Cardiovasc Intervent Radiol (2008) 31:S1–S20 DOI 10.1007/s00270-008-9296-6

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BSIR Abstracts 2007 - Scientific Session 1a Wednesday 31st October 07 - Scientific Session 1a Title Chairs

Vascular Dr Iain Gillespie & Dr Jane Phillips_Hughes

Main Auditorium: Tregonwell Hall 1. The “lightbulb” sign: an important angiographic feature in patients with Multiple Angiomyolipoma J. Lenton1, D.O. Kessel2, A.F. Watkinson3 1

?, ?, LS23 - Leeds/UK Interventional & Vascular Radiology, United Leeds Teaching Hospitals NHS Trust, LS1 3EX - Leeds/UK 3 Radiology, Royal Devon and Exeter Foundation Trust, Exeter/UK 2

AIMS: To report a novel and important angiographic finding and the outcomes of elective and emergent embolization of renal angiomyolipoma. MATERIAL AND METHODS: A retrospective review of all patients undergoing embolization of renal angiomyolipoma at a two centres between 1998 - 2007. Indications for treatment and angiographic images were reviewed. Incidence of acute rupture during embolization was noted. RESULTS: 14 patients underwent 20 episodes of embolization using polyvinyl alcohol (PVA) particles / coils. 11 were elective procedures for large or symptomatic angiomyolipoma and 9 were acute procedures for patients presenting with retroperitoneal haemorrhage. Patients presenting acutely with haemorrhage tended to have extensive multifocal renal involvement, a single patient showed active bleeding. Six out of 9 (66%) of the acute cases displayed the “lightbulb” sign i.e. splaying adjacent vessels due to peri-aneurysmal haematoma. This allowed treatment to be focused on the symptomatic aneurysm. The “lightbulb sign” was not present in any patient undergoing elective embolization. Aneurysm rupture with active extravasation occurred during embolization in 4 of 9 (44%) of patients in the acute group and 3 of 11 (27%) in the elective group. In one elective case aneurysm rupture occurred 48 hours following embolization with PVA alone. 5 patients required a subsequent embolization, 3 at a different site. CONCLUSION: Presence of the “lightbulb sign” is a strong indicator of the site of haemorrhage within the kidney. Embolization of the back door with PVA alone is unsafe as there is a significant risk of haemorrhage occurring during or after embolization. Selective embolization with a combination of polyvinyl alcohol particles and proximal coils is safe, effective and durable therapy for AML.

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Abstracts - Scientific Session 1a 2. Endovenous Laser Treatment for Varicose veins in an NHS Radiology department: Setting up, delivery and results. G. Ananthakrishnan1, R. Bhat2, G. Griffiths3, G. Houston4 1

Radiology, Ninewells hospital, DD1 9SY - Dundee/UK Radiology, Ninewells Hospital, DD19SY - Dundee/UK 3 Surgery, Ninewells hospital, DD1 9SY - Dundee/UK 4 Radiology, Ninewells Hospital, Dundee/UK 2

AIMS: The regional criteria for varicose vein treatment (skin changes and/or ulceration), are more stringent than the initial EVLT reports. Our aim was to determine if EVLT, could be applied to patients meeting these stringent criteria for treatment and to develop an outpatient based service in the radiology department and asses the effect on waiting times. MATERIAL AND METHODS: 35 patients were selected from the surgical waiting list and offered EVLT as an alternative to conventional surgery, on an outpatient basis in the radiology department. The initial study was performed in 15 patients and later as an extension in 20 patients, who were more technically challenging. Directed medical history and duplex examination were performed in the outpatient clinic. All procedures were performed in an interventional suite, using a Diomed 810nm laser and standard technique. Patients were discharged home with long leg bandage for a week and followed up at 6 weeks. An assessment on the effect on the waiting list was undertaken. RESULTS: Technical success was achieved in 38/40 legs in 33 of 35 patients. One patient required extension of treatment at a later date and one patient who was very thin and at increased risk of skin burns was not treated. Five patients required fluoroscopic guidance and/or additional catheters. At follow-up, there was symptomatic improvement in all treated patients. One patient had superficial thrombophlebitis. No other complications were reported. The procedure was well tolerated with a high level of satisfaction. Over the timescale of the study, the waiting list was reduced from 26 to 18 weeks. CONCLUSION: This experience has allowed prediction of the use of EVLT according to regional varicose vein treatment criteria and has confirmed its suitability in challenging cases. Performing this procedure in the radiology department has advantages of high quality ultrasound, back up of fluoroscopy in the interventional suite, catheter - guidewire availability and skills at catheter manipulation.The introduction of EVLT can help improve waiting times.

3. Laser Ablation of the Greater and Lesser Saphenous Veins is only an alternative to conventional truncal vein stripping M. Adiseshiah1, O. Agu2, C. Bishop2 1

Endovascular Unit, University College Hospital, N1 - London/UK Endovascular Unit, UCH London, London/UK

2

AIMS: We reviewed our experience of laser ablation of the truncal veins with surgical avulsions of reticular veins during a single episode, with particular reference to the 6 week post laser duplex examination MATERIAL AND METHODS: We recorded pre- and post-op duplex scan findings after truncal laser ablation and stab surgical avulsions of reticular veins at the same time. Of 116 legs in 101 patients, 86 (75%) had GSV incompetence and 30 (26%) had SSV incompetence.. Exposure to laser energy was varied to deliver 50 to 100 Joules/cm according to perceived degree of sclerosis of the target vein using a catheter 70cm long and graduated in cms. RESULTS: Of 116 truncal laser ablations, 2 cases demonstrated truncal reflux at 6 weeks post- op. Satisfaction rates were high according to a pre and post op questionnaire. Of the 86 patients with GSV incompetence, 85 cases exhibited LSV occlusion at 6 weeks but all showed a patent but competent sapheno-femoral junction. 1 case of 30 (3%) of SSV developed recurrent SSV incompetence and required a re-intervention with laser with a successful result. CONCLUSION: After truncal laser ablation with simultaneous stab reticular vein avulsion, the need for further intervention within 12 months approaches 0%.

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Abstracts - Scientific Session 1a 4. Stenting of peripheral arterio-occlusive disease in the femoropopliteal segment C. Dey1, M. Ashcroft2, W. King2, A. Odurny2, D. Thompson2 1

Radiology, SOUTHAMPTON UNIVERSITY HOSPITALS, SO22 6DE - SOUTHAMPTON/UK Department Of Radiology, Southampton University Hospitals, Southampton/UK

2

AIMS: 1. To review our experience of stenting in the femoropopliteal segment. 2. To ascertain patency and clinical outcome after stenting. 3. To relate outcome to patterns of disease. 4. To ascertain any difference in outcome with stent type. MATERIAL AND METHODS: A retrospective review of data from clinical notes, procedural databases and follow up data from clinics and ultrasound surveillance was carried out. All patients undergoing native superficial femoral (SFA) or popliteal artery stenting for occlusive or stenotic disease were included from 2005 to 2007. Assessment of presenting clinical category of chronic ischaemia, angiographic appearances, reason for stenting, immediate technical result, stent patency and clinical outcome was made. RESULTS: We reviewed 52 limbs in 52 patients (36 males, 16 females; age range of 47-93 years; mean of 73 years). 59% of treated lesions involved the SFA alone, 31% involved the popliteal artery and 10% involved both the SFA and popliteal artery. 54 % of the lesions were stenotic and 46% were occlusive. The length of the diseased segment ranged from <5cm to the whole length of SFA. A single stent was used in 77% patients, two stents in 17% patients and three stents in 6% patients. Most commonly, Cordis Smart (37), EV3 Protégé Everflex (13) and Bard Luminex (7) were used.Technical success was 100%.The cumulative primary assisted patency rates at 6, 12 and 18 months were 77%, 61% and 33% respectively. The cumulative secondary patency rates were 83%, 71%, and 49%. 5 patients required re-intervention. CONCLUSION: Our 6 and 12 month patency rates are superior to those published for angioplasty alone. In our series, which included a higher proportion of occlusions than in other published series of femoral stenting, the results suggest SFA and popliteal stenting may achieve better results than angioplasty on its own. The relationship of clinical category, morphological pattern of disease and stent type with stent failure will be discussed.

5. Diagnostic efficacy and safety of visceral angiography in the investigation of gastrointestinal bleeding in children K. Vendhan1, A.M. Barnacle2, D.J. Roebuck2, C.A. McLaren2 1

Interventional Radiology, Great Ormond Street Hospital, WC1N 3JH - London/UK Radiology, Great Ormond Street Hospital for Children NHS Trust, nw1 - london/UK

2

AIMS: Visceral angiography is well established as a valuable investigation for gastrointestinal (GI) bleeding in adults; it is performed far less commonly in the paediatric population. Results of a dedicated paediatric angiography service are unreported in the literature. A review was performed of the imaging results and clinical outcomes of all patients referred to our institution for visceral angiography with a history of suspected GI bleeding, to determine the safety, diagnostic rates and usefulness of this test. MATERIAL AND METHODS: Patients were identified from the Interventional Radiology case database. Images were available for review on the departmental digital imaging archive. Clinical information was obtained by case note review and cross-reference with clinical databases held in other departments. Angiography was deemed useful when the angiographic results led to a change in clinical management. RESULTS: 37 visceral angiograms were performed in 31 patients referred with suspected GI bleeding over a 7-year period.The subject age range was 3 months to 16 years (median age = 6.5yrs); 58% of subjects were male. All studies were available for review. Clinical follow up was available in 94% (29/31) patients. The immediate complication rate of angiography was 0%; there was no evidence of long-term complications. 36/37 of studies were diagnostic: 30/36 studies (83%) were positive, 3/36studies (8%) were equivocal and 3/36 (8%) were regarded as normal. 4/30 (13%) of the positive angiograms demonstrated active bleeding. All patients underwent other investigations for GI bleeding; the results of angiography differed from the results of other tests in 53% of the studies (19/36); and altered clinical management in 87% (26/29) of cases.3/36 angiograms were also therapeutic; 2/3 cases were coiled; 1/3 was coiled and had vasopressin infusion. CONCLUSION: Visceral angiography is a safe investigation in children. The test has a high diagnostic rate and significantly alters patient management in cases of suspected GI bleeding. Visceral angiography is recommended as a useful diagnostic test in this patient group.

