Cardiovasc Intervent Radiol (2015) 38:S13–S34 DOI 10.1007/s00270-015-1059-6
ABSTRACTS - SCIENTIFIC SESSION 1 WEDNESDAY 12 NOVEMBER-AORTIC INTERVENTION CHAIRS: DR DOUG TURNER & DR ALEX CHAPMAN MAIN AUDITORIUM
1. EXPLORING PATIENT COMPLIANCE WITH SURVEILLANCE, FOLLOWING ELECTIVE ENDOVASCULAR ANEURYSM REPAIR, USING A DIVERSE POPULATION MODEL Anthony D. Godfrey1, Abigail Morbi1, Mostafa Albayati1, Cliff P. Shearman1, Ian M. Nordon1 1 Vascular Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom. Aims: Integral to maintaining excellent outcomes post-endovascular aneurysm repair (EVAR) is a robust surveillance protocol and timely re-intervention. A signiﬁcant proportion of patients fail to comply with surveillance, exposing themselves to complications of endoleak and graft migration. We examine EVAR surveillance in Wessex, exploring factors that may predict poor compliance. Materials and Methods: Retrospective study of all patients who underwent EVAR between October 2008 and March 2013. Surveillance was conducted centrally (at the tertiary-referral trauma centre) and at 4 spoke-units. Surveillance compliance (attendance at imaging appointments) at varying time intervals and predictors of non-compliance, to include age, gender, co-morbid status and distance from surveillance site, were analysed for univariate signiﬁcance. Results: 179 consecutive elective EVAR cases were assessed. 50 patients (27.9%) were non-compliant with surveillance, with 12 (6.7%) having no imaging post-EVAR. At one-year, 56.1% (of 123 patients) were compliant. At years two and three, 41.5% and 41.2% (of 65 and 34 patients respectively) were compliant. There were no statistically signiﬁcant differences in age (p=0.77), gender (p=0.74) or co-morbid status (p=0.77) between compliant and noncompliant groups. Distance to central unit was non-signiﬁcant (p=0.67), irrespective of island or mainland residence. There was a trend towards compliance in upper-middle class socioeconomic groups (ABC1 v C1C2D), but overall predictive value was not signiﬁcant (p=0.82). Conclusion: Compliance with surveillance protocols post-EVAR is poor. No independent predictor of non-compliance has been conﬁrmed but socioeconomic status appears relevant. This study highlights an important issue, which needs to be addressed urgently, if we are to ensure the continued success of endovascular therapy.
2. COMPUTATIONAL ANALYSIS OF BLOOD FLOW AND MIGRATION FORCES IN BRANCHED STENT GRAFTS FOR ENDOVASCULAR REPAIR OF ABDOMINAL AORTIC ANEURYSM Harkamaljot Kandail1, Mohamad Hamady2, Xiao Xu1 1 Chemical Engineering, Imperial College London, London, United Kingdom 2 Interventional Radiology, Imperial College London, London, United Kingdom Aims: Reliability of antegrade and retrograde endografts, collectively known as Branched Stent Grafts (BSGs), has not been adequately analysed. This computational study is aimed to assess the haemodynamic consequences of BSGs for different anatomical variations. Materials and Methods: To simulate normal and angulated side branches of BSGs, ideal models were constructed with different visceral “take-off” angles (TOA). TOA was deﬁned as the angle between the centrelines of the main stent graft and side branch, with 90° representing normal alignment while 30° and 120° representing severely and mildly angulated side branch, respectively. Fenestrated Stent Grafts (FSGs) with the same TOAs were also studied for comparison. Computational simulations were performed by solving the mass and momentum conservation equations governing the blood ﬂow. Results: Blood recirculation zones were found in visceral side branches at all TOAs, with the strongest recirculation in retrograde BSG at TOA of 30° and the weakest recirculation in FSG at TOA of 90°. Mean outﬂow into each renal artery in antegrade BSG, retrograde BSG and FSG was 25.6%, 21.5% and 28.9% of the aortic inﬂow, respectively. At TOAs of 30°, 90° and 120°, all stent grafts experienced equal mean migration forces of 1.25, 1.69 and 1.95 N, respectively. Conclusion: Stent grafts with severely angulated side branches lead to strong recirculation in renal arteries thus increasing the risk of thrombosis. Blood ﬂow rate in renal arteries depends on the conﬁguration of stent graft with FSG giving maximum and retrograde BSG resulting in minimum renal ﬂow. Migration forces exerted on stent grafts depend on the TOAs and not on the conﬁguration of stent graft.
ABSTRACTS - SCIENTIFIC SESSION 1 3. IS DIGITAL SUBTRACTION ANGIOGRAPHY AN EFFECTIVE PROBLEM SOLVER WHEN CONFRONTING AN INCREASING ANEURYSM SAC SIZE WITH NO IDENTIFIABLE ENDOLEAK ON CT ANGIOGRAPHY? Seyed Ameli-Renani, Robert A. Morgan Radiology, St George’s Hospital NHS trust, London, United Kingdom Aims: To determine the role of digital subtraction angiography (DSA) in evaluating the presence of endoleaks after endovascular repair of abdominal aortic aneurysm (EVAR); in particular assessing whether DSA is useful in cases where surveillance CT angiography (CTA) shows increasing aneurysm sac size, but no identiﬁable endoleak. Materials and Methods: Single centre retrospective study of patients undergoing DSA for possible endoleak between Jan2009 and Jan-2014. Presence and type of endoleak and change in sac size on CTA; and presence and endoleak type on DSA assessed. Results: 34 patients (average age 78, range 59-90) underwent DSA following surveillance CTA showing an endoleak and/ or increasing sac size. In 7 cases (23%) CTA showed increasing sac-size but no endoleak. In all these cases, the subsequent DSA was negative and identiﬁed no endoleak. In 5 cases (14%), CTA showed an endoleak but DSA was negative. 22 cases exhibited an endoleak on both CTA and DSA. The type of endoleak identiﬁed was in concordance on both investigations in 18 (82%) of these cases. Taking DSA as the preferred investigation; CTA sensitivity for detecting endoleaks was 96%, speciﬁcity 67%, positive predictive value 82% and negative predictive value 91%. Conclusion: DSA adds little information in cases of increasing aneurysm sac size, where no endoleak is seen on CTA. When compared to DSA, CTA has a high sensitivity and negative predictive value and is thus a suitable surveillance tool.
4. DEVELOPMENT OF A DATABASE TO SCHEDULE , PLAN AND FOLLOW UP PATIENTS UNDERGOING ENDOVASCULAR ANEURYSM REPAIR (EVAR) Rakesh Patel, Leonardo Monzon, Kyriacos Patatas, Jackie Trant, Sharmini Desigan, Eldon Lehmann, Yaser Naji Imaging, Northwick Park Hospital, London, United Kingdom Aims: To develop an electronic database to facilitate the planning, booking and follow up of patients undergoing EVAR. Materials and Methods: A database was designed using Access 2010 after consultation with all potential stakeholders including vascular surgeons, administrative staff and interventional radiologists. A relational database with multiple tables facilitated the storage of large quantities of data without unnecessary space being used as a consequence of data duplication. Data conﬁdentiality and security was assured by installing the database on the Hospital NAS (network acquired storage) drive. The NAS drive is regularly backed up to ensure no data loss. Placement of the database on the NAS drive ensured full information governance compliance as well as allowing standard Hospital IT security protocols to be maintained. As a result, access to the database could be granted to individual trust user accounts. Results: Individual user accounts were created by the database administrator. A home screen was created for users to perform a number of functions including: search patients, add patients, view upcoming EVARs, view key information from the planning CTA and enter/view follow up information and further imaging results. Patients were added to the database by the vascular nurse specialist if deemed suitable for EVAR following discussion at our regional vascular MDT. Conclusion: The database has facilitated capture of key patient information and communication. Features such as the database automatically triggering when a patient is overdue a follow-up ensures no patients lost to follow-up. Hospital wide access has allowed clinicians, administrative staff, nurses and radiographers to access key EVAR information held in the database from clinic / wards / radiology department.
