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CIRSE 2014

Glasgow, UK

September 13-17

CIRSE 2014

ABSTRACTS & AUTHOR INDEX 4 PART 1:

4 PART 2: 4 PART 3: 4 PART 4:

Special Sessions, Special Session Controversies, Fundamental Courses, Honorary Lectures, Hot Topic Lectures, CIRSE Meets Lectures Free Papers Posters Author Index

Online Publication Number: 10.1007/s00270-014-0940-z

Cardiovascular and Interventional Radiological Society of Europe

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CIRSE 2014

Glasgow, UK

September 13-17

CIRSE 2014 PART 1

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

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Fundamental Course Basic principles of carotid artery intervention

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

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

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

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

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

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• Transient sinus bradycardia or asystole: they are common physiological responses to balloon dilatation of carotid bifurcation lesions. Intravenous atropine may be required. • Persistent hypotension: it occurs in 4%–11% CAS procedures. Hemodynamic monitoring for 24 h is essential. It responds to intravenous hydration and vasopressors. • Cerebral embolization: risk factors are - soft plaque; fresh thrombus; inadequate antiplatelet pretreatment; aggressive manipulation of guide wires, balloons, and stents, and prolonged and aggressive attempts to catheterize atherosclerotic, tortuous arteries. With clinical suspicion, intracranial DSA and recanalization of occluded arteries are mandatory measures. • Intracranial hemorrhage: it is a life-threatening complication. It occurs in approximately 0.3% CAS procedures. A sudden loss of consciousness preceded by severe headaches in the absence of intracranial vessel occlusion should be considered as a complication; the procedure should stop and anticoagulation should be reversed. Risk factors include: excessive anticoagulation, poorly controlled hypertension, and CAS in the presence of a recent (<3 weeks previously) ischemic stroke. • Hyperperfusion syndrome: it occurs in 0.3%–2.7% CAS procedures. Clinical manifestations include: ipsilateral headaches, nausea, vomiting, hypertension, seizures, and intracranial hemorrhage. The syndrome typically occurs in patients with severe carotid stenosis and poor collateral circulation. It is related to the impaired autoregulation of the microcirculation. The management comprises identifying high-risk patients and a meticulous blood pressure control using intravenous antihypertensive agents. • Dissection of the internal carotid artery (ICA): it is rare. Predisposing factors include: excessive tortuosity of ICA, aggressive manipulations, and post-dilatation of the distal stent edge. A flow-limiting dissection should be treated by an additional stent placement. • Acute stent thrombosis: It is rare and has been attributed to inadequate antiplatelet regimen and inappropriate stent deployment. • Arterial access site complications: proper puncture technique and regular use of vascular closure devices lowers the incidence of this complication.

Special Session Embolic agents: when, where and how 102.1 Coils and plugs – indication and technique M. Pech Klinik für Radiologie und Nuklearmedizin, Universitätsklinikum Magdeburg, Magdeburg, Germany Learning Objectives 1. To learn about the different types of coils and plugs available and their properties 2. To learn about the specific indications for the use of coils and plugs 3. To learn how to deploy coils and plugs including tips, tricks & pitfalls Coils and plugs are widely used for embolization during transarterial interventions. Their ubiquitous availability, ease and relative safety as well as their effectiveness are the best arguments in a variety of indications. They may also be used in combinations with other embolic devices or liquids. In this lecture, devices available in the market will be described with respect to recommended indications, differences in the application techniques such as plugs and coils, pushable vs. detachable systems, fibered vs. bioactive coils, and others. In addition, the presentation will provide an update on data available from clinical trials.

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Gelatin foam and particles: classification, indication and technique

Liquid embolic agents: technique, results and complications W.A. Wohlgemuth Institut für Röntgendiagnostik, Universitätsklinikum Regensburg, Regensburg, Germany

K. Zeleňák Department of Radiology, University Hospital, Martin, Slovak Republic Learning Objectives 1. To learn about the different types of particles and gelfoam available and their properties 2. To learn about the specific indications for the use of gelfoam and particles 3. To learn how to use gelfoam and particles, including tips, tricks & pitfalls Embolization is a nonsurgical, minimally invasive procedure. It involves the selective occlusion of blood vessels by purposely introducing emboli - in other words, deliberately blocking a blood vessel. Microparticles can be made of several types of materials, including polyvinyl alcohol (PVA), acrylamido PVA, PVA hydrogel, trisacryl, hydrogel core with Polyzene-F coating, and a combination of vinyl acetate and methyl acrylate with sodium acrylate alcohol copolymer. Embolization materials can be classified according to their physical and biological characteristics (shape, available sizes, size range, uniformity, aggregation, compressibility and elastic recovery, ability to expand, permanence, reperfusion rate, ability to be loaded with medications such as chemotherapeutic agents, loading time, and radioactivity). Embolization is used to treat a wide variety of conditions affecting different organs of the human body: 1. hemorrhage (epistaxis, recurrent hemoptysis, gastrointestinal bleeding, post-partum hemorrhage, uterine leiomyomas, and post-traumatic hemorrhage); 2. growths (benign prostatic hyperplasia, benign tumors (e.g. uterine leiomyomas, meningioma, nasopharyngeal angiofibroma, paraganglioma, angiomyolipoma, hemangioma, and hemangioblastoma) and malignant tumours [primary malignant tumors (e.g. hepatocellular carcinoma) and secondary malignant tumors (e.g. liver metastases of colorectal carcinoma)]; 3. portal vein (to generate liver hypertrophy); 4. splenomegaly with thrombocytopenia; and 5. renal ablation (could be useful for managing hypertension due to end-stage renal failure). The Gelfoam powder is used for temporary embolization, while embolization particles are used for permanent embolization. The Gelfoam powder tends to clump during injection, resulting in a more proximal (larger-vessel) occlusion. Small particles (<300 μm) are used when tissue death is desired, but they should not be recommended in the presence of AV shunting. For liver embolization, indicative sizes are 100–300 μm or 300–500 μm for trisacryl or PVA microspheres. Particle size should be matched to the delivery catheter used to prevent catheter occlusion. Forceful injection during the procedure may result in reflux of particles into a nontarget vessel due to ‘‘explosive’’ delivery. For uterine leiomyomas or bronchial artery embolization, the recommended diameter is 700–900 μm (compared to 500–700-μm trisacryl microspheres) for PVA microspheres and 900 μm for hydrogel polyzene-F microspheres. Frequent agitation may prevent clumping of PVA particles, which is a common problem. Forceful injection of trisacryl microspheres through an undersized catheter may result in microspheres cracking. The drug-eluting microspheres and radioactive Y-90 microspheres can be used to treat primary or secondary liver tumors. Adequate diagnostic angiography is the key for vasculature mapping and procedure planning; always watch for shunts and collateral circulation. Embolization must be performed under active fluoroscopy at all times to minimize the risk of reflux.

Learning Objectives 1. To learn about the different types of liquid embolic agents and their properties 2. To learn about indications and techniques for the use of liquid embolic agents 3. To learn about results and complications of the use of liquid embolic agents The main advantage of liquid agents is their ability to deeply penetrate into the vasculature leading to a complete and permanent occlusion. At present, the two agents histoacryl (N-butyl-cyanoacrylate; NBCA) and onyx (ethylene vinyl alcohol copolymer) are mainly used. NBCA quickly polymerises when it comes into contact with blood or saline; thus, it is mixed with different quantities of lipiodol (1:2–1:4) to prevent premature occlusion and to make it radioopaque. Even if it is very effective, the controllability of the embolisation process is difficult, sometimes leading to incomplete or unintended results, and the catheter tip may glue in. NBCA is mainly used in acute bleeding and preoperative tumor embolisation. Onyx is a liquid embolic agent comprising an ethylene vinyl alcohol copolymer dissolved in various concentrations of dimethyl sulfoxide (DMSO). Onyx is opacified with micronised tantalum powder. The physicochemical characteristics permit a very controlled application. The simultaneous performance of control angiographies during onyx application proves beneficial. Using the plug and push technique, it is possible to apply onyx against the direction of blood flow. Disadvantages are the high costs. Furthermore, the solvent DMSO requires a special catheter material, is toxic to the endothelium, and causes pain during onyx application. Currently, onyx is mainly used for embolotherapy of endoleaks after endovascular aortic aneurysm repair for the treatment of acute arterial bleeding and arteriovenous malformations.

102.4 Sclerosant agents: indication, technique and endpoints J.P. Burnes Medical Imaging, Monash Medical Centre, Clayton, VIC, Australia Learning Objectives 1. To learn about the different types of sclerosing agents and their properties 2. To learn about the specific indications for the use of sclerosing agents 3. To learn about techniques for the use of sclerosing agents including endpoints In a medical sense, sclerosis is defined as the stiffening or hardening of a structure, most freqently due to replacement of the normal tissue with connective tissue. It may also be defined as a resistance to change. When treating vascular malformations, it may often feel like we are trying to perform the former while the malformation is adhering to the latter. There are a wide variety of sclerosant agents available. Their method of action is to destroy and disrupt the vascular or lymphatic endothelium with subsequent vascular thrombosis and fibrosis. All act at the capillary or small channel level and many of them are potentially toxic and should be used with extreme care. If one were to design the ideal sclerosant, it would permanently obliterate the malformation being treated, be easily controllable and confined to the lesion and be non-toxic in both the long- and short-term. Unfortunately, no such agent exists, and we are left with a compromise of agents

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which vary widely in their efficacy, toxicity and complication profile. Commonly used sclerosant agents include but are not limited to • Venous sclerosants • Concentrated ethanol • Sodium tetradecyl sulphate (STS) • Polydocanol • Ethanolamine • Lymphatic sclerosants • All of the above plus • Doxycycline • Bleomycin • OK432 • Acetic acid • Hypertonic dextrose Commonly used venous agents include ethanol and STS. Ethanol denatures endothelial proteins and induces an intense inflammatory reaction. The use of ethanol carries a significant risk profile. In the literature, the recommended maximum dose is 1 ml/kg. In practice, it is rare to require more than 0.5 ml/kg; if doses greater than this are required to treat very large venous malformations, consideration should be given to combining its use with other sclerosant agents or performing multiple staged procedures. STS, polydocanol and ethanolamine are detergent sclerosants. They have a similar action to ethanol - damaging endothelial cells. STS may be combined with air to form a foamed solution using the Tessari technique. This increases the surface area of the sclerosant agent, maximising its contact area with the endothelial cell layer. Studies have shown that the stability of the foamed sclerosant is maximised with the use of air rather than CO2. Doxycycline is a tetracycline antibiotic. It was first described in the treatment of macrocystic lymphatic malformations in 1995. It is used at a concentration of 10 mg/ml. It has an efficacy of around 90% in treating macrocystic lymphatic malformations. Bleomycin is a cytotoxic chemotherapy drug used to treat SCC, lymphoma and certain testicular tumours. It was first used to treat lymphatic malformations in 1977. In a similar fashion to other sclerosants, it acts on the vascular endothelium. It is used in the treatment of venous malformations and both macro- and micro-cystic lymphatic malformations. Bleomycin has a significant risk profile. Potential complications include pulmonary fibrosis, which is dose dependent, idiosyncratic anaphylaxis and ARDS. OK432 is a solution of killed group A streptococci in a suspension containing penicillin. It is derived from bovine protein and as a result carries a theoretical risk of CJD; however, at present, the proteins are sourced from Australian cows and to date there has never been a case of bovine spongiform encephalopathy in Australia. It is manufactured in Japan and is used in the treatment of macrocystic lymphatic malformations with an efficacy of 80–90%. It does not have FDA approval at this time. The specific indications for sclerosants are dependent upon the type of malformation being treated and the anatomical location of the lesion. The endothelium of venous malformations is more robust than that of lymphatic malformations, and requires a more aggressive sclerosant. Lymphatic malformations may be treated with less physiologically aggressive sclerosants or with any of the sclerosants used to treat venous malformations. The specific sclerosant chosen is also dependent on the anatomical location of the malformation. This is primarily related to the degree and duration of post-procedural swelling and inflammation that the chosen agent will induce. This is particularly relevant in lesions in anatomically sensitive areas such as the orbit, surrounding the airway the calf and foot. Anatomical location may also influence the choice of sclerosant due to the potential risk to the surrounding anatomical structures and in particular nerves. The facial and sciatic nerves and the brachial plexus may be involved in malformations or in close anatomical proximity to them. Ectopic spillage of the sclerosant or direct

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injection into the nerve may result in nerve neurolysis, and the extent of nerve damage is impacted in part by the type of sclerosant injected. There are numerous techniques used to administer sclerosant agents into vascular malformations. The technique used will be determined by the type of malformation, its anatomical location, operator skill, the aim of treatment and the sclerosant agent being administered. High-flow vascular malformations may be accessed via the arterial inflow, venous outflow or direct puncture techniques. Low-flow malformations are typically accessed via direct puncture techniques where the malformation is punctured using a variety of access needles. One of the most difficult decisions in treating vascular malformations is determining when to stop a treatment session or a course of treatment. The volume of sclerosant injected is determined by the volume of contrast agent required to opacify the malformation at angiography or direct puncture venography. In the case of macrocystic lymphatic malformations, the cyst should be drained dry and sclerosant injected post-drainage to minimise the dilutional effect of the lymphatic fluid. One of the key issues in the use of sclerosants, particularly in treating high-flow malformations, is to control the flow through the lesion to maximise the dwell time of the sclerosant within the malformation and give the sclerosant sufficient time to act on the endothelium. This may also be an issue in some venous malformations. Agents used to assist with this include compression tourniquets, occlusion balloons, judicious use of coils and manual compression. When using ethanol, all compression should be released after each injection to minimise the risk of a large bolus of ethanol being released into the systemic circulation with cardiac complications at the end of the procedure.

Special Session Enteral tubes, enteral and parenteral nutrition 103.1 Percutaneous gastrostomy N. McEniff Interventional Radiology, St. James’s Hospital, Dublin, Ireland Learning Objectives 1. To report indications and contraindications 2. To learn how to manage and avoid complications 3. To illustrate current evidence and treatment strategies No abstract available.

103.2 Percutaneous direct jejunostomy and gastrojejunostomy H. van Overhagen Department of Radiology, Haga Teaching Hospital, Leyenburg, The Hague, Netherlands Learning Objectives 1. To report indications and contraindications 2. To learn how to manage and avoid complications 3. To illustrate current evidence and treatment strategies Percutaneous radiologic gastrostomy (PRG), transgastric jejunostomy (PTGJ), and jejunostomy (PRJ) are radiologic feeding techniques that can be used in patients with swallowing dysfunction or an obstruction of the upper digestive tract who need enteral feeding for a prolonged period (≥6 weeks). PRG is the first technique that should be considered, because feeding through the stomach is more physiological and may be

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associated with better digestion than that through the jejunum. The insertion of a feeding tube is technically easier into the stomach than into the small bowel. PTGJ should be considered in patients who had a partial resection of the stomach with too little space left for a feeding tube, patients with gastroesophageal reflux or aspiration, and diabetic patients with gastroparesis. PRJ should be considered in patients in whom the stomach cannot be used (for example in diffuse stomach cancer) or has been removed (often after surgery of the esophagus for cancer). Contraindications for all three techniques are the same: ascites, uncorrectable bleeding disorders, and a limited life expectancy. Moreover, patient preparation for all three techniques is the same i.e., fasting for at least 12 hours, an IV drip should be inserted, and the administration of IV antibiotics should be considered. During the procedure, patients should receive analgesics such as fentanyl (0.05–0.1 mg IV) and lidocaine (1%) locally or mild sedation. PTGJ technique: A nasogastric tube such as a 5-F PIER, MPA, or vertebral catheter is introduced into the stomach under fluoroscopic guidance. The stomach is inflated with air and punctured under ultrasonographic guidance with an 18-gauge needle preloaded with a Cope anchor (T-fastener) in the direction of the pylorus. The position of the needle within the stomach is controlled with a small injection of contrast material. The anchor is pushed into the stomach with a 0.035-inch stiff guidewire, the needle is removed, and an 8-F vascular sheath is introduced into the stomach over the guidewire. The position of the sheath is controlled with a small injection of contrast material. The pylorus is passed into the jejunum with a combination of the 5-F vascular catheter and a 0.035-inch hydrophilic guidewire, and when Treitz is reached, the hydrophilic guidewire is exchanged for a 0.035-inch stiff guidewire. Subsequently, the feeding tube such as a 12-F pigtail is inserted into the jejunum over the guidewire. The final position of the catheter is again controlled with a small injection of contrast material. PRJ technique: A nasojejunal tube such as a 5-F PIER, MPA, or vertebral catheter is introduced into the jejunum as far as possible under fluoroscopic guidance. Saline is introduced into the jejunum to enlarge and visualize the lumen of the bowel. The lumen of the jejunum is punctured under ultrasonographic guidance with an 18-gauge needle preloaded with a Cope anchor (T-fastener). The position of the needle is controlled with a small injection of contrast material. Under fluoroscopic guidance, the anchor is carefully pushed into the jejunum with a stiff 0.035-inch guidewire. By applying slight traction on the anchor, the tract into the bowel is dilated with a 10-F vascular tapered dilator. Subsequently, a 10-F feeding tube such as a 10-F pigtail catheter is inserted into the jejunum. The final position of the tube is controlled with an injection of contrast material. The feeding tubes and anchor are fixed to the skin with a suture. The feeding tubes are drained externally overnight to minimize intraperitoneal leakage. The next morning, a saline infusion is applied to the feeding tubes for several hours followed by enteral feeding in uneventful cases. In cases of abdominal pain, feeding is postponed or interrupted, the position of the tube is controlled with a contrast injection under fluoroscopy, and enteral feeding is continued once the pain has disappeared. The anchor and sutures are removed after 10 days. Results: The technical success rates of PTGJ and PRJ insertions are as high as 90%. PRJ insertion is technically more demanding than the former techniques and requires better ultrasonographic skills and equipment. Complications may occur in 5%–10% cases. Most important complications are leakage, peritonitis, wound infection, and catheter obstruction and dislodgement. Peritonitis may be minimized by not feeding the patient is case of abdominal pain, which may be caused by a leakage of bowel content. The obstruction of catheters may be avoided by refraining from the administration of grinded tablets through the catheter.

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References 1. Ho CS, Yeung EY. Percutaneous gastrostomy and transgastric jejunostomy. AJR 1992; 158: 251-257. 2. van Overhagen H, Ludviksson MA, Laméris JS, Zwamborn AW, Tilanus HW, Dees J, Hansen BE. Ultrasonographic and fluoroscopic-guided percutaneous jejunostomy. Experience in 49 patients. JVIR 2000; 11: 101-106. 3. van Overhagen H, Schipper J. Percutaneous Jejunostomy. Semin Intervent Radiol 2004; 21: 199-204.

103.3 Cecostomy A.M. Cahill Dept of Interventional Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America Learning Objectives 1. To report indications and contraindications 2. To learn how to manage and avoid complications 3. To illustrate current evidence and treatment strategies Fecal incontinence is a problem in all age groups but appears to be a much more prominent issue in children and young adults. In children, colonic dysmotility occurs due to a wide range of diseases such as spina bifida, cloacal malformations, anorectal or spine surgeries, or trauma. Chronic and severe constipation can result in fecal overflow incontinence or encopresis without an organic cause and is not an uncommon entity. In adults, idiopathic constipation is not uncommon along with other disorders of colonic dysmotility such as metabolic, endocrine, neurogenic, post pelvic surgery, vaginal or caesarian childbirth, and spinal trauma. Colonic manometry has been described as a useful tool in children for assessing the potential success of a cecostomy tube. Mousa et al proposed that generalized colonic dysmotility would benefit less from antegrade enemas and demonstrated an eventual improvement in colonic motility on colonic manometry post antegrade enema use resulting in the discontinuation of treatment. Colonic manometry has not yet been established as a reliable assessment tool in the adult population. Historically, appendicocecostomy was first described by Malone et al in 1990 and involves cannulating the appendix stump with a catheter to provide an antegrade continence enema (ACE procedure). Laparoscopic procedures can also be performed using the appendix when available including placing from the outset the low profile Chait Trapdoor cecostomy device. These methods require a surgical procedure. In addition, in patients with spina bifida, the appendix is often already in use as a Mitrofanoff stoma providing the Monti procedure as the only alternative. In 1996, Shandling et al described a pilot study in which a percutaneous cecostomy was created using a minimally invasive technique in 15 patients under fluoroscopic guidance in the interventional radiology suite. A Cope loop 10-F catheter was placed with two pediatric stay sutures for cecal apposition to the anterior abdominal wall. In a later published experience, this catheter was then replaced electively at six weeks with a new device, the low profile 10-F Chait Trapdoor device. This device provided the patients and families with a very innocuous cecal access with the ability to achieve antegrade enema washout with little fecal spillage. The Trapdoor device is then replaced annually by either advancing it into the cecum to be later evacuated or by exchanging it over a guidewire. Chait et al published a large experience of 124 cecostomy insertions yielding a 94% favorable satisfaction rating with very low complication rates. In this study, the authors refined the bowel preparation to oral sodium phosphate solution preceded by a fluid diet for two days, facilitating same day admission. Triple drug therapy, ampicillin, metronidazole, and gentamicin is recommended for pre- and post-procedural antibiotic prophylaxis. One must consider that a significant group

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of patients requiring cecostomy tubes have spina bifida having a predilection to latex allergy; therefore, the primary catheter placed should be of a non-latex type. Glucagon administered intravenously can provide increased cecal air distension with reduced peristalsis in addition to the reverse trendelenberg position during air enema insufflation. Cecostomy tubes can be placed in the setting of ventriculoperitoneal shunts, but ultrasound imaging does help localize and avoid fluid collections associated with these shunts. Immediately post procedure, the tube should be placed for gravity drainage to reduce the risk of cecal gaseous distension and potential peritoneal leakage and contamination. Antegrade enemas can usually begin a week post procedure, and the retention sutures are usually released after 10 days. Individualized routines can de designed as per the requirement of each patient, and this is best managed by a dedicated service such as an experienced cecostomy nurse/nurse practitioner. Potential complications with cecostomy tube placement include peritonitis, GI hemorrhage, local cellulitis, allergic reactions, and tube clogging or dislodgement. Sierre et al reported one case of self-limited GI hemorrhage within 24 hours of tube placement in a cohort of 20 patients. Complications reported have ranged from 60% to 84% that were mostly minor tube/stoma-related issues. Radiation dose reduction should always be a consideration especially when dealing with repeated tube-related maintenance procedures in pediatrics. Govia et al reported effective dose ranges for cecostomy tube changes ranging from 0.06 to 0.09 mSv using fluoroscopy for 7.5 pulses/s. References 1. Antegrade enemas for defecation disorders: do they improve the colonic motility? Aspirot A, Fernandez S, Di Lorenzo C, Skaggs B, Mousa H. J Pediatr Surg. 2009 Aug;44(8):1575-80. 2. Colonic dysmotility in constipation. Dinning PG, Di Lorenzo C. Best Pract Res Clin Gastroenterol. 2011 Feb;25(1):89-101. Review. 3. Malone PS, Ransley PG, Kiely EM: Preliminary report: The 3. Mitrofanoff P: Cystostomie continente trans-appendiculare antegrade continence enema. Lancet 1990;336:1217-18. 4. Laparoscopic-Assisted Percutaneous Cecostomy for Antegrade Continence Enema. Defreest L, Smith J, Whyte C. J Laparoendosc Adv Surg Tech A. 2014 Mar;24(4):261-64. 5. Laparoscopic placement of the Chait cecostomy device via appendicostomy. Stanton MP, Shin YM, Hutson JM. J Pediatr Surg. 2002 Dec;37(12):1766-67. 6. Refashioned short bowel segments for the construction of catheterizable channels (the Monti procedure): early clinical experience. Gosalbez R, Wei D, Gousse A, Castellan M, Labbie A. J Urol. 1998 Sep;160(3 Part 2):1099-102. 7. Percutaneous cecostomy: a new technique in the management of fecal incontinence. Shandling B, Chait PG, Richards HF. J Pediatr Surg. 1996 Apr;31(4):534-37. 8. Fecal incontinence in children: treatment with percutaneous cecostomy tube placement--a prospective study. Chait PG, Shandling B, Richards HM, Connolly BL. Radiology. 1997 Jun;203(3):621-24. 9. The cecostomy button. Chait PG, Shandling B, Richards HF. J Pediatr Surg. 1997 Jun;32(6):849-51. 10. Percutaneous cecostomy: updates in technique and patient care. Chait PG, Shlomovitz E, Connolly BL, Temple MJ, Restrepo R, Amaral JG, Muraca S, Richards HF, Ein SH. Radiology. 2003 Apr;227(1):246-50. Epub 2003 Feb 11. 11. Percutaneous cecostomy for management of fecal incontinence in pediatric patients. Sierre S, Lipsich J, Questa H, Bailez M, Solana J. J Vasc Interv Radiol. 2007 Aug;18(8):982-85. 12. Cecostomy in children with defecation disorders. Mousa HM, van den Berg MM, Caniano DA, Hogan M, Di Lorenzo C, Hayes J. Dig Dis Sci. 2006 Jan;51(1):154-60.

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13. Estimates of effective dose to pediatric patients undergoing enteric and venous access procedures. Govia K, Connolly BL, Thomas KE, Gordon CL. J Vasc Interv Radiol. 2012 Apr;23(4):443-50.

103.4 Parenteral nutrition B. Gebauer Klinik für Strahlenheilkunde, Charité, Universitätsmedizin Berlin, Berlin, Germany Learning Objectives 1. To report indications and contraindications 2. To focus on paediatric population and parenteral nutrition 3. To illustrate current evidence and treatment strategies Parenteral nutrition (PN) is a hyperosmolar, intravenously admitted solution of water, glucose, amino acids, lipids, added vitamins and dietary minerals. Total parenteral nutrition (TPN) is an infusion of PN via a central vein, whereas peripheral parenteral nutrition (PPN) is an administration through a peripheral venous access. PPN is usually recommended only in patients with a limited duration of PN, because the hyperosmolar PN could damage the vessel walls. In general, enteral nutrition (EN) should be preferred over PN if possible. Typical indications for PN are patients with resorption and digestion disorders (e.g. short bowel syndrome, acute Crohn’s disease, acute Colitis ulcerosa, high-output fistula), disorders requiring complete bowel rest (e.g. post-operative bowl anastomosis, pancreatitis) or passage disorders (e.g. ileus, peritoneal carcinomatosis). Relative indications for PN are anorexia (e.g. cancer, superior mesenteric artery syndrome), eating disorders (e.g. bulimia nervosa, anorexia nervosa), comatose patients or passage problems (e.g. oesophagus tumors). In these cases, EN is preferred over RN, if possible. For PN, central venous catheter placement and maintenance is crucial. Infectious catheter-related complications because of the nutritive solution and mechanical complications, e.g. catheter occlusions, are very frequent. References 1. Bozzetti F, Forbes A. The ESPEN clinical practice Guidelines on Parenteral Nutrition: present status and perspectives for future research. Clinical nutrition. 2009;28(4):359-64. 2. Cove ME, Pinsky MR. Early or late parenteral nutrition: ASPEN vs. ESPEN. Critical care. 2011;15(6):317. 3. Aspen Board of Directors the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. JPEN Journal of parenteral and enteral nutrition. 2002;26(1):1SA-138SA. 4. Fouque D, Vennegoor M, ter Wee P, Wanner C, Basci A, Canaud B, et al. EBPG guideline on nutrition. Nephrology Dialysis Transplantation. 2007;22(2):ii45-87. 5. Kochevar M, Guenter P, Holcombe B, Malone A, Mirtallo J, Directors ABo, et al. ASPEN statement on parenteral nutrition standardization. JPEN Journal of parenteral and enteral nutrition. 2007;31(5):441-48. 6. Koletzko B, Jauch KW, Verwied-Jorky S, Krohn K, Mittal R, Working group for developing the guidelines for parenteral nutrition of The German Society for Nutritional M. Guidelines on Parenteral Nutrition from the German Society for Nutritional Medicine (DGEM)–Overview. GMS German Medical: GMS e-journal. 2009;7:Doc27. 7. O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, et al. Guidelines for the prevention of intravascular catheter-related infections. Centers for Disease Control and Prevention. MMWR Recomm Rep. 2002;51(RR-10):1-29.

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8. Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M, Espen. ESPEN Guidelines on Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clinical nutrition. 2009;28(4):365-77. 9. Preiser JC, Schneider SM. ESPEN disease-specific guideline framework. Clinical nutrition. 2011;30(5):549-52. 10. Teitelbaum D, Guenter P, Howell WH, Kochevar ME, Roth J, Seidner DL. Definition of terms, style, and conventions used in A.S.P.E.N. guidelines and standards. Nutrition in clinical practice: official publication of the American Society for Parenteral and Enteral Nutrition. 2005;20(2):281-85. 11. Vinnars E, Wilmore D. Jonathan Roads Symposium Papers. History of parenteral nutrition. JPEN Journal of parenteral and enteral nutrition. 2003;27(3):225-31.

Special Session Visceral IR 104.1 Clinical and imaging assessment of mesenteric ischaemia K. Schürmann Diagnostic and Interventional Radiology, St.-Johannes-Hospital Dortmund, Dortmund, Germany Learning Objectives 1. To define clinical presentation and assessment of acute and chronic mesenteric ischaemia 2. To learn the different imaging modalities available for assessment 3. To understand the efficacy of different imaging modalities Mesenteric ischemia may be considered as an occlusive disease of the bowel supplying and draining blood vessels. The occlusion may occur on the arterial or venous side, it may be located in the proximal or the distal portion of the mesenteric vasculature, and it may be acute or chronic (1-4). The major bowel supplying vessels are the celiac trunk, superior mesenteric artery (SMA), and inferior mesenteric artery. SMA is the most important feeding vessel; the superior mesenteric and portal vein are the most important draining vessels. Acute mesenteric ischemia (AMI) is a life-threatening disease requiring prompt diagnosis and treatment. Symptoms of AMI are usually nonspecific, and there are no serum parameters reliably indicating or proving AMI (1,4). Timely diagnosis is based on clinical suspicion and early contrast-enhanced CT imaging. As a rule of thumb, acute mesenteric ischemia is caused by: • embolic or thrombotic occlusion of SMA in 70% patients • non-occlusive mesenteric ischemia (NOMI) in 20% patients • mesenteric vein thrombosis (MVT) in 10% patients (1-5) Diagnostic imaging If there is clinical suspicion of occlusive mesenteric ischemia, the diagnostic imaging method of choice is biphasic multislice CT (MSCT) after an intravenous administration of contrast agent (4-8). Multiplanar reconstructions are helpful in establishing and confirming the diagnosis. The arterial phase is required to detect mesenteric stenosis/occlusion and the venous phase is required to detect mesenteric vein thrombosis. In a recent meta-analysis, the sensitivity of MSCT in patients with AMI was found to be 93% and specificity was 96% (7). Because almost all patients suffering from mesenteric ischemia present with abdominal pain, abdominal plain films are frequently obtained in the early phase and also later in the course of the disease if it is not diagnosed. The findings of plain films are nonspecific; however, they may reveal other causes of abdominal pain, particularly, hollow organ perforation (1). If the plain films show signs of mesenteric ischemia, such as pneumatosis intestinalis or gas in the portomesenteric circulation, the disease is already far advanced, gangrene of the bowel has occurred, peritonitis is present, and mortality is consistently high.

Abstract Book Duplex sonography may demonstrate the proximal stenosis or occlusion of mesenteric vessels with good diagnostic accuracy (9). However, if findings are nonspecific, results highly depend on the experience of the investigator, and NOMI is not assessable. Bowel distention and bowel gas reduce the diagnostic capacity of duplex sonography. Overall, duplex sonography alone is insufficient in reliably diagnosing mesenteric ischemia. Reportedly, the diagnostic accuracy of duplex sonography is improved with the use of contrast agents (10). MR and MR angiography show vascular mesenteric pathology with high diagnostic accuracy (6). However, availability of MR is limited, and examination durations are much longer compared with CT. Due to the severe pressure of time in diagnosing, MR is not considered an advisable imaging tool in patients suspected to have AMI (4). In contrast, if chronic mesenteric ischemia is suspected, MR may be useful (11). Clinical classification of mesenteric ischemia Mesenteric ischemia may be classified into four clinical stages according to the onset and severity of symptoms: • asymptomatic • recurrent postprandial abdominal pain (“angina abdominalis”) • permanent abdominal pain, malabsorption syndrome • sudden onset of severe abdominal pain persisting for several hours These symptoms are nonspecific. Chronic or acute marked abdominal pain may also occur with multiple other nonvascular abdominal diseases, such as gastric or duodenal ulcer, several forms of bowel inflammation, bowel perforation, acute biliary or renal colic, contained aortic rupture, and others. Mesenteric vein thrombosis is not well captured with this classification, because symptoms due to MVT are mostly even more nonspecific. Stage 1 of arterial mesenteric ischemia is usually found accidentally with an abdominal CT or CTA. Treatment is normally not necessary. Chronic mesenteric ischemia (CMI) Symptoms of stages 2 and 3 are found in patients suffering from chronic mesenteric ischemia. Abdominal pain mostly begins at 20–30 min after a meal and persists for 1–3 h (1). Pain frequently increases over time and may become permanent. Because of fear of eating, patients complain of marked waste loss. The main cause of CMI is arteriosclerosis of the major splanchnic arteries. It depends on the degree of collateralization whether or not the patient develops symptoms (12). There are variable collaterals between the splanchnic arteries and variable collaterals of splanchnic arteries to extrasplanchnic vessels, such as hypogastric and lumbar arteries. In case of poor collateralization, occlusion of a single mesenteric artery may be sufficient to render the patient symptomatic, whereas good collateralization may preserve the patient asymptomatic even if all three major splanchnic arteries are occluded. As a rule of thumb, it is said that 2/3 or 3/3 splanchnic arteries have to be occluded before symptoms occur (1,12). The term “chronic” implies that elective treatment is possible; however, the chronic state may turn to acute at any time. Therefore, there is still a dire necessity for treatment. Acute mesenteric ischemia (AMI) Stage 4 symptoms may indicate life-threatening abdominal disease requiring urgent diagnosis and treatment. If other differential diagnoses as mentioned above can be excluded and symptoms persist for several hours, AMI has to be suspected. Occlusion of the proximal splanchnic arteries AMI caused by an obstruction of the proximal segments of the splanchnic arteries occurs mostly due to SMA occlusion that is of embolic nature in most cases; thrombosis favored by underlying arteriosclerotic stenosis is observed in 20%–30% cases (13). A typical patient with AMI is older than 70 years. Among all patients presenting with an acute abdomen, only 1% have AMI; however, in patients older than 70 years, the rate increases to 10% (14). Important risk factors are atrial fibrillation, major heart disease (coronary artery

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disease, congestive heart failure, and myocardial infarction), peripheral arterial occlusive disease, and arterial hypertension. Time to treat critical ischemia of the small bowel is approximately 6 h. Because diagnosis and treatment are frequently delayed, the lethality of AMI is still between 50%–90% and has not improved during the last decades (1,4). Based on pathophysiology, the clinical course of acute arterial mesenteric occlusion is divided into three stages: • initial stage (first 6 h): characterized by severe griping pains in the bowel, nausea, vomiting, diarrhea, and vertigo • intermediate stage (7–12 h): relief of symptoms, tolerable permanent abdominal pain, so-called “deceptive peace,” resulting from necrosis of intramural pain receptors • final stage (>12 h): increase in symptoms, paralytic ileus, penetrating peritonitis, shock, and death Nonocclusive mesenteric ischemia (NOMI) NOMI is a special form of acute mesenteric ischemia that refers to all forms of non-central mesenteric occlusions (3,4,15). NOMI mainly occurs perioperatively in patients following a major cardiac or aortic surgery. Different from this group of patients, NOMI is also observed in patients requiring long-term hemodialysis (16,17). Etiology is not fully understood. It is assumed that NOMI is caused by sympathetic dysregulation with spasm of the distal segments of the mesenteric circulation (1,3). NOMI is observed in 0.5%–1% of all patients undergoing a heart surgery (18). Mortality being approximately 50% is at least as high as or even higher than in acute SMA occlusion (3,4), because symptoms are nonspecific, and they are frequently diagnosed too late. The typical NOMI patient is older than 50 years and treated in the intensive care unit. Different from the other forms of mesenteric ischemia, not CTA but selective arterial DSA of the splanchnic arteries is the method of choice for diagnosis. Despite advances in technology, CTA is not yet able to depict the subtle changes in the periphery of the splanchnic arteries found with NOMI. Moreover, it does not allow CT for the evaluation of splanchnic blood flow, which is simply possible with DSA. Beside the criterion time to portal vein filling, the other two main DSA criteria for the diagnosis of NOMI are vessel morphology and a reflux of contrast medium into the aorta. Based on these three criteria, Minko et al developed a scoring system that well correlated with perioperative mortality (15). Finally, DSA offers the opportunity to combine diagnosis and therapy by infusing vasodilators via the catheter in SMA. Mesenteric vein thrombosis (MVT) Different from arterial mesenteric ischemia, MVT is observed more frequently in younger patients (<50 years) (2,4). Symptoms and prognosis of the patients vary considerably depending on the location, extension, and speed of thrombus formation (2,8,19). Patients with a combination of proximal and distal mesenteric vein thrombosis are more likely to develop mesenteric infarction than those with isolated thrombosis of the proximal mesenteric veins (19). Patients with slowly progressing chronic MVT may be asymptomatic due to the formation of venous collaterals protecting from mesenteric necrosis (2). Most patients present with non-specific symptoms, mainly diffuse abdominal pain that may last for days or even weeks until the diagnosis is conducted. Because symptoms are nonspecific and variable, diagnosis is frequently delayed explaining the potentially high mortality rate of up to 50% (2,8). In idiopathic MVT, no cause is detectable. The frequent causes of secondary MVT are blood clotting disorders, myeloproliferative diseases, pancreatitis, cancer (mainly pancreatic and hepatocellular carcinoma), liver cirrhosis, portal hypertension, and recent abdominal surgery (2). Biphasic contrast-enhanced MS-CT is the imaging method of choice for diagnosis (8). References 1. Brandt LJ, Boley SJ. AGA Technical Review on Intestinal Ischemia. Gastroenterology 2000; 118: 954-968. 2. Kumar S, Sarr MG, Kamath PS. Mesenteric venous thrombosis. N Engl J Med 2001; 345: 1683-1688.

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3. Trompeter M, Brazda T, Remy CT, Vestring T, Reimer P. Non-occlusive mesenteric ischemia: etiology, diagnosis, and interventional therapy. Eur Radiol 2002; 12: 1179-1187. 4. Klar P, Rahmaninan PB, Bücker A, Hauenstein K, Jauch KW, Luther B. Acute mesenteric ischemia: a vascular emergency. Dtsch Arztebl Int 2012; 109: 249-256. 5. Wiesner W, Khurana B, Ji H, Ros PR. CT of acute bowel ischemia. Radiology 2003; 226: 635-650. 6. Shih MC, Hagspiel KD. CTA and MRA in mesenteric ischemia: part 1, role in diagnosis and differential diagnosis. AJR Am J Roentgenol 2007; 188(2): 452-461. 7. Menke J. Diagnostic accuracy of multidetector CT in acute mesenteric ischemia: systematic review and meta-analysis. Radiology 2010; 256: 93-101. 8. Duran R, Denys AL, Letovanec I, Meuli RA, Schmidt S. Multidetector CT features of mesenteric vein thrombosis. RadioGraphics 2012; 32: 1503-1522. 9. Dietrich CF, Jedrzejczyk M, Ignee A. Sonographic assessment of splanchnic arteries and the bowel wall. Eur J Radiol 2007; 64(2): 202-212. 10. Hamada T, Yamauchi M, Tanaka M, Hashimoto Y, Nakai K, Suenaga K. Prospective evaluation of contrast-enhanced ultrasonography with advanced dynamic flow for the diagnosis of intes tinal ischaemia. Br J Radiol 2007; 80(956): 603-608. 11. Zeller T, Macharzina R. Management of chronic atherosclerotic mesenteric ischemia. Vasa 2011; 40(2): 99-107. 12. Alam A, Uberoi R. Chronic mesenteric ischemia treated by isolated angioplasty of the inferior mesenteric artery. Cardiovasc Intervent Radiol 2005; 28: 536-538. 13. Schneider TA, Longo WE, Ure T, Vernava AM. Mesenteric ischemia. Acute arterial syndromes. Dis Colon Rectum 1994; 37: 1163-1174. 14. Schoots IG, Koffeman GI, Legemate DA, Levi M, van Guli, TM. Systematic review of survival after acute mesenteric ischemia according to disease etiology. Br J Surg 2004; 91: 17-27. 15. Minko P, Stroeder J, Groesdonk HV, Graeber S, Klingele M, Buecker A, Schäfers HJ, Katoh M. A scoring system for angiographic findings in nonocclusive mesenteric ischemia (NOMI): correlation with clinical risk factors and its predictive value. Cardiovasc Intervent Radiol Published online 2014; DOI 10.1007/ s00270-014-0844-y. 16. Ende N. Infarction of the bowel in cardiac failure. N Engl J Med 1958; 258: 879-881. 17. Ori Y, Chagnac A, Schwartz A, Herman M, Weinstein T, Zevin D, Gafter U, Korzets A. Non-occlusive mesenteric ischemia in chronically dialyzed patients: a disease with multiple risk factors. Nephron Clin Pract 2005; 101: 87-93. 18. Fisoufi F, Rahmanian PB, Castillo JG, Scurlock C, Legnani PE, Adams DH. Predictors and outcome of gastrointestinal complications in patients undergoing cardiac surgery. Ann Surg 2007; 246; 323-329. 19. Johnson CC, Baggenstoss AH. Mesenteric vascular occlusion; study of 99 cases of occlusion of veins. Proc Meet Mayo Clin 1949; 24: 628-636.

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104.2 Management of acute mesenteric ischaemia J. Raupach Department of Radiology, University Hospital, Hradec Králové, Czech Republic Learning Objectives 1. To define the indications and options for treatment 2. To learn the endovascular techniques for treatment 3. To learn the outcomes and complications of endovascular treatment Acute mesenteric ischemia (AMI) is a life-threatening situation usually when superior mesenteric artery (SMA) occlusion develops. A sudden decrease in arterial blood perfusion to the intestines leads to bowel infarction and necrosis, and subsequent sepsis and death can occur. An early diagnosis and prompt treatment can re-establish mesenteric artery patency and decrease ischemic changes. Although operative SMA embolectomy was first reported in 1951 and was followed by other surgical approaches (SMA thromboendarterectomy in 1958 and aortomesenteric bypass in 1973), the mortality rate related to AMI still remains very high ranging from 60% to 80%. Current advances in endovascular therapy have allowed for a mini-invasive approach for restoring patency of SMA. This type of revascularization has become a preferred alternative even in cases of bowel infarction and perforation, because with the placement of synthetic bypasses, there is a high risk of bacterial contamination and graft infection. In the case of severe bowel ischemia and peritonitis, a subsequent laparotomy and resection of necrotic parts is necessary. Initial endovascular revascularization is a prerequisite for an optimal healing of bowel (intestinal) anastomosis. The current generation of multidetector computed tomography scanners (MDCT) allows for a rapid examination of the acute abdomen and the patency evaluation of mesenteric vessels. Moreover, MDCT is important because it helps in the detection of signs of advanced intestinal ischemia such as the presence of gas in the intestinal wall (pneumatosis intestinalis), in the portal system (pneumatosis portalis), or even signs of bowel perforation (pneumoperitoneum). MDCT also plays an important role when planning for the endovascular procedure; it displays access to the pelvic arteries, their tortuosity, stenotic lesions, and aneurysmatic dilations. The location and cause of SMA occlusion is an important factor influencing the type of catheterdirected therapy. Arterial embolism is the most common etiology of SMA occlusion, accounting for 40%–50% cases. Thromboemboli tend to lodge in the proximal part of the main trunk, just beyond the first few jejunal branches as SMA tapers. The origin of SMA is usually free. In contrast to acute SMA thrombotic occlusion, severe atherosclerotic changes and thrombosis are located just at the level of the SMA origin. The middle part of the trunk is usually filled across vascular collaterals. This situation accounts for 25%–30% AMI cases, and a history of postprandial abdominal pain, weight loss, and food intolerance can be present. The basic requirements to integrate the endovascular approach for the treatment of AMI include the 24/7 availability of a MDCT scanner, an angiographic theatre, and a team that is trained in this type of endovascular interventions. Endovascular arterial revascularization of SMA: Transcatheter embolus aspiration Femoral access is used preferentially. An 8–9-F angled guiding catheter is inserted behind the origin of SMA to gain a stable position, which is essential for the success of this method. A 0.035-inch hydrophilic steerable guidewire (Terumo) is then passed into the distal part of the main trunk. With the guidewire in place, the aspiration catheter (6F, 7F) is advanced close to the embolus. After pulling out the wire, aspiration is applied manually using a 20- or 50-ml syringe. The aspiration catheter is withdrawn during suction, and thus, the captured embolus is removed. An angled aspiration catheter is preferably used for better handling and ability to change the direction in

Abstract Book case of attachment to the vessel wall. The obstructed catheter with engaged embolus is withdrawn and flushed. Several passes through the occluded part are necessary to restore vascular patency. A 5–6-F catheter is used for large side branches aspiration. SMA thrombolysis Adjunctive local thrombolysis is performed in case of incomplete transcatheter embolus aspiration from the main mesenteric trunk or large side branches. The guiding 9-F catheter is left in the proximal part of SMA and a multi-side hole infusion catheter is inserted into the level of embolic occlusion. Local thrombolysis with rtPA at a rate of 0.5–1 mg/h is then utilized. An angiographic control of the thrombolysis efficiency is performed after 6 h. SMA stenting The SMA stenting technique is applied in the case of flow-limiting stenosis after aspiration or as an initial method in acute mesenteric thrombosis. The standard technique represents an approach from the femoral artery and passing the lesion with a 0.018-inch wire. An angled 6–8-F guiding catheter that is 55 cm long is then placed in the ostium of SMA and predilatation with a small balloon is performed. The tip of the guiding catheter could be behind the ostial lesion for a safe stent insertion. The occlusive lesions are stented with balloonexpandable stents or stent-grafts (6–8 mm). Self-expandable stents are used in the case of long or more distally located lesions. In cases of severe SMA angulation, brachial access is recommended. Other endovascular techniques: • retrograde recanalization and SMA stenting This technique represents a hybrid approach where during laparotomy, the peripheral part of SMA is exposed and punctured with a thin 21-G needle. A retrograde insertion of the 0.018-inch wire is performed into the aorta across the proximal occlusion. The wire is snared in the aorta and through-and-through access is gained. Standard AMS stenting from femoral or brachial access is then performed. Several variations of this technique are possible according to various centers. • mechanical thrombectomy by Rotarex • suction thrombectomy by AngioJet • pharmacologic thrombolysis with EKOS catheter • mechanical thrombectomy with a carotid filter Results of modern treatment of acute mesenteric ischemia: The recent generation of MDCT has made it possible to recognize more patients with AMI at an early stage, thereby increasing the chance of better treatment results. Rapid arterial mesenteric revascularization with endovascular techniques offers a less invasive alternative to conventional surgical treatment and improves the healing of bowel anastomosis. In the case of severe bowel ischemia, laparotomy and resection of necrotic parts is necessary. Two extensive multicenter studies have proved a lower frequency of bowel resection and lower long-term death rates after endovascular therapy compared with the standard surgical treatment of acute thrombotic occlusion. The results from our center support the primary application of endovascular therapy also in cases of acute embolic occlusion. Between 2003 and 2014, we used transcatheter aspiration in 37 patients (19 women and 18 men, median age 76 years) with acute embolic occlusion of SMA. Adjunctive local thrombolysis (n = 2) and stenting (n = 2) was used in this group. The median interval between the onset of symptoms and angiography was 24 hours (range 4–336). We were able to achieve complete recanalization of the trunk of SMA in 34 patients (91%). Necrotic bowel resection was performed in 15 patients (40.1%). The total in-hospital mortality of our group was 27.0% (10/37). Conclusion: Primary endovascular therapy of acute SMA occlusion with subsequent control laparotomy and bowel resection is a recommended algorithm and current practice at our center. Particularly, we considered transcatheter embolus aspiration as a very efficient and convenient technique which could be available at every vascular center.

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References 1. Elliott JW. The operative relief of gangrene of the intestine due to occlusion of the mesenteric vessels. Ann Surg 1895; 21: 9–23. 2. Stewart GD, Sweetman WR, Westphal K, Wise RA. Superior mesenteric artery embolectomy. Ann Surg 1960;151: 274–278. 3. Ribet M, Quandalle P, Wurtz A. Acute celio-mesenteric ischemia; revascularization surgery. Ann Chir 1973; 27: 626–630. 4. Sniderman KW, Bodner L, Saddekni S, et al. Percutaneous embolectomy by transcatheter aspiration. Work in progress. Radiology 1984; 150: 357–361. 5. Starck EE, McDermott JC, Crummy AB, et al. Percutaneous aspiration thrombectomy. Radiology 1985; 156: 61–66. 6. Ogihara S, Yamamura S, Tomono H, Iwabuchi H, Ebihara T, Mingawa Y et al. Superior mesenteric arterial embolism treatment by transcatheter trombo-aspiration. J Gastroenterol 2003; 38: 272–277. 7. Hladik P, Raupach J, Lojik M, Krajina A, Voboril Z, Jon B et al. Treatment of acute mesenteric thrombosis/ischemia by transcatheter thromboaspiration. Surgery 2005;137: 122–123. 8. Milner R, Woo EY, Carpenter JP. Superior mesenteric artery angioplasty via a retrograde approach in a patient with bowel ischemia - a case report. Vasc Endovasc Surg 2004; 38: 89–89. 9. Wyers M, Powell R, Nolan B, Cronenwett J. Retrograde mesenteric stenting during laparotomy for acute occlusive mesenteric ischemia. J Vasc Surg 2007; 45: 269–275. 10. Acosta S, Sonesson B, Resch T. Endovascular therapeutic approaches for acute superior mesenteric artery occlusion. Cardiovasc Intervent Radiol 2009; 32: 896–905. 11. Block T, Acosta S, Björck M. Endovascular and open surgery for acute occlusion of the superior mesenteric artery. J Vasc Surg 2010; 52: 959–966. 12. Heiss P, Loewenhardt B, Manke C et al. Primary percutaneous aspiration and thrombolysis for the treatment of acute embolic superior mesenteric artery occlusion. Eur Radiol 2010; 20: 2948–2958. 13. Zeleňák K, Sinák I, Janík J, Mikolajčík A, Mištuna D. Successful recanalization of acute superior mesenteric artery thromboembolic occlusion by a combination of intraarterial thrombolysis and mechanical thrombectomy with a carotid filter. Cardiovasc Intervent Radiol 2013; 36: 844–847. 14. Gagniere J, Favrolt G, Alfidja A, et al. Acute thrombotic mesenteric ischemia: primary endovascular treatment in eight patients. Cardiovasc Intervent Radiol 2011; 34: 942–948. 15. Popovič P, Kuhelj D, Bunc M. Superior mesenteric artery embolism treated with percutaneous mechanical thrombectomy. Cardiovasc Intervent Radiol. 2011; 34(suppl 2): S67–S69. 16. Ballehaninna UK, Hingorani A, Ascher E, Shiferson A, Marks N, Aboian E, Jimenez R, Jacob T, McIntyre T. Acute superior mesenteric artery embolism: reperfusion with AngioJet hydrodynamic suction thrombectomy and pharmacologic thrombolysis with the EKOS catheter. Vascular 2012; 20: 166–169.

104.3 Management of chronic mesenteric ischaemia L.P. Lawler Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland Learning Objectives 1. To define the indications and options for treatment 2. To learn the endovascular techniques for treatment 3. To learn the outcomes and complications of endovascular treatment Chronic mesenteric ischaemia (CMI) is uncommon and frequently a delayed diagnosis but common enough for all interventionalists to be aware of it. It represents <20% of all mesenteric ischaemic cases.

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The key to early diagnosis and intervention is an index of suspicion. Unlike its counterpart acute ischaemia, great benefits can be achieved through timely endovascular intervention. Three key clinical elements are 1. distinctive postprandial pain, 2. fear of eating and 3. weight loss. Without these, stenosis in isolation, no matter how severe, is not diagnosed. I prefer CTA for the imaging diagnosis and planning therapy, but DSA and MRA both have a role. Some feel that there must be more than one vessel compromise (of coeliac, SMA and IMA) to invoke bowel ischaemia, but this is not true. The integrity of the arcades and collaterals as well as distal disease may cause ischaemia from single-vessel stenosis. The majority of culprit lesions treated are SMA and sited at the ostium or juxta ostium though there is often associated distal disease. The end organ, bowel, is usually normal. The etiology is largely atherosclerosis but who really knows how many are burned-out vasculitis or connective tissue diseases. Though most patients have significant other sites of atherosclerotic disease (coronary, carotid and PVD), it appears that the mesenteric territory is spared symptomatic disease in most atherosclerotic patients. Not surprisingly, diabetes is prevalent in this patient group. Other causes of CMI include extrinsic disease of mesentery (e.g. carcinoid, sclerosing mesenteritis), retroperitoneum (e.g. RPF, radiation) and segmental arterial mediolysis. Rest assured that this condition is well within the skill set of most interventionalists. Technical challenges involve crossing the lesion and establishing a stable platform. Having done quite a few of these uneventfully, I will admit I still find the friable nature of the vascular territory and target somewhat frightening in its unpredictability. Depending on the angle of origin of the vessel, I use a femoral or brachial approach, the latter offering a mechanical advantage. I like a 6-F braided sheath with a radiopaque tip and usually cross the stenosis with a 0.035 system. With a stable platform and after heparinisation, I usually deploy a balloon mounted 4–5 mm × 15–20-mm expandable stent over a 0.018 or 0.14 inch wire. Coronary artery equipment is particularly well suited to this vessel territory. Technical success is over 90% with symptomatic relief in over 80% though recurrence can occur in up to 20% cases, and over the following 5 years, other vessel territory atherosclerotic conditions frequently manifest. Surgery has a role, but these are highly diseased vessels for vascular anastomoses. Median arcuate syndrome (MAS) deserves a special mention. It is frequently over-diagnosed based on imaging alone and endovascular and surgical therapies can have a significant morbidity and mortality risk. The key message is that a high angulated, stenotic origin of the coeliac artery behind the arcuate ligament is a very prevalent normal variant, and MAS is a diagnosis of exclusion that must be based on a sound clinical assessment, and an exclusion of other medical and psychiatric conditions before therapy is contemplated. It is simply erroneous to use the term MAS on CTA/MRA and DSA to describe this anatomic variant in the absence of supporting literature and can lead to over-treatment. References 1. Ferro C, Rossi UG, Seitun S, Bovio G, Fornaro R. Endovascular treatment of totally occluded superior mesenteric artery by retrograde crossing via the Villemin arcade. Cardiovasc Intervent Radiol. 2013 Jun;36(3):848-52. doi:10.1007/s00270-012-0469-y. Epub 2012 Aug 25. PubMed PMID: 22923330. 2. Turba UC, Saad WE, Arslan B, Sabri SS, Trotter S, Angle JF, Hagspiel KD, KernJA, Cherry KJ, Matsumoto AH. Chronic mesenteric ischaemia: 28-year experience of endovascular treatment. Eur Radiol. 2012 Jun;22(6):1372-84. doi:10.1007/s00330-011-2376-z. Epub 2012 Feb 3. PubMed PMID: 22302502. 3. Loffroy R, Guiu B, Cercueil JP, Krausé D. Chronic mesenteric ischemia: efficacy and outcome of endovascular therapy. Abdom Imaging. 2010 Jun;35(3):306-14. doi: 10.1007/s00261-009-9515-x. Epub 2009 Apr 16. Review. PubMed PMID: 19370299.

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4. Sarac TP, Altinel O, Kashyap V, Bena J, Lyden S, Sruvastava S, Eagleton M, Clair D. Endovascular treatment of stenotic and occluded visceral arteries for chronic mesenteric ischemia. J Vasc Surg. 2008 Mar;47(3):485-491. doi:10.1016/j.jvs.2007.11.046. PubMed PMID: 18295100. 5. Biebl M, Oldenburg WA, Paz-Fumagalli R, McKinney JM, Hakaim AG. Surgical and interventional visceral revascularization for the treatment of chronic mesenteric ischemia--when to prefer which? World J Surg. 2007 Mar;31(3):562-8. PubMed PMID:17334867. 6. Schaefer PJ, Schaefer FK, Mueller-Huelsbeck S, Jahnke T. Chronic mesenteric ischemia: stenting of mesenteric arteries. Abdom Imaging 2007 May-Jun;32(3):304-9. Epub 2006 Sep 6. Review. PubMed PMID: 16955377. 7. Schaefer PJ, Schaefer FK, Hinrichsen H, Jahnke T, Charalambous N, Heller M,Mueller-Huelsbeck S. Stent placement with the monorail technique for treatment of mesenteric artery stenosis. J Vasc Interv Radiol. 2006 Apr;17(4):637-43. PubMed PMID: 16614146. 8. Sheeran SR, Murphy TP, Khwaja A, Sussman SK, Hallisey MJ. Stent placement for treatment of mesenteric artery stenoses or occlusions. J Vasc Interv Radiol. 1999 Jul-Aug;10(7):861-7. PubMed PMID: 10435702. 9. Hallisey MJ, Deschaine J, Illescas FF, Sussman SK, Vine HS, Ohki SK, StraubJJ. Angioplasty for the treatment of visceral ischemia. J Vasc Interv Radiol. 1995 Sep-Oct;6(5):785-91. Review. PubMed PMID: 8541685. 10. Bobadilla JL. Mesenteric ischemia. Surg Clin North Am. 2013 Aug;93(4):925-40, ix. doi: 10.1016/j.suc.2013.04.002. Epub 2013 May 16. Review. PubMed PMID: 23885938. 11. Pecoraro F, Rancic Z, Lachat M, Mayer D, Amann-Vesti B, Pfammatter T, Bajardi G, Veith FJ. Chronic mesenteric ischemia: critical review and guidelines for management. Ann Vasc Surg. 2013 Jan;27(1):113-22. doi:10.1016/j.avsg.2012.05.012. Epub 2012 Oct 23. Review. PubMed PMID: 23088809.

104.4 Treatment of visceral artery aneurysms M.S. Hamady Interventional Radiology, Imperial College-London, London, United Kingdom Learning Objectives 1. To define the indications and options for treatment 2. To learn the endovascular techniques for treatment 3. To learn the outcomes and complications of endovascular treatment Visceral artery aneurysms (VAAs) are increasingly diagnosed as a result of advancing technology and widespread availability of developed imaging modalities across the world. Although VAAs are relatively rare, they can be associated with rupture and catastrophic outcomes. The arteries involved in order of frequency are splenic artery (60%–80%), hepatic artery (20%), renal (15%–22%), mesenteric vessels (8%), celiac trunk and its branches (8%) and inferior mesenteric artery (1%)1. There are two main types of VAAs: true and pseudoaneurysm. The true aneurysm has three outlining layers: adventitia, media and intima. The pseudoaneurysm has no proper wall, and it is contained by either adventitia alone or by surrounding soft tissues. The causes of true VAAs include atherosclerosis, vasculitis and fibromuscular dysplasia. The false aneurysm can be secondary to trauma, infection, inflammation, vasculitis or iatrogenic injury. Imaging CT angiography and MRA are the most frequent modalities used to establish the features of aneurysm including shape, type, size, multiplicity, collateral vessels and the status of surrounding tissues.

Abstract Book Imaging can be crucial in deciding the most appropriate intervention tool and in technical planning. Clinical presentation The majority of VAAs are diagnosed incidentally. However, ruptured aneurysm may present with excruciating pain, hemodynamic instability and collapse. The clinical examination is usually unrevealing. Indications for intervention The natural history of VAA is poorly understood. Therefore, there is no clear consensus or guidelines to dictate a clear set of criteria for intervention. Nevertheless, there is a general agreement among experts that treatment is indicated in 1) ruptured aneurysm, 2) aneurysm size of ≥2 cm, 3) growing aneurysm, 4) aneurysms associated with pregnancy and arthritis and 5) pseudoaneurysms, regardless of their size. Treatment options Several endovascular tools are available. These include coils, stentassisted coiling, covered stent, adhesive and non-adhesive liquid embolics, flow-diverting stent, occlusion device and thrombin injection. Regardless of the equipment used, the intervention must ensure complete isolation and thrombosis of the aneurysm. The choice should be tailored to the patient’s condition and aneurysm anatomy as well as the operator’s expertise. Due to a wide variety of interventional tools, interventional radiologists are required to familiarise themselves with these equipment in order to achieve the required success. Outcome of percutaneous intervention and open surgery The available evidence of treatment outcomes, whether open or endovascular, can be derived from the case studies of retrospective studies. There is a lack of prospective, well-controlled case studies or randomised trials. In a report of 51 VAAs from two leading European centres, 32 aneurysms were treated over a 5-year duration2. Seventeen patients had open repair and 15 patients had endovascular occlusions. All cases were technically successful in both groups. There was no in-hospital mortality in either group. Postoperative non-lethal complications were recorded in 23.5% open surgeries vs. 6.6% endovascular interventions. There was a significant difference in the length of stay in the favour of endovascular group with a mean hospital stay of 4 days vs. 17 days. The reintervention rate was equal in both groups (2 cases in each group). Fankhauser et al3 reported an endovascular experience over a 10-year duration with 185 VAAs. Bleeding was the main indication in almost half of those aneurysms (46%). One third of the treated cases were true aneurysms. Success was achieved in 98% cases using coils alone in the majority of cases. Thirty-day aneurysm-related mortality was 3.4%, and recurrence rate was low (3%). A single-centre experience with an open surgery of 54 patients reported a low mortality rate of 1.8% and major complications of 3.8%4. However, 97% operations were conducted electively in asymptomatic patients. In a literature review comparing open and endovascular interventions published in 2010, 1528 VAAs were identified2. Open repair was used in 678 patients and endovascular approach in 278 patients. The rest of the patients were treated expectantly. The success rate of endovascular treatment was high, i.e. approaching 90%. The interventional radiology approach demonstrated a clear advantage over open surgery for ruptured aneurysms with a reported mortality of 2.7% vs. 23.9%. However, there was no significant difference in mortality or overall postoperative non-lethal complications between the two modalities. Postembolization syndrome was the most common complication associated with endovascular treatment that was reported up to 30%. Furthermore, reintervention rate was higher with endovascular intervention (11.1% vs. 6.9%). However, recent development in embolization techniques and devices as well as growing experience of IR practitioners was not considered.

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1. Messina LM, Shanley CJ. Visceral artery aneurysms. Surg Clin North Am. 1997;77(2):425-442. 2. Cochennec F, Hamady M, et al. Contemporary management of splanchnic and renal artery aneurysms: results of endovascular compared with open surgery from two European vascular centers. Eur J Vasc Endovasc Surg. 2011 Sep;42(3):340-6. 3. Fankhauser GT, Stone WM, Naidu SG, et al. The minimally invasive management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg. 2011 Apr;53(4):966-70. 4. Pulli R, Dorigo W, Troisi N, Pratesi G, Innocenti AA, Pratesi C. Surgical treatment of visceral artery aneurysms: a 25-year experience. J Vasc Surg. 2008 Aug;48(2):334-42.

Technique – the typical renal artery percutaneous transluminal angioplasty/stenting procedure

Fundamental Course Basic principles of renal artery intervention 201.1 Current indications for renal percutaneous transluminal angioplasty/stenting J.G. Moss Department of Radiology, North Glasgow University Hospitals, Gartnavel General Hospital, Glasgow, United Kingdom Learning Objectives 1. To learn the results of relevant trials 2. To understand the indications for PTRA/S 3. To learn the contraindications Six randomised controlled trials conducted over the last 15 years testing either renal angioplasty and/or renal stenting against the best medical management have failed to demonstrate any clinically useful benefit from treating stenosis in atherosclerotic disease. The largest trial (CORAL) was published in 2013 (1). These trials have contained a broad mixture of patients with different degrees of stenosis and clinical indications, including either hypertension, impaired renal function or a combination of both. Outcomes have included blood pressure, renal function and cardiovascular events. There is anecdotal experience from many interventionalists across the globe of benefit in individual patients, but the identification of those patients’ phenotype remains elusive. A recent retrospective study of 467 patients suggested that patients with acute pulmonary oedema and the combination of rapidly declining renal function with refractory hypertension may be the two groups worthy of further study (2). Therefore, for the vast majority of patients with atherosclerosis, tablets and lifestyle modification should be the mainstay of care. There is good non-randomised data to suggest that angioplasty is worthwhile in patients with non-atheromatous disease and particularly, in fibromuscular dysplasia. However, this patient group is small. References 1. Cooper CJ, Murphy TP, Cutlip DE, et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med 2013. DOI: 10.1056/NEJMoa1310753. 2. Ritchie J, Green D, Chrysochou C, et al. High-risk clinical presentations in atherosclerotic renovascular disease: Prognosis and response to renal artery revascularization. http://dx.doi. org/10.1053/j.ajkd.2013.07.020.

J.H. Peregrin Dept of Diagnostic and Interventional Radiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic Learning Objectives 1. To learn the technique of PTRA/S and selection of equipment 2. To learn how to overcome difficult anatomy 3. To understand which complications may occur and how to deal with them Access Renal artery (RA) is commonly approached from femoral access. Brachial or radial artery approach is useful, particularly, when renal arteries have a steep downward angle. Dilatation/stent placement RA stenting by balloon-expandable stents is used in almost all atheromatous stenosis (sometimes except RA peripheral branch lesions) dilatation. A 6–7-F guiding catheter is positioned in the RA ostium, and stenosis is negotiated by a 0.018- or 0.014-inch wire. Tight stenosis can be predilated using a balloon of a size 1–2 mm smaller than the renal artery diameter. In majority of cases, stenosis is close to the RA ostium, and the stent should be placed such that approximately 1 mm protrudes into the aortic lumen. Final angiography can be performed through the guiding catheter close to the origin of the renal artery with the wire still in place. When only (usually preshaped) 5–6-F sheath is used, the RA ostium is catheterized using a diagnostic catheter of a shape fitting to the particular RA anatomy. A stenosis is then crossed by a 0.018- or 0.014-inch wire, and after the removal of the diagnostic catheter, a balloon-mounted stent is manipulated through the lesion. The stent support is inferior when compared to the guiding catheter. For final dilation, a 0.5–1-mm bigger stent than the artery diameter is used. Should we use a protective device? Peripheral embolization is fortunately a rare (but serious) complication of RA PTA. The currently available protective devices are rather difficult to use in renal arteries (due to the anatomy of RA). Moreover, till date, there are no evidence of the benefit of the use of this device in renal angioplasty, and therefore, it should be used in for protection device favorable RA anatomy and high risk patients only. Special subgroups Transplanted kidneys The technique varies according to the type of arterial anastomosis. Internal iliac (end-to-end) anastomosis often requires a contralateral (“crossover”) approach. The same approach can be used when an external iliac artery (end-to-side) anastomosis has a very steep “downgoing” take-off. Because transplant kidney artery stenosis is usually not of an atheromatous origin, the stents are less commonly used as a primary measure. However, the complications (extensive dissection or suboptimal dilatation) can be treated by stent placement. PTRA/stenting in children Renal artery stenosis in children is usually caused by fibromuscular dysplasia or arteritis. Because smaller arterial size coronary instrumentarium is usually employed, stents are used less frequently and little is known about the fate of a stented artery in growing renal vascular bed. References 1. Percutaneous vascular interventions in renal artery diseases. Kolluri R, Goldstein JA, Rocha-Singh K. Minerva Cardioangiol. 2006 Feb;54(1):95-107. Review.

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2. Tips and tricks in renal artery angioplasty and stenting: angiography, stent placement, embolic protection, complications, and contrast induced nephropathy. Patel RA, White CJ. Minerva Cardioangiol. 2010 Feb;58(1):113-26. Review. 3. Efficacy of embolic protection devices in renal artery stenting. Campbell JE, Stone PA, Bates MC. J Cardiovasc Surg (Torino). 2010 Oct;51(5):747-54. Review. 4. Percutaneous renal artery angioplasty and stenting: indications, technique and results. Kok HK, Leong S, Govender P, Browne R, Torreggiani WC. Ir J Med Sci. 2013 Sep;182(3):351-6. 5. Renal artery stenting: indications, techniques, and devices. Erwin PA, Shishehbor MH. Minerva Cardioangiol. 2013 Apr;61(2):189-99. Review.

201.3 New evidence and indications for renal denervation M.R. Sapoval Dept. of Cardiovascular Radiology, Hôpital Européen Georges Pompidou, Paris, France

Abstract Book enables a surgeon to deal with unexpected findings such as stones or a tight bladder neck that PAE cannot address. Pathological specimens can also be examined to ensure no underlying malignancy is missed. Refinements in TURP technique and improved patient selection have also helped to minimise morbidity and reduce length of stay, with some units performing it as a day case procedure. It also has the longest and most robust data to support its use, with a 1% per annum redo rate. Despite these reservations, PAE does have a role to play in B.O.O., which the imminent UK ROPE trial will help to determine. Men who have failed medical therapy and those who wish to avoid side effects such as retrograde ejaculation are ideal for PAE; in the few where it fails, a subsequent TURP is likely to be easier and less complicated. Medical therapy is essentially for life and can have noticeable side effects, so a single procedure that gives sufficient symptom relief should be considered. However, until long-term data that support the routine use of PAE are available, TURP remains the optimal treatment for men with symptomatic LUTS.

202.2 Prostate artery embolisation is inferior to transurethral resection of the prostate: Con

Learning Objectives 1. To learn the current evidence for renal denervation 2. To learn about the ongoing trials 3. To learn about other potential applications of the technique

N. Hacking Department of Clinical Radiology, University Hospitals Southampton, Southampton, United Kingdom

No abstract available. No abstract available.

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Technique - renal denervation

Bariatric gastric artery embolisation: Pro

J.A. Reekers Department of Radiology, Academic Medical Centre, Amsterdam, Netherlands

A. Arepally Interventional Radiology, Piedmont Healthcare, Atlanta, GA, United States of America

Learning Objectives 1. To learn about the various devices 2. To learn the anatomical limitations 3. To learn about potential complications and how to manage them No abstract available.

No abstract available.

202.4 Bariatric gastric artery embolisation: Con R.C. Stuart Surgeon, Glasgow, United Kingdom

Special Session Controversy Controversies in transcatheter embolisation

No abstract available.

202.1 202.5

Prostate artery embolisation is inferior to transurethral resection of the prostate: Pro M. Harris Urology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom For men with bladder outflow obstruction (B.O.O.), TURP has long been the gold standard. Numerous new options have emerged, with the hope of avoiding the need for anaesthesia and reducing morbidity such as retrograde ejaculation. PAE (prostate artery embolisation) is a novel approach where the reduced arterial supply induces gland reduction and has a significant effect on flow rates and voiding patterns. The side effect profile is favourable with reduced retrograde ejaculation, haematuria and risk of erectile dysfunction. Whilst these effects, along with volume reduction and IPSS questionnaire changes, are better than with medical therapy, they are still inferior to TURP (although matched head-to-head studies are required). Patients require radiation for PAE in the form of a CT angiogram to plan their treatment as well as screening during the procedure. TURP also

Radioembolisation is superior to portal vein embolisation for liver hypertrophy: Pro R. Salem Radiology, Northwestern University, Chicago, IL, United States of America No abstract available.

202.6 Radioembolisation is superior to portal vein embolisation for liver hypertrophy: Con A. Denys Radiology and Interventional Radiology, CHUV, Lausanne, Switzerland No abstract available.

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Special Session Interventional oncology: improving results through advanced technologies 203.1 Stereotaxy and robotic assistance R. Bale Clinic of Radiology, Medical University Innsbruck - SIP - Department for Microinvasive Therapy, Innsbruck, Austria Learning Objectives 1. To learn what is available today and tomorrow 2. To understand the advantages and drawback of stereotactic and robotic systems 3. To learn the compatibility of robots with different imaging modalities The success of image-guided percutaneous tumour ablation depends on accurate planning, guidance and control of the ablation necrosis. Recurrences often appear at the periphery of the lesion. In large tumours, a geometric overlap of ablation spheres is required to achieve an adequate treatment volume. However, conventional CT-US guidance techniques still do not deliver the RF ablation electrode into a precise configuration of overlapping volumes. The 3D map has to be mentally constructed by an experienced operator. Recently, different targeting technologies for percutaneous ablative therapy, including ultrasound navigation, stereotaxy and robotics have been described. Computer-assisted volumetric planning and tool tracking may aid in precise and safe delivery of an RF ablation electrode into a target in order to cover the tumour and including a safety margin. Key words Tumour ablation, image guidance, guidance devices, stereotaxy, stereotactic RFA (SRFA), 3D navigation, robotics Introduction Minimally invasive percutaneous image-guided tumour ablation therapy has gained increasing importance in the medical field. Precise electrode placement is required in order to prevent violation of sensitive structures due to electrode insertion and ablation and to obtain high levels of complete necrosis and low recurrence rates. Therefore, different guidance technologies including US navigation, stereotaxy and robotics have been developed [1]. US navigation US navigation combines preoperative CT/MR imaging with intraoperative US by following the US transducer with an optical or electromagnetic-based 3D tracking system [2]. 3D navigation/stereotaxy 3D-navigation systems allow tracking the position of a surgical tool, which is projected in real-time in the patient’s corresponding CT or MR images [1, 3]. Optical 3D navigation is based on active emitting or passive reflecting of light tracking elements, which are mounted to different tools and probes and recorded by a stereoscopic camera [1]. On one hand, it has a high technical accuracy in the range of 0.1– 0.4 mm; however, constant visual contact between the camera array, reference frames and instruments is required. In contrast, electromagnetic 3D navigation is based on the tracking of tiny sensor coils, which are incorporated in tools and do not necessitate visual contact with the electromagnetic field sensor system [3]. However, the sensitivity to external magnetic fields and metals may lead to incorrect position sensing of up to 4 mm. Treatment planning is based on multimodal 3D datasets (CT, MRI, PET and SPECT) of multiple trajectories on 2D and 3D reformatted images [1, 3]. Virtual flights along the planned trajectory may visualise critical anatomic structures and obstacles along or in close vicinity to the path. Special RFA planning software may visualise virtual treatment zones based on mathematical ablation models.

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Image-to-patient registration is usually based on skin fiducials (invasive markers directly placed into the target organ) or automated registration methods (‘modality-based registration’) [1]. During 3D-navigated puncture, deviation distance and angles of the tracked surgical tool from the surgical path are given in real time. In stereotactic radiofrequency ablation (SRFA), an aiming device is used for rigid and precise tool guidance [1, 4]. Robotics Robotic systems can be used for automated aiming of the planned trajectory. The subsequent needle introduction may be performed manually [5] or automatically monitored by the interventionalist [6]. Respiratory motion compensation Compensation of respiratory motion is essential [1]. In US navigation, corrections of the initial registration may be necessary to preserve acceptable registration accuracy in different patient and respiration positions [2]. Skin- or invasive marker-based techniques track the motion of the skin surface or target organ [7, 8]. In practice, respiratory motion compensation can be successfully achieved when the interventional CT/MRI scans, the registration procedure and the puncture are performed in maximal expiration, preferentially by the temporary disconnection of the endotracheal tubes in relaxed patients under general anaesthesia [1]. Discussion A major drawback of all conventional US-, CT-, or MRI-guided procedures that are based on 2D imaging is that the 3D visualisation of the anatomical situation and planning of the tumour ablation are operator-dependent mental work (‘mental 3D navigation’) [1]. In contrast, computer-assisted techniques directly link 3D imaging and guidance technology, and thus may substantially improve the technical abilities of percutaneous tumour ablation [1, 3]. Interactive visualisation tools facilitate the planning of the required coagulation necrosis with respect to a sufficient intentional margin. There are no limitations of in-plane electrode insertion because this technology is a true 3D intervention. In comparison with free-hand navigation, stereotactic aiming devices enable a quick adjustment of the trajectory at the best technical level and stable guidance of the probe introduction. Robotic alignment and probe insertion can be performed automatically without operator interaction. However, currently most robotic systems are cumbersome and still far away from routine clinical applicability. Highly accurate targeting irrespective of previous experience with image-guided punctures has been reported in numerous phantom studies and in initial animal studies [1, 4, 5, 7, 8]. Needle misplacement and repeated puncture attempts can be reduced, and the intervention may be enhanced in terms of safety and precise execution of the interventional goal. The disadvantages of the high-end guidance technology are the increased requirements on infrastructure and staff, specialised training and increase in treatment costs. However, the potentials of these guidance technologies in the field of interventional oncology cannot be neglected. Multifunctional image-guided therapy suites, which integrate several image modalities (US, CT or MR) and targeting technology (navigation systems, robots), may become increasingly important. References 1. Bale R, Widmann G. Navigated CT-guided interventions. Minim Invasive Ther Allied Technol 2007;16(4):196-204. 2. Penney GP, Blackall JM, Hamady MS, Sabharwal T, Adam A, Hawkes DJ. Registration of free-hand 3D ultrasound and magnetic resonance liver images. Med Image Anal 2004;8(1):81-91. 3. Wood BJ, Locklin JK, Viswanathan A, Kruecker J, Haemmerich D, Cebral J, Sofer A, Cheng R, McCreedy E, Cleary K, McAuliffe MJ, Glossop N, Yanof J. Technologies for guidance of radiofrequency ablation in the multimodality interventional suite of the future. J Vasc Interv Radiol 2007;18(1 Pt 1):9-24.

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4. Stoffner R, Augschöll C, Widmann G, Böhler D, Bale R. Accuracy and feasibility of frameless stereotactic and robot-assisted ct-based puncture in interventional radiology: a comparative phantom study. Rofo 2009;181(9):851-858. 5. Kettenbach J, Kronreif G, Figl M, Fürst M, Birkfellner W, Hanel R, Ptacek W, Bergmann H. Robot-assisted biopsy using computed tomography-guidance: initial results from in vitro tests. Invest Radiol 2005;40(4):219-228. 6. Cleary K, Melzer A, Watson V, Kronreif G, Stoianovici D. Interventional robotic systems: applications and technology state-of-the-art. Minim Invasive Ther Allied Technol 2006;15(2):101113. 7. Zhang H, Banovac F, Lin R, Glossop N, Wood BJ, Lindisch D, Levy E, Cleary K. Electromagnetic tracking for abdominal interventions in computer aided surgery. Comput Aided Surg 2006;11(3):127-136. 8. Banovac F, Tang J, Xu S, Lindisch D, Chung HY, Levy EB, Chang T, McCullough MF, Yaniv Z, Wood BJ, Cleary K. Precision targeting of liver lesions using a novel electromagnetic navigation device in physiologic phantom and swine. Med Phys 2005;32(8):2698-2705.

203.2 PET-CT C.T. Sofocleous Interventional Radiology Suite H118, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America Learning Objectives 1. To learn the best indications for PET-CT interventions 2. To learn the technique and results of PET-CT interventions 3. To learn how to reduce radiation dose for both the operator and the patient No abstract available.

203.3 Fusion imaging M.J.L. van Strijen Dept. of Radiology, Sint Antonius Hospital, Nieuwegein, Netherlands Learning Objectives 1. To understand different fusion methods 2. To learn the best indications for fusion 3. To understand the technique and results of fusion imaging Before starting an interventional procedure, one should realise that in almost every patient previous imaging data is available, acquired with dedicated protocols on advanced cross-sectional imaging equipment and with the use of appropriate contrast enhancement. Using these acquisitions in the actual intervention can be an excellent way to potentially reduce the amount of contrast needed and the total radiation dose for patient and operators. Non-contrast low-dose acquisitions on interventional imaging systems can then be used for registering these previously acquired volumes with the actual position of the patient on the table. Pre-interventional image analysis and preparation To be able to use the available data, it is necessary that these images have sufficient quality or have been segmented in a way that, for instance, vascular anatomy or tumour size and location can be viewed from any angle without being obscured by other overlying structures. Ideally, the initial acquisitions have a high resolution and are acquired with isotropic voxel size. Noise should be limited as much as possible, and contrast enhancement should be optimal. Segmentation needs to be performed on dedicated workstations with a high flexibility in tissue definition and standardised export features. Contour segmentation of areas of interest can be

Abstract Book very helpful in identifying the relevant anatomy and facilitating the fusion process. Despite the most precise preparation and fusion, the ability for manual adjustments of fused images is a necessary requirement. Vascular interventions: fusion with CT or MR angiography images In patients with poor renal function and in procedures that potentially require many contrast injections, the use of 3D information providing essential information on vascular anatomy can considerably reduce the need for contrast. This works particularly well in the relatively fixed abdominal aorta, for localising and targeting, for instance, renal arteries in fenestrated endovascular aneurysm repair. An otherwise complicated procedure requiring over 300 cc of contrast can be performed with as little as 40–80 cc. This works less well in the iliac arteries, where the introduction of stiff guidewires can severely distort the overlaid natural anatomical course of the vessels. Accurate sizing and placement in these situations require special techniques. In placing endoprosthesis in abdominal aorta aneurysm repair, millimetre precision is required, whereas road-mapping for tortuous vascular anatomy is less critical. In the thoracic aorta, cardiac movement and the shape of the aortic arch provide separate challenges, but recent experiences have shown that exact placement of endoprosthesis is more critical with important branching vessels in this area. Best experiences to date have been with 3D–3D registering techniques, but recently experiments have started with using only two 2D single-shot acquisitions with sufficient spacing to provide enough information for registering to previously acquired 3D DICOM image set. Non-vascular interventions: merging cone-beam CT with preinterventional CT and MR Although the image quality of CBCT is sufficient for performing needle path planning, additional information from pre-interventional CT or MR images may sometimes be required or can be very helpful in hard-to-visualise structures. In particular, the unique soft tissue information on MR scans can sometimes be very helpful for needle path planning or targeting. In these cases, the imported volume is registered to a CBCT volume based on anatomical landmarks, after which the needle planning can be performed on the imported volume. This technique is very helpful in needle interventions in soft tissue lesions or lesions only visible on contrast-enhanced CT. After segmentation and planning, additional graphical information on lesion size and location can be used as an overlay for plain fluoroscopy during the intervention or in repeat non-contrast imaging series in the course of the procedure. Another possible feature is the use of graphical depiction of the potential effect of dedicated intervention needles in, for instance, thermal ablation procedures. Monitoring the ablation is easier and the desired effect more reproducible. Disadvantages and potential pitfalls If the position of the patient changes considerably between the initial data set and the actual interventional procedure, severe misregistrations can occur. It is therefore essential to first focus on the relevant anatomy instead of the easily identifiable surrounding structures like bone or hard tissue–air interfaces in a more distant location. In particular, the major upper abdominal organs can change considerably in shape and anatomical location when changing from a prone to a supine position. In addition, normal breathing motion can interfere when targeting smaller lesions in organs highly subject to this movement. The use of dedicated breathing movement monitoring devices, fiducials as well as temporarily halting breathing in fully relaxed patients under general anaesthesia can help overcome this. The introduction of interventional materials of certain stiffness in flexible anatomic structures can also cause considerable displacement relative to the initial imaging series. Examples of this are the use of stiff guidewires in the iliac vasculature and the introduction of needles in fibrous tumours in a displaceable kidney.

