefit of allowing endoscopic access into the collection to remove necrotic debris. However, this procedure can be hampered significantly by the risk of haemorrhage. Of course the benefit of an endoscopic approach to infective necrosis is the absence of external drains which may become displaced. Nursing the patient is also easier. The surgical approach for the drainage of infective necrosis is now uncommonly undertaken as a primary procedure. Most surgical approaches are secondary to percutaneous drainage (see later). Pseudoaneurysm Visceral artery pseudoaneurysm as a complication of acute pancreatitis can occur anywhere around the pancreas but is most common in the splenic artery and the gastroduodenal artery. These can present with catastrophic haemorrhage, and it is wise to undertake CT visceral arteriography prior to the intervention and drainage of a patient with pseudocyst or a walled-off necrotic collection. Pseudoaneurysms are most appropriately dealt with by embolisation, surgery being rarely indicated. Biliary Obstruction Patients with biliary obstruction or gastric outlet obstruction as a consequence of pancreatic collections are most appropriately dealt with by the drainage of the pancreatic collection. However, where this is difficult, it may be necessary to provide biliary drainage either endoscopically or percutaneously for a period whilst the collection resolves or becomes amenable to drainage. Gastric outlet obstruction is a more difficult matter, but the placement of a covered duodenal stent, which can be removed later may be appropriate. Summary It is crucial to distinguish between the different types of peripancreatic and pancreatic fluid collections in determining the best approach for their management. Infected necrotic collections have significant mortality and require a prompt therapy. Surgical approaches are nowadays uncommonly required but are available.

1703.3 Percutaneous management M. Ryan Interventional Radiology, St James Hospital, Dublin, Ireland Learning Objectives 1. To learn the best indications of percutaneous procedures 2. To understand percutaneous procedures 3. To learn tips and tricks to increase success and limit complications Interventional radiology has long had an important role in the management of non-vascular and vascular complications associated with acute pancreatitis e.g., necrosis, pseudocyst, pseudoaneurysm, and abscess. The management algorithm has changed over the past decade as a result of greater understanding of the disease process of pancreatitis, its evolution, and the further refinement of minimally invasive techniques. Computed tomography (CT) is usually the preferred modality for guiding radiological pancreatic interventional procedures with the common access routes being via the left anterior pararenal space

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for pancreatic tail collections and through the gastrocolic ligament for pancreatic head and body collections. A careful planning of the access route is important to avoid the colon. Catheters of 8–12 F are usually sufficient for pseudocyst drainage. An average of 2–3 weeks drainage is required if there is no communication of the pseudocyst with the pancreatic duct and many weeks to months for pseudocysts with pancreatic duct communication. The percutaneous drainage of pseudocysts is associated with a success rate of 80%–90%. Pancreatic necrosis has a high mortality if it becomes infected, and the presence of infection can be first determined with CT-guided needle aspiration prior to drainage. The treatment of pancreatic necrosis has evolved and earlier intervention including drainage, necrosectomy, and either laparoscopic or EUS-guided cystogastrostomy is advocated by many specialist centers. Pancreatic abscess drainage has quoted a success rate varying between 32% (infected necrosis) and 90% (pancreatic abscess). The use of large or multiple catheters is often required for a complete drainage. The management of patients with severe acute pancreatitis can be time-consuming and labor-intensive for interventional radiologists, and it requires a multidisciplinary team approach with close communication between interventional radiologists, endoscopists, intensivists, and surgical personnel. References 1. The role of imaging-guided percutaneous procedures in the multidisciplinary approach to treatment of pancreatic fluid collections. Bennett S, Lorenz JM. Semin Intervent Radiol. 2012 Dec;29(4):314-8. 2. Acute complicated pancreatitis: redefining the role of interventional radiology. Lee MJ, Rattner DW, Legemate DA, Saini S, Dawson SL, Hahn PF, Warshaw AL, Mueller PR. Radiology 1992 Apr;183(1):171-4. 3. Interventional radiology in acute pancreatitis: friend or foe? Khorsandi M, Beatson K, Dougherty S, Zealley I, Kulli C. JOP. 2012 Jan 10;13(1):91-3. 4. Interventional radiology for necrotizing pancreatitis. Mamlouk MD, vanSonnenberg E. J Gastrointest Surg. 2011 Jul;15(7):1101-3.

1703.4 Treatment of vascular complications R. Jackson Radiology, Freeman Hospital, Newcastle-upon-Tyne, United Kingdom Learning Objectives 1. To describe the indications for vascular procedures 2. To learn about the technique and results 3. To learn tips and tricks to increase success and limit complications The major vascular complications of pancreatitis are arterial bleeding and venous thrombosis. Whilst arterial false aneurysms are a common cause of recurrent and catastrophic bleeding; other conditions such as peptic ulceration and Mallory–Weiss tears are also encountered. Bleeding due to gastric varices secondary to splenic vein thrombosis can also occur. The overall incidence of bleeding is more common in chronic rather than acute pancreatitis with arterial false aneurysms as the most common cause. Bleeding is more common in acute severe pancreatitis than uncomplicated pancreatitis. The overall rates of bleeding have been quoted between 1% and 14% with high rates of mortality (30%–40%). [1-3] Arterial phase CT and upper GI endoscopy are the first-line imaging modalities. Even when there is no active arterial bleeding, false aneurysms may be seen but can be subtle and may be masked by collateral veins in the presence of splenic and/or mesenteric vein thrombosis. Once diagnosed, false aneurysms should be treated [4].

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Not all causes of bleeding are diagnosed using CT, and endoscopy and intra-arterial angiography should be performed. Even when not actively bleeding, there may be angiographic clues to the culprit vessel such as areas of irregularity or ‘cut-off’ vessels. Arterial embolisation is occasionally necessary for peptic ulcers when medical and endoscopic management has failed. The splenic, gastroduodenal and pancreaticoduodenal arteries are the main sites for false aneurysms. Due to an extensive collateral supply, it is usually safe to embolise the vessel without major organ infarction. There are a number of techniques described. [5,6] The concept of closing the front and back doors to the bleeding point is important. Embolic agents include metal coils and Amplatzer plugs, particles and gelfoam and liquid embolic agents such as onyx and histoacryl glue. When the false aneurysm arises from a small inaccessible vessel, which has not responded to transarterial embolisation, there are a number of case reports of percutaneous thrombin injection. Occasionally, when the arterial anatomy allows and the vessel is not too small, it is possible to use covered stents to both stop bleeding and preserve the distal arterial flow. Splenic vein thrombosis is usually not symptomatic but may cause variceal bleeding particularly in the stomach due to ‘left sided’ portal hypertension. This can be difficult to manage endoscopically. Splenectomy may be necessary, but there are reports of partial splenic embolisation to reduce the flow and pressure in these varices. [7,8] It is likely that the number of bleeds that are not identified on CT, angiography or endoscopy are venous in origin and are rarely directly identified. The author has treated two patients with splenic vein false aneurysms using coil embolisation in one and a covered stent in the other via transplenic and transhepatic access, respectively. References 1. Major haemorrhagic complications of acute pancreatitis. E. Andersson, D. Ansari and R. Andersson. British Journal of Surgery 2010; 97: 1379-1384. 2. Potentially fatal bleeding in acute pancreatitis: pathophysiology, prevention, and treatment. Flati G, Andrén-Sandberg A, La Pinta M, Porowska B, Carboni M. Pancreas 2003; 26(1): 8-14. 3. Vascular Complications of Pancreatitis. IH Mallick, MC Winslet. Journal of Pancreas (Online) 2004; 5(5): 328-337. 4. Prevalence and treatment of bleeding complications in chronic pancreatitis. H. Bergert, F. Dobrowolski, S. Caffier, et al. Langenbeck’s Archives of Surgery 2004; 389(6): 504-510. 5. Vascular complications of pancreatitis: role of interventional therapy. JU Barge, JE Lopera. Korean Journal of Radiology 2012; 13(1): 45-55. 6. Endovascular repair of iliac, visceral and false aneurysms. R Jackson, JDG Rose, In Vascular Interventional Radiology. Current Evidence in Endovascular Surgery. Ed MG Cowling. Springer. 7. Splenic Artery Embolization for the Treatment of Bleeding Gastric Varices Secondary to Splenic Vein Thrombosis PA Stone, D Phang, et al. Annals of Vascular Surgery 2014; 28(3): 737. e7-737. e11. 8. Management of Bleeding Gastric Varices in Patients with Sinistral Portal Hypertension. Quanda Liu, Yang Song, et al. Digestive Diseases and Sciences. February 2014.

