Interventionell Radiologisches Olbert Symposium

FREE PAPER ABSTRACTS AND AUTHOR INDEX SALZBURG, 16.– 18.1.2014 Transnational congress of the German, Austrian and Swiss Societies (DeGIR, ÖGIR & SSCVIR) of Interventional Radiology

Online Publication Number: 10.1007/s00270-013-0798-5

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Drug-coated balloon (DCB) versus standard balloon for the treatment of de-novo lesions in the superficial femoral artery (SFA) and PI segment – first interim results of the Freeride study

Central venous access ports implanted at the forearm – a retrospective single-center analysis of 1,690 patients

K.-L. Schulte 1,B. Fernandez –Tresguerres2, R. Langhoff1; 1Berlin/DE, 2In den Dauen/DE Purpose: The use of paclitaxel DCB during percutaneous transluminal angioplasty (PTA) treatment of the femoropopliteal disease might be associated with significant reductions in restenosis rates. The Freeride study investigates the inhibition of restenosis by the DCB FREEWAY versus POBA (plain old balloon angioplasty) in the treatment of de-novo occluded, stenotic, re-occluded or restenotic lesions in the SFA and PI segment. Material and Methods: 280 patients were randomized either to Freeway DCB or to POBA in 23 centers worldwide. The primary endpoint is TLR rate at 6 months. Secondary endpoints investigated are late lumen loss and patency rate at 6 months, TLR at 12, 24 months follow-up (FU), and change in Rutherford classification at FU and MAE. Results: 68 patients enrolled, 42 of them have completed 6 month FU. Post-procedure results show remarkably more bail-out stenting after POBA compared with FREEWAY. At 6 months FU there is a significantly better clinical outcome according to Rutherford classification after FREEWAY vs. POBA (0 ± 1.29 vs. 1 ± 1.45; p=0.02). Furthermore, positive trends for the TLR rate (8% vs. 11.7% after POBA; p=0.68) and patency rate are observed. Conclusion: First results indicate FREEWAY might provide an advantage for PTA in SFA and PI segment lesions. DCB use might overcome existing limitations in PAD treatment.

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M. Wildgruber, S. Borgmeyer, J. Gaa, J. Ettl, H. Berger; Munich/DE Purpose: To retrospectively radiologically evaluate totally implanted central venous access ports of the forearm in terms of safety, technical feasibility, and device-related complications. Material and Methods: Between 2004 and 2012, 1,690 central venous arm ports were implanted in the forearm in 1,690 patients. Data were retrospectively analyzed with focus on technical success, short-term complications and long-term success. Neither antibiotic prophylaxis nor long-term anticoagulation was given on a standard basis. Results: Port implantation in the forearm succeeded in 99.2% of all cases (primary technical success rate). No major periprocedural complications were recorded. During the follow-up period of a total of 629,500 catheter days (372 days/patient), 139 devices had to be removed because of complications (8.2%). Among these, the most frequent complications were local infection (3.0%), venous thrombosis of the catheter-carrying vein (2.4%), catheter disconnection/catheter line displacement (1.5%) and occluding thrombus at the catheter tip requiring heparinization (0.9%). Complications were classified as periprocedural complications, early complications within the first 30 days and late complications thereafter. Conclusion: Radiologic placement of a totally implanted central venous arm port in the forearm is a safe procedure with a low rate of both early and late device-related complications. The method is effective for delivery of chemotherapy, parenteral nutrition, and frequent IV medication.