ABSTRACTS - SCIENTIFIC SESSION 1 5. SHOULD DEVELOPMENT OF A COMPLICATION FOLLOWING EVAR BE CONSIDERED A FAILURE OF INTERVENTION? Alfred Tan, Keith Hussey, Sivanathan Chandramohan, Wesley Stuart Vascular Surgical Department, Western Inﬁrmary, Glasgow, United Kingdom Aims: Endovascular aneurysm repair (EVAR) offers an early survival advantage over open repair. However the potential for stent graft-related complication and subsequent requirement for secondary intervention have been well described. Whether this represents ‘failure’ of primary therapy is uncertain. We sought to address this by evaluating cumulative survival. Materials and Methods: We retrospectively reviewed our EVAR database. Surveillance imaging and subsequent readmissions with stent graft-related complications were recorded, as were subsequent re-interventions. Survival was evaluated using the Kaplan-Meier method. Results: There were 402 stent grafts deployed during the study period with a median follow-up was 58 months. In 312 cases the aneurysm remained completed excluded at follow-up. Re-intervention was performed in 90 cases (22.3%), which included 14 procedures for type Ia endoleak, 6 interventions for rupture and 20 limb salvage procedures. The majority of these procedures (n=65) were performed within 12-months of stent graft deployment. There was no difference in the cumulative survival of the cohort with completed excluded aneurysms and those that required a re-intervention (although aneurysm related mortality was higher in the latter group, with 8 aneurysm related deaths following presentation with rupture). Conclusion: These data suggest that the development of a stent graft-related complication has no inﬂuence on cumulative survival. As such, although stent graft-related complications may result in increased morbidity and healthcare-related cost, that it would be wrong to consider this as a failure of primary therapy.
6. PROSTAR XL - PRIMARY AND SECONDARY SUCCESS WITH A LARGE-BORE SUTURE-MEDIATED PRE-CLOSURE DEVICE Frances Colgan, Alexander Nath, Paul Walker, Rob Williams Interventional Radiology Department, Newcastle-upon-Tyne Hospitals NHS Trust, Newcastle-upon-Tyne, United Kingdom Aims: To determine primary and secondary success rates with the ProStar XL closure device for large calibre (up to 24Fr) arteriotomy after endovascular intervention. To identify any association between previous arterial intervention (i.e. a scarred groin) and device failure. Materials and Methods: All patients undergoing pre-closure of a 14Fr or larger arteriotomy with the ProStar XL device were included. Patients were retrospectively identiﬁed by PACS search from 2010 onwards using permutations of the term “ProStar” in the report text ﬁeld. All deployments including those in the initial learning curve were included. Details of device success, prior endovascular or surgical intervention at the puncture site and subsequent access site complications were obtained from procedure reports and patient casenotes. Results: 186 Prostar devices were deployed by a single operator into 127 patients during 8 emergency and 119 elective procedures. All arterial access was performed under ultrasound guidance (184 common femoral artery, 2 superﬁcial femoral artery). 14 patients had undergone prior surgical or endovascular intervention at the access site. Successful deployment occurred in 176 (94.6%) of uses. In 6 of these, additional minor intervention was used, including use of NuKnit pledgets, additional manual compression or fascial closure. Primary failure, requiring immediate surgical closure of the artery, occurred in 10 (5.4%) cases. No failure occurred at a site of previous intervention. No patients had secondary device failure. Conclusion: This single-operator series demonstrates effective use of ProStar XL device with a high success and low complication rate. No device failure occurred in a scarred groin.
ABSTRACTS - SCIENTIFIC SESSION 1 7. HETEROGENEITY OF EVAR SURVEILLANCE IN SCOTLAND Waduud, Mohammed Abdul1; Choong, Wen Ling2; Ritchie, Moira3; Williams, Claire4; Yadavali, Reddi5; Lim, Shueh6; Buchanan, Fraser7; Bhat, Raj8; Ramanathan, Krishnappan9; Ingram, Susan10; Cormack, Laura11; Moss, Jonathon G12 1 Department of Surgery, Glasgow Royal Inﬁrmary, Glasgow, Scotland, United Kingdom; Academic Foundation Doctor Year 2 2 Department of Surgery, Aberdeen Royal Inﬁrmary, NHS Grampian, Aberdeen, Scotland, UK; Core Surgical Trainee Year 1 3 Institute of Health and Wellbeing Glasgow, University of Glasgow, Glasgow, Scotland, United Kingdom; Trial Manager 4 Institute of Health and Wellbeing Glasgow, University of Glasgow, Glasgow, Scotland, United Kingdom; Data Scientist 5 Department of Radiology, Aberdeen Royal Inﬁrmary, NHS Grampian, Aberdeen, Scotland, United Kingdom; Consultant Interventional Radiologist 6 Department of Radiology, Royal Inﬁrmary of Edinburgh, NHS Lothian, Edinburgh, Scotland, United Kingdom; ST2 Radiology 7 The School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland, United Kingdom; 3th year Medical Student 8 Department of Radiology, Ninewells Hospital, NHS Tayside, Dundee, Scotland, United Kingdom; Consultant Interventional Radiologist 9 The School of Medicine, University of Dundee, Dundee, Scotland, United Kingdom; 3th year Medical Student 10 Department of Radiology, Royal Inﬁrmary of Edinburgh, NHS Lothian, Edinburgh, Scotland, United Kingdom; Consultant Radiologist 11 Department of Radiology, Royal Inﬁrmary of Edinburgh, NHS Lothian, Edinburgh, Scotland, United Kingdom; SpR Radiologist 12 Department of Radiology, Gartnavel General Hospital, Glasgow, Scotland, United Kingdom; Professor of Interventional Aims: Surveillance following EVAR is mandatory; however no optimal EVAR surveillance protocol exists in the Scotland. The aim of this study was to identify variations in EVAR surveillance in Scotland and the subsequent impact on mortality if any. Materials and Methods: Standard surveillance protocols were identiﬁed from the 4 main vascular centres in Scotland (NHS Grampian, NHS Tayside, NHS Greater Glasgow and Clyde and NHS Lothian). Data collected included: dates of imaging surveillance, modality of imaging used and date of death (if applicable). The cause of death was ascertained from the death certiﬁcate in all cases. Results: All centres had surveillance data available for a minimum of 5 consecutive years. Centres were anonymised prior to analysis. In total data from 569 patients across all centres were analysed. Centres A & B utilised CT angiography and abdominal x-ray at discharge or 1 month, 6 months, 12 months and annually. Centre C used CT angiography at 1 month, 6 months, 12 months, 18 months, 24 months and annually. Centre D , pre-2006, utilised CT angiography at 1month, 6 months and annually and; post-2006, CT angiography at 1 month with routine surveillance performed with US aortogram and abdominal X-ray. 5-year mortality at the four centres was 36.3%, 46.3%, 33.2% and 28.9% respectively. There were no signiﬁcant differences in mortality at 5-years (p-value 0.371). Data relating to AAA-related mortality was too few for comparative analysis. Conclusion: There is no standardised post-EVAR follow-up amongst the four Scottish vascular centres. However this did not translate to poor outcome.