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Special Session Biliary and pancreatic malignancies: treatment options 1704.1 Intrahepatic cholangiocarcinoma: interventional treatment G. Carrafiello, A.M. Ierardi, C. Floridi Department of Radiology, University of Insubria, Varese, Italy Learning Objectives 1. To understand indications for IR vs. surgical treatment 2. To learn which technique to use for which case 3. To understand the outcomes and complications Complete surgical resection remains the only potentially curative option for patients with intrahepatic cholangiocarcinoma (ICC)1. Unfortunately, curative resection is possible in only approximately 30% patients due to locally advanced disease, distant metastases, or comorbidity in elderly patients. Even after resection, the recurrence rate is approximately 60%, resulting in a low 5-year overall survival (OS)1,2. Patients with resectable hilar cholangiocarcinoma often present obstructive jaundice and a small future remnant liver (FRL) ratio. A sequential approach comprising preoperative biliary drainage followed by portal vein embolization (PVE) is usually performed in several centers3,4. In unresectable ICC, overall survival (OS) with systemic chemotherapy is 95% of them correspond to adenocarcinomas (other rare types are squamous cell carcinoma, undifferentiated carcinoma, papillary carcinoma etc). Hilar cholangiocarcinoma is, predominantly, a slow-growing tumor with longitudinal spreading along the bile ducts. This type of macroscopic appearance corresponds to periductal infiltrating type. Typical mass-forming lesion with rich fibrous stroma is more common on the periphery of liver. A modified Bismuth–Corlette classification is widely used for the description of tumours invading the hilum of liver. It is essential for the preoperative planning of surgical, multimodality treatments as well as sole palliative procedures. The key issue of all techniques (palliative and curative) is to achieve an accurate bile duct patency. Bile duct obstruction, if not adequately compensated, can result in intrahepatic cholestasis with significant reduction of the patient’s quality and length of life. Long-term survival (≥5 years) of patients with hilar cholangiocarcinoma depends primarily on surgical treatment. However, Bismuth type III tumours are resectable at the cost of hemihepatectomy or extended hemihepatectomy, and Bismuth type IV tumours are resectable only in selected cases and the peak incidence of cholangiocarcinoma in western countries between 60–70 years of age favours only a limited intervention of surgeons. The median survival of resected patients due to a more aggressive surgical approach and improved perioperative care increased from 16 to 30 months in the last 20 years as referred from Italian centres. R0 resection margins still mean only a possible chance of cure for cholangiocarcinoma with median survival up to 47 months with significant drop to 17 months in R1 resection margins. T stage, lymphatic node status and histopathological grade are the widely accepted independent factors of patient prognosis. Especially, histopathological grade as an independent factor of prognosis is frequently missing in descriptions of patient groups referred to multimodal palliative treatments.

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At present, a wide choice of palliative treatments of biliary obstruction is offered. In addition to palliative surgical procedures, there are many endoscopic therapeutic methods [e.g. nasobiliary drainage, implantation of plastic prostheses or self-expandable metallic stents (SEMS)] and percutaneous therapeutic methods such as percutaneous drainage (PTBD) and implantation of plastic endoprostheses or metallic stents. There are several competing techniques and interventions for the palliative treatment of hilar cholangiocarcinoma like chemotherapy (intravenous, intra-arterial, chemoradiation), biologic therapies, radiation therapies (external beam, intraluminal brachytherapy), photodynamic therapies and intraluminal radiofrequency ablation; they, with the exception of intravenous chemotherapy, cannot be considered as standard care. More often, they are so-called tailored oncologic therapies. The majority of patients are treated in clinical trials with protocols which vary considerably and the results of trials are often limited because of a small number of involved subjects with variable performance status. The median survival time of palliated patients varied greatly from 3 to 35 months. Randomised trials that compared surgical palliative bypass procedures and the endoscopic placement of plastic prostheses showed an equal clinical efficacy. Plastic prostheses placement is associated with a reduced risk of complications, although with a higher risk of recurrent biliary obstruction because of occlusion. Endoscopic route is often used for the implantation of SEMS; however, the relief of all obstructed biliary branches is more technically difficult because of the complexity of hilar tumours. Therefore, specific approaches of stent implantations or only a selective decompression of biliary tract has to be selected. Randomised studies with currently available 6-F SEMS, which allows parallel implantations in endoscopic way, are expected. When we compare the implantations of SEMS percutaneously and endoscopically with previous studies, the benefit of the percutaneous approach was more obvious. Newer studies confirm similar stent patency, complication rate and survival of patients but favour percutaneous approach in the technical success of drainage procedures. We emphasize the most on maintaining bile duct patency for reaching a long-term survival. Plastic prostheses or external/internal percutaneous catheters are preferred as a definitive treatment for patients with a prognosis of 6 months), they have to be repeatedly replaced due to lumen obstruction (3 times narrower than SEMS) and thus, compared with SEMS are cost ineffective. Based on our experience, there is also a higher tolerance and compliance of the patient when using a metal stent. Covered metal stents were historically disadvantaged because of potential migration and cost, while the benefit of improved stent patency was not clear. We do not recommend the use of covered metal stents in the palliation of hilar cholangiocarcinoma due to the occlusion of side branches. Improving the prognosis of patients with tumours of subhepatal space can be observed using modern means of chemotherapy, locoregional chemotherapy and methods of external radiotherapy. Because of prolonged survival of these patients, we see obstruction of a metal stent more frequently. The average stent patency in studies (7.5–9.5 months) varies widely and also depends on the technical execution and potential brachytherapy after insertion. The obstruction of metal stent may occur due to intimal hyperplasia; tumour ingrowth or stent can be obstructed by detritus. In a group of 58 patients, who were introduced to self-expandable stents at our centre in the reference period of 2004 to 2008, the obstruction of the stent was observed in 38% patients. The early stent obstruction during the 5 months of implantation occurred in 14% patients. The management of stent obstruction resulted in a significant increase in the number of nonvascular interventions for patients and also increased the cost of palliation of the disease. External beam radiotherapy and mainly intraluminal brachytherapy can extend stent patency and thereby, the quality and survival of patients. The advantage of brachytherapy with Ir-192 is the