Salzburg, 16. – 18. Januar Salzburg, a 201417. –19. ar 19. Jänner Jä ännne n r 2014 20014

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Paclitaxel-coated balloon angioplasty for symptomatic central venous restenosis in patients with hemodialysis fistulas

Movement of stent-grafts after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms: comparison of patients with and without type 2 endoleaks

A. Massmann, P. Fries, K. Obst-Gleditsch, P. Minko, R. Shayesteh-Kheslat, G.K. Schneider, A. Bücker; Homburg/DE Purpose: Retrospective evaluation of standard plain old balloon angioplasty (POBA) and Paclitaxel-coated balloon angioplasty (PCBA) for central venous restenoses in patients with impaired hemodialysis fistulas. Material and Methods: 27 patients (male 15, mean age 66 ± 14 [39-90] years) with 32 non-malignant central venous stenoses (CVS) were treated initially by POBA. Symptomatic restenoses were treated by POBA or by PCBA after a single or repetitive re-POBA. All Paclitaxel-coated balloons (Elutax SV, AachenResonance, Germany; diameter 6-14 mm) were custom-made. Results: CVS included the axillary (11), subclavian (6), brachiocephalic (12) and/or superior vena cava (3). 3 patients had a combination of 2, 1 patient of 3 CVS. Primary technical and clinical success of initial and re-angioplasty was 100%. Re-intervention (POBA n=32; PCBA n=20) due to restenosis was necessary in 15 (55.6%) patients. Kaplan-Meier analysis revealed PCBA significantly superior to POBA (p=0.03). Median freedom from target lesion revascularization after PCBA was 12 months vs. 5 months after POBA. Re-restenosis intervals were significantly prolonged by PCBA (mean 9.5 ± 1.9 months) vs. POBA (mean 5 ± 4.9 months) (p=0.01). No minor/major procedure-associated complications occurred. Conclusion: Paclitaxel-coated balloon angioplasty of central venous re-stenosis yields a significantly longer freedom from TLR in patients with hemodialysis shunts and therefore should be considered the primary treatment approach.

R. Nolz, E. Schwartz, G. Langs, C.M. Loewe, D. Beitzke, A.G. Wibmer, A. Prusa, U. Asenbaum, J. Lammer, M. Schoder; Vienna/AT Purpose: To compare multidirectional stent-graft movement in patients with (EL-2) and without (nEL) a type 2 endoleak. Material and Methods: Out of 143 electively treated patients (129 men; mean age 73.6, range 53 – 90 years), 69 patients were in the EL-2, and 74 patients in the nEL group. For measurements, a surface model of the stent-graft, delimited by landmarks using purpose-built software, was derived for the pre-discharge and the last CT-follow-up. Categories of stent-graft surface movement of more than 3, 6, 9, 12, and 15mm were built, and for each category the percentage of moving area of the surface was measured. Freedom from stent-graft related endoleaks (srEL) was evaluated. Results: The mean follow-up was 35.0 ± 26.1 months. In all measured categories there was a clear trend towards a higher area of surface movement in the nEL compared with the EL-2 group, which achieved significance (p = 0.049) in the movement category > 12mm (16.0 ± 26.5 % vs. 10.1 ± 22.4%). Five (6.8 %) patients in the nEL and one (1.4 %) patient in the EL-2 group suffered from a srEL (p = 0.272). Conclusion: The presence of a type 2 endoleak reduces the area of moving stent-graft surface.

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Embolization of endoleaks using ethylene vinyl alcohol copolymer

Endovascular treatment of thoracoabdominal aortic aneurysms (TAAA) with the branched Jotec stent-graft: mid-term results

R. Müller-Wille, N. Zorger, C. Stroszczynski, P. Heiss, W.A. Wohlgemuth; Regensburg/DE Purpose: To determine the efficacy of type II endoleak embolization using liquid embolic agent ethylene vinyl alcohol copolymer (Onyx). Material and Methods: We reviewed the course of sixteen patients who underwent embolization of type II endoleak after endovascular aortic aneurysm repair (EVAR) using liquid embolic agent ethylene vinyl alcohol copolymer. Clinical success was defined as stabilization/ shrinkage of the aneurysm size during follow-up. Results: Embolization with embolic agent ethylene vinyl alcohol copolymer was successful in 13 of 16 patients (81.3%). Incomplete embolization of the nidus was associated with significant aneurysm sac enlargement during follow-up. Conclusion: Onyx is a favorable embolic agent for endoleak embolization. Complete embolization of the nidus is needed to achieve clinical success.