ABSTRACTS - SCIENTIFIC SESSION 2 WEDNESDAY 12 NOVEMBER-FARRAGO INTERVENTION CHAIRS: DR PAUL CROWE & DR ROB THOMAS HALL 1A
8. IVC FILTER RETRIEVAL - WHAT IS EXCESSIVE FORCE? Tze Y. Chan1, Usman Shaikh1, Andrew England2, Richard McWilliams1 1 Radiology Department, Royal Liverpool University Hospital, Liverpool, United Kingdom 2 Directorate of Radiography, University of Salford, Manchester, United Kingdom Aims: Indwelling IVC ﬁlters are associated with serious complications such as IVC occlusion, ﬁlter penetration, perforation, and migration hence the introduction of temporary ﬁlters. Long indwelling time is associated with higher retrieval complication rates e.g. venous dissection, caval tear, acute IVC thrombosis. The information for use (IFU) provided by the commercial companies advise that “excessive force should not be used”. The term “excessive” is vague and subjective leading to variability amongst interventional radiologists (IR). If the IFU were to provide an objective ﬁgure e.g. 20N, we suspect it is equally unhelpful to IR - what would 20N feel like when pulling on a ﬁlter? The aim of this study is to gain a better understanding of what IR consider to be excessive force during IVC ﬁlter retrieval and to understand the variability in their perception of force. Materials and Methods: We invited 37 IR to pull on a modiﬁed force tester attached to a Gunther Tulip IVC ﬁlter retrieval set (GTR). The participants were asked to pull as if they were retrieving an IVC ﬁlter and stop when they felt it was clinically unsafe to proceed. They were then asked to replicate 10N and 50N. All tasks were repeated 3 times. Results: We found that the range of maximum forces applied during retrieval varied between 1 - 79.8N. When asked to replicate 10N and 50N, the mean force produced was 23.5 and 38.1 respectively. A trend analysis showed that those who overestimate 10N are more likely to apply a greater overall maximum force. There is also no signiﬁcant trend with regards to operator grade or experience (number of retrievals performed). Conclusion: In conclusion, we found that there is a wide variation between IR as to what they consider “excessive force” when retrieving an IVC ﬁlter. Interventional radiologists are also poor at re-producing 10 and 50N.
9. THE IMPACT OF A PROSPECTIVELY MAINTAINED IR DATABASE ON IVC FILTER RETRIEVAL RATES James G. McGarry, PRem Tharanatnam, Soud Awaiyhan, Mark F. Given, Frank McGrath, Aoife Keeling, Michael J. Lee Interventional Radiology, Beaumont Hospital, Dublin, Ireland Aims: Retrievable IVC ﬁlters are intended to avoid long-term complications of permanent ﬁlters, such as IVC occlusion/ penetration, ﬁlter/strut migration, and recurrent venous thromboembolism (VTE). SIR guidelines advise “100% of patients should have attempted retrieval, unless a change in clinical circumstances contraindicates removal.” We aimed to determine the impact of a prospectively maintained database on retrieval rates of IVC ﬁlters at our institution over a 3-year period. Materials and Methods: All patients undergoing retrievable IVC ﬁlter insertions from 1st May 2011 to 31st April 2014 were identiﬁed. Each patient had been allocated a routine retrieval appointment at time of insertion. Non-retrieval prompted a discussion with the referring clinician regarding permanency. Results: 111 patients had retrievable IVC ﬁlters, 73 CelectTM and 38 Gunther TulipR (Cook Medical). The most common indications were VTE despite or with contraindication to anticoagulation (43.2%), peri-operative prophylaxis (37.8%), prethrombolysis of extensive VTE (6.3%), VTE with poor cardiopulmonary reserve (5.4%), and massive pulmonary embolism (4.5%). The ﬁlter was deemed permanent in 36 patients (32.4%) due to either a change in clinical status, or ongoing unsuitability for anticoagulation. Nine patients (8%) were deceased. Of the remaining 66 patients, 61 underwent attempted retrieval (92.4%), successfully in 58 (95%). Five of the 66 patients (10.3%) did not undergo retrieval all due to inadequate follow-up. Patients with perioperative indications were most likely to have retrieval. Conclusion: Our 92.4% attempted retrieval rate, and 95% success rate at retrieval, are among the highest published to date. A prospective database and routine retrieval appointments to prompt discussion with referring clinicians can signiﬁcantly improve retrieval rates.
ABSTRACTS - SCIENTIFIC SESSION 2 10. PROPHYLACTIC INTERNAL ILIAC BALLOON PLACEMENT PRIOR TO CAESAREAN SECTION IN PATIENTS WITH PLACENTA ACCRETA Paddy Nicholson, Liam Spence, John Buckley, David Tuite Radiology, Cork University Hospital, Roscommon, Ireland Aims: The incidence of placenta accreta has been rising steadily over the last decade. The placement of prophylactic internal artery balloons is well described in this condition - we will report our outcomes following the use of this technique. Materials and Methods: We retrospectively assessed the records of all patients with placenta accreta or one of it’s variants who underwent prophylactic internal iliac balloon placement prior to elective delivery. We assessed both maternal and foetal outcomes, and looked at a range of variables including blood loss, hysterectomy rates and foetal cord pH and Apgar scores. Results: Over a 44-month period, 22 patients with abnormal placentation underwent caesarean section after ﬁrst undergoing prophylactic placement of internal iliac artery occlusion balloons. Median follow-up duration was 2.08 years. Technical success was achieved in 100%. The median gestational age was 37 weeks 6 days, the median number of previous caesarean sections was 2.4, while median maternal age was 35 years. The median intraoperative blood loss was 1.4 litres, and the median number of blood units transfused was 2. Median duration of surgery was 90 minutes, median total length of hospital stay 7.5 days, while the median duration of ICU/HDU stay was 1.2 days. The balloons were inﬂated in 80% of cases, and no patient underwent subsequent hysterectomy. 23 live infants were delivered, and median Apgar scores and foetal cord pH values were within normal limits. There were no major maternal or foetal complications due to the procedure. Conclusion: Prophylactic placement of arterial balloons prior to caesarean section in patients with abnormal placentation is well tolerated and leads to satisfactory outcomes for both mother and foetus, with minimal complications. This highlights beneﬁts from involving the IR in the management of these patients.
11. PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY OF DIALYSIS FISTULAE USING A TRANSJUGULAR APPROACH Diana Bosanac, Anastasia Hadjivassiliou, Dominic Yu, Kate Steiner Radiology, Royal Free Hospital, London, United Kingdom Aims: To present our experience of transjugular approach in the treatment of poorly functioning/thrombosed upper limb dialysis ﬁstulas. Materials and Methods: We retrospectively analysed patients with poorly functioning/thrombosed dialysis ﬁstulae treated in our Interventional Radiology Department over a three-year period. We describe the transjugular ﬁstulopasty technique and compare it to the standard approach in terms of technical success and complications. Results: We treated 637 ﬁstulas in 438 patients and used the transjugular route in 86 of the procedures. The technical success rate of the transjugular approach was 70% for thrombosed ﬁstulas/those with long occlusions and comparable to the success of the standard approach. In stenosed ﬁstulas, the technical success rate was lower in the transjugular group - 77% vs 93%. We used the transjugular approach less frequently in stenosed ﬁstulas resulting in lower overall numbers treated. In addition, some of these patients had anatomical factors precluding access to the ﬁstula from the neck. Total complications were comparable between the two groups. Conclusion: Transjugular approach, either primary or as an adjunct to an antegrade puncture of the ﬁstula is safe with a comparable rate of procedural success in thrombosed dialysis ﬁstulae or those with long occlusions. It allows the treatment of the entire ﬁstula as well as any central outﬂow stenoses from a single approach without the need to puncture the ﬁstula itself.