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possibility of delivering higher doses of radiation in a short time without a significant irradiation of normal tissues. However, the radiation dose given by brachytherapy is limited to a maximum of 1 or 2 cm in depth. Between 1997 and 2000, we showed the benefit of brachytherapy in a prospective randomised study. In the group of patients treated with combined radiotherapy and stent implantation, the mean survival was 388 days. In the group of patients treated only with stent insertion, the mean survival was 298 days. In these cases, we used percutaneously implanted SEMS, intraluminal brachytherapy (Ir-192, total dose of 14 Gy) and external radiotherapy (total dose of 46 Gy). For a long time, systemic chemotherapy showed only limited benefits for patients with cholangiocarcinoma, only achieving a 30% response rate. The combination of systemic chemotherapy (gemcitabine) and regional chemoembolisation may enhance the effect of palliation in a selected group of patients with a median of overall survival as 21.1– 23 months (1-, 2- and 3-year survival rates 51.3%, 27.5% and 27.5%, respectively) . The potential benefit of regional chemotherapy with port system implanted percutaneously in intrahepatic cholangiocarcinoma was also reported by Tanaka et al. with a 26-month mean overall survival. Overall, intra-arterial therapies (chemoembolisation and chemoperfusion) offer a potential benefit and prolonged survival for patients with an unresectable cholangiocarcinoma. We prospectively evaluated the effect of intra-arterial chemotherapy on patients with SEMS implantation and radiotherapy. Hilar involvement with mass-forming and periductal infiltrating types of cholangiocellular carcinoma was predominant (84%). The median overall survival from disease diagnosis for all patients was 13.5 months. The median overall survival durations for patients with intra-arterial chemotherapy were 25.2 and 11.5 months for patients with systemic chemotherapy only. The 1-, 2- and 3-year survival rates were 88.2%, 52.9% and 10.1% and 43.5%, 25.4% and 0%, respectively. In addition, a remarkable minimal survival duration of 11 months was reached in a group of patients with a complex oncological therapy. Promising results have been shown in articles in Radiotherapy and Oncology. The median survival of patients with Klatskin-type tumours reached 34 months in novel retrospective studies of stereotactic fractionated radiotherapy. Studies with hypofractionated stereotactic body radiotherapy combined with chemotherapy (gemcitabine) in a very small group of patients reported a median time to progression of 30 months with a 2- and 4-year survival rate of 80% and 30%, respectively. The photodynamic therapy is limited to superficial tumour areas and is to be accompanied with additional interventions to the biliary system. The median survivals have varied between 12 and 16 months in several studies and have not clearly shown an advantage in a large group of patients. In conclusion, favourable prognosis for patients with unresectable hilar cholangiocarcinoma can be achieved using a complex tailored oncological therapy. Moreover, retrospective studies with stereotactic radiotherapy have shown very promising results and randomised studies of this are critically required. In future trials, it is necessary to consider not only on the diagnosis and localizations of cholangiocarcinoma but also the morphological characteristics (growth pattern, vascularisation) and grade of tumor, which can greatly influence the prognosis of patients as shown by the results from several studies of resectable diseases.

Abstract Book 4. Golfieri R, Giampalma E, Renzulli M, et al. Unresectable hilar cholangiocarcinoma: multimodality approach with percutaneous treatment associated with radiotherapy and chemotherapy. In Vivo 2006;20:757-760. 5. Eschelman DJ, Shapiro MJ, Bonn J, et al. Malignant biliary duct obstruction: long-term experience with Gianturco stents and combined-modality radiation therapy. Radiology 1996;200:717724. 6. Valek V, Kysela P, Kala Z, Kiss I, Tomasek J, Petera J. Brachytherapy and percutaneous stenting in the treatment of cholangiocarcinoma: a prospective randomised study. Eur J Radiol 2007;62:175-179. 7. Kubicka S, Rudolph KL, Tietze MK, Lorenz M, Manns M. Phase II study of systemic gemcitabine chemotherapy for advanced unresectable hepatobiliary carcinomas. Hepatogastroenterology 2001;48:783-789. 8. Kirchhoff T, Zender L, Merkesdal S, et al. Initial experience from a combination of systemic and regional chemotherapy in the treatment of patients with nonresectable cholangiocellular carcinoma in the liver. World J Gastroenterol 2005;11:1091-1095. 9. Burger I, Hong K, Schulick R, et al. Transcatheter arterial chemoembolization in unresectable cholangiocarcinoma: initial experience in a single institution. J Vasc Interv Radiol 2005;16:353-361. 10. Tanaka N, Yamakado K, Nakatsuka A, Fujii A, Matsumura K, Takeda K. Arterial chemoinfusion therapy through an implanted port system for patients with unresectable intrahepatic cholangiocarcinoma - initial experience. Eur J Radiol 2002;41:42-48. 11. Jarnagin WR, Fong Y, DeMatteo RP, et al. Staging, resectability, and outcome in 225 patients with hilar cholangiocarcinoma. Ann Surg 2001;234:507-517. 12. Chan SY, Poon RT, Ng KK, Liu CL, Chan RT, Fan ST. Long-term survival after intraluminal brachytherapy for inoperable hilar cholangiocarcinoma: a case report. World J Gastroenterol 2005;11:3161-3164. 13. Lee KH, Lee DY, Kim KW. Biliary intervention for cholangiocarcinoma. Abdom Imaging 2004;29:581-589. 14. Forsmo HM, Horn A, Viste A, Hoem D, Ovrebo K. Survival and an overview of decision-making in patients with cholangiocarcinoma. Hepatobiliary Pancreat Dis Int 2008;7:412-417. 15. Jarnagin WR, Bowne W, Klimstra DS, et al. Papillary phenotype confers improved survival after resection of hilar cholangiocarcinoma. Ann Surg 2005;241:703-712. 16. Ito F, Cho CS, Rikkers LF, Weber SM. Hilar cholangiocarcinoma: current management. Ann Surg 2009;250:210-218. 17. Huether A, Hopfner M, Baradari V, Schuppan D, Scherubl H. Sorafenib alone or as combination therapy for growth control of cholangiocarcinoma. Biochem Pharmacol 2007; 73:1308-1317. 18. Paik WH, Park YS, Hwang JH, et al. Palliative treatment with selfexpandable metallic stents in patients with advanced type III or IV hilar cholangiocarcinoma: a percutaneous versus endoscopic approach. Gastrointest Endosc 2009;69:55-62.

References 1. Seyama Y, Makuuchi M. Current surgical treatment for bile duct cancer. World J Gastroenterol 2007;13:1505-1515. 2. Chung YE, Kim MJ, Park YN, et al. Varying Appearances of Cholangiocarcinoma: Radiologic-Pathologic correlation. RadioGraphics 2009;29:683-700. 3. Kaassis M, Boyer J, Dumas R, et al. Plastic or metal stents for malignant stricture of the common bile duct? Results of a randomized prospective study. Gastrointest Endosc 2003;57:178-182.

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1704.4

Pancreatic tumours: irreversible electroporation

Pancreatic tumours: high intensity focused ultrasound

R.C.G. Martin1, D.S. Kwon2, M. Sellers3, K.T. Watkins4 1Surgery, Division of Surgical Oncology, University of Louisville, Louisville, KY, United States of America, 2Surgery, Division of Surgical Oncology, Henry Ford Hospital, Detroid, MI, United States of America, 3Piedmont Transplant Institute and Hepatobiliary Service at Piedmont Atlanta Hospital, Piedmont Atlanta Hospital, Atlanta, GA, United States of America, 4Department of Surgery, Stonybrook Hospital, Stony Brook, NY, United States of America