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Abstracts - Scientific Session 1a 6. Performing Cognitive Task Analysis of Iliac Artery Interventions: the thin end of the wedge? A. England1, D. Gould2, S. Johnson3, W.E. Lewandowski4, H. Woolnough3, C. Hunt3, M. Crawshaw5, A. Healey6 1

Medical Imaging & Radiotherapy, University of Liverpool, L69 3GB - Liverpool/UK Radiology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool/UK 3 Manchester Business School, University of Manchester, M15 6PB - Manchester/UK 4 N/a, William E Lewandoski Consulting, Shepherdstown/US 5 Psychology, University of Hull, Hull/UK 6 Radiology, Royal Liverpool & Broadgreen University Hospitals, L7 8XP - Liverpool/UK 2

AIMS: To identify, describe and detail the cognitive thought processes, decision-making, and physical actions involved in the successful performance of iliac endovascular procedures. MATERIAL AND METHODS: Subject matter experts (SME) were identified by BSIR and CIRSE using a transparent appointment process. A selection of commonly performed iliac arterial interventional procedures were selected for cognitive task analysis. Interventions were performed by subject experts and a video-record taken using 3 DVD recorders (room overview, fluoroscopy, operator) simultaneously. These video records were analysed by a team of three occupational psychologists to broadly categorise the procedure steps performed. This skeleton procedural algorithm of the procedure was further refinemed (particularly for key features for a successful outcome) using individual interview / review of videos with SMEs. RESULTS: Detailed task descriptions and decision protocols were developed for endovascular iliac interventions (iliac PTA & stent insertions). Further analysis was performed by SMEs to identify critical procedural steps that might be used as metrics. CONCLUSION: Complex iliac endovascular procedures were broken down and their constituent processes identified. It is envisaged that data collected in this way can be used as an educational resource, and provide performance objectives for VR simulation.

7. Success rates and complications of transaxillary arteriography in the paediatric population K. Vendhan1, S. Brew2, A.M. Barnacle3, C.A. McLaren4, D.J. Roebuck4 1

Interventional Radiology, Great Ormond Street Hospital, WC1N 3JH - London/UK Radiology, National Institute of Neurology, London/UK 3 Radiology, Great Ormond Street Hospital for Children, WC1N 3JH - London/UK 4 Radiology, Great Ormond Street Hospital for Children NHS Trust, nw1 - london/UK 2

AIMS: Transaxillary arterial catheterisation is a well-established approach for diagnostic and therapeutic procedures when transfemoral approach is not feasible. However there is no current literature on the feasibility or complication rates of this approach in children. We performed a review of the clinical outcomes of all paediatric patients who underwent transaxillary arteriograms in our institution MATERIAL AND METHODS: Patients were identified from a prospectively-maintained Interventional Radiology case database. Images were available for review on the departmental digital imaging archive. Clinical information was obtained from the database and by case note review. All angiograms were performed under general anaesthesia. The sheath used varied from 3 Fr to 6 Fr depending on the age and size of the child and the type of procedure. A record was made of the catheter size used, duration of procedure, the vessels selectively catheterised, any interventional procedures performed and any complications. RESULTS: 14 transaxillary angiograms were performed in 11 patients over an 8-year period. The age range was 1 week to 8 years (median age = 2.6 yr, minimum weight 2.7 kg). Axillary artery access (left = 11, right = 3) was performed with ultrasound guidance using a 21-gauge needle or 22-gauge cannula and was successful in all cases. In 7/14 (50%) a therapeutic procedure was performed. Indications for axillary access were: elective 8/14 (57%), combined axillary and unilateral or bilateral femoral access for complex intervention 2/14 (14%) and failed femoral access due to iatrogenic bilateral iliac occlusion 4/14 (28%). A self-limiting axillary pseudoaneurysm occurred in 1 patient (7%). Two complications of interventional procedures (one fatal graft rupture and one inadvertent glue embolization) were unrelated to the axillary access. CONCLUSION: Axillary access for angiography is feasible in children as small as 2.7 kg. The complication rate is acceptable.

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Abstracts - Scientific Session 1a 8. Use of the StarClose device in retrograde and antegrade punctures in a single institution. S.R. Coles1, J. Tibballs2, S. Nadkarni2 1

Radiology, Sir Charles Gairdner Hospital, 6009 - Perth/AU Radiology, sir charles gairdner hospital, wa - perth/AU

2

AIMS: To evaluate the complication rates of the StarClose device, compare the closure of retrograde and antegrade punctures and demonstrate the device learning curve. MATERIAL AND METHODS: Retrospective review of all StarClose deployments from April 2005-July 2007 in a single tertiary referral institution Radiology department was performed using an existing database. This was crossreferenced to the hospital PACS system. Procedure reports and hospital notes were reviewed to evaluate minor (managed with compression) and major (requiring intervention) complication rates in the immediate post procedure period and following 24 hours. RESULTS: 148 StarClose devices were used in 130 patients. 42 (28%) were deployed after antegrade and 103 (70%) after retrograde common femoral arterial punctures. 3 (2%) were deployed after axillary artery punctures. Sheath sizes ranged from 5 F to 8 F. 2 consultant interventional radiologists, 2 interventional fellows and a vascular surgeon placed the devices. Notes were available for review in 136 (92%) of cases. There were 16 (11%) immediate failures of device deployment, 9/103 (9%) retrograde and 7/42 (17%) antegrade. One major complication occurred which required surgical repair, following a retrograde puncture. 6 minor complications occurred. In the 24 hours following the 132 successful StarClose deployments no major and 8 (6%) minor complications occurred. No complications were seen following axillary artery puncture. No late complications were seen at clinical or radiological follow up. The total major complication rate was 1/148 (0.7%). The total minor complication rate was 24/148 (16%), 12/42 (29%) following antegrade punctures and 12/103 (12%) following retrograde punctures. When assessed by year, the primary successful deployment rate was 1 in 8 (12.5%) in 2005, 12 in 73 (16.4%) in 2006 and 3 in 66 (4.5%) in 2007.

9. Day Case Peripheral Angioplasty using Nurse-Led Admission, Discharge and Follow-up Procedures: arterial closure devices are not necessary. R.S. Kasthuri1, H. Andrews2, D. Karunaratne2, J. Sumner2, N. Chalmers3 1

, , WA3 4DW - Warrington/UK Radiology, Manchester Royal Infirmary, Manchester/UK 3 Radiology, Manchester Royal Infirmary, M139WL - Manchester/UK 2

AIMS: To audit the safety of day-case peripheral arterial intervention without the use of arterial closure devices using nurse- led admission, discharge and follow-up procedures. MATERIAL AND METHODS: Patients referred for elective peripheral vascular intervention were selected for daycase care according to pre-determined criteria using telephone triage.Post-procedure haemostasis was achieved using manual compression.Following 3 hours bed rest, the patients were mobilized and discharged at 5 hours.Patients were contacted the next working day by telephone to audit complications. RESULTS: 183 elective day case peripheral interventions were performed over a two year period predominantly using 6F sheaths. No closure devices were used. Five patients(2%) returned to the department with persistent groin symptoms the next day.One of these had a false aneurysm. Four required no further treatment. A single patient returned at day 6 with a delayed false aneurysm. CONCLUSION: Day-case peripheral vascular intervention can be safely performed in approprately selected patients without the use of arterial closure devices. Specialist radiology nurses have a major role in councelling, care and follow-up of these patients.