ABSTRACTS - SCIENTIFIC SESSION 2 12. CAN DRUG-ELUTING BALLOON ANGIOPLASTY REDUCE THE FREQUENCY OF INTERVENTIONS IN SELECTED HIGHMAINTENANCE DIALYSIS FISTULAE - EARLY RESULTS OF A CASE SERIES Tereza Cairns1, Michelle Gaffney1, Ramita Dey2 1 Medicine, Northampton General Hospital, Northampton, United Kingdom 2 Radiology, Northampton General Hospital, Northampton, United Kingdom Aims: There is anecdotal evidence of using drug eluting balloons (DEBs) in dialysis ﬁstulae. Our aim was to assess if use of DEBs could reduce the frequency of interventions in selected high-maintenance arterio-venous (AV) dialysis ﬁstulae, thus reducing total overall cost. Materials and Methods: DEB ﬁstuloplasty was performed in 11 patients with radiocephalic and brachiocephalic ﬁstulae, over 24 months. Patient selection was directed by 2 or more previous same-segment ﬁstuloplasties or a short period to re-stenosis following previous plain balloon (PB) ﬁstuloplasty. Data was gathered from the CRIS system and analysed using Excel 2013. The time intervals between PB and DEB intervention were compared to the intervals between DEB and subsequent intervention. Cost analysis was done using current UK HRG codes for vascular day cases. Results: 1 patient was lost to follow-up following transplant. 8 patients remain stenosis-free following DEB ﬁstuloplasty. There is a signiﬁcant difference in the stenosis-free period following DEB plasty compared to PB plasty (p=0.0043; unpaired t-test). Cost analysis shows that 1 day-case angioplasty episode attracts a tariff of £1590. Even with a DEB costing an additional £500 compared to £45 for a PB, the resultant saving of 2.1 ﬁstuloplasties per year, equates to a cost beneﬁt of £3339 per year for this cohort Conclusion: Some ﬁstulae need multiple maintenance interventions, with high procedural costs and inconvenience to the patient. Our early results show that use of DEBs in dialysis ﬁstulae is safe, with, even in this small series, an encouraging trend to prolonging time to restenosis compared to PB ﬁstuloplasty. There is considerable total cost-beneﬁt per ﬁstuloplasty avoided, even allowing for the high cost of DEBs.
13. PERCUTANEOUS NEPHROLITHOTOMY: IS “TUBELESS” PCNL WORTHWHILE? Nadia Mcallister1, Philip Haslam2 1 Freeman Hospital, Newcastle upon Tyne, United Kingdom 2 Freeman Hospital, Newcastle upon Tyne, United Kingdom Aims: Until recently, the placement of a large-bore tamponade tube following percutaneous nephrolithotomy (PCNL) was considered standard. Evolution of small tube and tubeless PCNLs promised to offer reduced hospital stay, postoperative pain and morbidity. This study compares the conventional and current practices and reports on differences in length of hospital stay, post-operative complications and technical success rates. Materials and Methods: Retrospective, single centre, review of all PCNLs performed in 2006 and 2013. Results: 102 and 118 PCNLs were performed in 2006 and 2013 respectively. The two cohorts displayed similar demographic data with an average age of 54 years. There was no statistically signiﬁcant differences in stone burden pattern. The overall rate of post-operative complications was similar in both groups (11%) and included (2006 and 2013 respectively) pleural effusion (2% vs 3%), blood transfusions (1% vs 3%), sepsis (4% vs 6%), post-operative obstructive hydronephrosis which required stenting (5% vs 1%). Embolisation (3%), haematoma (2%) and death (1%) were observed only in the 2013 cohort. A much higher stone clearance rate was achieved in 2013 (81%) compared to 2006 (67%). There was a higher rate of dual and multiple punctures in 2013 (20% vs 7%). The average length of uncomplicated post-operative stay was 5 days in 2006 (range 3-10) and 3 days in 2013 (range 1-15). Conclusion: No signiﬁcant increase in the post operative complication rate was observed when using a small nephrostomy catheter or stent compared with a tamponading catheter. This change in technique has however lead to a decrease in length of hospital stay despite this cohort comprising more complex cases including bilateral PCNLs and a higher number of multiple punctures.
ABSTRACTS - SCIENTIFIC SESSION 2 14. NEEDLE GUIDE SHORTENS THE LEARNING CURVE FOR SIMULATED ULTRASOUND ASSISTED NEEDLE PUNCTURE; A RANDOMISED TRIAL Pasha Normahani, Usman Jaffer, Prashant Singh, Mohammed Aslam, Nigel Standﬁeld Imperial College London, London, United Kingdom Aims: The task of US guided vessel cannulation can be technically difficult requiring the acquisition of hand eye coordination to direct both the probe and needle according to image display. Needle guides have been designed for use in conjunction with US probes to facilitate vessel puncture. We aimed to identify the learning curve of participants using conventional ‘free hand’ (FH) and ‘needle guide’ assisted (NG) techniques. Materials and Methods: 36 participants were randomly allocated to either FH or NG group. They were asked to consecutively perform up to 30 vessel punctures on a simulated phantom model. Quantitative metrics (Total time, number of skin punctures and posterior wall punctures) were recorded and compared between the two groups. The moving average and cumulative sum (CUSUM) methods were used to delineate the learning curve. Results: There was a signiﬁcantly higher rate of posterior wall punctures in the FH group compared to the NG group (26% vs. 15%, p < 0.0001). Participants in the NG group performed signiﬁcantly less number of skin punctures than the FH group (mean: 405 vs. 515; p < 0.0001). Using the CUSUM analysis, the acquisition of the learning curve was shorter for the NG group (mean 14.22 attempts, IQR 10.0-18.0) compared to the FH group (mean 20.36, IQR 14.0-28.0). The mean number of attempts to cross the threshold was signiﬁcantly less for the FH group (7.2 attempts vs. 16 attempts, p = 0.007) when using the moving average method. Conclusion: Using this simulated model, subjects acquired needle puncture skills following consecutive needle puncture attempts using both the FH and NG assisted techniques. The NG assisted puncture appears to be more intuitive with a shorter learning curve. NG assisted puncture may have a shorter path to proﬁciency, allowing trainees to attempt needle puncture earlier and with a greater degree of safety.
ABSTRACTS - SCIENTIFIC SESSION 3 THURSDAY 13 NOVEMBER-PERIPHERAL VASCULAR INTERVENTION CHAIRS: DR GRAHAM ROBINSON & DR JOO YOUNG CHUN MAIN AUDITORIUM
15. COMPLEX RECANALIZATION AND STENTING OF CHRONIC ILIOFEMORAL AND IVC OCCLUSIONS Nicos Fotiadis1, Narayanan Thulasidasan1, Constantinos Kyriakides2 1 Interventional Radiology, Chelsea and Westminster Hospital, London, United Kingdom 2 Vascular Surgery, The London Clinic, London, United Kingdom Aims: Chronic occlusion of the iliac veins and the inferior vena cava is a source of signiﬁcant morbidity to often otherwise healthy patients, but it can be successfully managed with percutaneous recanalization and stenting. We present our results in eleven consecutive symptomatic patients. Materials and Methods: From March 2011 to May 2014 11 consecutive patients (8 women, 3 men, mean age 37.8years range 23-51 years) with chronic disabling symptomatic non-malignant total occlusions of the iliac veins were treated. One patient also had an IVC occlusion and one had a common femoral and superﬁcial femoral vein occlusion. Scarring and disease of the common femoral vein was noted in 9 patients. Results: All procedures were performed under general anaesthesia. Technical success was achieved in all but one case in the initial procedure. In a patient with a common femoral , superﬁcial femoral and iliac veins occlusion recanalization was achieved with the second attempt through a combined long saphenous and internal jugular vein access. There was one early stent occlusion one month post procedure treated with re-stenting. Elective venography was performed in 5 patients six months post procedure with elective angioplasty of the common femoral vein. Signiﬁcant symptomatic improvement was achieved in ten out of the eleven patients. During a mean follow up 20 months (range 2- 37 months) all stents remained patent. Conclusion: Iliocaval recanalization is associated with high technical success, low complication rates, and good midterm patency rates.