Z. Meng Pancreatic cancer MDT, Fudan University Shanghai Cancer Center, Shanghai, China

Learning Objectives 1. To learn the possible clinical application of irreversible electroporation in the pancreas 2. To learn how to perform a pancreatic electroporation 3. To learn about the results and complications of pancreatic electroporation Objectives: Irreversible electroporation is a non-thermal injury high voltage (3000 volts) short pulse (90 μs) energy delivery system that allows soft tissue ablation and a complete cell membrane destruction of tumors encasing vital structures (i.e., arteries, veins, and bile ducts). We have applied IRE in a multidisciplinary approach for patients with locally advanced (stage 3) pancreatic adenocarcinoma. Methods: A review of our prospective IRB-approved database on patients with stage 3 pancreatic cancer treated with IRE was performed from July 2010 to November 2013. Perioperative 90-day outcomes, local recurrence, and overall survival were evaluated. Results: A total of 120 patients with locally advanced pancreatic adenocarcinoma underwent IRE of the pancreatic head (76%) or body (24%). All patients had undergone induction therapy with 52% patients receiving chemoradiation therapy and 48% patients receiving chemotherapy for a median duration of 7 months (5–13) prior to IRE with a median operative duration of 150 min (range 45–740) and median IRE delivery duration of 30 min (range 10–170 min). A total of 19% patients sustained adverse events with a median grade of 2 (range 1–3), median length of stay of 6 days (range 4–58). After a median follow-up of 24 months, 4 patients (3%) had local recurrence with a median overall survival of 23.5 months. Conclusion: To our knowledge, this study represents the largest series in the surgical management and multidisciplinary care of patients with stage 3 pancreatic adenocarcinoma. We believe that we have demonstrated the safety, feasibility, and efficacy metrics including the low IRE recurrence rate. We believe that these early outcome metrics and overall survival begin to establish the minimal standards in establishing future comparative studies. References 1. Bower, M., et al., Irreversible electroporation of the pancreas: definitive local therapy without systemic effects. J Surg Oncol, 2011. 2. Cannon, R., et al., Safety and early efficacy of irreversible electroporation for hepatic tumors in proximity to vital structures. J Surg Oncol, 2012. 3. Dunki-Jacobs, E., Philips, P., Martin, R.C.G., Evaluation of Thermal Injury to Liver, Pancreas, and Kidney During Irreversible Electroporation in an In-vivo Porcine Model. Br J Surg, 2013. 4. Martin, R.C., Irreversible Electroporation of Locally Advanced Pancreatic Head Adenocarcinoma. J Gastrointest Surg, 2013. 5. Martin, R.C. 2nd, et al., Irreversible electroporation therapy in the management of locally advanced pancreatic adenocarcinoma. J Am Coll Surg, 2012. 6. Martin, R.C. 2nd, et al., Irreversible Electroporation in Locally Advanced Pancreatic Cancer: Potential Improved Overall Survival. Ann Surg Oncol, 2012. 7. Philips, P., Hays, D., Martin, R.C.G., Irreversible Electroporation Ablation (IRE) of Unresectable Soft Tissue Tumors: Learning Curve evaluation in the first 150 patients treated. PLoS One, 2013.

Learning Objectives 1. To understand the indications for HIFU of pancreatic cancer 2. To understand the technique, limitations and complications of focused ultrasound 3. To understand the results of focused ultrasound in pancreatic cancers and integration with other techniques Objective: To evaluate the efficacy and safety of high intensity focused ultrasound (HIFU) in the treatment of advanced pancreatic cancer. Methods: From November 2009 to December 2013, 539 patients (stage III, 180 cases; stage IV, 359 cases) with pancreatic cancer were treated with HIFU at our center. We analyzed the efficacy and safety by imaging examination, follow-up, symptom, and therapy-related side effect. Results: In all, 21.3% (115/539) serum Ca19-9 decrease was observed. Cancer pain was relieved in 74.7% (403/539) patients. Coagulative necrosis by CT/MRI examination was observed. PR, SD, and PD of all were 13.8%, 59.5%, and 26.7%, respectively. The 1-year survival rate and median survival time were 35% and 9 months for the stage III group and 15.4% and 7 months for the stage IV group, respectively. In 7.1% patients, serum amylase level increased after treatment. Gastrointestinal (GI) dysfunction such as abdominal distension and anorexia with slight nausea was observed in 25 cases. Vertebral injury, identified by MRI, occurred in 2 cases, although no symptoms were seen. No severe complications such as skin burns, lesion bleeding, GI tract bleeding, or GI perforation were observed in any of the cases. Conclusions: HIFU may benefit advanced pancreatic cancer patient by stabilizing tumors, relieving pain, and prolonging life expectancy with less side effects.

Special Session Treatment options for fibroids 1705.1 Non-IR treatment options: surgical and medical I. Manyonda Department of Gynaecology, St George’s Hospital, London, United Kingdom Learning Objectives 1. To learn which surgical and medical therapies are available 2. To learn which patients are suitable for medical and surgical therapies 3. To learn the outcomes of medical and surgical therapies No abstract available.

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1705.2 UAE: evidence J.-P. Pelage Department of Radiology, University Hospital and Medical Center, Caen, France Learning Objectives 1. To learn the scientific evidence for UAE compared with other therapies 2. To understand the evidence for various embolics 3. To become familiar with the evidence regarding optimising outcomes No abstract available.

1705.3 UAE: pain and complication management V. Bérczi Department of Radiology and Oncotherapy, Semmelweis University, Budapest, Hungary Learning Objectives 1. To learn about the cause and timing of pain 2. To learn about different regimes for pain management 3. To learn about complications of UAE, how to avoid and manage them Uterine artery embolisation (UAE) for symptomatic fibroids may cause significant postprocedural pain. This can be regarded as the primary adverse effect of the therapy. Its magnitude varies in a wide range from very mild to extremely severe. Treating this pain, especially during the first 12 h, is essential; however, it can be challenging. The specific cause of the pain is not fully understood; fibroid ischaemia and transient uterine ischaemia are the most likely factors for the immediate postprocedural pain. In a study of 62 women, uterine ischaemia was assessed using T1-weighted gradient echo MR imaging before and 24 h after UAE. In-hospital postprocedural pain was evaluated by a verbal rating scale (1–3: mild, 4–6: moderate and 7–10: severe); the mean maximal pain was 7.7. Moderate or severe myometrial ischaemia, the percentage and volume of ischaemic tissue in the myometrium and a large volume of embolic material correlated with severe pain; thus, postprocedural pain can be, at least partly, explained by myometrial ischaemia (1). The Ontario Uterine Fibroid Embolization Trial reported that 30% of patients had intraprocedural pain, while 92% of patients experienced postprocedural pain (mean pain rating ± SD, 7.0 ± 2.5). The mean hospital length of stay was 1.3 nights; postprocedural pain was the most common indication for a length of hospital stay more than 1 night (18%) or 2 nights (5%). Revisit to the hospital (10%) and readmissions (3%) were primarily due to pain. Mean recovery time after UAE was 13.1 days (median, 10.0 days) (2). Various analgesic techniques are used for uterine fibroid embolisation (UFE): epidural anesthesia, opiates (morphine patient-controlled analgesia, PCA), paracetamol, nonsteroidal anti-inflammatory drugs or a combination of these. Morphine PCA was more effective in reducing post-UAE pain than fentanyl PCA in a prospective, nonrandomised study of 200 consecutive women having UFE. Pain perception levels were obtained on a 0–10 scale for the 24-h period after UFE. One hundred and eighty-five patients (92.5%) reported greater than baseline pain after UFE, and 198 patients (99%) required IV opioid PCA. One hundred and thirty-six patients (68.0%) developed nausea during the 24-h period (3). A recent study proved that EDA would provide superior analgesia for post-UAE pain at 6 and 24 h but with higher costs and an increased risk of complications (4). A randomised prospective study was performed in 80 patients; 40 patients received PVA particles mixed with ketoprofen, and 40