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Abstracts - Scientific Session 1b Wednesday 31st October 07 - Scientific Session 1b Title Chairs

General Intervention Prof Jon Moss & Dr Jeffrey Hussey

Purbeck Lounge 10. Imaging Guided Hydrodynamic Thrombectomy for Occluded Dialysis Fistulae: Short term outcome data. P. Littler1, A. Chiphang2, R.V. Gedela3, D. Gould4, S. Powell5 1

Radiology, Royal Liverpool Hospital, L7 8XP - Liverpool/UK Radiology, Royal Liverpool University Hospital, L7 8XP - Liverpool/UK 3 , , L16 3GE - Liverpool/UK 4 Radiology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool/UK 5 Radiology, The Royal Liverpool Hospital, Liverpool, Liverpool/UK

2

AIMS: To compare the effectiveness of image guided hydrodynamic thrombectomy for occluded dialysis fistulae with the Dialysis Outcomes Quality Initiative Guidelines (DOQI). MATERIAL AND METHODS: All patients with occluded dialysis fistulae presenting to the Royal Liverpool Hospital since 01/10/2006 have been treated with the AngioJet Rheolytic Thrombectomy Device (Possis Medical, Minneapolis, USA). Demographics, time of occlusion, adjunctive therapies, complications, and follow up data have been prospectively recorded. This data has been compared with the DOQI guidelines which recommends that percutaneous thrombectomy +/- angioplasty should achieve immediate patency in 85%, and unassisted functional patency in 40% at 3 months. RESULTS: 27 thrombectomy procedures in 20 patients (mean age 60 years, 15 native venous fistulae, 5 PTFE grafts) were performed over a 7 month period.The mean time from fistula occlusion to thrombectomy was 4.8 days (range 1 -16 days). Adjunctive therapies included angioplasty (n=27), stent (n=5) and stent graft (n=3). Symptoms during thrombectomy occurred in 9 patients (chest pain, hand pain, dyspnoea). 1 patient had MI 4 hours post procedure. 5 of 6 patients with chest pain or dyspnoea had transient ECG changes (ST depression,T wave inversion, bradycardia and bigeminy). Immediate patency was achieved in 25 (93%) procedures; 14 of these dialysed via the fistula within 24 hours.The remainder awaited duplex reassessment prior to using their fistula, with interim dialysis using existing neck lines. Unassisted functional patency (UFP) at 4 weeks was achieved in 17 (68%) procedures. UFP at 3 months was achieved in 15 (67%) procedures. 6 month UFP was achieved in 2 (50%) patients. 10 re-interventions (6 within 30 days) were performed in 8 patients for re-stenosis (3) or re-occlusion (7), all with immediate patency. Reinterventions occurred after 30 days in 4 patients (90, 110, 150, 224 days). CONCLUSION: Hydrodynamic thrombectomy appears an effective treatment for occluded dialysis access fistulae, and exceeds the standards laid down in the Dialysis Outcomes Quality Initiative Document. Further work is underway to assess long term unasssisted patency following hydrodynamic thrombectomy.

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Abstracts - Scientific Session 1b 11. Effectiveness of fibrin sheath stripping for tunnelled haemodialysis catheter malfunction: a single centre experience A.M. Papadopoulou1, O. Halliwell2, A.E. Padilla-Thornton3, P.L. Munk2, D.C. Morris4, G.M. Legiehn2 1

Radiology, Vancouver General Hospital, University of British Columbia, V5Z1M9 - Vancouver/CA Radiology, Vancouver General Hospital, University of British Columbia, V5Z 1M9 - Vancouver/CA 3 , , V5Z4P1 - Vancouver/CA 4 Radiology, Vancouver General Hospital, University of British Columbia, V5Z 1 M9 - Vancouver/CA 2

AIMS: To examine the effectiveness of percutaneous fibrin sheath stripping in restoring function of tunnelled haemodialysis catheters at our intitution and compare our results with the published literature. MATERIAL AND METHODS: Over a 24-month period, a total of 37 patient encounters for percutaneous fibrin sheath stripping procedures met the inclusion criteria for our analysis.These were performed on 26 malfunctioning tunnelled haemodialysis catheters in 19 patients. Tissue plasminogen activator infusion trials had failed to adequately restore catheter function in all patients prior to referral to Interventional Radiology. Radiographic contrast examination confirmed the presence of a fibrin sheath on either or both catheter ports in all cases. Patients were followed up until the time of catheter failure, catheter removal, a further stripping procedure or alternative access creation not due to catheter malfunction, and evaluated for duration and adequacy (flow rates >250 ml/min) of catheter function. Patient clinical records were retrospectively reviewed to assess clinical outcomes. RESULTS: The technical success rate was 100% and no complications were encountered. The right and left internal jugular veins were the access site for 92% (24/26) and 8% (2/26) of catheters, respectively. The same site had been used for at least one previous catheter placement in 69% (18/26). Of the 37 stripping procedures, 22 (59%) were the first intervention on the catheter. The remaining 15 (41%) were preceded by at least one stripping procedure and were in patients who had been included in the analysis once (11/15) or more times (4/15). The median duration of adequate catheter function after stripping procrdure was 84 days (range = 15-335 days), with median duration of function after the first, second and third strippings of 63 days (range = 18-430), 98 days (range=18-209) and 121 days (range = 21-157), respectively. CONCLUSION: Percutaneous fibrin sheath stripping is a safe and effective method of restoring patency of malfunctioning tunnelled haemodialysis catheters due to fibrin sheath formation. The outcomes of this procedure at our institution over the past 24 months compare favourably with those of the published literature.

12.‘Is there a future for GP direct access to Interventional Radiology? – A survey of primary care physicians’ S. Desigan1, M. Al-Qaisi2, M. Hamady3 1

Dept. Of Radiology, St.Mary's Hospital, NW7 1NE - London/UK Dept Of Interventional Radiology, St. Mary's Hospital, W2 1NY - London/UK 3 Dept. Of Radiology, St. Mary's Hospital, W2 1NY - London/UK 2

AIMS: To determine the perception of Interventional Radiology (IR) as a specialty amongst primary care physicians (General Practitioners/ GPs) and to assess willingness for direct referral. MATERIAL AND METHODS: A web-based and postal questionnaire survey of GPs in and around London was conducted.They were asked about willingness to refer medical problems directly to IR, awareness of who performs particular procedures, and who they would refer to for these procedures.The results and comments were assessed. Similar questionnaires were then sent to hospitals in London to determine availability of local IR services. RESULTS: 156 replies of the 400 questionnaires sent to GPs (39% response rate) were received. 19/26 replies were received from hospital radiology departments (73% response rate). All hospitals responding (19/19) provided an IR service including common IR procedures. 17% of GPs hadn’t heard of IR or were unaware of its scope. 50-75% thought that one or more of common IR procedure is done by non IRs. 37% of GPs were unwilling or unsure about making direct IR referrals. 39% were concerned about the clinical ability of IRs.45% of respondents admitted lack of knowledge of local availability of IR services and/or direct referral arrangements. CONCLUSION: A large proportion of GPs are unaware of IR services scope and availability. The majority would be happy to refer directly to IR if appropriate setting is provided. A significant concern is raised about the clinical skills and ability of IRs.

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Abstracts - Scientific Session 1b 13. Portal vein embolisation using the Amplatzer plug - adequate hypertrophy with reduced chance of nontarget embolisation. C.L. Bent1, D. Low1, I. Renfrew2, M. Matson3, T. Fotheringham4 1

Department Of Radiology, Barts and the London NHS Trust, E1 - 1BB/UK Radiology, Barts and the London NHS Trust, E1 1BB - London/UK 3 Radiology, Barts and The Royal London NHS Trust, E1 1BB - London/UK 4 Radiology, The Royal London Hospital, E1 3AA - London/UK 2

AIMS: Portal vein embolisation (PVE) is well established as a pre-operative technique before major hepatectomy. By increasing size and functional reserve of the future liver remnant (FLR), it has enabled safer, potentially curative hepatectomy in patients deemed unsuitable for resection. Several embolic agents are in use without significant differences in degree of hypertrophy. However, non-target embolisation particularly into the left portal vein is a complication which may jeopardise left portal venous flow limiting volume increase. We assess the routine use of an Amplatzer plug for PVE. MATERIAL AND METHODS: Patients considered suitable for hepatectomy but with small FLR underwent PVE. The technique involved a right lobe approach with an Amplatzer plug positioned within the main right portal vein followed by Histoacryl glue/lipiodol administered into the peripheral branches. Liver CT was performed 6 weeks post PVE to assess the FLR. FLR volume and degree of hypertrophy, outcome and complications, including nontarget embolisation, were documented. The surgeons were questioned regarding the ease of hepatectomy following Amplatzer plug placement. RESULTS: Nine of 13 patients since November 2005 requiring PVE were embolised using a right portal vein Amplatzer plug and glue. All embolisations using the Amplatzer plug were technically successful. Percentage increase of FLR ranged from 34% to 85% (mean:51.8%). There were no non-target embolisations to the left portal vein. Of 9 patients with an Amplatzer plug, 3 underwent successful right hepatectomy, 5 disease progression precluding hepatectomy and in 1, hypertrophy was insufficient relative to body mass and proceeded to TACE. Surgeons expressed greater ease of heptatectomy following embolisation with an Amplatzer plug due to less inflammation involving hila vessels often elicited by alternative embolic agents. CONCLUSION: Right PVE can be safely and successfully performed using an Amplatzer plug followed by glue. This reduces risk of embolisation to the left portal vein. The resection plane appears to demonstrate less inflammation during hepatectomy. Careful selection of patients is of utmost importance prior to PVE to reduce likelihood of unsuccessful resection.