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Future developments Currently, new techniques are being developed for facilitating the process of image fusion and the combined use of different image data sets. The automatic and intelligent recognition of anatomic structures, displacement and distortion of solid organs and vascular anatomy should be developed in dedicated and intuitive software. The next step could be automatic continuous live adaptations of the fused images, compensating for patient movement during the procedure and even prediction of deformation based on the characteristics of interventional devices. Robot assistance for catheter movement and needle guidance is also available currently, but this technology needs further development in seamless integration with the fusion process and the next generations of imaging equipment. References 1. Real-Time 3D Fluoroscopy Guidance During Needle Interventions: Technique, Accuracy, and Feasibility. Braak SJ, van Strijen MJL, van Leersum M, van Es HW, van Heesewijk JPM. AJR 2010;194(5):W445W451. 2. Multimodality Image Fusion-guided Procedures: Technique, Accuracy, and Applications. Abi-Jaoudeh N, Kruecker J, Kadoury S, Kobeiter H, Venkatesan AM, Levy E, Wood BJ. Cardiovasc Intervent Radiol 2012;35(5):986-998. 3. Type II Endoleak Embolization after Endovascular Abdominal Aortic Aneurysm Repair with Use of Real-time Three-dimensional Fluoroscopic Needle Guidance. van Bindsbergen L, Braak SJ, van Strijen MJL, de Vries JPM. JVIR 2010;21(9):1443-1447.

203.4 Magnetic resonance navigation A. Gangi Imagerie Interventionnelle, NHC, Strasbourg, France Learning Objectives 1. To learn about the advantages and drawbacks of MR navigation 2. To learn the best indications for MR-guided procedures 3. To learn about the specific tools, materials, and sequences adapted to MR-guided interventions No abstract available.

Special Session Metastatic neuroendocrine tumours 204.1 Clinical and pathological aspects of metastatic neuroendocrine tumours J.W. Valle Department of Medical Oncology, The Christie NHS Foundation Trust, Manchester, United Kingdom Learning Objectives 1. To learn the clinical presentations and treatment dilemmas in patients with NET 2. To learn about different pathological aspects and implications for treatment 3. To understand the role of multidisciplinary teams in the management of NETs No abstract available.

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204.2 Systemic and radionuclide therapies F. Forrer Klinik für Radiologie und Nuklearmedizin, Kantonsspital St. Gallen, St. Gallen, Switzerland Learning Objectives 1. To learn about nuclear imaging of NETs and its implication for management with systemic or nuclear medicine therapies 2. To become familiar with indication, treatment strategies and follow-up of NETs 3. To understand current results and future developments of nuclear medicine management of NETs Neuroendocrine tumors (NETs) are rare malignancies originating from neural crest cells. These cells belong to the amino precursor uptake and decarboxylation (APUD) system and can therefore accumulate and decarboxylate amine precursors. These cells can produce amines or hormones, such as histamine, serotonin, adrenaline, gastrin, and somatostatin (SST), that often contribute to the onset of symptoms [1]. Neuroendocrine cells are sparse throughout the body even though they are mainly concentrated in the gastrointestinal tract and pancreas. Tumors originating from neuroendocrine cells in the gastrointestinal tract are often referred to as gastroenteropancreatic (GEP) tumors. NETs can originate in different parts of the gastrointestinal tract (most frequently in the jejunum, ileum, appendix, and rectum) and in the endocrine pancreas (glucagonoma, insulinoma, VIPoma, and gastrinoma). However, NETs may originate in other anatomical sites (bronchial carcinoid, neuroblastoma, medullary thyroid cancer, pheochromocytoma, and paraganglioma) [2]. Secreting tumors may cause specific syndromes, including carcinoid syndrome, hypoglycemia, hyperglycemia, Zollinger–Ellison syndrome, and pheochromocytoma syndrome. The carcinoid syndrome (diarrhoea, skinflushing, abdominal cramps, nausea, vomiting, and valvular heart disease) is the most common clinical syndrome and is related to the production of serotonin and histamine [3]. Many tumors may remain asymptomatic for many years. In 20–50% of cases, the primary origin cannot be identified and only liver or skeletal metastatic disease is detectable [1]. More than 90% of NETs express SST receptors. SST is a peptide occurring in 14- and 28-aminoacid isoforms. It is ubiquitous in the body, occurring prevalently in the central and peripheral nervous systems, gut, and endocrine glands. It exerts inhibitory effects on various hormonal systems and physiological functions, including cell growth. Five subtypes of the SST receptor (SST1–5) have been identified and cloned [4]. Most NETs are characterized by a strong overexpression of SST receptors (SSTR), mainly subtype 2. SSTR is an attractive target for radiolabeled peptides since the density of receptors is vastly higher than on non-tumor tissue [4]. Radiolabeled peptides with a high affinity for the SST2 receptors may be used for the diagnosis of NETs and for peptide receptor radionuclide therapy (PRRT). [111In-DTPA0]-octreotide has been the first peptide used for the diagnosis of SST2 receptor-positive tumors and PRRT. This radiolabeled peptide, emitting photons for imaging and Auger electrons for therapy, often induced symptomatic relief, but objective morphological responses were rarely documented [5-8]. After the introduction of the chelator 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) other peptides, primarily [DOTA(0),Tyr(3)] octreotate (DOTATATE) and [DOTA(0),Tyr(3)] octreotide (DOTATOC) were labeled with 90Y or 177Lu and used for therapeutic applications. The rate of objective response obtained with these radiolabeled peptides ranges between 6% and 46%, owing to the differences in inclusion criteria adopted in different studies, length and type of therapy, and criteria of evaluation of the response. The present data in literature do not allow defining the

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most suitable peptide and radionuclide for the treatment of NETs. Instead, emerging evidence indicates that a combination of nuclides with different physical characteristics might be more effective than the use of a single nuclide. Kidney and bone marrow toxicity are the limiting factors for PRRT. Mild toxicity is often encountered, whereas severe toxicity is rare. Toxicity could be reduced and therapeutic efficacy enhanced with the aid of patient-specific dosimetry. Future directions include different issues of PRRT, such as defining the most suitable treatment scheme, evaluation of new peptides with different affinity profiles to other SST receptor subtypes, and reduction of toxicity [9,10]. With regard to the imaging and diagnosis of NETs, PET/CT is a rapidly emerging modality. Using radiopeptides with a high affinity for the SST receptors labeled with a positron-emitting radionuclide results in highly sensitive detection and high-resolution imaging of SST receptors in combination with morphological CT imaging. PET/ CT using 68Ga-labeled peptides, e.g., Ga-68-DOTANOC, proved to be the most sensitive and accurate in detecting SST receptor-positive tumors [11]. The diagnosis of insulinoma represents a special challenge as insulinomas are often SSTR-negative. On the other hand, insulinoma often overexpress glucagon-like peptide 1 (GLP-1) receptors. Recently, several very promising reports on GLP-1 receptor imaging have been published. It is most likely that GLP-1 receptor imaging will become the gold standard for imaging insulinoma in the future [12]. GLP-1 receptor scintigraphy proved to be more accurate than any other imaging modality in the pre-surgical localization of insulinoma. References 1. Modlin, I.M.; Oberg, K.; Chung, D.C.; Jensen, R.T.; de Herder, W.W.; Thakker, R.V.; Caplin, M.; Delle Fave, G.; Kaltsas, G.A.; Krenning, E.P.; Moss, S.F.; Nilsson, O.; Rindi, G.; Salazar, R.; Ruszniewski, P.; Sundin, A. Gastroenteropancreatic neuroendocrine tumours. Lancet Oncol., 2008, 9(1), 61-72. 2. Zikusoka, M.N.; Kidd, M.; Eick, G.; Latich, I.; Modlin, I.M. The molecular genetics of gastroenteropancreatic neuroendocrine tumors. Cancer, 2005, 104(11), 2292-2309. 3. Wiedenmann, B.; John, M.; Ahnert-Hilger, G.; Riecken, E.O. Molecular and cell biological aspects of neuroendocrine tumors of the gastroenteropancreatic system. J. Mol. Med., 1998, 76(9), 637-647. 4. Reubi, J.C. Peptide receptors as molecular targets for cancer diagnosis and therapy. Endocr. Rev., 2003, 24(4), 389-427. 5. Fjalling, M.; Andersson, P.; Forssell-Aronsson, E.; Gretarsdottir, J.; Johansson, V.; Tisell, L.E.; Wangberg, B.; Nilsson, O.; Berg, G.; Michanek, A.; Lindstedt, G.; Ahlman, H. Systemic radionuclide therapy using indium-111-DTPA-D-Phe1-octreotide in midgut carcinoid syndrome. J. Nucl. Med., 1996, 37(9), 1519-1521. 6. Kwekkeboom, D.; Krenning, E.P.; de Jong, M. Peptide receptor imaging and therapy. J. Nucl. Med., 2000, 41(10), 1704-1713. 7. Valkema, R.; De Jong, M.; Bakker, W.H.; Breeman, W.A.; Kooij, P.P.; Lugtenburg, P.J.; De Jong, F.H.; Christiansen, A.; Kam, B.L.; De Herder, W.W.; Stridsberg, M.; Lindemans, J.; Ensing, G.; Krenning, E.P. Phase I study of peptide receptor radionuclide therapy with [In-DTPA]octreotide: the Rotterdam experience. Semin. Nucl. Med., 2002, 32(2), 110-122. 8. De Jong, M.; Valkema, R.; Jamar, F.; Kvols, L.K.; Kwekkeboom, D.J.; Breeman, W.A.; Bakker, W.H.; Smith, C.; Pauwels, S.; Krenning, E.P. Somatostatin receptor-targeted radionuclide therapy of tumors: preclinical and clinical findings. Semin. Nucl. Med., 2002, 32(2), 133-140. 9. Giovacchini, G.; Nicolas, G.; Forrer, F. Peptide receptor radionuclide therapy with somatostatin analogues in neuroendocrine tumors. Anticancer Agents. Med. Chem. 2012, 12, 526-542. 10. Nicolas, G.; Giovacchini, G.; Mueller-Brand, J.; Forrer, F. Targeted Radiotherapy with Radiolabeled Somatostatin Analogues. Endocrin. Metab. Clin. 2011, 40, 187-204.

Abstract Book 11. Gibril, F.; Jensen, R.T. Diagnostic uses of radiolabelled somatostatin receptor analogues in gastroenteropancreatic endocrine tumours. Dig. Liver Dis., 2004, 36(Suppl 1), S106-120. 12. Christ, E.; Wild, D.; Ederer, S.; Béhé, M.; Nicolas, G.; Caplin, ME.; Brändle, M.; Clerici, T.; Fischli, S.; Stettler, C.; Ell, P.J.; Seufert, J.; Gloor, B.; Perren, A.; Reubi, J.C.; Forrer, F. Glucagon-like peptide-1 imaging for the localisation of insulinomas: a prospective multicentre imaging study. Lancet Diabetes Endocrinol. 2013, 1, 115-122.

204.3 Chemoembolisation and bland embolisation B.A. Radeleff Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany Learning Objectives 1. To learn how to select the best treatment strategy among the different techniques currently available 2. To learn how to use the current techniques and which clinical results and which complications to expect 3. To learn how to evaluate the current results reported in the literature Liver metastases from neuroendocrine tumors (NETs) are similar to hepatocellular carcinoma (HCC) in that both have a predominant blood supply from the hepatic artery. Using the ischemic effect of embolisation particles alone (bland embolisation; TAE) or combined with an intra-arterial injected chemotherapeutic agent (TACE), these minimally invasive procedures are indicated in NETs with progressive liver metastases or in a palliative situation when symptoms do not respond to somatostatin analogues. Loading the chemotherapeutic agent into the embolisation particles (drug-eluting beads, DEB) the so-called DEB-TACE has a higher local toxicity but a significantly lower rate of doxorubicin-related side effects. In the literature, there is still no significant difference with respect to the time to progression between SIRT, TAE and TACE/ DEB-TACE but there is a positive trend for TACE and DEB-TACE. References 1. Maire F, Lombard-Bohas C, O’Toole D, Vullierme MP, Rebours V, Couvelard A, et al. Hepatic arterial embolization versus chemoembolization in the treatment of liver metastases from well-differentiated midgut endocrine tumors: a prospective randomized study. Neuroendocrinology. 2012;96(4):294-300. 2. Guiu B, Deschamps F, Aho S, Munck F, Dromain C, Boige V, et al. Liver/biliary injuries following chemoembolisation of endocrine tumours and hepatocellular carcinoma: lipiodol vs. drug-eluting beads. Journal of hepatology. 2012;56(3):609-17. 3. Gaur SK, Friese JL, Sadow CA, Ayyagari R, Binkert CA, Schenker MP, et al. Hepatic arterial chemoembolization using drug-eluting beads in gastrointestinal neuroendocrine tumor metastatic to the liver. Cardiovascular and interventional radiology. 2011;34(3):566-72. 4. Peppa M, Brountzos E, Economopoulos N, Boutati E, Pikounis V, Patapis P, et al. Embolization as an alternative treatment of insulinoma in a patient with multiple endocrine neoplasia type 1 syndrome. Cardiovascular and interventional radiology. 2009;32(4):807-11. 5. de Baere T, Deschamps F, Teriitheau C, Rao P, Conengrapht K, Schlumberger M, et al. Transarterial chemoembolization of liver metastases from well differentiated gastroenteropancreatic endocrine tumors with doxorubicin-eluting beads: preliminary results. Journal of vascular and interventional radiology JVIR. 2008;19(6):855-61.

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6. Marrache F, Vullierme MP, Roy C, El Assoued Y, Couvelard A, O’Toole D, et al. Arterial phase enhancement and body mass index are predictors of response to chemoembolisation for liver metastases of endocrine tumours. British journal of cancer. 2007;96(1):49-55. 7. Strosberg JR, Choi J, Cantor AB, Kvols LK. Selective hepatic artery embolization for treatment of patients with metastatic carcinoid and pancreatic endocrine tumors. Cancer control, journal of the Moffitt Cancer Center. 2006;13(1):72-8. 8. Gupta S, Johnson MM, Murthy R, Ahrar K, Wallace MJ, Madoff DC, et al. Hepatic arterial embolization and chemoembolization for the treatment of patients with metastatic neuroendocrine tumors: variables affecting response rates and survival. Cancer. 2005;104(8):1590-602.

204.4 Radioembolisation R.J. Lewandowski Interventional Radiology, Northwestern University, Chicago, IL, United States of America Learning Objectives 1. To learn when to choose radioembolisation versus other techniques available 2. To learn about the technical strategies for performing radioembolisation in NETs 3. To learn about the results and complications of radioembolisation in NETs Neuroendocrine tumors are a group of uncommon tumors that typically arise in the endocrine cells and glands located throughout the body. Hepatic metastases develop in 50–95% of these patients, having a major adverse impact on the quality of life and survival. While systemic therapies can control the symptoms of this cancer, the disease can become refractory to treatment. Surgery and local ablative therapies are possible in only a small percentage of these patients. Given that hepatic metastases from neuroendocrine tumors contribute significantly to morbidity and mortality, transcatheter intraarterial therapies (particle embolization, chemoembolization with/ without drug-eluting beads, and radioembolization) are considered for those with unresectable tumors. These treatments have proven effective in delivering an anti-tumor response, palliating both bulk and hormonal symptoms. Because there is no evidence to support one intra-arterial therapy over another, treatment selection should be based on disease burden, liver function, patient performance status, quality of life, anatomic considerations, and local expertise. Radioembolization is recognized by the National Comprehensive Cancer Network as a treatment option for metastatic neuroendocrine cancer to the liver. Several studies have evaluated the use of radioembolization with the isotope yttrium-90 to treat patients with metastatic neuroendocrine cancer. Results based on this therapy show encouraging safety profiles, response rates, and survival outcomes. Impressively, these outcomes have been realized in patients when other intra-arterial embolotherapies have failed. This presentation will focus on the published medical evidence for radioembolization with yttrium-90 to treat patients with refractory unresectable metastatic neuroendocrine cancer to the liver. The safety and efficacy of this outpatient therapy will be highlighted, including a technical discussion regarding how to optimize outcomes. It will conclude with some clinical scenarios describing when to choose radioembolization over other embolotherapies. References 1. Murthy R, Kamat P, Nunez R, et al. Yttrium-90 microsphere radioembolotherapy of hepatic metastatic neuroendocrine carcinomas after hepatic arterial embolization. J Vasc Interv Radiol 2008;19(1):145–151.

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2. Kennedy AS, Dezarn WA, McNeillie P, et al. Radioembolization for unresectable neuroendocrine hepatic metastases using resin 90Y-microspheres: early results in 148 patients. Am J Clin Oncol 2008;31(3):271–279. 3. King J, Quinn R, Glenn DM, et al. Radioembolization with selective internal radiation microspheres for neuroendocrine liver metastases. Cancer 2008;113(5):921–929. 4. Rhee TK, Lewandowski RJ, Liu DM, et al. 90Y Radioembolization for metastatic neuroendocrine liver tumors: preliminary results from a multi-institutional experience. Ann Surg 2008;247(6):1029– 1035. 5. Kalinowski M, Dressler M, König A, et al. Selective internal radiotherapy with yttrium 90 microspheres for hepatic metastatic neuroendocrine tumors: a prospective single center study. Digestion 2009;79(3):137–142. 6. Saxena A, Chua TC, Bester L, et al. Factors predicting response and survival after yttrium-90 radioembolization of unresectable neuroendocrine tumor liver metastases: a critical appraisal of 48 cases. Ann Surg 2010;251(5):910–916. 7. Memon K, Lewandowski RJ, Mulcahy MF, et al. Radioembolization for neuroendocrine liver metastases: safety, imaging, and longterm outcomes. Int J Radiat Oncol Biol Phys 2012;83(3):887– 894. 8. Ozao-Choy J, Friedman ML, Kim AS, et al. Radioembolization for treatment of liver metastases from neuroendocrine tumors: correlation with imaging and biomarkers. Pancreas 2013;42(2):358–360. 9. Neperud J, Mahvash A, Garg N, et al. Can imaging patterns of neuroendocrine hepatic metastases predict response yttruim-90 radioembolotherapy? World J Radiol 201328;5(6):241–247.

Special Session Controversy Controversies in SFA treatment 301.1 Drug-eluting stents will show better 5-year patency rates than PTA: Pro K.N. Katsanos Interventional Radiology, Guy’s and St. Thomas’ Hospitals, London, United Kingdom Drug-eluting stents (DES) are self-expanding nitinol stents that provide elution of anti-restenotic drugs (sirolimus or paclitaxel) to the abluminal surface of the vessel employing polymer- or nonpolymerbased technologies. Most of coronary DES platforms provide prolonged release of sirolimus or a similar drug. Sirolimus (rapamycin) is a natural macrocyclic lipophilic lactone with cytostatic, immunosuppressive, and antibiotic properties that arrests the cell cycle and inhibits smooth muscle cell proliferation. On the contrary, paclitaxel is a cytotoxic agent that arrests cell mitosis and leads to smooth muscle cell death [1]. Although several DES have been used in the coronary circulation, only one - the sirolimus-eluting SMART stent (Cordis Endovascular, NJ, USA) - has been tested in the peripheral circulation. A doubleblinded, randomized, controlled trial compared the efficacy of a sirolimus-coated SMART CONTROL stent with that of a similar bare metal SMART CONTROL stent in the femoropopliteal arterial segment. The SIROCCO clinical research program was performed in two phases (I and II). Unfortunately, neither study achieved a significant reduction of restenosis compared to the bare control nitinol stent. Even after 4 years of follow-up, no difference in any metric between the two treatment groups was noted [2, 3]. On the other hand, the Zilver PTX investigated a paclitaxel-coated nitinol stent (Zilver PTX Nitinol Stent; Cook Medical, IN, USA) in the femoropopliteal arterial segment. To date, this study has been the largest, prospective, randomized trial for the endovascular

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treatment of symptomatic femoropopliteal peripheral artery disease (479 patients) and the first human study to demonstrate a biologic effect of cytotoxic paclitaxel directly applied to a stent-based platform in the femoral artery [4, 5]. The Zilver PTX stent is coated on its outer surface with 3 μg/mm2 of paclitaxel that is sprayed directly on the metallic surface, without the use of any polymer, binder, or excipient. Specifically, primary Zilver PTX deployment demonstrated significantly superior 2-year event-free survival (86.6% versus 77.9%, P = 0.02) and primary patency rates (74.8% versus 26.5%, P < 0.01) compared with the control group. Subgroup analysis of provisional DES (second-level randomization) demonstrated superior 2-year primary patency compared with the control bare metal stenting group (83.4% versus 64.1%, P < 0.01), while achieving a superior clinical benefit with significantly reduced target lesion revascularization (83.9% versus 68.4%, P = 0.05) [5]. Hence, promising long-term results of the ZILVER-PTX stent are expected in the femoropopliteal artery. References 1. Pastromas G, Katsanos K, Krokidis M, Karnabatidis D, Spiliopoulos S. Emerging stent and balloon technologies in the femoropopliteal arteries. ScientificWorldJournal. 2014 Feb 4;2014:695402. doi: 10.1155/2014/695402. eCollection 2014. 2. Duda SH, Pusich B, Richter G, et al. Sirolimus-eluting stents for the treatment of obstructive superficial femoral artery disease: six-month results. Circulation. 2002;106(12):1505–1509. [PubMed] 3. Duda SH, Poerner TC, Wiesinger B, et al. Drug-eluting stents: potential applications for peripheral arterial occlusive disease. Journal of Vascular and Interventional Radiology. 2003;14(3):291– 301. [PubMed] 4. Dake MD, Ansel GM, Jaff MR, et al. Paclitaxel-eluting stents show superiority to balloon angioplasty and bare metal stents in femoropopliteal disease: twelve-month zilver PTX randomized study results. Circulation. 2011;4(5):495–504. [PubMed] 5. Dake MD, Ansel GM, Jaff MR, et al. Sustained safety and effectiveness of paclitaxel-eluting stents for femoropopliteal lesions: 2-year follow-up from the Zilver PTX randomized and single-arm clinical studies. American College of Cardiology. 2013;61(24):2417– 2427. [PubMed]

301.2 Drug-eluting stents will show better 5-year patency rates than PTA: Con N. Chalmers Radiology Department, Manchester Royal Infirmary, Manchester, United Kingdom The search for the optimum and most cost-effective treatment for SFA disease is on-going, and in the meantime, there is a need for critical analysis of the evidence to detect commercial interests influencing what data is published and how it is presented. There is only one direct comparison of drug-eluting stents (DES) and balloon angioplasty (PTA) currently available - the Zilver PTX Trial, so analysis of this must form the basis of this debate (1,2,3). Previously, in the SIROCCO trials, the sirolimus-eluting Cordis SMART stent was not shown to be superior to the bare metal equivalent (4). Also, the everolimus-eluting Dynalink stent was not shown to have superior patency to the equivalent BMS in a non-randomised study (5). In the Zilver PTX Trial, the paclitaxel-eluting Zilver stent has been claimed to show superior patency compared with PTA at 12 and 24 months. Furthermore, the paclitaxel effect has been reported to persist up to 4 years. No 5-year data is as yet available. The Zilver PTX trial is therefore of potentially great importance, and the data require careful scrutiny. The Zilver PTX patient population had relatively short lesions of SFA (mean, about 6 cm), and the great

Abstract Book majority of these were stenoses rather than occlusions. In most patients, a satisfactory immediate result can be achieved in such lesions with balloon alone, yet in this trial, stents were deployed on over 50% of the PTA cohort. This was despite operators being encouraged to optimise the PTA result prior to stent placement. It seems likely that many “real world” operators would achieve a lower rate of bail-out stent placement in these simple TASC A lesions. Moreover, stent placement in the PTA cohort was regarded as ‘loss of primary patency’, whereas in the DES cohort it was not. Thus the outcome of the trial is at the mercy of the operator, and may be influenced by operator bias. Analysis ought to have been on an intentionto-treat (ITT) basis, and patients in both arms of the trial obviously should have been subject to the same analysis. This mishandling of the data invalidates the primary outcome measure in this trial. The trial’s 12-month outcome data was published in Circulation: Cardiovascular Interventions in 2011(1). The authors claimed superior clinical outcomes for the DES group. However, the data do not conclusively support this claim. The data show that there is improvement in ABI, Rutherford score and walking impairment score in both the PTA and DES groups with no significant difference between the groups. There was no difference in the rate of amputation or the incidence of ulceration in the 12-month period. There were more clinically driven reinterventions in the PTA group (17.5% vs 9.5%), usually because of persistent or recurrent claudication. There may be an element of subjectivity, and therefore possible bias, in the decision to re-intervene. The secondary patency rate has not been reported. Secondary patency is important because it is this that will determine the long-term clinical success in claudicants. Therefore, we do not know the secondary patency rate, but we do know that the 1-year clinical outcomes are identical in both cohorts. Thus, the primary use of DES resulted in 8% fewer reinterventions at 1 year, but at considerably increased cost compared with a balloon angioplasty plus bail-out stent approach. The cost effectiveness of both strategies is unknown. However, assuming €800 per stent, 1.5 stents per case and a 50% bail out stent usage, the additional cost of a primary stenting policy over 100 cases which might save 8 reinterventions in the first year would be €60,000. Cost effectiveness would only be achieved if the reintervention rate were reduced further beyond year 1, but this has not been demonstrated. The 2-year outcome data have been published in JACC (2). There is no difference in reintervention rate between the two arms between 12 and 24 months. Adverse events (mainly clinically driven reinterventions) occurred with the same frequency in both groups. Likewise, there was no difference in the rate of loss of primary patency between 12 and 24 months (11.3% and 9.3% for the PTA and DES cohorts, respectively). Thus the 2-year data show that the early reduction in reintervention conferred by DES is not sustained beyond 1 year. Beyond 2 years, the Zilver-PTX trial data has not been published in peer-reviewed form. The 4-year data was presented at CIRSE in 2013 (3), but no data comparing the primary randomization cohorts was given. Four-year TLR data comparing patients who received a DES versus those who received either balloon angioplasty or BMS show parallel curves beyond 1 year, confirming the potential benefit of the drug is restricted to the first 12 months. Summary The only randomised control trial data come from the Zilver PTX Trial. • The primary patency data from this trial is seriously flawed because the two cohorts have not been analysed using the same criteria. • Secondary patency rates have not been reported, yet secondary patency is the crucial measure of clinical benefit to patients. • There is an 8% reduction in reintervention rate associated with the primary use of DES in the first year, but this is not matched by improved clinical outcomes at 12 months. • There is no difference in reintervention rate beyond 12 months. • This suggests that the additional cost of a primary DES strategy cannot be justified.

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References 1. Paclitaxel-eluting stents show superiority to balloon angioplasty and bare metal stents in femoropopliteal disease: twelve-month Zilver PTX randomized study results. Dake MD, Ansel GM, Jaff MR, Ohki T, Saxon RR, Smouse HB, Zeller T, Roubin GS, Burket MW, Khatib Y, Snyder SA, Ragheb AO, White JK, Machan LS; Zilver PTX Investigators. Circ Cardiovasc Interv. 2011 Oct 1;4(5):495-504. 2. Sustained safety and effectiveness of paclitaxel-eluting stents for femoropopliteal lesions: 2-year follow-up from the Zilver PTX randomized and single-arm clinical studies. Dake MD, Ansel GM, Jaff MR, Ohki T, Saxon RR, Smouse HB, Snyder SA, O’Leary EE, Tepe G, Scheinert D, Zeller T; Zilver PTX Investigators. J Am Coll Cardiol. 2013 Jun 18;61(24):2417-27. 3. Zilver PTX- 4 years follow-up. M.D.Dake. CIRSE Barcelona 2013. http://www.esir.org/cview_2013/library/esir/. 4. Drug-eluting and bare nitinol stents for the treatment of atherosclerotic lesions in the superficial femoral artery: long-term results from the SIROCCO trial. Duda SH1, Bosiers M, Lammer J, Scheinert D, Zeller T, Oliva V, Tielbeek A, Anderson J, Wiesinger B, Tepe G, Lansky A, Jaff MR, Mudde C, Tielemans H, Beregi JP. J Endovasc Ther. 2006 Dec;13(6):701-10. 5. First clinical trial of nitinol self-expanding everolimus-eluting stent implantation for peripheral arterial occlusive disease. Lammer J1, Bosiers M, Zeller T, Schillinger M, Boone E, Zaugg MJ, Verta P, Peng L, Gao X, Schwartz LB. J Vasc Surg. 2011 Aug;54(2):394-401.

301.3 Drug-eluting balloons in all SFA lesions: Pro G. Tepe Department of Diagnostic and Interventional Radiology, Medical Centre of Rosenheim, Rosenheim, Germany No abstract available.

301.4 Drug-eluting balloons in all SFA lesions: Con M. Katoh Diagnostic and Interventional Radiology, HELIOS Clinic Krefeld, Krefeld, Germany Balloon angioplasty revolutionized the treatment of vessel stenosis and occlusion. Outcome, however, was limited by potential elastic recoil, dissection, and restenosis. The next improvement was achieved with the introduction of stents, which could tackle recoil and dissection; but restenosis due to neointimal hyperplasia was not affected. Antiproliferative drug delivery using drug-eluting stents (DES) seemed to cross this last frontier. However, late stent thrombosis, the need for long-term dual antiplatelet therapy, and continued restenosis led to a quest for alternative treatment options. In recent years, the drug-eluting balloon (DEB) emerged as a promising technology to combat the issue of restenosis. Today, all available DEBs are coated with the lipophilic chemotherapeutic agent paclitaxel with a dosage of 2–3 μg/mm2. The coating methods, however, differ greatly, which has direct impact on the pharmacokinetics (i.e., adherence of the drug during the delivery to the target lesion and release and transfer of the drug into the vessel wall upon inflation). To date, there are three randomized trials that support the use of DEB in femoropopliteal lesions. In the THUNDER [1] and FemPac [2] trials prototype iopromide-matrix-coated Paccocath catheter was compared with an uncoated balloon catheter. In both studies, late lumen loss and target lesion revascularization was significantly reduced in patients treated with DEB. These results were confirmed in the PACIFIER trial using the urea-matrix-coated IN.PACT Pacific catheter [3].

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Unfortunately, the aforementioned studies were limited in sample size, study design, and follow-up. Hence, there remain many unanswered concerns and challenges such as effectiveness of drugs other than paclitaxel, effectiveness of the different delivery systems, systemic toxicity, peripheral embolization during balloon inflation, and effectiveness and safety of DEBs after suboptimal balloon angioplasty or stent implantation. Finally, the value of DES for the treatment of femoropopliteal lesions remains unclear in this context. References 1. Tepe G, Zeller T, Albrecht T et al. Local delivery of paclitaxel to inhibit restenosis during angioplasty of the leg. N Engl J Med. 2008 Feb;358(7):689-99. 2. Werk M, Langner S, Reinkensmeier B et al. Inhibition of restenosis in femoropopliteal arteries: paclitaxel-coated versus uncoated balloon: femoral paclitaxel randomized pilot trial. Circulation. 2008 Sep;118(13):1358-65. 3. Werk M, Albrecht T, Meyer DR et al. Paclitaxel-coated balloons reduce restenosis after femoro-popliteal angioplasty: evidence from the randomized PACIFIER trial. Circ Cardiovasc Interv. 2012 Dec;5(6):831-40.

301.5 Bioabsorbable stents have a future: Pro A. Holden Radiology, Auckland Hospital, Auckland, New Zealand The long and mobile femoro-popliteal arterial segment is a challenging environment for endovascular intervention. Drug-eluting balloons have shown great promise for short and relatively simple lesions. However, for longer and more complex lesions, a scaffold is often required to prevent residual stenosis and flow-limiting dissection. An anti-restenosis strategy is also important, particularly in claudicants where long-term patency is vital. Drug-eluting stents have shown satisfactory patencies in intermediate-length lesions but suffer the problems of a permanent self-expanding metallic implant. Both physicians and patients would prefer a “leave nothing behind” approach if that was feasible. For many years, bioresorbable stents have been eagerly awaited in the SFA. A bioresorbable stent may provide a scaffold to optimise the acute result after angioplasty without the long-term irritation of a self-expanding stent. Such a scaffold must withstand the hostile environment of the SFA, provide mechanical support and integrity through vessel healing, remain biocompatible through resorption and facilitate drug delivery. Three bioresorbable stents have recently been studied in the SFA. The Abbott Esprit 1 Trial used a balloon expandable PLLA scaffold in iliac and femoral arterial lesions ≤50 mm in length that could be treated by a single 6.0 mm x 58 mm device. The study reported excellent procedural success. Although lesion length was very short (mean 35.7 mm), the patency data and improvement in Rutherford– Becker status at 1 year was very encouraging. The 480 Biomedical Stanza stent has been studied in the STANCE Trial. This flexible, self-expanding stent is a PLGA and bioresorbable elastomer composite and fully resorbs in 12–15 months. Acute performance and subsequent stent strut encapsulation and resorption has been carefully evaluated using optical coherence tomography (OCT). This study reported excellent procedural success and acute stent performance, treating longer lesions (up to 90 mm). Late lumen loss seen in the first cohort of patients was due to a combination of vessel recoil and neointimal hyperplasia. The device was modified in a second patient cohort with minimal vessel recoil. A paclitaxel drug-eluting version of the scaffold has recently entered the clinic in the SPRINT trial. The Igaki–Tamai bioresorbable scaffold has been used in the SFA in a 30-patient cohort. Again, acute procedural results were very good, although binary restenosis rates at 12 months were unacceptably

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high and further modifications are planned. Small clinician-initiated trials using coronary bioresorbable stents in the tibial arteries are being performed, but meaningful results are not yet available. No industry sponsored trials have evaluated drug-eluting stent technology below the knee, although several physician-initiated trials are underway. These are restricted to using coronary bioresorbable stents but have reported early success. To summarise the experience with bioresorbable stents in lower limb arteries, there is no doubt a device can now be manufactured that performs acutely as well as any self-expanding stent and fully resorbs in time. The challenge is to maintain vessel patency while the inflammatory process associated with resorption occurs. This challenge will undoubtedly be successfully overcome in the near future. It is likely that the primary strategy in lower limb revascularisation will be based on drug-eluting balloons. However, there will always be a need to scaffold some lesions due to flow-limiting dissection or residual stenosis. That scaffold should be bioresorbable.

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301.6

Predictors of failure and success of embolisation for traumatic bleeding

Bioabsorbable stents have a future: Con

Stent and stent-grafting in the trauma patient T. Sabharwal Department of Radiology, Guy’s and St. Thomas’ Hospital, London, United Kingdom Learning Objectives 1. To learn about clinical and imaging aspects of traumatic aortic injury 2. To learn about techniques and results of stent-grafting for traumatic aortic injury 3. To learn about techniques and results of stenting and stentgrafting for other types of traumatic vascular injuries No abstract available.

302.4 S.J. Park Radiology, Sun General Hospital, Daejeon, Korea

T.W.I. Clark Dept. Radiology, Penn Presbyterian Medical Center, Philadelphia, PA, United States of America

Learning Objectives 1. To learn about clinical factors influencing outcome in trauma patients 2. To learn about predictors for failure and success of embolisation for traumatic bleeding 3. To learn ways to optimise outcome of embolisation for traumatic bleeding

No abstract available.

Special Session Trauma: bleeding control

No abstract available.

302.1

Special Session Bone pain in cancer patients

Infrastructure and logistics for adequate trauma treatment O.M. van Delden Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands

303.1

Learning Objectives 1. To learn about infrastructural requirements for adequate trauma treatment 2. To learn about optimal logistics for the management of trauma patients 3. To learn about trauma imaging algorithms including the role of CT No abstract available.

302.2

Non-IR treatment options M. Fallon Edinburgh Cancer Research Centre, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom Learning Objectives 1. To understand conservative therapy options for bone pain in cancer patients 2. To illustrate success rates 3. To compare results of non-IR treatments with IR techniques

Embolisation in the unstable patient

No abstract available.

S.J. McPherson Radiology, Leeds General Infirmary, Leeds, United Kingdom

303.2 Ablation and embolisation

Learning Objectives 1. To learn the basics of management of haemodynamically unstable trauma patients 2. To learn techniques for embolisation of unstable trauma patients 3. To learn about results and complications of embolisation in unstable trauma patients No abstract available.

X. Buy1, R.L. Cazzato1, A. Gangi2, J. Palussière1 1Department of Radiology, Institut Bergonié, Bordeaux, France, 2Interventional Radiology, University Hospital of Strasbourg, Strasbourg, France Learning Objectives 1. To report the most appropriate indications for bone tumour ablation and embolisation 2. To learn how to manage and avoid complications 3. To report and illustrate various ablation techniques Bone metastases are the most common cause of chronic pain in cancer patients. Treatment strategy for patients with bone tumors

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requires consideration of many factors: a) histology of the tumor, with differentiation of benign and malignant tumors; b) careful evaluation of the patient’s general condition and understanding of the disease process; c) definition of the therapeutic goal: curative or palliative; and d) potential need for mechanical stabilization when treating weight-bearing bones. Interventional radiology offers various techniques for the management of bone tumors: consolidation with cementoplasty or percutaneous screw fixation, tumor ablation with radiofrequency, microwave or cryoablation, and embolization. All these techniques should be proposed in a multidisciplinary approach that involves oncologists, orthopedic surgeons, and radiotherapist. Bone tumor embolization is indicated for different clinical situations: a) before surgery to reduce perioperative blood loss; b) for palliative local tumor control or tumor debulking, particularly for hypervascular painful metastases - in such cases, other interventional radiology techniques such as cementoplasty and thermal ablation may also be considered as alternative or combined methods; and c) for a curative local control in benign tumors such as hemangiomas or aneurysmal bone cysts or for malignant oligometastates. Complications due to bone tumor embolization remain rare. Nontargeted embolization can occur; therefore, spinal tumors close to the radiculo-medullary artery are contraindicated. Post-embolization skin necrosis is exceptional. Secondary fracture is the most common delayed complication; thus, additional consolidation technique should always be considered when embolizing a weight-bearing bone. Conclusion: bone tumor embolization before surgery remains a major technique to reduce perioperative blood loss. For palliative or curative treatment of non-surgical bone tumors, thermal ablation techniques such as radiofrequency or cryoablation are generally preferred as they induce an effective controllable and reproducible tumor necrosis. However, for tumors where thermal ablation cannot be proposed (very large tumor or tumors in contact with vulnerable organs that cannot be displaced), bone embolization should be considered as an alternative. Embolization is also particularly useful to treat large hypervascular bone tumors where thermal ablation alone may be ineffective due to major thermal sink effect. For selected non-surgical oligometastatic patients in whom optimal local tumor control is required, bone embolization in combination with intraarterial perfusion of targeted chemotherapy may offer new perspectives. References 1. Amendola L, Simonetti L, Simoes CE, Bandiera S, De Iure F, Boriani S. Aneurysmal bone cyst of the mobile spine: the therapeutic role of embolization. Eur Spine J. 2013;22(3):533-41. 2. Barton PP, Waneck RE, Karnel FJ, Ritschl P, Kramer J, Lechner GL. Embolization of bone metastases. J Vasc Interv Radiol. 1996;7(1):81-8. 3. Chatziioannou AN, Johnson ME, Pneumaticos SG, Lawrence DD, Carrasco CH. Preoperative embolization of bone metastases from renal cell carcinoma. Eur Radiol. 2000;10(4):593-6. 4. Chiras J, Adem C, Vallee JN, Spelle L, Cormier E, Rose M. Selective intra-arterial chemoembolization of pelvic and spine bone metastases. Eur Radiol. 2004;14(10):1774-80. 5. Eustatia-Rutten CF, Romijn JA, Guijt MJ, et al. Outcome of palliative embolization of bone metastases in differentiated thyroid carcinoma. J Clin Endocrinol Metab. 2003;88(7):3184-9. 6. Finstein JL, Chin KR, Alvandi F, Lackman RD. Postembolization paralysis in a man with a thoracolumbar giant cell tumor. Clin Orthop Relat Res. 2006;453:335-40. 7. Kickuth R, Waldherr C, Hoppe H, et al. Interventional management of hypervascular osseous metastasis: role of embolotherapy before orthopedic tumor resection and bone stabilization. AJR Am J Roentgenol. 2008;191(6):W240-7.

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8. Kwon JH, Shin JH, Kim JH, et al. Preoperative transcatheter arterial embolization of hypervascular metastatic tumors of long bones. Acta Radiol. 2010;51(4):396-401. 9. Marciel AM, Van Zandt BL, Baxter AJ. Transcatheter arterial embolization for the palliation of painful bone lesions. Tech Vasc Interv Radiol. 2011;14(3):141-9. 10. Nair S, Gobin YP, Leng LZ, et al. Preoperative embolization of hypervascular thoracic, lumbar, and sacral spinal column tumors: technique and outcomes from a single center. Interv Neuroradiol. 2013;19(3):377-85. 11. Owen RJ. Embolization of musculoskeletal bone tumors. Semin Intervent Radiol. 2010;27(2):111-23. 12. Park SJ, Kim CH, Kim JD, et al. Spinal cord injury after conducting transcatheter arterial chemoembolization for costal metastasis of hepatocellular carcinoma. Clin Mol Hepatol. 2012;18(3):316-20. 13. Rossi G, Mavrogenis AF, Rimondi E, Braccaioli L, Calabro T, Ruggieri P. Selective embolization with N-butyl cyanoacrylate for metastatic bone disease. J Vasc Interv Radiol. 2011;22(4):462-70. 14. Van Tol KM, Hew JM, Jager PL, Vermey A, Dullaart RP, Links TP. Embolization in combination with radioiodine therapy for bone metastases from differentiated thyroid carcinoma. Clin Endocrinol (Oxf). 2000;52(5):653-9. 15. Buy X, Basile A, Bierry G, Cupelli J, Gangi A. Saline-infused bipolar radiofrequency ablation of high-risk spinal and paraspinal neoplasms. AJR Am J Roentgenol. 2006;186(5 Suppl):S322-6. 16. Gangi A, Buy X. Percutaneous bone tumor management. Semin Intervent Radiol. 2010;27(2):124-36. 17. Gangi A, Buy X, Garnon J, et al. [Pain management in oncology]. J Radiol. 2011;92(9):801-13. 18. Gangi A, Sabharwal T, Irani FG, Buy X, Morales JP, Adam A. Quality assurance guidelines for percutaneous vertebroplasty. Cardiovasc Intervent Radiol. 2006;29(2):173-8. 19. Gangi A, Tsoumakidou G, Buy X, Quoix E. Quality improvement guidelines for bone tumour management. Cardiovasc Intervent Radiol. 2010;33(4):706-13. 20. Moser T, Buy X, Goyault G, Tok C, Irani F, Gangi A. [Image-guided ablation of bone tumors: review of current techniques]. J Radiol. 2008;89(4):461-71. 21. Palussiere J, Dixmerias F, Buy X, et al. [Interventional radiology procedures in the treatment of bone metastasis]. Bull Cancer. 2009;96(11):1117-26. 22. Sabharwal T, Katsanos K, Buy X, Gangi A. Image-guided ablation therapy of bone tumors. Semin Ultrasound CT MR. 2009;30(2):78-90. 23. Dixmerias F, Palussiere J. [Management of painful bone metastases]. J Radiol. 2011;92(9):796-800. 24. Palussiere J, Pellerin-Guignard A, Descat E, Cornelis F, Dixmerias F. Radiofrequency ablation of bone tumours. Diagn Interv Imaging. 2012;93(9):660-4.

303.3 Cementoplasty and osteosynthesis F. Deschamps Department of Radiology, Institut Gustave Roussy, Villejuif, France Learning Objectives 1. To report the most appropriate indications for cementoplasty and osteosynthesis 2. To learn how to avoid complications 3. To illustrate bone augmentation techniques Cementoplasty and osteosynthesis are both percutaneous palliative treatments for patients suffering from for bone metastases. They are usually performed to reduce the pain when patient had osteoporotic or pathological fracture, but they can also be used to

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consolidate osteolytic bone metastases with a risk of fracture. They should not be considered as a cancer treatment. Nevertheless, they can be performed in association with radiotherapy or thermal-ablation techniques if a destruction of the tumor is required. Cementoplasty consists of the injection of polymethylmethacrylate within an osteolytic metastases under fluoroscopic or CT guidance. Vertebral metastases (necessitating vertebroplasty) and acetabular metastases (requiring acetabuloplasty) are the most common indications, but cementoplasty can be performed at any location where there is osteolytic bone metastasis. It is now well established that it has an analgesic effect (1-6), which justifies using this technique as first-line treatment, if radiotherapy has failed or is contraindicated, and/or if opioid treatments are poorly tolerated. For mechanical consolidation, cementoplasty is appropriate for vertebra and acetabulum because the strength property of the cement is strong in compression. However, for pathological fractures of the pelvis or for mechanical consolidation of osteolytic metastases of the proximal femur, its action is inadequate because the high mechanical stresses are in tension or in rotation (7). In such cases, osteosynthesis is required. Osteosynthesis consists of percutaneous insertion of cannulated screws under fluoroscopic or CT guidance. It requires a skin incision of <10mm and a guide pin and a cannulated screw driver to advance the screw. Osteosynthesis can be performed alone to stabilize a painful fracture, or in association with cementoplasty for better consolidation of osteolytic bone metastases (8). For osteolytic metastasis of the proximal femur, it significantly decreases the risk of fracture compared with cementoplasty alone (9). References 1. Cotten A et al. Percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of the percentage of lesion filling and the leakage of methyl methacrylate at clinical followup. Radiology 1996;200:525–530. 2. Alvarez L et al. Vertebroplasty in the treatment of vertebral tumors: postprocedural outcome and quality of life. Eur Spine J 2003;12:356–360. 3. Weill A et al. Spinal metastases: indications for and results of percutaneous injection of acrylic surgical cement. Radiology 1996;199:241–247. 4. Yamada K et al. Longterm pain relief effects in four patients undergoing percutaneous vertebroplasty for metastatic vertebral tumor. J Anesth 2004;18:292–295. 5. Anselmetti. Osteoplasty: percutaneous bone cement injection beyond the spine. Semin Intervent Radiol 2010;27(2):199–208. 6. Botton E et al. Cementoplasty for painful bone metastases: a series of 42 cases. Med Oncol 2011;Apr 17 (in press). 7. Deschamps F et al. Cementoplasty of metastases of the proximal femur: is it a safe palliative option? J Vasc Interv Radiol. 2012;23(10):1311–1316. 8. Deschamps f et al. Percutaneous stabilization of impending pathological fracture of the proximal femur. Cardiovasc Intervent Radiol. 2012;35(6):1428–1432. 9. Deschamps F et al. Percutaneous osteosynthesis plus cementoplasty decreases the risk of pathological fracture compared with cementoplasty alone. Free paper at CIRSE 2012. Lisbon, Portugal.

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303.4 HIFU A. Napoli Department of Radiological Sciences, University of Rome La Sapienza, Rome, Italy Learning Objectives 1. To report the most appropriate indications for HIFU 2. To illustrate how to enhance success rates 3. To compare results of HIFU to other IR techniques Bone is the third most common organ involved by metastatic disease behind the lung and liver. Bone metastases occur in up to 70% of prostate cancer patients and breast cancer patients. Post-cancer survival has increased with improvement in early detection and treatments. As a consequence, the number of patients developing metastatic bone disease during their lifetime has also increased. Quality of life may be significantly impaired as a consequence of painful bone metastases. Current treatments for patients with bone metastases are primarily palliative and include localized therapies (radiation and surgery), systemic therapies (chemotherapy, hormonal therapy, radiopharmaceutical, and bisphosphonates although the primary goal of the use of these therapies are often to address the disease itself), and analgesics (opioids and non-steroidal anti-inflammatory drugs). Recently, radiofrequency ablation has been demonstrated as a feasible treatment option for bone metastases. Following large efforts in the field of technological and medical research to significantly reduce the side effects of conventional treatment and to provide additional therapeutic options, several new modalities have been introduced in the last decades, including radiofrequency, laser, microwaves, and cryoablation. Treatment with external beam radiation therapy (EBRT) is the standard of care for patients with localized bone pain, and results in the palliation of pain for many of these patients. However, 20–30% of patients treated with radiation therapy do not experience pain relief. Re-treatment rates are generally reported in the range of 10-25%. Many patients with relapsed pain or poor response to initial radiation may be lost to follow-up or may not be referred back to oncologists for consideration of re-radiation. In addition to relapse and re-treatment, there is an increased risk of pathologic fracture in the peri-radiation period. The fracture rate reported in radiation studies is generally in the range of 1–8%. Furthermore, patients who have recurrent pain at a previously irradiated site may not be eligible for further radiation therapy secondary to limitations in normal tissue tolerance and increased long-term toxicity. There may also be a greater incidence of acute side effects of nausea and vomiting if the treatment field includes the stomach. A palliative treatment for painful bone metastases that is noninvasive, without long-term toxicity, and has minimal complications would be a useful tool for treating physicians and also a beneficial option for patients suffering from painful bone metastases. More recently, highintensity focused ultrasound (HIFU) techniques have been clinically implemented. The use of focused ultrasound for ablation therapy was first introduced in China in 1980s, with the development of biological focal field in 1997. Following the clinical implementation of HIFU, conventional ultrasound (US) has been widely adopted for ablation guidance with good results: this approach, however, limits treatment to externally targetable lesions and prevents real-time evaluation of procedure success. Magnetic resonance (MR) imagingguided focused ultrasound (MRgFUS) is a newly introduced, noninvasive method for reducing the pain in skeletal metastases, and it offers several key advantages over other noninvasive treatment modalities. MRgFUS enables the performance of three-dimensional treatment planning with MR imaging and continuous temperature mapping of treated tissue by using MR thermometry, thereby enabling real-time monitoring of thermal damage in the target zone. The concentration of acoustic energy on the intact surface of cortical bone produces a rapid temperature increase that mediates critical thermal damage to

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the adjacent periosteum, the most innervated component of mature bone tissue. Such thermal ablation has been shown to be an extremely effective approach for pain management. Target tissue is heated beyond the threshold for protein denaturation (50–60C°) for few seconds, resulting in coagulation necrosis. The absorption rate of ultrasound by cortical bone is up to 50 times higher, compared with other biological tissues, thus allowing only a minimal fraction of the applied energy to penetrate across the cortex. For pain palliation, the concentration of acoustic energy on the intact surface of cortical bone rapidly creates a temperature increase that determines critical thermal damage to the adjacent periosteum; because the periosteum is the highest innervated component of mature bone tissue, its ablation is an extremely effective approach for pain management. MRgFUS ablation is indicated to treat painful bone lesions from metastatic disease in patients with known history of malignancy, as shown by clinical or imaging examinations. In particular, MRgFUS ablation is indicated in patients who are considered radiation failures (those patients who received radiation without adequate symptom relief, those who can no longer undergo external beam radiation therapy for safety reasons, and those who refuse other therapy options). In our department, we have evaluated the safety and efficacy of MRgFUS treatment for pain palliation of lesions from different known primary tumors. Our study was conducted in patients who had exhausted EBRT and also in patients not previously treated with EBRT in target metastases, and it has demonstrated that MRgFUS can be effectively applied as primary noninvasive technique for pain palliation related to bone metastases. In our institution, all MRgFUS procedures, including pretreatment imaging, are performed on a 3-T MR imaging system (Discovery MR 750; GE Healthcare, Milwaukee, Wis) combined with the ExAblate MRgFUS system (InSightec, Tirat Carmel, Israel). For the clinical evaluation, data are collected at 1, 3, 7, and 14 days after treatment and thereafter at 30-day intervals for 1 year. Clinical data include an evaluation of a visual analog pain score (VAS), changes in the drug schedule, and improvements in quality of life. VAS is an 11-point pain scale that ranges between 0 and 10, where 0 is no pain at all and 10 is the worst pain. A partial response to treatment is defined as a drop of two points in VAS from the pretreatment baseline, with no increase in pain medication, or a reduction of 25% in pain medication without an increase in the reported pain score. A complete response is defined as a VAS of 0 without an increase in medication. A change in the drug schedule is defined primarily by a decrease in the intake of analgesics or opiates. The improvement in quality of life (as measured by the Brief Pain Inventory Quality of Life questionnaire) is used to assess the impact of pain relief on the key domains of daily living, including physical activity, work, mood, ability to walk, and ability to sleep. This procedure is performed on an outpatient basis and has the potential to be repeated if necessary; moreover, the absence of adverse events suggests this treatment option as a viable alternative to standard pain palliation treatments, including EBRT. In fact, although current guidelines did not find any unacceptable rates of long-term side effects that may limit the use of EBRT in patients with painful bone metastases, EBRT-related acute and long-term side effects can occur in 1.5–3% of cases. None of these toxicity effects, such as skin and gastrointestinal reactions, loss of nerve function or even pathological fractures and bone marrow damage, occurred during MRgFUS treatment. In conclusion MRgFUS ablation is an extremely promising alternative therapy for pain palliation in patients suffering from bone metastases. The major advantages of the technique include its noninvasive nature; the ability to perform three-dimensional MR imaging visualization for precise treatment planning; continuous temperature mapping of treated tissue with MR thermometry, which enables real-time monitoring of thermal damage in the target zone; and immediate post-treatment assessment of therapy. The treatment can be performed in a single session, is noninvasive, does not use ionizing radiation, and utilizes MR guidance for precise targeting and thermal control, which confers a high safety profile.

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References 1. Napoli A, Anzidei M, Marincola BC, Brachetti G, Noce V, Boni F, Bertaccini L, Passariello R, Catalano C. MR Imaging-Guided Focused Ultrasound For Treatment Of Bone Metastasis. Radiographics. 2013 Oct;33(6):1555-68. 2. Primary Pain Palliation And Local Tumor Control In Bone Metastases Treated With Magnetic Resonance-guided Focused Ultrasound. Napoli A, Anzidei M, Marincola BC, Brachetti G, Ciolina F, Cartocci G, Marsecano C, Zaccagna F, Marchetti L, Cortesi E, Catalano C. Invest Radiol. 2013 Jun;48(6):351-8. 3. MR-Guided High-Intensity Focused Ultrasound: Current Status of an Emerging Technology. Napoli A, Anzidei M, Ciolina F, Marotta E, Cavallo Marincola B, Brachetti G, Di Mare L, Cartocci G, Boni F, Noce V, Bertaccini L, Catalano C. Cardiovasc Intervent Radiol. 2013 Mar 9.

Special Session Complicated portal hypertension management 304.1 Indications and current evidence for TIPS P.E. Huppert Diagnostic and Interventional Radiology, Klinikum Darmstadt, Darmstadt, Germany Learning Objectives 1. To learn the indications for TIPS 2. To learn about outcomes in these patients 3. To learn how to improve quality of life and survival after TIPS No abstract available.

304.2 Treatment of portal vein obstruction I. Keussen Center for Medical Imaging and Physiology, Lund University Hospital, Lund, Sweden Learning Objectives 1. To review the aetiology of portal vein thrombosis 2. To describe the methods in chronic portomesenteric vein thrombosis recanalisation 3. To compare the results of medical and endovascular therapy in acute portal vein thrombosis Portal vein (PV) obstruction (PVO) is a relatively rare condition, which may have serious consequences (1,2). The most common cause is PV thrombosis. PV thrombosis in children is frequently caused by umbilical vein catheterization with secondary infection, and less frequently parasitosis. In adults, PV thrombosis is most frequent in patients with cirrhosis, but may be secondary to coagulation disorders, malignancy, infection, inflammatory diseases, external compression, or a combination of these entities. Esophageal varices may appear as soon as 1 month after the first symptoms of PV thrombosis (3). Idiopathic PVO may also be present (4). PVO may be either prehepatic or intrahepatic, include both localizations, or extend to more peripheral branches. Prehepatic occlusion is usually secondary to acute or chronic thrombosis or to malignant disease. Diagnosis is usually established using ultrasonography, computed tomography, or magnetic resonance tomography. Multiple collaterals as in cavernous transformation of PV or gastrointestinal, mesenteric, or subcutaneous varices may be detected on these examinations. If the intrahepatic PV branches are patent, the pressure gradient between these branches and the systemic circulation is low. In chronic PVO, pressure gradient between intrahepatic

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and open part of PV may be relatively low if the patient has welldeveloped collaterals. If only the splenic vein is obstructed with elevated pressure gradient, the condition is called “left-sided portal hypertension.” In case of acute PVO, the patient presents with symptoms of abdominal disorder with or without gastrointestinal bleeding. In case of chronic PVO, symptoms may be more diffuse and often include ascites, splenomegaly, chronic abdominal pain, and/or intermittent gastrointestinal bleeding. Asymptomatic PVO may be found accidentally and in most cases, does not require further attention. Depending on the severity of symptoms, anticoagulant therapy, endoscopic sclerotherapy, or tapping of ascites may be necessary. Surgical treatment methods include splenectomy, mesosystemic shunts, bowel resection, and liver transplant. Percutaneous interventional radiological (IR) options include the following (5): • Intraarterial thrombolytic therapy • Intraportal thrombolysis • Removal and fragmentation of the thrombus • Stent recanalization • Additional TIPS following the aforementioned methods • Partial splenic embolization • Variceal embolization The IR treatment is usually performed under general anesthesia, but in some cases, it may be performed under local anesthesia with systemic sedation. The patient’s heart rate, blood pressure, and oxygen saturation should be monitored continuously. Smallest possible instruments should be used. Planning of the IR treatment should be based on the location and extent of PVO. In case of extrahepatic PVO, percutaneous transhepatic or transjugular transhepatic, similar to the TIPS technique, should be used (6). If the intrahepatic PV branches are occluded, transhepatic access may be difficult or impossible. In these cases, trans-splenic access may be preferred. For a percutaneous transhepatic or trans-splenic access, a micropuncture technique is recommended. When access to PV has been established, venography is performed using ionic contrast or CO2. The pressure gradient is assessed, and recanalization of the obstructed segment is attempted. The occluded segment can usually be traversed using hydrophilic guidewire and standard angiographic catheters. Thrombolysis with or without thrombus fragmentation/aspiration may be attempted in cases of acute/subacute thrombosis. Use of different tools intended for the treatment of arterial or venous thrombosis may be beneficial. Stent or stent-grafts are used to stabilize the recanalized segment if necessary (7-9). Additional embolization of varices may be performed with an aim to increase the flow to the recanalized segment. After the procedures, the transhepatic or trans-splenic tract should be embolized with coils, plugs, and/or gelatine sponge. Intraarterial thrombolysis with an infusion of thrombolytics in SMA may be tried in cases of acute PV thrombosis. Another type of treatment is partial splenic embolization, which may also be performed in order to decrease the inflow of blood to the portal system and/or decrease symptoms (5). The results depend on the origin of PVO. Recanalization of the occluded segments has a relatively good outcome if intrahepatic PV branches are patent. Otherwise, additional TIPS may be necessary (10,11). In patients with malignant PV invasion, the outcome after stent placement is less favorable if the splanchnic veins are involved and/or if severe hepatic dysfunction is present (8). The treatment in children should be adapted to the age and size of the patient (12,13). Due to the relative rarity of PVO, comparison of results of different treatment methods is difficult, as is planning of randomized studies. It was reported that the recanalization rate was higher in patients receiving anticoagulation compared to no treatment at all (3). In reports describing endovascular treatment, the results were generally promising (5).

Abstract Book PVO is a serious condition, which may cause life-threatening bleeding or bowel ischemia. Imaging can define the extent and localization of PVO. The interventions provided by IR should be based on the decision of a multidisciplinary team. Possibility of future liver transplant should be discussed, if stents or stent-grafts are used. The IR treatment usually has a good outcome, but should be planned carefully according to the extent and localization of PVO, hemodynamic flow pattern, causality, and vascular anatomy. References 1. Cwikiel W. Interventional procedures involving portal vein circulation: a review. Acta Radiol. 2006 Mar;47(2):145-56. 2. Kirby JM, Cho KJ, Midia M. Image-guided intervention in management of complications of portal hypertension: more than TIPS for success. Radiographics. 2013 Sep-Oct;33(5):1473-96. 3. Turnes J, García-Pagán JC, González M, et al. Portal hypertension-related complications after acute portal vein thrombosis: impact of early anticoagulation. Clin Gastroenterol Hepatol. 2008 Dec;6(12):1412-7. 4. Valla DC, Condat B. Portal vein thrombosis in adults: pathophysiology, pathogenesis and management. Review. J Hepatol. 2000 May;32(5):865-71. 5. Semiz-Oysu A, Keussen I, Cwikiel W. Interventional radiological management of prehepatic obstruction of the splanchnic venous system. Cardiovasc Intervent Radiol. 2007 Jul-Aug;30(4):688-95. 6. Luo X, Nie L, Wang Z. et al. Transjugular endovascular recanalization of splenic vein in patients with regional portal hypertension complicated by gastrointestinal bleeding. Cardiovasc Intervent Radiol. 2014 Feb;37(1):108-13. 7. Woodrum DA, Bjarnason H, Andrews JC. Portal vein venoplasty and stent placement in the nontransplant population. J Vasc Interv Radiol. 2009 May;20(5):593-9. 8. Yamakado K, Nakatsuka A, Tanaka N. et al. Portal venous stent placement in patients with pancreatic and biliary neoplasms invading portal veins and causing portal hypertension: initial experience. Radiology. 2001 Jul;220(1):150-6. 9. Yamakado K, Nakatsuka A, Tanaka N. et al. Malignant portal venous obstructions treated by stent placement: significant factors affecting patency. J Vasc Interv Radiol. 2001 Dec;12(12):1407-15. 10. Citron SJ, Brantley SD. TIPS in portal vein occlusions: facilitation with percutaneous splenic access. J Vasc Interv Radiol. 1998 Mar-Apr;9(2):363-4. 11. Wils A, van der Linden E, van Hoek B. et al. Transjugular intrahepatic portosystemic shunt in patients with chronic portal vein occlusion and cavernous transformation. J Clin Gastroenterol. 2009 Nov-Dec;43(10):982-4. 12. Cwikiel W, Keussen I, Larsson L. et al. Interventional treatment of children with portal hypertension secondary to portal vein occlusion. Eur J Pediatr Surg. 2003 Oct;13(5):312-8. 13. Ling SC. Advances in the evaluation and management of children with portal hypertension. Semin Liver Dis. 2012 Nov;32(4):288-97.

304.3 Interventional management of hypersplenism T. Tanaka Radiology, Nara Medical University, Kashihara, Japan Learning Objectives 1. To review the aetiology and pathophysiology of hypersplenism 2. To learn how to embolise the spleen in hypersplenism, including long-term results 3. To learn how to manage complications after splenic embolisation In 1973, Maddison et al. first described splenic embolization for gastrointestinal hemorrhage (1). However, after Maddison’s report,

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CIRSE 2014 major complications, including splenic abscess and bacterial peritonitis, were reported to occur due to total embolization (2). To avoid these complications, Spigos et al. developed and reported on partial splenic embolization (PSE) in 1979, and this technique has been widely adopted (3). The advantages of PSE compared with splenectomy are as follows: use of local anesthesia, speed of the procedure, no need for blood transfusions, and, most importantly, preservation of functional splenic tissue to safeguard against severe infection. Currently, PSE is mainly applied for pancytopenia prior to interferon therapy, chemotherapy, radiofrequency ablation (RFA), and surgery (4-7). In addition, gastrointestinal variceal hemorrhage, severe portal hypertension with liver dysfunction and refractory ascites, and hepatic encephalopathy are occasionally treated with PSE (8-10). PSE techniques PSE technique could be divided into two groups: embolization of the peripheral area with particles and embolization of segmental areas with coils/particles. In the case of peripheral embolization using particles, a catheter tip is placed in the splenic artery near the splenic hilum, beyond the orifice of the pancreatic artery. Particles, suspended in an antibiotic solution mixed with contrast, are injected under fluoroscopic guidance until the blood flow in the peripheral splenic arterial branches slows down. The endpoint is reached when approximately two-thirds of the total splenic parenchyma is ablated. On the other hand, in the case of segmental embolization using coils/particles, several branches of the splenic artery are selectively catheterized beyond the anastomosis site to the short gastric arteries, left gastroepiploic artery, and caudal pancreatic artery to avoid collateral inflow from these arteries after embolization. The selected splenic branches are occluded until complete stasis of blood flow is achieved. Embolization of the splenic branches should be conducted until obtaining approximately 60%–70% infarction of the total splenic volume, which can be calculated using cone-beam C-arm CT. There are several advantages and drawbacks with these two procedures. Segmental embolization can predict the embolization volume during PSE using a cone-beam C-arm CT or a hybrid CT/ angio system. Long procedure times and high cost of coils are problems. Peripheral embolization is a simple technique with quick procedure times and low cost. However, the estimation of embolization volumes and determination of the endpoints of the injected particles are vague. Selection of embolic materials To date, there is no consensus in the selection of embolic materials for PSE. In clinical practice, GS particles are most commonly used, followed by coils and PVA. Spherical microspheres and Onyx agent could be promising new materials (11). A PubMed search found three English publications that compared embolic materials for PSE in clinical studies. First, Zhu et al. compared 300–500-μm polyvinyl alcohol (PVA) with 1–2-mm GS particles in a randomized control trial (12). Their results indicated that PVA achieved significantly higher numbers of platelet and leukocyte after PSE. Second, Liu et al. compared GS particles with Bletilla Striata particles, a Chinese product not available in Europe, USA, or Japan (13). Third, recently, we compared GS particles with coils. Our results indicated that there were no significant differences in the efficacy of PSE between the two (14). In the 1980s, it was reported that proximal occlusion with coils had a short-lasting effect because of the development of collateral vessels. However, current microcatheter techniques could embolize the distal branches, after connecting with the gastric arteries, which can achieve complete infarction of the corresponding area. Risk factors of complications Splenic abscess, bacterial peritonitis, portal vein thrombosis, and large pleural effusion and ascites have been reported as complications of PSE. Among them, splenic infection is the most critical complication. There are several possible mechanisms of splenic infection: anaerobic bacterial growth in the hypoxic tissue, percutaneous contamination by exogenous bacteria, and retrograde transport of enteric pathogens via a reversed portal flow (15). Several reports have indicated

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that poor liver function and large splenic embolization volume and/or ratio were obvious risk factors for complications of PSE (12, 16). Optimal embolization ratio/volume Previous reports indicated that splenic infarction ratio <50% resulted in a relapse of hypersplenism (17), whereas >70% increased the frequency of complications (12, 18). From these results, the optimal range of infarction ratio could be considered to be 50%–70%. In addition, recently, a Japanese group published more detailed results focusing on optimal embolization volume. From their results, the embolization volume >540 ml was a risk factor of complications, whereas a minimum of 388 ml was needed for a sufficient increase in platelet count (19). Therefore, in cases with splenic volume of <400ml - a small-sized spleen - splenectomy is recommended, whereas in cases with the splenic volume >700 ml - a very large size spleen - PSE should be conducted in 2 sessions (20). Estimation techniques of the embolization volume Several techniques have been reported to estimate the embolization ratio/volume before/during PSE. The first technique is an estimation based on the diameter of the splenic artery. Ou et al. used a digital subtraction angiography during PSE (21), whereas Kikuchi et al. used CT arteriography before PSE (22). Both techniques showed a correlation between actual embolization volume ratio and estimated embolization ration. The second technique uses CTs during arterial injection of contrast via splenic branches immediately before embolization using a cone-beam C-arm CT; alternatively, a hybrid CT/angio system is also useful to estimate the embolization volume via the corresponding branches. We recently developed a new system using computed volumetric analysis software to predict the splenic infarction ratio before PSE. Using Voronoi diagram method, CTs obtained before PSE were analyzed. Our initial results indicated that there was a strong correlation between the estimated infarction ratio and the actual infarction ratio [Unpublished data, to be presented at the 73rd JRS meeting in Yokohama in April 2014]. References 1. Maddison FE. Embolic therapy of hypersplenism. Invest Radiol 1973; 8:280–281. 2. Wholey MH, Chamorro H, Rao G, et al. Splenic infarction and spontaneous rupture of the spleen following therapeutic embolization. Cardiovasc Radiol 1978; 1:249–253. 3. Spigos DG, Jonasson O, Mozes M, et al. Partial splenic embolization in the treatment of hypersplenism. AJR J Roentgenol 1979; 132:777–782. 4. Tahara H, Takagi H, Sato K, et al. A retrospective cohort study of partial splenic embolization for antiviral therapy in chronic hepatitis C with thrombocytopenia. J Gastroenterol 2011; 46:1010–1019. 5. Kauffman CR, Mahvash A, Kopetz S, et al. Partial splenic embolization for cancer patients with thrombocytopenia requiring systemic chemotherapy. Cancer 2008; 112:2283–2288. 6. Hidaka H, Kokubu S, Nakazawa T, et al. Therapeutic benefits of partial splenic embolization for thrombocytopenia in hepatocellular carcinoma patients treated with radiofrequency ablation. Hepatol Res 2009; 39:772–778. 7. Poulin EC, Mamazza J, Schlachta CM. Splenic artery embolization before laparoscopic splenectomy. Surg Endosc 1998; 12:870–875. 8. Ohmoto K, Yamamoto S. Prevention of variceal recurence, bleeding, and death in cirrhosis patients with hypersplenism, especially those with severe thrombocytopenia. Hepatogastroenterology 2003; 50:1766–1769. 9. Romano M, Giojelli A, Capuano G, et al. Partial splenic embolization in patients with idiopathic portal hypertension. Eur J Radiol 2004; 49:268–273. 10. Yoshida H, Mamada Y, Taniai N, et al. Long-term results of partial splenic artery embolization as supplemental treatment for portal-systemic encephalopathy. Am J Gastroenterol 2005; 100:43–47.

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11. Gonsalves CF, Mitchell EP, Brown DB. Management of hypersplenism by partial splenic embolization with ethylene vinyl alcohol copolymer. Am J Gastroenterol 2010; 195:1241–1244. 12. Zhu K, Meng X, Li Z, et al. Partial splenic embolization using polyvinyl alcohol particles for hypersplenism in cirrhosis: A prospective randomized study. Eur J Radiol 2008; 66:100–106. 13. Liu R, Teng XJ, He JF, et al. Partial splenic embolization using Bletilla striata particles for hypersplenism in cirrhosis: A prospective study. Am J Chin Med 2011; 39:261–269. 14. Masada T, Tanaka T, Sakaguchi H, et al. Coils Versus Gelatin Particles with or without Intraarterial Antibiotics for Partial Splenic Embolization: A Comparative Evaluation. J Vasc Interv Radiol 2014 [Epub ahead of print] 15. Madoff DC, Denys A, Wallace MJ, et al. Splenic arterial interventions: anatomy, indications, technical considerations, and potential complications. Radiographics 2005; 25:S191–211. 16. Hayashi H, Beppu T, Okabe K, et al. Risk factors for complications after partial splenic embolization for liver cirrhosis. Br J Surg 2008; 95:744–750. 17. Sangro B, Bilbao I, Herrero I, et al. Partial splenic embolization for the treatment of hypersplenism in cirrhosis. Hepatology 1993; 18:309–314. 18. N’Kontchou G, Seror O, Bourcier V, et al. Partial splenic embolization in patients with cirrhosis: efficacy, tolerance and longterm outcome in 32 patients. Eur J Gastroenterol Hepatol 2005; 17:179–184. 19. Hayashi H, Beppu T, Masuda T, et al. Predictive factors for platelet increase after partial splenic embolization in liver cirrhosis patients. J Gastroenterol Hepatol 2007; 22:1638–1642. 20. Hayashi H, Beppu T, Okabe K, et al. Therapeutic factors considered according to the preoperative splenic volume for a prolonged increase in platelet count after partial splenic embolization for liver cirrhosis. J Gastroenterol 2010; 45:554–559. 21. Ou MC, Chuang MT, Lin XZ, et al. A novel method for the angiographic estimation of the percentage of spleen volume embolized during partial splenic embolization. Eur J Radiol 2013; 82:1260–1265. 22. Kikuchi K, Nakamura Y, Yoshimoto M, et al. Preoperative CT imaging analyzed using a 3D workstation before PSE to predict embolization volume. Jpn J Intervent Radiol 2012; 27:159–162.

304.4 Indications and current evidence for BRTO M. Darcy Interventional Radiology, Washington University in St Louis School of Medicine, St. Louis, MO, United States of America Learning Objectives 1. To learn how to indicate a patient for BRTO 2. To learn how to perform BRTO 3. To compare the results of BRTO and TIPS in the treatment of gastric varices Features of gastric varices Gastric varices (GVs) are less common than esophageal varices and they bleed less frequently; however, several factors combine to make them difficult to manage. They bleed at lower pressures than esophageal varices, thus raising questions about portal decompressive strategies to treat them. Also, GVs are more difficult for endoscopists to control; when bleeding does occur from GVs, there is a higher associated mortality, approaching 55%. Fundamental differences There are certain fundamental differences between transjugular intrahepatic portosystemic shunts (TIPS) and balloon-occlusion retrograde transvenous obliteration (BRTO) for managing GVs. TIPS is a decompressive strategy, whereas BRTO is an occlusive strategy. TIPS lowers portal pressures, thus addressing the underlying portal

Abstract Book hypertension but indirectly treating GVs. BRTO, however, is a local therapy more directly aimed at the bleeding varices themselves, but it does not lower portal pressure and, in fact, increases portal pressure, which has several implications. Although in many centers, TIPS has become a routine procedure taking around 1 hour to perform, BRTO can be technically very challenging. This is particularly true if the patient does not have a large gastrorenal shunt and the procedure has to be done via inferior phrenic or pericardiophrenic veins (1, 2). In one of the few singlecenter comparisons of these 2 techniques, the technical success was 100% and 91%, respectively, in the TIPS and BRTO groups (3). While tools specifically designed for BRTO could theoretically make the procedure easier, many of these are not available outside Asia. BRTO is also a more time-consuming procedure. Many operators can do TIPS in 60–90 minutes; however in BRTO, the balloon-occlusion catheter is typically left up for 4–12 hours even after the complex catheterizations and embolization of accessory outflow channels has been accomplished. Efficacy Technical success for BRTO has been reported as 79%–100% (4) and in 90%–97% of cases, GVs have been endoscopically proven to be eradicated (5, 6). In our retrospective series comparing TIPS and BRTO, follow-up endoscopy revealed eradication of the GVs in 60% of TIPS cases and 87% of BRTO cases (7). BRTO has shown good ability to prevent recurrent bleeding from GVs. In a recent comparative study by Sabri et al (3), at 12 months, the incidence of rebleeding from a GV source was 11% in the TIPS group and 0% in the BRTO group (P = .25). With 5-year follow-up Ninoi et al reported a 2.7% rate of recurrent gastric variceal bleeding after BRTO (8). This is in contradistinction to TIPS where rebleeding from gastric varices has been reported to occur in 10–30% of cases. An older study that evaluated TIPS for gastric variceal bleeding found rebleeding rates of 14%, 26%, and 31% at 1 month, 6 months, and 1 year, respectively (9). Of course, this was an older study using Wallstents and the rate of shunt dysfunction was higher than what we see in the current stent graft era. The data regarding rebleeding must take into consideration that in many studies, BRTO was done prophylactically in non-bleeding GVs. The ability to stop gastric variceal bleeding acutely is a little less clear. Kageyama (5) reported on BRTO done in patients who were actively bleeding. Rebleeding within 1 hour occurred in 6 of 39 (15%) patients. Severe liver disease (Childs class C) was a major risk factor for rebleeding in this study. Complications One of the main benefits of BRTO is the preservation of portal vein perfusion which leads to lower risk of complications such as liver failure or encephalopathy. It is known that patients with a high MELD score tend to do poorly after TIPS. Ferral and Patel (10) stated that a MELD >25 is associated with high early mortality, and Montgomery et al (11) recommended that elective TIPS should not be done in patient with a MELD >24. BRTO on the other hand not only does not lead to hepatic functional deterioration but may also actually help preserve hepatic function. Kumamoto et al (12) found that liver function deteriorated in patients with untreated gastrorenal shunts, whereas those treated with BRTO actually had improvement or stabilization of their liver function. Encephalopathy is also less prevalent after BRTO with most series reporting no encephalopathy. In a single-center comparison study, the rates of encephalopathy were 15% and 0% in the TIPS and BRTO groups, respectively (3). Since BRTO occludes some of the channels providing outflow from the portal system, BRTO causes some elevation of the portal pressures with subsequent problems such as increased ascites or aggravation of esophageal varices. In one long-term study of 78 patients, BRTO led to worsening of esophageal varices in 27%, 58%, and 66% of patients at 1, 3, and 5 years, respectively (8).

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Survival Survival post-BRTO has generally been quite good. Ninoi et al (8) reported 1-, 3-, and 5-year survival rates of 93%, 76%, and 54%, respectively, whereas another study (5) similar reported 92%, 75%, and 67%, respectively. There is a relative paucity of studies comparing survival without clear conclusions. Sabri et al (3) reported no significant difference in 12 month survival (74% for TIPS and 87% for BRTO, P = .22). Another study (13) reported cumulative survival rates at 1, 3, and 5 years of 81%, 64%, and 40%, respectively, after TIPS and 96%, 83%, and 76%, respectively, after transcatheter sclerotherapy (P < 0.01). However, upon further analysis, sclerotherapy only provided a survival benefit for Child–Pugh class A patients. For Child–Pugh classes B and C, there was no significant survival difference. There is one issue that may tend to over-estimate the benefit of BRTO in the current literature. Again, in most BRTO series, many if not all the patients had BRTO done prophylactically without actually having prior bleeding from GVs. This may make a difference since Naeshiro et al (14) showed that 10-year survival was 36% after BRTO was performed prophylactically versus 22% survival when BRTO was performed for active bleeding. Conclusion The best candidates for BRTO are patients whose primary problem is GVs (not caused by splenic vein pathology) and in whom there is no other reason to consider performing TIPS. Patients who are at high risk for liver failure or encephalopathy are particularly good candidates for BRTO. However, TIPS should be considered if the patient has bleeding esophageal varices in addition to GVs. TIPS is also a better option in those who have both gastric variceal bleeding as well as significant ascites. References 1. Imai Y, Nakazawa M, Ando S, Sugawara K, Hamaoka K, Oka M, et al. Balloon-occluded retrograde transvenous obliteration using a microballoon catheter for intractable gastric fundal varices. J Gastroenterol Hepatol. 2014;29(2):365-71. 2. Yamagami T, Yoshimatsu R, Miura H, Yamada K, Minami M. Successful balloon-occluded retrograde transvenous obliteration of gastric varix via pericardiacophrenic vein after embolization of portopulmonary venous anastomosis. J Vasc Interv Radiol. 2013;24(1):137-9. 3. Sabri SS, Abi-Jaoudeh N, Swee W, Saad WE, Turba UC, Caldwell SH, et al. Short-Term Rebleeding Rates for Isolated Gastric Varices Managed by Transjugular Intrahepatic Portosystemic Shunt versus Balloon-Occluded Retrograde Transvenous Obliteration. J Vasc Interv Radiol. 2014;25(3):355-61. 4. Saad WE, Simon PO, Jr., Rose SC. Balloon-occluded retrograde transvenous obliteration of gastric varices. Cardiovasc Intervent Radiol. 2014;37(2):299-315. 5. Kageyama K, Nishida N, Yamamoto A, Jogo A, Hamamoto S, Matsui H, et al. Risk Factors for Rebleeding and Prognostic Factors for Postoperative Survival in Patients with Balloon-Occluded Retrograde Transvenous Obliteration of Acute Gastric Variceal Rupture. Cardiovasc Intervent Radiol. 2014. Epub 2014/01/10. 6. Akahoshi T, Hashizume M, Tomikawa M, Kawanaka H, Yamaguchi S, Konishi K, et al. Long-term results of balloon-occluded retrograde transvenous obliteration for gastric variceal bleeding and risky gastric varices: a 10-year experience. J Gastroenterol Hepatol. 2008;23(11):1702-9. 7. Sauk S, Niemeyer M, Korenblat K, Kim SK. Outcomes from BRTO vs. TIPS in the Management of Isolated Gastric Varices: A Retrospective Study. Society of Interventional Radiology Annual Meeting; San Diego, CA; 2014. 8. Ninoi T, Nishida N, Kaminou T, Sakai Y, Kitayama T, Hamuro M, et al. Balloon-occluded retrograde transvenous obliteration of gastric varices with gastrorenal shunt: long-term follow-up in 78 patients. AJR Am J Roentgenol. 2005;184(4):1340-6.

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9. Barange K, Peron JM, Imani K, Otal P, Payen JL, Rousseau H, et al. Transjugular intrahepatic portosystemic shunt in the treatment of refractory bleeding from ruptured gastric varices. Hepatology. 1999;30(5):1139-43. 10. Ferral H, Patel NH. Selection criteria for patients undergoing transjugular intrahepatic portosystemic shunt procedures: current status. J Vasc Interv Radiol. 2005;16(4):449-55. 11. Montgomery A, Ferral H, Vasan R, Postoak DW. MELD score as a predictor of early death in patients undergoing elective transjugular intrahepatic portosystemic shunt (TIPS) procedures. Cardiovasc Intervent Radiol. 2005;28(3):307-12. 12. Kumamoto M, Toyonaga A, Inoue H, Miyakoda K, Morita Y, Emori K, et al. Long-term results of balloon-occluded retrograde transvenous obliteration for gastric fundal varices: hepatic deterioration links to portosystemic shunt syndrome. J Gastroenterol Hepatol. 2010;25(6):1129-35. 13. Ninoi T, Nakamura K, Kaminou T, Nishida N, Sakai Y, Kitayama T, et al. TIPS versus transcatheter sclerotherapy for gastric varices. AJR Am J Roentgenol. 2004;183(2):369-76. 14. Naeshiro N, Aikata H, Kakizawa H, Hyogo H, Kan H, Fujino H, et al. The long-term outcome of patients with gastric varices treated by balloon-occluded retrograde transvenous obliteration. J Gastroenterol Hepatol. 2013. Epub 2014/01/01.

Special Session Interventional acute stroke treatment: trials update and outlook 305.1 Studies on image-guided patient selection K.A. Hausegger Radiology, General Hospital Klagenfurt, Klagenfurt, Austria Learning Objectives 1. To learn about studies on image-guided patient selection in acute stroke 2. To understand the recent imaging algorithms for stroke 3. To learn how to select patients with this algorithm In many stroke units, mechanical thrombectomy (MTE) has become a well-accepted procedure in the treatment of patients with acute ischemic stroke. However, despite encouraging recanalization rates of occluded large intracranial vessels, ranging between 75% and 85%, good clinical outcome, defined as patients with a postictal mRS ≤2, has been reported in only 45–55% (1). This means that successful recanalization is futile in a significant proportion of the patients. Therefore, there is a clear demand for better patient selection criteria, which will enable the operator to identify patients who will benefit from revascularization procedures. Patient selection for MTE is based on the history, clinical status (NIHSS), and imaging findings. In the randomized prospective RESCUE trial, it was evaluated if multimodal pre-interventional MR or CT imaging may provide valid information to predict possible clinical outcome after successful revascularization. However, no difference was found in clinical outcome in patients with and without favorable penumbral pattern (2). In contrast, the DEFUSE 2 trial clearly showed that patients with a favorable MR-perfusion/diffusion pattern had a higher chance for a good clinical outcome after successful revascularization than did patients with a dismal mismatch pattern (3). In addition, it has been shown that perfusion CT may also serve as a valid tool for proper patient selection for MTE (4). The size of the penumbra area around the infarct core depends on the capacity of the collateral flow. Therefore, the degree of the collateral flow is essential for estimating the probability of a good clinical outcome. Perfusion studies are sophisticated tools to quantify

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this; however, collateral flow can be also estimated from the source images of CT-angiography or angiographically during MTE (5). In our experience, the so-called “black hemisphere” on the source images of CTA is indicative for zero collateral flow and therefore is a clear surrogate for a poor clinical outcome, irrespective of whether revascularization is successful or not. Another easily available predictor is the ASPECT score. Although there may be a high interobserver variability, several studies have shown that patients with an ASCECT score ≥7 have higher chances for good clinical outcome (6). Although the optimal imaging strategy before MTE in patients with acute ischemic stroke has not been defined, it may be assumed that multimodal CT or MR will become valid tools in this field. Further studies like the DUST trial are on the way (7). References 1. Hausegger KA, Hauser M, Kau T., Mechanical thrombectomy with stent retrievers in acute ischemic stroke. Cardiovasc Intervent Radiol. 2014; 9. [Epub ahead of print] 2. Kidwell CS, Jahan R, Gornbein J, et al., A trial of imaging selection and endovascular treatment for ischemic stroke. N Engl J Med. 2013, 368:914-23. 3. Lansberg MG, Straka M, Kemp S, et al.; MRI profile and response to endovascular reperfusion after stroke (DEFUSE 2): a prospective cohort study. Lancet Neurol. 2012; 11:860-7. 4. Burkart DJ, Day JS, Henderson K, Borsa JJ, et al.; Efficacy of peripheral interventional radiologists performing endovascular stroke therapy guided by CT perfusion triage of patients. J Vasc Interv Radiol. 2013; 24:1267-72. 5. Marks MP, G. Lansberg, M Mlynasch, et al.; Effect of collateral blood flow on patients undergoing endovascular therapy for acute ischemic stroke. Stroke. 2014; 45:1035-9. 6. Hill MD, Demchuk AM, Goyal M, et al.; Alberta Stroke Program early computed tomography score to select patients for endovascular treatment: Interventional Management of Stroke (IMS)-III Trial. Stroke. 2014; 45:444-9. 7. van Seeters T, Biessels GJ, van der Schaaf IC, et al.; Prediction of outcome in patients with suspected acute ischaemic stroke with CT perfusion and CT angiography: the Dutch acute stroke trial (DUST) study protocol. BMC Neurol. 2014; 14:37.