16. TASC II GUIDANCE FOR STENTING IN OCCLUSIVE ILIAC DISEASE - TIME FOR A REALITY CHECK Riad Alchanan, Keith W. Chiu, Vivek shrivastava, Duncan Ettles Radiology, Hull and East Yorkshire Hospitals NHS Trust, Hull, United Kingdom Aims: To determine real world outcomes for the treatment of long segment iliac disease in relation to published guidance. Materials and Methods: A retrospective review of all patients with long-segment iliac disease (>5cm, involving both CIA and EIA) treated by stent placement in a single centre over a ﬁve year period. Patient demographics, clinical presentation and TransAtlantic Inter-Society Consensus (TASC II) classiﬁcation were correlated with patency and re-intervention rates. Results: 59 patients underwent concurrent ipsilateral CIA and EIA stenting for long-segment iliac disease using selfexpandable bare-metal stents. 70% were male with a median age of 67 years (range 43-87 years). 39 (66%) patients presented with symptoms of intermittent claudication, 13 (22%) with critical limb ischaemia and 7 (12%) acute limb ischaemia. 9 (15%) patients had previously undergone endovascular intervention of the same iliac segments. Pre-treatment TASCII classiﬁcation designated 5 patients (8%) as type B, 6 (10%) type C and 48 (82%) as type D. Median follow-up was 26 months (range 0 -75 months). The 30-day re-intervention and all-cause mortality rates were 7% and 5%, respectively. 8 patients underwent further endovascular re-intervention and 2 patients had surgical bypass. Overall survival, primary and secondary patency were 91%, 85% and 89% at 1 year, 86%, 73% and 85% at 2 years, respectively. Major complications occured in 2 (3%) patients. Conclusion: Our data conﬁrms that TASC II recommendations for the treatment of long segment iliac disease are inappropriate and primary endovascular management should be the treatment of choice.
ABSTRACTS - SCIENTIFIC SESSION 3 17. DOES PHARMACOTHERAPY INFLUENCE OUTCOME FOLLOWING FEMORO-POPLITEAL SEGMENT STENTING? Alfred Tan, Caitlin Brennan, Kate Tilley, Keith Hussey, Sivanathan Chandramohan, Wesley Stuart Vascular Surgical Department, Western Inﬁrmary, Glasgow, United Kingdom Aims: TASC recommend life-long therapy with one of aspirin or Clopidogrel to promote long-term patency following stenting of the femoro-popliteal segment. Combination antiplatelet therapy (Aspirin and Clopidogrel) following angioplasty is associated with a reduction in PDGF and greater platelet function inhibition than single agent therapy. We have explored the inﬂuence of pharmacotherapy on outcome following femoro-popliteal segment stenting. Materials and Methods: This was a single-centre retrospective review of a prospectively maintained procedural database (October 2010 to June 2012). Index cases were identiﬁed and electronic patient health records were accessed. Pharmacological therapy at discharge was recorded from the immediate discharge document. Primary stent patency and survival were recorded. Results: Femoro-popliteal stenting was performed in 37 cases; the majority of patients were male (n=28), mean age 70 years (range 52-93 years). The majority of procedures were performed for critical limb ischaemia (n=27). Technical success was recorded in all cases. At twelve months for single agent antiplatelet (n=15), combination platelet (n=19) and anticoagulation (n=3) primary patency was 66.7%, 78.9% and 66.7%. Secondary intervention for limb salvage was less frequent in the combination antiplatelet group. Survival was 83.3%, 100% and 76.7% respectively for single agent, combination antiplatelet and anticoagulation respectively. Conclusion: These data suggest that combination antiplatelet therapy inﬂuences primary patency following femoropopliteal segment stenting. An interesting observation is a reduction in all cause mortality, which merits further investigation. These data would seem to justify the prescription of combination antiplatelet therapy following femoro-popliteal segment stenting.
18. OUTCOME FOLLOWING SALVAGE INTERVENTIONS ON THREATENED INFRA-POPLITEAL BYPASS GRAFTS IN PATIENTS WITH CRITICAL LEG ISCHAEMIA Sanjay Patel, Lampros Lymperopoulos, Vassilios Zymvragoudakis, Talia Lea, Tommaso Donati, Soundrie Padayachee, Konstantinos Katsanos, Hany Zayed Vascular Surgery, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom Aims: Infra-popliteal bypass is an established and effective method for limb salvage in patients with critical limb ischaemia (CLI). Secondary interventions maybe required in order to maintain graft patency. The aim of this study was to look at the frequency and outcomes of such interventions. Materials and Methods: Consecutive patients undergoing bypasses onto the infra-popliteal vessels for CLI (Rutherford 4-6) at a single institution were analysed between 2009-2013. The primary end points were graft patency, limb salvage and amputation free survival at 12 months by Kaplan Meier analysis. Results: A total of 122 infra-popliteal bypasses were performed in 116 patients. Distal anastomosis was on to the anterior tibial (n=38), peroneal (n=25), posterior tibial (n=22), tibio-peroneal trunk (n=21) or dorsalis pedis artery (n=10). Technical success was 100%, and 12 month primary patency, assisted primary patency and secondary patency was 57%, 66% and 68% respectively. Initial limb salvage was achieved in 94% of patients. Amputation free survival was 74% at 12 months. There were 64 secondary salvage interventions performed on 48 (39%) threatened grafts which included angioplasty of inﬂow/proximal anastomosis (28%) and outﬂow/distal anastomosis (31%), thrombolysis and angioplasty (23%), surgical intervention (18%). Amputation-free survival was not signiﬁcantly different between salvaged threatened grafts and non-threatened grafts (Log rank test, P=0.36). Conclusion: Secondary interventions in threatened infra-popliteal bypass grafts are successful at maintaining graft patency. Careful duplex surveillance of theses complex bypasses and timely intervention is associated with limb salvage rates which are similar to non threatened grafts.
ABSTRACTS - SCIENTIFIC SESSION 3 19. USE OF A NEW HYBRID NITINOL RING STENT (TIGRIS STENT) IN THE POPLITEAL ARTERY Aneeta Parthipun, Panos KITROU, Athanasios Diamantopoulos, Panos Gkoutzios, Irfan Ahmed, Konstantinos Katsanos Interventional Radiology, Guy’s and St. Thomas, London, United Kingdom Aims: To report the interim results of a single-centre prospective study investigating a novel hybrid heparin-bonded nitinol ring stent (TIGRIS; Gore Medical) in the popliteal artery. Materials and Methods: Patients with de-novo or restenotic popliteal arterial obstructive disease (Rutherford-Becker stage 3-5) were eligible for primary TIGRIS stent placement following balloon pre-dilation as necessary. Outcome measures included immediate technical and procedural success, vascular restenosis (evaluable by Duplex Ultrasound on the 50% threshold; PSVR>2.0), freedom from target lesion revascularization (TLR) and limb salvage. Results: Between August 2012 and February 2014, 46 TIGRIS popliteal stents were implanted in 43 patients (23 males, 75±11 years old). Chronic total occlusions were 26 out of 43 cases (60%). Treated lesion length was 10.7 ± 4.7cm (range, 5-20cm) and stent diameter ranged from 5 to 7mm. Technical and procedural success were achieved in all cases at the time of the procedure (46/46, 100%) and no in-hospital major adverse events occurred. After a median follow-up period of 6 months (range, 5-13 months) 5 patients have died. Overall freedom from TLR was 33/38 (87%). One patient underwent a major amputation and 2 patients had a femoropopliteal bypass due to stent re-occlusion. 6-month Duplex was available in 27 arteries (29 stents). Binary restenosis rate (≥50% on duplex scan plus the re-occlusions) was 8/30 (73%) at 6 months Collection of 1-year follow-up is ongoing. Conclusion: The new hybrid heparin-bonded TIGRIS stent may represent a potentially safe and effective endovascular option for the femoropopliteal artery.