14. Interventional radiology proficiency assessment: a pilot study using magnetic tracking of hand motion. D. Bakshi1, B. Diaz2, N. Harrison2, B. Sreeharsha1, S. Powell3, T. How4, D.A. Gould5 1

Radiology, Royal Liverpool Hospital, L7 8XP - Liverpool/UK Computer Science, University of Liverpool, L69 3GB - Liverpool/UK 3 Radiology, The Royal Liverpool Hospital, Liverpool, Liverpool/UK 4 Clinical Engineering, University of Liverpool, L7 8XP - Liverpool/UK 5 Radiology, Royal Liverpool University Hospital, L7 8XP - Liverpool/UK

2

AIMS: This study investigates the applicability of magnetic sensor tracking of hand position, orientation, velocity and acceleration to interventional radiology (IR) proficiency assessment. (Funded by a BSIR Research Bursary, 2005). MATERIAL AND METHODS: Following a brief tutorial, 7 expert and 12 novice subjects were studied during three performances of selective left and right renal artery catheterisation using a simple, fixed vascular model (Elastrat, Geneva). Catheter manipulations were presented on a monitor screen while hand position and orientation were tracked by two sensors on the back of each hand within the “sense volume” of a magnetic field generator (Aurora, NDI, Toronto). Tracking and video data were recorded synchronously, with labelling of procedure phases applied to hand position/orientation data. Data from expert and novice groups were compared. RESULTS: In individual phases (e.g. linear traversal), proficiency is reflected in identifiable differences in velocity and acceleration profile and best explained in terms of the separated x, y and z components of each sensor position. Hand motion path, as well as procedure time, decreased markedly with each repeat in both experts and beginners. Procedural preview enhanced performance as compared with description only. CONCLUSION: These results suggest the metrics measured are applicable to objective assessment of subject proficiency in IR procedures. There is however a demonstrable learning curve for experts when using the model, and hence a more detailed, comparative analysis of a larger subject sample is required. This is now underway, with identified specific skills / metrics, and with development of skeletal motion visualisation.

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Abstracts - Scientific Session 1b 15. An Audit of Multi-Detector Row Computed Tomographic Angiography (MDCTA) in Acute Gastrointestinal Bleeding: Dose a negative scan reassure/obviate the need for invasive angiography? C.S.M. Hay1, A. Milson1, I. Wells1, R. Miles2 1

X-ray, Derriford, PL6 - 8DH/UK Radiology, Derriford Hospital, pl6 8dh - Plymouth/UK

2

AIMS: MDCTA is an important emerging modality in the diagnosis of acute life threatening endoscopically occult GI haemorrhage. Several small studies have shown that 54-91% of massive GI bleeds may be detected with MDCTA (1, 2). Due to small patient numbers included in these studies meaningful specificities are not seen in the literature. This would be useful in predicting the outcome of patients with negative scans. At Derriford we have conducted an audit of the use of MDCTA in the diagnostic algorithm of acute GI bleeding , so as to elucidate the pick-up rate of 16 and 64-slice machines and to review the outcome of patients with negative scans. MATERIAL AND METHODS: 1) Review coding for admissions with GI haemorrhage in 2005 and 2006. 2) Interrogate radiology system for all of those undergoing MDCTA. 3) Obtain patient notes and review the patient journey for each with refrence to the outcome of the test, the severity of the bleed and adverse events/their time scale during the admission. 4) Compare our MDCTA pick-up rate to that found in the literature review. The standards agreed upon for the detection in active massive GI bleeds should be between 54-91% (1-2). Also determine the outcome in patients with negative scans and massive hamorrhage. RESULTS: Of 870 patients admitted with acute GI bleed 14 underwent MDCTA. 5 had positive scans and proceeded to invasive mesenteric angiogram which was positive in 2 cases. 2 out of five patients with positive scans had bleeding sites confirmed by angiography. This proportion is less than that reported in the literature. 9 patients had negative MDCTA. None of these patients experienced an adverse clinical outcome. CONCLUSION: In our audit of patients who suffered a massive GI bleed and had a negative MDCTA no patient had an adverse clinical outcome related to their hamorrhage in the following 48 hours or thereafter. We find MDCTA to be a very usefull test in the managment of the acute endoscopically negative GI bleed, especially in the on call situation where a negative MDCTA may obviate the need for invasive angiography in most cases. Invasive angiography is unlikely to add anything in such cases as well as being potentially time consuming and inconvenient out of hours.

16. AngioJet Hydrodynamic Thrombectomy in lower limb ischaemia: outcomes at 12 months R.V. Gedela1, D. Thavarajan2, S. Powell3, J. Brennan4, R. McWilliams5, J. Evans6, D. Gould5 1

, , L16 3GE - Liverpool/UK Vascular Surgery, Royal Liverpool University Hospital NHS Trust, L7 8XP - Liverpool/UK 3 Radiology, The Royal Liverpool Hospital, Liverpool, Liverpool/UK 4 Vascular Surgery, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool/UK 5 Radiology, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool/UK 6 Radiology, Royal Liverpool University Hospital NHS Trust, L7 8XP - Liverpool/UK

2

AIMS: To retrospectively review 12 month outcomes following Mechanical Thrombectomy (MT) in acute and critical lower limb ischaemia MATERIAL AND METHODS: 45 patients (31 male, age 41 - 90, mean 69.2years) with limb ischaemia (Rutherford I, IIa or IIb), presenting consecutively to a single institution between January 2002 and April 2007, were reviewed retrospectively. 29(64.4%) were acute (<14 days duration). Imaging showed thrombo-embolic occlusion of 46 vessels, which were then managed by MT (AngioJet, Possis, Minneapolis, US).Vessels treated were iliac (5), superficial femoral (7) popliteal (8), tibial (6) arteries, and 20 vascular grafts. RESULTS: There was complete technical success in 35(76.1%) procedures, partial success in 2(4.3%) and failure in 9(19.6%). Follow up data was available in 42 patients at 30 days, and 33 at 12 months (no follow up available in 13). Amputation free survival was 78% at 30 days, and 60% at 12 months. At 30 days there were 5(11.1%) major amputations, 3(6.7%) surgical bypass grafts and 4(9.5%) deaths (all had presented with critical ischaemia). Adjunct interventions performed to achieve primary patency were: angioplasty (n=42, 91.3%) and stent (n=5, 10.9%). Infusions of chemical lytic agents were required in 11(23.9%) for residual thrombus. CONCLUSION: MT was technically effective in removing occlusive thrombus in 76%, with adjunct interventions performed in 91%, of procedures. 78% of those with 30 day follow up remained amputation-free. Deaths occurred exclusively amongst cases presenting with critical limb ischaemia.While this is a small study, further data collection using a registry is underway.

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Abstracts - Scientific Session 1b 17. Experienced endovascular interventionalists objectively improve their skills by attending carotid artery stent training courses. S. Neequaye1, I. Van Herzeele1, R. Aggarwal2, M. Hamady3, A. Darzi4, T. Cleveland5, N.J. Cheshire6, P. Gaines5 1 Department Of Biosurgery And Surgical Technology, Imperial College London, St. Mary's Hospital, W2 1NY London/UK 2 Division Of Surgery, Oncology, Reproductive Biology And Anaesthetics (sora), Imperial College London - St. Mary's Hospital, W2 1NY - London/UK 3 Dept. Of Radiology, St. Mary's Hospital, W2 1NY - London/UK 4 Division Of Surgery, Oncology, Reproductive Biology And Anaesthetics (sora)p, Imperial College London - St. Mary's Hospital, W2 1NY - London/UK 5 Sheffield Vascular Institute, Northern General Hospital, Sheffield/UK 6 Dept. Of Vascular Surgery, St.Mary's Hospital, W2 1NY - London/UK

AIMS: Carotid artery stenting (CAS) is an advanced endovascular intervention with a steep learning curve. Its success is tempered by the need to ensure that all interventionalists possess technical proficiency prior to performing cases on patients. Virtual reality simulation has been proposed as a means to train and objectively assess technical performance without risks to patient safety. The aim of this study was, using a commercially available simulator, to objectively assess psychomotor skills acquisition of experienced interventionalists attending a two-day carotid artery stent course. MATERIAL AND METHODS: Eleven experienced endovascular physicians from several medical disciplines with minimal experience in carotid artery stenting participated in this study. During two identical two-day courses, cognitive and technical skills were trained using didactic sessions, case reviews, supervised VR simulation and livecases. Pre- and post-course skills were assessed through performance on the same carotid artery stent procedure using the quantitative and qualitative assessment parameters derived from the simulator. The Wilcoxon signed ranks test was used to compare performance across the two groups. RESULTS: Significant differences were noted between pre- and post-course performance for total procedure time (medians 36 vs. 20 minutes, P=0.005), fluoroscopic time (20 vs. 11 minutes, P= 0.016) and delivery-retrieval time of the embolic protection device (12 vs. 9 minutes, P= 0.007). Advancement of the guiding catheter or guiding sheath without a leading wire occurred to a greater extent pre-course versus post-course (199 vs. 152 millimetres, P= 0.050) as did spasm of the internal carotid artery (4 vs. 2, P= 0.049). CONCLUSION: This study has objectively proven a benefit for experienced interventionalists to attend carotid artery stenting courses for skills acquisition measured by a virtual reality simulator. In addition to providing participants with an insight into their skills, these data can be used to objectively audit course efficacy.