305.2 Completed stroke treatment studies and trials G. Schroth Abteilung Neuroradiologie, Inselspital, Universitätsspital Bern, Bern, Switzerland Learning Objectives 1. To learn about completed stroke treatment studies/trials 2. To understand where we stand with previous trial results 3. To learn the practical impact of these studies on the daily routine 1. Intravenous administration of thrombolytic drugs Intravenous administration of thrombolytic drugs has been evaluated in several randomised trials using recombinant tissue-type plasminogen activator (rt-PA) demonstrating efficiency up to 3–4.5 h after symptom onset (1,2). However, studies have shown a limited effect in patients with severe stroke and proximal vessel occlusion (3,4). In addition, due to the limited time window, only a minority of patients admitted to stroke centres are eligible for intravenous stroke treatment. 2. Intra-arterial application of thrombolytic drugs The landmark study for intra-arterial thrombolysis is the Prolyse in Acute Cerebral Thromboembolism (PROACT II) (5). In all, 180 patients with angiographically confirmed M1 and M2 occlusions were randomised within 6 h after symptom onset to be treated with 9 mg intra-arterial prourokinase and heparin or heparin only (control

Abstract Book group). A favourable clinical outcome (mRS ≤ 2) was achieved in 40% of the endovascularly treated patients and in 25% of the control group with a mortality rate of 25% and 27%, respectively. Recanalisation rate defined as TIMI 2–3 was significantly higher in the prourokinase group (66%) than that in the control group (18%). Intracranial haemorrhage in patients with neurological deterioration within 24 h was lower in the control group (2%) compared with those treated with prourokinase (10%). The PROACT study demonstrates that intra-arterial thrombolysis within 6 h after symptom onset significantly improves clinical outcome. This was confirmed by other studies, comparing intravenous thrombolysis with local intraarterial therapy (6). 3. Mechanical treatment approaches Endovascular mechanical treatment approaches can be divided into four groups according to their mechanical mechanism of action. 3.1 Thrombus disruption The simple mechanical manoeuvre, probing the thrombus with the microwire and/or advancing the microcatheter into or distally to the thrombus, has been shown to be able to improve the rate of successful recanalisation. Using this technique as an adjunct to intraarterial thrombolysis, successful recanalisation of M1 occlusions has been reported in 79% of patients (7). Another method of mechanical clot disruption is the use of percutaneous transluminal balloon angioplasty (PTA). Using this technique (8), sufficient recanalisation was achieved in 91.2% in the PTA group as compared with 63.9% in the thrombolysis group with a favourable clinical outcome in 73.5% versus 50%, respectively. By the EKOS system (EKOS, Bothell, USA), ultrasonic vibration is supposed to increase fluid penetration within the clot in order to augment the effect of intra-arterial thrombolysis. Recanalisation was reported in 57% of patients with a favourable clinical outcome in 43% (9). 3.2 Proximal thrombectomy, thromboaspiration Manual suction thrombectomy is performed by advancing an aspiration catheter (usually 4.5–5.5 F, e.g. VASCO-Aspiration Catheter, which is in use in Europe since 2002) to the proximal surface of the thrombus. Manual aspiration is then applied using a syringe or pump. Although this approach is widely used since many years in experienced European stroke centres, in the setting of a multimodal treatment, only a few systematic studies have been published on this approach (10-15). The Penumbra Pivotal Stroke Trial (16) prospectively recruited 125 stroke patients (mean NIHSS 18) within 8 h of symptom onset. Recanalisation of the target vessel was successful in 81.6% of patients. Nevertheless, good clinical outcome was achieved in only 25% of all patients and in 29% of patients with recanalisation of the target vessel. Mortality was comparatively high (32.8%) and symptomatic intracranial haemorrhage occurred in 11.2% of patients. 3.3 Distal thrombectomy Compared with proximal thrombectomy approaches, distal thrombectomy is technically more challenging, because the occlusion site has to be passed with a microcatheter in order to deliver the device distally to the thrombus. Several distal thrombectomy devices have been introduced into clinical practice (e.g. Catch, BALT, Montmorency, France; Phenox pCR/CRC/Bonnet, Phenox GmbH, Bochum, Germany). The Merci Retrieval system has been investigated in the MERCI trial (Mechanical Embolus Removal in Cerebral Ischemia) and subsequent Multi MERCI trial (17), which includes 164 patients (mean NIHSS 19) within 8 h of symptom onset. Intravenous rt-PA, intra-arterial thrombolysis or other mechanical treatment approaches were allowed in addition to the Merci device. Successful recanalisation was achieved in 57.3% of patients using the Merci retriever alone and in 69.5%, using additional recanalisation modalities. Overall, favourable clinical outcome was achieved in 36% of patients only. The clinical outcome of both, Penumbra and Merci trials are clearly inferior to the PROACT trial, Penumbra was even inferior to the untreated control group of PROACT II. The reason may be that with both

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techniques, which have never been used in experienced European stroke centres, the original single thrombus is fragmented, and fragments of the thrombus swept away and destroyed the collaterals. 3.4 Stent recanalisation The use of different stent systems has been reported in case reports and small case series. (18,19). The Stent-assisted recanalisation in acute ischaemic stroke (SARIS) trial is the first FDA-approved prospective trial investigating stenting in acute stroke treatment. Recanalisation rate was 100% with adjuvant therapies such as angioplasty, intravenous rt-PA and intra-arterial thrombolysis applied in 63% of patients. Moderate clinical outcome was achieved in 60% of patients (20). 3.5 Stent retriever The most recently introduced mechanical treatment approach are so called ‘stent retrievers’. Stent retrievers are self-expandable, resheathable and re-constrainable stent-like devices. Wakhloo et al. demonstrated the technical feasibility of using a retrievable, closed cell, self-expanding stent (Enterprise, Codman) for extracting foreign bodies and clots in in-vitro and in animal testing by partially deploying and then retracting the device (21). Henkes et al (22) reported their first use of a fully deployable, self-expanding stent (Solitaire AB, ev3/Covidien) as a thrombectomy device for emergency treatment of an M1 occlusion after previously failed mechanical thrombectomy with a distal clot retriever. The concept of stent retrievers combines the advantages of intracranial stent deployment with immediate flow restoration (23) and a thrombectomy device with definitive clot removal from the occluded artery (24). The complete removal of the device avoids the major disadvantages associated with permanent stent implantation, such as the need for double antiplatelet medication, which potentially increases the risk of haemorrhagic complications and the risk of in-stent thrombosis or delayed stenosis. Subsequent single-centre studies have demonstrated the potential to reduce the procedure time and to increase recanalisation rates to over 80%–90% (25,26). The largest retrospective study reported results from six large European stroke centres (27) treating 141 patients (median NIHSS 18). Successful recanalisation was achieved in 85% of target vessels with favourable clinical outcome in 55%. The STAR trial (28), the largest prospective multicentre trial on mechanical thrombectomy to date, was an international, multicentre, prospective, single-arm study evaluating the Solitaire FR in patients with anterior circulation strokes due to large vessel occlusion within 8 hours of symptom onset. Strict selection criteria for participating sites were applied. In all, 202 patients were enrolled (median NIHSS 17). All patients underwent pretreatment multimodal CT or MR imaging. Successful revascularisation was achieved in 79.2% of patients, and favourable clinical outcome was achieved in 57.9%. The rate of symptomatic intracranial haemorrhage was considerably low (1.5%). Procedural time to final recanalisation was the fastest reported so far with a median of 20 min, indicating a learning curve in experienced centres. The SWIFT study (Solitaire FR with the Intention for Thrombectomy) (29) was a prospective, randomised trial comparing the efficacy and safety of the Solitaire FR with the Merci device. The trial was halted a year sooner than anticipated on the advice of the safety monitoring committee due to a significantly better clinical outcome in the Solitaire FR patient group. The TREVO 2 study (Thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke) (30) was a similar trial comparing the Trevo Pro retriever (Concentric Medical/Stryker Neurovascular; USA) with the Merci device. Successful recanalisation was achieved in 89.7% of patients in the Trevo group compared with 63.3% in the Merci group with good clinical outcome in 55% and 40%, respectively. The recently published IMS III (30), MR Rescue (31) and Synthesis (32) trials were the first randomised controlled trials comparing endovascular stroke treatment with standard intravenous rt-PA administration. All three trials reported negative results for endovascular stroke treatment. However, all three studies have multiple flaws.

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Recruitment of patients was extremely low (between 0.7 and 3.5 patients/centre/year). This, as well as the extremely long door–needle time indicates that centres with a low experience in modern stroke management, especially in endovascular treatment, were involved. Modern stroke neuroimaging, including cross section angiography and thrombus imaging were not or only partly used. Patients with NIHSS down to 2 and without confirmed vessel occlusion were randomised and treated. Up to 24% of patients who were randomised into the endovascular group have not been treated at all. However, the main handicap of these studies is that exclusively or mainly, instruments and techniques have been used, which has not the goal to extract the thrombus en bloc but to fragment it (‘fragmentation of the thrombus with a microwire were achieved in 109 patients’) (32). Iatrogenic fragmentation of the thrombus destroys the collaterals, which are an equal important predictor of good clinical outcome as recanalisation and age (33,34). In summary, study design and quality control in these trials of studies have been performed mainly by neurologists and not by neuroradiologists with experience in image-guided, endovascular microsurgical neurointerventions. References 1. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. The New England Journal of Medicine. 1995;333(24):1581-7. Epub 1995/12/14. 2. Hacke W, Kaste M, Bluhmki E, Brozman M, Davalos A, Guidetti D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. The New England Journal of Medicine. 2008;359(13):1317-29. Epub 2008/09/26. 3. Fischer U, Arnold M, Nedeltchev K, Brekenfeld C, Ballinari P, Remonda L, et al. NIHSS score and arteriographic findings in acute ischemic stroke. Stroke. 2005;36(10):2121-5. Epub 2005/09/10. 4. Riedel CH, Zimmermann P, Jensen-Kondering U, Stingele R, Deuschl G, Jansen O. The importance of size: successful recanalization by intravenous thrombolysis in acute anterior stroke depends on thrombus length. Stroke. 2011;42(6):1775-7. Epub 2011/04/09. 5. Furlan A, Higashida R, Wechsler L, Gent M, Rowley H, Kase C, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II study: a randomized controlled trial. Prolyse in Acute Cerebral Thromboembolism. The Journal of the American Medical Association. 1999;282(21):2003-11. Epub 1999/12/11. 6. Mattle HP, Arnold M, Georgiadis D, et al. Comparison of intraarterial and intravenous thrombolysis for ischemic stroke with hyperdense middle cerebral artery sign. Stroke. 2008; 39: 379-83. 7. Arnold M, Schroth G, Nedeltchev K, Loher T, Remonda L, Stepper F, et al. Intra-arterial thrombolysis in 100 patients with acute stroke due to middle cerebral artery occlusion. Stroke. 2002;33(7):1828-33. Epub 2002/07/10. 8. Mattle HP, Arnold M, Lindsberg PJ, Schonewille WJ, Schroth G. Basilar artery occlusion (Review). Lancet Neurol. 2011;11:1002-14. 9. Nakano S, Iseda T, Yoneyama T, Kawano H, Wakisaka S. Direct percutaneous transluminal angioplasty for acute middle cerebral artery trunk occlusion: an alternative option to intra-arterial thrombolysis. Stroke. 2002;33(12):2872-6. Epub 2002/12/07. 10. Mahon BR, Nesbit GM, Barnwell SL, Clark W, Marotta TR, Weill A, et al. North American clinical experience with the EKOS MicroLysUS infusion catheter for the treatment of embolic stroke. AJNR American journal of neuroradiology. 2003;24(3):534-8. Epub 2003/03/15. 11. Chapot R, Houdart E, Rogopoulos A, Mounayer C, Saint-Maurice JP, Merland JJ. Thromboaspiration in the basilar artery: report of two cases. American Journal of Neuroradiology. 2002;23(2):282-4. Epub 2002/02/16.

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12. Lutsep HL, Clark WM, Nesbit GM, Kuether TA, Barnwell SL. Intraarterial suction thrombectomy in acute stroke. American Journal of Neuroradiology. 2002;23(5):783-6. Epub 2002/05/15. 13. Nedeltchev K, Brekenfeld C, Remonda L, Ozdoba C, Do DD, Arnold M, et al. Internal carotid artery stent implantation in 25 patients with acute stroke: preliminary results. Radiology. 2005;237(3):1029-37. Epub 2005/10/21. 14. Galimanis A, Jung S, Mono ML, Fischer U, Findling O, Weck A, et al. Endovascular therapy of 623 patients with anterior circulation stroke. Stroke; a journal of cerebral circulation. 2012;43(4):1052-7. Epub 2012/03/01. 15. Kang DH, Hwang YH, Kim YS, Park J, Kwon O, Jung C. Direct thrombus retrieval using the reperfusion catheter of the penumbra system: forced-suction thrombectomy in acute ischemic stroke. American Journal of Neuroradiology. 2011;32(2):283-7. Epub 2010/11/23. 16. Jankowitz B, Aghaebrahim A, Zirra A, Spataru O, Zaidi S, Jumaa M, et al. Manual aspiration thrombectomy: adjunctive endovascular recanalization technique in acute stroke interventions. Stroke. 2012;43(5):1408-11. Epub 2012/03/03. 17. The penumbra pivotal stroke trial: safety and effectiveness of a new generation of mechanical devices for clot removal in intracranial large vessel occlusive disease. Stroke. 2009;40(8):2761-8. Epub 2009/07/11. 18. Smith WS, Sung G, Saver J, Budzik R, Duckwiler G, Liebeskind DS, et al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke. 2008;39(4):1205-12. Epub 2008/03/01. 19. Levy EI, Mehta R, Gupta R, Hanel RA, Chamczuk AJ, Fiorella D, et al. Self-expanding stents for recanalization of acute cerebrovascular occlusions. American Journal of Neuroradiology. 2007;28(5):816-22. Epub 2007/05/15. 20. Brekenfeld C, Schroth G, Mattle HP, Do DD, Remonda L, Mordasini P, et al. Stent placement in acute cerebral artery occlusion: use of a self-expandable intracranial stent for acute stroke treatment. Stroke. 2009;40(3):847-52. Epub 2009/02/03. 21. Levy EI, Siddiqui AH, Crumlish A, Snyder KV, Hauck EF, Fiorella DJ, et al. First Food and Drug Administration-approved prospective trial of primary intracranial stenting for acute stroke: SARIS (stent-assisted recanalization in acute ischemic stroke). Stroke. 2009;40(11):3552-6. Epub 2009/08/22. 22. Wakhloo AK, Gounis MJ. Retrievable closed cell intracranial stent for foreign body and clot removal. Neurosurgery. 2008;62(5 Suppl 2):ONS390-3; discussion ONS3-4. Epub 2008/07/18. 23. Perez MA, Miloslavski E, Fischer S, Bazner H, Henkes H. Intracranial thrombectomy using the Solitaire stent: a historical vignette. Journal of Neurointerventional Surgery. 2012;4(6):e32. Epub 2011/12/16. 24. Mordasini P, Frabetti N, Gralla J, Schroth G, Fischer U, Arnold M, et al. In vivo evaluation of the first dedicated combined flow-restoration and mechanical thrombectomy device in a swine model of acute vessel occlusion. American Journal of Neuroradiology. 2011;32(2):294-300. Epub 2010/10/23. 25. Mordasini P, Brekenfeld C, Byrne JV, Fischer U, Arnold M, Jung S, Schroth G et al. Experimental evaluation of immediate recanalization effect and recanalization efficacy of a new thrombus retriever for acute stroke treatment in vivo. American Journal of Neuroradiology. 2013;34(1):153-8. Epub 2012/07/28. 26. Castano C, Dorado L, Guerrero C, Millan M, Gomis M, Perez de la Ossa N, et al. Mechanical thrombectomy with the Solitaire AB device in large artery occlusions of the anterior circulation: a pilot study. Stroke. 2010;41(8):1836-40. Epub 2010/06/12. 27. Brekenfeld C, Schroth G, Mordasini P, Fischer U, Mono ML, Weck A, et al. Impact of retrievable stents on acute ischemic stroke treatment. American Journal of Neuroradiology. 2011;32(7):1269-73. Epub 2011/05/14.

Abstract Book 28. Davalos A, Pereira VM, Chapot R, Bonafe A, Andersson T, Gralla J. Retrospective multicenter study of Solitaire FR for revascularization in the treatment of acute ischemic stroke. Stroke. 2012;43(10):2699-705. Epub 2012/08/02. 29. Pereira VMG, J, Davalos A, Bonafe A, Castano C, Chapot R, Liebeskind D, Nogueira RG, Arnold M, Sztajzel R, Liebig T, Goyal M, Besselmann M, Moreno A, Schroth G. Prospective Multi-Centre Single-Arm Study of Mechanical Thrombectomy using Solitaire FR in Acute Ischemic Stroke (STAR). Stroke. 2013; 44:2802-7. 30. Saver JL, Jahan R, Levy EI, Jovin TG, Baxter B, Nogueira RG, et al. Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised, parallel-group, non-inferiority trial. Lancet. 2012;380(9849):1241-9. Epub 2012/08/31. 31. Nogueira RG, Lutsep HL, Gupta R, Jovin TG, Albers GW, Walker GA, et al. Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trial. Lancet. 2012;380(9849):1231-40. Epub 2012/08/31. 32. Broderick JP, Palesch YY, Demchuk AM, Yeatts SD, Khatri P, Hill MD, et al. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. The New England Journal of Medicine. 2013;368(10):893-903. Epub 2013/02/09. 33. Kidwell CS, Jahan R, Gornbein J, Alger JR, Nenov V, Ajani Z, et al. A trial of imaging selection and endovascular treatment for ischemic stroke. The New England Journal of Medicine. 2013;368(10):914-23. Epub 2013/02/12. 34. Ciccone A, Valvassori L, Nichelatti M, Sgoifo A, Ponzio M, Sterzi R, et al. Endovascular treatment for acute ischemic stroke. The New England Journal of Medicine. 2013;368(10):904-13. Epub 2013/02/08. 35. Jung S, Gilgen M, Slotboom J, El-Koussy M, Zubler C, Kiefer C, Luedi R, Mono ML, Heldner MR, Weck A, Mordasini P, Schroth G, Mattle HP, Arnold M, Gralla J, Fischer U. Factors that determine penumbral tissue loss in acute ischaemic stroke. Brain. 2013;136: 3554-60. 36. Gratz PP, Jung S, Schroth G, et al. Outcome of standard and high-risk patients with acute anterior circulation stroke after stent retriever thrombectomy. Stroke. 2014; 45:152-8. doi: 10.1161/ STROKEAHA.113.002591.

305.3 Ongoing stroke treatment studies and trials D. Vorwerk Dept. of Diagn. and Imaging, Klinikum Ingolstadt, Ingolstadt, Germany Learning Objectives 1. To learn about ongoing stroke treatment studies 2. To understand the purpose of these studies/trials 3. To understand what would be the impact of these studies on stroke treatment No abstract available.

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305.4 The future of acute stroke treatment: the neurologist’s view H.S. Markus Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom Learning Objectives 1. To understand the neurologist’s view on acute stroke treatment today 2. To learn what we could expect in the future 3. To learn what we need from evidence-based medicine to shape the future of acute stroke treatment Intravenous thrombolysis has transformed the management of patients with acute stroke. However, only a minority of patients are eligible, and it has only limited benefit in those patients to whom it is given. In particular, the recanalisation rates in patients with occlusion of the large basal intracerebral vessels is low. A number of strategies are being evaluated in clinical trials to improve the effectiveness of thrombolysis and the proportion of patients who might benefit from it. Alternative thrombolytic agents being evaluated include tenecteplase and desmoteplase. Intra-arterial clot retrieval is being tested in a number of clinical trials. Ultrasound is being evaluated as an adjunct to intravenous thrombolysis. Intravenous tPA is licensed for patients within 4½ hours of stroke onset. Imaging studies suggest that some patients outside this time window may still have salvageable ischaemic penumbra. Both MR and CT methods for identifying penumbral tissue are being included in clinical trials in which only those patients with potentially salvageable tissue are being randomised to thrombolytic therapy outside the 4½-hour window. Interest in neuroprotection has waned after a number of clinical studies have failed to support experimental data suggesting efficacy of a variety of agents. However, it is likely that there will be more trials in this area; approaches such as hypothermia are currently being evaluated. We now know that there is a high risk of early recurrent stroke, particularly in the first 48 hours following an event. This risk is highest in patients with large artery atherosclerotic lesions as a cause of their stroke. More intensive antiplatelet regimens are being evaluated to see if this can reduce the early recurrent stroke rate.

Fundamental Course Basic principles of early-stage HCC management 901.1 Diagnostic criteria and staging work-up V. Vilgrain, M. Abdel-Rehim, M. Ronot, A. Sibert Department of Radiology, Hopital Beaujon, APHP, Clichy, France Learning Objectives 1. To learn how to perform state-of-the-art liver imaging 2. To learn how to choose among different imaging modalities and contrast media for the evaluation of liver nodules in cirrhosis 3. To learn when to resort to liver nodule biopsy Imaging is essential for diagnosing hepatocellular carcinoma (HCC). In cirrhosis, surveillance programmes using ultrasound are performed in patients with compensated cirrhosis to detect HCC at an early stage. When ultrasound depicts a nodule, contrast-enhanced imaging modalities including arterial phase are required. Non-invasive diagnosis based on contrast-enhanced imaging modalities (mostly MDCT and MRI) can be made due to the high specificity when hallmarks are observed. These two hallmarks are hypervascularity on arterial phase and wash-out on portal or delayed phase imaging. When the typical imaging findings are missing, other imaging findings, which increase the likelihood for HCC

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should be searched but are less specific such as corona enhancement, presence of fat within the nodule, hyperintensity on T2 and on high-b-value diffusion-weighted MR sequence, and hypointensity on hepatospecific phase using hepatobiliary contrast MR agents. When imaging fails to diagnose HCC, imaging-guided biopsy is indicated. Imaging is also crucial for treatment planning. Treatment is not only based on tumor characteristics such as size, hypervascularity, location, and vascular invasion but also on liver function and severity of portal hypertension. Imaging including elastography techniques is helpful for assessing the degree of portal hypertension.

901.2 Role of surgery: resection and transplantation H.Z. Malik Department of Hepatobiliary Surgery, Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom No abstract available.

901.3 Radiofrequency ablation: results and complications R. Lencioni Division of Diagnostic Imaging and Intervention, University of Pisa, Pisa, Italy Learning Objectives 1. To learn how RFA compares with resection in early-stage HCC 2. To learn the major limitations of RFA in early-stage HCC 3. To learn about the results of RFA in the treatment of early HCC with an insight into current guidelines Image-guided radiofrequency ablation (RFA) is widely accepted as the most appropriate therapeutic choice for patients with earlystage hepatocellular carcinoma (HCC) when surgical options, including resection and transplantation, are precluded. RFA has shown a superior anticancer effect and a greater survival benefit with respect to the seminal percutaneous technique, ethanol injection, meta-analyses of randomized controlled trials, and it is currently established as the standard ablative modality. An open question is whether RFA can compete with surgical resection as a first-line treatment. Randomized controlled trials completed so far have failed to provide an unequivocal answer. Uncontrolled investigations have also reported similar results for resection and RFA in very early stage tumors, i.e., a single HCC of ≤2 cm in diameter. However, caution is required when interpreting and generalizing these results, particularly, in the light of studies that suggest a non-negligible rate of incomplete pathologic response after RFA. Western blot studies performed in the liver specimens of patients who underwent RFA as a bridge treatment to transplantation showed that a tumor size of >3 cm in diameter and the presence of large (≥3 mm) abutting vessels result in a 50% drop in the rate of complete tumor eradication. Is a standard RFA still the best technique for tumor ablation in 2014? Several novel thermal and non-thermal techniques for tumor ablation, including microwave ablation and irreversible electroporation, seem to offer potential advantages over RFA and are currently undergoing clinical investigation. Advances in ablation systems and devices are highly warranted. However, progress in image guidance and monitoring is also a key to success. To be able to compete with surgical resection, image-guided ablation needs to offer a more accurate prediction of the procedure outcome in each patient. The variability in outcomes needs to be minimized via a careful treatment planning. In addition, the outcome of the ablation procedure needs to be carefully documented by providing evidence that an “A0” treatment has been achieved.

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

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

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

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

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References

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

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

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

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

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

902.2

902.4

Renal denervation: SYMPLICITY HTN-3 evidence: overview

Renal denervation: beyond hypertension

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

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

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

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

References

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

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

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

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

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

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

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

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

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

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

Abstract Book 3. Benati A, Dalle Ore G, Da Pian R, Bricolo A, Maschio A, Perini S. Transfemoral selective embolisation in the treatment of some cranial and vertebro-spinal vascular malformations and tumours. Preliminary results. J Neurosurg Sci. 1974; 18(4): 233-8. 4. Truumees E, Dodwad S-N, Kazmierczak C D. Preoperative embolization in the treatment of spinal metastasis. J Am Acad Orthop Surg. 2010; 18 (8): 449-53. 5. Tralhão J G, Kayal S, Dagher I, Sanhueza M, Vons C, Franco D. Resection of hepatocellular carcinoma: the effect of surgical margin and blood transfusion on long-term survival. Analysis of 209 consecutive patients. Hepatogastroenterology. 2007; 54 (76): 1200-6. 6. Jacobs W B, Perrin R G. Evaluation and treatment of spinal metastases: an overview. Neurosurg Focus. 2001; 11(6): e10. 7. Owen RJT. Embolization of musculoskeletal tumors. Radiol Clin North Am. 2008; 46(3): 535-43. vi 8. Heary R F, Bono C M. Metastatic spinal tumors. Neurosurg Focus. 2001; 11(6): e1. 9. Prabhu V C, Bilsky M H, Jambhekar K et al. Results of preoperative embolization for metastatic spinal neoplasms. J Neurosurg. 2003; 98 (Suppl 2): 156-64. 10. Jones K, Meyers P, Gobin P, Liu A-H. Embolization of spinal tumors. In: Operative Techniques in Neurosurgery. New York, NY: Elsevier Science; 2003: 156-62. 11. Shi H, Jin Z, Suh D C, Lee H K, Li L. Preoperative transarterial embolization of hypervascular vertebral tumor with permanent particles. Chin Med J (Engl). 2002; 115(11): 1683-6. 12. Reuter M, Heller M, Heise U, Beese M. Transcatheter embolization of tumors of the muscular and skeletal systems. Rofo. 1992; 156 (2): 182-8. 13. Gellad F E, Sadato N, Numaguchi Y, Levine A M. Vascular metastatic lesions of the spine: preoperative embolization. Radiology. 1990; 176(3): 683-6. 14. Nair S, Gobin YP, Leng LZ, Marcus JD, Bilsky M, Laufer I, Patsalides A. Preoperative embolisation of hypervascular thoracic, lumbar, and sacral spinal column tumors: technique and outcomes from a single center. Interv Neuroradiol. 2013; 19(3): 377-85. 15. Kato S, Murakami H, Minami T, Demura S, Yoshioka K, Matsui O, Tsuchiya H. Preoperative embolisation significantly decreases intraoperative blood loss during palliative surgery for spinal metastasis. Orthopedics. 2012; 35(9): e1389-95. 16. Schmidt R, Rupp-Heim G, Dammann F, Ulrich C, Nothwang J. Surgical therapy of vertebral metastases. Are there predictive parameters for intraoperative excessive blood loss despite preoperative embolisation? Tumori. 2011; 97(1): 66-73. 17. White A P, Kwon B K, Lindskog D M, Friedlaender G E, Grauer J N. Metastatic disease of the spine. J Am Acad Orthop Surg. 2006; 14 (11): 587-98. 18. Manjila S1, Haroon N, Parker B, Xavier AR, Guthikonda M, Rengachary SS. Albert Wojciech Adamkiewicz (1850-1921): unsung hero behind the eponymic artery. Neurosurg Focus. 2009; 26(1): E2. 19. Basile A, Rand T, Lomoschitz F et al. Trisacryl gelatin microspheres versus polyvinyl alcohol particles in the preoperative embolization of bone neoplasms. Cardiovasc Intervent Radiol. 2004; 27(5): 495-502. 20. Hai Bin Shia, Dae Chul Suha, Ho Kyu Leea, Soo Mee Lima, Dae Hong Kima, Choong Gon Choia, Choon Sung Leea, Seung Chul Rhima. Preoperative transarterial embolisation of spinal tumor: embolisation techniques and results. AJNR Am J Neuroradiol. 1999; 20: 2009-15. 21. Sun S, Lang E V. Bone metastases from renal cell carcinoma: preoperative embolization. J Vasc Interv Radiol. 1998; 9(2): 263-9. 22. Schirmer C M, Malek A M, Kwan E S, Hoit D A, Weller S J. Preoperative embolization of hypervascular spinal metastases using percutaneous direct injection with n-butyl cyanoacrylate: technical case report. Neurosurgery. 2006; 59: E431-432 author reply E431-432.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Fundamental Course Basic principles of intermediate-advanced HCC management

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Prostatic artery embolization (PAE) has emerged as an alternative to surgical treatments for benign prostatic hyperplasia (BPH). Patient selection and refined technique are essential for good results. BPH can be treated safely by PAE with low rates of side effects, and thereby reducing prostate volume with clinical improvement in lower urinary tract symptoms (LUTS) and quality of life (QoL) without urinary incontinence, ejaculatory disorders, or erectile dysfunction. A multidisciplinary approach is essential for understanding the disease, to select a good candidate, and to achieve better results. Patient Selection A multidisciplinary team of interventional radiologists, diagnostic radiologists, and urologists should be involved in patient selection and follow-up. Any patient who has LUTS [International Prostate Symptom Score (IPSS) over 7] and is refractory to or intolerant to selective alpha-blockers or/and 5 alpha-reductase can be a candidate for PAE. The prostate size for PAE should be >30 grams. Patients with prostate size ranging from 30 to 90 grams are candidates for transurethral resection of the prostate or laser treatment. Open surgery is usually performed for patients with >90 grams. IPSS (evaluated as mild, moderate, and severe) and the International Index of Erectile Function (IIEF; evaluated as severe, moderate, mild-to-moderate, mild, and no dysfunction) are used as assessment tools by our medical team. Patients with malignancy and any other cause of voiding dysfunction are excluded. To assess a baseline QoL index, patients complete a questionnaire that includes the question, “If you were to spend the rest of your life with your urinary condition just the way it is now, how would you feel about that?” The answers range from terrible, unhappy, mostly dissatisfied, mixed, mostly satisfied, pleased, and delighted. Before intervention, the urologist orders digital rectal examination (DRE), prostate specific antigen (PSA), and prostate biopsy, if concern is indicated. Prostate biopsy is an urologist personal decision. As a general recommendation, the following patients should undergo prostate biopsy with a minimum of 12 cores and have a negative histopathology report prior to treatment by PAE: a) patients with DRE findings suspicious for prostate cancer, b) patients with baseline PSA levels of >10 ng/mL, and c) patients with baseline PSA levels of >2.5 ng/mL and <10 ng/mL and free PSA of <25% of total PSA. Patients with cystoscopy findings suspicious for bladder cancer must undergo biopsy and have a negative histopathology. Multiparametric magnetic resonance of the prostate may help in selected cases. If prostate biopsy is performed, patients must wait for 30 days to undergo PAE. General contraindications for PAE are bladder atonia, neurogenic bladder disorder or other neurological disorder that is impacting bladder function (e.g., multiple sclerosis), urethral stricture, bladder neck contracture, sphincter abnormalities, urinary obstruction due to causes other than BPH, large bladder diverticula or stones, chronic renal failure or other potentially confounding bladder or urethral disease or condition. We indicate urodynamic testing in every patient before PAE. It is one of the most important methods to identify good candidates and achieve better results. It is performed safely by experienced personnel, but there is a risk of urinary infection. Active urinary tract infection is a contraindication for PAE. Patients do not routinely receive continuous antibiotic due to AUR, but if they have been medicated, we maintain the treatment. Patients with acute urinary retention (AUR) and indwelling catheters are instructed to exchange urinary catheters every month in order to reduce the risk of urinary tract infection. In patients with AUR, the catheter is removed and urodynamic studies are attempted to establish a baseline. Investigations follow the urodynamic practice standards of the International Continence Society. Intravesical obstruction is defined as a bladder outlet obstruction index (BOOI) of >40. The calculation to determine BOOI uses the detrusor muscle pressure (Pdet) at maximum urinary flow rate (Qmax) and is represented by the equation BOOI = Pdet @ Qmax − 2 Qmax.

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Urodynamic evaluation, transrectal or suprapubic ultrasound (US), and magnetic resonance imaging (MRI) baselines are established for each patient. Although urodynamic testing is an invasive procedure, it is very important for patient selection. Some patients have infravesical obstruction due to enlarged prostates in association with bladder disorders and detrusor muscle hypocontractility. These patients are not good candidates for PAE. Imaging Protocol US prostate volume is measured by standard transabdominal view or transrectal approaches if prostate biopsy is necessary. Prostate vascularization can be visualized using Doppler and transabdominal ultrasound measures post-void residual urine volume and bladder and prostate volume. Bladder evaluation comprises the measurement of wall thickness and its characteristics such as the presence of diverticula, trabeculations, and other possible findings such as polyps, calculus, or other lesions. The protrusion of the median lobe is measured using the Prostate Protrusion Index (IPP) and prostate volume is measured using three incidences. For transrectal ultrasound, the patient is positioned in the left lateral position ensuring that the knees are bent up towards the chest. We do not use lithotomy position, but it is an option. MRI of the prostate pre- and post-PAE can be performed either on 1.5 or 3.0 Tesla magnet, using a phased array coil. An endorectal coil is not necessary. Main sequences are a T2-weighted turbo/fast spin echo sequence (TSE, FSE, FRFSE), and a dynamic pre- and post-contrast T1-weighted volumetric interpolated sequences (LAVA, VIBE, THRIVE). No breath-hold is required. Parallel imaging (ASSET, I-PAT, SENSE) can be used to reduce sequence time. We suggest a slice thickness of 4 mm for 1.5 Tesla or 3 mm for 3.0 Tesla. For the dynamic T1 sequence, we recommend a pre-contrast and 15–20 sequential post-contrast phases (with no temporal gap) for 15–25 seconds in each phase, and contrast medium injection should start together with the first sequence acquisition. Total sequence time can range between 4 and 6 minutes. A gadolinium-based contrast medium must be infused using a power injector at a dose of 0.1 mL/kg (or 0.2 mL/kg) followed by 20 mL of saline flush. Prostate measurements (cephalocaudal, transverse, and anteroposterior) were obtained and volume was calculated by the ellipse formula. Computed tomography with contrast can be useful in identifying the characteristics of the main artery supplying the prostate and any arterial atherosclerotic lesion or obstruction that could contraindicate or make the intervention more difficult. We have not used it, because some anatomical information can be achieved with MRI and mainly because we advocate the need to study and/or catheterize any suspect artery with potential for feeding the prostate. We also need to be concerned about the use of the additional dose of contrast medium in this group of elderly patients relative to the benefit. All this information can be achieved performing a pelvic arteriogram during the day of the procedure. PAE is not a painful procedure, and patients typically receive oral hydration, non-opioid pain relievers, antibiotic, and nonsteroidal anti-inflammatory drugs, if needed. Proton pump inhibitor for gastric and duodenal protection is indicated. Dysuria and frequent urination are the most common symptoms immediately after PAE and usually last for 3–5 days. Patients with dysuria after embolization are afraid of AUR, and we have instructed them to take alpha-blockers for one week after PAE. After this period, with consultation and medical examination, they discontinue taking alpha-blockers. Patients keep in touch during the first week and return for consultation 1–3 months after the procedure. Technical and Clinical Success and Complications We consider it as a technical success when the main bilateral prostatic arteries are embolized. The aim of PAE is to produce as much gland ischemia as possible, because we have observed that better long-term clinical and urodynamic results are correlated with prostate ischemia.

Abstract Book Clinical success is defined by multiple criteria: removal of the Foley catheter in patients with AUR, LUTS symptom improvement according to IPSS and QoL, and no sexual disorders or serious adverse events from the treatment. We have observed a significant QoL improvement after PAE as reported by the patient questionnaire, and an objective urodynamic data corroborate these self-reported assessments. In a subgroup of 108 patients with a mean follow-up of 15 months (range, 3 months–5.4 years), we have observed that the age of patients ranged from 46 to 78 years (mean, 64 years). Prostate volume ranged from 30 to 252 cm3 (mean, 90 cm3; SD ± 45). One hundred and eleven PAE were performed in 108 patients. The embolization of at least one prostatic artery was achieved in 110/111 (99.1%) procedures and 107/108 (99.1%) patients. Technical success (bilateral PAE) was achieved in 104/111 (93.7%) procedures and unilateral PAE in 6/111 (5.4%). Immediate clinical success was obtained in 96.3% (104/108) patients. During a mean 15-month follow-up, it was observed that symptoms improved from 19.6 (severe) to 7.6 (mild) according to the mean IPSS score (p = 0.000); QoL improved from unhappy/dissatisfied (QoL 4.8) to pleased/satisfied (QoL 1.6; p = 0.000). Mean PSA value increased 25 times in 24 h after PAE and reduced to 50% of baseline during follow-up (reduced from 5.8 ng/mL to 3.2 ng/mL; p = 0.001), peak urinary flow increased by 2 times (mean Qmax increased from 6.1 mL/s to 13.8 mL/s; p = 0.000), and mean prostate volume reduction was 30% by MR (range, 90 cm3 –62.4 cm3 ; p = 0.001). Most complications were classified as minor: a minimal amount of blood/ mucus mixture in the stool (9%); reduction of the ejaculation volume (9%); transient hematuria (6.3%); urinary tract infection (5.4%); transient hematospermia (4.5%); and transient ischemia of the bladder (0.9%), seminal vesicle (0.9%), and rectum (0.9%). One patient (0.9%) had an urinary tract infection after urodynamic testing that required prolonged hospitalization for intravenous antibiotic therapy (severe complication). Symptoms recurrence (IPSS > 8) was observed in 14/104 (13.5%) patients in a mean duration of 14.7-month (range, 3–36 months) follow-up. Recurrence (12/14 patients; 85.7%) were related to prostate volume of <80 cm3 (mean, 57.8 cm3; p = 0.003) and with patients (9/14; 64.3%) who had PSA in 24 h after PAE inferior to 100 ng/mL (mean, 86.6 ng/mL; p = 0.044). Adverse events were evaluated for severity using the NCI CTCAE (Common Toxicity Criteria for Adverse Events) according to the National Institutes of Health (version 4.0; edition 5.28.2009). Final Comments Prostatic artery embolization has emerged as an alternative to surgical treatments for BPH. Patient selection and refined technique are essential for good results. BPH can be treated safely by PAE with a low rate of side effects and can reduce prostate volume by an average of >30%. Overall clinical improvement in LUTS assessed by IPSS, QoL, and urodynamic data is achieved without urinary incontinence, ejaculatory disorders, or erectile dysfunction. Nevertheless, a multidisciplinary approach with urologists, diagnostic radiologists, and interventional radiologists is essential. References 1. AUA Practice Guidelines Committee. AUA guideline on management of benign prostatic hyperplasia. I. Diagnosis and treatment recommendations. J Urol 2003; 170:530-547. 2. Carnevale FC, Antunes AA, da Motta Leal Filho JM et al. Prostatic artery embolization as a primary treatment for benign prostatic hyperplasia: preliminar results in two patients. Cardiovasc Intervent Radiol 2010; 33:355-361. 3. Schafer W, Abrams P, Liao LM, et al. Good urodynamic practices: uroflowmetry, filling cystometry, and pressureflow studies. Neurourol Urodyn 2002; 21:261-74. 4. Carnevale FC, da Motta-Leal-Filho JM, Antunes AA et al. Quality of life and clinical symptoms improvement support prostatic artery embolization for patients with acute urinary retention due to benign prostatic hyperplasia. J Vasc Interv Radiol 2013; 24(4):535-42.

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

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

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

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The inferior vesical artery is the main branch supplying the prostate gland. It usually arises as the second or third branch of the anterior trunk of the internal iliac artery. Generally, one main prostatic artery is found on each side. Moreover, in some patients, the main prostatic artery and any additional prostatic branches arise from the superior vesical, internal pudendal, obturator, or middle rectal arteries. The inferior vesical artery can be catheterized from the same ipsilateral oblique perspective using the microcatheter under the vascular roadmap, and DSA is performed with the manual injection of 2–3 mL contrast medium in the oblique and posterior–anterior views. The arteriograms in these projections are very important to identify the prostatic branches, thus avoiding non-target embolization, collaterals, and shunts. After reviewing both projections, the catheter is advanced into IVA at the ostium of the prostatic arteries, and flow-directed embolization is performed. The use of small diameter hydrophilic microcatheters is mandatory in the catheterization of the prostatic arteries due to the small calibre of the vessel and their tendency to spasm. We use microcatheters of <2.4 Fr with an inner diameter of 0.028 inches and 0.014 inch hydrophilic microwires. When vasospasm occurs, nitroglycerin can be used, but it has a limited utility due to severe atherosclerosis in these arteries. As embolic agents, we prefer using calibrated 300–500 μm particles. To each 2 mL syringe of microspheres, we add 10 mL iodinated contrast medium and 10 mL saline to get a high dilution, thereby avoiding early proximal occlusion. We use a 1 cc Luer-lock syringe for embolization. If continued, a forward flow is observed when more embolic agents are injected. At the end of the embolization, a venous phase and blush can be observed, and total stasis is considered as the end point. After a good end point has been achieved, the microcatheter should be pulled back to the origin of IVA; final control DSA is obtained with a manual injection of contrast medium, and additional prostatic branches are searched for. If any accessory prostatic branch is not embolized, poor long-term clinical results may occur, including reduced prostate shrinkage and recurrence of LUTS symptoms. Embolization is performed on the contralateral side using the same technique. A more time-consuming procedure is the identification of the branches of the anterior internal iliac artery and the relationship of these vessels with the prostate. As described above, the Foley balloon is the most important landmark for that aim, considering prostatic vessels that are situated immediately below the balloon and anterior in the oblique view. Posterior branches below the balloon correspond to rectal arteries, and its embolization must be avoided using proximal coils if necessary. Other measures to reduce procedure time are using a good fluoroscopy, collimation, and imaging amplification during intervention to obtain a good image of the small prostatic vessels. We are aware that some of these measures can significantly increase patient irradiation per unit time, but we do believe that globally, as we reduce the exposure time, the total doses for patient and operator are lower. After the procedure, patients remain 6–8 h without moving the puncture leg to avoid bleeding complications from disrupting the vascular site. We do not remove the Foley balloon in the initial 24 h after procedure to facilitate bladder void without straining, which reduces the risk of puncture site complications. The Foley catheter is removed after 24 h in patients without AUR. Patients with AUR and chronic use of indwelling catheter are instructed to return in 15 days for the removal of the indwelling catheter to attempt spontaneous voiding. If the catheter cannot be removed, another attempt is made every week. We consider a clinical failure if the patients cannot urinate spontaneously after 2 months, and another intervention is programmed to review the possible non-embolized prostatic collaterals. Patients receive intravenous hydration 12 h after the procedure, proton pump inhibitor for gastric and duodenal protection, and nonopioid pain relievers, if necessary. We have noticed that embolization of the prostate is much less painful than embolization in other territories; therefore, analgesics are infrequently necessary.

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In conclusion, PAE is an affordable but challenging alternative treatment in BPH that requires refined technique and a well-trained interventional team for successful and safe results.

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References

H. Henkes Ärztl. Leiter des Radiolog. Zentrums & Ärztl. Dir. der Klinik für Neuroradiologie, Katharinenhospital - Klinikum Stuttgart, Stuttgart, Germany

1. Carnevale FC, Antunes AA. Prostatic artery embolization for enlarged prostates due to benign prostatic hyperplasia. How I do it. Cardiovasc Intervent Radiol. 2013 Dec;36(6):1452-63. 2. Antunes AA, Carnevale FC, da Motta Leal Filho JM, Yoshinaga EM, Cerri LM, Baroni RH, Marcelino AS, Cerri GG, Srougi M. Clinical, laboratorial, and urodynamic findings of prostatic artery embolization for the treatment of urinary retention related to benign prostatic hyperplasia. A prospective single-center pilot study. Cardiovasc Intervent Radiol. 2013 Aug;36(4):978-86. 3. Carnevale FC, da Motta-Leal-Filho JM, Antunes AA, Baroni RH, Marcelino AS, Cerri LM, Yoshinaga EM, Cerri GG, Srougi M. Quality of life and clinical symptom improvement support prostatic artery embolization for patients with acute urinary retention caused by benign prostatic hyperplasia. J Vasc Interv Radiol. 2013 Apr;24(4):535-42. 4. Carnevale FC, da Motta-Leal-Filho JM, Antunes AA, Baroni RH, Freire GC, Cerri LM, Marcelino AS, Cerri GG, Srougi M. Midterm follow-up after prostate embolization in two patients with benign prostatic hyperplasia. Cardiovasc Intervent Radiol. 2011 Dec;34(6):1330-3. 5. Carnevale FC, Antunes AA, da Motta Leal Filho JM, de Oliveira Cerri LM, Baroni RH, Marcelino AS, Freire GC, Moreira AM, Srougi M, Cerri GG. Prostatic artery embolization as a primary treatment for benign prostatic hyperplasia: preliminary results in two patients. Cardiovasc Intervent Radiol. 2010 Apr;33(2):355-61.

1004.4 Prostate artery embolisation: difficult arterial anatomy J. Golzarian Department of Interventional Radiology & Vascular Imaging, University of Minnesota, Minneapolis, MN, United States of America Learning Objectives 1. To learn the basic arterial anatomy and pre-procedural imaging 2. To describe the use of imaging techniques during the procedure including dyna CT 3. To learn how to overcome anatomical difficulties No abstract available.

Special Session Chronic ischaemia of the brain: revascularisation 1005.1 Carotid stenting today: standard practice or increasingly infrequent? P. Brennan Department of Neuroradiology, Beaumont Hospital Dublin, Dublin, Ireland Learning Objectives 1. To learn the current status of trial evidence of stenting vs. endarterectomy 2. To understand the practical impact of previous trials in carotid stenting 3. To learn how carotid stenting could be a standard practice again No abstract available.

Intracranial stenting after the SAMMPRIS study: dead or alive?

Learning Objectives 1. To learn the SAMMPRIS trial results 2. To understand the weak points of the trial design 3. To understand the practical impact of the trial on our daily decision-making process on IC stenting No abstract available.

1005.3 How to avoid peri-interventional stroke, haemorrhage and hyperperfusion G. Schroth Abteilung Neuroradiologie, Inselspital, Universitätsspital Bern, Bern, Switzerland Learning Objectives 1. To learn about the complications of revascularisation techniques 2. To learn how to avoid these complications 3. To learn how to manage these complications To avoid complications in the endovascular treatment of chronic brain ischaemia a clear concept and strategy is required, which should be developed by a close collaboration between neuroradiologists, neurologists and vascular neurosurgeons. Treatment decisions should be taken in the setting of an experienced neurovascular centre, including a neurovascular outpatient clinic. The multiprofessional team should include experts in cardiology and anticoagulation. An expert in carotid ultrasonology as well as state of the art equipments for conventional and transcranial Doppler sonography should be available. Advanced neuroimaging including CT/MR angiography and perfusion are essential. Neurosurgeons and vascular surgeons with experience in extra-intracranial bypass surgery must be included in the rational decision making. The presence of these surgical expertise, at least on call, is also required in case of a complication if a ventricular drainage, surgery for haematoma or hemicraniectomy is needed. Indication for recanalisation In intracranial stenosis, the main indications are symptoms despite best medical treatment. Till date, the indication for elective treatment of carotid stenosis is mainly protection against ischaemic stroke. An improvement of cognitive impairment by normalisation of the cerebral blood flow (CBF), even in ‘asymptomatic patients’ is currently under investigation as another possible indication to treat haemodynamically relevant carotid stenosis. Pre-interventional clinical checkup should focus on general (e.g. smoking, hypertension, diabetes, coagulopathy) and focal (e.g. vasculitis, fibromuscular dysplasia) risk factors for complications. The age of the patient and expectancy of life must be balanced with the risk of the procedure. Premedication normally double aggregation with aspirin and clopidogrel at least three days before the intervention or as a loading dose must be applied, including the monitoring of resistance against antiplatelet therapy, which is present in 6%–27% for aspirin and even more for clopidogrel (low responders up to 48%). Advanced neuroimaging CTA and/or MRA including a cross section anatomical visualisation of supra-aortic vessels from the aortic arch up to distal intracranial branches should be available when treatment options are discussed. A knowledge of anomalies or severe stenosing-arteriosclerotic changes of the proximal vessels

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in front of the stenosis to be treated may lead to the decision of a surgical instead of an endovascular approach. Randomisation of the patients in recent studies comparing carotid endarterectomy and stenting has been performed, unfortunately, without cross sectional anatomy of the supra-aortic vessels by CTA or MRA (SPACE I, II, EVA3S, ICSS). The length, size and configuration of the stent can be selected based on this information in advance. Imaging of plaque morphology may be helpful in selecting techniques and instruments for the endovascular treatment. An unstable, vulnerable plaque may indicate stenting with a proximal protection device, which enables the passage of stenosis and the plaque in flow arrest from the very beginning of the procedure, whereas stents with a wider stent mesh design without any protection device may be used in stable plaques. Lesions with DWI restriction of the hemisphere ipsilateral to the stenosis indicate ongoing thromboembolic events due to an unstable plaque and are combined with a higher risk of stenting. In this case, carotid endarterectomy may be preferred or stenting have to be performed with a proximal protection device in flow arrest with a subsequent aspiration of plaque material. In contrast, susceptibility weighted imaging lesions in the brain may indicate microbleeds with a subsequent higher risk of bleeding complication after recanalisation. Measurement of brain perfusion and reserve capacity may be helpful in predicting the risk of stroke for an individual case and situation. A measurement of the reserve capacity or selective arterial spin labelling MR techniques can predict if endovascular (MOMA; Parodi System) or surgical cross clamping of the internal carotid artery during CEA or CAS will be tolerated. Optimised digital subtraction angiography biplane equipment, with a capability to construct roadmap and 3D rotation angiography, is state-of-the-art for intracranial interventional procedure and is helpful for the endovascular treatment of flow restrictions at the origin of brachiocephalic trunk, subclavian, vertebral and carotid arteries. Stent artefacts can be reduced by flat detector cone-beam technology and dedicated software for the suppression of metallic artefacts. PTA balloons and stents including drug-eluted stents and balloons adapted to the special situation can be selected in advance, based on the information of the cross-sectional images as well as the optimal technique. The predilation of a carotid stenosis with or without protection depends on the degree and configuration of the stenosis. In intracranial stenosis, aggressive medical treatment or PTA without stenting may be an option and in complex stenosis, if the endovascular access is difficult. We have also to keep in mind, that the SAMMPRIS trial with its complication rate of 14.7% is restricted to the complex Wingspan stent and Gateway balloon system. Using this technique, multiple steps, each with a dedicated risk have to be performed: • Microcatheter advanced through the stenosis • Exchange of the microwire to a 3-m long exchange wire • Removal of the microwire over the 3-m exchange wire • Introduction of Gateway balloon over the 3-m exchange wire • Inflation of the Gateway balloon with the risk of wire perforation and dissection, which may be clinically silent until blood pressure increases • Removal of the Gateway balloon over the exchange wire • Insertion of the stent over the 3-m exchange wire • Passage of the relatively big stent system through the stenosis, immediately after balloon dilatation • Unsheathing of the relatively long, self-expanding Wingspan stent These multiple steps are time-consuming; the exchange manoeuvre is complex, and in contrast to a balloon-mounted stent, plaque material detached by unprotected predilatation can embolise in distal branches following deflation of the balloon and/or subsequent passage of the stent system. In addition, the length of the selfexpanding Wingspan stent is relatively long, which may cover and occlude collaterals before and distal from the stenosis. This may be

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one of the reasons for the high rate of perforator strokes in basilar artery stenosis in the SAMMPRIS trail. Moreover, the radial force of the self-expanding Wingspan stent may be one of the reasons for the high rate of restenosis in Wingspan trials. In contrast to the Gateway–Wingspan system, the treatment of intracranial stenosis based on balloon-mounted stents allows a precise placement of a relatively short stent in one step. Thereby, plaque material is directly fixed to the vessel wall by the stent and not exposed to the bloodstream after deflation of the balloon. Recent developments in the design and flexibility of balloonmounted stents and the stent catheters in combination with distal access catheter technology allow a rapid and precise stent protected recanalisation of intracranial stenosis, if indicated. The use of drug-eluted stents and/or drug-eluted balloons, especially in cases of restenosis may be another step forward to avoid complications and to decrease the risk of stroke and the rate of restenosis. The monitoring of the patient after the intervention e.g. at a neurointensive or stroke unit including a precise monitoring and management of the blood pressure is the last step to avoid complication. This also includes the control of the effect of the intervention including measurement of flow, vessel wall imaging and detection of iatrogenic embolic events e.g. by performing DWI as quality control after the intervention, which may help to learn from mistakes and to improve the material and techniques. References 1. Bakker FC, Klijn CJ, Jennekens-Schinkel A, Kappelle LJ. Cognitive disorders in patients with occlusive disease of the carotid artery: a systematic review of the literature. J Neurol. 2000;247:669-676. 2. Bokkers RP, van Osch MJ, Klijn CJ, Kappelle LJ, Hendrikse J. Cerebrovascular reactivity within perfusion territories in patients with an internal carotid artery occlusion. J Neurol Neurosurg Psychiatry. 2011;82(9):1011-1016. 3. Bokkers RP, van Osch MJ, van der Worp HB, de Borst GJ, Mali WP, Hendrikse J. Symptomatic carotid artery stenosis: impairment of cerebral autoregulation measured at the brain tissue level with arterial spin-labeling MR imaging. Radiology. 2010;256(1):201-208. 4. Brinjikji W1, Kallmes DF, Lanzino G, Cloft HJ. Carotid revascularization treatment is shifting to low volume centers. J Neurointerv Surg. 2014 Apr 8. doi: 10.1136/neurintsurg-2014-011180. [Epub ahead of print]. 5. Chimowitz MI, Lynn MJ, Derdeyn CP, et al. Stenting versus aggressive medical therapy for intracranial arterial stenosis. N Engl J Med. 2011;365(11):993-1003. 6. Everts R, Wapp M, Burren, Kellner-Weldon, El-Koussy, Jan, Michel, Schroth. Cognitive functions and emotional state in patients with carotid artery stenosis. Swiss Med Weekly., in press. 7. El-Koussy M, Schroth G, Do DD, Gralla J, Nedeltchev K, von Bredow F, Remonda L, Brekenfeld C. Periprocedural embolic events related to carotid artery stenting detected by diffusionweighted MRI: comparison between proximal and distal embolus protection devices. J Endovasc Ther. 2007;14(3):293-303. 8. Grunwald IQ, Papanagiotou P, Reith W, Backens M, Supprian T, Politi M, Vedder V, Zercher K, Muscalla B, Haass A, Krick CM. Influence of carotid artery stenting on cognitive function. Neuroradiology. 2010;52:61-66. 9. Kastrup A, Groschel K, Schnaudigel S, Nagele T, Schmidt F, Ernemann U. Target lesion ulceration and arch calcification are associated with increased incidence of carotid stentingassociated ischemic lesions in octogenarians. J Vasc Surg. 2008;47(1):88-95. 10. Miao Z, Song L, Liebeskind DS, Liu L, Ma N, Wang Y, Mo D, Gao F, Zhao X, Dong K, Zhang D, Gao P. Outcomes of tailored angioplasty and/or stenting for symptomatic intracranial atherosclerosis: a prospective cohort study after SAMMPRIS. J Neurointerv Surg. 2014 Apr 23. doi: 10.1136/neurintsurg-2014-011109. [Epub ahead of print].

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11. Mono ML, Karameshev A, Slotboom J, Remonda L, Galimanis A, Jung S, Findling O, De Marchis GM, Luedi R, Kiefer C, Stuker C, Mattle HP, Schroth G, Arnold M, Nedeltchev K, El-Koussy M. Plaque characteristics of asymptomatic carotid stenosis and risk of stroke. Cerebrovasc Dis. 2012;34:343-350. 12. Prabhakaran S, Wells KR, Lee VH, Flaherty CA, Lopes DK. Prevalence and risk factors for aspirin and clopidogrel resistance in cerebrovascular stenting. AJNR Am J Neuroradiol. 2008;29(2):281-285. 13. Vajda Z, Aguilar M, Göhringer T, Horváth-Rizea D, Bäzner H, Henkes H. Treatment of intracranial atherosclerotic disease with a balloon-expandable paclitaxel eluting stent: procedural safety, efficacy and mid-term patency. Clin Neuroradiol. 2012;22:227-233. 14. Vajda Z, Güthe T, Perez MA, Heuschmid A, Schmid E, Bäzner H, Henkes H. Neurovascular in-stent stenoses: treatment with conventional and drug-eluting balloons. Am J Neuroradiol. 2011;32:1942-1947.

1005.4 Management of hyperperfusion syndrome E.M. Arsava Department of Neurology, Hacettepe University, Faculty of Medicine, Ankara, Turkey

Abstract Book Doppler monitoring during the pre and postoperative period may be helpful in identifying high-risk patients and diagnosing the development of CHS in a timely manner. Although large-scale head-to-head comparisons of endarterectomy and stenting do not suggest a significant variability in the prevalence of CHS with either treatment modality, there are certain differences in terms of clinical presentations. As dual antiplatelet therapy is a standard of care in patients undergoing carotid angioplasty stenting, CHS in this setting has the potential for a more malignant course in comparison to patients undergoing endarterectomy where antiplatelets are used less frequently and therefore, are more stable in terms of hemostasis. In addition, symptoms occur more acutely (generally within 36 hours) in patients undergoing stenting, while symptoms of endarterectomy-related CHS generally manifest after 3–7 days following the procedure. A tight control of blood pressure in the postoperative period is of utmost importance in the prevention and treatment of CHS. Alpha-2 adrenergic agonists and beta-blockers are generally the first-line drugs of choice due to their minimal vasodilatatory effects on the cerebral vasculature. The treatment plan should also include the treatment of other potential complications that may develop during the course of CHS like cerebral edema, hemorrhage, or seizures. References

Learning Objectives 1. To understand the physiopathologic background of hyperperfusion syndrome 2. To learn in which patients or clinical settings we can expect to have this problem 3. To learn how to manage hyperperfusion syndrome Cerebral hyperperfusion syndrome (CHS), albeit relatively uncommon, is a potentially life-threatening complication of carotid revascularization therapies i.e., carotid endarterectomy and carotid angioplasty with stenting. The major pathophysiology that underlies CHS is the failure of the normal cerebrovascular autoregulatory response. Under physiological conditions, cerebral arteries respond to decreases in cerebral blood flow by vasodilatation and to increases in cerebral blood flow by vasoconstriction, thereby keeping cerebral perfusion at a steady state level. Concordantly, in patients with severe carotid artery stenosis, the compromised cerebral blood flow due to proximal stenosis is compensated by vasodilatation within the distal cerebral vasculature as part of the autoregulatory response. Following revascularization, either by endarterectomy or stenting, the normal expected reaction is the reversal of vasodilatation and normalization of cerebral blood vessel diameters, which generally occurs within several hours after the procedure. Failure in this normalization for any reason will result in ongoing hyperemia within the territory distal to the artery undergoing revascularization, thereby leading to disruption in blood brain barrier integrity, vasogenic edema, hemorrhage, and elevation of intracranial pressure. Despite variable reports in the literature, CHS is considered to occur in 0%–3% patients undergoing carotid revascularization. In these patients, cerebral blood flow increases to 100%–200% over baseline, reaches a maximum over 3 to 4 days and returns to baseline only after 1–2 weeks after the procedure. The clinical manifestations depend on the severity of the hyperemic response and range from headache, vomiting, confusion, seizures, and focal neurologic deficits to intracerebral hemorrhage and coma in its most severe form. The identification of patients who are potentially under the risk of developing CHS is the most critical step in the prevention and management of this entity. A prior history of hypertension and diabetes mellitus, old age, high-grade carotid artery stenosis, poor collateral circulation, contralateral carotid artery occlusion, diminished preoperative cerebrovascular reactivity, and postoperative systemic hypertension are considered among the most important predisposing factors for CHS. The use of perfusion imaging and transcranial

1. van Mook WN, Rennenberg RJ, Schurink GW, van Oostenbrugge RJ, Mess WH, Hofman PA, de Leeuw PW. Cerebral hyperperfusion syndrome. Lancet Neurol. 2005 Dec;4(12):877-88. 2. Moulakakis KG, Mylonas SN, Sfyroeras GS, Andrikopoulos V.Hyperperfusion syndrome after carotid revascularization. J Vasc Surg. 2009 Apr;49(4):1060-8. 3. Ogasawara K, Sakai N, Kuroiwa T, Hosoda K, Iihara K, Toyoda K, Sakai C, Nagata I, Ogawa A; Japanese Society for Treatment at Neck in Cerebrovascular Disease Study Group. Intracranial hemorrhage associated with cerebral hyperperfusion syndrome following carotid endarterectomy and carotid artery stenting: retrospective review of 4494 patients. J Neurosurg. 2007 Dec;107(6):1130-6.

Honorary Lecture Andreas Gruentzig Lecture 1301.1 Standard clinical guidelines for interventional oncology: where are we at present? P.L. Pereira Dept of Radiology, Minimally Invasive Therapies and Nuclearmedicine, SLK-Clinics GmbH, Ruprecht-Karls-University Heidelberg, Heilbronn, Germany Medicine undergoes a constant development process, making guidelines and standard operative procedures an important tool for the medical community. This is especially true in oncology, a discipline in which multidisciplinarity and combined therapies are essential for better outcomes. Principles of guidelines are based on current scientific knowledge with participants coming from different medical societies and on the consensus of medical experts, also called good clinical practice. Furthermore, high-quality guidelines are necessary not only for a structured knowledge transfer but also to find their place in the structures of the health system, being more and more a reference for discussions with reimbursement institutes and insurances. At the very least, evidence-based guidelines serve as a basis for creating and updating disease management programs and for defining quality indicators that will be used for the certification process of comprehensive cancer centers. If one refers to the number of papers and conferences focused on

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interventional radiology, one is forced to admit that the interventional oncology is taking a large place in interventional radiology. Over the last 30 years, interventional oncology has developed palliative monotherapies such as transarterial chemoembolization and radioembolization for hepatic tumors; moreover, it could also obtain curative issues for selected patients with renal, hepatic, or pulmonary cancers. Nevertheless, it must be noted that apart from hepatocellular carcinoma, international recommendations do not seem to recognize the value of interventional oncology. The reasons are probably multiple. The expertise for these treatments or at least the number of experts is still limited. Few hospitals under 600 beds have a radiology department that can offer the entire spectrum of interventional radiology. An interventional oncologist must be present as a therapist at the same level as the other specialists; therefore, it is necessary to have consultations as well as to perform the follow-up of oncological patients. A second potential reason is the relatively low level of evidence of clinical studies in interventional oncology. Our studies are often feasibility or observational studies, sometimes comparative and often retrospective with levels of evidence that remain lower than those usually encountered in oncology. Additionally, in some countries, a certain level of competition between medical disciplines restricts the establishment of interventional treatments in standard algorithms. Finally, performing large clinical studies remains challenging without support, e.g., of large pharmaceutical companies. This lecture is a critical review on international guidelines in oncology in relation to the evidence of effectiveness in interventional oncology.

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2. Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Prognostic role of echocardiography among patients with acute pulmonary embolism and a systolic arterial pressure of 90 mm Hg or higher. Arch Intern Med. 2005;165:1777-1781. 3. Kuo WT, Gould MK, Louie JD, Rosenberg JK, Sze DY, Hofmann LV. Catheter-directed therapy for the treatment of massive pulmonary embolism: Systematic review and meta-analysis of modern techniques. J Vasc Interv Radiol. 2009;20:1431-1440. 4. Jaff MR, McMurtry MS, Archer SL, Cushman M, Goldenberg N, Goldhaber SZ, Jenkins JS, Kline JA, Michaels AD, Thistlethwaite P, Vedantham S, White RJ, Zierler BK. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: A scientific statement from the american heart association. Circulation. 2011;123:1788-1830.

1302.2 Aggressive treatment of deep vein thrombosis: what the trials have taught us S. Kee Interventional Radiology, UCLA Medical Center, Los Angeles, CA, United States of America No abstract available.

1302.3 Catheter-directed thrombolysis for DVT: tips, tricks and pitfalls

Hot Topic Symposium Treatment of DVT and PE: paradigm shift? 1302.1 Emerging therapies for pulmonary embolism N. Kucher Universitätsklinik für Angiologie, Inselspital, Schweizer Herz- und Gefässzentrum Bern, Bern, Switzerland Acute pulmonary embolism (PE) is a potentially fatal clinical condition spanning a broad spectrum of clinical outcomes. Low-risk patients with stable hemodynamic presentation, normal cardiac biomarkers, and normal right ventricular function have an excellent short-term prognosis with mortality rates of less than 1% once therapeutic levels of anticoagulation therapy are established. Intermediate-risk patients with stable hemodynamic presentation but increased cardiac biomarkers plus imaging evidence of right ventricular dysfunction have early mortality rates of approximately 6% due to progressing right ventricular failure. For these patients, the role of early revascularization, including systemic thrombolysis, catheter-directed treatment, or surgical embolectomy, is debatable and will be discussed during the presentation. High-risk PE is defined as PE with hemodynamic instability and is associated with early mortality rates of greater than 15%. These patients are candidates for rapid revascularization to avoid progression to irreversible cardiogenic shock and death. The focus of the presentation will be to discuss the data on various options for catheter-directed treatment, including catheter-directed thrombolysis, pharmacomechanical thrombolysis, and mechanical thrombus removal, without adjunctive thrombolytics. References 1. Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: Clinical outcomes in the international cooperative pulmonary embolism registry. Lancet. 1999;353:1386-1389.

K.R. Thomson Radiology, Alfred Hospital, Melbourne, VIC, Australia Tip #1. Select those patients for thrombolysis who are most likely to have a good result. When thrombosis has been present for 6 weeks and is now bad enough to cause the haematologist to seek help, it is not thrombolysis you will be offering but a recanalisation. Tip #2. An isolated segment without both inflow and outflow will thrombose again after thrombolysis. The treatment needs to cover substantially all of the thrombus. Tip #3. While it is fashionable to do a “single-stop” thrombolysis, when faced with an extensive ilio-femoral DVT, a long soak in a thrombolytic overnight is a good alternative. Schedule the patient for late afternoon and bring them back for a clean-up the next morning. This makes good use of the hospital’s activity patterns, and the patient will not be going home the same day anyway. Trick #1. Most of the mechanical thrombolytic devices are a little small for big veins. Use an angled guide catheter to allow you to sweep the device you are using across the vessel. Trick #2. I prefer to use a retrievable IVC filter for a large-volume ilio-femoral DVT. You only need one pulmonary embolus to ruin your day. The filter can be removed once the patient is established on oral anticoagulants. If there are significant risk factors, you may want to leave it in place. Trick #3. Spend some effort in educating the vascular ward staff about thrombolysis. The dividend this will pay in the ability to place your overnight patients in the vascular ward rather than in the expensive care unit. Once you have the nurses on board, suggest it to the Medical Administration as a cost-saving measure.

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Pitfall #1. Not following Tip #1. A prolonged thrombolysis will increase the risk of complications. The good results from four days of thrombolysis will be outweighed by complications. Pitfall #2. Promising the patient excellent normal anatomy. Know when to stop and let the patient’s own systems restore order. You just have to give them a leg up by establishing flow. Pitfall #3. A really good thrombolysis can be ruined by poor venous inflow. If this means using two punctures because the lowest vein is too small, it does not matter. References Bjarnason, H. Acute Lower Extremity DVT, Image Guided Intervention, Mauro et al (Eds), 2nd ed. Ch 101, P 755-765. Elsevier, Philadelphia.

1302.4 Single session therapy for DVT: devices and patient selection G.J. O’Sullivan Interventional Radiology, U.C.H. Galway, Galway, Ireland Single session devices include the AngioJet (Medrad/Bayer) and the Trellis (Covidien). A newer larger device (AngioVac) will be discussed by one of my colleagues (N. Kucher, Bern). Single session therapy relies on good in-flow from the popliteal vein; if the popliteal vein is thrombosed or scarred, then avoid it and aim instead for CDT (see preceding lecture; K.R. Thomson, Melbourne, AU). That said, about 80% of patients are suitable for single session therapy. A how-to approach will be used and appropriately referenced. With skill and experience, an ilio-femoral DVT can be successfully treated within 1 hour and the patient can go home that day. Critical to success with any method of thrombus removal is determining the age of the thrombus and I completely agree with the previous speaker here. Personally, I do not touch patients who have a thrombus between 1 month and 6 months old. Pre-operative imaging is critical to evaluate which patients need an IVC filter, as well as determining anatomical variants and likely causes. I like CTPA and CTV but others prefer Echo and MRV. Ultrasound is essential to decide on puncture point(s). Large sheaths are needed, usually 10/11 F. The popliteal vein can usually accommodate up to 16 F, so 10 F is not a problem. Almost all patients with an ilio-femoral DVT require a venous stent to alleviate the compressive lesion or stenotic vein; in Europe, we are fortunate to have at least 3 venous indicated stents. Stents need to be large in diameter and extend from flow to flow. References 1. Pharmacomechanical thrombectomy of acute deep vein thrombosis with the Trellis-8 isolated thrombolysis catheter. O’Sullivan GJ, Lohan DG, Gough N, Cronin CG, Kee ST: J Vasc Interv Radiol, 2007 Jun;18(6):715-24. 2. Treatment of acute inferior vena cava and iliac vein thrombosis with pharmacomechanical thrombectomy using simultaneously operating “kissing” Trellis-8 thrombolysis catheters. Kamel Abdel Aal AM, Hamed MF, Saddekni S, Osman S, Zarzour J: J Endovasc Ther; 2011 Oct;18(5):739-43. 3. Isolated pharmacomechanical thrombolysis plus primary stenting in a single procedure to treat acute thrombotic superior vena cava syndrome. O’Sullivan GJ, Mhuircheartaigh JN, Ferguson D, Delappe E, O’Riordan C, Browne AM: J Endovasc Ther; 2010 Feb;17(1):115-23. 4. Aggressive percutaneous mechanical thrombectomy of deep venous thrombosis: early clinical results. Arko FR, Davis CM 3rd, Murphy EH, Smith ST, Timaran CH, Modrall JG, Valentine RJ, Clagett GP: Arch Surg, 2007 Jun;142(6):513-8; discussion 518-9.

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Fundamental Course Basic principles of aorto-iliac disease treatment 1701.1 Treatment triage: which patients are eligible candidates? I. Robertson Interventional Radiology Unit, Gartnavel General Hospital, Glasgow, United Kingdom Learning Objectives 1. To learn how to select patients for aorto-iliac intervention and know the TASC classification 2. To learn which patients are more suitable for surgery 3. To learn the results of aorto-iliac intervention Symptomatic patients with PAOD presenting with lifestyle-limiting claudication or critical limb ischaemia are potential candidates for intervention assessment. The initial management of patients presenting with symptomatic PAOD includes best medical treatment and supervised exercise. In most centres, unlike femoropopliteal disease, aortoiliac intervention may be considered for patients before failure of medical management. The assessment should include clinical examination, haemodynamic status and non-invasive imaging. Clinical/haemodynamic assessment comprises physical examination, pulse palpation, ABPI and ideally, treadmill testing. Patients with suitable findings should then undergo a non-invasive assessment. Non-invasive imaging should evaluate the target lesion site, length, inflow and runoff. Doppler ultrasound can provide useful initial assessment but may not provide a sufficient anatomical detail to allow complete triage. MR angiography and contrast CT angiography allow excellent image assessment of the lesion, inflow and outflow. Treatment decisions are best taken within a multidisciplinary group that includes vascular surgeons and interventional radiologists. Clinical factors including claudication distance/evidence of critical limb ischaemia, haemodynamic status and imaging should be considered. The Rutherford classification forms a structured assessment of clinical status in six grades from asymptomatic to gangrene; Rutherford grades 2–3 or above are the potential candidates for intervention. In addition, TASC II classification forms an internationally accepted basis for anatomical description of aortoiliac lesions. TASC A lesions include unilateral or bilateral stenoses of CIA or unilateral or bilateral single short (<3 cm) stenosis of EIA. TASC B lesions include short (<3 cm) stenosis of the infrarenal aorta, unilateral CIA occlusion and single or multiple stenosis totalling to 3–10 cm involving EIA that do not extend into CFA. TASC A and B lesions are most readily suitable for endovascular intervention and offer >80% 3-year aggregate patency rates and >65% 10-year patency rates. The more complex and challenging TASC II C and D lesions include bilateral CIA occlusions, bilateral EIA stenosis and heavily calcified lesions. Treatment decisions for this group have traditionally been more balanced between surgery and intervention dependent to a greater extent on individual patient factors and the risk benefit ratio. There is increasing evidence for an endovascular first approach in this group, particularly, in TASC C lesions. These will clearly be more technically challenging. Preliminary results suggest that in experienced centres, endovascular first as an option for some TASC II D lesions is an appropriate option. References 1. Rossi M, Iezzi R. (2014) Cardiovascular and Interventional Radiology Society of Europe. Guidelines on Endovascular Treatment in Aortoiliac Arterial Disease. Cardiovasc Intervent Radiol (2014) 37:13–25.

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1701.3

Technique - lesions at the aortic bifurcation

Technique - aortic and iliac artery stenoses

D.K. Tsetis Unit of Interventional Radiology, University Hospital Heraklion, Heraklion, Greece

T. Jahnke Department of Diagnostic and Interventional Radiology / Nuclear Medicine, FEK Friedrich-Ebert-Krankenhaus GmbH, Neumünster, Germany

Learning Objectives 1. To understand when to use the kissing technique 2. To learn which stents to use and when 3. To understand potential complications of aortic bifurcation lesions Reconstruction of the aortoiliac bifurcation with “kissing” angioplasty and/or stenting is the most commonly used endovascular technique. Indications include pelvic and lower limb ischemia (short-distance claudication, critical ischemia, and/or blue toe syndrome) due to atherosclerosis or Takayasu’s disease. Due to the rapid evolution of minimally invasive endoluminal materials and accumulation of experience, the technique can even be applied successfully in TASC C and D lesions. Stenting may be performed as a primary or secondary procedure due to failed or inadequate PTA. Predilatation can facilitate primary placement of stents; however, primary stent placement without predilatation (“direct” stenting) is commonly used, as it potentially reduces distal embolization by trapping atheroma and clot between the stent and the arterial wall. In addition, there is some evidence that this technique results in less intimal hyperplasia. It is suggested that primary (or direct) stenting may be particularly good for complex stenosis (irregular, eccentric, ulcerated, or calcified lesions) and occlusions. According to the “kissing” technique, bilateral stents are deployed simultaneously and ideally should extend 5–15 mm into the distal aorta. New self-expanding stent designs have enabled better anatomic results with “kissing” stenting; however, there is no solid evidence of any long-term advantage of self-expanding over traditional balloon-mounted stents. Polytetrafluoroethylenecovered stents may further improve patency rates by preventing tissue ingrowth and may reduce complications. They may be particularly useful in patients with an extensive aortoiliac disease. Complications include aortoiliac rupture, aortoiliac dissection with or without associated thrombosis, distal embolization, access-site hematoma, pseudoaneurysm, puncture site infection, infected stent, and myocardial infarction. To prevent arterial rupture, as a general rule, balloons and balloon-expandable stents should not be sized to a maximum of the native aorta immediately proximal to the diseased segment, especially in heavily calcified lesions. To prevent thromboembolic complications, a good technique with an adequate antiaggregant therapy and periprocedural heparinization is essential. References 1. Uberoi R and D. Tsetis. Standards for the Endovascular Management of Aortic Occlusive Disease. Cardiovasc Intervent Radiol. 2007; 30:814-819. 2. Sabri SS et al. Outcomes of covered kissing stent placement compared with bare metal stent placement in the treatment of atherosclerotic occlusive disease at the aortic bifurcation. J Vasc Interv Radiol. 2010 ;21:995-1003. 3. Björses K et al. Kissing stents in the aortic bifurcation--a valid reconstruction for aorto-iliac occlusive disease. Eur J Vasc Endovasc Surg. 2008; 36:424-431. 4. Greiner A et al. Does stent overlap influence the patency rate of aortoiliac kissing stents? J Endovasc Ther. 2005; 12:696-703.

Learning Objectives 1. To learn how to cross and treat stenoses 2. To learn when to stent 3. To learn how to deal with complications No abstract available.

1701.4 Recanalising the acute and chronic aorto-iliac occlusion S.D. Qanadli Radiology, University Hospital of Lausanne, Lausanne, Switzerland Learning Objectives 1. To learn how to cross chronic occlusions 2. To learn how to manage acute occlusions 3. To learn which complications may occur and how to deal with them in both acute and chronic occlusions The endovascular management of total occlusions, acute as well as chronic, remains one the challenges that interventional radiologists (IRs) are facing in daily practice. Up to 20% procedure failures have been reported to be related to inability to cross chronic total occlusion (CTO). Furthermore, challenges are not only technical but also related to prolonged procedure time and additional radiation exposure delivered to the patient and to the staff. Recent advances in biomaterials and dedicated technologies have markedly improved the procedure success. However, this improvement may be limited to procedures performed by skilled and experienced IRs. In addition, a deep knowledge of lesion characteristics and the underlying disease significantly help to reduce failure rate and complications. The objective of this study is to learn how to cross CTO, manage acute occlusions, and deal with complications. An optimal strategy for crossing CTO should integrate the following steps: (1) time from the onset (at least 2 months), (2) CTO characteristics: anatomic site (ostial or post-ostial and common and/or external iliac arteries), extent (aortic involvement and length), patency of collaterals (iliac arteries, lumbar arteries, and inferior mesenteric artery), presence of calcifications (mural and endoluminal), (3) access site (femoral or brachial and ipsilateral or controlateral), (4) crossing approach (antegrade or retrograde or combined), and (5) guidewire-based crossing technique (intraluminal or intentionally subintimal, drilling or penetrating technique, or re-entry technique). Indications, advantages, and limitations of the different options will be discussed. A special focus will be provided on the current role of devices aiming to assist crossing or to assist re-entry. Acute iliac occlusion results in ischemia that requires urgent treatment to prevent amputation or death. A rapid intervention is therefore vital for re-establishing the flow. Catheter-directed thrombolysis and adjunctive angioplasty and stent placement are standard therapies. Mechanical thrombectomy has also become available for arterial occlusions but is usually used in conjunction with thrombolysis. The criteria for selecting the optimal vascular access and placing the catheter for thrombolytic delivery are presented. Acute aortic occlusion is a rare condition. Specific management is usually dictated by the underlying cause and the severity of clinical symptoms.

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Special Session Vascular trials update 1702.1 Carotid S. Macdonald Chief Medical Officer, Silk Road Medical, Sunnyvale, CA, United States of America Learning Objectives 1. To learn about the latest trial results 2. To learn which patients benefit most from CAS 3. To learn about adjunctive medical therapy No abstract available.