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M. Funovics, J. Lammer; Vienna/AT Purpose: Retrospective single-center case series. Material and Methods: In 2012, 8 patients with TAAA unfit for open surgery underwent endovascular treatment. The visceral aortic segment was excluded with a 4-fold branched Jotec stent-graft. Proximal thoracic stent-grafts and distal tubular bifurcated abdominal stent-graft s were used. Bridging stent-grafts (Atrium Advanta-V12) were inserted via surgical or percutaneous brachial approach. Results: No procedure-related mortality occurred. All visceral arteries were engaged in 6/8 patients (one stenosed celiac artery was not connected, two renal arteries required ilio-femoral bypass). Primary endoleak rate was 4/8 (type I: 3, type III: 1). Assisted Endoleak rate was 2/8 (one type V and one type III untreated due to comorbidity). Complete exclusion after secondary interventions in 6/8. Complications included partial neurologic deficit in 1/8, infection with surgical revision of groin in 1/8. Mean follow-up was 12 ± 4 months. Secondary type Ib endoleak occurred in 1/8 due to distal dilatation. Sac expansion was present in the two patients with type III and V endoleaks. Exclusion was stable in 5/8 patients. Conclusion: The Jotec stent-graft is safe and effective. Our liberal indication for a staged approach leads to higher incidence of secondary percutaneous procedures but lower operative stress. The results are favourable, reflecting the high comorbidity in our collective.

Salzburg, 16. – 18. Januar Salzburg, ar 201417. –19. 19. Jänner Jä ännner 2014 20

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Novel ascending aortic stent-graft design: experimental, cadaveric, and clinical

Planning and performance of percutaneous procedures of lung and liver inside the angio-suite: double angulation of needle positioning based on 3D-angio-CT data sets combined with a robotic system

M. Popovic, G. Erman, G. Berzaczy, D. Berzaczy, A. Wielandner, J. Lammer, M. Funovics; Vienna/AT Purpose: Endovascular stent-graft treatment of the ascending aorta is feasible in special indications. The purpose of this investigation was to evaluate a novel stent-graft design in phantoms, cadavers, and one clinical patient. Material and Methods: A stent-graft was specifically designed for application in the ascending aorta. This includes fixation of the apices facing the inner curvature with metal levers distally, thereby eliminating the forward movement due to apex fixation near the nose cone. The device was deployed in three aortic phantoms and four cadavers. The distance between the actual and the intended landing position along the inner and outer curvatures was recorded. Ultimately, the device was implanted in a patient with a large pseudoaneurysm. Results: The stent-grafts were successfully deployed in all phantoms and cadavers. The total error range in placing the proximal end of the stent-graft was within 1mm proximal and 14mm distal to the intended landing zone on the inner curvature and between 2 and 8mm distal to the intended landing zone on the outer curvature. In the clinical application, the stent-graft was deployed without complications, and the patient was discharged from the hospital within 7 days. Conclusion: The novel stent-graft design allows its safe and precise placement into the ascending aorta.

L. Pallwein-Prettner, G. Schmid, P. Waldenberger; Linz/AT Purpose: Limited time-slots in the CT-suite can be compensated with a transfer of minimally invasive procedures into the angio-suite. We present our preliminary experiences planning and performing percutaneous punctures of liver and lung based on 3D angio-CT data sets combined with a robotic system. Material and Methods: We performed punctures in liver or lung on 10 patients, based on 3D angio-CT data sets (Xper-guide, Allura Philips). This system additionally allows the implementation of external data sets (MR, CT) for image fusion. After determining entry-point and target, needle positioning was performed under fluoroscopic control using a robotic guidance system for double angulated needle positioning (iSYS). Organ movement was compensated under general anesthesia. A second angio-CT was performed to determine de-facto needle position in relation to pre-procedure planning. Results: In all cases (10/10) correct needle positioning was achieved. There was no needle-displacement at the entry point, but displacement of the target within 3-5 mm was found in 4/10 cases. This can be explained by intracorporeal needle bending. All procedures were completed successfully. Conclusion: The use of 3D angio-CT data combined with a robotic system allows for transferring percutaneous procedures of liver and lung into the angio-suite.