18 . 4 Years Experience of Computed Tomography Guided Radiofrequency Ablation of Renal Tumours A. Abdellaoui1, O. Summerfield2, A.F. Watkinson3 1

Radiology, Royal Devon & Exeter Hospital, EX2 5DW - Exeter/UK Radiology, Royal Devon and Exeter Hospital, Exeter/UK 3 Radiology, Royal Devon and Exeter Foundation Trust, Exeter/UK 2

AIMS: To evaluate the safety, technical success, and efficacy of radiofrequency ablation of renal tumours. Material and Methods:22 percutanous radiofrequency ablations of renal tumours were performed over 4 years. 20 presumed primary renal cell carcinoma (9 biopsy proven) and 2 second primary or metastasis of contralateral RCC. Indications were comorbidity, solitary kidney and tumour size < 5cm. The average patient age was 71 years (range, 56-84 years) and the average tumour size was 3.6 cm (range, 2.5-4.9 cm). Patients were followed up using CT 3 months post procedure and yearly thereafter. RESULTS: Technical success was achieved in all patients. The average length of stay was 2.4 days. The follow-up ranged between 3-46 months. 6 patients needed hydrodissection of the tumour away from adjacent structures. All tumours showed a satisfactory response. Successful treatment was defined as decrease in size of the lesion and the absence of enhancement of residual tissue during the follow-up CT. There was no recurrence in 20 primary RCC. 2 patients developed multiple small tumours in the kidney that could be metastatic from previous contralateral RCC. We recorded 3 complications: perinephretic haematoma, psoas collection and urinoma, which were treated conservatively without clinical sequelae. Only one patient died during follow up, of brain metastasis from a primary lung cancer. CONCLUSION: CT guided radiofrequency ablation of renal tumours is a safe procedure and has shown promising early and mid-term results in a selected group of patients. Patients with previous nephrectomy for renal cell carcinoma should be given careful consideration.

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Abstracts - Scientific Session 2a Thursday 1st November 07 - Scientific Session 2a Title Chairs

Vascular Dr Ray Ashleigh & Dr Andrew Wood

Main Auditorium: Tregonwell Hall 19. The effect of angiographic equipment upgrades on radiation doses in uterine fibroid embolization. J.S. Freedman1, P. Crowe2 1

Radiology, Birmingham Heartlands Hospital, b17 9JH - Birmingham/UK Radiology, Birmingham Heartlands Hospital, b9 5ss - Birmingham/UK

2

AIMS: Upgrading angiographic equipment represents a major capital investment for any institution. New state-ofthe-art equipment promises many advantages including radiation dose reduction. We assess the impact this investment has on radiation doses in uterine fibroid embolisation (UFE) at two centres. MATERIAL AND METHODS: We reviewed 193 consecutive UFE procedures undertaken at two centres, which recently upgraded their angiographic equipment from two manufactures. Screening time (min:sec) and DAP radiation doses (cGy.cm2) were recorded. Average times and doses for old and new equipment were compared. In addition, a subset of cases for 12 months prior to and after equipment upgrades, were compared to reduce the effect of the learning curve. RESULTS: We present data, which show that new equipment delivers a significant reduction in radiation doses during UFE. Average screening times and doses from the two centres pre-upgrade were 18:22min/ 17757 cGy.cm2 and 16:57min/ 9144cGy. cm2. Following the upgrade average screening times and doses from the two centres reduced to 15:13min/ 4802cGy.cm2 and 12:20min/ 3846cGy.cm2. In the subset of procedures performed in the 12 months immediately prior to and after equipment upgrades, doses were reduced from 13693cGy.cm2 and 6194cGy.cm2 to 4803cGy.cm2 and 4337cGy.cm2. CONCLUSION: As UFE procedures are frequently performed on women of childbearing age and the ovaries are within the primary beam throughout the procedure, meticulous attention to dose saving techniques is essential. Our study shows that significant reductions in radiation dose can be achieved by upgrading out-of-date equipment, providing compelling evidence to justify the capital expenditure.

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Abstracts - Scientific Session 2a 20. Uterine Artery Embolisation for Symptomatic Adenomyosis – Mid-term Results M.J. Bratby1, W.J. Walker2 1

Radiology, St George's Hospital, SW17 OQT - London/UK Radiology, Royal Surrey County Hospital, GU2 7XX - Guildford/UK

2

AIMS: The clinical manifestations of adenomyosis are similar to those from uterine fibroids. However adenomyosis is an important separate entity which usually requires hysterectomy due to poor response to hormonal treatment or endometrial ablation. There have been a number of studies demonstrating promising short-term results following treatment with uterine artery embolisation (UAE). There have been 2 previous reported series with follow-up over 2 years after treatment, both of which have demonstrated a significant recurrence rate in clinical symptoms. We present data which confirms this finding. MATERIAL AND METHODS: 27 women (mean age 46.4 years, range 39-56) with adenomyosis were treated with UAE. Diagnosis was made by magnetic resonance imaging (MRI) in the majority, although adenomyosis was confirmed in five patients early in our series by core biopsy. 15 women had co-existent fibroids. Clinical assessment has been performed by self-completed standardised questionnaires prior to the procedure, and at follow-up intervals of 6 and 12 months and yearly thereafter. Clinical response has assessed menorrhagia, dysmenorrhoea and bulk symptoms on a four-point scale (entirely resolved, improved but not resolved, the same or worse). RESULTS: There was diffuse adenomyosis in 19 women (average uterine volume = 528ml), and focal adenomyosis in another eight (average diameter of adenomyoma= 6.6cm). 12 women had adenomyosis without any associated fibroids. Self-completed questionnaires were returned in 89% (24/27) of women when combining the 6 and 12 months time intervals. Initial results were promising with 82% of patients reporting either partial or a complete improvement in menorrhagia at 6 months with a similar figure of 79% seen at 1 year. Data on clinical response 2 years after UAE is currently available in 14 women. Six of these women did not have coexistent fibroids. There was a reported deterioration in the clinical symptoms of menorrhagia in 45.5% at 2 years and 54.5% at 3 years. CONCLUSION: There is a high rate of recurrence in menorrhagia symptoms two years following UAE for adenomyosis. This treatment option should only be offered to patients who are aware of this limited long-term efficacy.

21. Do Asymptomatic Angiographic Stenoses And Occlusions Become Symptomatic In Patients With Peripheral Vascular Disease? A.N. Keeling1, K. Khalidi1, P.A. Naughton2, F.P. McGrath1, M.J. Lee3 1

Dept Of Academic Radiology, Beaumont Hospital, 9 - Dublin/IE Dept Of Vascular Surgery, Beaumont Hospital, 9 - Dublin/IE 3 Radiology, Beaumont Hospital, Dublin/IE 2

AIMS: To determine the clinical outcome of patients with asymptomatic lower limb angiographic stenoses and occlusions. MATERIAL AND METHODS: All patients undergoing peripheral angiography +/- angioplasty in the Interventional Radiology Department were evaluated over a 4 year period from 01/01/99 to 31/12/02. Both angiographic reports and patients medical notes were reviewed. Only patients with angiographic stenoses (>50%) or occlusions on the asymptomatic leg were included. Clinical follow-up, including development of intermittent claudication (IC) or critical limb ischaemia (CLI), and subsequent endovascular treatment were recorded. RESULTS: 66 patients, 61% male, average age 73.6 years (range 47 – 92 years) were included. All patients had formal conventional angiography, with 34% having contralateral angioplasty. The right lower limb (59%) and the superficial femoral artery (59%) were the most common sites for asymptomatic lesions, with a mean ipsilateral ABI of 0.73. Stenoses (63%) accounted for the majority of asymptomatic lesions. During the follow-up period (2.4 years mean, range 1 month – 6 years), 32% of patients developed symptoms (21% IC, 11% CLI) on average 3.4 years after the initial angiogram, with 44% requiring treatment, 33% endovascular and 11% surgical. Risk factors were abundant with 75% being smokers. CONCLUSION: Asymptomatic peripheral angiographic stenoses and occlusions only become symptomatic in 32% of patients, thus it is difficult to justify performing angioplasty at presentation, given the associated risks.

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Abstracts - Scientific Session 2a 22. Infrainguinal stents, will fem-pop bypass become obselete? R.J. O'Neill1, T. Richards2, S. Habib3, S. Whitaker4 1

Radiology, Nottingham University Hospitals NHS Trust, NG7 2UH - Nottingham/UK Vascular Surgery, Nottingham University Hospitals NHS Trust, Nottingham/UK 3 Radiology, Nottingham University Hospital, Nottingham/UK 4 Radiology, Nottingham University Hospitals NHS Trust, Nottingham/UK 2

AIMS: To evaluate the use of long self expanding nitinol intra arterial stents designed for use inferior to the inguinal ligament. Superficial femoral and popliteal artery stents, a series of 100 cases using the Protégé EverFlex and Edwards Life Sciences stents with one year follow-up. MATERIAL AND METHODS: A series of 100 cases of percutaneous angioplasty from 2005 to 2007, where a stent or stents were deployed in the superficial femoral or popliteal arteries. Prospective data collection of pre-procedural symptoms and risk factors, angiographic findings, TASC classification, procedural details and subsequent clinical and duplex follow-up. RESULTS: The majority of the 100 cases were those of critical limb ischaemia with superficial femoral artery occlusions 4cm to 42cm in length (mean 21cm, mostly TASC C and TASC D) where conventional subintimal angioplasty had failed and stent placement was for reasons of limb rescue. Stented lengths varied from 4cm to 44cm using 1 to 5 stents. A 97% (97/100) primary patency rate was recorded. The authors are currently collecting the one year follow up data. CONCLUSION: The authors will demonstrate the one year patency rate and indicate the success or otherwise of the use of these stents in superficial femoral artery occlusions.