Abstract Book received bland PVA particles. Fifty-three patients who were asymptomatic 8 h after embolization were discharged. The level of pain was assessed using a numeric pain score scale. In addition, 8 h after UAE, 13 of the 40 patients in the group without ketoprofen (32%) reported severe or very severe pain, whereas none of the patients in the group receiving ketoprofen reported a similar pain. Nineteen of the 40 patients without ketoprofen (48%) were treated as inpatients, but only 10 of the ketoprofen group (25%) were treated as inpatients. The use of PVA particles mixed with ketoprofen resulted in a statistically significant reduction in pelvic pain during the first 8 h after UAE as compared with the use of PVA alone. However, no significant differences in pain scores were seen after 8 h (5). The EMMY trial results showed that UAE patients experienced significantly less pain during the first 24 h after treatment than hysterectomy patients. The pain score was significantly higher in non-white patients. The same trial showed that UAE patients returned significantly sooner to daily activities than hysterectomy patients (28.1 versus 63.4 days; p < 0.001) (6). UAE is an increasingly popular treatment for patients having symptomatic uterine fibroids. It is generally a safe and effective procedure with less risks and complications than surgery (hysterectomy or myomectomy). However, knowledge of all possible complications, their prevention and management is essential for all interventional radiologists performing UAE. The list of absolute contraindications for UAE is relatively short (pregnancy, known or suspected gynecologic malignancy and current uterine or adnexal infection). A recent literature review and meta-analysis aimed to analyse the spectrum of complications associated with UAE relative to surgery and compare the risk of reintervention as well as minor, major and overall complications. UAE had a significantly lower rate of major complications relative to surgery, but it comes at the cost of increased risk of reintervention in the future (7). The rates of complications from 76 nonrandomised studies (n = 11,195) were amenorrhea (4.2%), pain (3.6%), discharge and fever (3.4%), fibroid expulsion (1.5%), hot flushes (1.4 %), uterine infection/infection (1.4%), shoughing (1.1%) and repeat UAE (0.5%). The remaining complications include intrauterine necrosis, failure due to unilateral UAE, groin complications, dysmenorrhea, abdominal swelling, failure despite bilateral UAE, headache, pelvic infection and urinary bladder symptoms; all of these were below 0.5% (7). Anatomical variations should be considered always, e.g. a case report showed that an ovarian artery originated from the external iliac artery (8). The size of fibroids (diameter of >10 cm) are not considered as a significant risk according to a recent study (9). Few deaths were reported over the last 19 years, most of them were due to sepsis or pulmonary emboli. The mid-term results of a radiological and surgical approach to uterine fibroids were compared in 121 women with reproductive plans who presented with intramural fibroid(s) larger than 4 cm. The patients were randomly selected for either UAE or myomectomy. The efficacy and safety of the two procedures were compared. UAE was less invasive and as symptomatically effective and safe as myomectomy, but myomectomy appeared to have superior reproductive outcomes in the first 2 years after treatment (10). Magnetic resonance-guided high intensity focused ultrasound (MRgHIFU) are also used to treat symptomatic uterine fibroids in increasing numbers. In a recent study, the rate of reintervention was significantly lower after UAE than that after MRgHIFU. The total quality of life questionnaire score improvement was significantly higher after UAE than that after MRgHIFU (11). All interventional radiologists and gynecologists should be aware of the effectiveness and safety of all alternatives of fibroid treatments and should inform the patients accordingly. References 1. Ruuskanen A, Sipola P, Hippeläinen M, Wüstefeld M, Manninen H. Pain after uterine fibroid embolisation is associated with the severity of myometrial ischaemia on magnetic resonance imaging. Eur Radiol. 2009;19:2977-2985.

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2. Pron G, Mocarski E, Bennett J, Vilos G, Common A, Zaidi M, Sniderman K, Asch M, Kozak R, Simons M, Tran C, Kachura J; Ontario UFE Collaborative Group. Tolerance, hospital stay, and recovery after uterine artery embolization for fibroids: the Ontario Uterine Fibroid Embolization Trial. J Vasc Interv Radiol. 2003;14:1243-1250. 3. Kim HS, Czuczman GJ, Nicholson WK, Pham LD, Richman JM. Pain levels within 24 hours after UFE: a comparison of morphine and fentanyl patient-controlled analgesia. Cardiovasc Intervent Radiol. 2008;31:1100-1107. 4. van der Kooij SM, Moolenaar LM, Ankum WM, Reekers JA, Mol BMJ, Hehenkamp WJK. Epidural Analgesia Versus PatientControlled Analgesia for Pain Relief in Uterine Artery Embolization for Uterine Fibroids: A Decision Analysis. Cardiovasc Intervent Radiol. 2013,36:1514-1520. 5. Pisco JM1, Bilhim T, Duarte M, Ferreira A, Santos D, Pires FM, Oliveira AG. Pelvic pain after uterine artery embolization: a prospective randomized study of polyvinyl alcohol particles mixed with ketoprofen versus bland polyvinyl alcohol particles. J Vasc Interv Radiol. 2008;19:1537-1542. 6. Hehenkamp WJ1, Volkers NA, Birnie E, Reekers JA, Ankum WM. Pain and return to daily activities after uterine artery embolization and hysterectomy in the treatment of symptomatic uterine fibroids: results from the randomized EMMY trial. Cardiovasc Intervent Radiol. 2006;29:179-187. 7. Martin J1, Bhanot K, Athreya S. Complications and reinterventions in uterine artery embolization for symptomatic uterine fibroids: A literature review and meta analysis. Cardiovasc Intervent Radiol. 2013;36:395-402. 8. Kwon JH1, Kim MD, Lee KH, Lee M, Lee MS, Won JY, Park SI, Lee do Y. Aberrant ovarian collateral originating from external iliac artery during uterine artery embolization. Cardiovasc Intervent Radiol. 2013;36:269-271. 9. Parthipun AA, Taylor J, Manyonda I, Belli AM. Does size really matter? Analysis of the effect of large fibroids and uterine volumes on complication rates of uterine artery embolisation. Cardiovasc Intervent Radiol. 2010;33:955-959. 10. Mara M, Maskova J, Fucikova Z, Kuzel D, Belsan T, Sosna O. Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovasc Intervent Radiol. 2008;31:73-85. 11. Froeling V1, Meckelburg K, Scheurig-Muenkler C, Schreiter NF, Kamp J, Maurer MH, Beck A, Hamm B, Kroencke TJ. Midterm results after uterine artery embolization versus MR-guided highintensity focused ultrasound treatment for symptomatic uterine fibroids. Cardiovasc Intervent Radiol. 2013;36:1508-1513.

1705.4 High intensity focused ultrasound M. Matzko Abt. Radiologie, Klinikum Dachau, Dachau, Germany Learning Objectives 1. To learn about the indications for HIFU 2. To learn how to perform HIFU 3. To learn about the outcomes of HIFU No abstract available.

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Fundamental Course Basic principles of femoro-popliteal disease treatment 1801.1 Treatment triage: which patients are suitable candidates? J.-P. Beregi Service de radiologie et imagerie médicale, CHU Carémeau, Nîmes, France Learning Objectives 1. To learn how to select patients for femoro-popliteal intervention and know the TASC classification 2. To learn which patients are suitable for endovascular intervention 3. To learn the results of femoro-popliteal interventions Patients suitable for endovascular techniques were at the beginning of the interventional radiology all patients who were contraindicated to surgery. This simple definition became more complex due to the knowledge of interventional radiologists in pathology and the availability of new techniques and improvements in their results. 1. Clinical demand First, interventional radiologists learned that they should not treat images but patients. This first basic principle should always be considered. The clinical status of the patients, based on Leriche and Fontaine or Rutherford classification, should be the first step of our approach. 2. General status Second, the presence of additional disease should be known. If the risk of death or the benefit for the patient is minimal, intervention should be cancelled. Usually, there is no emergency to treat isolated SFA lesions. When an SFA lesion is discovered and managed, we have to look for the other possible lesions located in carotids, coronaries, aorta, and visceral arteries. 3. Vascular Anatomy and TASC classification The anatomy of the lesion is the third step which is important for an endovascular decision. TASC recommendation will be detailed. Results of endovascular techniques should be known. 4. Specific cases If most lesions are due to atheroma, other diseases can occur. Thrombosis of SFA can be due to an embolic process. In conclusion, before considering endovascular treatment for SFA lesions, a consultation with the patient is recommended to evaluate: • Indication/clinical status • General status • Anatomy of the lesion to evaluate the technique with vascular approach and materials • Specific cases to decide the approach • Contraindication such as infections, a risk of haemostatic problems (which treatment, cancer etc.) • To inform the patients about the technique, complications and success with expected patency at a duration of 1–5 years. • To obtain their approval • To establish a professional relationship The consultation is a specific moment where you have to inform the patient about the benefit/risk of the intervention, to appear as a physician and not a technician. You are responsible for the intervention and not the people who ask you to do it. References 1. Management of peripheral arterial disease patients: comparing the ACC/AHA and TASC-II guidelines. Curr Med Res Opin. 2008 Sep 24;9:2509-522. 2. ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report. Circulation. 2006 Mar 21;113(11):e463-654.