1702.2 Thoracic aortic aneurysm H. Rousseau1, T. Mokrane1, C. Lions1, B. Saint Lebes2 1Dept. of Radiology, CHU Rangueil, Toulouse, France, 2Dept. of Vascular Surgery, CHU Rangueil, Toulouse, France Learning Objectives 1. To learn about the latest trial results 2. To learn which patients benefit most from TEVAR 3. To learn how to minimise paraplegia Diseases of the thoracic aorta are rare, with an incidence of 2–3.5 cases per 100,000 person-years compared with those comprising the acute coronary syndrome, with an incidence of >200 cases per 100,000 person-years [1] [2]. Thoracic aortic diseases mainly comprises 6 entities: true thoracic aortic aneurysm (TAA), traumatic aortic rupture (TAI), aortic dissection, intramural hematoma (IMH), penetrating aortic ulcer (PAU), and false aneurysm, with a significant overlap of these diseases. All these entities can occur either as an acute aortic syndrome (AAS) or as chronic forms of the diseases. Recent guidelines, consensus documents, and overview articles have summarized the current knowledge and made recommendations regarding the management of thoracic aortic diseases [2, 3]. Whereas, patients with AAS involving the ascending aorta are to be treated by surgery and those with diseases of the descending thoracic aorta are usually treated medically; only in the event of complications, these patients become candidates for surgery or increasingly, for treatment with thoracic endovascular aortic repair (TEVAR) [3]. Most data on TEVAR originates from registries, with only very limited information derived from randomized controlled clinical trials. Therefore, it is necessary to get as much information as possible from other databases. Nevertheless, TEVAR has evolved into a safe and effective therapy for different aortic pathology resulting in promising long-term results. [4] True Thoracic Aortic Aneurysms A meta-analysis [5], including 17 studies, involved 517 patients treated with OR and 538 patients treated with TEVAR, all as elective cases. The authors found that in the endovascular cohort of patients, a lower 30-day mortality rate (0%–8% vs 1%–18%, p < 0.0001) and a better paraplegia rate (0%–13% vs 0%–7%, p < 0.0007). No significant difference were described in terms of early stroke rate, more common in the TEVAR group (0%–10% vs 0%–7%) or in terms of major reintervention rate at 48 months, more frequent in the OR group (8.4% vs 7%). Likewise, a further meta-analysis reported similar results regarding the treatment of ruptured TAAs [6]. It included 28 studies, involving 81 patients who underwent OR and 143 patients treated by TEVAR. Early mortality rate (18.9% vs 33% p < 0.016) and myocardial

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

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

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

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

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

1702.4 Infrapopliteal segment S. Sharma1, S. Kumar2 1Dept of Cardiac Radiology, All India Institute of Medical Sciences, Delhi, India, 2Cardiac Radiology, All India Institute of Medical Sciences, Delhi, India Learning Objectives 1. To learn about the latest trial results 2. To learn which patients benefit most from drug-eluting devices 3. To learn about adjunctive medical therapy The management of advanced obstructive infrapopliteal disease poses challenges due to unfavorable image morphology characterized by diffused, multifocal, and multi-segment occlusive lesions with poor or absent distal run-off vessels. Below-the-knee (BTK) disease is not the same as above knee disease and often presents with critical limb ischemia (CLI). Patients frequently have comorbidities, such as diabetes and renal failure. Both intima and media are diseased with an involvement of smaller arteries. The disease frequently involves long segments, has heavily calcified arteries, and additional proximal femoropopliteal disease. There are no TASC guidelines for BTK lesions. Leg ulcers may have multifactorial etiologies, including neuropathy, infection, venous insufficiency, and arterial insufficiency. These patients require a multispecialty higher level of care. Further, minor amputations are not regarded as treatment failure. Many a times, vascular interventions are performed to lower the level of amputation. The occurrence of restenosis is difficult to evaluate due to a variety of issues, including lack of uniform angiographic follow-up, heavy calcification precluding optimal duplex ultrasound and CT angiography, low eGFR if present precluding MR angiography, and inability to perform anklebrachial pressure index due to the presence of ulcers or its unreliability due to diffuse occlusive disease. Long-term patency rates also do not have a linear relationship with clinical outcomes. Wound or ulcer healing relate better to the outcome, and limb salvage rates are better than patency rates for predicting the outcome of endovascular revascularization. Short-term patency, resulting in pulsatile blood flow to ischemic ulcers, promotes repair mechanisms and tissue salvage. Treatment strategies include medical management, wound care, and endovascular and surgical revascularization. Endovascular procedures include balloon angioplasty [including drug-eluting balloons (DEB)], stenting [bare-metal stent (BMS) and with coatings such as carbon and pharmacologic agents (DES)], and therapeutic angiogenesis. In suitable patients with severe limb ischemia with a life expectancy of >2 years and a usable vein, bypass surgery was advocated (BASIL trail) for infrainguinal lesions1. Bypass had better patency rates than endovascular techniques but with no significant difference in limb salvage rate. In patients with <2-year life expectancy,

Abstract Book balloon angioplasty (PTA) may be an alternative as it is associated with less morbidity and cost, and such patients are unlikely to enjoy the long-term benefits of surgery. No clear guidelines are available for the treatment of isolated BTK disease. PTA of tibial arteries in patients with CLI had 1-year primary patency rate between 33%– 37%, a secondary patency rate of 56%–63%, and a limb salvage rate of 75%–100%2,3. Early infrapopliteal stent trials results were not better than PTA in terms of patency rates and were limited by many issues, including small numbers, usage of stents not designed for this anatomic location, short follow-up durations, and limited structured studies. There is a paucity of well-designed prospective randomized studies comparing these two techniques. No definite benefits in terms of patency or limb salvage were seen in published studies. Stents have been traditionally used as a bail-out therapy subsequent to suboptimal angioplasty. There is experimental evidence to suggest that BMS with passive coating, amorphous silicon carbide coating, and magnesium alloys reduce the thrombogenicity of the device. InPeria 11 trial4 evaluated PTA versus carbon-coated stents in infrapopliteal disease and showed some benefit at 3-month follow-up for the stent group. However, there was no effect on the amputation rate at 3 and 9 months. Moreover, nitinol stents for infrapopliteal disease have shown some promising results. XCELL trial5 data demonstrated that primary infrapopliteal nitinol stenting to treat CLI is safe and effective in improving 6- and 12-month outcomes. There is growing evidence that DEB and DES can improve the outcomes of BTK endovascular recanalization. These have the potential to shorten the duration and quantity of antiplatelet drugs and may result in higher drug tissue bioavailability due to higher drug surface area in these anatomical locations. DEB has the advantage that there is no foreign material, and drug delivery is homogenous and immediate. These also do not predispose to chronic inflammation and thrombosis and hence, have the potential for lower restenosis6. DEBATE-BTK is a randomized, open-label, single-center study comparing drug-eluting balloons and PTA7. Patients with diabetes, CLI, significant stenosis or occlusion of >40 mm of at least 1 BTK vessel with distal runoff, and with >1-year life expectancy were included. Binary in-segment restenosis at a 1-year angiographic or ultrasonographic follow-up was the primary endpoint. Clinically driven target lesion revascularization, major amputation, and target vessel occlusion were included as secondary endpoints. In all, 132 patients with 158 infrapopliteal lesions were enrolled. The mean length of treated segments was 129 ± 83 mm in the DEB group compared with 131 ± 79 mm in the PTA group (P = 0.7). Binary restenosis, assessed by angiography in >90% patients, occurred in 20/74 lesions (27%) in the DEB group compared with 55/74 lesions (74%) in the PTA group (P < 0.001); target lesion revascularization was observed in 12 patients (18%) versus 29 (43%; P = 0.002) lesions and target vessel occlusion in 12 (17%) versus 41 (55%; P < 0.001). Only 1 major amputation occurred in the PTA group (P = 0.9). DEB compared with PTA significantly reduced 1-year restenosis rates and improved target lesion revascularization with lower target vessel occlusion in treatment of BTK lesions in diabetic patients with CLI. Further, IN.PACT DEEP trial is a 2:1 randomized controlled trial designed to assess the efficacy and safety of infrapopliteal arterial revascularization between IN.PACT Amphirion paclitaxel drug-eluting balloon (IA-DEB) and standard balloon angioplasty (PTA) in patients with CLI. Altogether, 358 patients at 13 European centers were enrolled. It will assess the overall impact on infrapopliteal artery patency, limb salvage, wound healing, pain control, quality of life, and patient mobility; 1-year results should be shortly available. Moreover, the use of DES has shown good results. The proven efficacy of DES in the treatment of coronary artery disease gave rise to the notion that they may have a better patency compared with BMS in small infrapopliteal vessels. YUKON BTX trial8 was a prospective, randomized, multicenter, double-blind trial comparing sirolimuseluting stents (SES) with BMS for the treatment of focal infrapopliteal

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

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

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

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

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

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

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or surgery); deep vein thrombosis (indication for anticoagulation); cholecystitis (amenable for percutaneous drainage); bowel ischemia or perforation (indication for surgery); and features of the abdominal compartment syndrome (requiring percutaneous drainage of ascites or surgery). The conveyance of these specific CT findings to clinicians caring for these challenging patients will have more clinical impact on patient management than providing any radiologic score. References 1. Fagenholz PJ, Fernandez-del Castillo C, Harris NS, Pelletier AJ, Camargo CA. Direct medical costs of acute pancreatitis hospitalizations in the United States. Pancreas 2007;35(4):302-7. 2. Shaheen NJ, Hansen RA, Morgan DR, Gangarosa LM, Ringel Y, Thiny MT et al. The burden of gastrointestinal and liver diseases, 2006. Am J Gastroenterol 2006;101(9):2128-38. 3. Banks PA, Freeman ML. Practice guidelines in acute pancreatitis. Am J Gastroenterol 2006;101(10):2379-400. 4. Besselink MG, Van Santvoort HC, Boermeester MA, Nieuwenhuijs VB, van Goor H, Dejong CH et al. Timing and impact of infections in acute pancreatitis. Br J Surg 2009;96(3):267-73. 5. Petrov MS, Shanbhag S, Chakraborty M, Phillips AR, Windsor JA. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology 2010;139(3):813-20. 6. Frossard JL, Steer ML,Pastor CM. Acute pancreatitis. Lancet 2008;371(9607):143-52. 7. Werner J, Feuerbach S, Uhl W, Buchler MW. Management of acute pancreatitis: from surgery to interventional intensive care. Gut 2005;54(3):426-36. 8. Bollen TL, van Santvoort HC, Besselink MG, van Es HW, Gooszen HG, van Leeuwen MS. Update on acute pancreatitis: ultrasound, computed tomography, and magnetic resonance imaging features. Semin Ultrasound CT MR 2007;28(5):371-83. 9. Arvanitakis M, Delhaye M, De Maertelaere V, Bali M, Winant C, Coppens E et al. Computed tomography and magnetic resonance imaging in the assessment of acute pancreatitis. Gastroenterology 2004;126(3):715-23. 10. Amano Y, Oishi T, Takahashi M, Kumazaki T. Nonenhanced magnetic resonance imaging of mild acute pancreatitis. Abdom Imaging 2001;26(1):59-63. 11. Morgan DE, Baron TH, Smith JK, Robbin ML, Kenney PJ. Pancreatic fluid collections prior to intervention: evaluation with MR imaging compared with CT and US. Radiology 1997;203(3):773-78. 12. Lau ST, Simchuk EJ, Kozarek RA, Traverso LW. A pancreatic ductal leak should be sought to direct treatment in patients with acute pancreatitis. Am J Surg 2001;181(5):411-15. 13. Bradley EL III. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992. Arch Surg 1993;128(5):586-90. 14. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013 Jan;62(1):102-11. 15. Delrue LJ, De Waele JJ, Duyck PO. Acute pancreatitis: radiologic scores in predicting severity and outcome. Abdom Imaging 2010;35:349-61. 16. Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology 1990;174:331-6. 17. Bollen TL, Singh VK, Maurer R, Repas K, van Es HW, Banks PA, et al. A comparative evaluation of radiologic and clinical scoring systems in the early prediction of severity in acute pancreatitis. Am J Gastroenterol 2012;107(4):612-9.

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

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

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

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

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

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

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

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Special Session Biliary and pancreatic malignancies: treatment options 1704.1 Intrahepatic cholangiocarcinoma: interventional treatment G. Carrafiello, A.M. Ierardi, C. Floridi Department of Radiology, University of Insubria, Varese, Italy Learning Objectives 1. To understand indications for IR vs. surgical treatment 2. To learn which technique to use for which case 3. To understand the outcomes and complications Complete surgical resection remains the only potentially curative option for patients with intrahepatic cholangiocarcinoma (ICC)1. Unfortunately, curative resection is possible in only approximately 30% patients due to locally advanced disease, distant metastases, or comorbidity in elderly patients. Even after resection, the recurrence rate is approximately 60%, resulting in a low 5-year overall survival (OS)1,2. Patients with resectable hilar cholangiocarcinoma often present obstructive jaundice and a small future remnant liver (FRL) ratio. A sequential approach comprising preoperative biliary drainage followed by portal vein embolization (PVE) is usually performed in several centers3,4. In unresectable ICC, overall survival (OS) with systemic chemotherapy is <1 year. Because most cholangiocarcinoma patients develop distant metastases at late stages only, locoregional therapy is an interesting therapeutic strategy. Locoregional therapies include intra-arterial therapies (IATs) [(e.g., transarterial chemoembolization (TACE), drug-eluting bead (DEB)TACE, radioembolization)], stereotactic radiotherapy, hepatic artery pump therapy, and ablation. Considering the rarity of ICC and the variation in treatment regimens, data on IATs are limited primarily to small, single institution series. Recently, a five-center study that included 198 patients was reported in which the safety and efficacy of IATs were examined in patients with ICC5. The authors concluded that locoregional therapy was safe and was associated with intrahepatic disease control in up to 70% patients. Hepatic artery infusion (HAI) therapy is another type of liver-directed arterial therapy. HAI therapy typically requires a surgical approach to place the pump apparatus. Because of a limited data in ICC, further reports are required to define its role in locoregional therapy for ICC6. Yttrium-90 is a pure β-emitter that decays to stable zirconium-90 with an average energy of 0.94 mega-electron volt (half-life 2.67 days), with a mean tissue penetration of 2.5 mm and a maximum range of 11 mm. The principle of SIRT is based on the preferential delivery of the radioactive microspheres to tumor vessels, resulting in a high dose local radiotherapy without major effects on normal tissue. Different from TACE, SIRT requires an optimal perfusion and blood flow in the tumor to allow the generation of free radicals by ionization of water molecules near the tumor cell DNA7. For patients with ICC, there are few data on radioembolization at present reporting smaller numbers of patients, even if radioembolization enables a formidable outcome compared with published chemotherapy data in terms of local tumor control rate, time to progression, and overall survival in patients who are not eligible for surgery at a very good toxicity rate8. Percutaneous image-guided ablation therapy is widely used for the treatment of liver cancer because of its minimal invasiveness, repeatability, relatively low cost, easy performance, and potential application in a wide spectrum of patients. RFA and MWA are two of the most commonly used modalities and are valuable therapeutic

Abstract Book modalities for HCC9. The local tumor control, treatment-related complications, and long-term survival were equivalent for these two modalities in treating HCC10. In literature, complete ablation rates for ICCs of 5 cm were 88%–97%11,12,13. The median overall survival and disease-free survival time of ICC after ablation were 8.8 and 4 months, respectively, thereby having a poorer prognosis than that of HCC9. The underlying reason may be attributed to the histological features of ICC. ICC is non-encapsulated and always has a tendency to infiltrate adjacent tissues. It is the invasion of local and hepatic ducts by ICC that leads to the low rate of curative resection and the high recurrence rate after treatment. In general, it is necessary to completely destroy the tumor plus 0.5–1 cm of the adjacent liver in an attempt to ensure a tumor-free margin. Because of the aggressive nature of ICC, a larger area of coagulation necrosis should be recommended in clinics in order to ensure enough safety margin. Centrally located tumors are more difficult to treat successfully as a result of heat loss caused by extensive vascularity in the hepatic hilum. During RFA, heat loss occurs at the needle tip, mainly through convection by means of blood circulation14. Preliminary TAE may be effective to decrease this negative effect12. Analyzing the causes of death for patients with HCC and ICC after thermal ablation, some differences were highlighted. Death from liver failure and upper gastrointestinal bleeding for HCC after ablation is higher than that for ICC. This may be due to the different liver backgrounds. Patients with HCC have a higher hepatitis infection rate, worse liver function status, and a higher cirrhosis rate than those with ICC. In contrast, ICC has a tendency to infiltrate the surrounding bile duct, blood vessels, and/or hepatic parenchyma. Further, infectious complications are more frequent than those for HCC9,11. In conclusion, locoregional therapy appears to have a therapeutic role in patients with unresectable disease, particularly for those who have limited or no extrahepatic disease. The presented data suggest that the specific role of the interventional radiology procedures should be investigated further in large, randomized, prospective studies. References 1. Maithel SK, Gamblin TC, Kamel I, et al. Multidisciplinary approaches to intrahepatic cholangiocarcinoma. Cancer 2013;119:3929–3942. 2. Kuhlmann JB, Blum HE. Locoregional therapy for cholangiocarcinoma. Curr Opin Gastroenterol. 2013;29:324–328. 3. Geisel D, Malinowski M, Powerski MJ, et al. Improved Hypertrophy of Future Remnant Liver after Portal Vein Embolization with Plugs, Coils and Particles. Cardiovasc Intervent Radiol. 2013 Dec 6. [Epub ahead of print] PMID:24310828. 4. Kasai Y, Hatano E, Iguchi K, et al. Prediction of the remnant liver hypertrophy ratio after preoperative portal vein embolization. Eur Surg Res. 2013;51(3-4):129–137. 5. Hyder O, Marsh JW, Salem R, et al. Intra-arterial Therapy for Advanced Intrahepatic Cholangiocarcinoma: A Multi-institutional Analysis [published online ahead of print July 12, 2013]. Ann Surg Oncol. 2013. 6. Vogl TJ, Schwarz W, Eichler K, et al. Hepatic intraarterial chemotherapy with gemcitabine in patients with unresectable cholangiocarcinomas and liver metastases of pancreatic cancer: a clinical study on maximum tolerable dose and treatment efficacy. J Cancer Res Clin Oncol. 2006;132:745–755. 7. Rafi S, Piduru SM, El-Rayes B, et al. Yttrium-90 radioembolization for unresectable standard-chemorefractory intrahepatic cholangiocarcinoma: survival, efficacy, and safety study. Cardiovasc Intervent Radiol. 2013;36:440–448. 8. Hoffmann RT, Paprottka PM, Schon A, et al. Transarterial Hepatic Yttrium-90 Radioembolization in Patients with Unresectable Intrahepatic Cholangiocarcinoma: Factors Associated with Prolonged Survival. Cardiovasc Intervent Radiol. 2012;35:105–116.

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9. Xu HX, Wang Y, Lu MD, Liu LN, et al. Percutaneous ultrasoundguided thermal ablation for intrahepatic cholangiocarcinoma. Br J Radiol. 2012;85:1078–1084. 10. Chiou YY, Hwang JI, Chou YH, et al. Percutaneous ultrasoundguided radiofrequency ablation of intrahepatic cholangiocarcinoma. Kaohsiung J Med Sci. 2005;21:304–309. 11. Kim JH, Won HJ, Shin YM, et al. Radiofrequency ablation for the treatment of primary intrahepatic cholangiocarcinoma. AJR Am J Roentgenol. 2011;196:W205–209. 12. Carrafiello G, Lagana D, Cotta E, et al. Radiofrequency ablation of intrahepatic cholangiocarcinoma: preliminary experience. Cardiovasc Intervent Radiol. 2010;33:835–839. 13. Kim JH Won HJ, Shin YM, Kim PM, et al. Radiofrequency ablation for recurrent intrahepatic cholangiocarcinoma after curative resection. Eur J Radiol. 2011; 80:e221–225. 14. Goldberg SN, Hahn PF, Tanabe KK et al. Percutaneous radiofrequency tissue ablation: does perfusion-mediated tissue cooling limit coagulation necrosis? J Vasc Interv Radiol. 1998;9:101–111.

1704.2 Hilar cholangiocarcinoma: intraluminal therapies V. Válek Department of Radiology, University Hospital Brno, Masaryk University, Brno, Czech Republic Learning Objectives 1. To understand indications for IR vs. endoscopic treatment 2. To learn which technique to use for which case 3. To understand the outcomes and complications The most common symptom of cholangiocarcinoma is painless jaundice. Even though the cause of jaundice could be a small-sized tumour, the unfavourable localisation of the common perihilar type greatly influences the prognosis of patients. Hilar cholangiocarcinoma (Klatskin-type tumor) arises from the epithelium of the intrahepatic bile ducts and >95% of them correspond to adenocarcinomas (other rare types are squamous cell carcinoma, undifferentiated carcinoma, papillary carcinoma etc). Hilar cholangiocarcinoma is, predominantly, a slow-growing tumor with longitudinal spreading along the bile ducts. This type of macroscopic appearance corresponds to periductal infiltrating type. Typical mass-forming lesion with rich fibrous stroma is more common on the periphery of liver. A modified Bismuth–Corlette classification is widely used for the description of tumours invading the hilum of liver. It is essential for the preoperative planning of surgical, multimodality treatments as well as sole palliative procedures. The key issue of all techniques (palliative and curative) is to achieve an accurate bile duct patency. Bile duct obstruction, if not adequately compensated, can result in intrahepatic cholestasis with significant reduction of the patient’s quality and length of life. Long-term survival (≥5 years) of patients with hilar cholangiocarcinoma depends primarily on surgical treatment. However, Bismuth type III tumours are resectable at the cost of hemihepatectomy or extended hemihepatectomy, and Bismuth type IV tumours are resectable only in selected cases and the peak incidence of cholangiocarcinoma in western countries between 60–70 years of age favours only a limited intervention of surgeons. The median survival of resected patients due to a more aggressive surgical approach and improved perioperative care increased from 16 to 30 months in the last 20 years as referred from Italian centres. R0 resection margins still mean only a possible chance of cure for cholangiocarcinoma with median survival up to 47 months with significant drop to 17 months in R1 resection margins. T stage, lymphatic node status and histopathological grade are the widely accepted independent factors of patient prognosis. Especially, histopathological grade as an independent factor of prognosis is frequently missing in descriptions of patient groups referred to multimodal palliative treatments.

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At present, a wide choice of palliative treatments of biliary obstruction is offered. In addition to palliative surgical procedures, there are many endoscopic therapeutic methods [e.g. nasobiliary drainage, implantation of plastic prostheses or self-expandable metallic stents (SEMS)] and percutaneous therapeutic methods such as percutaneous drainage (PTBD) and implantation of plastic endoprostheses or metallic stents. There are several competing techniques and interventions for the palliative treatment of hilar cholangiocarcinoma like chemotherapy (intravenous, intra-arterial, chemoradiation), biologic therapies, radiation therapies (external beam, intraluminal brachytherapy), photodynamic therapies and intraluminal radiofrequency ablation; they, with the exception of intravenous chemotherapy, cannot be considered as standard care. More often, they are so-called tailored oncologic therapies. The majority of patients are treated in clinical trials with protocols which vary considerably and the results of trials are often limited because of a small number of involved subjects with variable performance status. The median survival time of palliated patients varied greatly from 3 to 35 months. Randomised trials that compared surgical palliative bypass procedures and the endoscopic placement of plastic prostheses showed an equal clinical efficacy. Plastic prostheses placement is associated with a reduced risk of complications, although with a higher risk of recurrent biliary obstruction because of occlusion. Endoscopic route is often used for the implantation of SEMS; however, the relief of all obstructed biliary branches is more technically difficult because of the complexity of hilar tumours. Therefore, specific approaches of stent implantations or only a selective decompression of biliary tract has to be selected. Randomised studies with currently available 6-F SEMS, which allows parallel implantations in endoscopic way, are expected. When we compare the implantations of SEMS percutaneously and endoscopically with previous studies, the benefit of the percutaneous approach was more obvious. Newer studies confirm similar stent patency, complication rate and survival of patients but favour percutaneous approach in the technical success of drainage procedures. We emphasize the most on maintaining bile duct patency for reaching a long-term survival. Plastic prostheses or external/internal percutaneous catheters are preferred as a definitive treatment for patients with a prognosis of <3–4 months. In prolonged palliative therapy (>6 months), they have to be repeatedly replaced due to lumen obstruction (3 times narrower than SEMS) and thus, compared with SEMS are cost ineffective. Based on our experience, there is also a higher tolerance and compliance of the patient when using a metal stent. Covered metal stents were historically disadvantaged because of potential migration and cost, while the benefit of improved stent patency was not clear. We do not recommend the use of covered metal stents in the palliation of hilar cholangiocarcinoma due to the occlusion of side branches. Improving the prognosis of patients with tumours of subhepatal space can be observed using modern means of chemotherapy, locoregional chemotherapy and methods of external radiotherapy. Because of prolonged survival of these patients, we see obstruction of a metal stent more frequently. The average stent patency in studies (7.5–9.5 months) varies widely and also depends on the technical execution and potential brachytherapy after insertion. The obstruction of metal stent may occur due to intimal hyperplasia; tumour ingrowth or stent can be obstructed by detritus. In a group of 58 patients, who were introduced to self-expandable stents at our centre in the reference period of 2004 to 2008, the obstruction of the stent was observed in 38% patients. The early stent obstruction during the 5 months of implantation occurred in 14% patients. The management of stent obstruction resulted in a significant increase in the number of nonvascular interventions for patients and also increased the cost of palliation of the disease. External beam radiotherapy and mainly intraluminal brachytherapy can extend stent patency and thereby, the quality and survival of patients. The advantage of brachytherapy with Ir-192 is the

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

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

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

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1704.4

Pancreatic tumours: irreversible electroporation

Pancreatic tumours: high intensity focused ultrasound

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

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

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

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

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

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

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

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

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

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

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

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1801.2

1801.3

Technique – treating TASC A-D lesions

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

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

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

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

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

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1801.4

1802.2

Patient follow-up and indications for re-intervention

Endothermal treatment of varicose veins

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

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

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

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

No abstract available.

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

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

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

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

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

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

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

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

Special Session Controversies in liver tumour ablation 1804.1 Will radiofrequency ablation replace surgery for small liver metastases? A. Gillams Imaging Dept, The London Clinic, London, United Kingdom Learning Objectives 1. To learn about results of ablation and resection in the treatment of small colorectal liver metastases 2. To learn about limitations of ablation and resection in the treatment of small colorectal liver metastases 3. To learn how to combine resection, ablation and systemic chemotherapy in patients with colorectal cancer liver metastases Results of resection and ablation Both surgical resection and ablation can result in long-term survival; 10–20% of selected patients can survive up to 10 years. Solbiati recently reported a 5-year survival of 48%, 7-year survival of 25% and 10-year survival of 18% in 99 patients with <4-cm tumours treated with ablation. We have reported a 3-year survival of >80% in patients with solitary <4-cm tumours. Ablation can and does cure. The main problem in comparing resection and ablation is that the 2 techniques are nearly always used in different populations, and ablation is generally reserved for patients with poorer prognosis, including those with higher comorbidity, unresectable disease and more extra-hepatic disease, i.e. ablation has been applied as a palliative procedure and resection as a curative one. When ablation is used to treat patients with potentially operable diseases, the results are very similar to those achieved with resection. Kim et al. reported on 505 colorectal patients treated with resection or ablation. Ablation was used in 177 patients with unresectable disease due to comorbidity, more numerous and scattered tumours or tumours that were ill located for resection. Within this population, a subgroup with solitary <3-cm tumours had a 5-year survival of 51% independent of whether they underwent resection or ablation. There are 4 other retrospective studies that show comparable survival between resection and ablation, particularly when ablation is applied to smaller <3-cm tumours. One interesting approach from Otto et al. was to use RFA as a firstline treatment for smaller tumours (median 3 cm) and resection for larger tumours (median 5 cm). The local recurrence rate was higher following ablation, but there were more therapeutic options for new or recurrent disease after ablation, and the estimated 5-year survival was similar: 48% for ablation and 51% for resection. One other paper reports higher local recurrence rates following ablation but comparable survival. In situations where ablation can achieve the same local tumour control as resection, there is no basis for the recommendation of surgery over and above ablation. All ablationists must work harder for achieving local tumour control. This means that high-volume centres have access to appropriate guidance for ablation through CE-CT, US-CT co-registration, appropriate anaesthetic support, scrupulous attention to staging and full definition of all tumours and intra-procedural assessment of treatment efficacy with more ablation at the same session as required with margins.

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Limitations for resection and limitations for ablation Tumour size Ablation is most effective in smaller tumours. Local tumour progression rates are consistently higher for larger tumours. Although the cut off varies in different papers, most authors define the optimal tumour as <3 cm. Even better results are achieved in <2-cm tumours. Solbiati reported a 5% local tumour progression for <2-cm tumours, rising to 10% for <3-cm and 45% for >3-cm tumours. Some centres will treat well-located (easily accessible and located away from major vessels) Ablation is most effective in smaller tumours. Local tumour progression rates are consistently higher for larger tumours. Although the cut off varies in different papers, most authors define the optimal tumour as <3 cm. Even better results are achieved in <2-cm tumours. Solbiati reported a 5% local tumour progression for <2-cm tumours, rising to 10% for <3-cm and 45% for >3-cm tumours. Some centres will treat well-located (easily accessible and located away from major vessels) <5-cm tumours. Hammill reported local tumour progression of 3% for <3-cm, 4% for <5-cm and 27% for >5-cm tumours. Ablation, with current technology, is not recommended as a curative procedure in >5-cm tumours. tumours. Hammill reported local tumour progression of 3% for <3-cm, 4% for <5-cm and 27% for >5-cm tumours. Ablation, with current technology, is not recommended as a curative procedure in >5-cm tumours. Tumour location As for resection, ablation of a good margin of normal-appearing liver around the tumour is essential for good tumour control. Tumour proximity to large vessels, which prevents an adequate margin, increases the chances of local tumour progression both for resection and ablation. Many surgeons are reluctant to resect tumours on the hepatic venous confluence for this reason. Increasing the ablative margin size reduces the chance of local tumour progression; 1–1.5cm margin carries a lower recurrence rate than 0.5–1.0-cm margin, which in turn is better than <0.5-cm margin. Some tumour locations require removal of a large volume of normal liver parenchyma. These are usually deeper tumours located on anatomic boundaries; for example, between right and left lobes or on the junction between segments 7 and 8. Historically, resection has been carried out without much concern for future therapeutic options. However, 40–70% of patients will develop new liver metastases on follow-up, and the future therapeutic options are dependent on the volume of functional liver remaining; therefore, a more conservative approach with better sparing of normal liver tissue will impact the overall outcome. Some, but not all, surgeons will refer small solitary tumours, which are ill located for resection directly to ablation. Ablation next to vulnerable structures such as the colon or duodenum necessitates the use of adjunctive measures to create a barrier between the ablation zone and the vulnerable structure. Displacement of adjacent structures using gas or fluid is an easy technique and should be a part of the routine armamentarium of any ablation practice. Ablation next to the central bile ducts is more difficult. There has been some success using high-flow intraductal cooling via a nasobiliary tube. The implications of biliary injury can be highly significant, and some authors advocate avoiding tumours in this location. Invasiveness, complications and co-morbidity Liver resection remains a highly co-morbid procedure and is only possible in fit patients. Liver resection still carries a mortality risk although mortality rates in experienced modern surgical practices should be <3% and certainly <5%. Major morbidity is still high at approximately 25–30%. Morbidity can be even higher, up to 40%, in the over 70-year age group. Liver resection can compromise residual liver function and cause portal hypertension, thrombocytopaenia and post-operative complications such as sepsis, biliary stricture or leak, thereby compromising important chemotherapy or ablation. Staged resection and portal vein embolisation have been employed to compensate for the large amount of normal-functional liver that

Abstract Book is often removed. Percutaneous RFA is much less invasive, mortality is rare and major complications <2.5% have been reported from several experienced centres. Open ablation without resection still carries a mortality (<2.3%) and a higher morbidity than percutaneous RFA and should be reserved for patients who cannot undergo a percutaneous ablation. Laparoscopic ablation is a highly skilled technique but has been successfully developed in a few centres; the mortality and morbidity is less than that for the open approach but more than that for the percutaneous approach, and again, the laparoscopic approach should be used when there is a contraindication to the percutaneous approach. When resection? When chemotherapy? When ablation? And in which combination? Treatment choices depend on liver tumour number, size and distribution; the presence of extra-hepatic disease; potential for radical therapy to extra-hepatic sites of disease; disease-free interval between the primary resection and the diagnosis of liver metastases; stage of the primary tumour; success of the primary treatment; patient comorbidity and response to chemotherapy. Definitions of resectability and ablatability vary between centres in part due to local resources and expertise. Resectable disease For some years, all patients have received neoadjuvant chemotherapy followed by resection in those who respond. Chemotherapy is used as a triage mechanism, with many centres not advocating radical therapy in non-responders. A more recent fashion is de novo resection in those having resectable tumours followed by adjuvant chemotherapy, with neoadjuvant chemotherapy being reserved for tumours that are not readily resectable at presentation. Oncologists argue about the benefit of adjuvant chemotherapy; there are reported significant differences in progression-free survival but less evidence for an improvement in overall survival. Unresectable but ablatable disease Several ablation groups have published RFA survival data in unresectable patients of 50% at 3 years and 30% at 5 years. Although most centres agree that ablation adds a survival advantage to systemic chemotherapy in inoperable patients, this is still not universal. Randomised controlled trials have struggled to accrue, and the one RCT that did get started, closed early and was insufficiently powered. Inevitably, there was some cross-over between treatment groups with 8.5% of the chemotherapy arm only undergoing liver resection, and the chemotherapy arm also received significantly more salvage chemotherapy. However, this RCT (CLOCC) showed a significant difference in progression-free survival between the 2 groups at 3 years (27.6% for the ablation group vs. 10.6% for the chemotherapy group; p = 0.025). The overall survival at 30 months was not significantly different, but the survival curves continue to separate on long-term follow-up; 47% vs. 36% at 4 years and 40% vs. 30% at 5 years. We would advocate ablation with adjuvant chemotherapy in patients who are ablatable de novo and neoadjuvant chemotherapy in non-ablatable patients with the hope that downsizing will allow a definitive treatment with ablation and/or resection. Resectable with adjunctive measures but also ablatable - which route is better? Five-year survival following resection with adjunctive measures such as portal vein embolisation is 25%. Some, but not all, of these patients will have de novo ablatable disease with comparable survival. Forty percent of patients fail to complete their planned resection programme after portal vein embolisation, either due to inadequate liver hypertrophy or tumour progression. There is some evidence that portal vein embolisation stimulates tumour growth in the contralateral lobe. Ablation could be a better, far less traumatic and less complex treatment journey with a greater chance of treatment completion. In patients with normal volume liver and normal background liver parenchyma, it is possible to ablate up to 9 liver metastases in 2 treatment sessions 4 weeks apart.

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Similarly, staged resection is associated with poorer overall survival and many patients fail to complete the treatment programme due to complications or disease progression. For those with de novo ablatable disease, ablation should seriously be considered as these patients are more likely to complete radical treatment to all sites of disease. Resectable and ablatable There is sufficient retrospective data showing comparable survival results in appropriate patients that RCT should be considered. This has been debated, often heatedly, within the surgical community for over a decade. An RCT would be welcomed by the percutaneous ablation community. References 1. Agcaoglu O, Aliyev S, Karabulut K, El Gazzaz G, Aucejo F, Pelley R, Siperstein AE, Berber E. Complementary use of resection and radiofrequency ablation for the treatment of colorectal liver metastases: an analysis of 395 patients. World J Surg 2013;1333-9. 2. Bale R, Widmann G, Schullian P, Haidu M, Pall G, Klaus A, Weiss H, Biebl M, Margreiter R. Percutaneous stereotactic radiofrequency ablation of colorectal liver metastases. Eur Radiol 2012;930-7. 3. Gillams AR, Lees WR. Five-year survival in 309 patients with colorectal liver metastases treated with radiofrequency ablation. Eur Radiol 2009;1206-13. 4. Hamada A, Yamakado K, Nakatsuka A, Uraki J, Kashima M, Takaki H, Yamanaka T, Inoue Y, Kusunoki M, Takeda K. Radiofrequency ablation for colorectal liver metastases: prognostic factors in non-surgical candidates. Jpn J Radiol 2012;567-74. 5. Sorensen SM, Mortensen FV, Nielsen DT. Radiofrequency ablation of colorectal liver metastases: long-term survival. Acta Radiol 2007;253-8. 6. Siperstein AE, Berber E, Ballem N, Parikh RT. Survival after radiofrequency ablation of colorectal liver metastases: 10-year experience. Ann Surg 2007;559-65. 7. Hammill CW, Billingsley KG, Cassera MA, Wolf RF, Ujiki MB, Hansen PD. Outcome after laparoscopic radiofrequency ablation of technically resectable colorectal liver metastases. Ann Surg Oncol 2011;1947-54. 8. Jakobs TF, Hoffmann RT, Trumm C, Reiser MF, Helmberger TK. Radiofrequency ablation of colorectal liver metastases: mid-term results in 68 patients. Anticancer Res 2006;671-80. 9. Kim KH, Yoon YS, Yu CS, Kim TW, Kim HJ, Kim PN, Ha HK, Kim JC. Comparative analysis of radiofrequency ablation and surgical resection for colorectal liver metastases. J Korean Surg Soc 2011;25-34. 10. Solbiati L, Ahmed M, Cova L, Ierace T, Brioschi M, Goldberg SN. Small liver colorectal metastases treated with percutaneous radiofrequency ablation: local response rate and long-term survival with up to 10-year follow-up. Radiology 2012;958-68. 11. Otto G, Duber C, Hoppe-Lotichius M, Konig J, Heise M, Pitton MB. Radiofrequency ablation as first-line treatment in patients with early colorectal liver metastases amenable to surgery. Ann Surg 2010;796-803. 12. Reuter NP, Woodall CE, Scoggins CR, McMasters KM, Martin RC. Radiofrequency ablation vs. resection for hepatic colorectal metastasis: therapeutically equivalent? J Gastrointest Surg 2009;486-91.

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1804.2 Will microwave ablation replace radiofrequency ablation? M. Bezzi Department of Radiological Science, University of Rome La Sapienza, Rome, Italy Learning Objectives 1. To learn about differences and advantages of MW with respect to RF 2. To learn about complications of MW with respect to RF in the treatment of patients with liver tumours 3. To learn about results of MW and comparative studies with RF in patients with liver tumours No abstract available.

1804.3 Is there a role for irreversible electroporation in the liver? O. Seror Radiology, Hôpital Jean-Verdier, Bondy, France Learning Objectives 1. To learn about evidence coming from preclinical studies regarding IRE of the liver 2. To learn about clinical results of IRE in the treatment of liver tumours 3. To learn about advantages and limitations of IRE Since the 5 years that irreversible electroporation (IRE) has been available for clinical use, its role in the treatment of liver tumors remains unclear. One must admit that in the same time, many other alternative ablative technologies such as radiofrequency, microwave frequency, or cryotherapy have improved and are easier to use. However, it must be pointed out that in opposition to all other physical ablation techniques, the main lethal effect of IRE does not rely on thermal coagulation of the tissue. Several experimental studies in animal models have confirmed that IRE once performed in liver leaves the lumens of small bile ducts and vessels intact within the ablation zone. Moving into clinical settings, IRE appears currently as a unique option for safe curative treatment of non-resectable liver tumors located in areas too dangerous/risky for any thermal techniques because of the likelihood of collateral thermal injuries. Despite the benefit of using IRE for tumors located in critical areas such as the central nodules abutting the main bile duct, IRE is still performed only in few expert centers. In fact, up to now, too many technical limitations to set up the generator properly were encountered during IRE procedures, such as the need of placing several electrodes roughly parallel and performing accurate measurements of all inter-electrodes spacing, rendering the procedure lengthy and cumbersome. Currently, there is a clear trend to simplify IRE procedures, thanks to the worldwide growing clinical experience and huge improvements accomplished in the field of imaging guidance. The time to include IRE in the standard spectrum of therapeutic strategies has arrived.

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1804.4 Is high intensity focused ultrasound in the liver clinically acceptable? F. Orsi Unit of Interventional Radiology, IEO Istituto Europeo di Oncologia, Milan, Italy Learning Objectives 1. To learn about results of HIFU in the treatment of liver tumours 2. To learn about advantages and limitations of HIFU for the treatment of liver tumours 3. To learn about future prospects of HIFU in the liver High-intensity focused ultrasound (HIFU) is a highly precise medical procedure using focused ultrasound energy for selectively burning and destroying the tumor tissue at depth within the body without harming overlying and adjacent structures within the path of the beam. The possibility that HIFU therapy might be developed as a result of controlling local heating phenomena was introduced by Lynn et al. in the 1940s, but the technique was not developed at that time because of inadequate targeting methods. The advent of more sophisticated imaging techniques has led to a resurgence of interest in HIFU. Unlike radiofrequency or cryoablation, which are also used to ablate tumors, HIFU is completely non-invasive and can be used to reach tumoral areas that are deep within the body if there is an acoustic window for allowing for the transmission of ultrasound energy. Preliminary reports underline a reduced toxicity with HIFU ablation compared with other ablation techniques because of the non-invasive nature of the procedure. Initial devices never used widely in clinical practice were transrectal probes, which have been used predominantly to treat prostate cancer. Extracorporeal devices are significantly larger and can be used to treat a variety of problems, most commonly intra-abdominal solid tumors. As a result, these extracorporeal devices use transducers with a longer focal length using both ultrasound or MRI for targeting the organ. While USgFUS has been widely validated for the treatment of lesions in abdominal moving organs, MRgFUS is still currently facing decisive challenges in this field, mainly regarding lesion accessibility to the HIFU beam and tracking of lesion position in moving organs, such as liver and kidneys. Several studies on HIFU treatment of HCC and secondary liver metastases in human clinical trials have been already published. Wu et al. used an extracorporeal HIFU device to treat 68 patients with liver malignancies, showing complete tumor ablation in 30 cases, in which surgical excision followed HIFU treatment. HIFU has also been used by Li et al. for palliation in patients with advanced-stage liver cancer, observing 87% of symptomatic improvement after treatment. In Oxford, UK, in 2005, 22 patients with liver metastases were treated with HIFU, revealing a favorable adverse event profile compared with open or minimally invasive techniques. The only randomized clinical trial was performed by Wu et al., who randomized patients between transarterial chemoembolization (TACE) alone and HIFU after TACE. The median survival times were 11.3 months in the combined HIFU–TACE group and 4 months in the TACE-only group (p = 0.0042). Authors from Chongqing University in China (Zhang et al.) observed that ablation with HIFU can safely achieve large areas of coagulation necrosis in tumors close to major blood vessels without any damage to vascular integrity. Hence, this therapy can be applied to treat many patients who cannot undergo conventional treatment techniques due to either absolute and relative contraindications or tumor location. Ng et al. [8] involving 49 patients receiving HIFU for unresectable HCC showed that the technique was effective in 79.5% of cases. The study found that only tumor size (≥3.0 cm) was a significant risk factor affecting the complete ablation rate. The 1- and 3-year overall survival rates were 87.7% and 62.4%, respectively. Cheung et al. in 2012 reported that HIFU was well tolerated in 100 HCC patients with cirrhosis: 18 patients (13%) developed

Abstract Book complications, mainly represented by skin and subcutaneous tissue injuries. In the same study, 90% of complete tumor response after HIFU was reported. There was no complete or partial tumor response in the TACE group. HIFU was shown to be a safe treatment, and none of the patients receiving HIFU as a bridging therapy developed complications due to intolerance after the procedure. In a more recent publication, they also reported that in the treatment of HCCs sized 3–8 cm, HIFU ablation alone or together with TACE may produce better survival outcomes than TACE alone would. General anesthesia is commonly used during HIFU ablation of liver tumors to control the position of the liver through respiratory movement control. However, complete ablation sometimes cannot be achieved because the liver is located behind the rib cage and ultrasound energy cannot pass through bones. When tumors are deeply located, the liver can be pushed down by holding a prolonged inspiration, and small tumors at the dome of the liver can be ablated. Large and deep tumor masses sometimes cannot be completely treated because the energy may not be homogeneously delivered within the tumor through the narrow rib spaces. Tumors located in the left liver lobe are usually completely and better targeted because they are not entirely covered by the ribs. Furthermore, as a larger tumor requires a longer ablation time, the skin and the subcutaneous tissue unavoidably absorb a large amount of acoustic energy, leading to the so-called “fat sclerosis” phenomenon. References 1. World J Gastroenterol. 2013 Nov;19(43):7494-9. 2. Tech Vasc Interv Radiol. 2013 Dec;16(4):192-200. 3. Cardiovasc Intervent Radiol. 2013 Dec;36(6):1464-76. 4. J Ultrasound Med. 2013 Oct;32(10):1855-62. 5. World J Gastroenterol. 2013 May;19(20):3083-9. 6. HPB (Oxford). 2013 Aug;15(8):567-73. 7. Hepatobiliary Pancreat Dis Int. 2012 Oct;11(5):542-4. 8. World J Surg. 2012 Oct;36(10):2420-7. 9. Br J Radiol. 2012 Oct;85(1018):e940-6.

Special Session Patient safety and quality assurance in interventional radiology 1805.1 What is quality assurance? Lessons from radiation oncology L.M. Kenny Division of Oncology, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia Learning Objectives 1. To learn about requirements for quality assurance systems 2. To learn about quality assurance systems in radiation oncology 3. To learn about applicability of radiation oncology quality assurance systems in IR Radiation oncology (RO. has developed sophisticated programmes of quality assurance (QA), which aim to provide consistency and safety in treatment. RO practice standards or QA programmes exist in many states, countries and regions of the world. Support from medical physicists affiliated to the departments of RO usually underpins the day-to-day QA process. QA programmes should include a feedback mechanism for the identification of issues and correction in a continuous fashion. The more sophisticated the delivery of treatment, the greater the need for exacting quality standards. Although QA programmes for RO standards quite rightly have a major focus on ensuring accurate radiotherapy delivery, comprehensive programmes cover the whole care pathway from initial referral processes through every single step of decision making, the accurate delivery of care, requisite staff, record keeping

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and communication. Once a decision has been made to treat, there needs to be rigour in treatment planning, identifying and mapping out the volumes of targets for treatment and avoidance, the planning process, the actual delivery of treatment and the follow-up. Documentation of outcomes, including complications, is important as is the holistic care of the patient. QA is not just about the equipment used. Being able to identify and accurately treat the target tissue is critical in radiotherapy and is just as critical in interventional oncology. There is no consolation for a geographic miss of the target that otherwise could have been averted by careful planning and treatment delivery, no matter how sophisticated the technology used to deliver the treatment. For complex RO procedures, evidence supports better outcomes in larger RO units with higher patient numbers. The principles applied to QA for RO are directly applicable to interventional oncology.

1805.2 The role of regulatory agencies: do they help or do they hinder? J. Wilkinson Director of Devices, Medicines and Healthcare products Regulatory Agency, London, United Kingdom Learning Objectives 1. To learn about the role of regulatory agencies in health care 2. To learn about the role of regulatory agencies in IR 3. To learn how regulatory agencies and IR can work together Patient safety in relation to medical devices is a multi-stakeholder activity with manufacturers, notified bodies, regulators, healthcare professionals, patients and public, all playing important roles. The goal of MHRA is to ensure that the system works well in enabling new and innovative technologies to be introduced whilst minimising risk to patients. Clinical input is required at all stages of the process but feedback from real-life clinical practice is probably the most important activity universally. This includes adverse incident reporting, but goes much further as we seek to work with the clinical community on continuous improvement of safety and performance. The agency strives for very pro-active surveillance, and this can lead to activities such as sharing analysis of registry data as well as feeding into training needs for clinicians and identifying opportunities for product or standards development. In short, we aim to be partners and facilitators in supporting the continuous improvement of clinical practice rather than an austere regulator who intervenes only when things go wrong. The need for an evolving relationship between MHRA and clinical community were highlighted in two recent reviews of the agency lead by Parliamentary Under Secretary of State, Earl Howe, (1) and Chair of the Academy of Medical Royal Colleges, Professor Terence Stephenson (2). References 1. PIP Silicone Breast Implants: Review of the actions of the MHRA and Department of Health, May 2012, https://www.gov.uk/ government/uploads/system/uploads/attachment_data/ file/216537/dh_134043.pdf. 2. Independent Review into MHRA access to expert clinical advice. Stephenson, April 2014.

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1805.3 How CIRSE can improve patient safety in IR A.-M. Belli Dept. of Radiology, St. George’s Hospital, London, United Kingdom Learning Objectives 1. To learn about basics of patient safety in IR 2. To learn about CIRSE’s patient safety standards 3. To learn about the role of checklists in IR IR is a unique specialty using imaging to guide minimally invasive therapeutic procedures, often replacing standard surgery. The procedures are complex and require specific training and facilities to ensure the best results. Interventional radiologists require expertise in imaging and radiation safety. They have to know how to apply their techniques in multiple diseases and organs and how to take care of their patients. However, because healthcare systems and training throughout Europe differ, it is essential to ensure that training is harmonised as far as possible, and that all IRs comply with basic IR standards. To this end, CIRSE produced the IR curriculum to either act as a template for national curricula or to be simply adopted. The curriculum emphasises the need for patient care, clinical knowledge and technical skills, clinical governance and systems-based practice. The assessment of competence is measured by clinical practice and by passing the European Board of Interventional Radiology (EBIR). The aim of this qualification is to standardise training across Europe to produce competent IRs. The use of radiation to guide our interventions also means that we must be aware of radiation safety and adopt methods to minimise radiation dose to patients and staff alike. CIRSE has been active in advising the European Commission’s MEDRAPET project. These are guidelines on radiation protection education and the training of medical professionals in Europe. These guidelines will eventually lead to legislation, ensuring that all practitioners using ionising radiation will be suitably trained. CIRSE has appointed a radiation subcommittee to advise on radiation safety issues, and this is also a key component of the curriculum. Ensuring IRs are trained and educated to a uniform standard throughout Europe will provide a solid infrastructure as a foundation. This is the surest way of improving patient safety.

1805.4 Quality improvement guidelines in interventional oncology T. de Baère Dept. of Interventional Radiology, Institut Gustave Roussy, Villejuif, France Learning Objectives 1. To learn about fundamentals of quality assurance in oncology 2. To learn about the use of quality improvement guidelines in IO 3. To learn about the role of CIRSE in quality assurance in IO Interventional oncology is a growing field of practice that can provide treatment of malignant disease with high efficacy and low morbidity. Interventional oncology is a rapidly evolving subspeciality that is technology driven and is at the crossing of different specialities, namely imaging and surgery. Due to its rapid growth and requirement both in the field of imaging and patient care, interventional oncology has had to face several challenges. Quality requirement during the procedure includes imaging through the quality of images, irradiation to the patient and physician, treatment planning, needle or catheter guidance, and the use of anesthesia. Furthermore, the challenge of sterility and adapted environment to interventional oncology is important as well as preand post-procedure factors such as indication of treatment, antibiotherapy, post-procedural pain management. In order to minimize

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the risk due to variations, standard processes may help to improve quality while decreasing the impact of inevitable human error, such lesson has been learned from nuclear industry or aviation. The introduction of safety checklists is responsible for decreasing the complications in the surgical literature. Such safety checklists must include a procedure planning/sign-in section when the patient is in the IR room and a sign-out section to assure post-intervention care. Quality improvement implies to have metrics in order to evaluate our practice and the impact of various measures taken on these metrics. Establishment of standardized metrics will allow the compilation of comparative data. Such standardized metrics should be provided by the scientific society to their members to allow comparison. In the coming era of quality-driven health care, those who can prove their expertise will be rewarded with patient referrals and thirdparty reimbursements. Qualification and quantification of this quality by metrics will build the credibility of interventional oncology and ensure the survival and growth of the specialty. These efforts to improve quality must be pursued on a continuous basis because “quality is a never-ending cycle of continuous improvement,” as written by W. Edwards Deming, who is the father of the Toyota Production System.

Abstract Book organs is present. As the indications for resective or ablative methods broadly overlap, patients’ wish and referring physicians’ preference is decisive in most cases. In conclusion, the treatment of SRC is recommended if patients have a long life expectancy, a good medical condition, a linear tumor growth, and a biopsy-proven SRC. Active surveillance is recommended, if patients with small renal lesions are older than 70 years and have no or slow tumor growth, relevant comorbidities, and limited life expectancy. References 1. Beisland C et al: Natural and clinical course of renal cell carcinoma – better prospect for the patients. Scand J Surg 2004;93:97-101. 2. Margulis V et al: Analysis of clinicopathologic predictors of oncologic outcome provides insight into the natural history of surgically managed papillary renal cell carcinoma. Cancer 2008;112(7):1480-8. 3. Shuch B et al: Adverse health outcome associated with surgical management of small renal mass. J Urol 2014;191:301-8.

2501.2 Ablation: results and complications D.J. Breen Radiology, University Hospital Southampton, Southampton, United Kingdom

Fundamental Course Basic principles of renal cancer management 2501.1 Triage of the small renal cancer patient J. Tacke Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Klinikum Passau, Passau, Germany Learning Objectives 1. To present the current indications for local management of renal cell carcinoma 2. To learn how to select patients for ablation, surgery or active monitoring 3. To present the current indications and techniques for biopsy of the renal mass before ablation Due to an increasing incidence of small renal cancer (SRC) – in Germany, about 15,500 new cases per 100,000 persons are expected to have SRC in 2014 – there is a strong need for optimum patients triage. The decision to or not to treat a suspected renal tumor remains difficult if no absolute criteria of malignancy are present. Reliable tumor markers are still not available. To understand the natural course of renal tumors, it is important to be aware that malignancy may be size-dependent. Many studies have shown that small tumors (3–5cm) are considered to be less malignant than larger ones. Further, a considerable percentage of small tumors may be benign. On the other hand, small tumors may also grow aggressively and demonstrate an invasive character. Moreover, the growth rate of small tumors is unknown at the time of detection, but may be of importance, particularly in elderly patients. Thus, the decision-making process for treatment or active surveillance depends on the tumor size, appearance, and growth rate as well as patient age. If there is any doubt regarding the etiology of a renal lesion, a histological proof of etiology (with an accuracy of about 90% for image-guided percutaneous biopsy) is mandatory. Current guidelines recommend treatment of a non-metastasizing SRC if it is resectable in size and location and if the patient can tolerate surgery. For resective treatments, recurrence-free survival and cancer-specific survival are about 95–99% and 91–96%, respectively. Due to comparably good long-term results for ablative therapy, SRC <3.5 cm in diameter may be treated successfully even by RF ablation or cryotherapy if no invasion of collecting system or adjacent

Learning Objectives 1. To learn about techniques for ablation 2. To discuss the results of ablation techniques 3. To discuss the complications of each ablation technique and their management Outcomes from image-guided renal tumour ablation continue to mature and indicate that it is an effective therapeutic option alongside the more traditional partial nephrectomy. It is often suggested that image-guided tumour ablation should still be reserved for elderly patients with a poor performance status. However, it should be noted that even in major centres, partial nephrectomy incurs major complications at a rate of 4%–30% [1] and necessarily, can incur warm ischaemic functional injury to the operated kidney besides the undoubtedly higher costs and longer bed stay for patients. Laparoscopic and robotic partial nephrectomy are still only routinely practiced in a handful of teaching centres. Meanwhile, outcome data from percutaneous, image-guided renal tumour ablation suggests that this procedure has an increasingly negligible subtotal treatment rates and a local recurrence rate of 2%–3%, which is likely to be oncologically insignificant. A vast majority of the published literature on renal tumour ablation has centred around RFA or cryoablation (CRA) with surprisingly few publications detailing outcomes from microwave and even less from IRE. A consensus opinion suggests that RFA and CRA obtain comparable recurrence-free survival for tumours of <3 cm but that the improved visualisation and robustness of CRA yields effective treatment dividends at >4 cm. The meta-analysis by Kunkle et al [2] in 2008 demonstrates that the treatment efficacy of CRA exceeded that of RFA, but the more recent analysis by El Dib [3] shows no statistical difference between the two techniques. With regards to complications, both CRA and RFA are generally well tolerated. Most large series quote major complications like Clavien– Dindo grade 2 and above, requiring active interaction at 4%–6% [4, 5]. In general, self-limiting haematoma formation is noted, but occasionally, active bleeding, pneumothorax and pelvicalyceal leakage are also found. Increasingly, the percutaneous literature in highvolume centres suggests that anterior–posterior tumour location is no longer an issue in terms of complications. In the author’s experience, cryoablation incurs little or no pelvicalyceal injuries due to

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its unique ability to preserve collagenous structures, but caution should clearly be undertaken when ablating in the vicinity of the pelviureteric junction. References 1. Uzzo R et al. J. Urol. (2001. 166:6. 2. Kunkle DA et al. Cancer (2008. 113:2671. 3. El Dib R et al. BJUI (2012. 110:510. 4. Atwell TD et al. J Vasc IR (2012. 23:48. 5. Breen DJ et al. BJUI (2013. 112:758.

2501.3 Surgery: results and complications M. Sullivan Department of Urology, The Churchill Hospital, Oxford, United Kingdom Learning Objectives 1. To learn about indications and techniques for nephron-sparing surgery in renal cancer 2. To discuss the results of surgical techniques 3. To present the complication rates of surgical techniques Until recently, the standard of care for curative therapy for renal cell cancer (RCC) was radical nephrectomy. In 2014, nephron sparing surgery is recommended for localised RCCs and radical nephrectomy for those with locally advanced tumour growth, when partial nephrectomy is not feasible due to unfavourable location of the tumour, e.g. centrally or when patients’ general health has significantly deteriorated or patients’ choice (1,2). This shift has been driven by an equal oncological efficacy with partial nephrectomy for renal tumours of <4 cm and 4–7 cm, an increased incidental detection of small renal masses (<4 cm) with a significant proportion of these being benign (approximately 20%. (3), the possibility of late recurrence of RCC in the contralateral kidney and a higher rate of new onset chronic kidney disease (CKD) or worsening of CKD following radical nephrectomy that leads to more cardiovascular events and worse overall survival (3). Approximately 25% of new presentations for RCC undergoing surgery have CKD (3). Following surgery for RCC, cancer survival data split by TNM staging presently gives a 5-year cancer specific survival of 81% for stage I, 74% for stage II, 53% for stage III and 8% for stage IV (4). Open radical nephrectomy has significant bleeding in 6.5% of cases, infection in 5.7%, pleural damage in 9.3% and splenic/bowel injury/ pulmonary embolism and lymphatic collections in <1% (3). Complications for open partial nephrectomy are a little higher than open radical nephrectomy primarily due to bleeding events. Urinary fistulae occur in 4.4% of cases (5). Laparoscopic and robotic partial nephrectomy appear to have equivalent oncological outcomes to the open approach, but studies tend to be immature (2). Complications are also equivalent to the open approach with the exception of bleeding with the laparoscopic approach, which is higher (2). These reported procedures have tended to occur in a limited number of specialised centres. Lymphadenectomy is restricted to staging, because extended lymphadenectomy does not improve survival. Surgery can be curative in metastatic disease if all deposits can be excised. The role of cytoreductive nephrectomy or cytoreductive partial nephrectomy in the era of tyrosine kinase inhibitors is unclear though several trials are trying to answer this question. References 1. EAU Guidelines. Renal Cell Carcinoma 2013. 2. AUA Guideline for the Management of Clinical Stage 1 renal mass 2009. 3. Treatment of localised renal cell carcinoma. Van Poppel et al, Eur Urol 2011, 60: 662-72.

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4. AJCC Renal Cell Cancer survival data 2014. 5. A prospective randomised EORTC Intergroup Phase 3 study comparing the complications of elective nephron-sparing surgery and radical nephrectomy for low stage renal cell carcinoma. Van Poppel et al, Eur Urol 2007, 51: 1606-15.

2501.4 Patient follow-up and imaging J. Garnon Interventional Radiology, University Hospital of Strasbourg, Strasbourg, France Learning Objectives 1. To present the current clinical strategies for follow-up of patients after ablation 2. To learn when and how to image the patient after renal ablation 3. To learn how to detect residual/recurrent tumours and indications for retreatment Follow-up is mandatory for any renal tumor that is ablated. The goal of follow-up is initially to look for complications and confirm the complete ablation and to search for local and distant recurrence of the disease. It should include repeated clinical, biological, and radiological evaluations, and therefore, it needs the close collaboration between the urologist and the interventional radiologist. During the initial days after ablation (mainly the first 24 hours), the main goal of follow-up is to rule out a complication. The most frequent complication is bleeding. Clinical examination should look for hematuria and flank pain, which may indicate a hematoma. A biological analysis should include at least an evaluation of the renal function and hemoglobin. Any significant modification of these blood parameters may indicate a complication. At this point, imaging is optional in many centers and may be reserved for doubtful cases or when a complication is clinically or biologically suspected. In contrast, some radiologists systematically advocate an ultrasound before the patient is discharged. In the initial months (6 months to one year) after ablation, the goal is to confirm the complete ablation of the lesion and relies on imaging only. MRI is the best imaging modality to precisely evaluate the ablated area. Whenever possible, it should include dynamic enhanced sequences with subtraction imaging, which show complete devascularization of the tumor in case of complete ablation. Care should be taken to not misinterpret postoperative inflammatory changes as a tumor. When MRI is contraindicated, a triple phase enhanced CT scan should be performed. Moreover, contrast-enhanced ultrasound may be interesting, but there are very few studies that have currently evaluated enhanced ultrasound in this specific indication. There is no clear consensus for the duration of imaging. Most radiologists perform MRI (or CT) at 1, 3, 6, and 12 months after the treatment to confirm that ablation is complete. After this period, imaging is performed to identify any local and distant recurrence of the disease. The radiological exploration should, therefore, not only focus on the ablated tumor but also on the kidneys and all other organs (adrenal, pancreas, liver, lymph nodes, lung, bone etc). Imaging is usually repeated every 6 months during 2 years and thereafter, every year. Follow-up should theoretically continue for a lifetime.

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Special Session Acute lower limb ischaemia 2502.1 Epidemiology, clinical presentation and imaging A. Buecker Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum des Saarlandes, Homburg, Germany Learning Objectives 1. To understand the epidemiology of acute lower limb ischaemia 2. To learn to recognise the clinical presentation of acute lower limb ischaemia 3. To learn about different methods of imaging and how to differentiate acute from chronic lower limb ischaemia No abstract available.

2502.2 Morbidity, mortality, limb loss rates and patient selection G.S. Goh Radiology, Alfred Health, Melbourne, VIC, Australia Learning Objectives 1. To learn about the associated morbidity and mortality of ALI 2. To learn about the clinical outcomes of different treatment methods including surgery 3. To learn about the cost effectiveness of revascularisation and amputation The mortality and morbidity of acute limb ischaemia can be high if not treated early due to the development of localised tissue and nerve ischaemia. If untreated altogether, the morbidity and mortality also remain high. Pain and significant functional limb loss may result, and in some cases, limb amputation may be required. Identifying the group of patients who would benefit from thrombolysis and/or embolectomy and treating these patients in a time-critical manner, often urgently, is important to maximise the chances for a favourable clinical outcome.

2502.3 Thrombolysis: evidence and technique D.O. Kessel Department of Radiology, St. James’s University Hospital, Leeds, United Kingdom Learning Objectives 1. To learn how to select patients and perform thrombolysis 2. To learn about the evidence for outcomes of thrombolysis 3. To learn how to avoid and manage complications Key points · Management of acute arterial occlusion should be based on the clinical syndrome/clinical category. · Treating claudicants is contentious due to the risks inherent in thrombolysis. · Treatment of severe ischaemia aims to restore circulation before there is irreversible damage to muscles and nerves. · Thrombolysis typically takes several hours to restore blood flow and is unsuitable when the limb is immediately threatened. · Thrombolysis for in situ thrombosis is almost always accompanied by a procedure to treat the underlying arterial stenosis. · Pharmacological thrombolysis produces a systemic ‘lytic state’ with the risk of severe bleeding.

Abstract Book · The risks of thrombolysis increase with patient age and appear much greater in patients over 75 years old. Acute occlusion of an artery or a bypass graft is typically the result of in situ thrombosis or secondary to an embolus from a proximal source. It is important to recognise that the blockage of a peripheral artery gives rise to a spectrum of clinical sequelae, which correlates with the degree of circulatory compromise. Management of acute limb ischaemia should be based on the presenting clinical syndrome and the cause of the occlusion. The abrupt loss of the major arterial supply to a limb produces a typical syndrome: painful, cold white leg with absent pulses. Irreversible damage to muscles and nerves will occur unless the circulation is reestablished within a few hours. Occlusion of a significantly diseased vessel or a small branch vessel may result in little or no change in symptoms. For example, when in situ thrombosis occurs in an already diseased artery, established collaterals compensate partially for the loss of in-line flow. In these circumstances, the limb remains viable and the patient may present with de novo claudication or an increase in symptoms. This explains why most patients with occluded superficial femoral arteries do not present with acute limb ischaemia. Conversely, when a bypass graft occludes, there are usually severe symptoms due to a lack of collaterals. The severity of acute lower limb ischaemia should be graded according to the following categories. Category I: Viable: Not immediately threatened II: Threatened: Requires revascularisation IIa: Marginally: Salvageable if promptly treated. Minimal/no sensory loss IIb: Immediately: Salvageable with immediate revascularisation. Increasing sensory loss, rest pain, mild-to-moderate weakness III: Irreversible: Major tissue loss/permanent nerve damage. Inevitable profound sensory loss and paralysis Patients with category II ischaemia require revascularisation to prevent amputation. Patients with category I ischaemia are treated for symptom relief, e.g. severe claudication. A variety of techniques exist to minimise damage and restore circulation to the acutely ischaemic limb; in simple terms, these are as follows: · Adjunctive anticoagulation: Heparin infusion to prevent the propagation of thrombus and preserve microcirculation · Removal of the blockage: Surgical embolectomy, percutaneous thrombectomy, pharmacological/pharmacomechanical thrombolysis · Bypass of the blockage: Surgical bypass graft In order to understand thrombolysis, it is necessary to have working knowledge of the physiological processes involved in the formation of a blood clot. Abnormal flow, abnormal vascular endothelium and hypercoagulability states, all predispose to thrombosis. Unless the underlying cause is treated, rethrombosis is very likely. Formation of a blood clot is a natural response to vascular injury and in normal circumstances has a protective role by limiting bleeding. When thrombosis results in vascular occlusion, distal ischaemia causes a variety of syndromes depending on the territory, the presence of a collateral circulation and whether there is distal embolisation at the time of thrombosis. Arterial occlusion can be asymptomatic and benign or have devastating clinical consequences. Stages of formation of a blood clot Platelet plug The release of tissue factor (thromboplastin) from the subendothelial matrix of atheromatous plaque triggers the extrinsic coagulation pathway. This produces thrombin, which is central to the clotting process. Thrombin activates platelets, leading to the following: · Adhesion to the vessel wall. · Adhesion stimulates platelet degranulation and expression of glycoprotein IIb/IIIa receptors.

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· IIb/IIIa receptors bind to fibrinogen. · Fibrinogen cross-links platelets, resulting in aggregation. Formation of the platelet plug can be blocked by platelet inhibition with aspirin or clopidogrel or IIb/IIIa receptor antagonists such as abciximab. Thrombolysis is not effective against platelet plug. Thrombus formation If the platelet plug progresses, the intrinsic coagulation cascade will be activated. · Platelet degranulation releases thromboxane A2 and ADP, which activate more platelets. · Active platelets interact with coagulation factors. · Thrombin production increases. · Thrombin cleaves fibrinogen into fibrin monomers. · Fibrin monomers cross-link to form a polymer. · The mesh of fibrin polymer traps blood cells and platelets to form a true blood clot. · Clot enlargement slows blood flow with subsequent vascular occlusion. · Clot propagates proximally and distally. Fibrin polymer is the substrate for thrombolysis. Thrombolysis Cross-linked fibrin is naturally broken down by circulating plasmin and is the target for thrombolysis. · All currently available thrombolytic agents are serum proteases. · Proteases activate plasminogen to form plasmin. · Plasmin cleaves the fibrin polymer and thus breaks down clots, allowing restoration of blood flow. · Unbound plasmin has a half-life of only 0.1 second and is rapidly broken down by circulating α2 -antiplasmin. Agents such as streptokinase and urokinase bind circulating plasminogen creating free plasmin; this is rapidly neutralized by α2 -antiplasmin. · Once the α2 -antiplasmin is exhausted, the residual plasmin will degrade fibrinogen, factor V and factor VIII, leading to a bleeding tendency. ‘Fibrin-specific’ agents such as tissue plasminogen activator have a markedly increased affinity for plasminogen when bound to fibrin. · Production of plasmin is greatest where it is most needed, i.e. within the blood clots. · Bound plasmin has 50 times greater half-life than its free counterpart, increasing its effectiveness. · Fibrin-specific agents make a systemic ‘lytic state’ less likely as they result in lesser reductions in circulating plasminogen and fibrinogen levels. · However, as there is always some depletion of fibrinogen in combination with fibrin degradation products and unbound plasmin, a systemic lytic state can develop. Peripheral arterial thrombolysis In 2003, a systemic review of coronary artery thrombolysis identified 142,097 patients in 14 trials and showed a clear benefit of systemic thrombolysis in terms of acute mortality and cardiac morbidity. Compared with this, there is little evidence for thrombolysis in peripheral arterial ischaemia. There have been 3 Cochrane reviews related to peripheral arterial thrombolysis; these included only 2,427 patients in total. The reviews compared outcomes with surgery (1,283 patients), between agents (687 patients) and infusion techniques (457 patients). These trials showed us that: · There is no significant difference in limb salvage or death at 30 days, 6 months and 1 year between patients randomised to initial surgery or initial thrombolysis. · Major haemorrhage is more common in patients having thrombolysis. · Distal embolization is more common in patients having thrombolysis. · Intra-arterial thrombolysis is superior to intra-venous thrombolysis in outcomes and safety.

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· Streptokinase is associated with greater risk of haemorrhage than recombinant tissue plasminogen activator (rt-PA). · ‘High-dose’ and ‘forced-infusion’ techniques or adjunctive agents such as platelet glycoprotein IIb/IIIa inhibitors may speed up thrombolysis, but these are not accompanied by lower amputation rates or a decreased need for adjunctive endovascular or surgical procedures. Techniques of thrombolysis Contraindications to thrombolysis The following list is not exhaustive but includes the most important contraindications: · Immediately threatened limb · Active bleeding diathesis · CVA/TIA within 2 months · Surgery within 6 weeks · CPR within 6 weeks · Uncontrolled hypertension · Oral anticoagulation Consent Any discussion of procedure, alternatives and risks and questions asked must be recorded. The following are important risks: · Major haemorrhage (approximately 7%) · CVA (approximately 3%) · Major amputation 10–20% for Class IIa ischaemia · Adjunctive surgery, angioplasty and stenting · Death, particularly if there is a complication · Major haemorrhage (approximately 7%) Arterial access · Choose a site that will allow access to deliver the drug, perform thrombus aspiration and also to treat any underlying lesion (PTA/ stenting). · Consider ultrasound guided puncture. · Ensure that the sheath is securely taped in place with a clear dressing to allow inspection. Procedure · Attempt to traverse the occlusion with a guidewire. This is a good predictor of success. Highly organised thrombus is unlikely to lyse. Techniques There is no evidence of improved limb salvage or death for any technique. Low-dose infusion: Position an end- and side-hole catheter with its tip in the thrombus and then commence an infusion, e.g. 0.5 mg/ hour rt-PA. Accurate delivery requires a syringe driver, e.g. a Graseby pump. High-dose techniques: Inject a bolus, e.g. 5-mg rt-PA throughout the thrombus . This may be repeated 2–3 times at 10–15 minute intervals. Subsequently, a high-dose infusion, e.g. rt-PA (5 mg/hour) or a low-dose infusion should be administered. In general, no more than 20-mg rt-PA is given before starting low-dose infusion. Forced-infusion techniques: There are various proprietary devices; these produce high-pressure jets of the lytic agent, which penetrate and disrupt the thrombus. Split infusions: For extensive thrombus, the agent can be delivered proximally through a sheath and more distally via a catheter. The dose is divided equally between the 2 infusions. Heparin infusion: 500–1000 IU/hour to reduce the risk of pericatheter thrombus formation or thrombus propagation. Heparin can be administered either via an intravenous infusion or through the side arm of the arterial sheath. Drugs should be administered according to a local protocol, ideally on a dedicated drug chart. Check angiography Angiography is performed at intervals and the catheter repositioned as necessary to maintain an intra-thrombus position. There is no absolute timing; every 2–4 hours for high dose and low-dose infusions are often left overnight.

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Monitoring The patient must be cared for in a ward able to provide close monitoring and to respond immediately to any deterioration. The following must be checked hourly: · Puncture site · Limb viability · Routine observations, including neurological Adjunctive techniques Antiplatelet agents: All patients should be taking aspirin and, if necessary, a loading dose of 500–1,000 mg can be given intravenously. There is limited evidence to suggest that dual antiplatelet agents may improve outcome at the expense of an increase in bleeding complications. Analgesia: Strong analgesia should be available. Endpoints As a general principle, there should be progressive reduction in the volume of thrombus on each angiogram. If there is no progress between studies, then either the dose should be increased or the procedure terminated. If there is still residual thrombus at the point of lytic stagnation, thrombus aspiration can be attempted. If the flow is sluggish, then rethrombosis is very likely unless there is a treatable lesion. Complications Complications of thrombolysis are common and can be life threatening. Bleeding: Treatment should be stopped immediately if there is evidence of bleeding and if necessary a haematological opinion obtained Puncture site: If there is bleeding around the arterial sheath, it is usually worth exchanging for a sheath one size larger. Stroke: If a neurological deficit develops, the infusion should be stopped and urgent CT arranged. If there is a thrombotic stroke, then a neurological opinion should be obtained regarding continuing therapy. Distal embolization: Distal embolization occurs as the thrombus fragments and can cause clinical deterioration, in the worst case trash foot. Consider thrombus aspiration and if the clinical condition allows, continue infusing to lyse the emboli. Summary Thrombolysis remains a useful tool, particularly for category IIa acute limb ischaemia. There is no evidence that accelerated techniques of drug delivery improve key outcomes of limb salvage, need for surgery or death. New agents may appear with increased ‘fibrin specificity’, potency and resistance to plasminogen activator inhibitor. Future developments are likely to focus on combined techniques rather than a purely pharmacological approach. References 1. Surgery versus thrombolysis for initial management of acute limb ischaemia. Berridge DC, Kessel DO, Robertson I. Cochrane Database Syst Rev. 2013 Jun 6;6:CD002784. doi: 10.1002/14651858. CD002784.pub2. Review. PMID: 23744596. 2. Fibrinolytic agents for peripheral arterial occlusion. Robertson I, Kessel DO, Berridge DC. Cochrane Database Syst Rev. 2013 Dec 19;12:CD001099. doi: 10.1002/14651858.CD001099.pub3. Review. PMID: 24357258. 3. Infusion techniques for peripheral arterial thrombolysis. Kessel DO, Berridge DC, Robertson I. Cochrane Database Syst Rev. 2004;(1):CD000985. Review. PMID: 14973961.

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2502.4 Mechanical thrombectomy: evidence and technique H.-J. Wagner Department of Radiology, Vivantes Klinikum im Friedrichshain, Berlin, Germany Learning Objectives 1. To learn about mechanical thrombectomy devices and when they are indicated 2. To learn about the evidence for outcomes of mechanical thrombectomy 3. To learn how to avoid and manage complications No abstract available.

Special Session Abdominal aorta - Evidence forum 2503.1 Fenestrated versus Chimney EVAR for pararenal aortic aneurysms A. Katsargyris, E. Verhoeven Department of Vascular and Endovascular Surgery, Klinikum Nürnberg Süd, Nuremberg, Germany Learning Objectives 1. To learn how to select and triage patients 2. To learn the technical features of both techniques 3. To summarise advantages and disadvantages of both techniques Introduction Open repair of pararenal abdominal aortic aneurysms (AAA) is a complex surgical procedure that results in higher mortality and morbidity rates due to cardiopulmonary and renal complications and may be prohibited for high-risk patients.[1] Standard endovascular repair (EVAR) alone has no or little application in pararenal AAA due to the too short proximal landing zone. Fenestrated endovascular repair (F-EVAR) with custom made fenestrated grafts for the visceral branches is now an accepted alternative to open surgery for pararenal AAA.[2, 3] The chimney graft (CG) technique (Ch-EVAR) referring to stent-grafts that are implanted parallel to the aortic stent-graft to preserve flow in visceral aortic branches was also reported in the treatment of pararenal AAA.[4] This abstract describes the 2 different endovascular approaches (F-EVAR, Ch-EVAR), reviews reported results, and discusses advantages and limitations of each method. F-EVAR This technique refers to the use of customized stent-grafts with fenestrations that fit the anatomy of the visceral aortic branches with the aim of finding a suitable proximal landing zone at the level of the pararenal aorta. F-EVAR involves catheterization of both fenestrations and visceral arteries with subsequent stenting of the target vessels. The use of a fenestrated stent-graft was first reported in 1999.[5] Since then, several authors have published their experience with excellent short- and mid-term results.[3, 6] F-EVAR was not only used to treat primary pararenal AAA but also to repair paraanastomotic pseudoaneurysm after prior conventional open AAA repair or proximal type I endoleak after prior EVAR.[2, 3, 7, 8] Up to now, results on almost 1000 patients treated with F-EVAR have been published with 3 large series in Europe and 1 in the USA, reporting F-EVAR in more than 100 patients each.[2, 3, 7, 8] A recent literature review from our group including 10 F-EVAR series with 931 patients showed a cumulative operative target vessel preservation of 98.6%.[9] Early proximal type I endoleak was detected in 4.3% of patients. Thirty-day in-hospital mortality was 2.4%. Postoperative impairment of renal function was noted in 9.8%

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of patients. Dialysis was required in 1.5% of patients. Perioperative acute myocardial ischemia occurred in 2.3%, pulmonary complications in 2.3%, spinal cord ischemia in 0.8%, and ischemic stroke in 0.3% of patients. Mean follow-up ranged from 6 to 25 months. A total of 58/2431 target vessel occlusions were reported, accounting for a cumulative target vessel patency rate of 97.6%. A retrospective investigation of our F-EVAR series in Groningen showed an overall target vessel patency of 95.7% at 1 year and 88.6% at 4 years.[10] Patient survival was not widely reported. In our 8-year experience, estimated survival rate was 90.3%, 84.4%, and 58.5% at 1, 2, and 5 years, respectively.[2] Most recently, the GLOBALSTAR registry reported survival rates of 94%, 91%, and 89% at 1, 2, and 3 years, respectively.[8] Ch-EVAR Ch-EVAR involves the placement of a single or multiple stent-grafts parallel to the main aortic stent-graft to extend the proximal sealing zone, while maintaining side branch patency. Ch-EVAR was initially introduced as a “bail-out” procedure for accidentally over stented aortic branches. Later on, Ch-EVAR was used also as an adjunct to enable EVAR for some pararenal AAA in urgent and emergency settings in patients unfit for open surgery.[11] The technique has been additionally proposed as a potential alternative option in elective patients who are poor surgical candidates for open repair or not/ less suitable for F-EVAR. There are many small case series describing promising early results with Ch-EVAR in the abdominal aorta. A recent review reported cumulative Ch-EVAR outcomes from 14 publications with a total of 176 patients.[12] Cumulative operative target vessel preservation was 98.7%. Early proximal type I endoleak was detected in 10.2% of patients. Thirty-day in-hospital mortality was 3.4%. Perioperative renal complications were noticed in 9.7% of patients. Postoperative dialysis was required in 2.3% of patients. Perioperative acute myocardial ischemia occurred in 2.3% of patients. Perioperative ischemic stroke was noticed in 1.4% of patients. Mean follow-up ranged from 1 to 17 months. Target vessel patency at 6 months was 97.7% with no available data for longer term. Estimated patient survival was not reported. Discussion Is it possible to compare F-EVAR with Ch-EVAR? Conduction of a randomized trial to compare the 2 techniques does not seem realistic as the patient cohorts are too different. Even if successful, such a trial would result in low relevance and therefore have a low impact. A comparison based on the available literature is difficult for the same reasons. Reported patient cohorts are not comparable in terms of urgency of treatment and anatomy. F-EVAR requires manufacturing of a stent-graft, which can take up to 6 weeks, whereas all published series of Ch-EVAR do include a number of acute or semiacute patients.[13] The number of involved target visceral vessels is also different: it is lower in Ch-EVAR compared with F-EVAR, which reflects a different AAA configuration. Finally, a publication bias is inherent when comparing outcomes on the basis of previously published series. Despite the above limitations, some outcomes can be compared with caution. Operative target vessel preservation is very good in both techniques, but Ch-EVAR seems to be associated with more type Ia endoleaks. Some of these so-called gutter endoleaks appear to be “low flow” and may disappear during follow-up. Other gutter endoleaks, however, can quickly become larger and lead to aneurysm rupture and death as recently reported.[14] It is therefore too early to consider type I gutter endoleaks as a benign outcome as pressurization of the sac may be ongoing with aneurysm rupture as a result. Beyond gutter endoleaks, Ch-EVAR also appears to be associated with an increased ischemic stroke rate compared with F-EVAR. This is clearly related to the required upper access (brachial/ axillary artery) to introduce CG.

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The validation of F-EVAR is based on more than 6000 patients treated over a period of >10 years with published outcomes in almost 1000 patients. The overall number of reported Ch-EVAR cases is still small (<200) with short-term follow-up only. A number of important issues in Ch-EVAR still need to be evaluated and resolved such as optimal degree of oversizing, balloon vs self-expandable CG, and repair options of gutter endoleaks. Durability is also a crucial item that requires time to prove the concept. F-EVAR and Ch-EVAR do not necessarily target identical surgical risk patients with the same anatomical features. Severe angulation in the aortic arch and the descending thoracic aorta is a relative contraindication for Ch-EVAR, but is not relevant to F-EVAR. On the other hand, Ch-EVAR, in contrast to F-EVAR, can handle sharp take-off renal arteries much easily due to the upper approach. Finally, F-EVAR still requires customization, whereas Ch-EVAR offers a good option in some acute patients. Off-the-shelf fenestrated grafts have been proposed but in our opinion are far from being able to challenge either F-EVAR or Ch-EVAR at this moment, even if first optimistic reports emerge.[15] Conclusions F-EVAR is now a well-validated technique that offers a minimal invasive alternative for suitable low- and high-surgical risk patients with pararenal AAA. Ch-EVAR has demonstrated feasibility in pararenal AAA, but current evidence is not enough to support its widespread use in all elective patients. Ch-EVAR is justified in acute patients that are unfit/at high-risk for surgery as a bail-out treatment in case of unintentional renal artery coverage or in elective patients that are poor candidates for open surgery or F-EVAR. References 1. Jongkind, V., et al., Juxtarenal aortic aneurysm repair. J Vasc Surg, 2010; 52: 760-7. 2. Verhoeven, E.L., et al., Fenestrated stent grafting for shortnecked and juxtarenal abdominal aortic aneurysm: an 8-year single-centre experience. Eur J Vasc Endovasc Surg, 2010; 39: 529-36. 3. Amiot, S., et al., Fenestrated endovascular grafting: the French multicentre experience. Eur J Vasc Endovasc Surg, 2010; 39: 537-44. 4. Patel, R.P., et al., Endovascular aortic aneurysm repair with chimney and snorkel grafts: indications, techniques and results. Cardiovasc Intervent Radiol, 2013; 36: 1443-51. 5. Browne, T.F., et al., A fenestrated covered suprarenal aortic stent. Eur J Vasc Endovasc Surg, 1999; 18: 445-9. 6. Verhoeven, E.L., et al., Treatment of short-necked infrarenal aortic aneurysms with fenestrated stent-grafts: short-term results. Eur J Vasc Endovasc Surg, 2004; 27: 477-83. 7. O’Neill, S., et al., A prospective analysis of fenestrated endovascular grafting: intermediate-term outcomes. Eur J Vasc Endovasc Surg, 2006; 32: 115-23. 8. Early results of fenestrated endovascular repair of juxtarenal aortic aneurysms in the United Kingdom. Circulation, 2012; 125: 2707-15. 9. Katsargyris, A., et al., Comparison of outcomes with open, fenestrated, and chimney graft repair of juxtarenal aneurysms: are we ready for a paradigm shift? J Endovasc Ther, 2013; 20: 159-69. 10. Grimme, F.A., et al., Visceral stent patency in fenestrated stent grafting for abdominal aortic aneurysm repair. J Vasc Surg, 2014; 59: 298-306. 11. Lee, J.T., J.I. Greenberg, and R.L. Dalman, Early experience with the snorkel technique for juxtarenal aneurysms. J Vasc Surg, 2012; 55: 935-46. 12. Wilson, A., et al., Systematic review of chimney and periscope grafts for endovascular aneurysm repair. Br J Surg, 2013; 100: 1557-64. 13. Larzon, T., K. Eliasson, and G. Gruber, Top-fenestrating technique in stentgrafting of aortic diseases with mid-term follow-up. J Cardiovasc Surg (Torino), 2008; 49: 317-22.

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14. Schiro, A., et al., The chimney technique in endovascular aortic aneurysm repair: late ruptures after successful single renal chimney stent grafts. Ann Vasc Surg, 2013; 27: 835-43. 15. Sobocinski, J., et al., Off-the-shelf fenestrated endografts: a realistic option for more than 70% of patients with juxtarenal aneurysms. J Endovasc Ther, 2012; 19: 165-72.