23. Intracranial angioplasty and stent implantation in atherosclerotic lesions J. Maskova1, F. Charvat2, J. Lacman2 1

Radilogy, Central Military Hospital, 168 00 - Prague/CZ Radiology, Central Military Hospital, 168 00 - Prague/CZ

2

AIMS: Authors report periprocedural and short term results of intracranial stenoses treatment using angioplasty and stent implantation. MATERIAL AND METHODS: In the interval from 8/2002 to 4/2007 (56 months) 53 patients with intracranial atherosclerotic stenosis were treated in our department.There were 12 women and 41 men in which 56 procedures were performed with 53 stents implantations. Age was in range from 36 to 83 years (mean age 63 years). 48 lesions were symptomatic, five were asymptomatic. Tandem extracranial lesions were treated in 12 patients. Both side stenoses were treated in one patient, in one patient tandem intracranial lesions were stented. 46 stenoses (84%, n=55) were located in anterior circulation. Nine stenoses were in posterior circulation (16%). All procedures were done from femoral approach, using single groin puncture. Patients were given Plavix and Anopyrin 3 days before the procedure. Bolus of Heparin was given in the beginning of procedure. Combination of Plavix and Anopyrin was used for 1 month after the procedure and Anopyrin long- life. Balloon – expandable stents were used in 41 lesions (77% n=53), self-expandable stents were used in 12 lesions (23%, n=53). RESULTS: Primary technical success was achieved in 48 patients (91%, n=53), in 5 patients stent implantation was unsuccessful in the first session; three of them were successfully treated during the second session (secondary technical success 96%).There were 9 periprocedural complications (16%, n=56), two minor, without sequelae, seven major leading to change of treatment and prolonged hospital stay. One procedure related dead occurred. CONCLUSION: Intracranial angioplasty and stent implantation in symptomatic atherosclerotic lesions documents a high rate of technical success and a low rate of subsequent stroke, this procedure is technically feasible, but in very tortuous vessels it can still be challenging to reach the target segment. Our periprocedure results and complication rate correlate with current literature.

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Abstracts - Scientific Session 2a 24. Management of the Internal Iliac Artery during Aorto-Iliac Reconstruction (EVAR) M. Adiseshiah1, J. Brookes2, M. Raphael3 1

Endovascular Unit, University College Hospital, N1 - London/UK Radiology, University College Hospital, NW1 2BU - London/UK 3 Endovascular Unit, UCH London, London/UK 2

AIMS: During EVAR, the internal iliac artery (IIA) must be taken into account in planning for the lower landing site in 20-40% of patients. This presentation is concerned with the incidence and problems associated when one or both IIAs require attention during EVAR. The importance of this artery in the avoidance of immediate and longer term morbidity is highlighted. MATERIAL AND METHODS: Analysis of a personal series of 273 patients undergoing EVAR, and a world literature review are the basis of the study. The incidence of common or IIA pathology which mandated IIA attention was estimated. The techniques for dealing with the IIA were reviewed, and the complications of these manoeuvres analysed. RESULTS: The reason for IIA intervention was invariably common and or IIA aneurysm associated with the abdominal aneurysm. 53 (19.4%) of our patients required attention to one or both IIAs. This is at the lower end of reported incidence which can be as high as 40%.The IAA has been reported to be coiled/occluded, covered without coiling or bypassed, but with little evidence of reduction in complications for the re-vascularisation procedures.The commonest complications of these manoeuvres in decreasing order of frequency are buttock claudication (5075%), erectile dysfunction (10-20%), bowel ischaemia (1-2%), late aneurysm formation (1%), and spinal and lumbosacral ischaemia (with paraparesis and bed-sores) (0.3-0.5%). CONCLUSION: The IIA is important when planning the lower landing site in EVAR, although over half of all patients will not require this consideration. There is evidence that in bilateral IIA coverage, IIA revascularisation on one side probably reduces the complication rate. Even without pre-emptive measures the incidence of serious complications seems to less than 2 %, but the incidence of buttock claudication approaches 75%.

25. Mid-Term Results of Endovascular Repair of Isolated Iliac Artery Aneurysms A. Bajwa1, M. Davis1, B. Rose1, R.E. Bell2, T.W. Carrell2, P.R. Taylor2, C. Sandhu3, R. Salter3, T. Sabharwal4, J. Reidy5 1

Vascular Surgery, Guy's and St Thomas' NHS Foundation, London/UK Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London/UK 3 Interventional Radiology, Guy's & St Thomas' Hospital, SE1 9RT - London/UK 4 Interventional Radiology, Guy's and St Thomas' NHS Foundation Trust, London/UK 5 Radiology, GUYS AND ST THOMAS HOSPITAL TRUST, SE1 - LONDON/UK

2

AIMS: The evidence for the natural history of isolated iliac artery aneurysms is poor, but repair is usually advised when the diameter reaches 3-4cm. Open surgery for iliac artery aneurysms are a major undertaking and associated with procedure-related morbidity and mortality. We report our experience of endovascular repair of isolated iliac artery aneurysms. MATERIAL AND METHODS: There were 50 patients, with 56 isolated iliac artery aneurysms, treated from 19972007. Data was prospectively collected on a computerised database with CT follow-up at 3 months, and annually thereafter. RESULTS: The median age was 74 years (range 36-94) with 47 men and 3 women. Follow-up was a mean of 2.6 years (range 3 months-8 years). The mean aneurysm diameter was 47mm (18-102mm). The aneurysms were localised to the common iliac artery in 49 patients and to the internal iliac artery in 1 patient. Internal iliac artery embolisation was undertaken in 35 patients.There were 6 patients with short proximal necks or bilateral aneurysms requiring a bifurcated aortic device. Technical success was achieved in 49/50 patients, with exclusion of the sac in 49/50 patients. One failure was due to difficulty with access and treated with combined radiological intervention and open surgery. In-hospital mortality was 0/50, with 5 deaths during the follow-up period, none of which were aneurysm-related. One device occluded on day 2 post-operatively, and was successfully treated by thrombectomy and fasciotomy. There were 2 late endoleaks which were successfully treated endovascularly and one late device occlusion treated with a femoro-femoral crossover graft. The overall intervention-free survival was 80% at 2.6 years. CONCLUSION: Endovascular repair of isolated iliac artery aneurysms is safe and associated with good mid-term results. Long term follow up is essential.

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Abstracts - Scientific Session 2a 26. Subintimal Angioplasty: Long-term Follow-up. A.N. Keeling1, M.F. Given2, K. Khalidi1, F.P. McGrath1, M.J. Lee2 1

Dept Of Academic Radiology, Beaumont Hospital, 9 - Dublin/IE Radiology, Beaumont Hospital, Dublin/IE

2

AIMS: To determine long-term success rates following percutaneous subintimal angioplasty (SIA) in patients with lower limb occlusive lesions. MATERIAL AND METHODS: Over a 4 year period, 69 consecutive patients (63% male, average age 76 years, range 55 – 92 years) underwent SIA as a result of occlusive atherosclerotic lesions. Critical limb ischaemia (CLI) accounted for the majority of SIA (79%), with intermittent claudication (IC) present in the remainder (21%). The population comprised smokers (68%), diabetics (DM) (47%) and longstanding atherosclerotics (41% had previous intervention). Majority of treated lesions were femoropopliteal (73%). Ankle brachial indices and clinical follow-up were recorded post SIA. RESULTS: SIA was performed on 72 lesions, with an initial procedure success rate of 86% (n=62). Procedure failure was due to heavily calcified lesions and failure of re-entry. Complications (9.7%) included 1 arterial thrombus, 4 vessel ruptures (no clinical sequelae) and 2 groin haematomas. ABI’s improved from a mean of 0.53 pre – SIA (range 0.25 – 1.12) to 0.84 (range 0.49 – 1.21) post – SIA. Clinical symptomatic improvement was seen in 72% overall at initial 6 month follow-up. 69% of claudicants were claudication free at longer follow-up (maximum 6 years, mean 3.8 years), however CLI demonstrated 57% limb salvage and ulcer healing on longer follow-up. There were 26 (37.6%) non-procedure related deaths in the follow-up period. CONCLUSION: Primary lower limb subintimal angioplasty is a feasible therapeutic option for occlusive atherosclerotic lesions in both intermittent claudication and critical limb ischaemia.

27. Endovascular treatment of priapism. How we do it. Y. Joshi1, D. Brennan1, J. Brookes2, C.M. Allen3, J. Raja4 1

Radiology, UCLH, NW12PG - London/UK Radiology, University College Hospital, NW1 2BU - London/UK 3 University College Hospital, Department of Imaging, London/UK 4 Radiology, UCLH hospital, NW12PG - London/UK 2

AIMS: Discuss the aetiology of priapism and its types. Briefly review imaging modalities in diagnosis. Refresher on the arterial anatomy in this area. Explain how to identify the patients in whom superselective embolisation is likely to succeed and illustrate this with our technique including choice of embolic material. MATERIAL AND METHODS: We will present a pictorial review of selected treated cases.The diagnostic imaging will be discussed including the use of MRI and all cases will be illustrated with DSA images. RESULTS: We will describe our technique with tips and tricks in regard to patient, arterial branch and embolic material selection. Short and mid term follow up data will be reviewed. CONCLUSION: Superselective embolisation in the treatment of priapism is relatively novel. Most single institutes have limited experience and the current literature is composed predominantly of sporadic case reports. We are a tertiary referral centre for the treatment of priapism and thus have a generous selection of cases. We will present our data and in particular our technique and tips on patient selection.