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1801.2

1801.3

Technique – treating TASC A-D lesions

Role of drug-eluting stents/balloons in the SFA and popliteal artery

S. Müller-Hülsbeck Radiology and Neuroradiology, Diako Flensburg, Flensburg, Germany

T. Rand Dept. of Radiology, KH Hietzing, Vienna, Austria

Learning Objectives 1. To learn different recanalisation techniques required in femoropopliteal disease from TASC A-D 2. To learn when stenting is indicated 3. To learn the possible complications and how to deal with them An endovascular procedure (in a suitable patient) for femoropopliteal disease treatment, based on interdisciplinary consensus, comprises 4 elementary keystones: (I) lesion access, (II) lesion crossing, (III) lesion treatment, and (IV) lesion follow-up. The talk will focus on lesion access and lesion crossing principles for endovascular specialists. Moreover, basic strategies for lesion treatment will be covered. When evaluating lesion access principles, different potential access routes beside the common femoral artery (CFA) must be considered. However, a standard access via CFA in an antegrade or retrograde manner is most common, followed by transpedal (infragenual) and brachial access. The latter ones are especially warranted when CFA access can be problematic due to lesion location or impossible/failed lesion access. Once a secure and safe lesion access is obtained in an antegrade or retrograde manner, lesion crossing can be initiated. Lesion crossing for both, short-distance and long-ranging stenoses/ occlusions may be somewhat challenging. Strategies and algorithms for successful crossing will be presented. The must-haves in terms of basic device technology will be presented including different wire and catheter technology as well as re-entry technologies. Once a lesion is successfully treated, plain old balloon angioplasty (POBA) will definitely be an established treatment step. It is still under discussion whether one should stay with POBA (when a good result is obtained) or should go ahead with drug-eluting technology (balloon or stents) or bare metal stents. References 1. Marques L, Preiss M, Preuss H, Hopf-Jensen S, Mueller-Huelsbeck S. Treating with an implant: BMS or DES? J Cardiovasc Surg (Torino). 2013 Aug;54(4):455-67. 2. Lammer J, Zeller T, Hausegger KA, Schaefer PJ, Gschwendtner M, Mueller-Huelsbeck S, Rand T, Funovics M, Wolf F, Rastan A, Gschwandtner M, Puchner S, Ristl R, Schoder M. Heparin-bonded covered stents versus bare-metal stents for complex femoropopliteal artery lesions: the randomized VIASTAR trial (Viabahn endoprosthesis with PROPATEN bioactive surface [VIA] versus bare nitinol stent in the treatment of long lesions in superficial femoral artery occlusive disease). J Am Coll Cardiol. 2013 Oct 8;62(15):1320-7. 3. Rastan A, Krankenberg H, Baumgartner I, Blessing E, MüllerHülsbeck S, Pilger E, Scheinert D, Lammer J, Gißler M, Noory E, Neumann FJ, Zeller T. Stent placement versus balloon angioplasty for the treatment of obstructive lesions of the popliteal artery: a prospective, multicenter, randomized trial. Circulation. 2013 Jun 25;127(25):2535-41.

Learning Objectives 1. To learn the rationale for drug-eluting balloons and their mechanism of action 2. To learn the rationale for drug-eluting stents and their mechanism of action 3. To learn the results of trials using these therapies and compare these with non-drug-eluting technologies The development of drug-eluting stents (DES) was mainly driven by the intention to overcome the major limitations of bare metal stents, such as neointimal hyperplasia and in-stent restenosis. The idea was that antiproliferative drugs, such as paxlitaxel and sirolimus, could be released from the stent struts and inhibit hyperplasia. Zilver PTX study includes more than 1000 patients, and was based technically on the use of paclitaxel adsorption to the stent struts. Primary patency rate after 12 months was 85% and TLR 15%. Moreover, the register allowed further analysis of the treatment of TASC C and D lesions, with lesion lengths up to 27 cm. Even in this subgroup, primary patency after 1 year was still 85% and 15% underwent TLR. Fracture rate of stents was 2.1%. In the meantime, even the 2-year results of the randomized study show very convincing results. Drug-coated balloons (DCB) represent another innovative development for the treatment of femoropopliteal lesions. The idea is to combine the positive effects of drugs, which is to inhibit neointimal proliferation on the one hand and to avoid the negative effects of foreign material implantation on the other. Generally, DCB use paclitaxel as a mediator; however, they differ from each other by the socalled “spacer substance.” Thunder, Levant I, and Pacifier were pilot trials that showed safety and also indicated efficacy. Subgroup analysis from the Levant I trial indicated that the chronic foreign material effect of Nitinol stents might be reduced by a shortterm application of paclitaxel. It appears, as described by Tepe et al, that even dissections and restenoses need not be treated with stents, and results could be improved with the use of DEB alone. New strategies may also arise with the use of DEB, namely from “whole lesion coverage” to “spot stenting”. Nevertheless, there is still no data regarding the comparison of DEB with stents or DEB. Therefore, the decision regarding which therapy option might be the best in individual patients treatment must still be taken by the interventionalist. References 1. Effectiveness of Zilver PTX eluting stent in TASC C/D lesions. Leopardi et al. J Cardiovasc Surg (Torino). 2014;55(2):229. 2. Zilver PTX Investigators. 2-year follow-up. Dake MD, et al. J Am Coll Cardiol. 2013;61(24):2417-27. 3. The LEVANT I trial. Scheinert D et al. JACC Cardiovasc Interv. 2014;7(1):10-9. 4. THUNDER study. Tepe G et al. J Endovasc Ther. 2013; 20(6):792.

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1802.2

Patient follow-up and indications for re-intervention

Endothermal treatment of varicose veins

J. Lammer Department of Cardiovascular and Interventional Radiology, University Hospital Vienna, Vienna, Austria

L. Oguzkurt Radiology, Baskent University, Adana Teaching and Medical Research Center, Adana, Turkey

Learning Objectives 1. To learn how to follow up with patients post-intervention 2. To learn the imaging criteria for re-intervention 3. To learn the clinical criteria for re-intervention and which interventions should be offered in recurrent disease