20. MANAGEMENT OF OCCLUSIVE ATHEROSCLEROTIC DISEASE OF THE AORTIC BIFURCATION Candice Galea, Keith Hussey, Matthew Underwood, Jack Clark, Sivanathan Chandramohan Vascular Surgical Department, Western Inﬁrmary, Glasgow, United Kingdom Aims: Complex occlusive arterial disease of the aortic bifurcation can be managed endovascularly or surgically. ‘Kissing stents’ deﬁned as bilateral common iliac stents that extend into the distal aorta, such that the walls of the stents come into apposition. Evidence from the world literature on the utility and long term durability of this technique is mixed. The aim of the present work was to compare the outcome of kissing stents with aortic bifurcation graft. Materials and Methods: A prospectively maintained interventional radiology database and theatre registries were reviewed to identify index cases. Arterial imaging and electronic patient health records were reviewed. Speciﬁc outcome measures included technical success and primary patency. Results: There were 50 kissing stents deployed and 56 aortic bifurcation grafts performed. Patient demographics were comparable between the patient groups. The lesions managed endovascularly were predominantly TASC A or B (n=17 and n=23), where-as in the surgical group the majority were TASC D (n=39). Technical success was recorded in all cases. Postprocedural complications were uncommon in the endovascular group (n=4) and common in the surgical group (n=16). Primary patency for kissing stents and aortic bifurcation grafts were 89.8% and 85.7% at one year and 84.8% and 82.1% at two years. Conclusion: Although the indications and morphology of target lesions for intervention may not be directly comparable, these data would seem to suggest that with the correct case selection kissing iliac stents are a durable therapy, with comparable patency to surgical bypass and a lower complication proﬁle.
ABSTRACTS - SCIENTIFIC SESSION 3 21. ACUTE THROMBOSIS OF COVERED STENTS IN THE PERIPHERAL ARTERIES: AN UNDERESTIMATED PHENOMENON Aneeta Parthipun, Said Lamki, Yuri Gupta, Tarun Sabharwal, Konstantinos Katsanos Interventional Radiology, Guy’s and St. Thomas’, London, United Kingdom Aims: Little is known about the incidence of acute thrombosis and limb ischemia after covered stent placement in the peripheral arteries. We report results of a single-centre retrospective audit investigating the phenomenon in the aortoiliac and infrainguinal arteries. Materials and Methods: Patients with supra- and infrainguinal peripheral arterial occlusive disease were eligible for VIABAHN stent placement following balloon pre-dilation as required. Relevant patient archives were retrospectively audited and scrutinised for any events of acute limb ischemia with angiographically conﬁrmed covered stent thrombosis. Correlation of thrombotic events with baseline anatomical and clinical variables was performed. Results: The study covered a period of over 5 years (July 2008 - December 2013). Patient notes of a total of 100 cases that had undergone covered stent (VIABAHN, Gore Medical; 137 stents) placement during that period were analysed. In 29 cases VIABAHN stents were placed in the aortoiliac arteries and in 71 cases in the infrainguinal vessels without any periprocedure or short-term (30-days) major complications. After a median follow-up of 1 year (range, 0.1-5.5) there were 12 events of acute covered stent thrombosis presenting with acute limb ischemia symptoms. Thrombosis rate in the aortoiliac segment was zero (0%). All acute thromboses occurred in the femoropopliteal segment (rate 16.9% - incidence of 15 events per 100 person-years). 8 resulted in a bypass graft or amputation and 4 were successfully thrombolysed. Conclusion: Acute thrombosis of VIABAHN covered stents in the femoropopliteal arteries is a true phenomenon with an underestimated incidence. Patients present with acute limb ischemia and may end up with major amputations.
ABSTRACTS - SCIENTIFIC SESSION 4 THURSDAY 13 NOVEMBER-GI & HEPATOBILIARY CHAIRS: DR HAMI MERZHAD & DR PHIL HASLAM HALL 1A
22. A LARGE UK CENTRE EXPERIENCE OF UPPER GI STENTING Walter Sprenger De Rover1, Abdullah Saeed1, Rajeev Singh1 1 Radiology, Royal Derby Hospitals, Derby, Derbyshire, United Kingdom. Aims: Upper GI stents are a safe, effective, minimally invasive method of treatment in both benign and malignant disease. The role of ﬂuoroscopic guided stent insertion has been increasing steadily as a treatment for strictures and symptomatic obstruction. We review our service and share our experience with oesophageal, pyloric, duodenal and post bariatric bypass surgery stenting including uncovered, covered, permanent, removable and biodegradable stents. We also aim to highlight selected cases demonstrating our technique in a step wise pictorial manner. Materials and Methods: A retrospective review in a single centre using consultant logbooks, ICMtm clinical management software and PACs (picture archiving and communications system) was performed to identify all cases of over a 7 year period between June 2006 to July 2013 Results: 79 cases(40 female, 39 Male) were identiﬁed. Indications included malignant strictures (n=53), malignant stricture with trachea-oesophageal ﬁstulas (n=12), post bariatric surgery (n=8), benign disease (n=4) and strictures post oesophageal cancer resection (n=3). 55% were initially attempted by endoscopy and 22% had previously been stented. 3 stents were unsuccessful (patient pulled out wire before deployment, Stent migrated) and 1 complication was identiﬁed (false passage). 3 patients reported chest pain within 6 hours but no pathological cause for the pain was found. The median stay post insertion is 3 days (range 1-41). Conclusion: In patients with oesophageal strictures, radiological stenting provides a safe, effective method of symptomatic relief as both a 1st line treatment in those patients not able/suitable for endoscopic placement as well as after endoscopic attempts.
23. PARALLEL TIPSS FOR THE MANAGEMENT OF SHUNT INSUFFICIENCY IN PATIENTS WITH COMPLICATIONS OF PORTAL HYPERTENSION: A TERTIARY LIVER UNIT 19 YEAR EXPERIENCE” Homoyoon Mehrzad1, Neil Rajoriya2, D. Tripathi2, Kamarjit Mangat1, Simon Olliff1 1 Interventional Radiology, University Hospital Birmingham, Birmingham, United Kingdom 2 Liver Unit, University Hospital Birmingham, Biirmingham, United Kingdom Aims: The aim of this study was to assess the efficacy of parallel TIPSS in a large UK tertiary referral liver centre. Materials and Methods: A retrospective study was performed from patient electronic databases and case-notes. 1st TIPSS (index) and parallel TIPSS were performed over a 19 year period. Index TIPSS was done as “rescue” therapy for variceal bleed refractory to endoscopic treatment, or for refractory ascites. Results: Results: A total of 550 TIPSS procedures were done in our centre in 19 years. 11 (2%) patients (8M:3F) had a parallel TIPSS. Index TIPSS: Indications: 4 Oesophageal (OV) haemorrhage, 3 gastric variceal (GV) haemorrhage, 1 stromal variceal haemorrhage, 3 for refractory ascites. Peri-Index/Parallel TIPSS period: Median time between index TIPSS and parallel TIPSS insertion was 72 days. 7 patients had dilatation of the index TIPSS in the interim if on-going symptoms or raised PPG despite index TIPSS. Parallel TIPSS: Clinical indications cited for parallel TIPSS included: 7 variceal re-bleeds & 2 ascites reaccumulation . Five index TIPSS were blocked/narrowed on imaging. Follow-up: Median follow-up was 30 months. One patient had transient encephalopathy, but no other complications. Nine patients (81%) had a resolution in symptoms. One patient had on-going GV bleeding requiring Thrombin injection and 1 patient had ascites with no ﬂow in parallel TIPSS 4 days post-procedure. Secondary patency was 82% with a median number of interventions of 1.5. 92% patients were alive at 1 month with 86% 1 year survival. Conclusion: Parallel TIPSS is a safe and effective method to treat TIPSS insufficiency. The majority of patients not only had a good haemodynamic result, but also resolution of symptoms. Its role in reducing portal pressure should be considered if a clinical or haemodynamic evidence of primary TIPSS shunt failure unresponsive to dilatation
ABSTRACTS - SCIENTIFIC SESSION 4 24. BLEEDING RISK ASSESSMENT PRIOR TO LIVER BIOPSY Mark W. Little1, Michael Desborough2, James Briggs1, Philip Reid1, Stephen Hibbs3, James A. Sutcliffe1, Eoghan McCarthy1, Kader Allouni1, Jane Phillips-Hughes1, Susan Anthony1, Mark Bratby1, Raﬁuddin Patel1, Charles R. Tapping1, David Keeling2, Raman Uberoi1 1 Radiology, John Radcliffe Hospital, Oxford, United Kingdom 2 Haematology, John Radcliffe Hospital, Oxford, United Kingdom 3 ICU, John Radcliffe Hospital, Oxford, United Kingdom Aims: To determine: 1. How bleeding risk is assessed prior to liver biopsy 2. Whether patients with prolonged PT or aPTT are investigated to determine the cause of coagulopathy 3. Whether transfusion with FFP and platelets are performed at appropriate thresholds Materials and Methods: Retrospective case note review of 567 patients having liver biopsy (53 transjugular, 514 percutaneous) between January2009-November2011. In addition, an online survey was distributed to BSIR members to assess current UK practice of assessing bleeding risk prior to liver biopsy Results: Bleeding history was not routinely taken; all patients were screened with PT/aPTT and platelet count. 98.9% of patients had platelets above the 60x109/l threshold for transfusion. None of the 6 patients with platelets below the threshold were transfused. 99.6% of patients had a PT22s received FFP. All patients with an aPTT greater than 50s were investigated; 9 patients for whom new diagnoses were made: 3 causes not associated with a bleeding risk (2 factor XII deﬁciencies and 1 lupus anticoagulant) and 6 where there may be a mild risk (2 mild mixed deﬁciencies, 2 vitamin-K deﬁciencies, 1 factor XI deﬁciency and 1 suspected factor deﬁciency, not characterised further). No patient with a prolonged aPTT had unexpected bleeding. 49 responses were received from the survey. 37% routinely take a bleeding history, however this is only used to guide further coagulation tests in 36%. If a patient had a PT above the radiologists’ threshold, 58% would use empirical treatment with FFP. Conclusion: There is an ongoing tendency for bleeding history to be missed, and PT/aPTT to be used to screen bleeding risk. When abnormalities in PT/aPTT/platelets are detected, the management is often inconsistent.