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Abstracts - Scientific Session 2b Thursday 1st November 07 - Scientific Session 2b Title Chairs

Non-vascular Dr Richard Edwards & Dr Colin Todd

Purbeck Lounge 28. An International Multicenter Randomized Comparison Of Balloon Kyphoplasty And Non-surgical Management In Patients With Acute Vertebral Body Compression Fractures F. Smith1, D. Wardlaw1, J. Van Meirhaeghe2, L. Bastian3, S. Boonen4 1

Department Of Orthopaedics, Woodend Hospital, Aberdeen/UK Dienst Orthopedie En Traumatologie, Algemeen Ziekenhuis Sint-Jan, Brugge/BE 3 Orthopädie, Unfall-, Hand- Und Wiederherstellungschirurgie, Klinik für Orthopädie, Unfall-, Hand- und Wiederherstellungschirurgie, Leverkusen/DE 4 I.g. Geriatrie, UZ Gasthuisberg, Leuven/BE 2

AIMS: Balloon kyphoplasty (BKP) is a minimally invasive procedure for treatment of osteoporotic and cancerrelated Vertebral Compression Fractures (VCF). The randomized, controlled Fracture Reduction Evaluation (FREE) trial was initiated to compare effectiveness and safety of BKP to non-surgical management (NSM) for the treatment of acute painful VCFs. We describe the primary endpoint of the ongoing 2-year study. MATERIAL AND METHODS: 300 patients with 1-3 non-traumatic VCFs ( )3 months old) were randomly assigned to either BKP or NSM.The primary endpoint, the change in QOL as measured by SF-36 Physical-Component-Summary (PCS) at one month, and device/procedure-related safety were analyzed in the intent-to-treat population. Secondary endpoints were analyzed in a per-protocol-population and included SF-36 subscales, EQ-5D, selfreported back pain and function using the Roland Morris Disability Questionnaire (RMDQ). All patients were referred for appropriate osteoporosis medical therapy. RESULTS: Mean patient age was 73 years and 77% were female. 97% had VCFs due to primary osteoporosis. For PCS, the difference in change at one month follow-up was 5.73p in favor of BKP over NSM (p<0.0001). All physical component SF-36 subscales, total EQ-5D score, back pain function were significantly improved for BKP compared to NSM (p<0.0001). There was one device-related (soft tissue hematoma) and no bone cement-related serious adverse events. CONCLUSION: Compared to NSM, BKP demonstrated superior short-term pain, function and quality of life outcomes with comparable safety profile for the treatment of acute, painful VCF.

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Abstracts - Scientific Session 2b 29. Utility of Dyna-CT Following Endovascular Aortic Aneurysm Repair (EVAR) – Preliminary Experience. L.A. Ratnam1, M.J. Bratby2, R.M. Walkden3, M.G. Meister4, G.J. Munneke3, A.M. Belli5, R. Morgan6 1

Radiology, St.George's Hospital, London/UK Radiology, St George's Hospital, SW17 OQT - London/UK 3 Radiology, St.George's Hospital, SW170QT - London/UK 4 Radiology, St.George's Hospital, SW17 - London/UK 5 Radiology, St. Georges Hospital, London/UK 6 St Georges hospital, London/UK 2

AIMS: To assess utility and diagnostic quality of on-table Dyna-CT in identifying endoleaks, immediately post EVAR. MATERIAL AND METHODS: Over a 10 month period, 19 Dyna-CTs (Axiom Artis dTA; Siemens Medical Solutions) were performed. Immediately post EVAR, all patients had on table aortography, followed by Dyna-CT imaging. Subsequent follow up was with either CT or duplex scanning. All images were retrospectively reviewed by 2 Consultant Vascular Radiologists, and assessed for the presence and type of endoleak, as well as the diagnostic quality of the images. RESULTS: Of the 19 Dyna-CTs performed, 89.5% (17) were felt to be of good or excellent quality (scale of 1-5). The 2 images scored as only adequate or poor quality were due to poor post-processing early in our experience. Blind reporting of Dyna-CT images identified 8 Type II endoleaks and 1 Type I, and 1 either Type I/II endoleak. No endoleak was identified in 9 cases. The Type I leak seen on Dyna-CT was subsequently identified on aortography and successfully treated with a Palmaz stent. Follow up duplex confirmed no leak. The possible Type I/II leak was not identified on aortography or on follow-up CT. This may have been due to resolution of a Type II leak, as in 3 of the Type II leaks seen on Dyna-CT but not on aortography or follow-up imaging. In 2 of these cases, further review suggested that the appearance of a Type II leak may have been due to contrast layering in the posterior aneurysm sac, resulting in a false positive Dyna-CT. In all other cases, Dyna-CT findings corresponded with that of aortography and follow-up imaging. The sensitivity of Dyna-CT in endoleak detection was 100% and the specificity was 69.23%. CONCLUSION: Dyna-CT produces images which are of good diagnostic quality.The early results suggest that it may have a useful place at the completion of EVAR procedure.

30. Quality of life assessment following pelvic osteoplasty for bone metastases: The Glasgow experience N. Mathias1, S. Athreya2, R. Edwards3 1

Radiology, Gartnavel general Hospital, G12 0YN - Glasgow/UK Radiology, Gartnavel General Hospital, G12 0YN - Glasgow/UK 3 Radiology, Gartnavel General Hospital, Glasgow/UK 2

AIMS: Painful bone metastases significantly affect many aspects of quality of life of oncology patients. Osteoplasty is an option to relieve the pain and improve the quality of life. The aim of this study is to assess the quality of life after osteoplasty in our series. MATERIAL AND METHODS: The list of all the patients who underwent pelvic osteoplasty from September 2002 till January 2007 was obtained from the Radiology information system.These patients had both pre and 1 month post procedure quality of life assessment as per the Brief Pain Inventory (BPI) protocol. The results were analyzed to assess any change in the quality of life. Appropriate statistical analysis was performed. RESULTS: 23 patients underwent pelvic osteoplasty from September 2002 till January 2007. There were 22 female and 1 male patients with ages ranging from 39 to 77 years. A completed pre and 1 month post procedure assessment were analysed. The average pain and quality of life assessment score were 7.1 and 5.6 pre-procedure and 3.0 and 3.5 at 1 month post procedure respectively, which is significant. CONCLUSION: Pelvic osteoplasty for painful bony metastases, significantly improves pain control and quality of life. Larger studies are needed to further quantify the outcome

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Abstracts - Scientific Session 2b 31. Ureteric injury - radiological experience with the intra-operative rendevous procedure C. Austin1, R.O. Illing2, D. Smith3, T. Philp4, C.M. Allen5 1

Radiology, University College London, NW12 1BU - London/UK Department Of Imaging, University College Hospital, NW1 2BU - London/UK 3 Department Of Urology, St Marys Hospital, London/UK 4 Department Of Urology, University College Hospital, London/UK 5 University College Hospital, Department of Imaging, London/UK 2

AIMS: To describe the technique of the ureteric rendevous procedure. To date, the majority of reported case series describe open repair of distracted ureteric injury or strictures that have failed primary stenting. This minimally invasive technique, performed under imaging guidance, is an alternative to open surgical repair. MATERIAL AND METHODS: Between 2002 and 2007, a series of 40 cases requiring the ureteric rendevous procedure were identified at our centre. The methodology was reviewed and technical aspects of the procedure were noted. Factors affecting thre success or failure of the procedure were recorded. RESULTS: The ureteric rendevous procedure is a joint procedure between the Urologist and Radiologist. The Urologist inserts a ureteroscope retrogradely under direct vision, while the Radiologist inserts a guidewire antegradely through a pre-inserted nephrostomy under fluroscopic control. An attempt is made to pass the guidewire across the ureteric defect or stricture, which is then snared through the ureteroscope.The rendevous may be made entirely under imaging guidance, or through a combination of imaging and direct vision with methylene blue injected from the top end. In 38 cases the rendevous procedure was successful, allowing insertion of a doubleJ stent in either an antegrade or retrograde fashion. In two cases this procedure was unsuccessful. Images taken during this procedure will be presented and reasons for technical success or failure discussed. CONCLUSION: The ureteric rendevous procedure is a minimally invasive technique for the treatment of distracted ureteric injury or stricture which has failed primary stenting.We have found it to be an excellent adjunct to existing procedures for ureteric injury, demonstrating success in 95% of cases and obviating the need for open surgical repair.