2503.2 Iliac sidebranch graft for aorto-iliac aneurysms L.B. Lönn, T. Resch National Hospital; Cardiovascular Radiology Dep X2021, University of Copenhagen; Faculty of Health Sciences, Copenhagen, Denmark Learning Objectives 1. To define the indications for treatment 2. To learn how to select and triage patients 3. To learn technical features of both techniques Indications for treatment Endovascular aortic repair (EVAR) is a well-established procedure for abdominal aortic aneurysm (AAA) repair. Compared with open surgery, EVAR results in fewer postoperative complications and reduced length of hospital stay as well as reduced 30-day mortality rate. On the other hand, secondary rupture rates as well as the need for reintervention during follow-up have been higher for EVAR. The first randomised controlled trials (RCT) indicated that the initial benefit from EVAR on survival rates was offset after 2–4 years, whereas more recent data show similar long-term survival after EVAR and open surgery. AAA is accompanied by aneurysms or ectasia of the common iliac artery in approximately 40% of the patients, while isolated iliac aneurysms account for 2% of aortoiliac aneurysms. There are several options to deal with common iliac arteries that are unsuitable landing zones for stent-graft limbs. In an ectatic iliac artery (<23 mm), most currently available AAA stent-graft systems provide bellbottom iliac limbs to allow sealing in the common iliac arteries. In the setting of irregular iliac arteries, one option is to land above or below the ectatic portion of the artery to allow for limb sealing. However, one must be aware that an ectatic iliac artery (>15 mm) is prone to dilate during follow-up. This might compromise the distal seal leading to migrations, endoleaks and repressurisation of the aneurysm. Thus, close follow-up is warranted when stent-grafts land in ectatic iliac arteries. If an actual common iliac artery aneurysm exists or the vessel measures >22 mm, it precludes the landing of the stent-graft in this zone. EVAR then has to be extended into the external iliac artery. In this situation, the internal iliac artery can either be sacrificed by simple coverage or embolisation, or it can be revascularised by endovascular or surgical means. To learn how to select and triage patients In up to 25–30% of patients undergoing EVAR, internal iliac artery coverage is necessary. Pelvic arterial flow is then dependent on the existing collateral flow to be sufficient to avoid pelvic ischaemic complications. The main collaterals in this context are the ascending collaterals from the profunda femoral artery, contralateral branches from the internal iliac artery, circumflex branches from the external iliac and finally the inferior mesenteric artery. The most common complication to internal iliac artery coverage or embolisation is buttock claudication, which occurs in up to 30% of patients after unilateral sacrifice. For bilateral repair, this number is significantly higher, affecting up to 90% of patients. Other ischaemic complications such as impotence, bowel ischaemia and scrotal slouching are much less studied and likely more uncommon but do occur, particularly after bilateral internal iliac artery sacrifice. A particular situation occurs in patients undergoing extensive endovascular repair such as thoracoabdominal aortic aneurysm. As these patients will have stent-graft coverage of critical intercostal arteries

Abstract Book supplying the spinal cord, they are very dependent on collateral spinal flow to avoid spinal cord ischaemic complications such as paraplegia. Here the internal iliac arteries play a critical role in collateral supply and should be preserved. The strategy for AAA with concomitant common iliac artery aneurysms is clear. First, identify patients at risks such as those with a contralateral hypogastric disease, former abdominal or groin surgery or previous aortic repair. Also keep in mind that the majority of AAA cases present with asymptomatic disease, and thus the effect of iatrogenic pelvic ischaemic disorders as described above are particularly upsetting for the patient. The options available for internal iliac revascularisation are as follows: A: Staged procedure if embolisation is necessary in order to build collateral supply to the occluded side. The embolisation must be as proximal as possible to recruit the collaterals. However, the proof of this concept is not well documented B: Surgical external-to-internal bypass C: Branched iliac stent-graft Technical features A branched iliac stent-graft is a bifurcated device with the main body placed in the common iliac artery and the branches into the external and internal iliac arteries. It provides direct blood flow to the hypogastric arteries. Branched iliac stent-grafts allow treatment in this group of patients with aneurysmal or short common iliac arteries while maintaining patent internal iliac arteries, and are combined with standard infrarenal EVAR devices to complete an endovascular repair of an aortoiliac aneurysm. These devices can be used uni- or bilaterally. Several studies have shown the feasibility of such a repair as well as adequate midterm patency rates. A single comparative study from M. Austermann and coworkers in the Journal of Vascular Surgery has shown this procedure to be highly efficient and less comorbid than its open repair equivalent. There are currently two commercially available devices for internal iliac flow preservation in the setting of unsuitable common iliac landing zones. The devices are mated with commercially available infrarenal stent-grafts from the same manufacturers (Cook Medical and Gore). The delivery technique is similar for the two devices. A unilateral repair is most commonly done through a transfemoral approach. The iliac branch graft is positioned in the common iliac artery and its position, both longitudinally and rotationally, is controlled by angiography and stent-graft markers. Use of preoperative CTA planning as well as intraoperative fusion techniques are very useful to optimise implantation and reduce contrast and X-ray dose during the procedure. The internal iliac limb is preloaded with a catheter through which a through-and-through wire is placed after snaring from one femoral artery to the other. The through-andthrough wire placement is either performed first and the wire then fed into the internal iliac artery branch catheter (Gore device) or the wire is snared via the preloaded catheter after the device is positioned and partially deployed (Cook device). Once the device is positioned properly and the through-and-through wire established, a 12-F Flexor introducer (Cook) is passed over the wire and positioned into the internal iliac limb of the bifurcated device. A double puncture of the 12-F valve is then done and a second wire is used to catheterise the target internal iliac artery. This wire is replaced by a stiff wire over any catheter once a stable position is achieved in a deep branch of the internal iliac artery. A bridging covered stent is then placed over the through-and-through wire and positioned into the internal iliac artery. A minimum landing zone of 10 mm is necessary in the internal iliac artery and markers visualise the minimum overlap in the internal iliac branch. For the Gore device, a Viabahn, likewise a covered stent is used. For the Cook device, either a Fluency covered stent (Bard) or an Advanta covered stent (Atrium) is used. The main device is then fully deployed to complete the iliac branch implantation. The AAA repair is then completed with an AAA stent-

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graft placed from the contralateral groin and a bridging stent-graft positioned between the contralateral limb of the AAA device and the iliac bifurcation device. In the setting of bilateral pathology of the common iliac arteries or where the artery is very short, a modified delivery is sometimes needed. This is due to the fact that the crossover manipulation can be a challenge if the iliac branch device protrudes significantly above the aortic bifurcation. The internal iliac artery limb of the device can then be reached from a transaxillary approach instead. Finally, other technical features such as the sandwich technique, short-cut technique, crossover chimney technique and double bifurcated stent-graft technique will not be discussed in this abstract. In the light of the commercially available iliac branched stent-grafts from Cook and Gore manufacturers, this is absolutely the technique that should be promoted as the first-line treatment. Conclusion: Preservation of the internal iliac artery is a must in young patients if EVAR has been chosen instead of open technique. Physically active patients and patients with previous groin surgery and a contralateral stenosis of the internal iliac artery should be offered a branched stent-graft technique if there is a suitable anatomy. References 1. Outcomes of a novel technique of endovascular repair of aneurysmal internal iliac arteries using iliac branch devices. Austermann M, Bisdas T, Torsello G, Bosiers MJ, Lazaridis K, Donas KP. J Vasc Surg. 2013 Nov;58(5):1186-91. doi: 10.1016/j. jvs.2013.04.054. 2. Surgical versus endovascular repair by iliac branch device of aneurysms involving the iliac bifurcation. Donas KP, Torsello G, Pitoulias GA, Austermann M, Papadimitriou DK. J Vasc Surg. 2011 May;53(5):1223-9. doi: 10.1016/j.jvs.2010.10.121. 3. Long-term results of iliac aneurysm repair with iliac branched endograft: a 5-year experience on 100 consecutive cases. Parlani G, Verzini F, De Rango P, Brambilla D, Coscarella C, Ferrer C, Cao P. Eur J Vasc Endovasc Surg. 2012 Mar;43(3):287-92. doi: 10.1016/j. ejvs.2011.12.011. 4. Endovascular treatment of iliac aneurysm: concurrent comparison of side branch endograft versus hypogastric exclusion. Verzini F, Parlani G, Romano L, De Rango P, Panuccio G, Cao P. J Vasc Surg. 2009 May;49(5):1154-61. doi: 10.1016/j.jvs.2008.11.100. 5. Endovascular repair of aortoiliac aneurysmal disease with the helical iliac bifurcation device and the bifurcated-bifurcated iliac bifurcation device. Wong S, Greenberg RK, Brown CR, Mastracci TM, Bena J, Eagleton MJ. J Vasc Surg. 2013 Oct;58(4):861-9. doi: 10.1016/j.jvs.2013.02.033.

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At first glance, this result is challenging to EVAR enthusiasts, who have long been certain that EVAR is the preferred option for patients with ruptured AAA. This preference is supported by the data from small single-centre case series and combined series with potential selection biases. The trial thus already has its detractors, and I suspect that many of these have not read the paper. The CONSORT diagram showing the flow of patients through the trial records a 25% mortality for patients who received EVAR in the endovascular strategy group and a 22% mortality for those patients who received EVAR in the open repair group. Open repair was associated with a 38% mortality in the endovascular strategy group and 37% mortality in the open repair group. So we see that when EVAR was actually delivered, it was associated with a lower mortality than open repair, but this is not the question asked by the trial. The trial was designed to assess if a strategy of endovascular repair versus open repair reduces early mortality for patients with suspected ruptured AAA. Randomisation occurred on clinical suspicion of ruptured AAA, and patients were randomised to either of the strategies mentioned above. The endovascular strategy group had CT, assessment for EVAR and subsequent EVAR if suitable. Open repair was delivered to those patients in the endovascular strategy group who were not suitable for EVAR. EVAR was delivered to 60% of patients. There was thus no second randomisation after suitability for EVAR was decided, and the trial is not a head-to-head trial of EVAR and open repair. The open strategy group did not have mandatory CT and went to theatre for open repair. EVAR enthusiasts have not been necessarily proven wrong as evidenced by the CONSORT diagram. The anticipation that EVAR should yield better results is based on previous case series and pooled data for patients treated by EVAR but not the assessment of a strategy as in the IMPROVE trial, which is a multi-centre randomised trial involving 29 centres from UK and 1 centre from Canada. An important but unsurprising finding is that EVAR shows better results when patients are treated under local anaesthesia. There has already been much criticism of the trial at meetings, and the trial investigators published a commentary on the paper in EJVES in April 2014. References 1. Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial. IMPROVE trial investigators. BMJ 2014 Jan;348:f7661. 2. An endovascular strategy for suspected ruptured abdominal aortic aneurysm brings earlier home discharge but not early survival or cost benefits. IMPROVE trial investigators. EUR J Vasc Endovasc 2014 Apr;47:333-4.

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Trials update for planned and emergency EVAR

Endovascular aneurysm sealing (EVAS)

R.G. McWilliams Dept. of Radiology, Royal Liverpool University Hospital, Liverpool, United Kingdom

O. Pellerin Interventional Radiology, Hopital Européen Georges Pompidou, Paris, France

Learning Objectives 1. To learn about the latest trial results 2. To learn which patients benefit most from EVAR 3. To learn if debate between open surgery and EVAR makes sense Heading the list of recent trials involving EVAR since CIRSE 2013 is the IMPROVE trial, which was published in the British Medical Journal in January 20141. This is another well-conducted trial from Imperial College, London, which also gave us the UK EVAR trials. The acronym comes from The Immediate Management of Patients with Rupture: Open Versus Endovascular Repair. The trial conclusion is that a strategy of endovascular repair was not associated with significant reduction in either 30-day mortality or cost. Long-term data will follow as with the UK EVAR trials.

Learning Objectives 1. To learn how to select patients for EVAS 2. To learn technical features of EVAS 3. To learn the outcomes and complications of endovascular treatment Endovascular grafts are being investigated to successfully treat aneurysmal aortic disease. However, one of the main concerns regarding this treatment is the persistence of outside graft flow, namely endoleak. Their occurrence ranges from 7% to 37% of endovascular aortic aneurysm repairs. An incomplete sealing between the endovascular prosthesis and aneurysm neck, defects within the prosthesis itself, or patent branches arising from the aneurysm causes these endoleaks.

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Type 1 is observed when there is at the proximal or distal neck an enlargement that creates an imperfect endovascular graft coaptation to the vessel wall. Types 3 and 4 endoleaks are related to fabric tears, particularly in bifurcated endovascular prostheses, which may occur after a difficulty has been encountered in the deployment of the graft or after guidewire manipulation to insert the second limb. Types 1, 3, and 4 lead to rapid aneurysm enlargement and need appropriate treatment to prevent aortic rupture. Minor endoleaks associated with patent branches (type 2) often do not produce aneurysm enlargement but create an inside-out pressure elevation. There are numerous options to manage an endoleak. They range from endovascular repair to conversion to an open surgical procedure. Types 1, 3, and 4 are usually managed with bare stent, covered stent, prosthesis extension, or new prosthesis implantation to resort the correct neck or arm sealing. Type 2 could be managed either by endovascular or direct puncture. The endovascular approach has to cope with a difficult navigation to the target artery using tortuous collateral. The percutaneous approach with a direct aneurism sac puncture is usually performed under C-arm CBCT guidance. That may offer a smart alternative to the classic embolization procedure. In that setting, the aneurysm bag is tackled at the level where the endoleak is observed on the angio-CT scanner previously performed. The image registration technique within the C-arm CBCT and the angio-CT scanner increase the targeting of the circulating part of the aneurysm. Then a short navigation into the aneurysm allows reaching the lumbar or the inferior mesenteric artery responsible for the endoleak. Usually, a combination of coils and liquid embolic agent injection is performed to seal lumbar arteries and/or the inferior mesenteric artery. References 1. Rand T, et al. Quality improvement guidelines for imaging detection and treatment of endoleaks following endovascular aneurysm repair (EVAR). Cardiovasc Intervent Radiol. 2013. 2. Klein S, et al. Thoracic type II endoleak embolization using direct percutaneous puncture. Cardiovasc Intervent Radiol. 2012. 3. Lehmkuhl L, et al. Dynamic CT angiography after abdominal aortic endovascular aneurysm repair: differences in contrast agent dynamics in the aorta and endoleaks--preliminary results. J Vasc Interv Radiol. 2012. 4. Sucandy I, et al. Endovascular management of the patent inferior mesenteric artery in two cases of uncontrolled type II endoleak after endovascular aneurysm repair. N Am J Med Sci. 2011.

Special Session Vascular malformations: state-of-the-art management 2504.1 Vascular malformation (VM) classification, clinic and typical imaging features G. Soulez Radiology, CHUM-University of Montreal, Montreal, QC, Canada Learning Objectives 1. To learn about the clinical presentation of vascular malformations 2. To learn key imaging features that influence treatment strategies 3. To learn how to classify vascular malformations I. INTRODUCTION Vascular malformations comprise a wide spectrum of lesions involving all parts of the body. On the basis of cellular kinetics and clinical behavior, Mulliken and Glowacki proposed in 1982 the most helpful classification for vascular abnormalities 1. They classified vascular

Abstract Book anomalies in two major categories: 1. vascular tumors (lesions that arise by endothelial hyperplasia) and 2. vascular malformations (lesions that arise by dysmorphogenesis and exhibit normal endothelial turnover). Hemangioma is the most common vascular tumor, occurring in the skin of 4%–10% of infants 1. They have an early rapid growth during the first year of life and stabilization at 2 years followed by slow regression from 2 to 7 years of age. The term hemangioma must be only applied to this pediatric entity. Vascular malformations are localized or diffuse errors of embryonic developments at some stage of either vasculogenesis or angiogenesis. They presumably are present at birth, although they may not become evident until adolescence or adulthood, and they persist throughout life. They are the most frequently encountered vascular anomalies in adult patients 1. Malformations, to the contrary of hemangiomas, do not regress spontaneously and can result in venous stasis, ischemia, localized consumptive coagulopathy, and skeletal anomalies. Boys and girls are equally affected. We will review in this presentation the clinical and imaging features of vascular malformations and discuss key imaging features influencing treatment strategies. II. CLASSIFICATION OF VASCULAR MALFORMATION This classification based on the histological appearance of the abnormal channel, flow characteristics and clinical behaviour was updated during the 1992 meeting of the International Society for the Study of Vascular Anomalies (ISSVA) 2. Vascular malformations are classified in slow-flow malformations, including capillary malformations (CM); venous malformations (VM); lymphatic malformations (LM); capillary and venous malformations (CVM); capillary, lymphatic and venous malformations (CLVM); and high-flow malformations including [arteriovenous fistula (AVF. and arteriovenous malformations (AVM)]. III. INVESTIGATION OF VASCULAR MALFORMATION III. 1. CLINICAL EXAMINATION Vascular malformations usually present during childhood. Since they are often stimulated by hormonal influences, such as puberty or pregnancy, patients are frequently seen for the first time in the late teens or even later. Depending on the type of malformation, patients can present with numerous symptoms such as apparition or worsening of a soft tissue mass, pain, heaviness, pulsation, hemorrhage, distal ischemia, skin discoloration, skin atrophy, and congestive heart failure 3. On physical examination, the clinician should assess the coloration of the skin, softness of the mass, presence of a thrill and dilated veins, and variation of the mass with Valsalva maneuver. Scars of previous surgeries should be noted. Examination should include an inspection of the entire skin and mucous membranes for the presence of telangiectasia or dysplastic veins. Limb length discrepancy and lymphedema should be noted. III. 2. CLINICAL PRESENTATION AND IMAGING STUDIES Following clinical examination, Doppler ultrasound is the firstline imaging modality to discriminate between high- and low-flow malformations 4. Then MRI is the best examination to assess the extension of the malformation and plan interventional treatment. Catheter angiography is now essentially performed before AVM embolization. Venous malformation VMs are the most frequent vascular malformations. They appear as a compressible soft tissue mass with a bluish discoloration and sometimes dysplastic veins. Their anatomic distribution is head and neck (40%), trunk (20%), and limbs (40%). On grey-scale ultrasound, they are seen as a compressible hypoechoic or iso-echoic lesion infiltrating soft tissue with a slow flow on Doppler examination. Hyperechoic areas with acoustic shadowing related to phleboliths can be observed. Phleboliths can also be seen on plain film and are pathognomonic of VM. On MRI, VMs are characterized as soft tissue mass with a hypo- or isosignal on T1-weighted sequence 5. Delayed contrast enhancement

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is observed after gadolinium injection. On T2-weighted sequence, VMs show a characteristic bright hypersignal. Volumetric analysis is more sensitive to assess therapeutic response 6. Lymphatic malformation LMs are characterized by a firm mass involving mainly head and neck or cervicothoracic area, the trunk being less frequently involved. They are divided in macrocystic LM made of uni- or multiloculate cysts easily seen on ultrasound and microcystic LM, which are made of microcysts difficult to distinguish on ultrasound. On Doppler ultrasound, no flow is observed inside the cyst of macrocystic LM whereas small vessels with high resistance arterial flow can be seen in the septas 7. Microcystic LM are very infiltrative and show frequently a hyperechoic heterogeneous structure. On MRI, both macro- and microcystic LM display a bright hypersignal on T2-weighted sequences; however, cyst size >2 cm3 are observed in macrocystic LM 8. After contrast injection, there is no enhancement inside the cysts but cyst wall can display post-contrast enhancement. Finally, mixed forms of LM combining macro- and microcystic components can frequently be observed. Arterio-venous malformation AVMs are characterized by a pulsatile mass frequently involving the head and neck and peripheral limbs. Truncular AVMs are less frequent and mainly involve the pelvis. On Doppler ultrasound, AVMs are made of multiple hypoechoic serpiginous tubular structures displaying a high flow with a high diastolic component on the arterial side and congestive dilated veins with a systolic modulation on the venous side. On MRI, a flow void is typically seen on both T1- and T2-weighted sequences indicating high flow. Magnetic resonance angiography (MRA) with 3D gadolinium-enhanced acquisition or, if possible, time-resolved angiography (4D angiography) are helpful to detect the nidus of the malformation and identify feeding arteries and draining veins. Selective catheter angiography still remains the best examination to evaluate the architecture of the malformation (nidus, feeder, and draining vessels) and the feasibility of therapeutic embolization. IV. CONCLUSION Interventional radiology is now pivotal in the management of vascular malformations either as a single therapeutic option or in combination with surgery. However, the physician must adequately classify the vascular malformation, evaluate the associated symptoms, and establish a prognosis before proceeding to invasive therapy. The interventional radiologist needs to work in a multidisciplinary team and be personally involved in the diagnosis, imaging work-up, and follow-up of patient referred to the clinic of vascular anomalies. References 1. Mulliken JB, Fishman SJ, Burrows PE. Vascular anomalies. Current problems in surgery. 2000;37:517-584. 2. Enjolras O. Classification and management of the various superficial vascular anomalies: Hemangiomas and vascular malformations. The journal of dermatology. 1997;24:701-710. 3. Legiehn GM, Heran MKS. Classification, diagnosis, and interventional radiologic management of vascular malformations. Orthopedic clinics of North America. 2006;37:435-474. 4. Dubois J, Alison M. Vascular anomalies: What a radiologist needs to know. Pediatric radiology. 2010;40:895-905. 5. Dubois J, Soulez G, Oliva VL, Berthiaume MJ, Lapierre C, Therasse E. Soft-tissue venous malformations in adult patients: Imaging and therapeutic issues. Radiographics: a review publication of the Radiological Society of North America, Inc. 2001;21:1519-1531. 6. Caty V, Kauffmann C, Dubois J, Mansour A, Giroux MF, Oliva V, Piche N, Therasse E, Soulez G. Clinical validation of semiautomated software for volumetric and dynamic contrast enhancement analysis of soft tissue venous malformations on magnetic resonance imaging examination. European radiology. 2014;24:542-551.

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7. Trop I, Dubois J, Guibaud L, Grignon A, Patriquin H, McCuaig C, Garel LA. Soft-tissue venous malformations in pediatric and young adult patients: Diagnosis with doppler us. Radiology. 1999;212:841-845. 8. Legiehn GM, Heran MK. Classification, diagnosis, and interventional radiologic management of vascular malformations. The orthopedic clinics of North America. 2006;37:435-474, vii-viii.

2504.2 Technique and material for low-flow VMs J.P. Burnes Medical Imaging, Monash Medical Centre, Clayton, VIC, Australia Learning Objectives 1. To learn about materials used for sclerotherapy 2. To learn the technique of sclerotherapy 3. To learn how to avoid and manage complications of sclerotherapy Low-flow vascular malformations are of two main types: venous malformations and lymphatic malformations. They are characterised by the absence of any arterial inflow, and, as their names imply, they are comprised of either abnormal venous or lymphatic channels. Clinically, they are often present at birth and grow commensurately with the child. They may occur anywhere in the body. Lymphatic malformations are subdivided into macrocystic and microcystic malformations on the basis of the size of the cysts. Most authors define macrocysts as being greater than 10 mm in diameter. Diagnosis is based on their clinical appearance and patient history. Imaging is primarily based on ultrasound and MRI. Ultrasound is used to characterise the lesions as low flow and to identify cystic spaces within the lesion. MRI allows the accurate determination of their anatomical extent. Optimal MR sequences include fat suppressed T2, STIR or PD images. Typically, venous malformations demonstrate contrast enhancement, whereas lymphatic malformations do not; however, contrast is not required for diagnosis or lesion characterisation. Angiographic imaging is not required to diagnose or treat low-flow malformations. Treatment options include surgery or interventional radiology (IR) techniques. The mainstay of IR therapy involves direct puncture sclerotherapy. Access to the lesion may be performed under ultrasound guidance; however, this may not always be feasible or necessary. The malformations are punctured using a variety of puncture needles, and intralesional location confirmed with aspiration of either blood or lymphatic fluid and injection of a contrast material. In the case of lymphatic malformations, ideally macrocystic lesions should be drained dry prior to injection of sclerosant to minimise the dilutional effects of the lymphatic fluid on the sclerosant agents being used. Fluroscopic imaging and contrast injections are used to confirm the intralesional location of the puncture needles, and various agents are then injected into the malformations to induce fibrosis. In case of venous malformations, venous thrombosis also occurs. The aim of sclerotherapy is to induce an intense inflammatory response within the malformation with the long-term goal being fibrosis. The agents used to sclerose the malformation are dependent on several factors, including the type of malformation being treated, anatomical location, operator experience and sclerosant availability in your practice. The anatomical location of the lesion may influence the agent chosen as different agents are associated with different degrees of inflammation and swelling and risks of damage to localised anatomical structures. Venous malformation sclerosants Sclerosant agents used to treat low-flow venous malformations include, but are not limited to, concentrated ethanol, sodium tetradecyl sulphate (STS), polidocanol and bleomycin.

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Lymphatic malformation sclerosants There are myriad agents that have been used to sclerose lymphatic malformations, including doxycycline, OK432, bleomycin, acetic acid, hypertonic dextrose and all of the agents used to treat venous malformations. Complications that may be encountered in treating low-flow venous malformations can be divided into systemic and localised complications. Systemic complications include acute EMD cardiac arrest, acute cor pulmonale, renal failure and pulmonary emboli. These can be managed by adhering to strict sclerosant volume limitations, particularly in respect to the use of concentrated ethanol. Maximal recommended doses in literature are 1 ml/kg. The maximum volume that should be injected at a time should be limited to 0.2 ml/ kg with at least 10 minutes between injections. It is critical to release any tourniquets or other venous occlusion devices after each injection to ensure that there is no large bolus of ethanol released into the systemic circulation at the end of the procedure. Localised complications include skin necrosis, nerve damage and rarely compartment syndrome. These are best managed by ensuring that the sclerosant agents are only injected into the malformation. Even when the sclerosant is only injected into the malformation, skin or nerve damage may occur secondary to compression or leaching of sclerosant into dermal vasculature or neural vasa vasorum. The vast majority of skin necrosis will heal by secondary intention with skin grafting required in around 1–5% of cases.

2504.3 Technique and material for high-flow AVMs P. Waldenberger Institut für Diagnostische & Interventionelle Radiologie, Krankenhaus der Barmherzigen Schwestern Linz, Betriebsgesellschaft m.b.H., Linz, Austria Learning Objectives 1. To learn embolisation techniques and strategies for AVMs 2. To compare various embolisation agents 3. To learn how to avoid and manage complications of AVM embolisation No abstract available.

2504.4 Special considerations in paediatric VMs A.M. Barnacle Radiology, Great Ormond Street Hospital, London, United Kingdom Learning Objectives 1. To learn classification of syndromes involving AVMs 2. To learn specific tricks for safe paediatric intervention 3. To learn different forms of treatment and possible advantages of endovascular therapy Paediatric interventional radiology (IR) has a role in the diagnosis and management of all types of vascular anomalies in childhood. Infantile haemangiomas are by far the commonest vascular anomaly occurring in children. In the past, IR had an occasional role in the embolisation of complex, ulcerating lesions to slow their rapid growth and allow healing to occur. This is now confined to history with the advent of beta-blocker treatment for troublesome infantile haemangiomas. There is however still the need for occasional biopsy of some rapidly growing lesions in childhood, including for differentiation between infantile and congenital haemangiomas and for diagnosing rarer lesions such as tufted angioma and kaposiform haemangioendotheliomas. Rapidly involuting haemangioma (RICH. occasionally presents at birth with extreme mass effect and severe high output cardiac failure, and urgent embolisation is required in

Abstract Book such cases. In our experience, these occur most commonly in the liver and on the scalp [1]. Angiography in such small sick babies requires meticulous technique and attention to details such as total saline flush and contrast volumes. Axillary arterial access may be useful in infants when femoral access has already been used or obliterated by emergency intensive care access procedures [2]. There is an interesting cohort of patients that presented childhood disfiguring sequelae of neonatal RICHs with very large dysplastic veins that respond surprisingly well to sclerotherapy. Slow-flow vascular malformations generate the largest workload in a busy paediatric vascular anomalies centre. Although present from birth, venous malformations (VMs) tend to increase in size and symptomatology as puberty begins. It is common for diagnosis to be delayed and a significant proportion of patients arrive in an IR clinic with an incorrect diagnosis and often with a history of incorrect treatment. Part of the role of a specialist centre is to confirm the correct diagnosis promptly and to reassure the child and family regarding outcomes and prognosis. Equally, there is often much work to be done in re-setting expectations and helping children and their families to accept what is a life-long diagnosis and to understand that IR management is aimed at symptom control and not cure. In many cases, conservative management with the use of compression garments and physiotherapy is all that is required during early school years and often sclerotherapy can be delayed until puberty. Much of the actual venous sclerotherapy technique is similar to that used in adults with extra caution needed regarding dose limits for sodium tetradecyl sulfate and alcohol. Pre- and intra-operative hyperhydration should be considered where sclerosant volumes are predicted to be high. Children with lymphatic malformations tend to present in clinic at a younger age than those with VMs because of their mass effect and cosmetic issues. Simple macrocysts respond well to sclerotherapy using standard techniques [3], but, as always, microcystic lesions can be very difficult to shrink. Bleomycin has a definite role to play, but there is still no clear consensus on whether bleomycin should be avoided in infancy and how stringent respiratory follow-up should be. Complex lesions that affect the airway, chest and entire limbs need to be managed in conjunction with a specialist multi-disciplinary team. We have found that planned post-resection sclerotherapy can be invaluable in complex lymphatic lesions where post-operative seromas are well-recognised. Complex mixed low-flow syndromic lesions (such as Klippel– Trenaunay syndrome and Proteus syndrome) usually present in childhood and again require a multi-disciplinary approach. IR often has less of a role to play in such cases than in orthopaedic and plastic surgeries. A proportion of complex cases involving an entire limb have large dysplastic lateral (marginal) veins, and there is increasing evidence that endovenous laser ablation (EVLT) of these veins should be considered early [4]. Attention must be paid to the drainage pattern of these large dysplastic veins, which often drain directly into the IVC or common iliac vein. Pre-EVLT embolisation of the distal vein may be prudent. High flow arteriovenous malformations (AVMs) are largely quiescent in childhood, and the role of IR should be to actively advocate a conservative approach. In a proportion, however, intervention is required, especially if the high-flow lesion is causing overgrowth during childhood development. As with all high-flow cases, embolisation should only be offered by specialist centres with significant experience in treating such cases. We find that head and neck AVMs are best co-managed with experienced neuro-interventional radiologists. Embolisation techniques are similar to those used in adults, but special caution is advocated regarding contract volumes and radiation dose. Large volumes of Onyx should be avoided in small children due to the associated DMSO solvent released into the circulation.

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References 1. Rapidly involuting congenital haemangioma (RICH. of the liver. Roebuck D, Sebire N, Lehmnn E, Barnacle A. Ped Radiol 2012;42:308-14. 2. Ultrasound-guided transaxillary access for diagnostic and interventional arteriography in children. Roebuck DJ, Vendhan K, Barnacle AM, Brew S, McLaren CA. J Vasc Interv Radiol 2010;21:842-7. 3. Percutaneous sclerotherapy for lymphatic malformations: a retrospective analysis of patient-evaluated improvement. Alomari A, Karian V, Lord D, Padua H, Burrows P. J Vasc Interv Radiol 2006;17:1639-48. 4. The use of endovenous laser treatment in toddlers. King K, Landrigan-Ossar M, Clemens R, Chaudry G, Alomari A. J Vasc Interv Radiol 2013;24:855-8.

Special Session IR clinical specialty 2505.1 Key requisites for the IR practice I. Robertson Interventional Radiology Unit, Gartnavel General Hospital, Glasgow, United Kingdom Learning Objectives 1. To learn about facility requirements 2. To learn about staff requirements 3. To learn how to communicate with patients and colleagues Interventional radiology (IR) is undergoing a period of rapid growth and evolution around the world. Despite cultural differences, variations in healthcare environments and regulatory bodies, the success of IR practice depends on several key factors. Facility requirements Building a successful IR service needs an analysis of both the internal and external sources of referrals and should consider both inpatient and outpatient IR services. Few interventional radiologists will have the opportunity to build a unit from inception. Most often, we will be joining a unit that has existing inpatient and outpatient referrals. The potential scope of IR activity is most readily influenced by existing clinical specialties. Particularly important are the presence of inpatient renal, vascular and oncological services. If these key services are on-site, even if currently underdeveloped, there are significant opportunities for internal expansion. External links to neighbouring hospitals in key specialities such as oncology offer further opportunities to develop IR services though this usually requires considerably more work. Increasingly, IR procedures are day-case or outpatient based. This trend effectively extends the range of IR beyond existing inpatient activity, and access to an effective day-case unit is essential to a modern IR service. While physical beds in a day-case unit are a key component, there are important implications for nursing and extended care practitioners in the development and delivery of care for day-case and outpatient IR patients, which should be included when planning the service. The development of IR outpatient clinics is a key requisite for establishing a clinical service, particularly as we experience a shift to daycase and outpatient procedures. Undertaking elective IR procedures without clinical assessment effectively makes the operator a technician and should be avoided. The IR clinic should underpin all referrals and is pivotal to the long-term development and reputation of the unit. Getting access to a suitable outpatient clinic estate can be surprisingly difficult but deserves persistence. Outpatient clinics work well only when in an appropriate environment with suitable

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administrative support. Do not plan to use rooms/offices in the radiology department as an easy ad hoc option; the appointment system, access to notes, secretarial support and environment are not suited to running an effective clinic. Clearly, the interventional department facilities and range of equipment must reflect the scope of services, and this will vary between units. At the core, all units will need access to an angiographic facility. Individual country regulations will dictate key legal requirements for the environment, but some overall features are relevant in all countries. The increase in the complexity of medical devices, an increased requirement for infection control measures and the need to work with combination therapies requires larger rooms and at a minimum a clean air environment. Increasingly, angiographic facilities are co-located in a theatre environment to fulfil requirements. Delivering an entire service from mobile image intensifiers placed in theatre is not a suitable solution. Mobile units do not afford suitable image quality, have limited heat dissipation and the environment does not usually give the same degree of radiation protection. Access to good quality ultrasound equipment within the interventional room is invaluable. Access to CT and MR is essential for both the non-invasive assessment planning of vascular and non-vascular intervention and intervention particularly in oncological therapies such as ablation. IR has been very successful at delivering a wide range of procedures using local anaesthesia, but access to suitable staff and facilities for general anaesthesia are essential for some procedures. Staff requirements IR requires a team of healthcare professionals beyond medical staff. Interventional radiologists have a duty to lead and contribute to the development and education of the group and promote team working. Each staff member must clearly understand their own role but be prepared to work flexibly to ensure best patient outcomes. The skill mix and number of interventional radiologists to provide elective services within a particular unit will depend on the unit size and scope of services provided. Increasingly, there is a requirement to support 24/7 access to IR particularly for haemorrhage control, nephrostomy access and endovascular intervention. On-call rotas in IR can be onerous, and the development of a sustainable system usually requires a 1:6 minimum rotation. Some units will have insufficient staff to develop sustainable 24/7 cover and for such units, a collaborative arrangement with neighbouring units is often the best option. IR nurses possess the skills of a theatre/recovery nurse with a detailed knowledge of the equipment and procedures performed within IR. In many countries, despite the knowledge and technical skill required, specific tailored educational qualifications are not available. Local education programmes for this group are an invaluable resource, and the leadership of local IR groups should prioritise support and education. IR radiographers have a detailed knowledge of angiographic and other imaging equipment and the safe and appropriate use of ionising radiation, interventional equipment and procedures. IR radiographers provide a vital team element for the safe provision of services both in- and out-of-hours, and experienced personnel are essential in a functioning unit. The requirement for interventional procedures now exceeds available interventional radiologists in many countries. The range and complexity of IR procedures has increased, but we still need to provide basic imaging and intervention. Some departments have successfully used extended role practioners, either radiographers or nurses with additional training and competencies, to provide basic interventional procedures. In many centres, this has focused on vascular access techniques, but there is an opportunity for advanced practice to make greater contributions to procedural care, patient management and follow-up. Again, this is an area where there are often limited national educational programmes, and local investment in a training programme and support is essential.

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Communication with patients and colleagues Communication is a cornerstone of medical practice. Shared decision making with patients and more extensive clinical teams have made effective communication even more vital. Communication, like other skills, can be improved with appropriate education, but evidence shows that doctors are often reluctant to accept the need to focus on this area. Most research and practical tuitions focus on improving communication in the doctor–patient relationship. Effective communication not only improves the patient’s perception of their healthcare but also improves outcomes and reduces the likelihood of litigation. In practice, doctors are sued more often for failures of written or verbal communication than for issues of technical competence. Effective communication involves shared decisions made in a consultation in an appropriate environment (e.g. the IR clinic. that demonstrates attentive listening and displays empathy, respect and honesty. Interventional radiologists are becoming increasingly clinical in their practice, and we should all consider how effective our communication skills are and how we might improve them. Time spent undertaking development in this area with opportunities to practice in a simulated environment is invaluable and has been rewarding. Communication with colleagues has been less well studied, but the failures of effective communication are often implicated in significant adverse events and malpractice. IR interacts with multiple disciplines that will not be familiar with the detail or complexity of IR procedures, and therefore external communication is vital. It is the responsibility of interventional radiologists to ensure that written and verbal communication clearly documents the pre-procedure process, the relevant technical details of the procedure and the aftercare process. Standardised procedure and aftercare profromas provide a structured effective way of delivering written information and help ensure better outcomes. The recently introduced surgical pause and brief is an excellent example of developing a standardised process to ensure communication and help prevent adverse outcomes. Considerable work has been undertaken to improve structured verbal communication with colleagues most often using an SBAR format (Situation, Background, Assessment, Recommendation). This technique though most often used verbal communication can be useful for written communication and is of particular value in critical situations. IR is delivered as a team, and it is essential that communication within that team is carried out in a respectful and effective fashion. There is good evidence that effective communication within teams improves patient outcomes and job satisfaction for the healthcare professionals. Regular team meetings ensuring that all team members have an opportunity to communicate and be listened to in an appropriate environment will help build team relationships and improve patient care. Investment in the local IR team is pivotal to better patient outcomes and the success of an IR unit.

image-guided procedures to diagnose and treat diseases in nearly every organ system. The concept behind IR is to diagnose and treat patients using the least invasive techniques currently available in order to the minimize the risk to the patient and improve health outcomes” (1). Following that description, it is mentioned, “Many conditions that once required surgery can now be treated non-surgically by interventional radiologists. By minimizing the physical trauma to the patient, peripheral interventions can reduce infection rates and recovery time as well as shorten hospital stays” (2). While patients may prefer such treatment, colleagues who may be replaced by such a shift may not be equally enthusiastic and may not try providing such treatment or may look out for other options. Does quality win? Let us assume that quality will ultimately win and structures within national medical systems will change subsequently. Specialities able to provide a better service will be empowered to provide service for patients. That would apply if systems would react on the basis of current knowledge by recent data. Why may providing data be important? In the era of evidence-based medicine, guidelines are developed on the basis of consistent, reproducible, and solid data, looking at randomized controlled trials and meta-analysis. IR is not a field known for many randomized controlled trials with public funding, and the CE mark paradox is a part of that reality. In order to convince clinical colleagues, medical authorities, or national institutes deciding about reimbursement it is crucial to discuss on the basis of scientific and sound data. How may we demonstrate quality trough data? IR may be more accepted if professional societies would stimulate, foster, or organize clinical trials/registries with the potential advantage of faster enrolment. Clinical results of IR may be documented on a national or professional society level providing a database for technical/clinical complications, success, or relevant results such as survival or quality of life. Such a database triggered and provided by a national or a professional society may also be used to monitor new devices drifting into the market on the basis of CE labeling in Europe without clinical trials being available. The registry of the German IR Society (DeGIR) organized within the national society of radiology (DRG) will be explained as such a potential tool.

2505.2

IR: multidisciplinary team

Demonstrating quality through data

A. Adam Radiology, Guy’s and St. Thomas’ Hospital, London, United Kingdom

P. Reimer Radiology, Klinikum Karlsruhe, Karlsruhe, Germany Learning Objectives 1. To learn about the importance of data 2. To learn how to set up a national database 3. To learn how to use data to improve quality Public recognition of IR in social media While positioning IR as a clinical speciality or subspecialty, turf battles within medicine remain a constant struggle, social media is beginning to recognize IR. A current description reads as follows, “Interventional radiology (abbreviated IR or VIR for vascular and interventional radiology, also referred to as Surgical Radiology) is a medical sub-specialty of radiology which utilizes minimally invasive

References 1. http://en.wikipedia.org/wiki/Interventional_radiology searched March 31, 2014. 2. Society of Interventional Radiology -- Global Statement Defining Interventional radiology. http://www.sirweb.org/news/newsPDF/ IR_Global_Statement.pdf. 3. http://www.degir.de/site/qualitaetssicherung?PHPSESSID=v8oe7d 7164cmlqchjgmt0io37me3shuq searched March 31, 2014.

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Learning Objectives 1. To learn how to establish IR within a multidisciplinary team 2. To learn the pros and cons of a multidisciplinary team 3. To learn about the keys for success Interventional radiology is one of the most clinically effective, costefficient, innovative and exciting disciplines in medicine. It enables its practitioners to treat patients very well with fewer complications and at a lower cost than traditional surgical methods. However, despite these advantages, interventional radiology is constantly struggling for survival. The main reason for its fragile state is the lack of infrastructure for clinical practice.

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In recent years, interventional radiologists have increasingly practised as clinicians, seeing patients in clinics, taking ward rounds, writing clinic letters and referring patients to other disciplines. However, the subspecialised nature of modern medicine makes it difficult for radiologists to receive large numbers of direct referrals as most of them are not seen as practitioners in a specific organ system. Participation in multidisciplinary meetings increases the visibility of interventional radiologists and enables them to contribute to decisions on treatment; this in turn increases referrals. The relationship between interventional oncology and radiation oncology is particularly important; there is a significant overlap between these disciplines, which are usually complementary rather than competitive. Joint appointments and contribution to each others training would increase the effectiveness of both these fields of practice.

2505.4 IR: stand-alone C.R. Hamilton Hamilton Vein Center, Houston, TX, United States of America Learning Objectives 1. To learn how to establish a stand-alone IR practice 2. To learn the pros and cons of a stand-alone practice 3. To learn about the keys for success Introduction For 11 years, I was in a hospital-based group providing both diagnostic radiology and interventional radiology services. I left my group 4 and 1/2 years ago to start my own stand-alone IR practice. This abstract is based on my experience in developing my IR practice. How to establish an IR stand-alone practice: Starting a medical practice can be overwhelming. Hiring an experienced consultant who knows how to efficiently and effectively set up a medical practice is very useful. A lot of decisions need to be made with regard to the infrastructure, for example, phone systems, information technology and computer systems. Spending money to get it right from the start is very worthwhile. It takes a lot more time and money to use suboptimal equipment or to replace it than it does to get it done right at the beginning. Unless you are an expert at billing, collections and insurance negotiations, hire someone who is and can navigate this arena for you. It can take months to get credentialled with insurance companies and the government. Insurance contracts can take a long time to finalise. Writing a business plan that details exactly what you intend to do is important. There are many books about how to write a business plan, and even Microsoft Word has a business plan template. Developing your plan forces you to be specific in what types of procedures you are going to do and how you are going to get patients. It also makes you examine all of the costs that go into running a clinic and projected revenue from the different types of cases and volumes of cases. Financial projections must be made even though they may not be very accurate. Plan on there being unexpected expenses, delays in payment and other surprises. Make sure you either have enough of your own money to fund the start-up period or get a line of credit from a bank. One of the most common reasons businesses fail is because they run out of money during the start-up period. Your practice may grow and develop completely differently from your plan - my practice certainly did. However, developing a plan forces you to organise your ideas and think through options. Hire great people. If you are leaving a practice and working with some people who are outstanding, get them to leave with you. It is true that you get what you pay for in this area. I have found that if you pay a little more and make an employee happy with their salary and their work environment, you will get a huge return on what you

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spend. Excellent, engaged and motivated employees can be very productive and will allow you to have fewer employees overall. When hiring staff especially at the beginning, it is important that they know they are crucial to the success of the practice and that they are bought into doing everything they can to make the practice succeed. Getting the right staff is imperative because if you have a couple of good people who will do everything they can to make the practice succeed, you do not need a large staff. Pros and cons of stand-alone IR Cons It is an enormous amount of work to start a medical practice. Do not underestimate the time and effort that goes into a project like a stand-alone IR facility. You will not have an income for quite a while; for me, it was about 2 years. Getting patients can be very challenging even when physicians say that they are happy to send patients to you. You may not be able to do as much of the types of cases that you had planned to do. Managing staff is difficult and takes work to do it well. It is very stressful in the beginning because you do not know if you are going to fail or succeed. Pros You are in charge. There are no excuses. There is no one to blame if the practice fails. You get to choose your staff, so they are accountable to you and not the hospital system. You can have your staff treat patients the way you want. Decisions can be made quickly and without endless discussions. It is much easier to have a vision for your practice and strive to make it a reality without the interference of other physicians and administrators. Independence from the hospital is liberating. Keys to a successful stand-alone IR practice Different skills are required in a stand-alone setting than in a hospital setting. Technical ability and a strong work ethic are a requirement but are only a small part of success. I have found several factors crucial to success. 1. Good bed-side manner Physicians should enjoy talking with patients and be comfortable with people. It is important to be outgoing and make a human connection with patients. Believe in what you do; if you are passionate about your work, it comes through to patients, physicians and others. If you view your work as just a job, it comes through to everyone, and do not do a stand-alone IR practice. 2. Customer service Hire great staff, and treat your staff like you want them to treat your patients. Be interested in your staff and genuinely care about them. Treat your employees with respect and be fair with them. Then expect your staff to take great care of your patients. Be easy to work with not only with patients but also with referring physicians. Make it easy to schedule appointments with you and to get their patients treated. Be sure to send follow-up letters and make phone calls to referring physicians. 3. Marketing/Education It is crucial to let the medical community and public know what you do and have to offer. Physician to physician is usually best. Lunch and learns are good; this is where the IR physician goes to another physician’s office and visits them trying to make a personal connection as well as educate them about procedures and pathologies we can treat. Dinners are also good where several physicians are invited and the IR physician can give an educational talk. Physician liaisons or sales representatives can help generate referrals by visiting physician offices on your behalf. A good website is important. I have found social media less helpful but do some social media anyway.

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Talks to community groups and seminars to the public are useful. Mass media such as print, TV, digital and radio can work but get expensive very quickly; so if you do it track the money you spend and track the patients you get from it. Make sure you are getting a good return on your investment. 4. Flexibility It is important to be flexible and to figure out what works and what does not work and be able to adjust accordingly not only with marketing but also with the types of procedures and types of referring doctors. Find what works well and easily, and do more of it. Do less of what is very hard and time consuming. You do not have control over everything, and some things do not work the way you want them to.

Fundamental Course Basic principles of hepatic colorectal metastases management 2601.1 Triage of the metastatic colorectal patient for local treatment G.J. Poston Department of Hepatobiliary Surgery, Aintree University Hospital, Liverpool, United Kingdom Learning Objectives 1. To learn about results of chemotherapy regimens in patients with colorectal cancer metastatic to the liver 2. To learn how to select patients for resection and ablation and the importance of biomarkers as prognostic factors 3. To learn about the role of chemotherapy before and after resection or ablation Multidisciplinary team (MDT) working has been a legal requirement for the treatment of cancer patients in the UK for the last 10 years. In 2011, the National Institute of Health and Clinical Excellence recommended that patients with an advanced (stage 4) colorectal cancer should be managed by designated specialised MDTs set up specifically for this purpose (NICE CG131: Guidance for the management of colorectal cancer, nice.org). The reasoning behind this recommendation was growing evidence that the decision-making capability with regard to local treatments of liver metastases was distinctly lacking among colorectal surgeons in general hospitals (Morris E et al. 2010, Jones R et al. 2012, Young A et al. 2013). In 2013, the responsibility of delivering such care assigned to the Specialised Commissioning Board of NHS, England who defined the service as follows to cover a population of a minimum of 2, and ideally 3 million people: MDT membership: The hepatobiliary and pancreas MDT should have multidisciplinary individuals who have the appropriate training, experience and resources to treat the relevant area(s) of HPB services. • Dietician • Gastroenterologist • Hepatologist • Histopathologists • Nuclear medicine • Oncologist • Pathologist • Radiologist (Diagnostic and Interventional) • Radiotherapist • Specialist nurses • Surgeon The MDT members must hold specific and relevant training, expertise and experience for the relevant HPB condition. MDT must have agreed formal links, clinical policies and care pathways with the relevant cancer networks. It is essential that all MDT members have a minute discussion of all new cases.

Abstract Book With specific regard to colorectal liver metastases, the following were recommended: Secondary Liver Tumours: colorectal Colorectal cancer (CRC) secondary tumours in the liver are one of the most common liver tumours. Imaging, using computerized tomography and magnetic resonance imaging (MRI), is performed in most local hospitals, but decisions on surgery and interventional radiology will be taken by the specialist liver centre MDTs in line with NICE Guidance on Colorectal Cancer (CG131, 2011) and NICE Quality Standards for colorectal cancer (2012). Chemotherapy can be provided locally according to cancer network guidelines. Subsequently, the National Cancer Action Team issued the following recommendations with regard to activity in the secondary and tertiary care centres: Radical Management of Liver Metastases For a radical management of liver metastases, their diagnosis is the responsibility of the colorectal or other site-specific MDT. The specified three levels of care are as follows: Level one care: This requires: • Case discussion at the treatment planning meeting of the specialist HPB MDT • Treatment plan (decision on suitability for radical treatment) by the specialist HPB MDT • Treatment delivery under the care of a core member of the specialist HPB MDT • Treatment delivery in the specialist HPB MDTs named single site for that treatment It comprises: • Tumour surgical resection (open and laparoscopic) • Open, laparoscopic, percutaneous and endoscopic tumour ablation • Percutaneous interventional procedures including TACE, SIRT and portal vein embolisation Level two care: This requires: • Case discussion at the treatment planning meeting of the specialist HPB MDT • Treatment plan (decision on suitability for radical treatment) by the specialist HPB MDT • The authorised personnel responsible for the treatment and the allowed site or sites of treatment delivery to be restricted to only certain ones agreed in the network patient pathways It comprises systemic treatment and radiotherapy as a part of the radical management of liver metastases. Level three care: This is not strictly applicable as it is radical management, but the issue is dealt with by the policy for all scans showing liver predominant metastatic colorectal cancer to be sent for opinion to the specialist HPB MDT and an integrated treatment plan, involving both local and systemic treatment strategies enacted upon. References 1. NICE (2001) ‘Improving outcomes on upper GI cancers, NICE Cancer Service Guidance’ (nice.org). 2. NICE TA176 (2009) ‘Use of cetuximab in first line treatment of unresectable kras wild type liver limited metastatic colorectal cancer’ (nice.org). 3. NICE Clinical Guideline 131 (2011) ‘Guidance on the management of colorectal cancer’ (nice.org). 4. Guidance on commissioning cancer services: Improving outcomes in upper gastro-intestinal cancer, the manual. Department of Health (2001). 5. Association of Upper Gastrointestinal Surgeons. Guidance on minimum surgeon volumes, 2010 (augis.org). 6. Association of Upper Gastrointestinal Surgeons of Great Britain & Ireland, (AUGIS), Provision of Services Document, 2011 (augis.org).

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7. NICE Quality Standard 20 (2012), colorectal cancer. 8. Surgical management and outcomes of colorectal cancer liver metastases. Morris EJA, Forman D, Thomas JD, Quirke P, Taylor EF, Fairley L, Cottier B, Poston G. Brit J Surg. 2010; 97: 1110-8. 9. Effect of specialist decision-making on treatment strategies for colorectal liver metastases. Jones RP, Vauthey JN, Adam R, Rees M, Berry D, Jackson R, Grimes N, Fenwick SW, Poston GJ, Malik HZ. Br J Surg. 2012; 99(9):1263-9. 10. Impact of multidisciplinary team working on the management of colorectal cancer. Ye YJ, Shen ZL, Sun XT, Wang ZF, Shen DH, Liu HJ, Zhang WL, Chen YL, Zhou J, Poston GJ, Wang S. Chin Med J (Engl). 2012; 125(2):172-7. 11. Variation in referral practice for patients with colorectal cancer liver metastases. A. L. Young1, R. Adair1, A. Culverwell2, J. A. Guthrie2, I. D. Botterill3, G. J. Toogood1, J. P. A. Lodge1 and K. R. Prasad1. Brit J Surg. 2013;100:1627-32.

2601.2 Ablation: results and complications T.K. Helmberger Institut für Diagnostische und Interventionelle Radiologie und Nuklearmedizin, Klinikum Bogenhausen, Munich, Germany presented by T.F. Jakobs Department of Radiology, Krankenhaus Barmherzige Brüder München, Munich, Germany Learning Objectives 1. To learn how to perform a state-of-the-art ablation of colorectal liver metastases: indications, contraindications and devices 2. To learn how to avoid and manage complications of liver metastases ablation 3. To learn how ablation compares to resection in liver colorectal metastases patients It is estimated that there are more than 200,000 new cases of colorectal cancer per year in the EU. In about 25–35% of the cases, there will be synchronous or metachronous metastases, mainly to the liver. In this advanced tumor stage, the mean 5-year survival is about 10% (+ X predominantly due to new biological therapies). Due to significant surgical advances, about 20% of patients with liver metastases can be successfully resected with 5-year survival rates of around 50%. Nevertheless, the vast majority of patients are primarily not eligible for a hepatic resection, but about 25% of these patients may benefit from a local ablative therapy as radiofrequency or microwave ablation. Meanwhile, there is a broad database confirming that in metastases less than 3 cm in size, thermal ablation is at least as successful as resection. This is also proven for patients with advanced disease where thermal ablation is combined with systemic therapies, resulting in 5-year survival rates of about 50% and 10-year survival rates of 18%. Moreover, local thermal ablation is a safe procedure with (minor and major) complications rates less than 5%, including post procedure pain, hemorrhage, and rarely bile duct injury or abscess. However, mainly depending on tumor localization, size, and procedural technique, local recurrence after thermal ablation can be up to 25%; this also has to be considered as a procedure-related late complication. Thermal ablation of hepatic colorectal cancer metastases is a powerful tool, comparable to resection, which expands the therapeutic armamentarium significantly, particularly in a multimodality treatment concept. References 1. Gillams A et al. (accepted for publication in 2014) Thermal ablation of colorectal liver metastases - A position paper by an international panel of ablation experts. Radiology [in press]. 2. Park MJ, Kim TH, Lee KM, Cheong JY, and Kim JK (2013) Radiofrequency ablation of metastatic liver masses: recurrence patterns and prognostic factors based on radiologic features. Hepatogastroenterology 60(123): 563-7.

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3. Minami Y and Kudo M (2013) Radiofrequency ablation of liver metastases from colorectal cancer: a literature review. Gut Liver 7(1): 1-6.

2601.3 Intra-arterial chemotherapy: results and complications O. Pellerin Interventional Radiology, Hopital Européen Georges Pompidou, Paris, France Learning Objectives 1. To learn how to perform intra-arterial therapy for colorectal liver metastases: indications, contraindications, materials 2. To learn the results of intra-arterial infusion therapies and chemoembolisation in the treatment of colorectal liver metatsases 3. To learn if and how intra-arterial therapies can be combined with systemic chemotherapy and curative treatments Colorectal carcinoma is a major public health concern with its annual mondial incidence of approximately one million cases and annual mortality of 500,000 cases. The liver is the organ most frequently affected by metastases with a frequency of 40%–60% (contemporaneous in 25% cases). While surgical resection is the only curative therapy, many patients are not eligible due to the infiltrative nature of liver metastases. Systemic chemotherapy and biotherapy regimens are the conventional treatment options. Under such circumstances, intra-arterial therapy may play a major role, because intraarterial therapies have the advantage that liver tumors are fed exclusively by the hepatic artery while the liver is only vascularized by 30% arterial input. Intra-arterial hepatic chemotherapy (IAHC) and transarterial chemoembolization (TACE) are under the scope of that regimen. These therapeutic options are used in several indications in combination or not to systemic chemotherapy when the response is inefficient. They are also used as a first-line therapy to produce maximal response to convert non-surgical patients to those suitable for surgery/ablation. IAHC with 5-fluorodeoxyuridine or oxaliplatinum allows a 90% response rate and 40%–50% conversion to surgery of the initially inoperable patients. TACE is used in colorectal liver metastases with a promising response rate because of the use of iritontecan drug-eluting beads (DEBIRI). DEBIRI is usable as a firstline treatment in combination to systemic chemotherapy in endstage treatment for heavily pretreated patients. However, the DEBIRI overall survival remains unknown and needs to be studied. References 1. Aliberti C, et al (2006) Trans-arterial chemoembolization of liver metastases from colorectal cancer using irinotecan-eluting beads: preliminary results. Anticancer Res. 2. Levi F, et al (2013) Final results of first European phase II trial of intravenous cetuximab and hepatic artery infusion of irinotecan, 5FU, and oxaliplatin in patients with unresectable liver metastases from wt KRAS colorectal cancer after systemic treatment failure. J Clin Oncol. 3. Martin RC, et al (2012) Irinotecan drug-eluting beads in the treatment of chemo-naive unresectable colorectal liver metastasis with concomitant systemic Fluorouracil and oxaliplatin: results of pharmacokinetics and phase I trial. J Gastrointest Surg. 4. Pellerin O, et al (2011) Intra-arterial treatment of liver metastases from colorectal carcinoma. J Radiol.

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2601.4 Radioembolisation: results and complications R. Salem Radiology, Northwestern University, Chicago, IL, United States of America Learning Objectives 1. To learn how to select patients with colorectal liver metastases for radioembolisation 2. To learn about potential complications and results of radioembolisation in the treatment of colorectal liver metastases 3. To learn how to manage radioembolisation in combination with systemic chemotherapy and surgery No abstract available.

Special Session Chronic critical limb ischaemia 2602.1 Clinical presentation and wound management V. Bérczi1, Z. Szeberin2 of Radiology and Oncotherapy, Semmelweis University, Budapest, Hungary, 2Department of Surgery, Semmelweis University, Budapest, Hungary 1Department

Learning Objectives 1. To learn how to assess a wound 2. To learn about the particular problems in diabetic patients 3. To learn about basic wound care Patients with critical limb ischemia (CLI) present with longstanding symptoms of peripheral artery disease such as rest pain, i.e., pain across the base of the metatarsal heads at rest relieved by dependency, or with tissue loss - ulceration, dry gangrene, or wet gangrene. The Rutherford and Fontaine symptom classification systems are the most widely used. CLI is identified as Rutherford stages 4, 5, and 6 or Fontaine stages III and IV. The Rutherford and Fontaine symptom scales have traditionally been the most widely used classifications for CLI. Originally CLI was defined as an ankle pressure <40 mmHg in the presence of rest pain and <60 mmHg in the presence of tissue necrosis in non-diabetic population. Later, transcutaneous oximetric measurement (TcPO2) was added (CLI ≤ 20 mmHg). Due to the demographic changes over the last 40 years, especially the global, epidemic, and dramatic rise in the incidence of diabetes mellitus and chronic kidney failure, the spectrum of CLI population has shifted. It has become increasingly difficult to perform meaningful outcomes analysis for patients with threatened limbs using these existing classification systems when the results of novel techniques of revascularization have been tested. Particularly in patients with diabetes, limb threat is part of a broad disease spectrum. Infrapopliteal macrovascular disease and microvascular dysfunction (e.g., precapillary sphincter malfunction, capillary leakage, arteriovenous shunting, and venous pooling) are the major components of impaired perfusion of diabetic foot. Perfusion is only one determinant of outcome; sensory and motor neuropathy, plantar pressure redistribution, wound extent, and the presence and severity of and altered response to infection also greatly impact the threat to a limb. The guidelines by the International Working Group on the Diabetic Foot (IWDGF) published in 2011 on the diagnosis and treatment of peripheral arterial disease in patients with diabetes and a foot ulcer is also available. The Society for Vascular Surgery created a new classification (WIfI: Wound, Ischemia, and foot Infection. of the threatened lower

Abstract Book extremity that reflects these important considerations. Wounds are stratified to four grades (0–3) based on size, depth, severity and anticipated difficulty achieving wound healing. Ischemia grades (0–3) are based on ankle-brachial Doppler index or TcPO2. Infection grades (0–3) are determined by clinical manifestation of local and systemic symptoms. The WIfI system provides four stages which help to assess the risk of amputation and the expected benefit from revascularization. This classification was also designed to define the stages of CLI that might be useful for outcome analyses, clinical decision-making and prospective studies. Treatment options for lower extremity revascularization must take into consideration the risk of the intervention relative to the patient’s medical condition versus the expected improvement in the patient’s clinical condition (e.g., decreased pain, ulcer healing) and the durability of the intervention in the context of the patient’s life expectancy. A chronic lower extremity wound is a typical, physiologically impaired situation when the wound bed is poorly vascularized, contains devitalized tissue, and has bacterial invasion (infection). It is a matter of utmost importance to achieve the best possible conditions for wound healing following revascularization. Necrotic tissues should be removed by surgical debridement, irrigation with saline, enzymatic cleansing (clinical studies remain controversial) or biologic debridement (maggot therapy). Topically applied growth factors (GF) (platelet-derived GF, epidermal GF, and granulocyte-macrophage colony stimulating factor) have been used in clinical trials. Topically applied antiseptic and antimicrobial agents are irritating and potentially cytotoxic, leading to delayed healing and can cause contact sensitization. Their usage is only recommended in selected populations, e.g. silver dressings are used by many clinicians to decrease the heavy bacterial surface contamination. There are many different types of wound dressings to ensure ideal healing condition. Wounds must be continuously monitored as their characteristics and dressing requirements change over time. Faster healing was observed in the moist environment created by special dressings supporting easier migration of epidermal cells. Consensus opinion agrees on the following general principles for chronic wound management: hydrogels for the debridement stage, foam and low-adherence dressings for the granulation stage, and hydrocolloid and low-adherence dressings for the epithelialization stage. Negative pressure wound therapy has gained increased popularity recently. This method is a sealed wound-care system: an adjustable negative pressure is applied via an airtight adhesive film that covers the wound. It drains wound exudate and is thought to promote blood circulation and healing. Medical, surgical, endovascular, podiatric, nursing and orthotic experts should work together in order to achieve complex management in patients with lower limb gangrene and ulcer. References 1. Mills JL Sr, Conte MS, Armstrong DG, Pomposelli FB, Schanzer A, Sidawy AN, Andros G; Society for Vascular Surgery Lower Extremity Guidelines Committee. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg 2014;59:220-234. 2. Alavi A, Sibbald RG, Mayer D, Goodman L, Botros M, Armstrong DG, Woo K, Boeni T, Ayello EA, Kirsner RS. Diabetic foot ulcers: Part I. Pathophysiology and prevention. J Am Acad Dermatol. 2014;70:1.e1-18. 3. Alavi A, Sibbald RG, Mayer D, Goodman L, Botros M, Armstrong DG, Woo K, Boeni T, Ayello EA, Kirsner RS. Diabetic foot ulcers: Part II. Management. J Am Acad Dermatol. 2014;70(1):21.e1-24. 4. Apelqvist J. Diagnostics and treatment of the diabetic foot. Endocrine. 2012;41:384-397.

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CIRSE 2014 5. Hinchliffe RJ, Andros G, Apelqvist J, Bakker K, Friederichs S, Lammer J, Lepantalo M, Mills JL, Reekers J, Shearman CP, Valk G, Zierler RE, Schaper NC. A systematic review of the effectiveness of revascularization of the ulcerated foot in patients with diabetes and peripheral arterial disease. Diabetes Metab Res Rev. 2012;28 (Suppl 1):179-217. 6. Schaper NC, Andros G, Apelqvist J, Bakker K, Lammer J, Lepantalo M, Mills JL, Reekers J, Shearman CP, Zierler RE, Hinchliffe RJ. Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot. Diabetes Metab Res Rev. 2012;28 (Suppl 1):218-224.

2602.2 Drug therapy: salvage or adjunctive M. Bratby Radiology, Oxford University Hospital, Oxford, United Kingdom Learning Objectives 1. To learn when to use prostaglandin therapy 2. To learn when to use dual anti-platelet therapy 3. To learn about the role of new anti-coagulation drugs Critical limb ischaemia (CLI) occurs after chronic lack of blood supply sets off a cascade of pathophysiological events that lead to rest pain or trophic lesions of the legs. Initially, the response to ischaemia is angiogenesis, promoting the enlargement of pre-existing collaterals to aid and increase blood flow to the critically ischaemic limb. These responses fail to supply the necessary amount of blood flow and oxygen to the limb causing arterioles in patient with CLI to become maximally vasodilated and insensitive to provasodilatory stimuli. This phenomenon called vasomotor paralysis is thought to be the result of chronic exposure to vasorelaxing factors. These changes lead to oedema, a major concern for these patients. Patients often hold their limbs in a dependent position to alleviate ischaemic rest pain combined with impaired vasomotor control; this leads to the further aggravation of oedema, which compresses the already compromised capillaries and impairs the diffusion of nutrients to tissues. There is further endothelial dysfunction leading to microthrombosis with the capillaries and exacerbation of oedema formation. Endothelial trauma results in increased free radical production, inappropriate platelet activation and leucocyte adhesion. The end result is that tissue oxygen exchange at the capillary level is impeded and less effective. Many patients greatly benefit from the restoration of blood flow required for wound healing and limb salvage; however, reinstating macrovascular blood flow alone does not reverse the microvascular derangements and initiates reactive hyperaemia and exacerbate an already complex problem. Therefore, there are a multitude of factors to find the optimal management including medical management, revascularisation or amputation. Patients with CLI experience significant morbidity with cardiovascular event rates surpassing those in patients with symptomatic coronary artery disease. The multicentre randomised trial of edifoligide for the prevention of vein graft failure in lower extremity bypass surgery (PREVENT III) confers the best data for CLI patients. A 2.7% perioperative mortality rate, 5.2% graft occlusion rate, 16% mortality rate at 1 year, 80% secondary patency rate at 1 year and an 88% limb salvage rate at 1 year was observed. Various reports have demonstrated that cardioprotective medications such as statins, antihypertensive medication and antiplatelet agents are associated with a decreased cardiovascular event rate in patients with PAD although there is less data on these agents for patients at greatest risk - patients with CLI. In the PREVENT III cohort, 45% were taking statins, 59% beta-blockers and 80% antiplatelet agents. Only statin use was associated with improved survival in CLI patients 1 year after revascularisation, whereas the use of

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beta-blockers and antiplatelet agents had no effect on survival. Forty percent diabetic patients with CLI progress to gangrene compared with 9% in non-diabetic patients. Limb salvage rates are reported to be lower in diabetic patients. There is a prospective randomised controlled trial in type 2 diabetic patients with established macrovascular disease which examined the effect of pioglitazone, a synthetic ligand for the peroxisome proliferator-activated receptor that when activated alters the transcription of genes to improve insulin sensitivity. Treatment with pioglitazone reduced the composite of all-cause mortality, non-fatal myocardial infarction and stroke but had no significant effect on the rate of leg revascularisation or amputation. There is evidence that patients undergoing angioplasty benefit from aspirin therapy; clopidogrel is a useful alternative to patients who cannot tolerate aspirin. There is indirect evidence from coronary revascularisation data to support the use of dual therapy with antiplatelet agents to reduce occlusion rates following angioplasty or stent placement. There is limited data suggesting low molecular weight heparin is superior to unfractionated heparin for the prevention of early- and mid-term occlusion after femoro-popliteal angioplasty. There is a single study of abciximb in high-risk patients with long segment femoro-popliteal interventions showing improved early patency. Placebo-controlled studies have evaluated the use of iloprost for CLI. Norgren reported a 43.5% incidence of limb loss in the placebo group with no significant difference in the iloprost group at 6 months. Similarly, Brass showed that lipoecraprost failed to modify the 6-month amputation rate in patients with CLI in patients, who were not candidates for revascularisation. Emerging therapies are important to evaluate given the large number of patients not eligible for revascularisation and the suboptimal outcomes with current limited medical management options. Gene therapy offers potential efficacious therapy. Genes included in early studies were vascular endothelial growth factor and fibroblast growth factor. Over 1000 patients have been treated in phase I and II trials with similar adverse events between treatment and control groups. Endothelial progenitor cells derived from bone marrow or peripheral blood are another subset of emerging therapies implicated in the regeneration of injured endothelium and neoangiogenesis. There are some promising early results in certain subsets of patients. Long-term concerns remain regarding the potential for angiogenesis-triggered malignancies and the impact of angiogenesis on processes such as retinopathy and atherosclerotic plaque destabilisation. References 1. Conte MS et al. Results of PREVENT III: multicenter, randomized trial of edifoligide for the prevention of vein graft failure in lower extremeity ypass surgery. J Vasc Surg 2006; 43:742-50. 2. Dormandy J et al. Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study (PROspective pioglitAzone Clinical Trial in macroVascular Events): a randomised controlled trial. Lancet 2005; 366:1279-89. 3. Norgren et al. Iloprost in the treatment of ischaemic ulcers of the lower limb. Eur J Vasc Surg 1990; 4:463-7. 4. Brass et al. Parenteral therapy with lipo-ecraprost, a lipid-based formulation of a PGE1 analog, does not alter six-month outcomes in patients with CLI. J Vasc Surg 2006; 43:752-9. 5. Tapping CR et al. The changing face of vascular interventional radiology: the future role of pharmacotherapies and molecular imaging. CVIR 2013; 36:904-12.

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2602.3 Patency vs. clinical success of revascularisation S. Spiliopoulos Department of Interventional Radiology, Patras University Hospital, Rion, Greece Learning Objectives 1. To learn about the clinical outcome measures 2. To learn about surveillance after revascularisation 3. To learn about the limits of revascularisation (e.g. Buerger’s disease) The mortality rate of patients suffering from CLI was nearly 25% and over 50% at 1 and 5 years, respectively, and 45% of these patients are alive with two limbs and 30% have suffered an amputation at 1 year. In the US, the incidence of CLI-related amputations ranges from 12 to 50 major amputations per 100,000 individuals per year. [1, 2] Without prompt revascularization, CLI entails a high risk of major amputation and amputation-related mortality and morbidity. The technical goal of revascularization procedures for CLI is creating patency in at least one straight line of blood flow to the distal foot. According to the SIR reporting standards for peripheral procedures, technical success is defined as “the substantial relief of stenosis or occlusion with residual narrowing of 20% or less, significant hemodynamic improvement, and no major morbidity.” On the other hand, clinical success has different definition and outcome measures. According to the same document, clinical success in CLI, which is the primary clinical outcome of any endovascular revascularization procedure, is to prevent limb amputation by relieving or significantly improving the typical symptoms of chronic ischemic rest pain or enabling wound healing of ischemic skin ulcers. Therefore, the primary clinical outcome measure following CLI revascularization procedures is “limb salvage” or “amputation-free survival.” [3] Of note, the non-progression of gangrene following revascularization, limiting the level of amputation to a pre-scheduled minor amputation with subsequent healing of the surgical wound, should also be considered as clinical success. Notably, although patency represents a crucial criterion of endovascular revascularization success in CLI as it is a discrete and comparable end point, it does not always match with clinical success. This phenomenon could be termed as “hemodynamic failure.” [4] As opposed to technical success, which should be assessed by criteria indicating anatomic (<30% final residual stenosis measured at the narrowest point of the vascular lumen and <50% recurrent stenosis) and hemodynamic success (ABI or thigh/ brachial index improved by 1.0 or greater above baseline and not deteriorated by <0.15 from the maximum early post-procedure level or pulse volume recording distal to the reconstruction maintained at 5 mm above baseline for patients with incompressible vessels), clinical success should be documented by the observation of specific clinical symptoms/data such as the immediate improvement by at least 1 clinical category and the sustained improvement by at least 1 clinical category in patients with Rutherford–Becker 4 disease, while in patients suffering from Rutherford–Becker 5 and 6 disease (tissue loss), improvement is documented as an advancement of at least 2 categories as to reach the level of claudication. [5] Objective hemodynamic criteria such as an ABI change can also be used in order to assess Rutherford–Becker classification change or to indirectly evaluate blood supply to the limb during the wound healing process. Post-procedural survival and peri-procedural morbidity are also primary clinical outcome measures necessary to assess procedural safety and immediate clinical impact of limb reperfusion as well as to evaluate the mid- and long-term effects of endovascular revascularization in the survival of CLI patients who are characterized by numerous co-morbidities and an elevated rate of cardiovascular death. In order to assess morbidity and mortality, major and minor complications should be accurately defined and documented in detail. Secondary clinical outcome measures for CLI

Abstract Book revascularization include target lesion revascularization (TLR)-free survival, minor amputation rate, and the improvement of patient function and quality of life. A rigorous clinical and imaging follow-up following endovascular revascularization procedures is of the utmost importance in order to warrant clinical success. All CLI patients need life-long followup, beginning while in bed rest in the initial post-procedural period. The monitoring of vital signs and urine and checking the arterial puncture site during bed rest is usually required for a minimum of 5 hours and up to 12–24 hours. It is advised not to discharge the patient prior to cardiovascular risk factors modification (uncontrollable hypertension or diabetes) and wound assessment. Patient education on wound care, dietary habits, and risk factor modification is crucial. Regular follow-up visits should be scheduled at 1, 3, 6, and 12 months, and then yearly after the procedure unless a relapse of symptoms occurs and should include both monitoring and surveillance as follows: detailed physical examination, ABI measurements and Rutherford classification of PAD, wound healing assessment comparison of ulcer dimensions with objective means such as photos and rulers, risk factors evaluation, medical therapy modification if necessary, update of medical history record, and color flow duplex ultrasound (DUS). Surveillance using other imaging modalities such as CTA, MRI, and DSA can also be performed but should be mainly reserved for ambiguous DUS results and as a part of pre-procedural planning in selected cases. [6] As limb amputation has been related to superior peri-operative mortality rates, prolonged hospital stay, and decreased overall survival rates compared with revascularization, there are very few absolute contraindications to endovascular revascularization in cases of limb-threatening ischemia; these include a non-salvageable limb (infected gangrene of the mid portion of the foot or non-infected gangrene extending above the level of the forefoot amputation). [7] Moreover, revascularization should not be attempted in cases of specific vasculitis such as Buerger’s disease requiring conservative therapy (smoking cessation, systematic pharmacotherapy, etc.). [8, 9] The diagnosis of Buerger’s disease is based on both clinical and angiographic criteria, and the latter include small- to mediumsized vessel involvement of both extremities, segmental occlusive lesions, and collateralization around areas of occlusion (cork-screw collaterals). [10, 11] Infected gangrene confined to the foot amenable to surgical debridement and antibiotic therapy should not preclude a revascularization attempt. Institutionalized, permanently immobile, and mentally impaired patients, suffering from advanced Rutherford–Becker 6 CLI would in many cases not benefit from revascularization compared with primary amputation and should be treated ad hoc. Additionally, although uncorrectable coagulopathy is considered an absolute contraindication to endovascular revascularization in the ambit of limb-threatening CLI, the decision should be case sensitive considering whether the alternative options such as above the knee amputation are safer. Other relative contraindications include a “white” leg without any sign of BTK or pedal runoff (selective angiogram with the catheter placed just above the tibial trifurcation might reveal a target run-off vessel and justify a revascularization attempt): patients not able to cooperate can lay down for the necessary time period (consider anesthesiologist and closure devices); severe allergy to contrast media (consider using CO2 as contrast media), borderline renal function (again consider using CO2 or adequate hydration and minimal amounts of contrast media), and contraindication to antiplatelet therapy that would largely compromise the clinical success of endovascular treatment compared with surgical bypass. Finally, another contraindication to endovascular treatment is life-threatening heparin-induced thrombocytopenia (HIT) syndrome; as apart from the fact that heparin is essential during angioplasty both as a bolus dose and for flushing, most of the endovascular materials such as catheters and guide-wires contain heparin. HIT syndrome usually occurs 4–14 days after heparin administration and could be fatal. If using heparin substitutes

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such as direct thrombin inhibitors, e.g., daparanoid, bivalirudin, and fondaparinux in combination with heparin-free endovascular materials is not an option, then endovascular revascularization should not be attempted. [12, 13] References 1. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus For The Management Of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45(Suppl 1): A5–A67. 2. Spiliopoulos S, Katsanos K, Pastromas G, et al. Initial Experience With Ticagrelor In Patients With Critical Limb Ischemia and High On-Clopidogrel Platelet Reactivity Undergoing Complex Peripheral Endovascular Procedures. Cardiovasc Intervent Radiol 2014 Feb 8. [Epub ahead of print]. 3. Society Of Interventional Radiology Standards Of Practice Committee Guidelines For Percutaneous Transluminal Angioplasty. J Vasc Interv Radiol 2003; 14:S209–S217. 4. Pentecost MJ, Criqui MH, Dorros G, et al. Guidelines For Peripheral Percutaneous Transluminal Angioplasty Of The Abdominal Aorta And Lower Extremity Vessels. A Statement For Health Professionals From A Special Writing Group Of The Councils On Cardiovascular Radiology, Arteriosclerosis, Cardio-Thoracic And Vascular Surgery, Clinical Cardiology, And Epidemiology And Prevention, The American Heart Association. J Vasc Interv Radiol 2003; 14:S495–S515. 5. Sacks D, Marinelli DL, Martin LG, Spies JB, and the members of the Society of Interventional Radiology Technology Assessment Committee. Reporting Standards For Clinical Evaluation Of New Peripheral Arterial Revascularization Devices. J Vasc Interv Radiol 2003; 14:S395–S404. 6. van Overhagen H, Spiliopoulos S, Tsetis D. Below-The-Knee Interventions. Cardiovasc Intervent Radiol 2013; 36:302–11. 7. Liapis CD, Balzer K, Valentini FB, Fernandes e Fernandes J. In ‘European Manual of Medicine. Vascular Surgery’ SpringerVerlang, Berlin, Heidelberg, 2007. 8. Bozkurt AK, Cengiz K, Arslan C, et al. A Stable Prostacyclin Analogue (Iloprost. In The Treatment Of Buerger’s Disease: A Prospective Analysis Of 150 Patients. Ann Thorac Cardiovasc Surg 2013; 19:120–5. 9. Donas KP, Schulte S, Ktenidis K, Horsch S. The Role Of Epidural Spinal Cord Stimulation In The Treatment Of Buerger’s Disease. J Vasc Surg 2005; 41:830–6. 10. Shionoya S. Diagnostic Criteria Of Buerger’s Disease. Int J Cardiol 1998; 66(Suppl 1):S243–S245. 11. Fujii Y, Soga J, Nakamura S, et al. Classification Of Corkscrew Collaterals In Thromboangiitis Obliterans (Buerger’s Disease): Relationship Between Corkscrew Type And Prevalence Of Ischemic Ulcers. Circ J 2010; 74:1684–8. 12. Kodityal S, Manhas AH, Udden M, Rice L. Danaparoid For Heparin-Induced Thrombocytopenia: An Analysis Of Treatment Failures. Eur J Haematol 2003; 71:109–13. 13. Karnabatidis D, Spiliopoulos S, Tsetis D, Siablis D. Quality Improvement Guidelines For Percutaneous Catheter-Directed Intra-Arterial Thrombolysis And Mechanical Thrombectomy For Acute Lower-Limb Ischemia. Cardiovasc Intervent Radiol 2011; 34:1123–36.

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2602.4 Procedural complications and their management H.I. Manninen Clinical Radiology, Kuopio Univ. Hospital, Kuopio, Finland Learning Objectives 1. To learn how to prevent complications 2. To learn how to recognise complications early 3. To learn about different tools for solving complications The procedural complications in endovascular interventions for CCLI occur in 5–10% of patients and half of them are major (Matsi PJ et al.). The complications can be categorized as local or systemic. The most common local complications are access site bleedings, mainly pseudoaneurysms or hematomas. Temporary AV fistulas can occur, but they are rarely clinically manifested. The most feared complication due to arterial access is retroperitoneal bleeding contributed by high inguinal puncture and seems to be more common in elderly patients. Puncture below the middle level of femoral caput under fluoroscopic control is usually safe. US-guided punctures may also be useful. Iliac artery perforations are potentially life threatening. These are usually due to catheter manipulations and associated with forceful dilatations of calcified lesions using oversized balloons. The small calcified arteries of elderly women seem to be especially fragile. Postdilatation of some nitonol stents has been anecdotally associated with iliac artery ruptures. In infrainguinal arteries, arterial perforations are usually clinically less important but can seldom cause compartmental syndrome if the bleeding is continued, which is more common in patients receiving anticoagulants. The use of subintimal recanalization techniques with or without re-entry catheters do not seem to increase the complication rate (Bausback et al.), nor do the novel retrograde pedal accessory puncture techniques. Distal embolization is usually associated with recanalization of subacute total occlusions in iliac and femoral arteries. Local thrombosis is encountered mainly during the manipulation of diffusively diseased infrapopliteal arteries with poor distal out-flow and is often attenuated by arterial spasms. Adequate heparin administration, preferably under ACT control during the intervention and liberal use of intra-arterial nitro in the case of spasms are the best ways to avoid this complication. Subacute thrombosis at the puncture site is sometimes encountered after the use of collagen plug closure devices; these devices should be cautiously used in calcified arteries. Systemic complications are mainly due to the nephrotoxicity of iodine contrast media and contributing factors are underlying renal disease caused, e.g., by diabetes and dehydration of the patient. Sufficient pre- and postinterventional hydration with IV fluids is mandatory. Cardiac infarction is a rare complication but may be encountered during lengthy stressful interventions, especially if there is significant bleeding due to vascular rupture. Allergic reactions, although rare, have to be always remembered and in case of anamnestic allergy, adequate prophylaxis is to be considered. The diagnosis of local puncture site complications is confirmed using US and in case of pseudoaneurysms, US-guided thrombin injection is usually very effective. In case of diffuse active bleeding, prolonged compression, e.g., FemoStop system can be tried but in case of brisk bleeding with rapidly increasing size of the hematoma, surgical closure has to be done urgently. Also, the thrombotic occlusion of common femoral artery caused by vascular closure plug is best treated by surgical thrombectomy. Distal thromboembolisms are usually managed by aspiration and local catheter delivery of thrombolytics. The neurointerventional distal access and aspiration catheters are effective and less traumatic than conventional aspiration catheters in infrapopliteal arteries. In case of arterial rupture, prolonged balloon dilatation is usually very effective in infrainguinal arteries. In case of iliac perforation, balloon dilatation should be done with low pressure, and protamine should be given to remove the heparin effect. Fluid resuscitation is usually mandatory

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due to hemodynamic collapse in these patients. Only after stabilization of the hemodynamics, opening of the balloon and angiography is possible. In case of extensive rupture and/or continued bleeding, the placement of a stent graft/covered stent is the best option. The placement of aortic occlusion balloon from contralateral iliac to secure this may be necessary. References 1. Matsi PJ, Manninen HI. Complications of lower-limb percutaneous transluminal angioplasty: a prospective analysis of 410 procedures on 295 consecutive patients. Cardiovasc Intervent Radiol 1998;21:361-5. 2. Bausback Y, Botsios S, Flux J et al. Outback catheter for femoropopliteal occlusions: immediate and long-term results. J Endovasc Ther 2011:18;13-21.

Special Session Thoracic aorta - Evidence forum 2603.1 TEVAR for thoracic aortic aneurysm and aortic dissection M.A. Funovics Klinik für Radiodiagnostik, Medizinische Universität Wien, Vienna, Austria Learning Objectives 1. To understand indications and imaging assessment for treatment 2. To define techniques for endovascular treatment excluding debranching 3. To learn outcomes for TAA and dissections No abstract available.