25. PSEUDOANEURYSMS IN HEPATICOPANCREATICOBILIARY PATIENTS: A SINGLE CENTRE 5 YEAR EXPERIENCE Shaun Quigley, John Adu, Mohammed Akhtar, Tim Fotheringham, Snehal Patel, Debbie Low Interventional Radiology, Barts Health, London, United Kingdom Aims: Pseudoaneurysms of the visceral arteries are a life-threatening condition encountered in hepaticopancreaticobiliary patients. We describe the management of this entity in a complex patient group in a tertiary HPB centre Materials and Methods: Imaging records of patients referred from the HPB unit for angiography and transarterial embolisation over a 5 year period were retrospectively reviewed. Patients with pseudoaneurysms of the visceral arteries were identiﬁed and their procedures reviewed. Follow up ranged from 1-58 months. Demographics, pseudoaneurysm aetiology, vessel type and embolisation technique were recorded. Technical success, clinical success (rebleed prompting further imaging) and complication rates were obtained. Results: 46 patients had 53 pseudoaneurysms, two patients had 4 and 5 pseudoaneurysms respectively. Aetiologies included necrotic pancreatitis (37.7%), percuteneous transhepatic cholangiography (24.5%) Whipple’s procedure (22.6%) and others (15.1%). Vessels affected included the right hepatic artery (24.5%), gastroduodenal artery (20.7%) and splenic (18.9%). Coil embolisation was performed in 39 (73.6%) and a covered stent placed in 7 (13.2%). The remaining pseudoaneurysms were treated with thrombin (5.7%), gelfoam (5.7%), PVA (5.7%) histoacryl glue (3.8%) and an Amplatzer vascular plug (1.9%). More than one embolisation technique was used in 9/53 aneurysms. Technical success was achieved in 47 (88.7%) and clinical success in 41 (77.4%). 15 repeat procedures and 10 repeat interventions were performed in 12 patients. The complication rate was 18.8% including non target embolization and arterial dissection. Conclusion: Visceral pseudoaneurysms in the hepaticopancreaticobiliary patient are difficult to manage, requiring several treatment approaches and associated with a high complication rate.
ABSTRACTS - SCIENTIFIC SESSION 4 26. MINIMALLY INVASIVE T-TUBE INSERTION FOR OESOPHAGEAL PERFORATION AND ANASTOMOTIC LEAK FOLLOWING OESOPHAGECTOMY Aidan Shaw1, Abrie Botha2, Aneeta Parthipun1, Panos Gkoutzios1, Renato Dourado1, Athanasios Diamantopoulos1, Irfan Ahmed1, Konstantinos Katsanos1, Tarun Sabharwal1 1 Interventional Radiology, Guy’s and St Thomas’ Hospital, London, United Kingdom 2 Upper GI Surgery, Guy’s and St Thomas’ Hospital, London, United Kingdom Aims: Late presentation of oesophageal perforation and anastomotic leak following oesophagectomy are associated with a high morbidity and mortality. Whilst surgery still remains an important treatment option for both conditions, the non-operative approach is essential for when less invasive techniques are required. T-tubes promote the formation of granulation tissue and are well described as a surgical treatment option for the late presentation of oesophageal perforation. We describe a minimally invasive rendezvous hybrid technique using endoscopic, computed tomography (CT) and ﬂuoroscopic guidance, which has now been performed four times in our institution. The percutaneous approach has not been previously described for oesophageal anastomotic leaks. Materials and Methods: Pre-operative planning is performed with computed tomography (CT) and contrast swallow studies. The procedure is performed in the CT suite. Access to the collection associated with the leak/perforation is performed using CT. A wire is then either snared from the endoscope or from the collection with ﬂuoroscopic guidance to attain through and through access. Following serial dilatation, the T-tube is then passed from the mouth and out through the access site. Results: The procedure has been performed in our institute four times with 100% technical success. With three patients, the procedure was the deﬁnitive treatment. One patient required surgery, however the T-tube relieved the sepsis and acted as a bridge to surgery. Conclusion: We present a novel technique for minimally invasive T-tube insertion for the successful treatment of oesophageal perforation and anastomotic leak following oesophagectomy.
27. FLUOROSCOPIC GUIDED INSERTION OF A NEW OESOPHAGEAL STENT FOR LEAK FOLLOWING BARIATRIC SURGERY, OESOPHAGEAL PERFORATION AND TRACHEO-OESOPHAGEAL FISTULA FORMATION Aidan Shaw, Aneeta Parthipun, Renato Dourado, Irfan Ahmed, Tarun Sabharwal Interventional Radiology, Guy’s and St Thomas’ Hospital, London, United Kingdom Aims: Leaks following bariatric surgery, oesophageal perforation and tracheo-oesophageal ﬁstula formation are conditions associated with a high morbidity and mortality. All sets of patients are high risk for major abdominal surgery and the nonoperative approach is preferred as a ﬁrst line management. The Taewoong Niti-S Oesophageal Beta StentTM is a new oesophageal stent designed speciﬁcally for the treatment of leaks following bariatric surgery. Traditional covered stents have been troubled by high rates of migration. This new stent has a double layer design to prevent migration and a suture to facilitate removal and re-positioning. We describe our experience of its successful use in our institute in the treatment of patients with leaks following bariatric surgery, oesophageal perforation and tracheo-oesophageal ﬁstula formation. Materials and Methods: Pre-operative planning is performed with computed tomography (CT) and contrast swallow studies. The procedure is performed under ﬂuoroscopic guidance. A catheter and wire are manipulated across the leak into the stomach. The anti-migration “bumps” of the stent are then sited either side of the leak or ﬁstula. Results: The stent has been sited ﬁve times in our institute. All patients have been treated successfully and following the removal of the stent no residual leak/perforation has been identiﬁed with no patients requiring further surgery. Conclusion: The new oesophageal Beta stent is a successful minimally invasive treatment method for patients with leaks following bariatric surgery, oesophageal perforation and tracheo-oesphageal ﬁstula formation.