32. Radiological Removal of "Buried Bumper" Flanged Gastrostomy Tubes J.C. Jobling, P.D. Thurley Radiology Department, City Campus, Nottingham University Hospitals NHS Trust, NG5 1PB - Nottingham/UK AIMS: Flanged gastrostomy catheters may occasionally become buried in the gastric wall, with associated blockage and abscess formation. This is thought to bed due to prolonged unrelieved tension on the catheter. Removal of the gastrostomy may be very difficult either surgically or endoscopically. We have reviewed the patients we have treated for "buried bumpers" and describe our method of removal, specific technical problems and complications. MATERIAL AND METHODS: 6 patients were identified prospectively between October 2004 and May 2007. Data was obtained by review of the hospital notes. All procedures were performed under conscious sedation with monitoring of pulse, blood pressure and oxygen saturations. An oro-cutaneous wire was placed through the gastrostomy tube. The track was dilated. Then a combination of traction on the balloon after inflation in the gastrostomy tube and pushing from the cutaneous side with a large bore dilator were employed to bring the catheter back into the stomach lumen. It was then removed orally. A new catheter was placed, the route depending on the clinical scenario. RESULTS: Average age of the group was 64.7 years (range 29.5-85.6). All patients required feeding gastrostomy for long term neurological conditions. All buried bumpers were removed successfully, being replaced in three cases via the same track with flanged catheters, in two cases with self retaining loop catheters and in one case with a flanged catheter at a new site. In one case the stretching of the balloon catheter caused it to become "shrink wrapped" onto the wire which had to be exchanged. In one case a reinserted flanged catheter became reburied within two weeks. It was removed and replaced with a loop catheter. CONCLUSION: "Buried bumpers" are a rare clinical problem. Surgical removal has been described, both at laparotomy and laparoscopy. Endoscopic removal is also recognised, but neither have been successful at our unit in this high risk group. Removal using interventional radiology techniques has not been described to the best of our knowledge. It requires persistence and considerable force from both above and below, but has been consistently successful with no major complications.

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Abstracts - Scientific Session 2b 33. Radiofrequency ablation of renal tumours in patients with solitary kidney. N.I. Fotiadis1, I. Ahmed2, T. Sabharwal3, A. Saini1, A. Adam4 1

Radiology, Guy's and St Thomas' Hospital, SE17EH - London/UK Radiology, Guy's and St Thomas' Hospital, London/UK 3 Interventional Radiology, Guy's and St Thomas' NHS Foundation Trust, London/UK 4 Radiology Department, Guy's and St Thomas' Hospital, SE1 7EH - London/UK 2

AIMS: There is limited short-term data available regarding radiofrequency ablation (RFA) of renal tumours in a solitary kidney.We present our mid-term results regarding safety and efficacy of RFA in patients with solitary kidney with a mean follow up of two years. MATERIAL AND METHODS: From the 51 patients treated in our institution with RFA for renal tumours since February 2002, eleven (ten men, mean age 64.4, range 39-78) had a solitary kidney. Ten had a history of previous nephrectomy(ies) and one a congenital solitary kidney. Procedures were performed under conscious sedation and mainly CT guidance.The clinical and radiographic characteristics were evaluated, including renal function, length of stay and complications. RESULTS: Twelve tumours were treated in eleven patients (mean size 2.08cm range 0.8-4.2cm). Ablation resulted in complete tumour eradication, and there was no serious complications. The mean preoperative creatinine was 147.72mmol/l. There was a mean 10% increase in serum creatinine in the first trimester post procedure and at a mena 24.5 months follow up there was a 14% increase. No patient is on permanent haemodialysis. CONCLUSION: RFA is a safe and effective alternative treatment for renal tumours in a solitary kidney.

34. Managing malignant tracheo-oesophageal fistula: The Glasgow experience S. Athreya1, N. Mathias1, J. Moss2, I. ROBERTSON3, R. Edwards2 1

Radiology, Gartnavel General Hospital, G12 0YN - Glasgow/UK Radiology, Gartnavel General Hospital, Glasgow/UK 3 , GARTNAVEL GENERAL HOSPITAL, G120YN - GLASGOW/UK 2

AIMS: The aim of this study is to review our experience of using self expanding metallic stent to treat tracheooesophageal fistulae over a 12 year period. MATERIAL AND METHODS: The list of all the patients who under went tracheobronchial or oesophageal stenting for tracheo-oesophageal fistula from January 1995 till April 2007were obtained from radiology information system. The sites of primary tumour, site of stenting and type of stents deployed were recorded.All the patients underwent watersoluble swallow 24 hours following the stenting to assess the position and patency. Also the efficacy of the procedure, complications and clinical outcome were analysed. RESULTS: A total of 34 patients underwent 48 procedures (39 oesophageal and 9 tracheobronchial stenting).25 patients had oesophageal carcinoma and 9 bronchial neoplasm causing tracheo-oesophageal fistulas. The age ranged from 24 to 90 years, with 18 male patients.The procedures were technically successful in all the cases. There were no immediate complications. Late complications included, stent migration (n=5), blocked stent due to tumour in growth (n=5).The symptoms recurred in 2 patients within a month and 2 patients had repeated episodes of aspiration. Thirteen patients required further procedures, either oesophageal or tracheobronchial stenting. Two patients died within 30 days. The survival ranged from 14 days to 2 years. CONCLUSION: Self expanding stents for malignant tracheo-oesophageal fistula is a safe procedure offering effective palliative treatment.

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Abstracts - Scientific Session 2b 35. Survey of Current Practice of Radiofrequency Ablation in Britain E. Helbren1, A. Stannard2, D. Breen3, S. Roy-Choudhury4 1

, Heart of England NHS Foundation Trust, B91 3FD - Solihull/UK Surgery, Heart of England NHS Foundation Trust, Birmingham/UK 3 Radiology, Southampton University Hospitals NHS Trust, Southampton/UK 4 Radiology, Heart of England NHS Foundation Trust, Birmingham/UK 2

AIMS: Radiofrequency ablation is a rapidly evolving technique increasingly used for the treatment of a range of malignant tumours. Our aim was to gather data on how it is used across Britain. MATERIAL AND METHODS: Two questionnaires, containing both open and closed questions, were developed; one for trusts currently performing RFA, the other for trusts that are not. Contacts were crosschecked using named contacts from equipment manufacturers. Questions covered hospital size, indications, aims, specialities involved and patient work up. Where, with what guidance method and which manfacturers equipment RFA was performed. How admission was managed, length of stay and follow up imaging protocols. RESULTS: 198 acute trusts in Britain were contacted. 108/198 (55%) responses have been received so far. 30 trusts (averaging 850 beds each) currently perform RFA and one uses microwave ablation as an alternative. Annually 1072 RFA procedures are performed. Of these the most common indications are colorectal metastases to liver (342/1072), renal tumours (203/1072) primary HCC (192/1072) and osteoid osteomas (138/1072). RFA was used with intent to cure in 662/1072 (62%) cases. Prior to RFA 25/30 (83%) discussed patients at MDT. 25/30 (83%) of patients were cared for by the referring clinician with 19/30 (63%) seeing the interventionalist before admission. In 22/30 (73%) of trusts radiology was the only service to offer RFA. No trust had a service which did not involve a radiologist. RFA was performed in the CT suite in 25/30 (83%) with CT being the most common, 22/30 (73%), guidance method. Mean inpatient stay was 1.4 days (range 1-3 days). Follow-up schedules varied including CT (22/30), MRI (11/30) and PET (1/30) Of those trusts currently not performing RFA (average size 522 beds) 52/78 (72%) currently refer patients to another centre. Lack of radiological experience was the most common reason 52/78 (70%) for not performing RFA. 21/78 (28%) indicated that they had plans to introduce the service in the future. CONCLUSION: Practice of RFA reflects international trends although the numbers performed are relatively low. More training and education is required to increase expertise and availability if the technique is to succeed.

36. Radiologically inserted gastrostomy for upper GI cancer. L. Williams1, J. Thornton-Chan2, P. Puro3, H.U. Laasch4 1

Clinical Radiology, Manchester Royal Infirmary, M13 9WL - Manchester/UK Christie Hospital, University of Manchester, M20 4BX - Manchester/UK 3 Department Of Radiology, Christie Hospital, Manchester/UK 4 Department Of Radiology, Christie Hospital, M20 4 BX - Manchester/UK 2

AIMS: To analyse the success and complication rate of radiologically placed gastrostomy (RIG) for cancer patients in a tertiary referral centre. MATERIAL AND METHODS: The case notes and computer records of 57 patients who underwent radiologically placed gastrostomy (RIG) between December 2004 and March 2006 were retrospectively reviewed. This mostly included patients with curable disease, where the risk of seeding precluded the per-oral route. Minimum follow up time was 14 months. The complications, both early and late were recorded. All RIGs were performed by a single interventional radiologist. RESULTS: One patient was lost to follow up. In two patients the procedure was not attempted due to the presence in each case of a gastric volvulus, giving a technical success rate of 96% (intention to treat). The mean age was 63 years (28-83).Vygon© balloon replacement tubes were used for 48/54 (89%) of cases. 72% of patients had head and neck tumours and 26% had oesophageal malignancy. Complications were encountered in 27/54 (50%) of patients. Early complications (8/54 (15%)) were relatively less frequent than late complications (23/54 (43%)). Examples of early complications were pain, haemorrhage and those related to sedation. Late complications included local infection, peritonitis, tubal dislodgement, leakage, aspiration and balloon rupture. No single complication predominated. The most common complication was local infection identified in 8/54 (15%). Complications necessitated tubal replacement in 13/ 54 (24%). CONCLUSION: The complication rate (50%) was significantly higher than that described for other indications. Cancer patients are often significantly debilitated by malnutrition and immune suppressed by aggressive treatment regimes.The vast majority of complications can be remedied by relatively simple measures, but this may include tubal replacement, as occurred in 24% of cases in this study. RIGs in cancer patients are high maintenance devices and good communication with clinical colleagues is clearly vital. New ways of preventing stoma infection are now being explored.

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