2603.2 TEVAR for aortic trauma and Marfan syndrome T. Pfammatter Division of Diagnostic and Interventional Radiology, University Hospital Zürich, Zurich, Switzerland

Abstract Book of the left subclavian artery origin, becomes necessary in up to 60% patients. These anatomical constraints are associated with relevant early failures; early proximal type I endoleaks have been observed in 4.2%–14% patients treated for TAI (3, 5). The collapse of thoracic aortic stent grafts have been reported to occur particularly in patients treated for TAI (6). This complication is asymptomatic in 51%–59% patients and often detected on imaging before discharge. Oversizing of the stent graft of >20% and severe proximal angulation leading to “beaking” have been associated with this complication (6-8). These clinical and laboratory observations prompted the development of a new generation of thoracic stent grafts (Zenith TX2 Pro-Form/Cook, Valiant Captivia/Medtronic, Conformable TAG/ Gore, and Relay Plus/Bolton). The modifications involve changes in the delivery system allowing a more precise delivery and better apposition of the uppermost stent graft element (Zenith and Relay) or the addition of a bare stent crown combined with alterations in the exoskeleton geometry increasing its radial force and improving its conformability (C-TAG). Short-term clinical observations with these newer stent grafts are promising (7, 9, 10). Meanwhile, good mid-term results have been achieved with the first generation of commercially available thoracic stent grafts. As TAI survivors have a long life expectancy and the aorta becomes tortuous and dilated with advancing age, we will not know for many years whether the new devices enable a definitive solution. Patients with other heritable aortic conditions such as Marfan syndrome undergo their first surgery, most commonly for ascending aneurysms with or without aortic valve insufficiency, as young adults. A continuous degeneration of other aortic segments is associated with serious complications, including dissection, aneurysm, and rupture. Due to the low prevalence of Marfan syndrome and the inherent aortic weakness, the largest published experience with endovascular repair includes just 16 patients (11). Endovascular repair has been performed particularly under emergency circumstances such as aneurysm rupture or complicated Stanford type B dissection. In high-risk patients, endovascular repair may represent a definitive solution, but in younger, operable patients, it is still considered a useful adjunct or bridge to open surgical treatment. At mid-term follow-up, open or endovascular reinterventions have been performed in 17%–33% of this population (12, 13). References

Learning Objectives 1. To understand patient selection and indications for treatment 2. To define the techniques of endovascular treatment 3. To understand outcomes for trauma and Marfan syndrome Based on imaging, blunt traumatic aortic injuries (TAIs) are classified into 4 grades, ranging from intimal tears to free rupture. Over time, injuries grade 1and 2 tend to be stable, but as progression to false aneurysms may rarely occur, follow-up imaging has been recommended if they are not treated (1). In 1997, the first cases of TAIs treated by stent grafts were published (2). Ten years later, a survey by the American Association for the Surgery of Trauma showed that endovascular treatment had been chosen for 65% TAI patients (3). No randomized trial comparing open with endovascular repair of this rare condition has yet been performed. However, a multicenter prospective study and metaanalysis of comparative studies demonstrated a significant reduction in procedural mortality and ischemic spinal cord events associated with TEVAR (3, 4). The stent grafts used in the first decade of endovascular treatment were essentially tube stent grafts derived from abdominal aortic devices, which had been adapted for the treatment of degenerative aneurysms of the descending thoracic aorta. The TAI population is generally younger and therefore, has smaller aortic diameters and shorter radii of the arch. As the aortic isthmus is involved in over 90% TAIs, anchoring of the prosthesis in the arch, proximally

1. Osgood MJ, Heck JM, Rellinger EJ, et al. Natural history of grade I-II blunt traumatic aortic injury. J Vasc Surg. 2014; 59(2):334-41. 2. Kato N, Dake MD, Miller DC, et al. Traumatic thoracic aortic aneurysm: treatment with endovascular stent-grafts. Radiology. 1997; 205(3):657-62. 3. Demetriades D, Velmahos GC, Scalea TM, et al. Operative repair or endovascular stent graft in blunt traumatic thoracic aortic injuries: results of an American Association for the Surgery of Trauma Multicenter Study. J Trauma. 2008; 64(3):561-70; discussion 70-1. 4. Xenos ES, Abedi NN, Davenport DL, et al. Meta-analysis of endovascular vs open repair for traumatic descending thoracic aortic rupture. J Vasc Surg. 2008; 48(5):1343-51. 5. Hoffer EK, Forauer AR, Silas AM, Gemery JM. Endovascular stentgraft or open surgical repair for blunt thoracic aortic trauma: systematic review. J Vasc Interv Radiol. 2008; 19(8):1153-64. 6. Jonker FH, Schlosser FJ, Geirsson A, Sumpio BE, Moll FL, Muhs BE. Endograft collapse after thoracic endovascular aortic repair. J Endovasc Ther. 2010; 17(6):725-34. 7. Canaud L, Alric P, Branchereau P, et al. Open versus endovascular repair for patients with acute traumatic rupture of the thoracic aorta. J Thorac Cardiovasc Surg. 2011; 142(5):1032-37. 8. Fairman RM, Tuchek JM, Lee WA, et al. Pivotal results for the Medtronic Valiant Thoracic Stent Graft System in the VALOR II trial. J Vasc Surg. 2012; 56(5):1222-31 e1.

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9. Khoynezhad A, Azizzadeh A, Donayre CE, Matsumoto A, Velazquez O, White R. Results of a multicenter, prospective trial of thoracic endovascular aortic repair for blunt thoracic aortic injury (RESCUE trial). J Vasc Surg. 2013; 57(4):899-905 e1. 10. Melissano G, Civilini E, Bertoglio L, Logaldo D, Chiesa R. Initial clinical experience with the modified Zenith “Pro-Form” TX2 thoracic endograft. J Endovasc Ther. 2010; 17(4):463-70. 11. Waterman AL, Feezor RJ, Lee WA, et al. Endovascular treatment of acute and chronic aortic pathology in patients with Marfan syndrome. J Vasc Surg. 2012; 55(5):1234-40; discussion 40-1. 12. Preventza O, Mohammed S, Cheong BY, et al. Endovascular therapy in patients with genetically triggered thoracic aortic disease: applications and short- and mid-term outcomes. Eur J Cardiothorac Surg. 2014. 13. Eid-Lidt G, Gaspar J, Melendez-Ramirez G, et al. Endovascular treatment of type B dissection in patients with Marfan syndrome: Mid-term outcomes and aortic remodeling. Catheter Cardiovasc Interv. 2013; 82(7):E898-905.

2603.3 TEVAR induced neurologic and vascular complications A. Chavan, B. Schmuck, O. Eldergasch, R. Thomas Institut für Diagnostische & Interventionelle Radiologie, Klinikum Oldenburg gGmbH, Oldenburg, Germany Learning Objectives 1. To learn risk factors for neurological complications 2. To learn adjunctive procedures to minimise complications 3. To learn treatment options for complications Thoracic endovascular aneurysm repair (TEVAR) has become the mainstay of treatment for descending thoracic aortic aneurysms; branched and fenestrated endograft technology has made inroads into the management algorithm of thoracoabdominal aortic aneurysms. An ever emerging role for stent grafts in the management of complicated type B dissections is becoming apparent. Although apparently less invasive than open repair, TEVAR is not possible without procedural hazards. Vascular and neurological complications constitute the lion’s share of these hazards. Vascular complications at the entry portal include access site bleeding and hematomas as well as injury to the access vessels, sometimes resulting in dissection or rupture (1,2). Such complications were reported in the earlier days of TEVAR before the turn of the century in approximately 3%–8% patients. However, the large and relatively rigid introducer systems of yesteryears (up to 27 F) have been replaced by sleeker, more flexible systems with diameters below 24 F. This, combined with an increasing experience of the interventionalist, has led to a certain improvement in the rate of such access site complications without being able to entirely eliminate their occurrence. The key to reducing or avoiding these complications lies in proper patient selection and adequate pre-procedural assessment of the iliac and femoral vessels. The probability of complications increases with the grade of calcification and tortuosity of the iliac vessels. In patients with heavily calcified and tortuous iliac vessels, externalization of the guide wire over the brachial artery (through-and-through wire technique) often assists in getting the introducer system past the iliac vessels. An iliac vessel diameter of at least 8 mm (and preferably 9 mm) is essential to easily accommodate 24 F systems. Should TEVAR be the only option in patients with gracile iliacs in whom an iliac conduit is contemplated, then the patient should be adequately informed about a higher risk of post-procedural paraplegia (3). At the proximal end, the retrograde type A dissection is a rare but well documented vascular complication of TEVAR. It has been observed in patients undergoing TEVAR for aneurysms as well as for type B dissections. The estimated incidence lies between 1% and 3%. Such iatrogenic type A dissections most often require open surgical repair and are associated with a high mortality (2,4).

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In patients with type B dissections undergoing stent grafting, TEVAR may lead to an uncontrolled tearing of the intimal flap while introducing or releasing the endograft, thus worsening the situation and necessitating open repair in some cases. Despite successful endografting in type B dissections, aortic rupture as an acute or delayed complication is well documented (1,2). The same holds true for persistent distal vessel ischemia, especially of the abdominal and pelvic vessels. Bare-metal stenting of the true lumen distal to the stent graft or fenestration of the intimal flap further downstream are often required to deal with such ischemia (5). Rare complications include non-neurological embolic complications, especially in the left upper extremity and abdominal visceral organs such as the spleen and the kidneys, resulting either from coverage of the origin of the left subclavian artery or thrombosis of the false lumen causing thromboembolism. Procedure-related stroke is one of the most dreaded complications of TEVAR. Although periprocedural stroke after TEVAR is primarily an embolic complication, injury to the arch vessels with dissection of these vessels may also be contributory. The incidence of stroke ranges between 3%–6%. In 17%–33% patients with stroke, it proves lethal. The risk factors associated with stroke are obesity, iatrogenic blood loss, and vascular embolization. The risk of stroke during TEVAR is also directly associated with atheroma burden of the aortic arch, previous history of stroke, coverage of the proximal descending or the entire descending aorta (extent A or C coverage), Type III aortic arch, and zone 1 deployment. The incidence of stroke is significantly higher amongst patients with coverage of the left subclavial artery without previous carotid-subclavian bypass (2,3,6-8). A further devastating complication of TEVAR is spinal cord injury resulting in paraparesis or paraplegia. Spinal cord ischemia complicating TEVAR is less common than stroke, with a reported incidence of 2%–3% (8). Aneurysm as an underlying pathology and the use of an iliac conduit are more frequently associated with postoperative spinal cord ischemia (SCI) after TEVAR (3). Further risk factors include preoperative renal insufficiency, extent C endovascular coverage, and a previous history of open or endovascular repair (8). Early detection and intervention to augment spinal cord perfusion pressure is effective in decreasing the magnitude of injury and preventing permanent paraplegia resulting from SCI following TEVAR. Routine somatosensory evoked potential monitoring, serial neurological assessment, aggressive arterial pressure augmentation, and cerebrospinal fluid drainage may benefit patients at risk of paraplegia (9,10). Future strategies to reduce the incidence of TEVAR-related vascular and neurological complications must include better patient selection and pre-procedural assessment, lower profile, and less traumatic introducer systems, meticulous intraprocedural monitoring as well as early detection and intervention to augment spinal cord perfusion pressure in case of SCI. References 1. Svensson LG, Kouchoukos NT, Miller DC, et al (2008): Expert consensus document on the treatment of descending thoracic aortic disease using endovascular stent-grafts. Ann Thorac Surg; 85: 1-41. 2. Fattori R, Nienaber C, Rousseau H, et al (2006): Results of endovascular repair of the thoracic aorta with the Talent Thoracic stent graft: the Talent Thoracic Retrospective Registry. J Thorac Cardiovasc Surg; 132: 332-339. 3. Khoynezhad A, Donayre CE, Bui H, et al (2007): Risk factors of neurologic deficit after thoracic aortic endografting. Ann Thorac Surg; 83(2): S882-S889. 4. Eggebrecht H, Thompson M, Rousseau H, et al (2009): Retrograde Ascending Aortic Dissection During or After Thoracic Aortic Stent Graft Placement: Insight From the European Registry on Endovascular Aortic Repair Complications. Circulation; 120: S276-S281.

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5. Chavan A, Rosenthal H, Luthe L, et al (2009): Percutaneous inter ventions for treating ischemic complications of aortic dissection. Eur Radiol; 19: 488-494. 6. Kotelis D, Bischoff MS, Jobst B, et al (2012): Morphological risk factors of stroke during thoracic endovascular aortic repair. Langenbecks Arch Surg; 397(8): 1267-1273. 7. Gutsche JT, Cheung AT, McGarvey ML et al (2007): Risk factors for perioperative stroke after thoracic endovascular aortic repair. Ann Thorac Surg; 84(4): 1195-1200. 8. Ullery BW, Cheung AT, Fairman RM, et al (2011): Risk factors, outcomes and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair. J Vasc Surg; 54(3): 677-684. 9. McGarvey ML, Mullen MT, Woo EY et al (2007): The treatment of spinal cord ischemia following thoracic endovascular aortic repair. Neurocrit Care; 6(1): 35-39. 10. Cheung AT, Pochettino A, Mcgarvey M, et al (2005): Strategies to manage paraplegia risk after endovascular stent repair of descending thoracic aortic aneurysms. Ann Thorac Surg; 80: 1280-1289.

to cannulate the supra-aortic vessels for branch insertion. Several device manufacturers are developing branched devices, although none of these are currently commercially available. Similarly, fenestrated endografts are under investigation, but none are available. In the absence of a totally endovascular solution, the mainstay of therapy for aortic arch aneurysms are hybrid procedures. There is also limited experience on the use of chimney grafts for aortic arch aneurysms, although the outcomes of these procedures in the aortic arch are suspect.

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The rapid clinical adoption and acceptance of focal tumor ablation for the treatment of various small focal cancers, such as hepatocellular carcinoma as well as renal and lung cancer, have been predicated upon the development of robust image-guided intervention platforms. Transition of this paradigm to becoming ever more useful is based upon the development of both better ablation tools (such as RF, MW, and IRE devices) and new procedural image guidance systems (such as image fusion and navigation devices) that can improve tumor targeting, yet best use of these tools is predicated upon a solid foundation of tissue-specific systematic characterization and optimization. Accordingly, we will highlight many of the advances and insights learned from our world-class Applied Radiology Laboratory program at Hadassah Hebrew University Medical Center in Jerusalem that has performed such characterization for multiple ablation devices. In addition, it is becoming ever more apparent that better elucidation of energy–tissue interaction is required to understand potentially beneficial and harmful local, organ, and systemic effects of our interventional oncologic therapies. Here too, we will demonstrate the Israeli contributions to this rapidly growing field of research inquiry.

Total aortic arch aneurysm exclusion R.A. Morgan Interventional Radiology, St George’s NHS Trust, London, United Kingdom Learning Objectives 1. To learn the indications and options for aortic arch aneurysm treatment 2. To describe techniques for hybrid debranching and stent-graft placement 3. To learn the outcomes for hybrid debranching procedures With an increasing experience of endovascular treatment of descending aortic aneurysms, interventionalists have developed adjunctive techniques for treating aneurysms that involve part or all of the aortic arch. The key to success is the provision of a proximal landing zone for an adequate seal between the non-aneurysmal aorta and the aortic endograft to prevent a proximal type 1 endoleak into the aneurysm sac. With regard to the aortic arch, this entails endograft coverage of the origins of one, two or all three of the supraaortic arteries. The preservation of blood flow is clearly essential to the innominate and left common carotid arteries. Previously, it was thought that the left subclavian artery could be covered without maintaining the flow to the left arm and left vertebral arteries; however, it is now known that this practice is associated with increased complications, and the restoration of the flow to the left subclavian artery is also routinely practiced. The methods available for the preservation of the flow into the supra-aortic arteries to enable aortic arch endografting are hybrid procedures, branched or fenestrated endografts. Hybrid procedures refer to the surgical bypass of one or more supra-aortic arteries followed by endograft placement. Left carotid to left subclavian artery bypass and right to left carotid artery bypass have low complication rates in experienced hands and do not require surgical access into the thorax. In contrast, innominate artery bypass does require a sternotomy with a potential increased complication rate. Most interventionalists perform endograft insertion as a separate procedure to the surgical bypass procedure, because this practice has better outcomes compared with simultaneous bypass and endograft placement. Although the very first endovascular procedures that were performed in patients with aortic arch aneurysms were branched endografts, branched graft technology has been slowly developed in this location. This is due in no small part to the potential complications of prolonged manipulations in the aortic arch while attempts are made

CIRSE meets CIRSE meets Israel: Innovations in IR 2605.1 Advances and innovations in tumour ablation: from Israel with love N. Goldberg Radiology, Hadassah University Hospital, Jerusalem, Israel

References 1. Appelbaum L, Ben-David E, Faroja M, Nissenbaum Y, Sosna J, Goldberg SN. Irreversible electroporation ablation: creation of large-volume ablation zones in in vivo porcine liver with fourelectrode arrays. Radiology. 2014 Feb;270(2):416-24. 2. Ben-David E, Ahmed M, Faroja M, Moussa M, Wandel A, Sosna J, Appelbaum L, Nissenbaum I, Goldberg SN. Irreversible electroporation: treatment effect is susceptible to local environment and tissue properties. Radiology. 2013 Dec;269(3):738-47. 3. Faroja M, Ahmed M, Appelbaum L, Ben-David E, Moussa M, Sosna J, Nissenbaum I, Goldberg SN.Irreversible electroporation ablation: is all the damage nonthermal? Radiology. 2013 Feb;266(2):462-70. 4. Appelbaum L, Sosna J, Pearson R, Perez S, Nissenbaum Y, Mertyna P, Libson E, Goldberg SN. Algorithm optimization for multitined radiofrequency ablation: comparative study in ex vivo and in vivo bovine liver. Radiology. 2010 Feb;254(2):430-40. 5. Appelbaum L, Mahgerefteh SY, Sosna J, Goldberg SN. Imageguided fusion and navigation: applications in tumor ablation.Tech Vasc Interv Radiol. 2013 Dec;16(4):287-95.

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2605.2 Novel endovascular solutions to arch, peri-renal and abdominal aortic aneurysms E. Atar1, D. Silverman2, M. Goodman2 Department, Rabin Medical Center Hasharon Hospital, Petah Tikva, Israel, 2Vascular Surgery, Shiba medical center, Ramat Gan, Israel 1Radiology

Most abdominal aortic stent-grafts share the common concept of sealing: proximal radial force attachment and contralateral limb cannulation. Endovascular aortic aneurysms involving the visceral arteries are frequently conducted using custom-made fenestrated stentgrafts with the off-label use of chimneys, snorkels, sandwiches, or hybrid procedures. Arch lesions (aneurysms/dissections) have no off-the-shelf endovascular systems and are primarily handled surgically (elephant trunk or debranching) or in a hybrid procedure. Endospan™ is developing a conceptually new endovascular approach to endovascular aortic repair for infra-renal, juxta-renal, and arch pathologies using a design philosophy that relies on single-lumen modules and their in situ anastomosis using an effective, while spatially minimized, coupling mechanism, which is referred to as the hourglass/gateway pair. For infrarenal aneurysms (i.e. AAA), the Horizon™ system comprises of three modules: (i) iliac-to-iliac module that has a centered opening - a “gateway” - facing the abdominal aorta. This system is a true 14-Fr OD. The second module has the hourglass-shaped distal end, which is inserted through the gateway and firmly grabs it in its waist. The third component is telescopically introduced and cranially and accurately deployed at the proximal aneurysm neck. The FIM clinical study was conducted successfully in 10 patients in Western Europe during 2012–2013 and an EU pivotal study is currently being initiated. For the perirenal aortic aneurysms, a branched, extended third module is provided, and off-the-shelf, ePTFE covered stents are to be used as bridging components between these branches and the renals/SMA. The celiac artery has a dedicated scallop. This system is referred to as the HOstile Neck STentgraft (HONEST™) system. This system has undergone preclinical testing and is planned to enter EU clinical studies in H2 2014. The third and most unaddressed segment in aortic endografting is undoubtedly the aortic arch, for which the Nexus™ endograft system is being developed. The concept of sealing is based on three modules: (i) a main module with a primary gateway facing the ascending aorta and a secondary gateway for the LCCA; (ii) an ascending aorta module, with a proximal hourglass coupling mechanism; and (iii) an off-the-shelf ePTFE covered stent, either self- or balloon-expandable. LCCA–LSCA anastomosis is required prior to the endovascular intervention. Preclinical development has been successfully completed, and first human implantations are expected to be performed in early 2014. The entire stent-graft design, manufacturing, testing, and management premises are based in Herzlia, Israel.

2605.3 Advances in endovascular simulation G. Bartal Radiology, Meir MC, Kfar-Saba, Israel Our patients have very complex disabilities that require deep clinical background and high technical skills, which have to be constantly reevaluated and updated, particularly on a case-to-case basis. The only reliable, scientifically validated concept that meets all of the above requirements is medical simulation [1]. With an evolving implementation of low profile access for endovascular devices and expanding use of closure devices, we face an era

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of virtually “pure” endovascular practice by dedicated endovascular interventionists [2, 3]. Endovascular training should use simulations that have been shown to be a valid representation of the steps of the training objective, replicated with an appropriate level of fidelity (realism of replication. [4]. In most of the teaching hospitals, the residents and fellows are typically trained by chance. If they are lucky, they are in the right institution with the appropriate trainers and have an access to the relevant material. Patient-specific simulated rehearsal of the CAS procedure significantly improves operative performance compared to a generic VR warm-up or no warm-up. This technology requires further investigation with respect to improved outcomes on patients in the clinical setting. Patient-specific rehearsal constitutes a unique tool that may help tailor endovascular material choice, and optimize the preoperative preparation of the interventionalist and team [4]. PROcedure Rehearsal Studio has the following features: 1. uploads patient CTA scans and create 3D model to simulate, analyze, and evaluate preoperative surgical treatment options; 2. enables physicians to practice patient specific EVAR, TEVAR, and carotid procedures; 3. may reduce user errors and improved procedure outcomes; and 4. creates unlimited library of patient specific cases and share cases among users. The endovascular simulation training should be tailored to the trainees and become an integral part of the residency and fellowship. References 1. Bott OJ, Wagner M, Teistler M. Previous computer-based simulation can improve C-arm training. Trainees can manipulate the x-ray tube in a ‘virtual’ real-life setting to practice obtaining radiographs efficiently with minimal dose. Diagnostic Imaging Europe. 2006 Jun;26(4):1-3. 2. Gould D. CIRSE Simulation Task Force (CSTF). 2009. 3. Desender L, Rancic Z, Aggarwal R; European Virtual Reality Endovascular Research Team. Patient-specific rehearsal prior to EVAR: A pilot study. Eur J Vasc Endovasc Surg. 2013 Jun;45(6):639647. 4. Willaert WI, et al. Simulated procedure rehearsal is more effective than a preoperative generic warm-up for endovascular procedures. Ann Surg. 2012 Jun;255(6):1184-1189.

Special Session NSCLC and lung metastases: treatment options 2701.1 Surgery for NSCLC: patient selection A.J.B. Kirk Thoracic Surgery, Golden Jubilee National Hospital, Glasgow, United Kingdom Learning Objectives 1. To present the selection criteria for lung surgery according to respiratory function 2. To describe the selection criteria for lung surgery according to extent of the disease 3. To present indications for combined therapy with chemotherapy and radiation therapy Anatomical lung resection for patients with NSCLC is associated with excellent local control and the potential for cure. It remains the mainstay of treatment in the management of patients where radical therapy, with an intent to cure, is feasible. Selection of these patients for surgery should be done by a lung cancer multidisciplinary team (MDT).

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The suitability and selection of patients for surgery can be considered under an oncological and medical rationale. Oncological: The basis of oncological selection is the TNM classification of lung cancers. This is established for each individual patient based on the CT and PET CT findings. T: In general, any T tumour up to and including T3 may be suitable for lung resection. T4 tumours where there is direct extension into the oesophagus, vertebral column or heart are clearly not suitable for resection. However, the occasional T4 tumour where there are additional nodules in ipsilateral lobes may be suitable for a surgical approach. N: A histological confirmation of enlarged and/or FDG-avid mediastinal lymph nodes is essential for accurate staging. This can be accomplished by mediastinoscopy or EBUS. Patients staged as N0 and N1 are viewed as suitable surgical candidates. N2 disease diagnosed preoperatively is generally seen as a contraindication to surgery. However, recent experience suggests that surgery for single-station or single-zone N2 disease may be associated with an improved survival. M: It is counterintuitive that surgery for metastatic disease in lung cancer is appropriate. However, there is a small cohort of patients with solitary cerebral or adrenal metastases where metastasectomy plus a radical treatment of the lung will primarily achieve significant survival benefit from this radical approach. Resume of oncological criteria: In general, patients staged as T1-T3, N0-1 and M0 represent the majority of patients who will undergo lung resection for NSCLC (i.e. UICC stage I and II). Medical: Lung cancer is a disease of the late middle-aged and elderly and is often associated with a history of cigarette smoking. Therefore, many of these patients will have significant comorbidities. Although medical fitness involves a number of factors including weight, comorbidities and cardiovascular factors, the mainstay of assessment is the respiratory system. Patients undergoing surgery for NSCLC will generally have a performance status (PS) of 0 or 1, but PS2 patients may be considered. Respiratory fitness: Apart from a comprehensive assessment of the respiratory system, specialised pulmonary function tests are required for all patients. As a minimum, FEV1 and TLCO should be recorded. In borderline cases, additional tests of function including a shuttle walk test, ventilation–perfusion scintigraphy or a cardiopulmonary exercise test may be required to aid decision making. More important than the measured values (absolute or percentage predicted) are the calculated post-operative predicted FEV1 and TLCO. If either of these are <40%, the risk of postoperative ventilation is increased. If either are <30%, mortality risks are higher, and other modes of therapy apart from surgery should be considered. Summary: An adequate assessment of patients undergoing anatomical resection for lung cancer is essential if the maximum number of patients are to be treated. Extending the surgical indications in patients with poor or borderline lung function may necessitate anatomical segmentectomy or wedge resection. Such strategies to increase the resection rate are as yet unproven, and it is vital that these procedures are assessed alongside other modalities of therapy such as SABRE and RFA. A proper assessment of these techniques must be conducted within the confines of the multi-professional team, ideally within a clinical trial situation. Improved outcomes may also be achieved by adopting minimally invasive surgery and enhanced recovery programmes. Multimodality therapy designed to optimise patient outcomes are discussed in MDT postoperatively and are evidence-based. In general, patients with post-resection pathological staging of >T2a and/ or >N0 are eligible for adjuvant chemotherapy. R1 resections may require radiotherapy. As mentioned repeatedly, the key to optimum patient management is by discussing patients in a formally managed MDT.

Abstract Book References 1. Guidelines on the radical management of patients with lung cancer. Lim E, Baldwin D, Beckles M et al. Thorax 2010;65(Suppl III):iii1-iii27. 2. Management of lung cancer. Scottish Intercollegiate Guidelines Network (SIGN). Edinburgh: SIGN; 2014. SIGN publication no. 137. February 2014. Available from URL: 3. The diagnosis and treatment of lung cancer. Issued: April 2011. NICE clinical guideline 121. Available from URL: guidance.nice.org. uk/cg121.

2701.2 Stereotactic radiation therapy of NSCLC: indications and results L.M. Kenny Division of Oncology, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia Learning Objectives 1. To define best candidates for SBRT 2. To present clinical outcomes of SBRT 3. To highlight contraindications for SBRT Stereotactic ablative radiation therapy (SABR) is an excellent choice of treatment in medically inoperable patients. SABR describes the delivery of a small number of radiotherapy fractions to deliver a high dose with the aim of ablating tissues. Whether SABR is considered for localised NSCLC depends on the capacity of the multidisciplinary team to consider all options, the ability to deliver high quality precision radiation treatment, patient choice if they are given one and the ability of local expertise. Quality assurance for the planning and treatment delivery needs to be high and strict guidelines need to be followed. A number of large studies have contributed to a good understanding of the biological doses required in order to provide a high chance of local cure while keeping complications within acceptable limits. A risk-adapted schedule needs to be considered i.e. 3 × 18–20 Gy for T1; 5 × 11–12 Gy for T2 or T1 with broad chest wall contact and 8 × 7.5 Gy if adjacent to the heart, hilum or mediastinum. The location of the primary cancer does not influence the outcome, provided these guidelines are followed. Considering that the biologically effective dose to the cancer is >100 Gy, we would expect the local control at 3 years to be in the order of 90%. In addition, if the biologically effective dose for normal tissue is kept as <210 Gy, there is a low risk of mortality (approximately 1%) and an acceptable grade 3 and 4 toxicity (<9% centrally located cancers and <6% for peripherally located cancer). In a large series of 676 patients with stage 1 and 2 NSCLC treated by SABR, the following results were reported by Senthi et al. The local recurrence rate at 2 years was 4.9% and at 5 years was 10.5% with a median duration of recurrence of 14.9 months. The regional recurrence rate at 2 years was 7.8% and at 5 years was 12.7% with a median duration of recurrence of 13.1 months. Moreover, the distant relapse rate at 2 years was 14.9% and at 5 years was 19.9% with a median duration of recurrence of 9.6 months. Specific survival after SABR is in the order of 80% at 3 years, but the overall survival rate is much poorer due to the comorbidities of this group of patients. Results from SABR are at least as good as wedge resection although overall survival is higher in the surgical group due to better performance status at the outset. References 1. Senthi et al. thelancet.com/oncol Vol13 August 2012.

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2701.3 Ablation of NSCLC: indications and results D.E. Dupuy Diagnostic Imaging, Rhode Island Hospital, Providence, RI, United States of America Learning Objectives 1. To define best candidates for percutaneous ablation 2. To present clinical outcomes of percutaneous ablation 3. To highlight contraindications for percutaneous ablation Multiple, image-guided, ablative techniques are being developed for use in patients with primary non-small cell lung cancer (NSCLC) or oligometastatic pulmonary lesions in whom surgery is not an option. Radiofrequency ablation is the most studied technique, but other approaches under development include microwave ablation, laser ablation, cryoablation, and irreversible electroporation. Surgical resection is the standard treatment for patients with stage I and II NSCLC if pulmonary function is adequate and medical comorbidity does not preclude surgery. For patients who are surgical candidates and have a single or limited number of lung metastases and no uncontrolled systemic disease, surgical resection is the standard therapeutic approach. For patients who have either a small primary NSCLC or a single or limited number of pulmonary metastases and are not candidates for surgery based upon age, underlying lung disease, and other medical comorbidities or who refuse surgery, radiofrequency ablation, or other image-guided techniques may provide an important option, depending upon the presence of adequate local expertise. There are no trials comparing these techniques with each other or with external beam or stereotactic body radiation therapy. Current important clinical data will be reviewed. References 1. American Cancer Society. Cancer facts and figures 2014. Atlanta, GA: American Cancer Society; 2014. 2. Long-term results of lung metastasectomy: Prognostic analyses based on 5206 cases. The International Registry of Lung Metastases. J Thorac Cardiovasc Surg. 1997;113(1):37–49. 3. Ahmed M, Brace CL, Lee FT, Goldberg SN. Principles of and advances in percutaneous ablation. Radiology. 2011;258(2):351–69. 4. Goldberg SN, Gazelle GS, Compton CC, McLoud TC. Radiofrequency tissue ablation in the rabbit lung: efficacy and complications. Acad Radiol. 1995;2(9):776–84. 5. Dupuy DE, Zagoria RJ, Akerley W, et al. Percutaneous radiofrequency ablation of malignancies in the lung. AJR Am J Roentgenol. 2000;174(1):57–9. 6. Organ LW. Electrophysiologic principles of radiofrequency lesion making. Appl Neurophysiol. 1976-1977;39:69–76. 7. Goldberg SN, Dupuy DE. Image-guided radiofrequency tumor ablation: challenges and opportunities - part I. J Vasc Interv Radiol. 2001;12(10):1021–32. 8. Lee JM, Jin GY, Goldberg SN, et al. Percutaneous radiofrequency ablation for inoperable non-small cell lung cancer and metastases: preliminary report. Radiology. 2004;230(1):125–34. 9. de Baere T, Palussiere J, Auperin A, et al. Midterm local efficacy and survival after radiofrequency ablation of lung tumors with minimum follow-up of 1 year: prospective evaluation. Radiology. 2006;240(2):587–96. 10. Simon CJ, Dupuy DE, DiPetrillo TA, et al. Pulmonary radiofrequency ablation: Long-term safety and efficacy in 153 patients. Radiology. 2007;243(1):268–75. 11. Lencioni R, Crocetti L, Cioni R. Response to radiofrequency ablation of pulmonary tumors: a prospective, intention-totreat, multicentre clinical trial (the RAPTURE study). Lancet Oncol. 2008;9(7):621–8.

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12. Ambrogi MC, Fanucchi O, Cioni R, et al. Long-term results of radiofrequency ablation treatment of stage 1 non-small cell lung cancer: a prospective intention-to-treat study. J Thorac Oncol. 2011;6(12):2044–51. 13. Kashima M, Yamakado K, Takaki H, et al. Complications after 1000 lung radiofrequency ablations in 420 patients: A single center’s experience. AJR Am J Roentgenol. 2011;197(4):W576–80. 14. Dupuy DE. Treatment of medically inoperable non-small-cell lung cancer with stereotactic body radiation therapy versus image-guided tumor ablation: can interventional radiology compete? J Vasc Interv Radiol. 2013;24(8):1139–45. 15. Simon CJ, Dupuy DE, Mayo-Smith WW. Microwave ablation: principles and applications. RadioGraphics. 2005;25(Suppl 1):S69–S83. 16. Ward RC, Healey TT, Dupuy DE. Microwave ablation devices for interventional oncology. Expert Rev Med Devices. 2013;10:225–38. 17. Brace CL, Hinshaw JL, Laeseke PF, Sampson LA, Lee FT Jr. Pulmonary thermal ablation: comparison of radiofrequency and microwave devices by using gross pathologic and CT findings in a swine model. Radiology. 2009;251(3):705–11. 18. Martin RC, Scoggins CR, McMasters KM. Safety and efficacy of microwave ablation of hepatic tumors: a prospective review of a 5-year experience. Ann Surg Oncol. 2010;17:171–8. 19. Wolf FJ, Grand DJ, Machan JT, Dipetrillo TA, Mayo-Smith WW, Dupuy DE. Microwave ablation of lung malignancies: effectiveness, CT findings, and safety in 50 patients. Radiology. 2008;247(3):871–9. 20. Vogl TJ, Worst TS, Naguib NN, Ackermann H, Gruber-Rouh T, Nour-Eldin NE. Factors influencing local tumor control in patients with neoplastic pulmonary nodules treated with microwave ablation: a risk-factor analysis. AJR Am J Roentgenol. 2013;200(3):665–72. 21. Belfiore G, Ronza F, Belfiore MP, Serao N, di Ronza G, Grassi R, Rotondo A. Patient’s survival in lung malignancies treated by microwave ablation: our experience on 56 patients. Eur J Radiol. 2013;82(1):177–81. 22. Hall RR, Beach AD, Baker E, Morison PC. Incision of tissue by carbon dioxide laser. Nature. 1971;232:131–2. 23. Vogl TJ, Straub R, Lehnert T, et al. Percutaneous thermoablation of pulmonary metastases. Experience with the application of laser-induced thermotherapy (LITT. and radiofrequency ablation (RFA), and a literature review [in German]. Rofo. 2004;176(11):1658–66. 24. Rosenberg C, Puls R, Hegenscheid K, et al. Laser ablation of metastatic lesions of the lung: long-term outcome. AJR Am J Roentgenol. 2009;192(3):785–92. 25. Gage AA. History of cryosurgery. Semin Surg Oncol. 1998;14:99– 109. 26. Gage AA, Baust JG. Mechanisms of tissue injury in cryosurgery. Cryobiology. 1998;37:171–86. 27. Hinshaw JL, Littrup PJ, Durick N, et al. Optimizing the protocol for pulmonary cryoablation: a comparison of a dual- and triple freeze protocol. Cardiovasc Intervent Radiol. 2010;33(6):1180–5. 28. Hinshaw JL, Lee FT Jr, Laeseke PF, Sampson LA, Brace C. Temperature isotherms during pulmonary cryoablation and their correlation with the zone of ablation. J Vasc Interv Radiol. 2010;21(9):1424–8. 29. Maiwand MO. The role of cryosurgery in palliation of tracheobronchial carcinoma. Eur J Cardiothorac Surg. 1999;15(6):764–8. 30. Wang H, Littrup PJ, Duan Y, Zhang Y, Feng H, Nie Z. Thoracic masses treated with percutaneous cryotherapy: Initial experience with more than 200 procedures. Radiology. 2005; 235(1):289–98. 31. Kawamura M, Izuma Y, Tsukada N, et al. Percutaneous cryoablation of small pulmonary malignant tumors under computer tomographic guidance with local anesthesia for nonsurgical candidates. J Thorac Cardiovasc Surg. 2006;131(5):1007–13.

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32. Yashiro H, Nakatsuka S, Inoue M, et al. Factors affecting local progression after percutaneous cryoablation of lung tumors. J Vasc Interv Radiol. 2013;24(6):813–21. 33. Wang H, Littrup PJ, Duan Y, Zhang Y, Feng H, Nie Z. Thoracic masses treated with percutaneous cryotherapy: Initial experience with more than 200 procedures. Radiology. 2005;235(1):289–98. 34. Yashiro H, Nakatsuka S, Inoue M, et al. Factors affecting local progression after percutaneous cryoablation of lung tumors. J Vasc Interv Radiol. 2013;24(6):813–21. 35. Rubinsky B, Onik G, Mikus P. Irreversible electroporation: a new ablation modality- clinical implications. Technol Cancer Res Treat. 2007;6(1):37–48. 36. Davalos RV, Mir IL, Rubinsky B. Tissue ablation with irreversible electroporation. Ann Biomed Eng. 2005;33(2):223–31. 37. Dupuy DE, Aswad B, Ng T. Irreversible electroporation in a swine lung model. Cardiovasc Intervent Radiol. 2011;34(2):391–5. 38. Maor E, Ivorra A, Leor J, et al. The effect of irreversible electroporation on blood vessels. Technol Cancer Res Treat. 2007;6(4):307–12. 39. Thomson KR, Cheung W, Ellis SJ, et al. Investigation of the safety of irreversible electroporation in humans. J Vasc Interv Radiol. 2011;22(5)611–21. 40. Usman M, Moore W, Talati R, Watkins K, Bilfinger TV. Irreversible electroporation of lung neoplasm: a case series. Med Sci Monit. 2012;18(6):CS43–7.

2701.4 Ablation of pulmonary metastases: indications and results A. Gillams Imaging Dept, The London Clinic, London, United Kingdom Learning Objectives 1. To define best candidates for percutaneous ablation 2. To present clinical outcomes of percutaneous ablation 3. To highlight potential indications for adjuvant chemotherapy before or after ablation TUMOUR-SPECIFIC CONSIDERATIONS The local success of thermal ablation depends on the tumour size and location. As the sole treatment modality thermal ablation has been successfully applied to <3–3.5 cm tumours. Larger tumours are usually ablated in conjunction with another therapeutic modality such as radiotherapy. The location next to >3 mm diameter blood vessels or bronchi can, but not necessarily, result in incomplete ablation. More aggressive ablation next to these structures can compensate, and complete ablation can be achieved. Peripheral tumours are easier to access and are less likely to lie in close proximity to larger vessels and are therefore, easier to treat. The ablation of tumours in close proximity to important neural structures, such as the phrenic nerve or brachial plexus, or oesophagus, calls for careful ablation with adjunctive measures to separate the ablation zone from the vulnerable structure and prevent thermal injury. Ablation is the optimal treatment modality for multiple lung metastases and can be used to treat as many as 10 separate deposits at two or three treatment sessions. In general, only one hemithorax is treated in a single session. An analysis of how the number of tumours impacted survival in a cohort of 122 patients with colorectal metastases showed similar survival in patients who had five or fewer metastases as compared with those who had six or more tumours (p = 0.22) as long as all the visible sites of disease were ablated. Although any metastatic deposit can be treated, the most common tumour groups to be referred for ablation are colorectal, sarcoma, head and neck and renal tumours.

Abstract Book COLORECTAL METASTASES Colorectal metastases form the largest single cohort of patients. Results from metastasectomy suggest a survival advantage. Number, distribution and speed of development i.e. disease-free interval between primary resection and the development of lung metastases, are considered when deciding whether a patient is operable. Surgical preference is given to fit patients with <3 metachronous metastases, preferably unilateral, a longer disease-free interval and no extrapulmonary disease. Ablation is currently considered in inoperable patients. Our analysis of 122 patients who were not operable candidates but who had small volume colorectal lung metastases showed a median survival of 41 months and a 3-year survival of 57%. Survival was better in patients with smaller tumours; median 51 months, 3-year survival 64% for ≤2 cm tumours versus 31 months and 44% for 2.1–4 cm tumours (p = 0.08). A history of ablated/resected liver metastases, systemic chemotherapy or prior lung resection, total number of lung metastases ablated and uni- or bi-laterality did not impact survival. Results from other centres are not different. Yamakado et al reported a 3-year survival of 47% in a multicentre trial of 71 patients and found that the dominant factors were untreated extrapulmonary disease and tumour size. Yan et al reported a 3-year survival of 46% in 55 patients. The favourable factors in this paper were small size of ≤3 cm, peripheral location and repeat ablation for recurrence based on multivariate analysis. SARCOMA METASTASES There is good evidence that repeated sequential metastasectomy is beneficial. The reported 3-year survival is between 30% and 54%, and the 5-year survival is 15%–40%, median survival of 12–18 months. Results from the ablation literature include the following: Nakamura et al reported on 20 patients with a mean of 7 metastases, mean size 1.4 cm. The overall 1- and 3-year survival were 58% and 29%, respectively, median 12.9 months; however, for the subgroup who had complete ablation of all visible disease, the 1- and 3-year survival was 89% and 59%, respectively (4). Our results of RF or MW ablation of 87 sarcoma metastases in 36 patients also reflected the therapeutic intent of ablation. We preferentially used MW in larger tumours. Particularly good results were achieved in 55 <2 cm metastases treated with radiofrequency yielding a 95% primary control rate, and mean (median not reached), 2and 3-year overall survival were 51 months, 94% and 85%, respectively. Median, 1- and 2-year progression-free survival was 12 months, 53% and 23%, respectively. Prior DFI was the only significant factor to impact overall survival. Ablation can be used in inoperable patients with small volume lung-only disease but also in operable patients for whom surgery would be inappropriate, too invasive at that particular time point or would interrupt other therapy. ADJUVANT AND NEODAJUVANT CHEMOTHERAPY Oncologists vary in their approach to chemotherapy for small-volume CT detected asymptomatic lung metastases particularly, if all sites of visible disease can be successfully eradicated with ablation. Therefore, in many instances, a patient with a few readily ablatable pulmonary metastases will undergo de novo ablation without adjuvant chemotherapy. For patients who are not suitable for ablation on presentation, chemotherapy can be used to downsize tumours to render them ablatable. Tumours that disappear with chemotherapy nearly always recur in due course; therefore, chemotherapy is only a holding measure and a definitive treatment such as ablation is required to eradicate metastasis. CONCLUSION Ablation is a very effective tool for the local control of small-volume lung tumours. It is the optimal technique for bilateral or small volume but multifocal disease. References 1. Yan TD, King J, Sjarif A, Glenn D, Steinke K, Morris DL. Percutaneous radiofrequency ablation of pulmonary metastases from colorectal carcinoma: prognostic determinants for survival. Ann Surg Oncol 2006;13:1529-37.

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2. Simon CJ, Dupuy DE, DiPetrillo TA, Safran HP, Grieco CA, Ng T et al. Pulmonary radiofrequency ablation: long-term safety and efficacy in 153 patients. Radiology 2007;243:268-75. 3. Chua TC, Thornbury K, Saxena A, Liauw W, Glenn D, Zhao J et al. Radiofrequency ablation as an adjunct to systemic chemotherapy for colorectal pulmonary metastases. Cancer 2010;116:2106-14. 4. Nakamura T, Matsumine A, Yamakado K, Matsubara T, Takaki H, Nakatsuka A et al. Lung radiofrequency ablation in patients with pulmonary metastases from musculoskeletal sarcomas [corrected]. Cancer 2009;115:3774-81. 5. Gillams A, Khan Z, Osborn P, Lees W. Survival after radiofrequency ablation in 122 patients with inoperable colorectal lung metastases. Cardiovasc Intervent Radiol. 2013;36(3):724-30. Epub 2012 Oct 17. 6. Koelblinger C, Strauss S, Gillams A. Outcome after radiofrequency ablation of sarcoma lung metastases. Cardiovasc Intervent Radiol. 2014;37(1):147-53. 7. Yamakado K, Hase S, Matsuoka T et al. Radiofrequency ablation for the treatment of unresectable lung metastases in patients with colorectal cancer: a multicentre study in Japan. J Vasc Interv Radiol. 2012;18: 393-398.

Special Session Pedal angioplasty 2702.1 Imaging, indication, and patient selection D. Karnabatidis Department of Diagnostic and Interventional Radiology, Rion University Hospital, Patras, Patras, Greece Learning Objectives 1. To learn about different imaging strategies 2. To learn about non-contrast MRA 3. To learn which patients benefit from pedal revascularisation Crural arterial occlusive disease is a common finding in patients presenting with critical limb ischemia, especially in diabetic patients. Open surgical bypass is not indicated in many cases in this specific subgroup of patients due to high perioperative morbidity and mortality rates and the absence of distal anastomotic target. Distal open bypass surgery is often technically challenging in cases of extensive medial wall calcifications or even impossible if an appropriately healthy distal vessel conduit is absent. Therefore, minimally invasive infrapopliteal endovascular revascularization is today considered a first-line therapy for the treatment of CLI attributed to lesions afflicting the distal tibial arteries at the malleolar level or even extend below the ankle and involves the dorsalis pedis and plantar arteries at the inframalleolar level. The initial diagnosis of the distal distribution of the disease may be performed by high frequency duplex ultrasound (HFDUS). Preprocedural imaging assessment and planning may be conducted using various non-invasive imaging modalities such as multidetector computed tomography angiography (CTA), magnetic resonance (MR) and HFDUS. CTA is noninvasive and rapidly performed, with better spatial resolution than MRA, but requires the largest volume of contrast infusion, exposes patients to high doses of radiation, and is subject to interpretive error due to reconstruction artifacts especially in heavily calcified arteries, limiting its usefulness in many patients with diabetes. For patients in whom the planned intervention is a surgical bypass, DSA and MRA will provide high quality images of the lower extremity arterial anatomy. For patients in whom a catheter-based intervention is the likely treatment, a diagnostic DSA immediately followed by a catheter-based treatment in the same procedure is the preferred approach. In patients with pre-existing renal dysfunction, in which gadolinium-enhanced MRA is contraindicated, DSA or CTA can be performed. However,

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patients should have an infusion of intravenous normal saline solution or sodium bicarbonate before the procedure to reduce the incidence of contrast-induced nephropathy. Although all the specific non-invasive modalities are appropriate in assessing large-diameter arterial vessels, small-caliber pedal outflow vessels are best evaluated by time-resolved contrast-enhanced MRA and superselective DSA with the catheter positioned proximal to the infrapopliteal trifurcation. [1] Time-resolved imaging of contrast kinetics (TRICKS) MRA is an accurate method of evaluating patients for popliteal and infrapopliteal arterial occlusive disease and can be used for planning percutaneous interventions. [2] Because TRICKS MRA can produce a consistently high image quality in both calf stations without the need for bolus timing and even in the presence of asymmetric disease, it is a potentially valuable method of assessing the infrageniculate arteries in patients requiring revascularization. MRA has been reported to produce better outcomes compared with non-selective intra-arterial DSA in the evaluation of distal infrapopliteal vessels due to the superior ability to detect arterial blood flow rates as low as 2 cm/s. In addition, the suboptimal filling of patent distal vessels below long occlusions is a limitation of DSA and sideby-side comparison of TRICKS and DSA identified up to 27% of distal arteries patent by MRA but not visualized by DSA. In contrast, venous overlay is an artefact that can negatively influence the diagnostic accuracy of MRA. [3] Notably, discordance did not affect the treatment plan in any patient. [4-6] Non-contrast enhanced (NCE) MRA is today a valid alternative imaging modality especially in patients with stage 3 or 4 chronic kidney disease and in predialysis patients in increased risk for nephrogenic systemic fibrosis. NCE MRA method has reported the visualization of most vessel segments with good or excellent confidence of vessel visualization, few artifacts, and excellent background suppression, giving moderate agreement with contrast-enhanced MRA. [7] NCE MRA techniques include the older timeof-flight and phase contrast techniques as well as the most recent ECG-gated partial Fourier fast spin echo and balanced steady-state free precession with and without arterial spin labeling. [8] Angioplasty techniques have evolved to enable the minimally invasive revascularization of foot vessels including the pedal and plantar arch. To date, amassed evidence about angioplasty and/or stenting of the below-the-ankle arteries are scarce and limited to small patient cohorts. [9] Nonetheless, the safety and feasibility of employing standard subintimal or intraluminal recanalization techniques of the pedal and plantar arteries for limb salvage has been extensively reported and continues to grow in every day clinical practice. [10, 11] Patients who will benefit from pedal angioplasty are those suffering from CLI (Rutherford–Becker grade 4–6 disease). As the primary aim of infrapopliteal angioplasty in CLI is limb salvage achievable by the recanalization of one straight line of pulsatile blood flow to the foot o adequately reperfuse the limb, pedal angioplasty should be performed to provide oxygen and nutritives to the distal ischemic tissue. Moreover, outflow improvement will assist in preserving the patency of the inflow infrapopliteal vessels. References 1. van Overhagen H, Spiliopoulos S, Tsetis D. Below-the-knee interventions. Cardiovasc Intervent Radiol. 2013; 36(2):302-11. 2. Mell M, Tefera G, Thornton F, Siepman D, Turnipseed W. Clinical utility of time-resolved imaging of contrast kinetics (TRICKS. magnetic resonance angiography for infrageniculate arterial occlusive disease. J Vasc Surg 2007; 45:543-8. 3. Huegli RW, Thalhammer C, Jacob AL, Jaeger K, Bilecen D. Intraarterial MR-angiography on an open-bore MR-scanner compared to digital-subtraction angiography of the infra-popliteal runoff in patients with peripheral arterial occlusive disease. Eur J Radiol. 2008; 66(3):519-25. 4. Swan JS, Caroll TJ, Kennell TW, Heisey DM, Korosec FR, Frayne R, et al. Time-resolved three-dimensional contrast-enhanced MR angiography of the peripheral vessels. Radiology 2002; 225:43-52.

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5. Lapeyre M, Kobeiter H, Desgranges P, Rahmouni A, Becquemin JP, Luciani A. Assessment of critical limb ischemia in patients with diabetes: comparison of MR angiography and digital subtraction angiography. AJR Am J Roentgenol. 2005; 185:1641-50. 6. Sommerville RS, Jenkins J, Walker P, Olivotto R. 3-D magnetic resonance angiography versus conventional angiography in peripheral arterial disease: pilot study. ANZ J Surg. 2005; 75:373-7. 7. Priest AN, Joubert I, Winterbottom AP, See TC, Graves MJ, Lomas DJ. Initial clinical evaluation of a non-contrast enhanced MR angiography method in the distal lower extremities. Magn Reson Med. 2013; 70(6):1644-52. 8. Miyazaki M, Akahane M. Non contrast enhanced MR angiography: established techniques. J Magn Reson Imaging 2012; 35(1):1-19. 9. Katsanos K, Diamantopoulos A, Spiliopoulos S, Karnabatidis D, Siablis D. Below-the-ankle angioplasty and stenting for limb salvage: anatomical considerations and long-term outcomes. Cardiovasc Intervent Radiol. 2013; 36(4):926-35. 10. Palena LM, Brocco E, Manzi M. The clinical utility of below-theankle angioplasty using “transmetatarsal artery access” in complex cases of CLI. Catheter Cardiovasc Interv. 2014; 83(1):123-9. 11. Manzi M, Fusaro M, Ceccacci T, Erente G, Dalla Paola L, Brocco E. Clinical results of below-the knee intervention using pedalplantar loop technique for the revascularization of foot arteries. J Cardiovasc Surg (Torino). 2009; 50(3):331-7.

2702.2 Dedicated material and procedural patient management H. Kobeiter Department of Radiology, Henri Mondor Hospital, Créteil, France Learning Objectives 1. To learn about material specifically for pedal angioplasty 2. To learn how to use drug-eluting devices in the pedal artery 3. To learn how to keep the leg still No abstract available.

2702.3 Technique and complication management M.G. Manzi Interventional Radiology Unit, Policlinico Abano Terme, Abano Terme, Italy Learning Objectives 1. To learn how to access a calf artery 2. To learn how to deal with a dissection 3. To learn how to deal with an occlusion No abstract available.

2702.4 Digital artery access for foot artery recanalisation L.M. Palena Interventional Radiology Unit, Policlinico Abano Terme, Abano Terme, Italy Learning Objectives 1. To learn when to use a digital artery access 2. To learn how to access a digital artery 3. To learn about the success rate of digital artery access Critical limb ischemia (CLI) is a major cause of morbidity, especially threatening the limb, and mortality (1) and affects a large number of patients all around the world, leading to important health issues and

Abstract Book severe disabilities. Major and minor amputations are usually associated with significant increases in mortality risk, and every effort should be pursued to minimize amputations and ensure limb and foot salvage, maintaining the walking ability (2). Arterial revascularization is the first-line treatment to relieve clinical symptoms related to CLI such as rest pain or improve wound healing (2,3). Endovascular interventions have been increasingly used for the treatment of patients with severe below-the-knee and below-theankle arterial disease and CLI related to good clinical results (4-11). However, standard percutaneous approach and techniques for the recanalization of below-the-knee and foot arteries occlusions can still be inadequate as procedural failure can occur in up to 20% of patients (4) related to long total chronic occlusions, wall calcifications, and a diffuse involvement of the foot arteries (12), compromising distal run-off at the foot level after tibial recanalization. In addition to the traditional approach, retrograde access, trans-collateral recanalization, and pedal–plantar loop techniques have been beneficial in increasing success rates (13-16). Nonetheless, even these strategies may fail or prove unfeasible when the distal vessels are also diseased (15). For this reason, technical improvements are necessary for percutaneous revascularization of below-the-knee atherosclerotic disease. Retrograde transmetatarsal artery access, a novel approach to recanalize challenging below-the-knee and total occlusions of the foot arteries in the setting of CLI, appears to be of help to increase technical and clinical success rate. Procedure Three days before the procedure, the patients are pretreated with aspirin (75–160 mg) and ticlopidine (500 mg), or clopidogrel (300 mg). After local anesthesia, an antegrade access to the common femoral artery is obtained under ultrasound guidance (7.5-MHz linear probe), and a 5-F sheath is deployed. Then, 5,000 units of unfractionated heparin is administered. The target vessel for recanalization is chosen according to the angiosome and wound-related artery concepts according to the clinical indications and surgical targets. The first attempt to recanalize the target vessel is made via antegrade recanalization. Specifically, intraluminal revascularization is attempted as the first choice in calcified vessels using a 0.014-inch guide wire and support catheter or catheter balloon; when intraluminal revascularization fails in uncalcified or spot calcified vessels, a subintimal technique is performed using a 0.018-inch guide wire and support catheter or catheter balloon. When antegrade techniques fail, retrograde recanalization and SAFARI techniques are immediately considered during the same procedure (17), but when the anterior and posterior tibial arteries and/or pedal/plantar arteries are occluded or unfeasible for puncture (thin and diseased arteries), then the metatarsal artery access route is considered. The access is created after pharmacological support to avoid spasms that can compromise the puncture and wiring of small vessels. For this, 5 mg/2 mL of verapamil is diluted to 10 mL with saline, and 9 mL of this solution is injected intra-arterially as distal as possible, close to the foot. Local anesthesia is administered close to the target area, and 1 mL of the diluted verapamil together with lidocaine is injected into the subcutaneous tissue to avoid spasms (18). In our experience, the best site to perform the access is at the dorsum of the foot through the first dorsal metatarsal artery; the plantar site had not been proven as a practical way to gain access. By way of the dorsal branch of the first metatarsal artery, it is usually possible to reach the plantar arch, and across the arch, it is possible to recanalize the dorsalis pedis or lateral plantar artery. The puncture is performed with a 21-gauge needle under ultrasound (dedicated hockey stick probe) or fluoroscopic guidance with contrast medium injection and at the maximum magnification to identify the target vessel. We usually use the Micropuncture Introducer Set (Cook Medical, Cook Group Incorporated, William Cook Europe A.p.S., Denmark), which is useful for gaining access. After access creation, retrograde intraluminal recanalization of the

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metatarsal artery and plantar arch is performed followed by intraluminal or subintimal recanalization of the foot and tibial vessel followed by the rendez-vous technique, engaging the antegrade catheter left in the tibial artery after the failed antegrade attempt. The procedure is completed by the antegrade access and passing the guide wire beyond the puncture site, retrieving the microsheath, and inflating a catheter balloon (1.5 mm in diameter), achieving hemostasis at the metatarsal artery level. For tibial and foot arteries dilation, the balloons are sized by visually estimating the distal reference vessel diameter as well as the target lesion delivered via the antegrade access and inflated for at least 1 minute at nominal pressure. The challenges associated with access creation is the recanalization of the small vessels that could be compromised by the spasms; a 0.014-inch guide wire could be useful to avoid these but does not provide the necessary support. Usually, using a 0.018-inch guide wire (V18®; Boston Scientific Corp., Natick, MA, USA. and support catheter (CXI; Cook), we obtain a good compromise between support, pushability, and spasm. We also use a microsheath; sheathless technique is possible but it is not recommended. In our experience, related to the poor support in the small vessels with the sheathless technique, there is a possibility to inject contrast media through the microsheath and exchange catheters and guide wires without damaging the access site in the small vessels. After the procedure, aspirin is continued indefinitely, and ticlopidine or clopidogrel is continued for 3 months (19). After discharge, clinical follow-ups are routinely performed at 1-month and then at 3-month intervals. In our experience, technical success (ability to deliver the catheter balloon across the lesions and inflate it at nominal pressure. was achieved in 86.84% of cases with adequate angiographic results (<50% residual stenosis and non-complications). Technical failures were related to spasms or no true lumen re-entry after successful transmetatarsal artery access. Clinical improvement was observed in the patients having technical successful tibial and foot artery recanalization with a significant increase of TcPO2. after 15 days, from 10.3 ± 7.6 (pre-treatment value) to 50.7 ± 8.2 (post-treatment value) mmHg and was maintained during the follow-up (mean 6.7 ± 2.3 months; range 1–14). No major amputations were observed (limb salvage rate 100%). Amputation-free survival rate calculated by Kaplan–Meier analysis was 83.5% at 12 months. The patients with technical failure obtained inferior clinical benefit due to femoro-popliteal recanalization or did not have clinical improvement and underwent minor amputations. Compared with patients treated by means of antegrade revascularization, radiation exposure was higher in patients treated by retrograde transmetatarsal artery access. The fluoroscopy time was 45.5 ± 56.1 vs 52.5 ± 11.5 minutes, and the radiation dose was 69.1 ± 83.2 vs 94 ± 26.5 Gym2 (p < 0.001). Conclusions Digital artery access is of particular value in challenging cases of CLI and foot wounds, providing good clinical results and amputationfree survival rate but is reserved for extreme cases in which other revascularization strategies or options are unfeasible or contraindicated. X-ray dose exposure is higher than antegrade recanalization techniques for the patients and interventionists, and it could be considered before using this technical strategy. References 1. Faglia E, Clerici G, Clerissi J, Gabrielle L, Losa S, Mantero M, Caminiti M, Curci V, Lupattelli T, Morabito A. Early and five-year amputation and survival rate of diabetic patients with critical limb ischemia: data of a cohort study of 564 patients. Eur J Vasc Endovasc Surg. 2006;32:484–490. 2. TASC II Working Group. Inter-society consensus for the management of peripheral arterial disease (tASC II). J Vasc Surg. 2007;45:S5–S67.

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3. Palena LM, Manzi M. Extreme below-the-knee interventions: retrograde transmetatarsal or transplantar arch access for foot salvage in challenging cases of critical limb ischemia. J Endovasc Ther. 2012;19:805–811. 4. BASIL trial participants. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): multicentre, randomised controlled trial. Lancet. 2005;366:1925–1934. 5. Soder HK, Manninen HI, Jaakkola P, Matsi PJ, Radanen HT, Kaukanen E, Loponen P, Soimakallio S. Prospective trial of infrapopliteal artery balloon angioplasty for critical limb ischemia: angiographic and clinical results. J Vasc Interv Radiol. 2000;11:1021–1031. 6. Faglia E, Dalla Paola L, Clerici G, Clerissi J, Graziani L, Fusaro M, Gabrielli L, Losa S, Stella A, Gargiulo M, Mantero M, Caminiti M, Nonkovic S, Curci V. Peripheral angioplasty as the first-choice revascularization procedure in diabetic patients with critical limb ischemia: prospective study of 993 consecutive patients hospitalized and followed between 1999 and 2003. Eur J Vasc Endovasc Surg. 2005;29:620–627. 7. Dorros G, Jaff MR, Dorros AM, Mathiak LM, He T. Tibioperoneal (outflow lesion. angioplasty can be used as primary treatment in 235 patients with critical limb ischemia: five-year follow-up. Circulation. 2001;104:2057–2062. 8. Romiti M, Albers M, Brochado-Neto FC, Durazzo AE, Pareira CA, De Luccia N. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg. 2008;47:975–981. 9. Schmidt A, Ulrich M, Winkler B, Klaeffling C, Bausback Y, Braunlich S, Botsios S, Kruse HJ, Varcoe RL, Kum S, Scheinert D. Angiographic patency and clinical outcome after balloonangioplasty for extensive infrapopliteal arterial disease. Catheter Cardiovasc Interv. 2010;76:1047–1054. 10. Kawarada O, Fijihara M, Higashimori A, Yokoi Y, Honda Y, Fitzgerald PJ. Predictors of adverse clinical outcomes after successful infrapopliteal intervention. Catheter Cardiovasc Interv. 2012;80:861–871. 11. Rocha-Singh KJ, Jaff M, Joye J, Laird J, Ansel G, Schneider P, VIVA Physicians. Major adverse limb events and wound healing following infrapopliteal artery stent implantation in patients with critical limb ischemia: The XCELL trial. Catheter Cardiovasc Interv. 2012. doi: 10.1002/ccd.24485. [Epub ahead of print]. 12. Graziani L, Silvestro A, Bertone V, Manara E, Andreini R, Sigala A, Mingardi R, De Giglio R. Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease severity. Eur J Vasc Endovasc Surg. 2007;33:453–460. 13. Gandini R, Pipitone V, Stefanini M, Maresca L, Spinelli A, Colangelo V, Reale CA, Pampana E, Simonetti G. The “Safari” technique to perform difficult subintimal infragenicular vessels. Cardiovasc Intervent Radiol. 2007;30:469–473. 14. Rogers RK, Dattilo PB, Garcia JA, Tsai T, Casserly IP. Retrograde approach to recanalization of complex tibial disease. Catheter Cardiovasc Interv. 2011;77:915–925. 15. Fusaro M, Agostini P, Biondi-Zoccai G. “Trans-collateral” angioplasty for a challenging chronic total occlusion of the tibial vessels: a novel approach to percutaneous revascularization in critical lower limb ischemia. Catheter Cardiovasc Interv. 2008;71:266–272. 16. Manzi M, Fusaro M, Ceccaci T, Erente G, Dalla Paola L, Brocco E. Clinical results of below-the-knee interventionas using pedalplantar loop technique. J Cardiovasc Surg. 2009;50:331–337. 17. Manzi M, Palena LM, Cester G. Endovascular techniques for limb salvage in diabetics with crural and pedal disease. J Cardiovasc Surg. 2011;52:485–492. 18. Manzi M, Palena LM. Retrograde percutaneous transmetatarsal artery access: new approach for extreme revascularization in challenging cases of critical limb ischemia. Cardiovasc Intervent Radiol. 2013;36:554–557.

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Special Session Haemodialysis access management 2703.1 Endovascular treatment of immature fistulas C. Hohl Radiologie, St. Marienkrankenhaus Siegen, Siegen, Germany Learning Objectives 1. To learn possible causes of insufficient maturation of fistulas 2. To learn how to perform endovascular intervention on immature fistula 3. To compare results of endovascular and surgical therapy The prerequisite for hemodialysis is a functional vascular access. Whereas in the US, many patients are dialyzed via catheters, in Europe, the majority of patients are provided with arteriovenous (AV) shunts. The placement of autogenous AV fistulas is preferred over prosthetic grafts as they are associated with a lower incidence of death and accessrelated complications such as hematoma, pseudoaneurysms, and infection as well as having a higher primary and secondary patency rate (1). AV fistulas typically require one to three months to “mature.” While KDOQI recommends fistula placement six months prior to the initiation of dialysis (2), this is widely not the case for a variety of reasons. Fistula maturation requires adequate arterial inflow, adequate venous outflow, and the ability of the vein to dilate to increase blood flow, enough to allow repetitive cannulation for dialysis. The three main reasons for maturation failure are arterial and venous problems and the presence of accessory veins (3, 4). Vascular mapping before AV fistula creation has been shown to result in the decrease of non-matured AV fistulae. For optimal results, both arterial and venous evaluation is required for fistula creation (5). The identification of delayed or missing maturation is not very complex. Besides physical examination as the basis of every fistula evaluation, there is ultrasonography and fistulography. During the physical examination, any visible large venous branches should be noted. If there is a doubt over the suitability of the fistula, a duplex ultrasound is very helpful. Ultrasound can determine vein diameter, areas of stenosis, significant accessory veins, and blood flow. A draining vein <4 mm in diameter and a blood flow <500 ml/min indicates a fistula that is unlikely to mature in more than two-thirds of patients without some type of intervention. Knowing the nature and location of the lesion is essential for adequate diagnostic fistulography puncture, allowing therapeutic intervention in the same setting. Any fistula that fails to mature adequately and demonstrates abnormal physical findings should be studied aggressively, and abnormalities that are detected should be corrected before a plan to create a new access is made. Two different types of therapy can be offered: endovascular and surgical. Endovascular treatment: The two main endovascular treatment options, depending on the underlying pathology, are balloon angioplasty and vein obliteration. In a prospective observational study, all patients with early failure underwent evaluation and treatment. Vascular stenosis and the presence of a significant accessory vein alone or in combination are found to be the culprits in most instances. Venous stenosis was present in 78% of the cases. A majority of these lesions (48%) were found to be close to the anastomosis. A significant accessory was present in 46% of the cases. Percutaneous balloon angioplasty was performed with a 98% and vein obliteration with a 100% success rate. After intervention, it was possible to initiate dialysis using the fistula in 92% cases (4). Venous stenosis within the body of a fistula is best treated with balloon angioplasty. Juxta-anastomotic stenosis may be treated surgically or percutaneously. A prospective non-randomized study of patients showed that outcomes were similar using angioplasty or surgery. Restenosis rates were significantly higher following angioplasty (6).

Abstract Book Surgical Treatment: The surgical approach is usually performed under local anesthesia, and the vein is mobilized proximally and reanastomosed to the proximal part of the radial artery. This procedure is more difficult at the elbow and it is often easier to attempt balloon angioplasty, reserving surgery only when it fails. Poor arterial inflow should be identified preoperatively by ultrasound, but this is not always possible. Part of the assessment of the non-maturing fistula should include the detailed assessment of the inflow circuit. Arterial stenosis >50% coupled with poor flow should undergo angioplasty. If this fails to improve fistula flow rates, it is unlikely that surgical bypass will be of help. References 1. Tordoir J, Canaud B, Haage P, et al. EBPG on Vascular Access. Nephrology Dialysis Transplantation 2007; 22:ii88-ii117. 2. KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease. American Journal of Kidney Diseases KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease 2007; 49:S12-S154. 3. Natário A, Turmel-Rodrigues L, Fodil-Cherif M, et al. Endovascular Treatment of Immature, Dysfunctional and Thrombosed Forearm Autogenous Ulnar-basilic and Radial-basilic Fistulas for Haemodialysis. Nephrology Dialysis Transplantation 2010. 4. Beathard G, Arnold P, Jackson J, Litchfield T et al. Aggressive Treatment of Early Fistula Failure. Kidney International 2003; 64:1487-1494. 5. Malovrh M. Non-matured Arteriovenous Fistulae for Hemodialysis: Diagnosis, Endovascular and Surgical Treatment. Bosnian Journal Of Basic Medical Sciences 2010; 10:S13-S17. 6. Tessitore N, Mansueto G, Lipari G, et al. Endovascular versus Surgical Preemptive Repair of Forearm Arteriovenous Fistula Juxta-Anastomotic Stenosis: Analysis of Data Collected Prospectively from 1999 to 2004. Clinical Journal of the American Society of Nephrology 2006; 1:448-454.

2703.2 Stent-grafts: current evidence in grafts and native fistulas Z.J. Haskal Vascular & Interventional Radiology, University of Virginia, Charlottesville, VA, United States of America Learning Objectives 1. To learn about possible indications for stent-graft implantation in haemodialysis fistulas 2. To learn which stent-graft to use and where and when to implant 3. To compare the results of stent-graft implantation with other endovascular or surgical therapy No abstract available.

2703.3 Drug-eluting balloons: current evidence R.B. Shoenfeld Surgicenter, The Access Center at West Orange, West Orange, NJ, United States of America Learning Objectives 1. To learn about pathophysiology of stenoses of the haemodialysis shunt 2. To review results of angioplasty using drug-eluting balloons in haemodialysis fistulas 3. To compare these results with regular balloon angioplasty, cutting balloons, stenting and surgery No abstract available.

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2703.4 Paediatric dialysis: state-of-the-art interventions S. Sierre Department of Interventional Radiology, Hospital de Pediatría “Prof. J.P. Garrahan”, Buenos Aires, Argentina Learning Objectives 1. To learn key imaging features in the paediatric vascular system 2. To learn how to approach a paediatric patient referred for haemodialysis 3. To learn about dedicated materials and equipment available Introduction Endovascular procedures have demonstrated to be a successful tool for extending the life of functional vascular accesses (VAs) for hemodialysis in adult patients with minimal invasiveness and better venous preservation. [1, 2] In children, endovascular dialysis access interventions are feasible with significant clinical and technical success rates, particularly related to VA patency. [3] This presentation will attempt to provide an insight into the multiple radiological techniques that can be employed for surveillance, maintenance, and salvage of hemodialysis VA in children, highlighting the particular issues related to this group of patients. In pediatric ESRD patients, an adequate VA for a prolonged period of time is critical. However, the delivery of long-term hemodialysis therapy in children is complicated by smaller vascular caliber, lower arterial flow rates, and the potential life-long requirement for hemodialysis access. Hence, VA creation in pediatric patients should be not only aimed at providing an adequate portal for hemodialysis in the immediate-term but also considered as part of a long-term dialysis access strategy. [4, 5, 6] Pediatric literature related to the outcome of permanent VA is sparse, mainly due to the small number of patients actually treated with long-term chronic HD in relation to adults. [4-8] Moreover, fewer reports are published on interventional radiology techniques and their results on the maintenance of VA in children [3]. Vascular interventional radiology in pediatrics differs from adult vascular interventions in several aspects, and we are frequently faced with the need for miniaturization of equipment appropriate for pediatric use. This issue is particularly necessary in dialysis access interventions. [3, 6, 7] Furthermore, in pediatric patients, special consideration must be given to the choice of sedation or anesthesia, maintenance of temperature control, fluid balance, contrast dose, radiation safety, and equipment selection. However, despite these anatomical and technical issues, significant clinical and technical success rates have been achieved with endovascular techniques in pediatric patients. [3] Pediatric VA management requires close monitoring by a multidisciplinary team made up of pediatric nephrologists, nurses, vascular surgeons, and interventional radiologists to ensure a VA for lifelong use. Interventional radiologists have assumed a lead role in initial salvage procedures, extrapolating this experience from the adult reports to our pediatric population. [3, 4, 8, 9] General principles In children, native arterio-venous fistulas (AVF) have demonstrated to have greater patency rates, lower associated morbidity and mortality, and decreased overall cost when compared with grafts (AVG). In this age group, synthetic grafts should be reserved for patients who have exhausted autologous veins, especially in those who have too small veins or those with previous and recurrent AVF failure. Furthermore, native AVF have the longest patency and require fewer interventions once they are successfully cannulated for hemodialysis. [3, 4, 7, 8] In pediatrics, VA angiography (fistulogram) is undertaken in the presence of clinical evidence for access dysfunction or as a part of a systematic surveillance program. Fistulograms should be performed by the puncture of the graft or the vein segment of a native

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VA. Puncture of the brachial artery for diagnostic purposes should be performed in some selected cases of inflow problems in forearm native fistulae, hyperdebit (steal syndrome), non-maturing VA, and hand ischemia. Most of the diagnostic procedures (mapping venography, fistulogram) may be performed with no need of anesthesia support or minimal sedation. General anesthesia is recommended for therapeutic procedures (angioplasty, declotting). As reported in adults, the underlying stenoses responsible for VA dysfunction predominates at the venous anastomosis of grafts in the anastomotic area of forearm native AVF (post-anastomotic venous segment) and in the venous outflow far from the anastomosis of upper arm AVF. Percutaneous transluminal angioplasty (PTA) is considered the first therapeutic option for these stenoses, and should be performed if greater than 50% stenosis is present in either the arterial or venous portion of VA. [1-3, 10, 11] Contraindications for dialysis access interventions are very similar to those reported for adult patients, emphasizing that the decision to treat a dialysis access with endovascular techniques is always made based on the patient’s condition, number of alternative access sites available, and expertise of the treating team. Angioplasty/stenting Some basic concepts about PTA and stent deployment in children may include: [1-3, 10] Angioplasty - The principles of dilation techniques are similar to those described in adults. - Stenoses are treated with balloon angioplasty, which is usually an outpatient procedure. - High-pressure balloons (inflatable up to 25–30 atm) are often necessary to abolish the stenosis waist. - For PTA, access is always gained from the graft or from the vein no matter where the lesion is located. In this age group, lesions rarely involve the arterial feeder. - Central vein stenoses should be treated with PTA. In pediatric series, the mean initial success rate was 90% for PTA (84.5% for AVF and 90% for AVG). Elastic recoil has been reported as the main factor related to PTA failure. Cutting balloons may be used in this group of patients. [3] Stent deployment - Stent deployment in pediatric patients should be discussed and wisely decided and might remain as an ultimate resource. - Stenting should be avoided whenever possible; frequently, its patency is limited because stenosis recurs either instent or at its extremities, likely related to neointimal hyperplasia [2, 10, 11]. However, stents are valuable and useful in specific indications, mainly related to PTA complications and limitations. Early recurrence following an apparently successful PTA is probably an indication for repeat PTA rather than stenting at least in the first instance. [2, 3, 10, 11] All authors of recent literature agree in concluding that if necessary, only self-expandable stents should be used. [2, 10, 11] Declotting procedures Declotting techniques include pharmacomechanical and purely mechanical methods. The choice of the declotting technique should be individualized to the needs of the patient and the skills of the interventionalist attempting the salvage procedure. Particular considerations should be taken into account in this population with the use of thrombectomy devices as described for other thrombectomy indications. - Considerations should be made for the possibility of fluid overload issues and secondary hemolytic anemia. - Bradycardia secondary to hemolysis and adenosine release can occur. Different methods utilizing mechanical thromboaspiration or thrombectomy devices demonstrate equivalent success rates and negligible rates of complications. [1, 2, 3]

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In pediatrics, for declotting purposes, r-TPA is the thrombolytic agent of choice with associated systemic heparinization. In selected cases, combined procedures, which refer to a surgical and an endovascular approach might be considered as a valuable alternative in thrombosed VA, allowing VA salvage in cases where endovascular techniques alone were not able to achieve a successful VA revascularization, preserving the patients’ venous capital. [3, 12] Several studies have reported excellent results for interventional radiology techniques by experienced hands in adult patients. [1, 2, 10, 11] However, there are very few studies reporting endovascular VA salvage procedures in children. In pediatrics, there is only one study reporting results after percutaneous declotting techniques: [3] - 85% success rate for thrombosed AVG - 30% success rate for thrombosed AVF (in this study, if flat non-running forearm native AVF is excluded, the success rate for AVF declotting procedures rises to 71.5%). Endovascular treatment therefore appears to be preferable, except for flat non-running forearm fistulae. Results for declotting procedures in children are relatively similar to those reported in adults with no significant differences. Further pediatric studies are needed. Survival The long-term function and survival rates of native AVF in children have been reported equivalent to those of adults. [8] A study including vascular interventional radiology procedures in pediatric patients reported: - Primary patency rates at 6 months, 1 year and 2 years, respectively, were as follows: AVF: 71%, 50%, and 25% AVG: 56%, 30%, and 6% (p = 0.05). - Secondary patency rates at 1, 2 and 3 years, respectively, were as follows: AVF: 73%, 50%, and 20% AVG: 64%, 36%, and 20% (p = NS). [3] Thrombosed VA present worse results and patency rates compared with stenotic dysfunctional VA. [1-3, 10, 11] Conclusion Endovascular dialysis access interventions in children are feasible with significant clinical and technical success rates. Interventional radiology procedures are an essential tool for the management of VA for hemodialysis in children in order to prolong VA survival and for venous preservation. Venous preservation is a main goal in this population and should be considered as part of a long-term dialysis access strategy taking into account the potential life-long requirement for hemodialysis access in this population. Surveillance programs are necessary for the early detection and treatment of access complications in order to extend VA survival. References 1. Turmel-Rodrigues L. Declotting a thrombosed Brescia-Cimino fistula by manual catheter-directed aspiration of the thrombus. Cardiovasc Intervent Radiol 2005; 28: 10-6. 2. Natario A, Turmel-Rodrigues L, Fodil-Cherif M, et al. Endovascular treatment of immature, dysfunctional and thrombosed forearm autogenous ulnar-basilic and radial-basilic fistulas for haemodialysis. Nephrol Dial Transplant 2010; 25: 532-8. 3. Briones L, Diaz Moreno A, Sierre S, Lopez L, Lipsich J, Adragna M. Permanent vascular access survival in children on long-term chronic hemodialysis. Pediatr Nephrol 2010; 25: 1731-8. 4. Chand DH, Valentini RP, Kamil ES. Hemodialysis vascular access options in pediatrics: considerations for patients and practitioners. Pediatr Nephrol 2009; 24: 1121-8. 5. Vascular Access 2006 Work Group. Clinical practice recommendation 8: vascular access in pediatric patients. Am J Kidney Dis 2006; 48(Suppl 1): S274-6.

Abstract Book 6. Souza RA, Oliveira EA, Silva JM, Lima EM. Hemodialysis vascular access in children and adolescents: a ten-year retrospective cohort study. J Bras Nefrol 2011; 33: 422-30. 7. Ramage IJ, Bailie A, Tyerman KS, McColl JH, Pollard SG, Fitzpatrick MM. Vascular access survival in children and young adults receiving long-term hemodialysis. Am J Kidney Dis 2005; 45: 708-14. 8. Sheth RD, Brandt ML, Brewer ED, Nuchtern JG, Kale AS, Goldstein SL. Permanent haemodialysis vascular access survival in children and adolescents with end-stage renal disease. Kidney Int 2002; 62: 1864-9. 9. National Kidney Foundation: KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for 2006 Updates: Hemodialysis Adequacy, Peritoneal Dialysis Adequacy and Vascular Access. Am J Kidney Dis 2006; 48(Suppl 1): S1-322. 10. Turmel-Rodrigues L, Pengloan J, Bourquelot P. Interventional radiology in hemodialysis fistulae and grafts: a multidisciplinary approach. Cardiovasc Interv Radiol 2002; 25: 3-16. 11. Aruny JE, Lewis CA, Cardella JF, et al. Quality improvement guidelines for percutaneous management of the thrombosed or dysfunctional dialysis access. J Vasc Interv Radiol 2003; 14: S247-53. 12. Raffini L. Thrombolysis for intravascular thrombosis in neonates and children. Curr Opin Pediatr 2009; 21: 9-14. 13. Bourquelot P, Cussenot O, Corbi P, et al. Microsurgical creation and follow-up of arteriovenous fistulae for chronic haemodialysis in children. Pediatr Nephrol 1990; 4: 156-9.

Special Session Practical issues in dose management 2704.1 Radiation hazards: skin injuries, cataract and neoplasms M. Rehani Radiation Protection of Patients, International Atomic Energy Agency, Vienna, Austria Learning Objectives 1. To become aware about the IR radiation hazards for the patient in particular skin injuries 2. To become aware about the IR radiation hazards for the medical staff, in particular cataract and neoplasm 3. To report and illustrate protective measures The beneficial aspects of use of X-rays in medicine are unquestionable. In this respect, therapeutic benefits through interventional procedures that employ ionizing radiations through fluoroscopy replace many surgical interventions and provide patient friendly options. However, hazards to patients and staff need attention and with careful management risks can be contained to acceptable level. Among a number of possible harmful effects of radiation, those that merit consideration in interventional practice are risk of skin injuries or hair loss to patients and of cataract to staff as well as temporary epilation to part of the body that is not protected by protective devices as well as carcinogenic risk to children or young patients. Other radiation effects are extremely unlikely. Radiation-induced skin injuries to patients in interventional procedures have been reported since the early 1990s. This is in contrast to skin injuries to staff that used to occur mainly in fingers about a century ago. For almost half a century prior to the 1990s, it was difficult to see reports of skin injuries even for staff. The increase in usage of fluoroscopy for complicated interventions that require long fluoroscopy time coupled with a continued lack of awareness among many interventionists and a lack of dose monitoring or no understanding of dose parameters, has resulted in continued occurrence of these injuries [Rehani and Srimahachota 2011].