Learning Objectives 1. To learn about the different thermal techniques 2. To learn about outcome differences 3. To learn about post-interventional care Varicose veins secondary to superficial venous insufficiency is a common medical condition affecting up to 25% of women and 20% of men. Reflux of the great saphenous vein (GSV) is the most common cause of this condition. Clinical symptoms and signs of varicose disease include leg pain, swelling, fatigue, burning sensation, skin discoloration, and ulceration. Endovenous thermal ablation methods such as laser, radiofrequency, or steam ablation are minimally invasive procedures that safely and effectively treat reflux involving GSV and small saphenous vein. These methods have been developed to reduce complications associated with conventional surgery and to improve the quality of life. All these methods use target temperatures for successful ablation. Temperature increase during laser ablation is fast with a high-peak temperature for a short time, whereas steam ablation and radiofrequency ablation have longer plateau phases and lower maximum temperatures. Endovenous thermal ablation methods offer comparable venous occlusion rates after the treatment of primary GSV varices with none of the modalities proving superior. However, steam ablation is a newer technique than laser or radiofrequency ablation, and we need more data on large populations. Tumescent anesthesia with or without an anesthetic solution is always applied before any thermal ablation and is a very important step to protect the tissues surrounding the ablated vein and to reduce pain during and after the ablation procedure. Successful occlusion rates ranging from 88% to 100% have been reported for all 3 ablation modalities. CEAP clinical classes and clinical severity and overall quality of life scores improve in all patients compared with those at baseline. Thermal ablation treatment for varicose vein causes minor complications such as pain, bruising, redness, and swelling in majority of patients for a variable time ranging from 2 days to 3 weeks. All these symptoms subside spontaneously. The incidence of venous thromboembolism, permanent nerve damage, or pulmonary embolism related to laser ablation is very low as reported in randomized controlled trials and case series investigating these modalities. Currently available clinical trial evidence suggests that thermal ablation methods are at least as effective as surgery in the treatment of varicose veins secondary to saphenous vein insufficiency.

No abstract available.

Special Session Venous forum 1802.1 Pelvic congestion syndrome A. Basile Interventional Radiology, Ospedale Garibaldi Centro, Catania, Italy Learning Objectives 1. To learn which vein(s) to treat 2. To learn what material to use for embolisation 3. To learn how to convey realistic expectations to the patient Pelvic congestion syndrome (PCS) is a frequently underestimated cause of chronic pelvic pain often found in women without other pathological causes of pelvic pain. Symptoms are varied and can be acute and severe or chronic and dull; classically, dyspareunia or menstrual disorder is observed more often in multigravidae. Imaging techniques may be capable of demonstrating only severe venous engorgement in the pelvis, so correlation with clinical history and physical examination lead to correct diagnosis with high sensitivity (94%) and specificity (77%), especially when other significant gynecological or pelvic pathologies are excluded. Therefore, gonadal venography through femoral or jugular access still remains the definitive imaging modality to diagnose patients with PCS. If reflux is present, selective catheterization and embolization can be performed. Interventional radiological embolization is curative in up to 83% cases. Sclerosing agents alone or in combination with coils or plugs are commonly used. Different interventional techniques have been reported; however, the most accepted one consists of bilateral ovarian vein embolization if the right ovarian vein is refluxing. If symptoms persist for a period of 3–6 months, it should be followed by the embolization of internal iliac veins, which is suggested to be performed without coils and only with sclerosing agents. Recent studies with a large cohort of patients have assessed the role of ovarian vein embolization and have reported a high value of technical and clinical success rate with ovarian vein distal embolization with either sclerosing agents or coils.

References 1. Nordon IM, Hinchliffe RJ, Brar R, Moxey P, Black SA, Thompson MM, Loftus IM. A prospective double-blind randomized controlled trial of radiofrequency versus laser treatment of the great saphenous vein in patients with varicose veins. Ann Surg. 2011;254:876-81. 2. Milleret R, Huot L, Nicolini P, Creton D, Roux AS, Decullier E, Chapuis FR, Camelot G. Great saphenous vein ablation with steam injection: results of a multicentre study. Eur J Vasc Endovasc Surg. 2013;45:391-6. 3. Murad MH, Coto-Yglesias F, Zumaeta-Garcia M, Elamin MB, Duggirala MK. A systematic review and meta-analysis of the treatments of varicose veins. J Vasc Surg. 2011;53:49S-65S. 4. Nesbitt C, Eifell RK, Coyne P, Badri H, Bhattacharya V, Stansby G. Endovenous ablation (radiofrequency and laser) and foam sclerotherapy versus conventional surgery for great saphenous vein varices. Cochrane Database Syst Rev. 2011.

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5. Dermody M, Schul MW, O’Donnell TF. Thromboembolic complications of endovenous thermal ablation and foam sclerotherapy in the treatment of great saphenous vein insufficiency. Phlebology. 2014. [Epub ahead of print]

1802.3 Non-endothermal treatment of varicose veins M. Åkesson Department of Clinical Sciences, Lund University, MedVASC AB, Malmo, Sweden Learning Objectives 1. To learn about the different non-thermal techniques 2. To learn about outcome differences 3. To learn about post-interventional care Introduction The management of superficial venous incompetence has over the last decade changed dramatically from classic surgery to more minimal invasive techniques. The patients have gained enormously from this change in techniques especially in post-operative care and postoperative pain. The healthcare systems have found techniques that are much less resource demanding, making it easier to treat the large number of patients suffering from superficial venous incompetence. New national guidelines such as the NICE guidelines for varicose veins in the legs have been developed in the UK, recommending endovenous techniques as the first-line treatment of varicose veins. The development of endothermal techniques have been successful, but they all require some type of anaesthesia, general or more commonly local, with the use of tumescents. This is normally well tolerated by most patients, but some find the distribution of tumescents quite painful. Due to this, alternative methods to endothermal techniques have been developed. These techniques can normally be carried out as an office-based procedure without any form of anaesthesia. Non-endothermal techniques use either some chemical reaction for ablation such as ultrasound-guided foam sclerotherapy (UGFS) or combining this technique with a mechanical device to damage the endothelium (mechanochemical ablation, MOCA). The latest contribution to non-endothermal techniques is a chemical adhesive method using catheter-delivered cyanoacrylate for truncal occlusion (VenaSeal™ Closure System; Sapheon Inc., NC, USA). Cyanoacrylate vein occlusion (VenaSeal™) The technique is built to eliminate the need for tumescent anaesthesia and post-operative compression used with thermal ablation techniques. Using a hydrophobic delivery catheter to deliver the cyanoacrylate adhesive (SCA) developed by Sapheon Inc., one will gain permanent closure of incompetent superficial truncal varicose veins. A previous study shows that the technique is feasible and safe and has a technical success rate of 97% primary closure of the great saphenous vein (GSV), and the 1-year occlusion rate is 92%. No major adverse events such as DVT or PE were noted. At 30-day follow-up, 6 patients (16%) had thrombophlebitis. The short-term closure rates are well comparable with thermal ablation methods, but longerterm results are still unavailable. Ultrasound-guided foam sclerotherapy The first to describe the technique to mix a sclerosant with air or carbon dioxide to produce a foam was Tessari. Using ultrasound as guidance, one can inject small volumes directly into superficial varicose veins. The technique can also be used for both primary and recurrent venous incompetence for ablation of GSV or small saphenous vein or their main branches. The largest meta-analysis comparing surgery with EVLA, RFA and UGFS examined 64 eligible studies, which included over 1200 limbs, using Doppler ultrasound findings. The average follow-up was 32 months and estimated pooled success rates at 3 years were highest for EVLA, with 94% closure, followed by