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Technical outcome, complications and effective patient dose of percutaneous CT-fluoroscopy guided screw placement for the fixation of unstable pelvic fractures

Diffusion-weighted MRI (DW MRI) vs. PET/CT for early treatment response assessment after Y90-radioembolisation

S.M. Häußler1, F.F. Strobl1, P. Paprottka1, O. Pieske1, B. Rubenbauer1, T.F. Jakobs1, R.-T. Hoffmann2, M.F. Reiser1, C.G. Trumm1; 1Munich/DE, 2Dresden/DE

A. Barabasch, A. Ciritsis, N. Hansen, C.K. Kuhl, N.A. Kraemer; Aachen/DE

Purpose: Percutaneous CT-fluoroscopy guided iliosacral screw placement is an increasingly used technique for fixation of pelvic instabilities. This minimally invasive option to open surgery may be used in patients with dislocation of the iliosacral joint or sacral fractures. Material and Methods: Our retrospective analysis includes 99 patients with longitudinal fractures of the sacrum and/or dislocation of the iliosacral joint treated with CT-fluoroscopy guided screw placement in our department from 11/2005 to 03/2013. Interventions were carried out under general anesthesia and CT-fluoroscopy (128-row scanner, Siemens Healthcare, Germany). Technical outcome, major/minor complications and effective patient dose were analysed. Results: 99 patients (mean age 53.1 ± 21.7 years, 50 male, 49 female) with dorsal pelvic ring instability were treated with CT-fluoroscopy guided screw placement. Intervention was technically successful in 99 patients (100%). No major and one minor local complication occurred (1%, slight screw dislocation). General complications included 3 cases of death by pulmonary embolism or cardiac events. Mean effective patient dose during an intervention was 12.28mSv ± 7.25mSv. Conclusion: CT-fluoroscopy guided screw placement for pelvic ring instabilities can be performed with high technical success and a low complication rate. This method provides excellent visualization of adjacent neural structures for precise screw placement and acceptable effective patient dose.

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Purpose: Radioembolisation (RE) is an established method for local treatment of otherwise refractory primary and secondary liver malignancies. Fluorodeoxyglucose (FDG) uptake quantified by standardized uptake value (SUV) in positron emission tomography (PET)/CT-scans is an established parameter for tumour response assessment and overall survival following RE. The aim of the study was to compare the accuracy of liver MRI to PET/CT for early treatment response assessment eight weeks after RE. Material and Methods: 112 REs in 65 patients were performed for treatment of liver metastases. 20 patients (13 female; mean age 62 ± 11y; 12 colorectal, 7 breast and 1 cholangiocellular carcinomas) received liver MRI and PET/CT-scans within 6 weeks prior and 8 weeks after RE of the right liver lobe. Three target lesions per patient were defined. In both modalities, changes of tumour size, ADC-value and SUV were compared before and after RE. Results: After RE, maximal SUV (SUVmax) decreased from 7.62 ± 3.19 to 5.16 ± 2.06 (p=0.0007). Minimal ADCvalue (ADCmin) increased from 0.55*10 - 3 ± 0.13*10-3 mm2/s to 0.76*10-3 ± 0.29*10-3 mm2/s (p=0.0003). A multi variance analysis (ANCOVA) showed a statistically significant association of SUVmax changes with changes in ADCmin (p=0.0176). Conclusion: Early response assessment after RE can be performed using DW-MRI which is shown to be at least as useful as PET/CT.