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It is not common to find an interventionalist who has seen a radiation-induced skin injury in a patient from a fluoroscopic-guided interventional (FGI) procedure. With a lack of awareness in some countries, it is also difficult to find an interventionalist who agrees that the procedures he/she performs can lead to skin injury in a patient. Miller et al. estimated that major radiation injuries occur in 1:10,000 and 1:100,000 procedures (based on 10 injuries reported every year in the USA from nearly 10 million interventions). Therefore, it is no wonder that many interventionalists may not have come across these injuries. This, however, does not rule out the possibility of patients incurring injuries but not getting diagnosed and being treated for other causes such as insect bite, grounding pads in operating table, and thermal burns to name a few common ones. Typically, one court case is filed in US every 4–5 weeks by patients suffering radiation-induced skin injuries from FGI [Rehani and Srimahachota 2011]. Patient related factors that contribute to risk are: smoking, poor nutritional status, compromised skin integrity, obesity, and overlapping skin folds. The order of radio sensitivity (higher to lower) is as follows: anterior neck, flexor surface of extremities, trunk, back, nape of neck, and scalp. Scalp is relatively resistant, but hair epilation in scalp occurs at lower doses as compared to hair in other parts. Individuals with light colored skin are most sensitive. Skin reaction grade in accordance with grading provided by the National Cancer Institute (NCI) are: A1 (0–2Gy) no grade; A2 (2–5 Gy) grade 1; B (5–10 Gy) grade 1–2, C (10–15 Gy) grade 2–3, and D (>15 Gy) grade 3–4. Awareness about potential risk, keeping a watch on the radiation dose delivered to patient, utilizing features in equipment to manage patient dose, and utilizing technique factors can all minimize probability of injury even in complex procedures. Hair loss also falls in the above category. In recent years, there has been growing concern with risk of radiation-induced catarcat among interventionalists. Author’s studies conducted among staff in cardiac catherization laboratories showed that lens opacities occurred in 30–50% of staff [Ciraj-Bjelac et al. 2010, Ciraj-Bjelac et al. 2012, Vano et al. 2013]. This includes nurses who while standing a bit away from X-ray tube normally do not have ceiling-suspended screen for eye lens protection. These lens injuries can lead to surgical cataract in the future. The International Commission on Radiological Protection (ICRP) had in recent years released a statement recommending a change in the threshold dose for the eye lens and dose limits for eye for occupationally exposed persons. The reduction in dose limit for eye lens from 150 mSv per year to 20 mSv/ye (averaged over 5 year period) is significant reduction warranting strengthening of protective actions. The higher workload that is typical now in many interventional suites, a lack of training in radiation protection, and non-availability or non-use of radiation protection devices can result in doses to the eye lens that are high enough to cause lens injuries. Among the neoplastic effects, anecdotal reports of hematologic malignancies and other cancers are now common conversation at societal meetings [Miller et al. 2010]. The brain is one of the least protected organs during interventional fluoroscopy procedures. Although the impact of radiation dose to the brain from chronic lowdose exposure has not been well studied, ionizing radiation is one of the few established causes of neural tumors. Studies of the incidence of nervous system tumors in atomic bomb survivors concluded that exposure to radiation doses of less than 1 Sv is associated with an increased incidence of nervous system tumors. A series of reports by Roguin et al. highlight findings of disproportionate reports of leftsided tumors and suggest the possibility of a causal relation to occupational radiation exposure [Roguin et al. 2013]. The study found that the death rate from brain cancer in radiologists was almost three times that of other medical specialists who did not use radiation. However, such studies cannot exclude other biological agents and chemicals unrelated to radiation as causative, and other case-control

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studies failed to identify a significant risk of brain tumors as a result of exposure to medical ionizing radiation. Epidemiological evidence for radiation-induced brain cancer in fluoroscopists is suggestive but by no means conclusive. One has to await careful reviews by international bodies like United Nations Scientific Committee on Effects on Atomic Radiation (UNSCEAR) and ICRP. Cancer risk is an issue both for staff in interventional suite and for patients. The most significant evidence comes from life-span study (LSS) cohorts who are survivors of atomic bomb in Hiroshima and Nagasaki. Although the atomic bomb survivor analyses have often been considered as high-dose studies, in fact, the mean dose in the exposed group in the LSS cohort is only 200 mSv, with >50% of the exposed individuals in the cohort (26,300 individuals) having doses <50 mSv. The epidemiological data suggest that the lowest dose at which good evidence exists for increased cancer risks in human is 10–50 mSv for an acute exposure and 50–100 mSv for a protracted exposure. Typical effective radiation dose to a patient in a PCI is about 10–15 mSv and this is the dose a typical interventionist may get in about 3–7 years of work when radiation protection is employed. It is not possible to draw firm conclusions of evidence of cancer in interventionists or patients undergoing interventional procedures from available studies. A number of studies have documented increased mutations in patients undergoing catheterization procedures. On the issue of which type of cancers are possible, a number of organizations such as ICRP, United Nations Scientific Committee on Effects on Atomic Radiation (UNSCEAR) and Biological Effects of Ionizing Radiations (BEIR) have reviewed the radiation effects in the survivors of atomic bombings in Hiroshima and Nagasaki. These studies have formed the basis of population cancer risk estimates following radiation exposure. Leukemia was the first cancer to be associated with atomic bomb radiation exposure, with preliminary indications of an excess among the survivors within the first 5 years after the bombings. An excess of solid cancers became apparent approximately ten years after radiation exposure. With increasing follow-up, excess risks of most cancer types have been observed, the major exceptions being chronic lymphocytic leukemia and pancreatic, prostate, and uterine cancer. In general consistent patterns of variation of risk with age at exposure are also seen in all studies - risks for all cancer types diminish with increasing age at exposure. Among the protective measures, reference is made to following resources: 1. Poster of 10 pears from the IAEA for radiation protection of staff (https://rpop.iaea.org/RPOP/RPoP/Content/Documents/ Whitepapers/poster-staff-radiation-protection.pdf). 2. Poster of 10 pears from the IAEA for radiation protection of patient (https://rpop.iaea.org/RPOP/RPoP/Content/Documents/ Whitepapers/poster-patient-radiation-protection.pdf). 3. Annals of ICRP publication 120 [ICRP 2013]. References 1. Ciraj-Bjelac O, Rehani MM, Sim KH, Liew HB, Vano E, Kleiman NJ Risk for radiation induced cataract for staff in interventional cardiology: Is there reason for concern? Catheterization and Cardiovascular Interventions. 2010; 76: 826-34. 2. Ciraj-Bjelac O, Rehani M, Minamoto A, Sim KH, Liew HB, Vano E. Radiation induced eye lens changes and risk for cataract in interventional cardiology. Cardiology 2012; 123(3): 168-71. 3. ICRP, Radiological Protection in Cardiology. Annals of ICRP. 2013; 42(1). 4. Miller DL, Balter S, Schueler BA,et al. Clinical radiation management for fluoroscopically guided interventional procedures. Radiology. 2010; 257(2): 321-3=32. 5. Miller DL, Klein LW, Balter S, Norbash A, Haines D, Fairobent L, Goldstein JA. Occupational health hazards in the interventional laboratory: progress report of the multispecialty occupational health group. J Vasc Interv Radiol. 2010; 21(9): 1338-41.

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6. Rehani M M., Srimahachota S. Skin injuries in interventional procedures. Radiat Prot Dosimetry. 2011; 147; 8-12. 7. Roguin A, Goldstein J, Bar O, Goldstein JA. Brain and neck tumors among physicians performing interventional procedures. Am J Cardiol. 2013; 111(9): 1368-72. 8. Vano E, Kleiman NJ, Duran A, Romano-Miller M, Rehani MM. Radiation-associated lens opacities in catheterization personnel: results of a survey and direct assessments. J Vasc Interv Radiol. 2013; 24(2): 197-204.

2704.2 How to implement a radiation protection safety culture in your department E.P. Efstathopoulos 2nd Department of Radiology, National and Kapodistrian University of Athens, Athens, Greece Learning Objectives 1. To illustrate differences in the various modalities of a single department 2. To propose practices for implementing radiation protection safety culture 3. To propose practices for better communication between technicians, IRs and nurses The increased use of ionisation radiation for diagnostic and therapeutic purposes in medicine has recognised the importance of establishing a culture for radiation protection in every radiology department. Radiation protection culture (RPC) incorporates education, actions and behaviours from all the staff involved in the everyday operation of the department. This importance is greater in an interventional radiology department where exposures of both patients and staff are maximised. According to the International Radiation Protection Association (IRPA), RPC is defined as the combination of knowledge, values, behaviours and experience of radiation protection (RP) in all its aspects for patients, workers, population and environment and in all exposure situations, combining scientific and social dimensions. The goal of RPC is to ensure patients’ safety, enhance radiation risk awareness, minimise unsafe practices, control radiation risks, share responsibility among workers, enrich radiation protection heritage for the next generation and improve the quality of a radiation protection programme. For the establishment of RPC, it is necessary to develop a strategic plan taking into account current knowledge and previous experience concerning ionisation radiation and radiation protection. To implement RPC, the strategic planning must be turned into an action plan and put into practice. The implementation of RPC should be based on justification, optimisation, dose limits and sharing of competence by training and education. The effectiveness of the strategy realisation is evaluated using qualitative and quantitative tools. There are two main ways to implement RPC. The first is focused on the continuous education and training of the people involved in using radiation with the development of courses and educational programmes and the attendance to congress and seminars. The second way is related to the effective communication among stakeholders at all levels (health authorities, medical staff, patients, general public and manufacturers). Additionally, the establishment of an RPC programme requires creation of a positive work environment, recognition of good practices and conviction of unsafe ones, quality assurance programmes, radiation doses according to ALARA (as low as reasonably achievable) principle, special attention to radiation protection of children and personnel dosimetry as well as guidelines and recommendations. The development of RPC is driven from the highest level. Leadership and RP professionals and associate societies are recognised to play a

Abstract Book vital role in embedding and promoting RPC in a medical unit. In conclusion, the deep knowledge of radiation risks, safety rules, individual behaviour and active participation of all stakeholders can enable the creation of a strong RPC. RPC ensures patient, staff and environment safety and increases productivity and efficiency. However, an RPC programme must be treated as a dynamic process that needs continuous upgradation. References 1. Draft IRPA Principles for Establishing a Radiation Protection Culture v6. 2. WHO, ‘Radiation Protection Culture in Health Care Settings’, 1st IRPA Workshop on Radiation protection Culture, Paris 2009. 3. Health Physics Society, ‘Radiation Safety Culture’, Position Statement of the Health Physics Society, 2012.

2704.3 Education and training in fluoroscopy-guided procedures: what, who and how G. Paulo Radiologia, Instituto Politécnico de Coimbra, ESTESC-Coimbra Health School, Coimbra, Portugal Learning Objectives 1. To report proper practice of fluoroscopy guided procedures 2. To emphasise the need for education 3. To illustrate training modes for fluoroscopy-guided procedures Technology and medical devices development are changing the way healthcare is being delivered to the patients in the last decades. The time of heavy and complicated surgical procedures, leading to long periods of patient hospitalization, is becoming a part of healthcare history because of the development of minimally invasive image-guided procedures. The increasing use of image-guided interventional procedures in medical practice is due to the demonstrated benefits of these procedures(1). Fluoroscopically guided interventional procedures (FGIP) are performed using X-ray beams with peak voltages ranging from 50 to 125 kVp and with filtrations ranging from the minimum permitted up to 1 mm of copper. Dose rates at the skin surface range from less than 1 mGy/min (very-low-dose–rate fluoroscopy) to several Grays per minute (digital subtraction angiography or cine angiography in a large patient)(2). The main advantages of using an image-guided minimally invasive interventional approach are the reduction of scars and pain and faster post-operative recovery. Moreover, FGIP are now considered the gold standard of care in many diseases of both vascular and non-vascular origin, and have replaced traditional surgical procedures in several fields. It has to be noted that in almost every case, FGIP are justified from the point of view of radiation protection(3). While the benefits of interventional radiology to patients are well recognized, there are also procedure-related risks. One of these risks, for many FGIP, is the potential for patient radiation doses high enough to cause radiation effects. The management of radiation exposure is therefore essential for these procedures(4). Dose optimization is possible through appropriate use of the basic features of interventional fluoroscopic equipment and intelligent use of dose-reducing technology(5). Many technical parameters can be adjusted during the procedure to reduce radiation use or to improve image quality, depending on the demands of the situation(6). The increasing use and complexity of imaging and interventional techniques have not been matched by increasing awareness and knowledge by prescribers and practitioners. The majority of health professionals involved in FGIP grossly underestimate the radiation doses for most commonly requested tests(7).

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According to MEDRAPET project(3), knowledge of radiation protection by itself is not enough and further skills and competences are needed. Training in radiation protection should become an essential part of FGIP teams training process. Clearly, the best FGIP team will use less fluoroscopy. Dose management and radiation protection training should therefore be an integral and essential component of any training and not stand-alone(8). The International Atomic Energy Agency (IAEA) Radiation Protection of Patients (RPOP) initiative has developed and made available for free several education tools for health professionals in order to support the optimization of FGIP to minimize the exposure of patients and staff to ionizing radiation. Medical simulators can help FGIP teams to improve skills in procedure performance. Simulators have proved to be efficient and safe tools for educating and training as they can rehearse procedures in an interventional laboratory environment without radiation and without the risk of a patient complication(1). FGIP are very team-dependent and therefore a special attention should be given to this aspect taking also into consideration that most of the FGIP are made under a stressful environment due to patient fragility and procedure complexity; therefore, it is necessary that each team member is aware of FGIP as a whole and also about each ones’ role and responsibility. The complexity of FGIP calls for the need of stable teams to allow the establishment of well-known routines, decreasing procedure time, and maximizing the equipment capability, consequently optimizing the procedure with clear benefits for the health system, hospital performance, and healthcare professionals and especially for patients. References 1. Bartal G, Vano E, Paulo G, Miller DL. Management of patient and staff radiation dose in interventional radiology: current concepts. Cardiovasc Intervent Radiol. 2013 Jul 16. 2. Balter S, Hopewell JW, Miller DL, Wagner LK, Zelefsky MJ. Fluoroscopically guided interventional procedures: a review of radiation effects on patients’ skin and hair. Radiology. 2010 Mar;254(2):326–41. 3. Damilakis J, Christofidis S, Paulo G. RADIATION PROTECTION No 175: Guidelines on radiation protection education and training of medical professionals in the European Union. 1st ed. Luxembourg: Publication Office of the European Union; 2014. 4. Miller DL, Balter S, Schueler BA, Wagner LK, Strauss KJ, Vañó E. Clinical radiation management for fluoroscopically guided interventional procedures. Radiology. 2010 Nov;257(2):321–32. 5. Mavrikou I, Kottou S, Tsapaki V, Neofotistou V. High patient doses in interventional cardiology due to physicians’ negligence: how can they be prevented? Radiat Prot Dosimetry. 2008 Jan;129(13):67–70. 6. Wagner L. Radiation injury is a potentially serious complication to fluoroscopically-guided complex interventions. Biomed Imaging Interv J. 2007 Apr;3(2):e22. 7. Picano E, Vañó E, Rehani MM, Cuocolo A, Mont L, Bodi V, et al. The appropriate and justified use of medical radiation in cardiovascular imaging: a position document of the ESC Associations of Cardiovascular Imaging, Percutaneous Cardiovascular Interventions and Electrophysiology. Eur Heart J. 2014 Mar;35(10):665–72. 8. Stecker MS, Balter S, Towbin RB, Miller DL, Vañó E, Bartal G, et al. Guidelines for patient radiation dose management. J Vasc Interv Radiol. SIR; 2009 Jul;20(7 Suppl):S263–73.

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2704.4 How to optimise angiographic equipment settings for radiation protection G. Bartal Radiology, Meir MC, Kfar-Saba, Israel Learning Objectives 1. To report major angiographic equipment settings 2. To propose practices optimising angiographic equipment settings 3. To compare image quality and dose at different settings State-of-the-art interventional fluoroscopy (angiographic) equipment represents top developments in the field of imaging and comprises many advanced features that were unavailable some years ago. Such a progress requires timely adaptation to a new environment in order to make safe, intelligent, and cost-effective use of the available machines and techniques. There is growing evidence that many interventionalists have a less than ideal understanding of the risks of radiation-induced injuries from X-rays. The main fraction of the patient and staff doses arises from fluoroscopy; therefore, the optimization of image quality and patient dose is essential [1]. The ultimate goal is to minimize radiation exposure without compromising image quality and keeping optimal diagnostic/interventional performance. IRs have to constantly thrive to achieve a reasonable balance between image quality and applied dose [2, 3]. We have to build up our knowledge of the specific equipment we use and must not rely completely on the manufacturer or radiographer. State-of-the-art interventional fluoroscopy systems comprise a range of the following features: · Virtually unlimited fluoroscopy time · DSA · 3D road maps · Cone-beam CT and many other options that are based on ionizing radiation · Optimization and intelligent use of available imaging options provides better imaging · Thus, improving IRs performance and reducing the dose The optimization of the angiography equipment and intelligent mastering of its advanced features is one of the basic requirements together with justification, which is recognized as viable means to win public confidence and reassure patients of the benefits of medical imaging [4]. For example, some IRs use “blind control” technique, covering the on-table console by the sterile sheet and not using a transparent cover. Yes, we are used to working in the dark during fluoroscopy and “feel” the catheters, but from time to time, our fingers might and usually do miss the right button or its direction, which leads to wrong actions such as moving or rotating the C-arm in an undesired direction, opening collimation shutters, changing table position, and more. Some other factors that can affect the image quality are ambient lights and bright objects, which may distract the operator’s eyes; simple solutions are dimming room lights and avoidance of reflections. In fluoroscopy-guided intervention, it is important to bear in mind that IR achieving the lowest patient dose will receive the lowest personal/professional dose. Staff doses correlate with patient doses, in that higher patient doses result in an increased amount of scattered radiation in the interventional suite [5]. We have constantly to aim for the following: 1. Shortest fluoroscopy time 2. Always use pulsed fluoroscopy with adequate case pulse sequence [6] 3. Last image hold (LIH) as well as last fluoroscopy hold (LFH) or store fluoro

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4. Obtain the lowest possible number of DSA runs and carefully plan each of the shortest DSA runs, ensuring optimal parameter selection 5. Use defined C-arm positions and angulations and iso-position functions, which save fluoroscopy time and consequently procedure time, bringing the image safely into the same condition as prior to moving the C-arm 6. Wisely and carefully use the road-map function Other factors to consider are the best position for workers inside the room, modifying the technical parameters and effects on exposure, and use of protective devices to minimize the dose to critical organs. IRs have to explain to the patient the benefits of the procedure versus the possible dangers of estimated radiation exposure, making this clear will ensure that ALARA (as low as reasonably achievable) is our leading principle, and in relevant cases, include it in informed consent. Clearly, we have to include the estimate organ and effective dose for each procedure in our reports as we already do for CT. The following fundamental aspects of radiation protection have to be considered when buying a new angiography system: 1. Real-time patient dose measurement and display in the cath lab 2. Patient dose report and its transfer to RIS at the end of the procedure [7] 3. Patient dose-saving tools and imaging protocols available in the X-ray system 4. Real-time staff dose measurement and display in the angiography room 5. Staff dose protection tools 6. Software to process patient and staff doses with automatic alerts for abnormal values [8] We have to provide relevant arguments regarding the value of medical radiation and integrating it into a broader context. Recently, major angiography equipment vendors offer very advanced tools, which allow significant reduction of patient exposure without compromising image quality; some of them deliver such features as an option for an extra cost. Clearly, it is our responsibility to make sure that such features will become an integral part of the equipment and not an option. References 1. E. Vano, et al. 1998c. Strapir, an European initiative for optimizing radiationprotection in interventional radiology. In: IAEA, Low Doses of Ionizing Radiation: Biological Effects and Regulatory Control. Proceedings of a symposium, Sevilla, Spain, November 17–21 1997, jointly organized by IAEA and WHO. IAEA, Vienna, Austria. 2. J. Williams, et al. The interdependence of staff and patient doses in interventional radiology. Brit J Radiology (1997) 70: 498–503. 3. D. L. Miller, et al. Radiation doses in interventional radiology procedures: the RAD-IR study. J Vasc Interv Radiol (2003M)14: 977–990. 4. M.S. Stecker, et al. SIR Safety and Health Committee; CIRSE Standards of Practice Committee (2009) Guidelines for patient radiation dose management. J Vasc Interv Radiol 20(7 Suppl): S263–S273. 5. G.D. Hartwell, et al. The value of composite protective shields in exposure reduction during interventional procedures. SIR 30 th Annual Scientific Meeting New Orleans, LA. March 31–April 5 2005 SS 10. Abstract No. 64. 6. G. Bartal, I. Ben-Hasid. The effect of pulse fluoroscopy on patient radiation exposure in vascular interventional radiology. Annual international meeting and post-graduate course of Cardiovascular and Interventional Radiological Society of Europe, Venice, Italy. September 27–October 1 1998. 7. FDA, 1995. Recording information in the patients’ medical record that identifies the potential for serious X-ray-induced skin injuries following fluoroscopically guided procedures. Statement September 15 1995, Food and Drug Administration, Rockville, MD, USA. 8. Söderman M, et al. Image noise reduction algorithm for digital subtraction angiography. Clinical Results Radiology (2013)269: 553–560.

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Honorary Lecture Josef Roesch Lecture 2901.1 Prostatic artery embolisation: familiar concept, new indication and state-of-the-art methods F.C. Carnevale Interventional Radiology, University of Sao Paulo Medical School, São Paulo, Brazil Rösch et al. reported the first clinical transcatheter visceral embolization procedure in 1972 [1]. Since then, embolization procedures have become progressively more sophisticated and the number, variety, and complexity of embolic agents has been increasingly applied to other organs and situations. Improvements in imaging and catheter technology have allowed for significant advances in embolization procedures. Interventional radiologic procedures have been used in all areas of medicine. Several therapeutic methods were developed in urology in the last decades. One of the most prevalent urological diseases is benign prostatic hyperplasia (BPH), with an estimated annual cost of LUTS/BPH treatment of $3.9 billion dollars [2]. In 1976, Mitchell et al. [3] described the treatment of massive hematuria caused by BPH and prostate cancer by embolization of prostate arteries using gelfoam and autologous clot. Other authors confirmed that the embolization technique was safe and effective to control bladder and prostate neoplasm bleedings [4-6]. The first published case in which it was recognized that embolization could have a therapeutic effect on BPH was by DeMeritt et al. in 2000 [7]. Pre-clinical studies showed that PAE could be performed safely with prostate size reduction without erectile dysfunction with the aim of treating prostate enlargement with embolization [8-10]. Carnevale et al. did the first intentional treatment of enlarged prostate due to BPH with PAE in humans in June 2008. In 2009 and 2011, they reported the preliminary results and the mid-term follow-up in two patients treated with PAE [11,12]. In 2011, Pisco et al. [13] reported their initial experience with PAE in 14 patients with LUTS associated with BPH showing clinical and quality-of-life improvements and prostate volume reduction during follow-up. Immediate clinical success and quality-of-life and urodynamic improvements have been obtained in 90% of patients with mean PSA value reduction of 50% of baseline with mean prostate volume reduction of 30%, as detected using MRI. Most reported complications were classified as minor and in less than 10% of patients; they were blood in the stool, reduction of the ejaculation volume, urinary tract infection, hematuria, hematospermia, and ischemia of the bladder, pelvic bone, seminal vesical and rectum. Symptoms recurrence has been observed in 15–20% of patients in a mean follow-up duration of 15 months [14-17]. Nowadays, with more than 500 procedures performed all over the world, physicians have demonstrated that PAE should be another minimally invasive alternative for the treatment of symptomatic patients with BPH [18-23]. References 1. Rösch J, Dotter CT, Brown MJ. Selective arterial embolization. A new method for control of acute gastrointestinal bleeding. Radiology 1972;102(2):303-6. 2. Saigal CS, Joyce G. Economic costs of benign prostatic hyperplasia in the private sector. J Urol 2005;173:1309-13. 3. Mitchell ME, Waltman AC, Athanasoulis CA, Kerr WS Jr, Dretler SP. Control of massive prostatic bleeding with angiographic techniques. J Urol 1976;115(6):692-5.

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4. Bischoff W, Goerttler U. Successful intra-arterial embolization of bleeding carcinoma of the prostate. Urologe A 1977;16:99-102. 5. Nadalini VF, Positano N, Bruttini GP, Medica M, Fasce L. Therapeutic occlusion of the hypogastric arteries with isobutyl2-cyanoacrylate in vesical and prostatic cancer. Radiol Med 1981;67(1–2):61-6. 6. Appleton DS, Sibley GN, Doyle PT. Internal iliac artery embolisation for the control of severe bladder and prostate haemorrhage. Br J Urol 1988; 61:45-7. 7. DeMeritt JS, Elmasri FF, Esposito MP, Rosenberg GS. Relief of benign prostatic hyperplasia-related bladder outlet obstruction after transarterial polyvinyl alcohol prostate embolization. J Vasc Intervent Radiol 2000;11(6):767-70. 8. Sun F, Sánchez FM, Crisóstomo V, Lima JR, Luis L, García-Martínez V, López-Sánchez C, Usón J, Maynar M. Benign prostatic hyperplasia: transcatheter arterial embolization as potential treatmentpreliminary study in pigs. Radiology 2008;246(3):783-9. 9. Faintuch S, Mostafa EM, Carnevale FC, Ganguli S, Rabkin DJ, Goldberg SN. Prostatic artery embolization as a primary treatment for benign prostatic hyperplasia in a canine model. J Vasc Interv Radiol. 2008;19(Suppl 2):S7. 10. Jeon GS, Won JH, Lee BM, Kim JH, Ahn HS, Lee EJ, Park SI, Park SW. The effect of transarterial prostate embolization in hormoneinduced benign prostatic hyperplasia in dogs: A pilot study. J Vasc Interv Radiol 2009;20(3):384-90. 11. Carnevale FC, Antunes AA, da Motta Leal Filho JM, et al. Prostatic artery embolization as a primary treatment for benign prostatic hyperplasia: preliminary results in two patients. Cardiovasc Intervent Radiol 2010; 33:355-61. 12. Carnevale FC, da Motta-Leal-Filho JM, Antunes AA, et al. Midterm follow-up after prostate embolization in two patients with benign prostatic hyperplasia. Cardiovasc Intervent Radiol 2011;34:1330-3. 13. Pisco JM, Pinheiro LC, Bilhim T, Duarte M, Mendes JR, Oliveira AG. Prostatic arterial embolization to treat benign prostatic hyper plasia. J Vasc Interv Radiol 2011; 22:11-19. 14. Carnevale FC, Antunes AA. Prostatic artery embolization for enlarged prostates due to benign prostatic hyperplasia. How I do it. Cardiovasc Intervent Radiol. 2013;36(6):1452-63. 15. Frenk NE, Baroni RH, Gonçalves OMG, Carnevale FC, Antunes AA, Srougi M, Cerri GG. MRI findings after prostatic artery embolization for treatment of benign hyperplasia. AJR Am J Roentgenol. 2014 [In press]. 16. Carnevale FC, Moreira AM, Antunes AA. “The PErFecTED Technique” – Proximal Embolization First, Then Embolize Distal for Benign Prostatic Hyperplasia. Cardiovasc Intervent Radiol 2014 (accepted for publication). 17. Carnevale FC. Prostate Embolization: Current Status. Society of Interventional Radiology, San Diego, CA, March 2014. 18. Bilhim T, Pisco JM, Rio Tinto H, Fernandes L, Campos Pinheiro L, Duarfte M, Pereira JA, Oliveira AG, O’Neill J. Unilateral versus bilateral prostatic arterial embolization for lower urinary tract symptoms in patients with prostate enlargement. Cardiovasc Intervent Radiol. 2013;36(2):403-11. 19. Pisco J, Campos Pinheiro L, Bilhim T, Duarte M, Rio Tinto H, Fernandes L, Vaz Santos V, Oliveira AG. Prostatic arterial embolization for benign prostatic hyperplasia: short- and intermediateterm results. Radiology 2013a;266(2):668-77. 20. Pisco JM, Rio Tinto H, Campos Pinheiro L, Bilhim T, Duarte M, Fernandes L, Pereira J, Oliveira AG. Embolisation of prostatic arteries as treatment of moderate to severe lower urinary symptoms (LUTS. secondary to benign hyperplasia: results of short- and mid-term follow-up. Eur Radiol 2013b;23(9):2561-72. 21. Bagla S, Martin CP, van Breda A, Sheridan MJ, Sterling KM, Papadouris D, Rholl KS, Smirniotopoulos JB, van Breda A. Early results from a United States trial of prostatic artery embolization in the treatment of benign prostatic hyperplasia. J Vasc Intervent Radiol 2014;25(1):47-52.

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22. Gao Y, Huang Y, Zhang R, Yang Y, Zhang Q, Hou M, Wang Y. Benign prostatic hyperplasia: prostatic arterial embolization versus transurethral resection of the prostate - a prospective, randomized, and controlled clinical trial. Radiology. 2014;270(3):920-8. 23. Somani BK, Hacking N, Bryant T, Coyne J, Flowers D, Harris M, Dyer J. Prostate artery embolization (PAE. for benign prostatic enlargement (BPE). BJU Int. 2014 Feb 18. doi: 10.1111/bju.12672. [Epub ahead of print]

Hot Topic Symposium HIFU: Just another IR modality? 2902.1 Principles of MR-HIFU: what an IR should know A. Melzer Institute for Medical Science and Technology, University of Dundee, Dundee, United Kingdom The MRgFUS device delivers high-intensity focused ultrasound energy, which is precisely directed from an extracorporeal phased array transducer towards the target tissue through the intact skin (i.e. MRgFUS comprises a non-invasive ablative therapy), resulting in irreversible coagulative necrosis and apoptosis when the temperature is maintained above 60°C for at least one second. MRgFUS procedures are performed in the MRI suite under continuous MR guidance and temperature monitoring. Sonication through the rib cage is possible by advanced beam steering, but it is not yet clinically approved. Real-time MR thermometry allows continuous temperature measurement at the target and surrounding tissues, enabling precise spatial location and intensity of the therapeutic energy in the tissue to be determined.[1] Because of the high resolution of the MR imaging, small lesions can be detected and accurately targeted with required tumour-free margins while avoiding injury to the surrounding vulnerable structures. Furthermore, thanks to the sharp drop in energy density outside the treatment focus, the resulting lesion is highly discrete, allowing essential tissues adjacent to the targeted volume to be spared. MRgFUS ablations are less affected by the heat-sink effect of adjacent large blood vessels and can be performed relatively close to the main bile ducts without damage; thus, providing the treatment with an outstandingly high safety/effectiveness profile as compared with other ablative therapies.[2] MRgFUS has proven to be effective with an outstanding safety profile in more than 8,500 treatments of symptomatic uterine fibroids, over 400 treatments of painful metastatic bone tumours, more than 200 treatments of breast cancer tumors, and over 40 treatments of prostate cancer as well as treatments of liver tumours and pancreatic tumours (see www.insightec.com for the latest results). We have initial promising experimental results for MRgFUS of moving organs (www.fusimo.eu). In patients with metastatic CRC confined to the liver, the non-invasive neoadjuvant focal MRgFUS treatment of the metastases is expected to improve survival by the following four mechanisms: (i) elimination of tumour spreading during surgery, (ii) better definition of target tumour-free margins using MRI and marking it to improve resection safety, (iii) tumour debulking before surgery would improve surgical outcomes, and (iv) MRgFUS may induce immune response, potentially affecting microscopic seeded metastases that are not a part of the resected liver. We have developed methods for targeted drug delivery by MRgFUS using novel encapsulation of doxorubicine by cyclodextrin (www. nanoproation.eu),[3] and the concept will be presented to use MRgFUS to increase the sensitivity of cancer cells to radiation therapy.[4]

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References 1. Ross JC, et al. Real-time liver motion compensation for MRgFUS. Med Image Comput Comput Assist Interv. 2008;11(Pt 2):806-13. 2. Orsi F, et al. High intensity focused ultrasound ablation: therapeutic option for solid tumors. J Cancer Res Ther. 2010;6:414-20. 3. Gourevich D, Dogadkin O, Volovick A, Wang LJ, Gnaim J, Cochran S, Melzer A. Ultrasound-mediated targeted drug delivery with a novel cyclodextrin-based drug carrier by mechanical and thermal mechanisms. JCR. 2013;170: 316-24. 4. Borasi G, Russo G, Alongi F, Nahum A, Candiano G.C, Stefano A, Gilardi M.C, Messa C. High-intensity focused ultrasound plus concomitant radiotherapy: a new weapon in oncology? Journal of Focused Ultrasound 2013;1:1-4.

Abstract Book 2. Primary Pain Palliation And Local Tumor Control In Bone Metastases Treated With Magnetic Resonance-Guided Focused Ultrasound. Napoli A, et al. Invest Radiol. 2013. 3. MR-Guided High-Intensity Focused Ultrasound: Current Status of an Emerging Technology. Napoli A, et al. Cardiovasc Intervent Radiol. 2013. 4. Osteoid Osteoma: MR-Guided Focused Ultrasound For Entirely Noninvasive Treatment. Napoli A, et al. Radiology. 2013.

2902.4 MR-HIFU for prostate: is the transurethral approach the right one? R. Chopra Department of Radiology, UT Southwestern Medical Center, Dallas, TX, United States of America

2902.2 MR-HIFU for uterine fibroids: which patients should be treated?

No abstract available.

M. Matzko Abt. Radiologie, Klinikum Dachau, Dachau, Germany No abstract available.

Special Session Image fusion for vascular interventions

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MR-HIFU for painful bone lesions: palliation or more?

Fundamentals and rationale for image fusion

A. Napoli Department of Radiological Sciences, University of Rome La Sapienza, Rome, Italy

1Service

H. Kobeiter1, V. Tacher1, J. Mayer1, P. Desgranges2, A. Rahmouni1 d’Imagerie Médicale, CHU Henri Mondor, Créteil, France, 2Vascular Surgery, CHU Henri Mondor, Créteil, France

Magnetic resonance imaging-guided focused ultrasound (MRgFUS) is an alternative noninvasive method for reducing pain in skeletal metastases. The concentration of acoustic energy on the intact surface of the cortical bone produces a rapid temperature increase that mediates critical thermal damage to the adjacent periosteum - the most innervated component of mature bone tissue. Such thermal ablation has been shown to be an extremely effective approach for pain management. This technique has also a potential role in achieving local tumor control, allowing de-novo mineralization of trabecular bone or reduction in lesion size. In our department, we are evaluating the safety and efficacy of MRgFUS treatment for pain palliation in patients with malignant (bone metastases) as well as benign (osteoid osteoma) lesions. Local tumor control was demonstrated by a reduction of lesion viability following MRgFUS procedure and by remineralization of spongy bone. Regarding the ablation of osteoid osteoma, MRgFUS was proposed as an alternative treatment option among other consolidated modalities, including radiofrequency ablation. At present, radiofrequency ablation is the most popular percutaneous technique, but it requires some degree of intervention. Our preliminary study demonstrates that MRgFUS for osteoid osteoma seems to be safe with good success and without treatment-related morbidity. Unlike other ablative techniques, MRgFUS is totally noninvasive and can be performed relatively fast in a single session with limited amount of energy deposition. In conclusion, MRgFUS is a completely noninvasive modality that allows effective and durable pain palliation in a single session even if a specific anesthesia protocol is needed. In bone metastasis, focused ultrasound energy may also detect metastasis necrosis, thus having potential future role for local tumor control. Furthermore, MRgFUS can be performed safely and effectively in patients with symptomatic osteoid osteoma. References 1. MR Imaging-Guided Focused Ultrasound For Treatment Of Bone Metastasis. Napoli A, at al. Radiographics. 2013.

Learning Objectives 1. To learn about the concept of image registration 2. To explain image registration modality by modality 3. To learn about the technical limits of image fusion Rationale Standard 2D angiography during endovascular repair of thoracic and thoracoabdominal aortic aneurysm is limited to (2D) projection in complex (3D) structures that may limit the development and use of endovascular technology. Flat panel detector provides the ability to perform intraoperative 3D imaging using rotational angiography. New technical developments in the angiographic rooms and workstations systems permit new guidance procedures through multimodality image fusion, such as preprocedural CT angiography (CTA) or MR angiography (MRA), is overlaid onto intraprocedural fluoroscopy, leading to 3D real time navigation. The clinical benefit and reduction in radiation exposure to patients and staff and contrast volume injected following the use of this new technique has been reported for vascular lesions of the brain and coronaries. The use of 3D guidance in aortic endovascular procedures is, however, not yet common practice. To date, little research has been presented on the application of C-arm cone-beam CT and image fusion guidance during aortic endovascular interventions, and there is little information about the usefulness of this technology in the treatment of aortic aneurysms or complex aortic disease. In our experience, (V Tacher et al) image fusion-guided complex EVAR showed a 100% success rate in stent-graft positioning, deployment, and catheterization of the target vessels. It has been considered feasible and safe when used for intraprocedural imaging guidance for complex EVAR. Furthermore, we reported a statistically significant reduction in contrast medium volume injected in the image fusion group versus the 2D and the 3D groups ( P = .0002 vs 2D angiography; P < .0001 vs 3D angiography), that is corroborated by another preliminary evaluation which demonstrates that the use of intraoperative C-arm cone-beam CT to guide the deployment of fenestrated endografts results in significantly lower contrast dosage (P < .001), with a trend toward lower fluoroscopy.

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In our experience, the contrast injections in the image fusion group were mainly used before and after visceral stent placement, as well as for the final control imaging of endograft deployment (i.e., final digital subtraction angiography). However, image fusion guidance did not necessarily require intraprocedural contrast agent injection to generate a roadmap, whereas it was required for 2D and 3D angiographic image guidance. We reported the case of a zero-contrast thoracic endovascular aortic repair using image fusion. Furthermore, in our experience, the mean X-ray exposure in dose–area product at the end of the intervention was reduced by 45% versus the 2D angiography and by 33% versus the 3D angiography in the IF group, even though cone-beam CT was used. This was most likely a result of the reduction of the need to perform multiple digital subtraction angiography procedures. Indeed, the 3D overlaid roadmap is synchronized with live fluoroscopy at any C-arm/table position, angle, and magnification. The 2D angiographic roadmapping does not allow any change of the table or C-arm position without losing image registration. Therefore, any movement requires a new roadmap, increasing X-ray exposure and injected contrast agent volume, whereas the 3D road-map registration allowed manual correction of the overlay. We also demonstrated a trend toward a reduction of type I endoleak on 1-week follow-up CT angiography compared with the patients treated with 2D angiography or 3D rotational angiography. This can be explained by more precise image guidance leading to a higher technical success rate and fewer postprocedural endoleak complications. In our report, image fusion guidance did not require more operative time than with 2D or 3D, even it required the acquisition of an unenhanced intraoperative cone-beam CT study and to manually coregister the CT angiography and cone-beam CT images. Dijkstra et al found a trend toward lower total operative times. Fundamentals Currently, each manufacturer has its own imaging protocol that is tailored to each system’s different rotation time, number of projections acquired, image quality, overlay procedure type, and time required for reconstruction and fusion. Image fusion and coregistration bring several imaging modalities together. Although the terms are often used interchangeably, image fusion is the overlay of two or more imaging data sets together as one display, whereas image coregistration consists of spatially aligning or matching the two imaging data sets to each other. Registration can be rigid or elastic (deformable). Only translation (panning) and rotation are possible with rigid coregistration whereas rotation, translation, and localized stretching are possible with elastic registration, which improves matching of anatomical structures. For example, a difference in patient positioning between diagnostic and intraprocedural imaging may be corrected by rotating the image, but a deformation of an organ secondary to placement of a rigid probe or a stent-graft would require localized stretching. Our protocol at Henri Mondor University Hospital: immediately before the intervention, the same preprocedural CT angiographic images described earlier were loaded onto a dedicated 3D workstation (Xtra Vision Release 8; Philips Healthcare) to register with intraprocedural imaging. The IF process enabled an overlay of fluoroscopy acquisition on a preprocedural CTA or MRA. It required the acquisition of an unenhanced intraoperative cone-beam CT study to register the two 3D data sets in the same spatial coordinates. The patient’s arms remained alongside the body for the cone-beam CT acquisition. The unenhanced cone-beam CT reference image acquisition was made at the beginning of the procedure and before the patient was prepared and draped. The area of interest was positioned in the system isocenter, and 120 projections (15 frames per second) were acquired over a 180° arc. The images were reconstructed into a 3D volume on the workstation. The same interventional radiologist who would later perform the intervention manually registered the CT angiography and cone-beam CT images.

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Coregistration of unenhanced cone-beam CT and preprocedural CTA was performed less than 5 minutes after image acquisition in all patients. CTA or MRA volumes are overlaid with an intraoperative low-dose CBCT; this step is performed automatically or by selecting common landmarks, such as calcifications, clips, or vessel borders, thus excluding the need for contrast injection. 3D CTA/MRA volumes can then be used as the background map for realtime navigation and deployment of endovascular devices and thus replace multiple 2D angiograms and 2D roadmaps. Landmarks are crucial for accuracy for this - it is preferable to use aortic wall calcifications, particularly target vessel borders or calcifications; in our experience, spine was not used as registration references. Then the coregistration was executed to ensure that the CT angiographic roadmap was precisely overlaid on live 2D fluoroscopy. The whole volume-rendering technique of the arterial tree was used to create the 3D roadmap. The volume-rendered overlay provided the projection of the target vessel on its entire length. This information was used to select the optimal C-arm angulation during catheterization. Stent implantation and control of stent placement success were evaluated using a DSA acquisition. Conclusion In conclusion, EVAR using CTA and MRA IF roadmap is safe and feasible. CTA and MRA provide information for planning, navigation, and more precise deployment of the stent graft and may decrease or suppress the reliance on contrast angiography during EVAR. References 1. Dijkstra ML, Eagleton MJ, Greenberg RK, Mastracci T, Hernandez A. Intraoperative C-arm cone-beam computed tomography in fenestrated/branched aortic endografting. J Vasc Surg 2011;53:583-590. 2. Tacher V, Lin M, Desgranges P, Deux JF, Grunhagen T, Becquemin JP, Luciani A, et al. Comparison of two-dimensional (2D. angiography, three-dimensional rotational angiography, and preprocedural CT image fusion with 2D fluoroscopy for endovascular repair of thoracoabdominal aortic aneurysm. J Vasc Interv Radiol. 2013;24:1698-1706. 3. Abi-Jaoudeh N, Kruecker J, Kadoury S, Kobeiter H, Venkatesan A, Levy E, Wood B. Multimodality image fusion-guided procedures: technique, accuracy, and applications. Cardiovasc Intervent Radiol 2012;35:986-998. 4. Lin CJ, Blanc R, Clarencon F, Piotin M, Spelle L, Guillermic J, Moret J. Overlying fluoroscopy and preacquired CT angiography for road-mapping in cerebral angiography. AJNR Am J Neuroradiol 2010;31:494-495. 5. Greenhalgh RM, Brown LC, Powell JT, Thompson SG, Epstein D, Sculpher MJ. Endovascular versus open repair of abdominal aortic aneurysm. N Engl J Med 2010;362:1863-1871. 6. Kobeiter H, Nahum J, Becquemin JP. Zero-contrast thoracic endovascular aortic repair using image fusion. Circulation 2011;124:e280-282. 7. Gupta A, Grunhagen T. Live MR angiographic roadmapping for uterine artery embolization: a feasibility study. J Vasc Interv Radiol 2013;24:1690-1697. 8. Kaladji A and al Prediction of deformations during endovascular aortic aneurysm repair using finite element simulation. Comput Med Imaging Graph. 2013 Mar. 9. Fukuda T. and al Evaluation of automated 2D-3D image overlay system utilizing subtraction of bone marrow image for EVAR: feasibility study. Eur J Vasc Endovasc Surg. 2013 Jul.

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3201.2

3201.3

Zero contrast intervention: a realistic ambition?

Fusion for peripheral artery disease

M. Das Department of Radiology, Maastricht University Medical Center, Maastricht, Netherlands

A. Holden Radiology, Auckland City Hospital, Auckland, New Zealand

Learning Objectives 1. To learn about the rationale of zero contrast intervention 2. To learn about results and if it is too early for clinical use 3. To learn about pitfalls and mistakes Contrast-induced nephropathy (CIN) is defined as decrease in renal function within 3 days after iodinated contrast media (CM) injection, as defined by the European Society of Urogenital Radiology (ESUR). It is assumed that 10% of all hospital-acquired renal failures are due to iodinated CM. In any case, the mechanism of renal toxicity is still not fully understood. Many patients who are referred for intervention are at an increased risk for CIN. Risk factors include advanced age (>60 years), diabetes, hypertension, known urological history or use of NSAIDs. Strategies have to be developed how to deal with such patients, i.e., to reduce or to avoid iodinated CM. For many years, CO2 has been used as an alternative contrast agent in interventional procedures; major drawbacks of this technique are limited image quality and patient discomfort and that it cannot be used above the diaphragm. Recently, image fusion has become available which makes use of per-interventional imaging such as MR and CT to guide interventional procedures. The overall goal would be to use this guidance to completely avoid CM during intervention. During this procedure, MR or CT imaging has to be matched to the anatomy of the patient; this is usually done by performing an unenhanced cone beam CT of the region of interest, which is then fused to the pre-interventional imaging. To date, several pitfalls have to be recognised with this technique. Digital subtraction angiography (DSA) still functions as the gold standard, e.g. in terms of stenosis detection. Thus, it has to be recognised that DSA has to validate the severity of stenosis which has been detected on CT or MR (potentially over- or underestimating the degree of stenosis); furthermore, the result of the procedure has to be validated as well and complications have to be excluded. Strategies to achieve are possible - e.g. ultrasound in peripheral arteries. During image guidance, the success of image fusion will largely depend on the accuracy of the image fusion and the ability to adapt for different patient positioning and movement during therapy. The initial fusion imaging has to match the current patient anatomy; this might be challenging if the patient has been positioned differently, has moved or the time delay between available imaging and intervention is so long that significant changes (e.g. surgery) has taken place in between, changing anatomy significantly. So far image fusion has been reported for placement of endovascular aortic prosthesis as well as peripheral artery intervention. These initial trials have shown the potential of the technique to substantially reduce the amount of CM. These trials have shown the feasibility in larger vessels, but to date no large data is available on smaller vessels, e.g. guidance for hepatic embolization, although imaging such as cone-beam CT has shown its value in the guidance and assessment of success. The ultimate goal of performing a zero-contrast intervention might still need more data as well as a consensus on how to perform the assessment of therapy success. Nevertheless, initial results have shown the potential to use image guidance during interventional procedures.

Learning Objectives 1. To understand the rationale for fusion for peripheral artery disease 2. To learn about the goal and current status of fusion for peripheral artery disease 3. To learn about limits of fusion for peripheral artery disease The fundamental principles of image fusion include the fusion of separate 3-dimensional imaging data sets from different imaging studies as well as accurate spatial co-registration of anatomy and pathology. These principles can be applied to peripheral artery intervention. There are 2 ways to perform image fusion in the interventional suite setting. A contrast-enhanced cone-beam CT performed at the start of the procedure can then be superimposed over the live fluoroscopy image using dynamic image overlay. This has the advantage of excellent spatial co-registration assuming movement during the study is minimised. The alternative (and preferred) method is to perform a non-contrast cone-beam CT at the start of the procedure and then fuse that data with a previous CT or MR data set. The arteries displayed in the original CTA or MRA are then superimposed with dynamic image overlay. Some manufacturers do not require a noncontrast cone-beam CT but can achieve fusion using AP and lateral fluoroscopy. In both situations, fusion is achieved by superimposing the bone and vascular calcification landmarks between the 2 data sets. In all fusion studies, the ability to manually “fine tune” the registration is important. The potential advantages of image fusion during peripheral artery interventional procedures include a reduction in procedure time, radiation dose and contrast volume. The major challenge is image misregistration. This can be due to patient movement between the cone-beam CT and the intervention, deformity of arteries by stiff guidewires and devices and differences in patient position between the imaging study and the intervention. The most successful peripheral artery image fusion to date has involved arteries of the head, neck, chest and abdomen. This is because patient position is easily reproduced between the pre-procedural CT or MR and the procedure so misregistration is minimised. CT is most commonly fused, and interventions have been performed in carotid, aortic and iliac arteries with minimal or no contrast. MR can also be used but an unsubtracted data set from the MRA study must be used to maximise bony registration. The advantage of MR fusion with its excellent arterial contrast resolution and no radiation is obvious. At Auckland Hospital, we compared 40 sequential patients who underwent iliac artery intervention using MR fusion to 42 patients who underwent iliac artery interventions using the same angiographic equipment but without fusion. The image fusion did not confer a saving in procedure time but produced a 26% reduction in radiation dose and a 74% reduction in contrast volume. Arterial intervention below the inguinal ligament with image fusion is particularly challenging because the limbs are invariably in quite different positions. One method is to create radiolucent moulds that support the patient’s legs during intervention in the same position as CT or MR. Strenuous efforts are underway to develop a software that can automatically re-register for differences in patient position. One application still being explored is the evaluation of tissue perfusion after intervention. This is possible and may be beneficial – for example, in interventions for critical limb ischaemia.

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3201.4 Fusion for endovascular prosthesis placement A.M.H. Sailer Radiology, Maastricht University Medical Centre, Maastricht, Netherlands Learning Objectives 1. To understand the rationale for fusion for endovascular prosthesis placement 2. To learn about the goal and current status of fusion for endovascular prosthesis placement 3. To learn about limits of fusion for endovascular prosthesis placement Rationale During endovascular interventional procedures, diagnostic angiography with iodinated contrast medium is traditionally used in order to facilitate safe manoeuvring of guidewires and catheters and to correctly position endovascular prostheses. Over the last decade, coregistration of different imaging modalities has been promoted in order to facilitate multimodality fusion image road-mapping. Fusion is a new alternative for conventional angiogram road-mapping in endovascular prosthesis placement. The technology follows two principles1: [1] to co-register and fuse pre-acquired image datasets, e.g. computed tomography angiography (CTA), magnetic resonance angiography (MRA) or magnetic resonance venography (MRV), to another dynamic imaging modality, commonly fluoroscopy and [2] to overlay real-time catheter, guidewire and prosthesis movements to the pre-acquired background dataset. The pre-acquired dataset thereby follows any rotation of the C-arm and table movements and it adapts to magnification. A non-contrast-administration 3D road-map is thereby acquired. Goals and current status The goal of the image fusion road-mapping technique is to reduce iodinated contrast volume during endovascular procedures. The availability of the 3D information on the fusion road-map allows choosing optimal C-arm projection angles for the particular intervention which might further result in a more efficient stenting procedure with a reduction of fluoroscopy and procedure times. Fusion guidance is a new technology and reports on different applications emerge in medical literature. In our clinic, we use fusion guidance during aortic, peripheral artery and central venous stenting procedures. Currently, six publications have reported successful endovascular prosthesis placement under fusion guidance. 2-6,8 Contrast volume reduction Kobeiter et al were the first to describe a single case of zero-contrast thoracic endovascular aortic repair under CTA fusion guidance. 2 Recently, a case of fusion with MRA for an iliac aneurysm occlusion with coils and stent placement using only 3 mm of contrast was published by the Frank Veith group. 3 In two prospective studies4,5 and one retrospective study6 on fusion guidance in complex endovascular aortic repair procedures, a significant reduction in procedural contrast volume was observed. Average reported iodinated contrast reduction in the fusion group compared with controls were 42 ml (p < 0.001)4, 40 ml (p = 0.037)5 and 160 ml (p < 0.001)6, respectively. Radiation dose and procedure time reduction Dijkstra et al. and Tacher et al. report a trend towards lower operative time using fusion technology than conventional angiography; however, these differences did not reach statistical significance.4,6 In the analysis of Sailer et al., a significant reduction in procedure time was observed of an average of 66 min (p = 0.022). 5 In both studies from Dijkstra et al. and Sailer et al., procedural fluoroscopy time was an average of 9 min lower in the fusion group. Although these differences in fluoroscopy time were not significant (p = 0.932 and p = 0.038, respectively), it might still be relevant as any reduction in live fluoroscopy means a net reduction in radiation exposure for the medical staff. Accurate placement of endovascular devices under

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assistance of fusion guidance thereby is likely to improve overall safety for both the patient and the interventional team. Limits CBCT radiation dose CTA/MRA/MRV with fluoroscopy image co-registration is performed using a C-arm cone-beam computed tomography (CBCT). CBCT does not result in additional radiation exposure for the medical staff, as all members are usually outside the interventional suite during acquisition. However, for patients, the application of CBCT may lead to an increase of procedural exposure to radiation. In a prospective study, the radiation dose of abdominal CBCT in 40 patients was prospectively evaluated.7 Effective dose (ED) of the CBCT run was estimated to be in the range of 1.1 mSv to 7.4 mSv. Mean ED for upper abdominal CBCT was 4.9 mSv (95% CI: 4.3 mSv, 5.4 mSv) and for lower abdominal CBCT was 3.5 mSv (95% CI: 3.0 mSv, 4.1 mSv); doses of the upper abdominal CBCT were significantly higher than pelvic CBCT (p = 0.003). A significant positive correlation between radiation dose and patient’s body weight (r = 0.55, slope = 0.045 mSv/kg, p < 0.001) was found. Radiation exposure of CBCT corresponded to the radiation exposure of on average of 7 min (95% CI: 5.5 min, 8.8 min) of fluoroscopy in the same region of interest. Application of CBCT will therefore result in a net reduction of patients’ total procedural radiation exposure if a reduction in fluoroscopy time of approximately 7 min is achieved. For every procedure, potential benefits of fusion guidance have to be weighed against this potential extra patient’s radiation dose. MRA/MRV/CTA artefacts In terms of diagnostic accuracy, one must realise that the fusion image road-map is only as accurate as the underlying MRA/MRV or CTA quality since artefacts hamper the usability of the fusion roadmap. Also, long timing intervals between diagnostic imaging and stenting procedure might cause inaccuracies. Especially for MRA, it is well known that MRA may indicate pseudo-lesions. Fully relying on the fusion road-map without diagnostic angiogram before stenting might therefore result in unnecessary interventions - a fact that needs to be considered when using fusion road-mapping. Rigid dataset co-registration Straightening and deformation of the vessel tree by stiff guidewires and stiff stent graft introduction devices are commonly observed, mainly at the level of kinking iliac arteries and elongated descending thoracic aorta.5 As co-registration with the pre-acquired dataset is performed in a rigid, non-elastic manner, any deformation of the vessel tree results in temporary overlay inaccuracy during manoeuvers with stiff devices, which partly resolves after stent deployment. Considering aortic prosthesis placement, diagnostic CTA scans are mainly performed during breath-hold inspiration - an artificial state which does not occur during prosthesis placement under anesthesia. The result is a mismatch between the pre-acquired CTA images and live fluoroscopy image due to respiration-related vessel displacement. It is mainly observed at the level of the aortic arch and peripheral segments of visceral branches. Inaccuracies in peripheral segments of vessels due to the diaphragm dome and organ movement do not limit the usability of the fusion road-map as long as the origin of relevant vessels does not change position. In the fusion road-map accuracy analysis, during endovascular aortic repair from Fukuda et al., the mean error of renal artery origin overlay image was 2 mm, with a standard deviation of 3 mm (range, 0–7 mm). Patient movement Any patient movement after CBCT acquisition results in fusion image mismatch to the same extent and in the same direction as the original movement. As patients are under anesthesia during aortic prosthesis placement and venous outflow recanalization and stenting, patient movement is not a problem in such applications.5 However, during peripheral artery interventions, leg movements are a considerable problem affecting the usability of the fusion road-map. In our preliminary experience of 20 peripheral artery interventions, fusion road-mapping was unusable due to major patient movement in

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three cases. Furthermore, different patient positioning in pre-interventional imaging and interventional procedure affects fusion roadmap precision. Fixing leg casts could attack these problems and are currently under development. References 1. Abi-Jaoudeh N, Kruecker J, Kadoury S, Kobeiter H, Venkatesan AM, Levy E, Wood BJ. Multimodality image fusion-guided procedures: technique, accuracy and applications. Cardiovasc Intervent Radiol. 2012;35:986-998. 2. Kobeiter H, Nahum J, Becquemin JP. Zero-contrast thoracic endovascular aortic repair using image fusion. Circulation. 2011;124:e280-282. 3. Sadek M, Berland TL, Maldonado TS, Rockman CB, Mussa FF, Adelman MA, Veith FJ, Cayne NS. Use of preoperative magnetic resonance angiography and the Artis zeego fusion program to minimize contrast during endovascular repair of an iliac artery aneurysm. Ann Vasc Surg. 2014;28:261.e1-5. 4. Dijkstra ML, Eagleton MJ, Greenberg RK, Mastracci T, Hernandez A. Intraoperative C-arm cone-beam computed tomography in fenestrated/branched aortic endografting. J Vasc Surg. 2011;53:583-590. 5. Sailer AM, de Haan MW, Peppelenbosch AG, Jacobs MJ, Wildberger JE, Schurink GW. CTA with Fluoroscopy Image Fusion Guidance in Endovascular Complex Aortic Aneurysm Repair. Eur J Vasc Endovasc Surg. 2014 doi: 10.1016/j.ejvs.2013.12.022. Epub 2014 Jan 30. 6. Tacher V, Lin M, Desgranges P, Deux JF, Grünhagen T, Becquemin JP, Luciani A, Rahmouni A, Kobeiter H. Image guidance for endovascular repair of complex aortic aneurysms: comparison of two-dimensional and three-dimensional angiography and image fusion. J Vasc Interv Radiol. 2013;24:1698-1706. 7. Sailer AM, Schurink GWH, Wildberger JE, de Graaf R, van Zwam WH, de Haan MW, Kemerink GJ, Jeukens CRLPN. Radiation exposure of abdominal cone beam computed tomography. Cardiovasc Interv Radiol. [accepted 1 April 2014]. 8. Fukuda T, Matsuda H, Doi S, Sugiyama M, Morita Y, Yamada M, Yokoyama H, Minatoya K, Kobayashi J, Naito H. Evaluation of automated 2D-3D image overlay system utilizing subtraction of bone marrow image for EVAR: feasibility study. Eur J Vasc Endovasc Surg. 2013;46:75-81.

Abstract Book ablation through preablation embolization of tumor vaculatures or TACE with post-/periablational hyperemia, increasing blood flow for TACE. Ablation and TACE can be administered in varying paradigms on the basis of the sequence and time between therapies. Although the combined strategy such as TACE combined with ablation has gained a consensus through the societies of interventional oncology and its usefulness has been proven through clinical studies in Asia, a well-designed prospective RCT is still warranted.

3202.2 Ablation with systemic therapies N. Goldberg Radiology, Hadassah University Hospital, Jerusalem, Israel Learning Objectives 1. To learn about the rationale of combining ablation and systemic therapies 2. To learn when to customise a combined treatment for the patient 3. To learn about trials and results of combined ablation and systemic therapies No abstract available.

3202.3 Combining transarterial and systemic therapies J.-F.H. Geschwind Vascular and Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America Learning Objectives 1. To learn about the rationale of combining transarterial and systemic therapies 2. To learn about techniques and timing of combined treatments 3. To learn about trials and results of transarterial and systemic therapies No abstract available.

3202.4 Ablation with immunotherapy

Special Session Combination therapies of liver tumours

C. Gouttefangeas1, S.P. Haen2, M. Widenmeyer1, P.L. Pereira3 , H.-G. Rammensee1 1Department of Immunology, Institute for Cell Biology, Tuebingen, Germany, 2Oncology, Haematology, Immunology, University Hospital, Tuebingen, Germany, 3Dept of Radiology, Minimally Invasive Therapies and Nuclearmedicine, SLK-Clinics GmbH, Ruprecht-Karls-University Heidelberg, Heilbronn, Germany

3202.1 Ablation and transarterial therapy H. Rhim Radiology, Samsung Medical Center, Seoul, Korea Learning Objectives 1. To learn when and how to combine ablation and transarterial treatments 2. To learn about results of combined ablation and transarterial treatments 3. To learn how to customise a combined treatment for the patient Ablation is accepted as a curative treatment option for early stage (<3 cm) hepatocellular carcinoma. However, the therapeutic efficacy of ablation for a tumor >3 cm is decreasing because of the limited ablation volume provided by current technology or increasing incidence of microsatellite nodules around the main tumor. There are several potential advantages in combining ablation and TACE. This includes the combined cytotoxic effects of the exposure to nonlethal hyperthermia in periablational tumor and adjuvant chemotherapy. Alteration in tumor perfusion can potentiate the effect of

Learning Objectives 1. To learn what is known about the impact of ablation on tumour immunity 2. To learn the status of present research and trials 3. To learn about potential future developments and clinical implications of immune therapy after ablation Over the last few years, thermoablative techniques have gained importance in the eradication of malignant tumours in selected patients with liver, lung or kidney cancer. One characteristic of local ablative treatments is the rapid induction of tumour cell death essentially by coagulative necrosis. Necrosis is not a silent death. Injured cells release their content in situ, including heat shock proteins and tumour-associated antigens, which can be taken up by local dendritic cells and lead to the activation of innate and adaptive immune components. Accumulating evidence indicates that thermoablation indeed modulates stress-protein expression, cytokine serum levels and various immune cell subsets. Moreover, the

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CIRSE 2014 activation of tumour-specific T cells and immunological memory has been demonstrated in animal tumour models. We have studied the effects of radiofrequency ablation on the immune system of cancer patients. One day after RFA, we observed a transient increase of soluble heat shock protein Hsp70 in the serum of a large proportion of treated patients. In addition, we showed that radiofrequency ablation can trigger adaptive immunity mechanisms, as assessed by tumour antigen-specific antibodies and tumour antigen-specific T cell responses in patients’ blood several weeks after treatment. Altogether, these findings indicate that thermoablative methods may not only result in the control of local tumour growth but also provide appropriate conditions for unleashing anti-tumour immunity. In many cases, however, these effects appear to be weak. A combination of thermoablation with immunomodulatory strategies such as adjuvants, selected chemotherapeutic agents or immunotherapy is therefore an attractive area of research. Preclinical models and first clinical approaches will be discussed.

Special Session Biliary interventions 3203.1 Percutaneous treatment of malignant hilar lesions P. Vilares Morgado Department of Radiology, Hospital S. João - Porto, Porto, Portugal Learning Objectives 1. To learn about percutaneous treatments of malignant hilar lesions and approaches 2. To understand success and potential complication rates 3. To learn how to manage and avoid complications The most effective treatment for malignant obstructive jaundice is surgical tumor resection and biliary–enteric anastomosis. However, because this disease is occult, the chance of surgical resection has usually been lost when diagnosed. In addition, the operative mortality is high at 2–5%. Percutaneous transhepatic biliary drainage and self-expandable metal stent placement are commonly used methods for the palliative treatment of obstructive jaundice, which can significantly improve the quality of life and extend the survival time. It is important to choose an appropriate approach as it can improve the success rate, reduce the trauma to the patient, and reduce the incidence of complications. The intrahepatic access route should avoid liver tumors (especially malignant ones). The right approach is chosen generally because of the thick bile duct and the large volume of the right lobe. When the stricture is located above the convergence, resulting in the isolation of the right anterior branch, right posterior branch, or the right lobe atrophy, or the portal vein of the right side has been invaded, a left approach should be chosen to drain more liver parenchyma. In patients with ascites, a left-sided drainage may be preferable because it might avoid ascites leaking around the catheter, which causes skin irritation. Hilar biliary obstruction is not only difficult to deal with in surgery but also a technical difficulty in interventional drainage. It is most often caused by hilar cholangiocarcinoma (Klatskin’s tumor), gallbladder cancer growing into the liver and/or hepatoduodenal ligament, advanced gastric cancer, lymphadenopathy in the hepatoduodenal ligament, or liver metastases, compressing hilar structures. For obstruction at the level of the bifurcation with the left and right hepatic duct still connected, draining only one lobe with a metal stent is usually sufficient; one stent is placed with its distal end in the common hepatic duct and proximal end in the drained bile duct. Although Inal et al reported no significant difference in the clinical response to treatment or stent patency rate with unilobar versus bilobar drainage even in Bismuth types II and III hilar obstructions, most authors suggest that survival is better with drainage of both

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sides of the liver. So bilobar drainage with metal stent is preferred in patients with obstruction at the level of the bifurcation with the left and right hepatic ducts isolated. In most cases, the contralateral side may be punctured and two stents are implanted from the ipsilateral and the contralateral side into the common bile duct placed in a “Y” configuration side-by-side. One advantage of this more anatomic “Y” placement is that the stents are both approachable endoscopically should stent occlusion occur. In addition, the patency rate of the “Y” configuration might be improved. If the obstruction does not extend beyond the secondary confluence and the guide wire can get across the stricture to the contralateral bile duct, stents may be placed from the ipsilateral side to the contralateral side and from the ipsilateral side into the common bile duct or duodenum in a “T” configuration. For cases with multiple obstructions of the intrahepatic bile duct, multi-drainage from multi-approach should be preferred. All the bile ducts should be drained as completely as possible in patients who also have biliary tract infections. For some cases, where it is difficult to achieve complete drainage, the bile duct should be drained, allowing for drainage of more functional liver. Imaging review is important for planning biliary drainage and stenting of hilar obstruction. Technical success of percutaneous biliary drainage has been reported as more than 90% and clinical success as more than 75% in all major series in a review study. Stents can occasionally get blocked due to either biliary sludge or tumor recurrence, resulting in the reappearance of jaundice, which may occur in 10–30% of patients at some point of their disease. Recurrent tumor growth can be either through the stent struts or overgrowth of the proximal or distal ends. If endoscopic intervention is not possible, percutaneous approach will be needed where a similar size or smaller metal stent is coaxially inserted into the blocked one with or without balloon dilatation. Stenting and drainage of the biliary tract is a safe procedure, but they have their share of complications (from 8% to 30%), which can be divided into immediate and late complications. Immediate complications include pain at the site of puncture, bile leak, and intrahepatic and extrahepatic bleeding, including hemobilia, pneumothorax, hemothorax, septicemia, and catheter-related problems of kinking or dislocation; the latter could be prevented using internal–external drainage catheters and locking pigtails. Patients may find the left lobe punctures less painful as these do not cross the intercostal space although bile leak or bleeding may be more common as there may be less liver to tamponade the puncture tract. Ultrasound guidance for avoiding vascular structures by far reduce bleeding complications. Bile leak and bleeding may be mild to severe, resulting in pain secondary to peritonitis, especially pain at the shoulder tip. Pneumothorax and hemothorax are rare and may result from transversing the pleura. Late complications include cholangitis, pancreatitis, liver abscess, septicemia, drainage catheter or stent blockage, and arterial or venous biliary fistula. Stent occlusion may result from tumor in-growth or may be due to biliary sludge. In our experience, most complications can be managed conservatively although the more serious ones may need further radiological or surgical intervention. Procedure-related mortality is very low (0–3%) although 30-day mortality is significant (2–20%), usually due to the underlying disease process, resulting from deranged liver function, malnutrition, and cancer cachexia. Metal stents have higher patency rates, shorter hospital stay for patients, and lower overall cost than plastic stents. Covered metal stents are now available, but stent migration and occlusion of sidebranches including cystic or pancreatic ducts causing cholecystitis and pancreatitis, respectively, are potential complications that may limit their use. The use of self-expanding metal stents has increased due to fewer long-term complications than those seen with the smaller diameter plastic stents, particularly early stent occlusion.

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It is well known that advances in adjuvant chemotherapy and radiotherapy also form a part of the palliative treatment, which prolongs life expectancy in patients who have had stents inserted, and thereby possibly outliving the stent patency period. Evidence indicates that those patients with cholangiocarcinoma who are unsuitable for surgery should be offered brachytherapy or photodynamic therapy in addition to biliary stenting as median survival and stent patency is prolonged compared with stenting alone. References 1. Indar AA, Lobo DN, Gilliam AD, Gregson R, Davidson I, Whittaker S, Doran J, Rowlands BJ, Beckingham IJ. Percutaneous biliary metal wall stenting in malignant obstructive jaundice. Eur J Gastroenterol Hepatol 2003; 15:915-919. 2. Molnar W, Stockum AE. Relief of obstructive jaundice through percutaneous transhepatic catheter-a new therapeutic method. Am J Roentgenol Radium Ther Nucl Med 1974; 122:356-367. 3. Laméris JS, Obertop H, Jeekel L. Biliary drainage by ultrasoundguided puncture of the left hepatic duct. Clin Radiol 1985; 36:269274. 4. Lammer J, Hausegger KA, Fluckiger F, Winkelbauer FW, Wildling R, Klein GE, Thurnher SA, Havelec L. Common bile duct obstruction due to malignancy: treatment with plastic versus metal stents. Radiology 1996; 201:167-172. 5. Hausegger KA, Thurnher S, Bodendorfer G, Zollikofer CL, Uggowitzer M, Kugler C, Lammer J. Treatment of malignant biliary obstruction with polyurethane-covered Wallstents. AJR Am J Roentgenol 1998; 170:403-408. 6. Schoder M, Rossi P, Uflaker R, Bezzi M, Stadler A, Funovics MA, Cejna M, Lammer J. Malignant biliary obstruction: treatment with ePTFE-FEP-covered endoprostheses initial technical and clinical experiences in a multicenter trial. Radiology 2002; 225:35-42. 7. Miyayama S, Matsui O, Akakura Y, Yamamoto T, Nishida H, Yoneda K, Kawai K, Toya D, Tanaka N, Mitsui T, Asada Y. Efficacy of covered metallic stents in the treatment of unresectable malignant biliary obstruction. Cardiovasc Intervent Radiol 2004; 27:349-354. 8. Schmassmann A, von Gunter E, Knuchel J, Scheurer U, Fehr HF, Halter F. Wallstents versus plastic stents in malignant biliary obstruction: effects of stent patency of the first and second stent on patient compliance and survival. Am J Gastroenterol 1996; 91:654-669. 9. Killeen RP, Harte S, Maguire D, Malone DE. Achievable outcomes in the management of proximal cholangiocarcinoma: an update prepared using “evidence-based practice” techniques. Abdom Imaging 2008; 33:54-57. 10. Bae JI, Park AW, Choi SJ, Kim HP, Lee SJ, Park YM, Yoon JH. Crisscross-configured dual stent placement for trisectorial drainage in patients with advanced biliary hilar malignancies. J Vasc Interv Radiol 2008; 19:1614-1619. 11. Lee MJ, Dawson SL, Mueller PR, Saini S, Hahn PF, Goldberg MA, Lu DS, Mayo-Smith WW. Percutaneous managment of hilar biliary malignancies with metallic endoprostheses: results, technical problems, and causes of failure. Radiographics 1993; 13:12491263. 12. Inal M, Akgul E, Aksungur E, Seydaoglu G. Percutaneous placement of biliary metallic stents in patients with malignant hilar obstruction: unilobar versus bilobar drainage. J Vasc Interv Radiol 2003; 14:1409-1416. 13. Cowling MG, Adam AN. Internal stenting in malignant biliary obstruction. Word J Surg 2001; 25:355-359. 14. van Delden OM, Laméris JS. Percutaneous drainage and stenting palliation of malignant bile duct obstruction. Eur Radiol 2008:448-456. 15.Lawson AJ, Benignfield SJ, Krige JEJ, Rischbieter P, Burmeister S. Percutaneous transhepatic self-expanding metal stents for palliation of malignant biliary obstruction. S Afr J Surg 2012; 50:54-60.

Abstract Book 16. George C, Byass OR, Cast JEI. Interventional radiology in the management of malignant biliary obstruction. World J Gastrointest Oncol 2010; 2:146-150. 17. Karnabatidis D, Spiliopoulos S, Katsakiori P, Romanos O, Katsanos K, Siablis D. Percutaneous trans-hepatic bilateral biliary stenting in Bismuth IV malignant obstruction. World J of Hepatol 2013; 5:114-119. 18. Liu F, Zhang CQ, Wang GC, Liu FL, Xu HW, Xu L, Feng K. Percutaneous biliary stent placement in palliation of malignant bile duct obstruction. Gastroenterol Res 2009; 2:289-294.

3203.2 Treatment of benign strictures, including roux loop approach M. Krokidis Department of Radiology, Cambridge University Hospitals, Cambridge, United Kingdom Learning Objectives 1. To learn about percutaneous treatments of benign strictures and approaches 2. To understand success and potential complication rates 3. To understand proper patient selection Postoperative benign biliary strictures may occur as anastomotic strictures after surgical bile duct repair or liver transplantation, strictures secondary to intraoperative injury (most commonly during laparoscopic cholecystectomy) or postoperative inflammatory strictures [1]. An effective management is necessary in such cases in order to avoid serious consequences like liver function deterioration, cholangitis, jaundice, abscess formation and sepsis [1]. An endoscopic treatment is the optimal initial management for benign biliary strictures; however, the endoscopic approach is impossible for patients who have previously undergone biliodigestive anastomosis [2] and may be very difficult in tight low biliary strictures [3]. In such cases, a percutaneous treatment with balloon dilation with or without long-term biliary drainage and bare or covered stent placement have been suggested as possible alternatives [2, 4-8]. The clinical presentation of postoperative benign biliary stenosis may be divided into an early and late phase. The early phase is usually secondary to an acute obstruction of the bile duct and becomes clinically evident with an increased jaundice and alteration of liver function tests. Fever and infection may not be present, but may appear later. The main indications for a percutaneous treatment of a postoperative benign biliary stricture are: a. patient’s poor general condition that does not permit another surgical intervention, b. the presence of altered anatomy that does not permit the endoscopic approach and c. septic status that requires a quick approach for decompression of the biliary tree. The main contraindication is the presence of non-correctable bleeding disorder. The treatment goals should be to improve and maintain bile duct patency as well to prevent stricture recurrence through a minimally invasive procedure. In the last 30 years, the percutaneous treatment of benign biliary strictures with balloon dilatation and stenting has been widely accepted as a valid therapeutic option with an acceptable complication rate [9]. Balloon dilation is usually performed with 8- or 10-mm wide and 2–4 cm long balloons. The size of the balloon is related to the type and location of stenosis: a l0-mm balloon is generally used for common bile duct stenosis, while for lesions located in the intrahepatic ducts, 6- to 8-mm balloons may be selected. In case of biliary-enteric stenosis, anastomoses is useful in performing dilation using a larger balloon varying from 10 to 20 mm in diameter; high-pressure balloons may also be used and be inflated up to 22 atm. Dilation needs to be slow and progressive in order to avoid laceration of the duct and massive bleeding into the biliary system, and it may be repeated several times, particularly, in case of fibrotic stenosis. The type of stricture is important in defining the response from dilation. In the

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CIRSE 2014 case of orthotopic liver transplantation, anastomotic strictures appear to have a better response when compared with non-anastomotic strictures that are caused by ischemic injury [10, 11]. References 1. Judah JR, Draganov PV (2007. Endoscopic therapy of bening biliary strictures. World J Gastroenterol 13:3531–3539. 2. Weber A, Rosca B, Neu BRösch T, Frimberger E, Born P, Schmid RM, Prinz C (2009. Long-term follow-up of percutaneous transhepatic biliary drainage (PTBD. in patients with benign bilioenterostomy stricture. Endoscopy 41:323–328. 3. Kim JH, Ko GY, Sung KB, Yoon HK, Gwon DI, Kim KR, Lee SG (2008. Bile leak following living donor liver transplantation: clinical efficacy of percutaneous transhepatic treatment. Liver Transpl 14:1142–1149. 4. Ko GY, Sung KB, Yoon HK, Kim KR, Gwon DI, Lee SG (2008. Percutaneous transhepatic treatment of hepaticojejunal anastomotic biliary strictures after living donor liver transplantation. Liver Transpl 14:1323–1332. 5. Kim ES, Lee BJ, Won JY, Choi JY, Lee DK (2009. Percutaneous transhepatic biliary drainage may serve as a successful rescue procedure in failed cases of endoscopic therapy for a post-living donor liver transplantation biliary stricture. Gastrointest Endosc 69:38–46. 6. Gwon DI, Shim HJ, Kwak BK (2008. Retrievable biliary stent-graft in the treatment of benign biliary strictures. J Vasc Interv Radiol 19:1328–1335. 7. Petersen BD, Timmermans HA, Uchida BT, Rabkin JM, Keller FS (2000. Treatment of refractory benign biliary stenoses in liver transplant patients by placement and retrieval of a temporary stent-graft: work in progress. J Vasc Interv Radiol 11(7):919–929. 8. Vellody R, Willatt JM, Arabi M, Cwikiel WB (2011. Temporary placement of stent grafts in postsurgical benign biliary strictures: a single center experience. Korean J Radiol 12(6):708–713. 9. Mueller PR, vanSonnenberg E, Ferrucci JT Jr, Weyman PJ, Butch RJ, Malt RA, Burhenne HJ (1986. Biliary stricture dilatation: multicenter review of clinical management in 73 patients. Radiology 160(1):17–22. 10. Pascher A, Neuhaus P (2005. Bile duct complications after liver transplantation. Transpl Int 18:627–642. 11. Krokidis M, Orgera G, Rossi M, Matteoli M, Hatzidakis A (2013. Interventional radiology in the management of benign biliary stenoses, biliary leaks and fistulas: a pictorial review. Insights Imaging 4(1):77–84.

3203.3 Percutaneous treatment of bile duct stones P.A.M.S. Almeida1, B. Gonçalves2 1Serviço de Imagiologia, Hospital de Sao Teotónio, Viseu, Portugal, 2Interventional Radiology, IPO Porto, Porto, Portugal Learning Objectives 1. To learn about percutaneous treatments of bile duct stones 2. To understand success and potential complication rates 3. To understand proper patient selection In patients presenting with jaundice, pain in the upper right quadrant, and fever probably indicating cholangitis and/or in those that have been submitted to surgery of the hepatobiliary system, it is mandatory to exclude the presence of biliary stones as the underlying cause of such symptoms. Medical treatment consists of managing complications of possible bile duct strictures until definitive therapy can be instituted. Most patients who present with cholangitis have a response to antibiotics and supportive management. Antibiotic therapy should be effective against Escherichia coli and Klebsiella, Enterococcus, Proteus, Bacteroides, and Clostridium species that are the most common underlying causal organisms.

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Approximately 70–80% of patients’ conditions responds to medical therapy and do not need urgent intervention. What is clear is that when ductal stones do become symptomatic the consequences are often serious and can include pain, partial or complete biliary obstruction, cholangitis, hepatic abscesses, or pancreatitis. Whatever the underlying cause might be, chronic obstruction leads to stasis and bile infection, primary conditions that favour stone formation and that contribute initially to fibrosis and later to secondary biliary cirrhosis and portal hypertension. So patients not having a response to empiric antibiotic therapy within 24 hours should be considered for immediate biliary decompression percutaneously or endoscopically depending on access and previous surgery. A direct surgical intervention should be considered as the ultimate solution. Proper imaging techniques should make every effort to visualize the biliary tree in patients who are jaundiced, with appropriate use of noninvasive and invasive techniques. Sonography and/or MRCP should be used to demonstrate the presence of stones and to exclude the presence of dilatation due to stenosis after an anastomotic stricture: · liver transplant · nontransplant choledochoenterostomy · iatrogenic postoperative injury (cholecystectomy, anatomical variants, etc.) · ischemic, including post liver transplant biliary lesions · inflammatory (sclerosing cholangitis) Treatment of the underlying cause is the objective of medical treatment of biliary stones. Primary stones are more common in southeastern Asian populations and have different compositions than secondary stones, and may be a consequence of biliary infection and stasis. Percutaneous treatment has been described as an alternative or adjunct to other forms of stone extraction. It is recommended that if facilities and expertise are available then its use should be considered when standard endoscopic treatment fails or is considered inappropriate. If biliary obstruction is demonstrated, the immediate imperative will be to provide adequate biliary drainage and this may be temporarily achieved by the use of an internal stent or internal/external biliary drain. Percutaneous access to the biliary system should be done with a common micropuncture triaxial introducing system. It can also be obtained using an established T-tube tract or introducer sheaths via the gallbladder. At the same time, percutaneous cholangiography can also provide useful diagnostic information. Once decompression is obtained by temporary insertion of a biliary drainage with recovering of the patients’ status, one should plan the intervention for better getting read of the stones. This may include selection of the best path to access the stones, choice of the adequate balloon dilatation, and appropriate balloon occlusion catheters. In order to have the best flush of the biliary tree, pigtail catheters might be also needed. Using Dormia-type baskets and “grasping devices” as well as bounded guidewires, we can remove, break, or push forward the stones into the gut. Other procedures such as overdilatation of the ampulla or use of a percutaneous endoscope insertion may be needed as per the case. Other methods include the following: - extracorporeal shockwave lithotripsy that may be used as an adjunct to oral dissolution therapy. By increasing the surface-tovolume ratio of the stones, it enhances the dissolution of stones as well as makes clearing of the smaller fragments easier. - lithotripsy is associated with a 70% recurrence rate for gallstones, is not approved by the US Food and Drug Association, and is restricted to investigational programs only.

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To prevent recurrent stenosis, a percutaneous catheter may be left in place for 8–12 weeks. In case of repeated/recurrent stenosis, retrievable covered stents and biodegradable stents are a proven valuable option. After stone extraction, ursodeoxycholic acid (10 mg/kg/day) works to reduce biliary secretion of cholesterol. In turn, this decreases the cholesterol saturation of bile. In 30–40% of patients, this results in the gradual dissolution of cholesterol-containing stones. However, in 50% of patients, stones may recur within 5 years once the drug is stopped. The role of the interventional radiologist is crucial, but only achieved with expertise in biliary percutaneous interventions in order to avoid potential complications and to properly treat these patients.

References

References

N. Ptohis Radiology, Attikon University Hospital, Athens, Greece

1. Mauri G et al. Biodegradable biliary stent implantation in the treatment of benign bilioplastic-refractory biliary strictures: preliminary experience. Eur Radiol 2013; 23:3304–10. 2. Hatzidakis A et al. Percutaneous removal of biliary calculi. Cardiovasc Interv Radiol 2009; 32:1130–8. 3. Gandini G et al. Percutaneous removal of biliary stones. Cardiovasc Interv Radiol 1990; 13:245–51. 4. Righi D et al. Role of interventional radiology in the treatment of biliary strictures following orthotopic liver transplantation. Cardiovasc Interv Radiol 2002; 25:30–35. 5. Neuhaus H et al. Randomized study of intracorporeal laser lithotripsy versus extracorporeal shock-wave lithotripsy for difficult bile duct stones. Gastrointest Endosc 1998; 47:327–34. 6. Bonnel DH et al. Common bile duct and intrahepatic stones: results of transhepatic electrohydraulic lithotripsy in 50 patients. Radiology 1991; 124:345–8. 7. Sato M et al. A case of complex hepatolithiasis successfully treated with a systematic approach. Hepatogastroenterology 1999; 46:3083–6. 8. Zanon E et al. Percutaneous transhepatic sphincterotomy – a report on 3 cases. Endoscopy1991; 23:25–8. 9. Moon JH et al. The role of percutaneous transhepatic papillary balloon dilation in percutaneous choledochoscopic lithotomy. Gastrointest Endosc 2001; 54:232–6. 10. Gil S et al. Effectiveness and safety of balloon dilation of the papilla and the use of an occlusion balloon for clearance of bile duct calculi. Am J Roentgenol 2000; 174:1455–60. 11. Chen MF et al. Percutaneous transhepatic cholangioscopic lithotripsy. Br J Surg 1990; 77:530–2. 12. Neuhaus H. Endoscopic and percutaneous treatment of difficult bile duct stones. Endoscopy 2003; 35:S31–4.

3203.4 Percutaneous cholecystostomy and gallbladder stone management J. Phillips-Hughes Radiology, John Radcliffe Hospital, Oxford, United Kingdom Learning Objectives 1. To become familiar with the imaging techniques 2. To learn how to manage and avoid complications 3. To understand proper patient selection Percutaneous cholecystostomy is now a well-recognised treatment option for acute cholecystitis, particularly in acutely unwell patients who are considered unfit for emergency surgery. Here we will look at the evidence base for cholecystostomy both with and without subsequent cholecystectomy, options and approach for gallbladder drainage and extension of the procedure to include stone removal.

1. Percutaneous cholecystostomy: the radiologist’s role in treating acute cholecystitis. Little MW, BriggsJH, Tapping CR, Bratby MJ, Anthony S, Phillips-Hughes J, Uberoi R Clin Radiol 2013 Jul;68(7):654-60.