ABSTRACTS - SCIENTIFIC SESSION 4 28. DOUBLE-LAYERED “KNITTED” COLONIC STENTS WITH INTERNAL COVERING MEMBRANE: INITIAL EXPERIENCE Brigid McCormack, Philip Borg, Jon Bell, Damian Mullan, Hans-Ulrich Laasch Dept. of Radiology, The Christie NHS FT, Manchester, United Kingdom Aims: To assess whether colonic stents with the covering membrane sandwiched between two knitted layers of Nitinol perform as well as uncovered braided stents. Materials and Methods: Over a four-year period, consecutive patients receiving doubled covered colonic EGIS stents (BVM Medical, Hinckley) in a supra-regional cancer centre were retrospectively reviewed regarding stent migration, obstruction and re-intervention rates. Stents were placed under ﬂuoroscopic or combined endoscopic/ﬂuoroscopic guidance. Data were extracted from log books, PACS and patient records with capture and analysis provided by Obsidian Health Ltd. Institutional Review Board approval was granted for this audit. Results: 21 stent insertions were attempted in 20 patients with a 76% (16/21) technical success rate. 53% were male (8/15). Primary malignancy was colorectal (67%), gynaecological (27%) and unknown (6%). Median stent length was 10 cm (range 10-12) all were 24mm in diameter. Median immediate stent expansion was 40% (range 0-100%). Stent migration was seen in 38% (6/16) at a mean of 121 days post insertion (range 2-298). Of these, 83% either required no further intervention (resolution of symptoms) or had conﬁrmed reduced disease following further chemotherapy. There were no reported cases of stent occlusion. Re-intervention rate was 19%. Mean survival was 174 days (range 5-484). Conclusion: Double knitted, covered stents seem to have a very acceptable re-intervention rate combined with good symptom relief. The high migration rate seemed to relate to patients receiving further treatment, reducing the tumour and the associated obstruction. The on-line database used in this pilot will be made available for a multi-centre study to investigate these small-scale results further.
ABSTRACTS - SCIENTIFIC SESSION 5 FRIDAY 14 NOVEMBER-INTERVENTIONAL ONCOLOGY CHAIRS: DR JON BELL & DR CHRIS HAMMOND MAIN AUDITORIUM
29. TRANSARTERIAL CHEMOEMBOLISATION(TACE) OF UNRESECTABLE HEPATOCELLULAR CARCINOMA- A WEBBASED SURVEY OF TREATMENT METHODS IN UK Shueh Hao Lim, Jim Gordon-Smith Dept Of Radiology, Edinburgh Royal Inﬁrmary, Edinburgh, United Kingdom Aims: Transarterial chemoembolisation (TACE) for unresectable hepatocarcinoma(uHCC) currently can be performed using conventional methods i.e lipiodol and doxorubicin or with newer drug eluting beads (DEB). Evidence remains equivocal as to which is the superior treatment. No overview of the practice of TACE in the UK is currently available. Materials and Methods: A web-based survey (Surveymonkey.com) of BSIR members was performed from December 2013 to March 2014. As well as asking, which treatment type was used, questions included, who was responsible for referral, treatment types, reasons for current practice, timing of follow-up imaging, volume of disease treated in a single session and volume of TACE performed annually. Results: Data was retrieved from 28 centers in UK. 11 centers performed more than 50 cases annually. 58% of centers used DEB only as their treatment method. 12% used conventional method, with the other 23% using a combination of both methods. 7% of centers currently used conventional method for non trial group and only DEB for trial group. Cost was the main reason deterring the change to DEB. 19% of clinicians interviewed would treat high volume disease in a single procedure. Referral for TACE mainly came from hepatologist (50%). 89% of centers performed their ﬁrst follow up scan within 4-6 weeks of procedure. Majority (89%) of interventionists disagree with the 2012 Cochrane statement that TACE should not be used for treatment for uHCC until stronger evidence is available. Conclusion: The survey demonstrates still a wide variation in the practice of TACE, within the UK. However with both forms of TACE being used in regular clinical practice in the UK, the possibility of creating a head to head trial between DEB and conventional TACE is realistic.
30. REVIEW OF OUTCOMES FOLLOWING TACE BASED ON HEPATOMA ARTERIAL-EMBOLISATION PROGNOSIS (HAP) SCORE Islah Din, Jana Klcova, Pawan Lekharaju, Omar Noorullah, Nick Stern, Pradesh Kumar, Elizabeth O’Grady Interventional Radiology, University Hospital Aintree, WIRRAL, United Kingdom Aims: Trans-arterial (chemo)embolisation (TACE) is now commonly performed for unresectable hepatoma. The HAP score was recently described and appears promising to determine patients likely to beneﬁt from TACE. We report our experience with HAP score to determine the prognosis of patients receiving TACE. Materials and Methods: Retrospective review of all the cases given TACE at University Hospital Aintree, UK (2006-2013). Imaging ﬁndings, types and number of TACEs and outcomes were recorded. HAP score [1 point each for albumin 400 ng/ml, Bilirubin >17 μmol/l, tumour diameter >7cm. HAP A = 0 points, B = 1, C = 2, D >2]. Results: 106 patients received TACE. Mean age 70; range of 34-88 with 88 (83%) male patients. 45% solitary lesion and 55% 2 or more lesions. Partial portal venous thrombosis was present in 4 cases; the portal veins were patent in all other cases. 65 (61.3%) patients received DEBDOX and the rest received Cisplatin-Lipiodol. 1 to 9 TACEs were performed with an average of 2.3 TACEs per case. HAP score A: 33 (31%); B: 33 (31%); C: 22 (21%); D: 18 (17%) patients. Overall median survival was 369 days (12.1 months). No 30 day mortality. Median survival by HAP score, A: 315 days; B: 581 days; C 358 days; D 212 days. Survival at 1 year: A 44 %; B 74%; C 45%, D 28%. 3 patients lost to follow up. Conclusion: Variable results for HAP scores A to C but HAP D clearly predicted the worst outcome for both overall and ﬁrst year survival.
ABSTRACTS - SCIENTIFIC SESSION 5 31. CRP IS A PREDICTOR OF OUTCOME IN PATIENTS WITH HCC UNDERGOING TACE Paddy Nicholson1, Kevin P. Murphy2, David Tuite2, Adrian Brady1, Owen J. O’Connor2, Peter MacEneaney1 1 Radiology, Mercy University Hospital, Cork, Ireland 2 Radiology, Cork University Hospital, Cork, Ireland Aims: The prognostic value of C-reactive protein (CRP) in patients with hepatocellular carcinoma (HCC) is well established, but there exists relatively little data regarding its use in HCC patients undergoing transarterial chemoembolisation (TACE). We sought to look at outcomes in our institutions in patients who underwent TACE for HCC. We further sought to evaluate the value of pre-embolisation CRP levels in predicting both clinical and radiological outcomes following TACE. Materials and Methods: This multi-centre study involved a retrospective review of 34 patients (73 ± 12 years, 29 male) who underwent a total of 100 TACE procedures over a six-year period. Pre-procedure CRP values were available in 90% of cases. Other factors evaluated included liver function tests and tumour markers (Bilirubin, Alkaline Phosphatase, transaminases (AST/ALT), gamma glutamyl transpeptidase (GGT), and alpha-fetoprotein). Following TACE, we evaluated both clinical factors (overall survival) and radiological response to TACE (as measured by modiﬁed RECIST criteria (mRECIST) on followup CT at 3 months). Results: Follow-up imaging was available in 85% of patients. Median follow-up was 28 months (range 1-76). No association was found between CRP and liver function tests, tumour markers, patient age or other biochemical parameters (r