Salzburg, 16. – 18. Januar Salzburg, ar 201417. –19. 19. Jänner Jä ännner 2014 20

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Temporary arterial embolization of liver parenchyma with degradable starch microspheres (EmboCept® S) in a swine model

Evaluation of plasmatic and parenchymal elution kinetics in a domestic pig model using Irinotecanloaded drug-eluting beads

C.C. Pieper 1,C. Meyer1, B. Vollmar2, K. Hauenstein2, H.H. Schild1, K.E. Wilhelm1; 1Bonn/DE, 2Rostock/DE

D.M. Gnutzmann, J. Mechel, A. Schmitz, N. Bellemann, T.L. Gockner, N. Kortes, T. Mokry, C.M. Sommer, U. Stampfl, H.-U. Kauczor, B. Radeleff; Heidelberg/DE

Purpose: To evaluate the embolic properties, time-to-reperfusion and possible histological changes of temporary embolization of liver tissue with degradable starch microspheres (EmboCept® S) in a swine model. Material and Methods: After arterial catheterization of the hepatic artery on the lobar level, EmboCept® S was injected until complete stasis of the blood flow was angiographically detectable in four adult minipigs. The time to complete angiographically determined reperfusion was recorded. The animals were sacrificed two to three hours after complete reperfusion and the liver was explanted. Histological examinations of the embolized liver parenchyma as well as untreated tissue were performed in three cases. Results: Embolization of the hepatic artery using EmboCept® S was technically successful in all cases with complete stasis on control angiography. A single vial of EmboCept® S (450mg/7.5ml) was sufficient in all cases to embolize a whole liver lobe. Angiography demonstrated complete reconstitution of hepatic arterial perfusion after a mean time-to-reperfusion of 32 min (range 26 to 39min). There was no histologically detectable difference between untreated tissue and parenchyma embolized with EmboCept® S. Conclusion: Temporary embolization of the hepatic artery using EmboCept® S is feasible with complete reperfusion after 30 minutes. Even after complete arterial blood flow stasis, we observed no alterations of the embolized liver parenchyma in histological examinations.

Purpose: Irinotecan is a chemotherapeutic agent for local therapy of hepatic metastases caused by colorectal cancer, applied by drug-eluting beads (DEB). The severity of systemic side effects may be linked to different elution kinetics depending on the type of DEB. The purpose of our study was to compare two types of DEB regarding their elution kinetics by measuring plasma and tissue concentration. Material and Methods: 16 domestic pigs were treated by embolization of the left lateral liver lobes with groups of 2 receiving 1ml either DC Bead®M1 (70-150μm, DEBIRI®; Biocompatibles, UK) or TANDEM® Microspheres (75μm, CeloNova, USA), each containing 50 mg Irinotecan. Plasma levels were measured at 8 points in time after completed embolization and at the time of sacrifice (1d, 48h, 72h, 7d). After sacrifice, samples were taken for tissue concentrations. Results: For the first 4 hours, Irinotecan blood levels were higher in the DEBIRI group than in the TANDEM group. Significant differences were detected at 10 and 20 minutes p.i. with significantly higher Cmax (Median 158.3ng/mL) in the DEBIRI arm at 10 minutes compared to TANDEM Cmax (Median 90.13ng/mL) at 20 minutes. Conclusion: After embolization, Irinotecan is released significantly faster from DEBIRI than from TANDEM Microspheres in a pig model.

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Demonstration of the heat sink effect in microwave ablation – an experimental pig liver model

The value of pre-treatment MRI findings to predicting the outcome of MRgFUS in ablation of uterine fibroids: how much ablation do we need to predict clinical success?

K.I. Ringe1, C. Lutat1, C. Rieder2, F. Wacker1, H.-J. Raatschen1; 1Hannover/DE, 2Bremen/DE Purpose: To demonstrate and quantify the heat sink effect in microwave ablation (MWA) of liver tissue. Material and Methods: Ex vivo MWA was performed in freshly slaughtered pig livers. Antennas (active tip 37mm) were inserted parallel to non-perfused and perfused (700 and 1,400ml/min) glass tubes (diameter 10mm) at different distances (10, 15 and 20mm). Using dedicated software, ablation zones (radius, area) were analyzed and compared (Kruskal-Wallis Test). In addition, temperature close to the glass tubes was measured continuously throughout the ablation cycle (10 minutes). Results: Maximum temperature during ablation decreased significantly with increasing flow and distance (p

Abstracts of the Interventionell Radiologisches Olbert Symposium IROS 2014, January 16– 18, 2014, Salzburg, Austria.

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