Abstract Book RFA (84%), surgery (78%) and UGFS (77%). Adverse events and complications include thrombophlebitis and skin staining, which could be expected in 15% of the cases, but transient visual symptoms have also been reported and are estimated to occur with an incidence of 0.5–1%. They may be reduced by using carbon dioxide instead of air for the mixture of foam. Mechanochemical ablation (MOCA) To overcome the infirmity of both endothermal ablation techniques and UGFS, Clarivein™ (Vascular Insights LLC, CT, USA) has been introduced. Clarivein™ is a mechanochemical device for truncal vein ablation and can be used without tumescent anaesthesia. Using mechanical abrasion and chemical abrasion simultaneously via injection of a sclerosant through a rotating wire, Clarivein™ is intended to overcome the low efficacy rates of truncal vein occlusion for UGFS. The first published results reported a closure rate at 6 months of 96%, and this rate was maintained at the subsequent 2-year followup. A comparison between Clarivein™ and RFA revealed significantly less pain with Clarivein™ in the first 14 days after the procedure. Mechanical problems and inability for the device to work in largediameter veins (>15 mm) and in recanalized recurrent truncal veins have been reported. References 1. McBride K. Changing to endovenous treatment for varicose veins: how much more evidence is needed? Surgeon 2011; 9: 150-159. 2. National Institute for Health and Clinical Excellence. Varicose veins in the legs (CG 168). See http://guidance.nice.org.uk/CG168. 3. Lawson J, Gauw S, van Vlijmen C, Pronk P, Gaastra M, Mooij M, Wittens CHA. Sapheon: the solution? Phlebology 2013; 28 (Suppl. 1): 2-9. 4. Almeida JI, Javier JJ, Mackay EG, Bautista C, Proebstle T. Cyanoacrylate glue great saphenous vein ablation: preliminary 180-day follow-up of a first-in-man feasibility study of a no-compression-no-local-anesthesia technique. J Vasc Surg 2012; 55: 297. 5. Tessari L, Cavezzi A, Frullini A. Preliminary experience with a new sclerosing foam in the treatment of varicose veins. Dermatol Surg 2001; 27: 58-60. 6. van den Bos R, Arends L, Kockaert M, Neumann M, Nijlsen T. Endovenous therapies of lower extremity varicosities: a metaanalysis. J Vasc Surg 2009; 49: 230-239. 7. Jia X, Mowatt G, Burr JM, Cassar K, Cook J, Frase C. Systematic review of foam sclerotherapy for varicose veins. Br J Surg 2007; 94: 925-936. 8. Elias S, Lam YL, Wittens CHA. Mechanochemical ablation: status and results. Phlebology 2013; 28 (Suppl. 1): 10-14. 9. van Eekeren RRJP, Boersma D, Konijn V, de Vries J-PPM, Reijnen MMJP. Post-operative pain and early quality of life after radiofrequency ablation and mechanochemical endovenous ablation of incompetent great saphenous veins. J Vasc Surg 2013; 57: 445-450.

1802.4 Management of central venous obstruction P. Haage Dept of Diagnostic and Interventional Radiology, Helios Klinikum Wuppertal, University Hospital Witten/Herdecke, Wuppertal, Germany Learning Objectives 1. To learn how to plan central vein recanalisation (imaging) 2. To learn about the different stent designs 3. To learn how to avoid complications One of the most common causes for benign central venous obstruction is haemodialysis related. The incidence of vascular access related to central venous obstruction, resulting in angioplasty is

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described to be >10-fold that of, for example, pacemaker-induced stenosis. Adequate venous outflow is important for proper functioning of haemodialysis access in end-stage renal disease patients and is considered the Achilles’ heel of vascular access. Obstruction of the upper central veins can lead to central venous hypertension, which may be the cause of shunt malfunction or even access loss. Such complications occur in 11–50% of haemodialysis patients. The most significant clinical symptom of central venous stenosis is swelling of the access arm; pain and paresthesia may result. Central venous obstructions have to be treated when they are severe and disabling such as impairing upper extremity swelling, wearisome pain or if they lead to inadequate haemodialysis. There is no conclusive evidence for pre-emptive treatment of asymptomatic central vein stenosis. Percutaneous intervention by PTA with or without stent deployment has been advocated to prolong vascular access patencies for more than 2 decades. It is now a common understanding that angioplasty should be applied as the primary treatment modality in central veins. Stent deployment is necessary in primary PTA failures such as elastic recoil or insufficient PTA. With respect to a conservative attitude, stent placement should also be considered in cases of early (3–6 months) reobstruction. The primary placement of a stent for central stenosis to prevent restenosis is not recommended anymore in view of the published results for primary or secondary stenting compared with primary PTA. Although stent-graft placement to treat central venous obstruction is safe and effective in case of PTA failure, its superior long-term patency rates is yet to be proven. Restenosis seems to be a steadily progressing process without apparent regression and is frequently observed. It is more likely to occur after thrombosis has occurred for the first time. The interventionalist must be sometimes prepared for multiple angioplastic reinterventions after the initial procedure. For that, early regular follow-ups and treatment of complications are compulsory to enable a functioning vascular dialysis access over an extended period. References 1. Agarwal AK, Patel BM, Haddad NJ. Central vein stenosis: a nephrologist’s perspective. Semin Dial 2007; 20: 53-62. 2. Altman SD. A practical approach for diagnosis and treatment of central venous stenosis and occlusion. Semin Vasc Surg 2007; 20: 189-94. 3. Anaya-Ayala JE, Smolock CJ, Colvard BD et al. Efficacy of covered stent placement for central venous occlusive disease in hemodialysis patients. J Vasc Surg 2011; 54: 754-9. 4. Bornak A, Wicky S, Ris HB et al. Endovascular treatment of stenoses in the superior vena cava syndrome caused by non-tumoral lesions. Eur Radiol 2003; 13: 950-6. 5. Haage P, Günther RW. Radiological intervention to maintain vascular access. Eur J Vasc Endovasc Surg 2006; 32: 84-9. 6. MacRae JM, Ahmed A, Johnson N et al. Central vein stenosis: a common problem in patients on hemodialysis. ASAIO J 2005; 51: 77-81. 7. Mansour M, Kamper L, Altenburg A et al. Radiological central vein treatment in vascular access. J Vasc Access 2008; 9: 85-101. 8. Mickley V. Central vein obstruction in vascular access. Eur J Vasc Endovasc Surg 2006; 32: 439-44. 9. National Kidney Foundation. K/DOQI clinical practice guidelines and clinical practice recommendations for 2006 updates: hemodialysis adequacy, peritoneal dialysis adequacy, aascular access. Am J Kidney Dis 2006; 48(suppl 1): 1-322. 10. Renaud CJ, Francois M, Nony A et al. Comparative outcomes of treated symptomatic versus non-treated asymptomatic highgrade central vein stenoses in the outflow of predominantly dialysis fistulas. Nephrol Dial Transplant 2012; 27: 1631-8.

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11. Shi YX, Ye M, Liang W et al. Endovascular treatment of central venous stenosis and obstruction in hemodialysis patients. Chin Med J (Engl) 2013; 126: 426-30. 12. Thalhammer C, Pfammatter T, Segerer S. Vascular accesses for hemodialysis - an update. Vasa 2013; 42: 252-63. 13. Tordoir J, Canaud B, Haage P et al. EBPG on vascular access. Nephrol Dial Transplant 2007; 22: 88-117.

Special Session Controversies in liver tumour ablation 1804.1 Will radiofrequency ablation replace surgery for small liver metastases? A. Gillams Imaging Dept, The London Clinic, London, United Kingdom Learning Objectives 1. To learn about results of ablation and resection in the treatment of small colorectal liver metastases 2. To learn about limitations of ablation and resection in the treatment of small colorectal liver metastases 3. To learn how to combine resection, ablation and systemic chemotherapy in patients with colorectal cancer liver metastases Results of resection and ablation Both surgical resection and ablation can result in long-term survival; 10–20% of selected patients can survive up to 10 years. Solbiati recently reported a 5-year survival of 48%, 7-year survival of 25% and 10-year survival of 18% in 99 patients with 80% in patients with solitary

Abstracts of CIRSE (Cardiovascular and Interventional Radiological Society of Europe) 2014. September 13-17, 2014. Glasgow, UK.

Abstracts of CIRSE (Cardiovascular and Interventional Radiological Society of Europe) 2014. September 13-17, 2014. Glasgow, UK. - PDF Download Free
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