Special Session IVC filters 3301.1 Current evidence

Learning Objectives 1. To learn the evidence for IVC filtration 2. To learn the evidence for early filter removal 3. To learn if there are still indications for permanent filters Venous thromboembolism (VTE) is the third most common disease of the cardiovascular system. It is associated with a 30-day mortality of approximately 6% for deep vein thrombosis and 12% for pulmonary embolism (PE). The rate of thromboembolism is particularly high in trauma patients, intensive care unit (ICU) patients, certain surgical populations, and cancer patients. The preferred method of both treatment and prophylaxis for VTE is anticoagulation. However, in a subset of patients, anticoagulation therapy is contraindicated or ineffective, and these patients often receive an inferior vena cava (IVC) filter. The sole purpose of an IVC filter is prevention of clinically significant PE. There are various guidelines with sometimes controversial recommendations regarding the use of IVC filters. The American College of Chest Physicians (ACCP) and American College of Radiology (ACR)/Society of Interventional Radiology (SIR) have each published evidence-based guidelines for the placement of IVC filters. ACCP recommends the placement of an IVC filter in patients with acute proximal DVT or PE if anticoagulant therapy is not possible because of the risk of bleeding. Importantly, ACCP does not recommend IVC filters as primary prophylaxis for any patient group. It is estimated that approximately half of all filters placed are consistent with these guidelines. ACR/SIR (2010) practice guidelines divide indications for filter placement into therapeutic and prophylactic. Therapeutic guidelines mirror ACCP recommendations with several additions, including the failure of or inability to achieve/maintain adequate anticoagulation, free-floating central venous thrombus, massive PE with residual DVT, and severe cardiopulmonary disease with VTE. Prophylactic indications occur in patients without VTE but who are at increased risk of PE and cannot receive effective primary prophylaxis (i.e., anticoagulation or compression stockings). Prophylactic indications are often seen in the setting of severe trauma or prior to major surgery. SIR also recognizes indications for the placement of retrievable filters; specifically VTE with transient inability to anticoagulate, PE prophylaxis in high-risk patients, and caval filtration in children. Relative contraindications to IVC filter placement are rare: uncorrectable severe coagulopathy and bacteremia are two specific relative contraindications. The use of retrievable filters in the prophylactic setting is largely responsible for the overall increase in number of filters placed. In 1999, 19% of filters were placed for prophylaxis. Today, prophylactic indications account for >50% of all filter placements. A study by Kim et al documented a dramatic shift toward the use of retrievable filters; 86.7% of filters placed in 2006 were retrievable versus 10.7% placed in 2002. It should be noted, however, that many of these retrievable design filters may have been placed for permanent filter indications. This shift toward retrievable filters together with a relaxation of thresholds for placement, including prophylaxis, is important in understanding

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the overall growth in the IVC filter market. Overall, the use of IVC filters, especially in prophylactic situations, will remain controversial until randomized studies are performed. The two basic IVC filter types are permanent and nonpermanent. Permanent filters have been available for approximately the past 35 years. Nonpermanent filters were developed to reduce the longterm complications of permanent filters, notably the increased risk of DVT. There are two primary subgroups of nonpermanent filters: temporary filters, which must be retrieved, and retrievable (or optional) filters, which can be retrieved. There is a subtype of retrievable filters - convertible filters - which can be structurally altered after implantation to no longer function as filters. Therefore, the filter is not removed, but the filtering capacity is eliminated by a percutaneous catheter-based procedure. IVC filters can be retrieved with a high overall success rate (98.2%) and a low complication rate (1.7%) using advanced techniques when the routine approach has failed; however, the use of advanced techniques is associated with a significantly higher complication rate. The preferential use of retrievable versus permanent devices for filter placement is financially advantageous for an IR unit only if at least 41% of them are eventually removed. The use of clinical criteria to select device type allows significant cost savings. The life expectancy of the patients is such that the potential benefit of filter removal can be considered. Patients who are not anticipated to survive beyond 6 months are unlikely to have any real benefit from filter retrieval or conversion. As a matter of principle, all IVC filters should be removed as soon as adequate anticoagulation can be established. In clinical practice, many optional filters often become permanent as a result of changes in the patient’s clinical status. The period of highest risk for PE in patients undergoing therapeutic anticoagulation for VTE cannot be precisely defined because of the heterogeneity of published studies. Patients with established VTE should not have clinical or objective evidence of failure or a complication of primary therapy before filter retrieval. These situations warrant continued caval filtration, perhaps even permanently. References 1. Francis CW. Clinical practice. Prophylaxis for thromboembolism in hospitalized medical patients. N Engl J Med. 2007;356(14):1438-44. 2. Molvar C. Inferior vena cava filtration in the management of venous thromboembolism: filtering the data. Semin Intervent Radiol. 2012;29(3):204-17. 3. Al-Hakim R, Kee ST, Olinger K, Lee EW, Moriarty JM, McWilliams JP. Inferior vena cava filter retrieval: effectiveness and complications of routine and advanced techniques. J Vasc Interv Radiol. 2014. 4. Janne d’Othée B, Faintuch S, Reedy AW, Nickerson CF, Rosen MP, Kaufman J, Kinney T, Streiff M, et al. Retrievable versus permanent caval filter procedures: when are they cost-effective for interventional radiology? J Vasc Interv Radiol. 2008;19:384-92. 5. Kaufman JA, Kinney TB, Streiff MB, Sing RF, Proctor MC, Becker D, Cipolle M, Comerota AJ, Millward SF, Rogers FB, Sacks D, Venbrux AC. Guidelines for the use of retrievable and convertible vena cava filters: report from the society of interventional radiology multidisciplinary consensus conference. J Vasc Interv Radiol. 2006;17:449-59. 6. Mahnken AH. [Vena cava filter. Which indications remain in the era of differentiated anticoagulation?]. Radiologe. 2013;53:209-15.

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3301.2 Unusual locations for IVC filter placement A.C. Roberts Dept. of Radiology, UCSD Medical Center, Thornton Hospital, La Jolla, CA, United States of America Learning Objectives 1. To learn the indications for supra-renal placement 2. To learn if superior vena cava placement is a suitable option 3. To learn if there are indications for the use of filters in children No abstract available.

3301.3 Complications of IVC filter placement T.B. Kinney Department of Radiology, UCSD Medical Center, San Diego, CA, United States of America Learning Objectives 1. To describe filter complications and their occurrence 2. To learn the mechanisms of filter complications 3. To learn how to avoid filter complications Successive generations of IVC filters have improved performance characteristics and insertion techniques. With the development of filters that have the option to be left in place indefinitely or be removed, the threshold to place IVC filters has apparently reduced so that ever increasing numbers of IVC filters are inserted. The device manufacturers have provided us with a wide diversity of IVC filters based on this increased demand. The subject of IVC filter insertion is limited by the lack of strong evidence-based practice. In 2014, even after 50 years of IVC filter use, it is difficult to present convincing evidence that it reduces mortality in patients who undergo IVC filter insertion. Adding to the confusion is that no less than four societies have offered varying criteria for the insertion of IVC filters. The ability to retrieve filters results in changed design parameters, which may herald complications not commonly seen with earlier generation permanent IVC filter designs. These complications include filter migration, perforation, fracture, complications of retrieval, and recurrent pulmonary embolism after filter retrieval. In a small number of cases, the filter is unable to be retrieved, which may be perceived by the patient as a complication and potential source for patient anxiety. Another issue raised by the PREPIC study is the feeling that anticoagulation is necessary during IVC filter indwell. The lack of adequate follow-up and IVC retrieval have also been recognized as issues. Because of certain instances of reported complications and this perceived lack of follow-up and IVC filter retrieval, FDA announced in 2010 that all filters should be considered for retrieval as soon as protection from PE is no longer needed. Complications of IVC filter placement include technical insertion problems; erroneous placement of IVC filters, which do not adequately protect from pulmonary embolism; and poor device choice for specific patient circumstances. Awareness of important venous anomalies, review of any available cross-sectional imaging studies before IVC filter insertion, and use of redundancy in IVC filter placement during the procedure will be discussed as methods to mitigate preventable complications during IVC filter insertion. It is hoped that PREPIC II will provide more evidence for the practice of retrievable IVC filter insertion. References 1. Decousus H, Leizorovicz A, Parent F, et al. A clinical trial of vena caval filters in the prevention of pulmonary embolism in patients with deep-vein thrombosis. N Engl J Med 1998; 338:409-16. 2. Kinney TB. Update on inferior vena cava filters. J Vasc Interv Radiology 2003; 14:425-40.

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3. Prepic study group. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d’Emboli Pulmonaire par Interruption Cave. randomized trial. Circulation 2005; 112:416-22. 4. Kaufman JA, Kinney TB, Streif MB, et al. Guidelines for use of retrievable and convertible vena cava filters: report from the Society of Interventional Radiology multidisciplinary consensus conference. J Vasc Interv Radiol 2006; 17:449-59. 5. Ray CE, Prochazka A. The need for anticoagulation following inferior vena cava filter placement:systemic review. Cardiovasc Interv Radiol 2008; 31:316-24. 6. Weinberg I, Kaufman J, Jaff MR. Inferior vena cava filters. J Am Coll Cardiol Intv 2013; 6:539-47.

Abstract Book tissue with a laser sheath can be used to free up the filter before retrieval. A completely different challenge is the lack of a suitable access of an upper extremity vein to reach the tip of the filter. In such circumstances, case reports have described using a transfemoral approach to pull the filter down into an iliac vein before retrieval from the other side or even a transhepatic venous approach to get to the top of the filter. Conclusion: The lecture should provide the advanced IR with ideas on how to retrieve a filter even if standard techniques are not successful. However, it is important to remember that optional filters are also permanent devices, and therefore, do not have to be removed at any cost. A good judgement to balance risk and benefit remains the key. References

3301.4 Difficult IVC filter retrieval C.A. Binkert Interventional Radiology, Kantonsspital Winterthur, Winterthur, Switzerland Learning Objectives 1. To learn how to perform difficult retrievals 2. To learn when to stop difficult procedures 3. To learn different techniques for difficult procedures Background: Inferior vena cava (IVC) filters help to prevent pulmonary embolism. However, the PREPIC trial has shown that although IVC filter reduces pulmonary embolism, they have long-term drawbacks, namely increased deep vein thrombosis and a high chance of venous insufficiency. Therefore, the concept of optional filters was adopted, which suggests the retrieval of the IVC filter when the indication of caval filtration is no longer present. Most optional or retrievable IVC filters have a simple process to be removed. Unfortunately, the standard retrieval is not always possible. The most common reason of a retrieval failure using standard technique is a filter tilted against the caval wall. Other problems are filters that are grown into the caval wall and can not be retrieved with regular force and technique. Nevertheless, the question is how to get these IVC filters out. Different retrieval techniques: Over the years, several non-standard retrieval techniques have been described using different approaches. One general advice is to go big when things become difficult, because a large access (16 F) provides many options, and upsizing during retrieval is at least cumbersome and sometimes not really possible. The simplest non-standard retrieval is to get the tip of the filter away from the caval wall. This can be performed either with a balloon, or a curved sheath, or a tip-deflecting wire or simply by steering a wire between the filter tip and the caval wall. Once the tip is away from the wall, standard techniques can be applied. However, sometimes the tip of the filter penetrates into the caval wall and need to be freed. One possibility is to use an endobronchial forcep in order to get a grasp on the tip of the filter. Obviously, great care has to be taken in order not to cut a hole into IVC. A little less aggressive approaches are the different loop-snare techniques. In principle, a loop is created around the tip of the filter using a reverse-shaped catheter and a long guidewire. The tip of the wire is then snared above the filter. Further, the created loop is pulled around the filter tip and finally into the sheath. The advantage of the loop-snare technique is that it can be abandoned nearly at any time without a danger to the patient. In some cases, the problem is not only the tilted filter, but an ingrowth of the filter into the caval wall. Pulling a little harder is one option, but the question is obviously how hard can you pull. In special cases, a controlled photothermal ablation of the filter-adherent

1. Circulation. 2005 Jul;112(3):416-22. Eight-year follow-up of patients with permanent vena cava filters in the prevention of pulmonary embolism: the PREPIC (Prevention du Risque d’Embolie Pulmonaire par Interruption Cave. randomized study. PREPIC Study Group. 2. J Vasc Interv Radiol. 2009 Sep;20(9):1210-4. Balloon-assisted removal of tilted inferior vena cava filters with embedded tips. Lynch FC. 3. J Vasc Interv Radiol. 2004 Jun;15(6):645-7. Difficult retrieval of a recovery IVC filter. Hagspiel KD, Leung DA, Aladdin M, Spinosa DJ, Matsumoto AH, Angle JF. 4. J Vasc Interv Radiol. 2008 Sep;19(9):1297-301. Embedded inferior vena cava filter removal: use of endobronchial forceps. Stavropoulos SW1, Dixon RG, Burke CT, Stavas JM, Shah A, Shlansky-Goldberg RD, Trerotola SO. 5. J Vasc Interv Radiol. 2007 Oct;18(10):1315-8. Loop-snare technique for difficult inferior vena cava filter retrievals. Rubenstein L, Chun AK, Chew M, Binkert CA. 6. J Vasc Interv Radiol. 2011 Jun;22(6):813-23. Photothermal ablation with the excimer laser sheath technique for embedded inferior vena cava filter removal: initial results from a prospective study. Kuo WT, Odegaard JI, Louie JD, Sze DY, Unver K, Kothary N, Rosenberg JK, Hovsepian DM, Hwang GL, Hofmann LV. 7. J Vasc Interv Radiol. 2005 Mar;16(3):391-4. Removal of Günther Tulip vena cava filter through femoral vein approach. Van Ha TG, Keblinskas D, Funaki B, Lorenz J. 8. J Vasc Interv Radiol. 2012 Jul;23(7):983-5. Transhepatic removal of an inferior vena cava filter. Hughes JA, Lynch FC.

Special Session Pre-, peri- and post IR patient care 3303.1 Pre-operative assessment and preparation K.S. Koulia Interventional Radiology, Metropolitan Hospital, Athens, Greece Learning Objectives 1. To learn about basic clinical exams 2. To learn about important co-morbidities 3. To understand the general information a patient should be aware of “It is much more important to know what sort of patient has a disease than what sort of disease a patient has” William Osler (1849–1919). Interventional radiology comprises invasive diagnostic imaging as well as a wide range of minimally invasive image-guided therapeutic procedures. The organs amenable to image-guided diagnostic and therapeutic procedures may involve any part of the human body,

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including the vascular, gastrointestinal, hepatobiliary, genitourinary, pulmonary, musculoskeletal, and the central nervous system. The extensive range of clinical scenarios that we confront as interventional radiologists makes preoperative assessment and preparation of our patients variable. Nonetheless, some general rules may apply for the majority of patients. Preoperative assessment and preparation are undoubtedly cornerstones of good practice. The goals are to set the indication for the procedure, to optimize patient’s condition, to minimize patient anxiety and obtain informed consent, and to develop an appropriate procedure and analgesia plan. Any special needs of the patient (e.g., language translator) must also be met. Key elements of pre-procedure assessment are evaluation and information. Proper evaluation is a comprehensive process that requires a careful initial review of the patient’s medical history. This process helps us reveal significant symptoms and their chronology and identify important co-morbidities and risk factors. Physical examination is equally important. A thorough physical examination should be completed from head to toe with concentration on anatomic areas that correlate with symptoms from the patient’s history. Vital signs as well as weight and height must always be recorded. Patient evaluation is supplemented by other clinical exams that include lab tests, ECG, and imaging studies. Lab tests to be conducted (tailor to specific procedure) include the following: hematology: CBC, Hct, and Hgb; coagulation status tests: platelets, PT, PTT, and INR; renal function tests: creatinine, BUN, GFR; liver function tests: bilirubin, albumin, ALP, AST, ALT, and GGT; blood chemistry tests: electrolytes, glucose, cholesterol, and CRP; viral hepatitis tests; and tumor markers. ECG is indicated for all patients with a history of cardiac disease and those undergoing a procedure that is likely to affect cardiac output or cause arrhythmia. Imaging tests vary according to the disease and include ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography. After patient evaluation and once the indication for an invasive diagnostic procedure or a therapeutic intervention has been set, the patient must be properly prepared. Bearing in mind the patient’s comorbidities and medication, we take the appropriate measures to ensure a safe and successful procedure. Important co-morbidities that need to be addressed to are diabetes, renal impairment, hypertension, heart failure, bleeding diathesis or anticoagulation, and history of anaphylactic reaction to intravascular contrast. Diabetes: non insulin-dependent diabetic patients should stop metformin at the time of any procedure involving intravascular iodinated contrast and should not restart until renal function has been checked 48 hours after the procedure. This is a precaution to avoid an unlikely but potentially fatal complication - lactic acidosis. Some patients will need to take insulin to control their diabetes over this period. Insulindependent diabetic patients should take their long-acting insulin as usual but omit the short-acting insulin if they are scheduled early in the morning. If they are scheduled later in the day, they should omit the short-acting insulin and halve the dose of the long-acting insulin. A 5% dextrose solution should be infused to provide 5–10 g/h of glucose. Renal impairment: contrast-induced nephropathy is reported to be the third most common cause of acute renal failure in hospitalized patients. The risk of contrast-induced nephropathy is highest in patients with chronic kidney disease (i.e., a GFR of less than 60 mL / minute / 1.73 m2), especially in the presence of diabetes. Other risk factors include dehydration, heart failure, age older than 70 years, and concurrent use of nephrotoxic drugs. The most important factor in protecting renal function is ensuring adequate hydration. The evidence for other regimens such as N-acetylcysteine is weak, but this regimen is relatively innocuous and can be administered as 600 mg PO pre- and post-procedure. Medication predisposing to nephrotoxicity (e.g., NSAIDS and ACE-Is) should be stopped if possible.

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Hypertension: this condition increases the rate of complications (e.g., cerebral infarction and hematoma). Patients should take any antihypertensive medication as usual. If they remain hypertensive during the procedure, they can be given 10 mg of nifedipine. Sedation and analgesia may also help blood pressure control. Heart failure: the patient’s condition should be optimized before angiography. Anticoagulation: patients on warfarin should discontinue it at least 3 days before the procedure. INR should be checked the day of the procedure. An INR of 1.5 or less is desirable. In case warfarin cannot be discontinued, e.g., if there is a mechanical heart valve, it should be converted to heparin a few days before the procedure. If the procedure is very urgent, the patient must be given fresh frozen plasma and a closure device may be used at the end of the procedure. Another regimen for the immediate reversal of warfarin is dried prothrombin complex (Beriplex). Patients on heparin should discontinue it 3 hours before the procedure. Regarding aspirin, there is no agreement on whether or not it requires cessation before interventional radiology procedures. Clopidogrel is usually not possible to discontinue in patients with coronary stents. In some cases, antiplatelet therapy or even double antiplatelet therapy is prescribed to patients before specific interventions, e.g., carotid stenting. Bleeding diathesis: patients with abnormal INR, e.g., liver disease, should be given vitamin K unless the procedure is urgent in which case they should be given fresh frozen plasma. Patients with low platelet count and clotting factors impairment require platelet and clotting factors transfusion. History of anaphylactic reaction to intravascular contrast: each department has a protocol for this situation. Patients should be pretreated with steroids and antihistamines. Before proceeding to any interventional radiology procedure, written informed consent is required. Patients must be provided with sufficient information in order to make informed decisions. A qualified doctor who understands the risks and side effects of the procedure should be responsible for obtaining informed consent. The patients must be updated about the purpose of the procedure; its general nature including analgesia, sedation, and aftercare; its anticipated outcome (technical and clinical success rates); and its common and serious side effects, including their management. Alternative therapeutic options should also be explained to the patients. If any questions arise, the doctor should explain in a comprehensive manner. The patients must not be pressured in any way, and the fact that they are entitled to change their mind or seek a second opinion at any time should be stressed. In some instances, informed consent is extremely difficult or impossible to obtain from the patient. In such cases, a relative may give consent. If in doubt, you should seek legal advice. In cases of emergencies, if you have not obtained informed consent, you may only provide whatever medical treatment is necessary to save life or prevent significant deterioration in the patient’s condition. References 1. Lee MJ, Fanelli F, Haage P, Hausegger K, van Lienden KP. Patient safety in interventional radiology: A CIRSE IR Checklist. Cardiovasc Intervent Radiol. 2012 Apr;35(2):244-246. 2. Corso R, Vacirca F, Patelli C, Leni D. Use of “Time-Out” checklist in interventional radiology procedures as a tool to enhance patient safety. Radiol Med. 2014 Mar 21. [Epub ahead of print]. 3. Payne CS. A primer on patient management problems in interventional radiology. AJR Am J Roentgenol. 1998;170:1169-1176. 4. Donald L. Miller. Safety in interventional radiology. JVIR. 2007 Jan;18(1):1-5.Drug-Induced Nephrotoxicity. 5. Cynthia A. Naughton. Drug-induced nephrotoxicity. Am Fam Physician. 2008 Sep 15;78(6):743-750. 6. Borgstede JP, Zinninger MD. Radiology and patient safety. Acad Radiol. 2004;11:322-3326.

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7. Bellomo R. The epidemiology of acute renal failure: 1975 versus 2005. Curr Opin Crit Care. 2006;12(6):557-560. 8. David Kessel, Iain Robertson.(Third edition-2011). Interventional Radiology-A survival guide; Churchill Livingstone Elsevier. 9. Lee, Watkinson (2010). Handbook of Angioplasty and Stenting Procedures; Springer. 10. Mauro et al (2008). Image-guided Interventions; Saunders Elsevier. 11. Kandarpa, Aruny.Fourth edition (2011). Handbook of Interventional Radiologic Procedures; Lippincott Williams and Wilkins.

3303.2 IR relevant sedation and analgesia techniques A. Vari Department of Surgery “Pietro Valdoni”, Sapienza University School of Medicine, Rome, Italy Learning Objectives 1. To understand the difference between sedation and analgesia 2. To learn about the different levels of sedation (light, moderate and deep) 3. To learn how to deal with overdosing (antidotes) Sedation and analgesia for interventional radiology (IR) procedures is safe and effective as well as has facilitated continuous expansion of the scope of this subspecialty, worldwide. Moderate-to-deep sedation provides optimal analgesia and anxiolysis for the vast majority of IR procedures. By reducing the level of consciousness, it enhances patient cooperation and immobility, provides amnesia, and allows an effective control of sympathetic reflexes (tachycardia, hypertension) ultimately realizing safe and optimal procedural conditions for the interventionalist(1). The increasing pressure on healthcare cost containment and the need to reduce hospital overcrowding have led to a widespread use of day care as an effective quality approach also for IR procedures. IR patients need to be kept stress-free, painless, immobile, and cooperative during the procedure, but their recovery has to be short to allow a fast and safe discharge. In this light, sedation techniques have gained a great popularity over general anesthesia for IR procedures. Sedation and analgesia describes a pharmacologically controlled state of depressed consciousness that allows protective reflexes to be maintained. The patient retains the ability to independently maintain his or her airway and to respond purposefully to verbal commands and/or tactile stimulation. The American Society of Anesthesiologists (ASA) Task Force on Sedation and Analgesia stated that “sedation and analgesia describes a state that allows patients to tolerate unpleasant procedures while maintaining adequate cardiorespiratory function and the ability to respond purposefully to verbal command and tactile stimulation.” The ASA task force decided that the term sedation and analgesia more accurately defines this therapeutic goal than does the more commonly used but imprecise term of “conscious sedation,” largely used in the past. Those patients whose only response is reflex withdrawal from a painful stimulus are sedated to a greater degree than encompassed by sedation and analgesia(2). The Joint Commission on Accreditation of Healthcare Organizations (JACHO) has introduced to its standards definitions for four levels of sedation and anesthesia. Minimal sedation, in which the patient responds normally; moderate sedation/analgesia (conscious sedation), in which airway and cardiovascular function is maintained; deep sedation/analgesia, in which the patient is not easily aroused; and anesthesia, in which the patient requires assisted ventilation. Sedation and analgesia may easily be converted to deep sedation with loss of consciousness because of the agents used and the physical status and drug sensitivities of the individual patient. The

Abstract Book administration of sedation and analgesia requires constant monitoring of the patient and the ability of the administrator to respond immediately to any adverse reaction or complication. Vigilance of the administrator and the ability to recognize and intervene as event complications or undesired outcomes arise are essential requirements for individuals administering sedation and analgesia(3). The requirements for sedation and analgesia need to be individualized for each patient. An essential understanding is determined by ASA status, anxiety and pain tolerance levels, history of opioids and benzodiazepines use, anticipated pain that will be produced by a particular procedure, and estimated duration of the procedure itself(4). Sedation is a dynamic and complex process whose crucial phases are represented by patient assessment (medical history and physical examination with a special focus on airway), informed consent, peri-procedural monitoring and record, post-procedural recovery, and discharge. Different intravenous sedation strategies are currently available. Typically, a sedative (hypnotic) agent is used in combination with an analgesic (usually a major opioid), since they are synergistic in producing desired (as well as undesired) effects. Sedative and analgesic drugs are administered by continuous infusion or given in small incremental doses, titrated to their clinical effect. An appropriate dose reduction is applied for elder and debilitated patients. Peri-procedural pain management for the chronic pain and/or opioid-dependent patient undergoing sedation can be challenging. Further analgesic strategies as regional techniques (central and peripheral nerve blocks with or without catheters) and/or pre-emptive non-opioid analgesia are commonly used in addition to intravenous sedation/analgesia(5). Safe administration of any sedation/analgesia protocol is based on a thorough knowledge of the pharmacology of sedative and analgesic drugs (with their reversal agents); local anesthetics and adjunct medications; and a sound experience in managing the most common complications of sedation (ventilatory, cardiovascular, anaphylaxis), including competence in basic and advanced life support(6). Safety is a cornerstone of sedation in the IR suite: all necessary resuscitation equipment should be available and in working order. In addition, the use of checklists, a supportive staff, and a proactive team approach represent essential factors for safe and successful administration of procedural sedation/analgesia. During this lecture, the audience will - understand ASA/JACHO definitions of sedation and their clinical implications - review basic pharmacology principles of sedatives and analgesics - focus on patient assessment, procedure selection, clinical relevance of essential monitoring, post-procedural recovery, and pain management - learn the most relevant sedation techniques in IR - deal with the most common complications of sedation and their management References 1. Patatas K, Koukkoulli A. The use of sedation in the radiology department. Clinical Radiology 2009; 64:655-663. 2. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists. An updated report by the American Society of Anesthesiology Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology 2002; 96(4):1004-1017. 3. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO): Comprehensive Accreditation Manual for Hospitals. Care of patients: Anesthesia Care Standards. 2002; TX15-17,TX 71-79. 4. Schupp CJ, Bernbaum K, Bernbaum M, Lang EV. Pain and anxiety during interventional radiologic procedures: effect of patients’ state anxiety at baseline and modulation of nonpharmacologic analgesia adjuncts. J Vasc Interv Radiol 2005; 16(12):1585-1592.

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5. Urman R, Kaye AD (Eds). Moderate and deep sedation in clinical practice. Cambridge University Press, New York, 2012. 6. Arepally A, Oechsle D, Kirkwood S, Savader SJ. Safety of conscious sedation in interventional radiology. Cardiovasc Interv Radiol 2001; 24:185-190.

3303.3 IR relevant locoregional techniques M.D. Stoneham Department of Anaesthetics, John Radcliffe Hospital, Oxford, United Kingdom Learning Objectives 1. To learn about different regional blocks 2. To learn about image guidance for locoregional blocks (incl. ultrasound) 3. To learn about complications of regional blocks Percutaneous IR techniques may be commonly performed using infiltration of local anaesthetic and do not commonly require specialised anaesthetic techniques. However, where access is more difficult or where surgical cutdown onto the vessel has to be performed, loco-regional techniques may be more appropriate. Regional anaesthetic techniques offer excellent analgesia and reduce the risks of general anaesthesia, which may be considerable in vascular patients with their considerable co-morbidities. Central neuroaxial blockade is the commonest loco-regional technique used for EVARs, either spinal anaesthesia, epidural or a combination of the 2 - combined spinal–epidural (CSE). Use of spinal/epidural anaesthesia in IR There is some evidence form large non-randomised series that patients undergoing EVAR under spinal, epidural or combined spinal–epidural anaesthesia have better outcomes in terms of reduced hospital stay and faster recovery.1 Although there is little randomised data available comparing choice of anaesthetic technique for EVAR patients, a recent meta-analysis of 10 studies comprising 13,459 patients given local (LA) or general anaesthesia (GA)2 showed no difference in 30-day mortality. The LA patients were older than the GA patients (WMD, 0.17; P = .006), with an increased burden of cardiac (LA vs GA: OR, 1.28; P = .011) and respiratory (LA vs GA: OR, 1.28; P = .006) comorbidity. However, LA EVAR was reported with shorter operative time (WMD, −0.54; P = .001) and hospital stay (WMD, −0.27; P = .001) and LA patients developed fewer post-operative complications (OR, 0.54; P < .001). There is some evidence that ruptured AAA may be better treated with EVAR rather than open repair. 3 Although the results of the IMPROVE trial have not been reported yet, a recent analysis of patients in the IMPROVE trial has been published showing lower mortality with the use of local anaesthesia rather than general. 4 Complications of spinal and epidural anaesthesia · Headache (now rare due to pencil-point needles) · Hypotension · Neurological injury (rare) · Infection (very rare) · No evidence for chronic back pain · Headache due to accidental dural puncture · Failure Upper limb blocks Brachial plexus blocks may be used for some IR cases involving the upper limb, e.g. fistula formation. The brachial plexus may be blocked at any site along its course, including interscalene, supraclavicular and axillary routes, together with direct anaesthesia of the brachial plexus branches such as ulnar, musculocutaneous, median or radial branches. There has been a gradual change in the way that peripheral nerves are located: from the traditional anatomical methods used before 1990 to the use of a nerve stimulator to detect nerves by electrical stimulation with small milliamp currents.

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Ultrasound is now most commonly used to visualise the nerves, to guide placement of the needle adjacent to the nerve and to directly observe the administration of local anaesthetic agents around them.5,6 References 1. Edwards MS et al. Results of endovascular aortic aneurysm repair with general, regional, and local/monitored anesthesia care in the American College of Surgeons National Surgical Quality Improvement Program database. J Vasc Surg. 2011 Nov;54(5):1273-82. 2. Karthikesalingam A, Thrumurthy SG, Young EL, Hinchliffe RJ, Holt PJ, Thompson MM. Locoregional anesthesia for endovascular aneurysm repair. J Vasc Surg. 2012 Aug;56(2):510-9. 3. Antoniou GA et al. Endovascular repair for ruptured abdominal aortic aneurysm confers an early survival benefit over open repair. J Vasc Surg. 2013 Oct;58(4):1091-105. 4. IMPROVE trial investigators. Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm. Br J Surg. 2014 Feb;101(3):216-24. 5. Chin KJ, Alakkad H, Adhikary SD, Singh M. Infraclavicular brachial plexus block for regional anaesthesia of the lower arm. Cochrane Database Syst Rev. 2013 Aug 28;8:CD005487. 6. Koscielniak-Nielsen ZJ, Dahl JB. Ultrasound-guided peripheral nerve blockade of the upper extremity. Curr Opin Anaesthesiol. 2012 Apr;25(2):253-9.

3303.4 Post-interventional patient management T.J. Cleveland Radiology, Sheffield Vascular Institute; Northern General Hospital, Sheffield, United Kingdom Learning Objectives 1. To learn about the different categories of pain drugs 2. To learn how to assess post-interventional pain 3. To learn about the pros and cons of different application routes (po, iv, sc) For any interventional or open surgical procedure to be successful, the patient needs careful and appropriate care after the procedure is complete. After some straightforward cases, such as for patients with good social support, this may be as an elective day case. For others, there may be complex care pathways to ensure a successful short-term outcome. Clear routine information and pathways for patients throughout their hospital stay are very useful to ensure both a consistent standard of care and that those caring directly for the patient have useful instructions. They also allow modifications to be made for individual circumstances. In general terms, a patient’s care will be planned to be either as a ‘day case’ or will require inpatient management. Some procedures will lend themselves to treatment with discharge on the same day, while others will not. In principle, those procedures which result in a patient who is highly unlikely to have post-procedural events that require medical or nursing input will be suited to day case treatment. Such procedures include simple angioplasty and stenting, venous interventions (e.g. elective IVC filter and varicocoele embolisation) and some biopsies. Other procedures have the need for short-term monitoring (such as carotid artery stenting and more complex biopsies) whilst others require longer inpatient care for recovery (such as EVAR) or treatment of other associated conditions (e.g. biliary drainage, leg ulcers and tissue loss). In addition, the patients’ home circumstances will dictate suitability for the day case care. Whilst many procedures carry low risk of shortterm problems, they are not free of such difficulties, so all patients should be discharged from hospital to a safe environment. This will

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usually be to a place where they have easy access to telephone contact with the hospital or emergency services, and should have a competent adult who can assist them. Post-procedural management may be considered in the following manner: Arterial/access closure Arterial closure can be either · Manual pressure · Closure devices Other procedures may utilise other devices (e.g. plugged biopsy). The utility of each of these are dependent upon · Patient factors · Procedure factors · Operator experience/training Post-procedural mobilisation Most patients do not wish to be mobilised immediately after a procedure; a period of recuperation is usually appreciated. However, even within the confines of staying in a bed or reclining chair, the ability to sit up, move around and perform toilet functions all serve to improve the patient experience. Also, a degree of confidence that bleeding is unlikely provides reassurance. Post-procedural plans for mobilisation will vary depending upon the procedure performed and patient characteristics. However, a clear plan needs to be defined at the completion of the operation, so that both patients and ward staff have clear and realistic expectations. Pain relief This is essential for all procedures, and varies from procedure to procedure, and between patients. The prevention and control of pain is much more effective, than treatment once a patient experiences pain. As a result all procedures should have a plan with instructions for the management of post operative pain. This may range from nurse prescribed simple analgesia (such as oral or IV paracetamol) through to patient controlled analgesia devices and anaesthesia. Drug therapy This can be classified into · Those drugs which should be stopped prior to treatment These are pre-procedural issues, but they may need to be restarted after the intervention, e.g. warfarin bridging protocols. · Those that need to be started for the procedure (e.g. Clopidogrel for carotid artery stents), and may need to be continued (for a period of time) after. · Those started after the procedure * Short term, e.g. heparin * Medium term, e.g. dual anti-platelets * Longer term, e.g. aspirin · Analgesia (see above) Blood pressure control In most cases, blood pressure measurement is mainly a monitoring process to ensure that bleeding complications are not encountered, and are promptly treated as required. In some cases, blood pressure may be manipulated to keep it low to prevent bleeding, e.g. percutaneous EVAR. In others, blood pressure may be low as a result of the procedure, e.g. carotid artery stenting. Anticoagulation Most patients undergoing vascular interventional procedures will be anticoagulated during the procedure. In many cases, this will require single doses of heparin and in some, monitoring of the effect and further doses may be required. As noted above, some patients will be anticoagulated prior to the intervention, either with warfarin, low molecular weight heparin or NOACs (new oral anticoagulants). Clear protocols about which procedures need these to be interrupted and which do not are required. In addition, some patients conditions may allow a temporary curtailment of the anticoagulation treatment (e.g. past history of DVT) whilst others (e.g. prosthetic cardiac valves) require continued anticoagulation. Clear protocols for the peri- and post-procedural mana-

Abstract Book gement of these drugs are vital. In addition, the restarting of drugs such as warfarin require care, but often can be satisfactorily achieved on an out-patient basis, thus improving the patient experience, whilst keeping the in-hospital costs to a minimum. Levels of care/location Depending upon · the type of procedure that has been undertaken · patient characteristics/co-morbidity · procedural events · local protocols Patients may be best managed on: · a dedicated day ward · a general ward · a specialist ward (e.g. vascular, GI, hepato-biliary) · post-operative unit · high dependency · intensive care · discharge from hospital One of the most frequently asked questions when considering an intervention is how long a patient is likely to be in hospital. A preprocedural plan for discharge frequently will keep the length of stay to a minimum and will allow for prompt discharge. Many day case patients may be ready and able to leave hospital before the end of the day. Protocols for discharge and nurse lead discharge will frequently help this process, and reduce the burden on interventional radiologists. Often interventional radiology procedures are a part of a wider pathway of care. In such circumstances, it is useful to have a clear definition of the responsibilities of the interventional radiologist and other clinical teams. Information on discharge/reasons for concern When a patient is discharged from hospital, the duty of care does not stop. Complications and problems relating to the procedure(s) can still occur. In addition, patients may develop unrelated problems and symptoms. If there is lack of understanding of interventional radiology procedures at the ward level, in community services, the understanding is even lower. Therefore, it is important that patients and general practitioners (GPs) are given comprehensive information about what to expect and what to be concerned about. This can be information given directly to patients for themselves and their carers. This may serve as a useful resource for emergency services, but electronic discharge summaries to GPs are also helpful. Such information should include a facility for the patient to be able to contact the hospital directly. Out-patient follow-up It is important that this is under the direction of interventional radiologists to · check patients for problems and complications · provide final meeting to close this episode of treatment · plan further treatment as appropriate · ensure long term therapy is in place (e.g. secondary prevention) · receive feedback from the patient on the journey of care · answer further questions · provide a management plan for communication with the GP · completion of follow up data Audit/data collection Many interventional radiology procedures are relatively new. It is particularly important that the outcomes related to these procedures are followed and logged. Often there are local and national (or international) audit projects (e.g. in the UK the National Vascular Registry) which collect data on procedures. This is not only to provide follow-up data on specific procedures but also to monitor the effectiveness and complications in departments and units. Operator-specific data are also collected in respect of revalidation and recertification. It is true to say that even with training packages and educational support, many ward doctors, trainees and nurses are not very fami-

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liar with many interventional procedures. It is vital for the success, both for individual patients, and the long-term future of these techniques, that the operators (interventional radiologists) take a close part in the post-procedural care and follow-up. Without this input, patients will not get the best outcomes and the audited results will not be as good as they can be. It is essential that all interventional radiologists should regard this is an integral part of their work, and that managers should allow them time to perform these functions.

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Abstracts of Free Papers (oral communications) sorted by presentation numbers

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Free Paper Session Randomized trials in IR 607.1 Drug-coated balloon (DCB) angioplasty versus conventional angioplasty for the treatment of the superficial femoral artery (SFA) and PI segment in PAD patients: first interim results of the FREERIDE study K.-L. Schulte1, B. Fernandez-Tresguerres2, R. Langhoff3; 1Vascular Center Berlin, Ev. Hospital Königin Elisabeth Herzberge, Berlin, Germany, 2Clinical Department, Eurocor GmbH, Bonn, Germany, 3Vascular Center, Sankt Gertrauden-Krankenhaus, Berlin, Germany Purpose: Paclitaxel DCB during percutaneous transluminal angioplasty (PTA) for femoropopliteal lesions in PAD patients might result in a significantly reduced restenosis rate. Thus, the FREERIDE study investigates the inhibition of restenosis by the FREEWAY DCB versus standard balloon (POBA) in the treatment of de-novo occluded, stenotic lesions or re-occluded and restenotic lesions in SFA and popliteal arteries (PI segment). Material and Methods: In all, 280 patients will be randomized either to FREEWAY DCB or POBA in 23 centers worldwide. The primary endpoint is clinically driven target lesion revascularization rate (TLR) at 6 months. Further, several secondary endpoints like late lumen loss and patency rate at 6 months; TLR at 12, 24 months follow-up (FU); improvement in Rutherford classification and ankle–brachial index (ABI); and MAE at FU will be investigated. Results: So far, 71 patients have been enrolled; 51 of them completed the 6-month FU, and 3 were not available for FU. At 6-month FU, positive trends were observed for the TLR rate (6.6% vs. 9.5% after POBA; p=0.7) and MAE (6.7 % vs 14.3 % after POBA; p=0.36). Furthermore, there are positive trends in the patency rate and improvement of Rutherford classification after FREEWAY PTA vs. POBA. Conclusion: The first interim results indicate that FREEWAY DCB might provide an advantage for angioplasty in SFA and PI segment lesions. DCB might overcome the existing limitations in the treatment of PAD.

607.2 BIOLUX P-II: a randomized clinical trial of Passeo-18 Lux DRB vs. POBA for the treatment of infrapopliteal artery lesions K. Deloose1, T. Zeller2, M. Brodmann3, M. Bosiers1, P. Peeters4, K.-L. Schulte5, D. Scheinert6 , U. Beschorner7, E. Pilger3; 1Department of Vascular Surgery, AZ Sint-Blasius, Dendermonde, Belgium, 2Angiology, Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany, 3Internal Medicine, Division of Angiology, Graz, Austria, 4Surgery, Imelda Ziekenhuis, Bonheiden, Belgium, 5Vascular Center Berlin, Ev. Hospital Königin Elisabeth Herzberge, Berlin, Germany, 6Clinical and Interventional Angiology, Park Hospital Leipzig, Leipzig, Germany, 7Medical Quality Analysis Center, CoreLab Bad Krozingen GmbH, Bad Krozingen, Germany

Abstract Book were randomized 1:1 at six European sites. At baseline, subjects presented with hypertension (86.1%), hyperlipidemia (68.1%), diabetes (66.7%), and critical limb ischemia (77.8%). At 30 days, MAE were 0.0% for DRB vs. 8.3% for POBA (p=0.239). At 6 months, target lesion primary patency showed a trend in favor of DRB (84.3%) vs. POBA (75.9%; p=0.330), and major amputations were 3.3% for DRB vs. 5.7% for POBA (p=0.655). Clinical improvement at 6 months, reflected by improvement in Rutherford class, was 59% for DRB vs. 47% for POBA, with 0% DRB subjects worsening vs. 6% POBA subjects (p=0.326). Clinical improvement in Rutherford 5 subjects was significant in the DRB group (p=0.002) compared with the POBA group (p=0.058). Conclusion: DRB, as compared to POBA, is associated with favourable functional and clinical outcomes and results in significant clinical improvement of Rutherford 5 subjects in the treatment of infrapopliteal artery lesions.

607.3 Fibered platinum coils vs vascular plugs in pelvic varices embolization for the treatment of pelvic congestion syndrome: 1-year follow-up randomized study A. Laborda1, M. Sanchez Ballestin1, I. De Blas2, M.A. de Gregorio3; 1GITMI, University of Zaragoza, Zaragoza, Spain, 2Epidemiology, University of Zaragoza, Zaragoza, Spain, 3Interventional Radiology, Clinico Universitario Zaragoza, Zaragoza, Spain Purpose: To compare the safety and efficacy of two embolic agents for the treatment of pelvic congestion syndrome: Nester coils (NS; Cook Medical) and Amplatzer vascular plugs (AVP; St. Jude Medical). Material and Methods: From May 2010 to September 2012, 55 consecutive patients (mean age 43.07±7.56 years; range 29–60) diagnosed of pelvic congestion syndrome due to pelvic varices (>6 mm pelvic venous caliber and venous reflux in ultrasonography) were randomized in 2 groups and treated with either NC (n=28) or AVP (n=27). Median cubital or jugular approach was used interchangeably, using 5F for NC and 6F for AVP. Both ovarian and hypogastric veins were targeted. Safety, efficacy, procedure time, fluoroscopy time, and radiation dose were compared. Results: In both groups, all veins were successfully embolized with no differences. The mean number of coils per case was 17.82±1.39 (NC) vs 4.18±0.48 (AVP). There were 6 re-embolizations due to no improvement in NC and 2 in AVP. At 1-year follow-up, there were no significant differences in clinical success (complete disappearance or improvement of symptoms 89.3% vs 92.6%) or in subjective improvement self-assessment (by VAS). Two coils migrated in the NC group and were retrieved without complications. Procedure time (45.24±3.89 vs 32.55±7.00 min), fluoroscopy time (33.71±8.83 vs 21.13±7.08 min) and radiation dose (PDA 348.66±81.84 Gycm2 vs 199.31±183.64 Gycm2) were significantly higher in the NC group (all p<0.0001). Conclusion: AVP embolization is as safe and efficient as NC embolization. AVP significantly reduces procedure and fluoroscopy time and radiation dose. Device migration and incomplete embolization is more frequent with NC, but larger studies would be necessary.

Purpose: Drug-releasing balloons have shown promising results in femoropopliteal disease; however, adequate evidence demonstrating improved outcomes in infrapopliteal arteries is currently lacking. BIOLUX P-II assesses the safety and performance of the Passeo-18 Lux paclitaxel-releasing balloon (DRB) vs. the uncoated Passeo-18 balloon (POBA) in the treatment of infrapopliteal lesions. Material and Methods: BIOLUX P-II is a prospective, international, multicenter, randomized trial with follow-ups at 30 days and 6 and 12 months. Safety and performance primary endpoints are major adverse events (MAE) at 30 days and target lesion primary patency at 6 months (assessed by an independent angiographic core laboratory). Results: Seventy-two subjects, 79.2% men, mean age 71.3±9.7 years

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607.4 Randomised controlled trial of Particles used in Uterine fibRoid Embolisation (PURE) – non-spherical polyvinyl alcohol (Contour PVA; Boston Scientific, USA) versus calibrated hydrogel microspheres with polyzene coating (Embozene; CeloNova Biosciences, USA): interim results R. Das1, I. Manyonda2, A.-M. Belli1; 1Department of Radiology, St. George's Hospital, London, United Kingdom, 2Department of Gynaecology, St. George's Hospital, London, United Kingdom Purpose: The PURE study is a randomised controlled trial designed to evaluate clinical, MRI and technical outcomes between two embolic agents in uterine artery embolisation (UAE): non-spherical polyvinyl alcohol (ns-PVA) and calibrated hydrogel microspheres (Embozenes). Material and Methods: Prospective, ethically approved non-sponsored randomised controlled trial in a UK tertiary IR unit. The study is designed to recruit 80 patients with a 6-month follow-up. UAE was performed via bilateral arterial access and following a standardised embolisation protocol and a single-blinded design. Primary outcome: Assessment of symptomatic improvement using the validated Uterine Fibroid Symptom and Health-related Quality of Life questionnaire (UFS-HRQOL). Secondary outcomes: Using contrast-enhanced MRI performed before and at 6 months after UAE 1. Percentage fibroid infarction of total fibroid burden and dominant fibroid. 2. Uterine and dominant fibroid volume reductions. 3. Uterine artery recanalisation and presence of ovarian collaterals. 4. Volume of embolic agent required, fluoroscopy time and radiation dose. Results: Forty patients have currently enrolled in the study and the full 6-month follow-up with interim comparative statistical analysis will be complete for CIRSE congress in September 2014. Analysis of volumes of embolic agent has demonstrated a statistically significant difference with a mean volume of 5.5 syringes (range, 1–12) of Embozenes used versus 3.8 vials of ns-PVA (range, 2–8) (p=0.05). No significant difference was detected with respect to fluoroscopy time or radiation dose. Conclusion: The study involves comprehensive clinical and MRI outcome assessment to evaluate two contemporary and widely used particulate embolic agents. The PURE study will guide IR practitioners regarding the relative efficacy of embolic agents in UAE.

607.5 Pre-procedure and post-procedure administration of Oxycodone improves pain management after uterine fibroid embolization G.M.G. Freire1, J.M. Motta-Leal-Filho2, R.N. Cavalcante3, B.D. Fina1, R.D. Rocha1, M.D.L. Messina3, I.D.P. Posso1, M.D. May3, M.L. Pinheiro Oliveira3, F.L. Galastri4, B.B. Affonso5, F. Nasser3; 1Radiologia Intervencionista e Cirurgia Endovascular, Hospital Israelita Albert Einstein, São Paulo, Brazil, 2Radiology, Hospital das Clinicas, University of Sao Paulo Medical School, São Paulo, Brazil, 3Radiologia Vascular Intervencionista, Hospital Israelita Albert Einstein, São Paulo, Brazil, 4Radiologia Vascular, Hospital Israelita Albert Einstein, São Paulo, Brazil, 5Interventional Radiology, Hospital das Clinicas de São Paulo Brazil, São Paulo, Brazil Purpose: To evaluate if standard anesthesia in combination to preand post-procedure administration of controlled-release oxycodone (CRO) improves pain control and decreases the amount of required

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post-procedure opioids in uterine fibroid embolization (UFE). Material and Methods: Between January 2009 and March 2010, 60 consecutive women were prospectively randomized in two groups for UFE: Group CRO, 30 patients that underwent standard anesthetic procedure plus Oxycodone and Group C (control group), 30 patients that underwent standard anesthetic procedure (combination of morphine intrathecal, sedation with propofol, intravenous analgesia with ketoprofen, and metamizole). Age, pain, nausea/vomiting, use and dose of morphine (PCA device), pre-procedure fibroid volume, and length of hospital stay were evaluated and compared in both groups. We also measured the fibroid volume by MRI and correlated with post-embolization pelvic pain over the first 24 hours. Results: A significant difference was seen in pain scores at 24 hours (p=0.029), with less pain in the CRO group. Morphine was administered at higher levels (p=0.130) and in more patients in the C group (p=0.017). Pruritus was lower in the CRO group (p=0.029). No correlation was seen between leiomyoma volume and pain levels over 24 hours. Hospital stay duration was not different between the two groups. Conclusion: The addition of CRO to standard analgesia for UFE provides better analgesia with lower pain scores in 24 hours, use of a lesser amount of morphine, and decreased incidence of pruritus.

607.6 DENER-HTN trial: a prospective randomized control trial of the efficacy of renal artery denervation in resistant hypertension M.R. Sapoval1, M. Monge2, H. Pereira3, The DenerHTN investigators, M. Azizi3; 1Department of Cardiovascular Radiology, Hôpital Européen Georges Pompidou, Paris, France, 2Clinical Investigation Center, Hôpital Européen Georges Pompidou, Paris, France, 3Unité de Recherche Clinique, HEGP, Paris, France Purpose: The DENER-HTN trial is a multicenter, prospective, open, randomized, controlled study with blind end-point evaluation of the efficacy, safety, and cost-effectiveness of renal denervation (RDN) using the Symplicity Catheter System in addition to standardized optimal medical treatment (RDN group) compared with standardized optimal medical treatment alone (control group) in patients with resistant hypertension (RH). The primary outcome is change in SBP assessed by ABPM at 6 months. Cost-effectiveness evaluation is performed at 1 year. We will report the 6-month results. Material and Methods: Patients were included when they had essential RH to ≥3 antihypertensive drugs, including a diuretic (office BP ≥ 140 and/or 90 mmHg), and were receiving a 4-week standardized triple therapy. Main exclusion criteria were non-suitable renal artery anatomy, secondary hypertension, and estimated glomerular filtration rate (eGFR) < 40 ml/min. After 4 weeks of the standardized triple therapy regimen, patients with a mean baseline daytime ambulatory SBP/DBP (dASBP/dADBP) ≥ 135 mmHg or 85 mmHg were randomized to the RDN or control group. In each group, antihypertensive treatment was reinforced by sequentially adding a new antihypertensive drug. Results: From 06/01/2012 to 10/15/2013, 106 were randomized at visit 1 after 4-week standardized triple therapy regimen. The clinical and biological characteristics of the two groups did not significantly differ at baseline. The 6-month results will be presented. Conclusion: The patients included in the DENER-HTN trial had confirmed essential RH. This superiority trial aimed at showing a 10-mmHg difference in dASBP with a 17-mmHg SD, an alpha risk of 5%, and a beta risk of 20%.

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607.7 Randomised trial comparing Hickman lines with ports for chemotherapy: a pilot study to inform a larger trial J.G. Moss1, R. Kasthuri2, J. Paul3, E. McCartney3, O. Wu4, M. Ritchie5, J. Dixon3; 1Department of Radiology, North Glasgow University Hospitals, Gartnavel General Hospital, Glasgow, United Kingdom, 2Radiology, Gartnavel General Hospital, Glasgow, United Kingdom, 3Oncology, Cancer Research UK, Glasgow, United Kingdom, 4Public Health, University of Glasgow, Glasgow, United Kingdom, 5Radiology, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom Purpose: Centrally inserted venous access devices are commonly used for chemotherapy. It is unclear which is most effective from a clinical or cost perspective. Material and Methods: This trial gathered data to inform the design of a larger randomised trial. Hundred patients requiring a venous access device for chemotherapy were randomised from a single UK site: 74 to a Hickman line and 26 to a port. The primary endpoint was complication rate. Secondary endpoints included chemotherapy interruption and device removal rates. Results: Seventy-three patients received a Hickman line, and 24 received a port. The study arms were well matched at baseline. Outcome data were available for the 97 patients receiving a device; no patients were lost to follow-up. Thirty-five (47%) Hickman pa-tients and seven (27%) port patients suffered one or more complication (p = 0.044). The most frequent complication in the Hickman arm was bloodstream infection (BSI) accounting for 23 (46%) of 50 complications. There were no BSIs in the port arm. Line occlusions were the most common complication in the port arm accounting for 9 (64%) of 14 complications. Of the devices removed, 17 (32%) and 1 (9%) were removed due to complication in the Hickman and Port arms, respectively. A pilot device-specific questionnaire indicated favourable results for 12 of 16 questions. The EQ-5D data from a health economic perspective showed ports to be associated with lower costs but fewer QALYs than Hickman lines. Conclusion: Ports appear to be more cost effective. A larger trial is needed to confirm these preliminary findings.

Free Paper Session Biliary interventions 1405.1 Percutaneous transhepatic endoscopic holmium laser lithotripsy for intrahepatic and choledochal biliary stones A.M. Ierardi1, M. Petrillo2, F. Fontana1, C. Floridi1, F. Piacentino1, G. Xhepa1, M. De Chiara1, G. Carrafiello1; 1Radiology, Uninsubria, Ospedale di Circolo, Varese, Italy, 2Radiology, Second University of Naples, Naples, Italy Purpose: To report our experience in treating complicated biliary calculi with percutaneous transhepatic endoscopic biliary holmium laser lithotripsy (PTBL). Material and Methods: Fourteen symptomatic patients with intrahepatic or common bile duct calculi underwent PTBL. Eight patients were previously subjected to unsuccessful endoscopic treatment; four patients were unsuitable for the endoscopic procedure. PTBL was performed with a flexible choledochoscope inserted through the percutaneous access sheath. A holmium laser was used to fragment the biliary stones. Sphincteroplasty was performed when considered necessary, and an occlusion balloon for the clearance of common biliary duct (CBD) calculi was used when continuous warm saline irrigation at high pressure was not sufficient. Clinical followup was performed by the referring physician. Technical success, clinical success and complications were evaluated.

Abstract Book Results: The technical success rate was 100%, and the overall clinical success rate was 100%. No patients underwent additional procedures for retained stones or developed de novo strictures or other complications related to the procedure. Hospital stay was no more than 4 days after the procedure. Duration of follow-up was 6-25 months (mean 12.6). One patient died from unrelated causes. During this period, no recurrence and/or complications related to the procedure were observed. No major complications were registered. Minor complications like temporary abdominal pain were considered not significant by the same patients. Conclusion: Complicated or large biliary calculi can be treated successfully with PTBL. In selected patients, this approach should become the first choice of treatment after other treatments are rejected.

1405.2 Eighteen years of experience in radiologic-endoscopic management of difficult bile duct stones: lessons learned A. Cannavale1, M. Corona1, P. Lucatelli1, G. Fanello2, F. Cereatti2, C. Cirelli1, A. D’Adamo1, F.M. Salvatori1, F. Fanelli1, F. Fiocca2; 1Vascular and Interventional Radiology Unit, Sapienza University of Rome, Rome, Italy, 2Department of Surgical Sciences and Organ Transplantation – P. Stefanini, Sapienza University of Rome, Rome, Italy Purpose: To report our 18-year experience in the radiologic-endoscopic management of “difficult bile duct stones.” Material and Methods: From 1994 to 2012, 299 symptomatic patients with difficult bile duct stones were admitted to our institution. Preoperative US exam and MRCP were performed to assess the location of bile stones and define anatomy situation according to the Tsunoda classification. Our technique consisted performing percutaneous transhepatic cholangiography (PTC)/biliary drainage(s) followed by dilating the PTC track up to 10 or 16 French within 3-7 days. All procedures were performed by percutaneous transhepatic cholangioscopy (PTCS) with electrohydraulic lithotripsy (EHL) coupled with interventional radiology techniques. We retrospectively analyzed our radiologic-endoscopic approach and reported our technical and clinical outcomes. Results: Most treated patients (290, 97%) had a history of previous surgical and interventional abdominal procedures. In almost all patients (298/299, 99.6%), stone clearance was achieved after a maximum of four consecutive sessions. Most patients (64.6%) were treated with PTCS/EHL alone; the remaining patients were treated either with radiologic techniques (26%) or both techniques (13.3%). Recurrence of stones occurred in 45 cases (15%, Tsunoda class III and IV) within 2 years and were successfully retreated. Major complications were as follows: 5 (1.6%) cases of massive bleeding requiring embolization, 2 (0.66%) of perforations of the main bile duct, and 17 (5.8%) of acute cholangitis treated with medical therapy and interventional techniques. Conclusion: From an 18-year experience, we learnt that our combined radiologic-endoscopic approach for “difficult hepatolithiasis” may guarantee both immediate and long-term clearance of stones with a low complication rate.

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1405.3 Bioabsorbable biliary stent in the treatment of benign biliary strictures: follow-up of more than two years C. Michelozzi, V. Pedicini, F. Melchiorre, D. Poretti, M. Tramarin, E. Lanza, G. Mauri, G. Brambilla, G. Cornalba; Radiologia Diagnostica ed Interventistica, Ospedale San Paolo Università di Milano, Milan, Italy Purpose: To report the outcome of patients treated with bioabsorbable biliary stent for benign biliary strictures. Material and Methods: Between March 2011 and February 2014, 27 bioabsorbable polydioxanone biliary stents (Ella-DV biliary stent; ELLA-CS, Czech Republic) were deployed in 23 patients with increased level of bilirubin due to postsurgical benign biliary stricture. All patients had stricture recurrence after multiple standard percutaneous or endoscopic treatments. This stent is made of polydioxanone, a material that allows obtaining a high radial force but that is reabsorbed within 6 months. All patients were followed up with clinical examination, ultrasound and serum bilirubin level. Results: In all cases, the procedure was technically successful in obtaining immediate resolution of the stricture. A 15-F delivery system was used in the first 19 patients and 11-F was used for the last 5 procedures. No immediate complications occurred. During follow-up (median duration 19 months, range 0-35 months), 21 (91%) patients were asymptomatic for restenosis; two developed intrahepatic lithiasis; two other showed signs of restenosis and needed percutaneous treatment, and in one, a second stent was placed. Conclusion: Percutaneous bioabsorbable biliary stent placement is feasible and effective in the treatment of benign biliary strictures. In the future, this novel treatment may replace percutaneous repeated bilioplasty and retrievable biliary stent placement as soon as longterm follow-up data will be available.

1405.4 Endoluminal radiofrequency ablation with subsequent stenting in biliary, pancreatic duct, and portal vein occlusions M. Mizandari1, N. Habib2, T. Azrumelashvili1; 1Diagnostic and Interventional Radiology, Tbilisi State Medical University, “High Technology Medical Center – University Hospital”, Tbilisi, Georgia, 2Division of Surgery, Oncology, Reproductive Biology & Anaesthetics, Imperial College London, London, United Kingdom Purpose: Percutaneous recanalization technique of malignant blocks is presented. Material and Methods: Eighty-two biliary duct, Wirsung duct and PV recanalization procedures have been performed on 70 cases: 55 with unresectable biliary block (pancreatic cancer, 17; cholangiocarcinoma, 17; gallbladder cancer, 8; hepatocellular carcinoma, 4; liver hilum metastatic invasion, 4; papilla of Vater tumor, 4; pancreatic met, 1), unresectable Wirsung block: 5 (all pancreatic cancer) and symptomatic PV tumor thrombus 10 (HCC, 8; liver cirrhosis, 1; liver sarcoma, 1). For 2 minutes, 10-15 watts was applied using a bipolar endoluminal RF device (Habib™ EndoHPB; EMcision Ltd., London, UK), placed in the duct or PV blocked area using a guidewire technique via percutaneous biliary/Wirsung drainage fistula or via direct US-guided percutaneous PV puncture. The procedure was completed with metal stent placement. A safety drainage catheter was repositioned in biliary and Wirsung duct cases. Results: Biliary and Wirsung patency was restored in 65 (95.2%) of 67 procedures; in 2 (4.8%) cases, guidewire conduction failed; and 4 cases generated stent occlusion in 7 and 8 months after RFA and stenting, requiring percutaneous drainage. PV procedures were performed in 7 (70.0%) cases; in 3 (30.0%) cases, guidewire conduction

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failed; and PV patency restoration was achieved in 6 cases. There was no 30-day mortality, hemorrhage, or pancreatitis following biliary and Wirsung duct RFA and stenting; in 1 case of PV thrombus processing, significant intra-abdominal bleeding was documented, and the patient died because of multiorgan failure. Conclusion: Endoluminal RFA and stenting is safe and effective in biliary and Wirsung duct block recanalization. A procedure to track coil embolization should be recommended in PV cases to avoid possible bleeding.

1405.5 Is percutaneous biliary drainage effective in lowering serum bilirubin for initiating chemotherapy? J. Levy1, M.C. Soulen1, D. Sudheendra1, M. Dagli1, J.I. Mondschein1, S.W. Stavropoulos1, R. Shlansky-Goldberg1, S.O. Trerotola1, U. Teitelbaum2, R. Mick3; 1Radiology, University of Pennsylvania, Philadelphia, PA, United States of America, 2Medical Oncology, University of Pennsylvania, Philadelphia, PA, United States of America, 3Biostatistics, University of Pennsylvania, Philadelphia, PA, United States of America Purpose: Previous studies reported that only 30% of patients undergoing percutaneous biliary drainage (PBD) normalized their bilirubin within 100 days in order to receive chemotherapy. For GI cancer, the bilirubin threshold for chemotherapy is 5 mg/dl or 2 mg/dl depending on the regimen. We examined the ability of PBD to achieve these relevant endpoints. Material and Methods: In all, 106 patients with malignant obstruction underwent PBD. The time taken to achieve bilirubin of 5 or 2 mg/dl and survival rates were estimated by Kaplan-Meier analysis. Pre-drainage categorical variables were analyzed by the log-rank test. Hazard ratios were calculated for continuous variables, and categorized by quartiles for the log-rank test. Results: Eighty-eight patients had bilirubin >5 mg/dl; 62% had ≤5mg/dl within 30 days, and 84% within 60 days, median 21 days. Further, 106 patients had bilirubin >2 mg/dl. 37% had ≤2 mg/ dl within 30 days and 70% within 60 days, median 43 days. Predrainage bilirubin predicted the time to achieve bilirubin ≤5mg/dl (p<0.0001), but not for bilirubin ≤2mg/dl (p=0.51). In patients with bilirubin of 5-15 mg/dl, bilirubin decreased to 5 mg/dl within 1-2 weeks, whereas in those with bilirubin of 15-40 mg/dl, it took 4-6 weeks. In patients with biliary primaries, bilirubin decreased to 2 mg/dl in a median of 69 days vs. 40 days for those with non-biliary primaries. Median survival rate was 100 days with 75% alive at 30 days and 60% alive at 60 days. Conclusion: PBD achieves clinically relevant reduction in serum bilirubin in most patients within 1-2 months, allowing administration of chemotherapy, irrespective of the pre-drainage serum bilirubin.

1405.6 Transhepatic vs transperitoneal approach for percutaneous cholecystostomy A.E. Helmy1, N. Shaida2, T.C. See1; 1Radiology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom, 2Radiology, Addenbrookes Hospital, Cambridge, United Kingdom Purpose: This study investigated the outcomes for all cholecystostomies performed over a 10-year period at our institution by comparing a transhepatic and transperitoneal approach. Material and Methods: Patients were identified by searching the local electronic, radiology and medical databases. A retrospective analysis was performed to record patient demographics, indication, modality, technique, complications and outcomes.

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Results: Ninety-six patients who underwent 101 procedures between 2004 and 2013 were included in this study. Median age was 77 (range 21-97). In all, 93 procedures were performed using ultrasound and 18 using CT. Fifty-eight procedures were performed using a transperitoneal approach, 41 using transhepatic and 2 were unknown. Technical success was achieved in 99/101 (98%) procedures. An early decrease in white blood cell count was observed in 54% cases and a decrease in CRP in 68%. Positive cultures were obtained from 70% (58/83). The most common organisms were E. coli (36%), Enterococcus (29.3%) and Klebsiella (21%) There were no procedurerelated mortalities. Mortality at 1 year was 25%, 3 years was 39% and 5 years was 59%. A single major bleeding-related complication was observed. Minor complications related to drain dislodgement or kinking and bile leak were noted in 26% cases. There was no significant difference in the complication rate for transhepatic (26%) vs transperitoneal (24%) route (p > 0.05). Conclusion: Percutaneous cholecystostomy is a safe procedure with a high technical success rate performed on patients with a limited life expectancy. The access route does not influence complication rate or outcomes. Therefore, the most easily visualised route to the gallbladder should be employed.

Free Paper Session GI interventions and biopsies 1406.1 Use of the Hunter device in children Z. Farhat1, J. Amaral1, P.R. John1, D.A. Parra2, M. Temple1, B. Connolly1; 1Pediatric Interventional Radiology, The Hospital for Sick Children, Toronto, Canada, 2Diagnostic Imaging, Image guided Therapy, The Hospital for Sick Children, Toronto, Canada Purpose: Bleeding is a recognized complication of image-guided percutaneous needle biopsies. The risk of bleeding can be minimized using a coaxial technique and plugging the tract with liquid or solid agents. We recently used the Hunter device (HD; condensed gelfoam torpedo) instead of standard gelfoam slurry (GS). The purpose is to examine our experience with HD in children regarding efficacy and safety in comparison with our previous practice of using GS. Material and Methods: A retrospective case-control study of 108 patients who underwent plugged biopsies using HD or GS, matched by organ and date, between 2011 and 2013. REB approval was obtained. Clinical demographics, coagulation parameters, procedural and imaging data, and complications were analyzed. Descriptive statistics were used. Results: Fifty-four HD cases (32 males, median age 5 years, weight 20 kg) were compared with 54 GS controls (32 males, median age 3.5 years, weight 18.9 kg). Biopsies involved focal lesions in 35 HD and 35 GS cases; organs included liver, kidney, spleen, and masses (abdominopelvic, mediastinal, chest, neck, and gluteal). In nonfocal biopsies (HD and GS), 1-5 passes were made, and in focal lesions, 2-40 passes. Eighteen HD and 8 GS cases received pre/periprocedural coagulation correction. Post-procedural hemoglobin dropped (>15) significantly in 1 HD and 7 GS cases, and 1 GS case required transfusion. A drop in end-tidal CO2 during slurry injection was attributed to GS escape to the pulmonary circulation in 1 patient. There was no significant intergroup difference in the procedure time. Conclusion: HD in children is a safe and effective option for plugged coaxial biopsies.

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1406.2 Percutaneous liver biopsy post-Fontan operation: a single pediatric institutional experience A.K. Guzman1, K. Dodds2, J. Rychik2, E. Rand2, G. Krishnamurthy3, M.S. Keller3, A. McIntosh3, D.J. Goldberg2, A.M. Cahill3; 1Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America, 2Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America, 3Interventional Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America Purpose: To describe the technique and outcomes of percutaneous liver biopsy in patients who have undergone the Fontan operation for congenital single ventricle disease. Material and Methods: A retrospective 5-year review of 67 patients was conducted in a tertiary pediatric institution (42 males and 25 females) with a history of the Fontan operation who underwent percutaneous liver biopsy to evaluate for the associated early-stage congestive hepatopathy. Medical records were reviewed for biopsy technique, complications, cardiac catheterization pressure measurements, and histological findings. Results: Sixty-eight biopsies were performed in 67 patients. The technical success rate was 100%. The mode number of samples acquired was 2 (range 1-7). In the right lobe, 49/68 (72.1%) biopsies were performed, in the left, 5/68 (7.4%), and in both, 14/68 (20.6%). Gelfoam was used for tract embolization in 50/68 (73.5%) biopsies. All biopsies were diagnostic. No intraprocedural complications occurred. In 11/68 (16.2%) biopsies, there was a drop of >2.0 g (range 2.0-3.1) in hemoglobin within 6 hours. Of these patients, 2 had an identifiable risk factor, having only stopped aspirin for 3 and 5 days pre-procedure. In 3/68 (4.4%) biopsies, late hemorrhage occurred post-discharge. Two patients stabilized after readmission and transfusion, and one developed hemobilia. The mean Fontan systemic venous pressure was 13.8 (range 6-26) in all patients and 13.9 (range 9-21, p=0.967) in patients with hemorrhage. Conclusion: Percutaneous liver biopsy provides essential information for diagnosing early-stage liver disease in the Fontan population. Though there is a risk of hemorrhage, it may be mitigated by timely cessation of anticoagulation medication. An elevated Fontan pressure was not a risk factor for hemorrhage.

1406.3 Effect of bariatric embolization on various appetite-driving hormones of obesity C.R. Weiss1, A. Arepally2, T. Moran3, C. Hu4, J. Singh1, H.-Q. Mao4, T.-H. Wang5, D.L. Kraitchman1; 1The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America, 2Interventional Radiology, Piedmont Healthcare, Atlanta, GA, United States of America, 3Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America, 4Material Science, Johns Hopkins University, Baltimore, MD, United States of America, 5Mechanical Engineering, Johns Hopkins University, Baltimore, MD, United States of America Purpose: Bariatric arterial embolization (BAE) is a new treatment for obesity, but its effect on various appetite-driving gut hormones of obesity are not well understood. Material and Methods: The selection of fundal arteries for BAE was based on a celiac DSA C-arm CT (Siemens Artis Zee). From the celiac axis, fundal arteries were targeted, and an anti-reflux microcatheter

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(Surefire mT) and 0.016-inch steerable guidewire were inserted. X-ray-visible 50-micron BaSO4 alginate-impregnated microbeads were infused in five pigs (BAE), and four pigs received sham saline injections. All animals received proton pump inhibitors starting 3 days before BAE. Gastric ulceration was assessed using endoscopy at 1 week post-BAE. Serial weekly weight and serum gut-derived hormones [ghrelin, glucagon-like peptide 1 (GLP-1), and peptide YY (PYY)] were obtained. Results: Weight declined in BAE animals at 1 week (BAE: −0.9±2.3 lbs; sham: 2.9±1.9 lbs), and weight gain remained impaired at 4 weeks (8.3±3 vs. 13.6±2 lbs, P<0.01). Failure of BAE pigs to gain weight was moderated by decreased ghrelin (1226±523 pg/ml vs. 1706±143 pg/ml , P<0.001) and increased GLP-1 (9.8±10 pM vs. 5.9±2 pM, P<0.001), yet PYY was unaffected (597.9±132 pg/ml vs. 664.6±117 pg/ml, not significant). Three BAE pigs had superficial gastric ulcers 1 week post-BAE. All BAE pigs showed evidence of food retention associated with impaired gastric emptying. Conclusion: Analogous to bariatric surgery, BAE targeting the fundal arteries significantly affects appetite-regulating gut hormones of obesity. There is significantly muted ghrelin production and a significant increase in GLP-1 levels signaling satiation, suggesting that BAE may be a less invasive method in treating obesity.

1406.4 Irradiation vs. conventional self-expandable metal stents for the treatment of unresectable esophageal cancer: a multicenter randomized controlled trial H.-D. Zhu, J.-H. Guo, G.-J. Teng; Radiology, Zhong-Da Hospital, Medical School, Southeast University, Nanjing, China Purpose: To evaluate the feasibility and safety of a combination of stent insertion and brachytherapy in patients with unresectable esophageal cancer. Material and Methods: Patients with unresectable esophageal cancer were randomly assigned to receive treatment with an esophageal irradiation stent (irradiation stent group) or a conventional esophageal stent (control group) between November 2009 and October 2012. The outcomes were measured in terms of overall survival, palliation of dysphagia, and procedure-related complications. Results: In all, 160 patients were randomly assigned to receive treatment with either an irradiation stent (n=80) or a conventional stent (n=80), 12 patients withdrew from the trial before stent insertion and 8 patients lost to follow-up. The median survival was 177 days (95% CI: 153-201) in the irradiation stent group vs.147 days (95% CI: 124-170) in the control group. The cumulative probability of survival at 90, 180, and 270 days in the irradiation stent group and the control group were 81.4% vs. 69.7%, 49.7% vs. 35.6%, and 33.3% vs. 14.8%, respectively. Dysphagia was relieved rapidly and markedly in both groups, but the mean dysphagia scores in the irradiation stent group were significantly lower than those in the control group since 1 month after stent insertion to the last follow-up. Major complications were severe chest pain (23% vs. 20%), fistula formation (8% vs. 7%), aspiration pneumonia (15% vs. 19%), hemorrhage (7% vs. 7%), and restenosis (28% vs. 27%) in the irradiation stent group vs. the control group. Conclusion: Inserting an irradiation esophageal stent relieves dysphagia caused by unresectable esophageal cancer and durably and subsequently prolongs survival compared with inserting a conventional covered stent.

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1406.5 Dual-centre UK-based experience in colorectal stenting over 7 years W. Sprenger De Rover1, W. Al-Obaydi1, R. Balamurugan2, R. Singh1; 1Radiology, Royal Derby Hospitals, Derby, United Kingdom, 2Radiology, Chesterfield Hospital, Chesterfield, United Kingdom Purpose: Colorectal cancer can present with obstructive symptoms, and stenting is increasingly used for decompression to palliate or as a bridge to curative surgery. We share our experience thus far as well as highlight selected interesting cases and techniques. A retrospective analysis of colonic stenting was performed as a combined endoscopic- and fluoroscopic- guided insertion at over 2 sites from 2006 to 2013. Material and Methods: A list of patients from the radiology information system (RIS) was cross referenced with the consultant’s logbooks. Results: In all, 168 procedures were identified. Nine surgeons and 2 radiologists were involved. (age range: 56-98 years; mean age 74.6 with 50% older than 75 years). Sixty emergency procedures, 12 for locally advanced fistulating tumours, 22 as a bridge to surgery and 68 for purely obstructive symptoms. The covered stents were used for fistulating tumours. Gastroscopic identification of the stricture level and fluoroscopic cannulation with a wire were performed. Stenting was performed by through-the-scope (TTS) technique (over the wire). Biopsies were performed before stent deployment for primary acute presentation. Our technical success rate was 90%, and clinical success rate was 88.5%. Two cases of perforation were identified but not thought to be directly related to the procedure (screening: 3.6-30.1 minutes; average 14 minutes). Conclusion: Our technical and clinical success rates are comparable to the current literature. Combined approach is safe and efficient with better screening time than fluoroscopy alone. No major complications were directly related to the procedure or during the procedure.

1406.6 Use of transnasal approach for gastroduodenal stenting S. Punamiya; Diagnostic Radiology, Tan Tock Seng Hospital, Singapore, Singapore Purpose: Gastroduodenal stents are inserted for palliation of malignant gastric outlet obstruction using endoscopic or radiological methods, both of which involve instrumentation via the oral cavity. This route is often associated with significant pain, gag reflex, and autonomic stimulation, requiring sedation/analgesia. We assessed the feasibility of a transnasal approach for gastroduodenal stenting. Material and Methods: Transnasal stenting was attempted in 8 consecutive patients (8 men and 2 women; mean age, 77 years; age range, 59-84 years) with gastroduodenal obstruction from unresectable or untreatable malignant disease between July 2011 and November 2013. The obstruction was at the level of (a) pylorus, secondary to gastric carcinoma (n=4) and cholangiocarcinoma (n=1); (b) duodenum, secondary to pancreatic carcinoma (n=2); and (c) gastrojejunostomy from recurrent gastric carcinoma (n=1). The obstructive lesion was crossed and stented from the nostril using fluoroscopic guidance and topical anesthesia. Pain was assessed at the end of the procedure using a standard 10-point visual analog scale. Results: All procedures were successfully completed via a transnasal approach without sedation or endoscopic assistance. Twelve uncovered self-expandable metallic stents were used to cross strictures of mean length of 5.5 cm (range, 2-9 cm). The stents were easily trackable across the nasopharyngeal angulation without significant discomfort. No complications were encountered. The mean pain score was 1.5 (range, 0-4).

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Conclusion: Transnasal gastroduodenal stenting is well-tolerated, feasible, and safe. It is an attractive alternative to conventional transoral endoscopic or radiological stenting.

Free Paper Session TEVAR and EVAR 1407.1 Scalloped TEVAR in challenging aortic arch anatomy: short- and medium-term results of a single-centre experience A. Alsafi1, C. Bicknell2, N. Rudarakanchana2, E. Kashef3, R. Gibbs2, M. Jenkins2, M.S. Hamady1; 1Interventional Radiology, Imperial College Healthcare NHS, London, United Kingdom, 2Vascular Surgery, Imperial College Healthcare NHS, London, United Kingdom, 3Radiology, Imperial College Healthcare NHS, London, United Kingdom Purpose: To present our short- and medium-term results of custommade scalloped thoracic stent grafts. Material and Methods: Prospectively acquired data related to patient demographics, procedure details, clinical outcome and complications were analysed. In addition, we analysed pre- and postoperative scans to evaluate aneurysm morphology, graft placement, side-vessel patency and endoleaks. Results: Twenty-one patients with a median age of 71 (35-81) underwent scalloped TEVAR, 8 of whom had a concomitant hybrid repair. Technical success was achieved in all cases. There was no retrograde dissection and conversion to open repair. One patient had inadvertent partial coverage of LCSA, requiring deployment of a non-covered stent. The vessel remained patent with no significant effect on flow. The median follow up period was 22 (1-128) weeks. Out of the 21 patients, 2 died in the hospital and 3 suffered a stroke. There were no type 1 endoleaks during the follow-up period. A type II endoleak was observed in 2 patients, one of whom had a significant sac enlargement requiring re-intervention. One patient had a type III endoleak requiring re-intervention. There were no cases of graft migration. Conclusion: Our midterm results show that scalloped TEVAR is an acceptable treatment for thoracic aortic aneurysms to increase the length of the landing zone without requiring extra-anatomic revascularisation. Further studies, particularly long-term outcome data, are required to establish a wider use of these modified thoracic endografts.

1407.2 Fenestrated and branched stent grafting for post-dissection thoracoabdominal aortic aneurysms K. Oikonomou1, A. Katsargyris1, R. Wolfgang2, E. Verhoeven1; 1Department of Vascular and Endovascular Surgery, Klinikum Nürnberg Süd, Nuremberg, Germany, 2Department of Radiology, Klinikum Nürnberg Süd, Nuremberg, Germany

Abstract Book due to multiple organ failure and one due to cardiac decompensation. Renal function impairment occurred in one (5%) patient. Perioperative spinal cord ischaemia (SCI) occurred in two (10%) patients (temporary). One (5%) patient developed late SCI due to a diminishing endoleak. Mean follow-up (FU) was 12.2 months (range 1-29 months). There was one late death, aneurysm was unrelated. Two target vessel occlusions were noticed (one renal artery and one celiac trunk) during FU, both were asymptomatic. Endoleak was diagnosed in eight (40%) patients during FU, including three type Ib side-branch endoleaks and five type II endoleaks. Reintervention was required in three (15%) patients, all for type Ib endoleak. Three out of five type II endoleaks resolved spontaneously. Mean aneurysm sac diameter reduced from 67.9 ± 5.4 mm to 57.1 ± 6.3 mm (p = 0.007) with a false lumen thrombosis rate of 65% during FU. Conclusion: F/Br-TEVAR is feasible for patients with a post-dissection TAAA. It is associated with a need for reintervention, but seems to lead to favourable aneurysm remodeling.

1407.3 Aortic reconstruction with fenestrated and branched stent grafts after previous open or endovascular aortic surgery A. Katsargyris1, K. Oikonomou1, R. Wolfgang2, E. Verhoeven1; 1Department of Vascular and Endovascular Surgery, Klinikum Nürnberg Süd, Nuremberg, Germany, 2Department of Radiology, Klinikum Nürnberg Süd, Nuremberg, Germany Purpose: To review our experience with fenestrated and branched stent grafts for juxtarenal (JAA) and thoracoabdominal aortic aneurysms (TAAA) after previous aortic surgery. Material and Methods: A prospectively maintained database including all consecutive patients with JAA or TAAA treated with fenestrated and branched stent grafts after previous open or endovascular aortic surgery within the period March 2002-November 2013. Results: Of the 676 patients treated with fenestrated and branched aortic stent grafts, 122 (110 males, mean age 70 ± 9.5 years) had previous open or endovascular aortic surgery. The prior operations were as follows: open infrarenal aortic surgery in 63%, EVAR in 27%, open thoracic aortic surgery in 7.4% and TEVAR in 2.5%. Indication for the current treatment was JAA in 53.3% (65/122) and TAAA in 46.7% (57/122). Technical success was 94.3% (115/122). Operative target vessel perfusion success with endovascular means was 98.5% (391/397). Thirty-day operative mortality was 4.1% (5/122). Major complications occurred in 16.4% (20/122), and mean follow-up was 22.5 ± 21 months. Estimated survival was 91.2 ± 3% and 81.1 ± 4.6% at one and three years, respectively. Estimated target vessel patency was 97.2 ± 1.1% and 96.3 ± 1.2% at one and three years, respectively. Estimated freedom from reintervention was 91.6 ± 3.1% and 82.1 ± 5.4% at one and three years, respectively. Conclusion: Fenestrated and branched stent grafting represents a feasible option for the repair of JAA and TAAA after prior endovascular or open aortic surgery. It is associated with a high technical success rate and favourable mortality and morbidity compared to redo open aortic surgery.

Purpose: To present our experience with fenestrated and branched TEVAR (F/Br-TEVAR) in the treatment of post-dissection thoracoabdominal aortic aneurysms (TAAAs). Material and Methods: A prospectively maintained database including all patients with post-dissection TAAAs who underwent F/ Br-TEVAR within the period October 2010-January 2014. Results: A total of 20 patients (16 males, mean age 65.7 ± 7.7 years) were treated. All cases were technically successful, but in one case, a retroperitoneal approach was required for renal artery catheterization. Two (10%) patients died within 30-days post-operatively: one

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1407.4 Cerebral microembolisation and silent cerebral infarction with thoracic endovascular aortic repair A.H. Perera1, N. Rudarakanchana1, C.D. Bicknell1, L. Monzon2, M.S. Hamady2, O. Kirmi3, R.G. Gibbs1; 1Vascular Surgery, Imperial College London, London, United Kingdom, 2Interventional Radiology, Imperial College London, London, United Kingdom, 3Neuroradiology, Imperial College London, London, United Kingdom Purpose: Overt clinical stroke occurs in 2-8% patients undergoing TEVAR. Silent cerebral infarction (SCI), a brain injury detected incidentally on imaging, is now recognised to contribute to cognitive decline and as a predictor of future stroke, dementia and depression. This study investigates cerebral microembolisation and SCI in patients undergoing TEVAR. Material and Methods: Pre-operative CT aortograms were evaluated for aortic atheroma graded 1-5. Intraoperative transcranial Doppler of bilateral middle cerebral arteries was performed, and microembolic events were identified. A subgroup of patients underwent pre- and post-operative cerebral MRI to identify SCI. Results: Out of the 25 patients, 16 underwent TEVAR, 3 TEVAR + carotid-subclavian bypass and 6 arch/visceral hybrid procedures. Microemboli were detected in all cases and more frequently in (i) patients with severe aortic atheroma (grade 4-5, median emboli 151, IQR 95-210 vs. 1-3, 48, 34-85; p=0.02); (ii) left MCA compared to right (28-146, 83 vs. 19-66, 41; p=0.003) and (iii) treatment (stent graft)related compared with diagnostic wire/catheter passage (20-160, 55 vs. 15-41, 24; p=0.001). Microemboli per procedural step included wire, median emboli 7 (IQR 4-17); catheter manipulation, 20 (9-33); contrast injection, 34 (17-101); stent-graft insertion, 4 (3-8); stentgraft manipulation, 12 (2-28); deployment, 50 (24-141); and delivery device removal, 4 (2-7). There were two post-operative strokes (8%), and SCI was observed in 8/12 patients undergoing MRI. Conclusion: Two-thirds of patients undergoing MRI had evidence of SCI – a previously unrecognised burden, implying the risk of cerebral injury following TEVAR is higher than that presently acknowledged. This study has identified high-risk patients and procedural phases, which will determine future strategies to minimise cerebral injury.

1407.5 When not to use the Multilayer Flow Modulator: lessons learned from using it outside indications for use in 38 cases S. Sultan, M. Sultan, N. Hynes; Vascular and Endovascular Surgery, Western Vascular Institute, Galway, Ireland Purpose: The aim is to scrutinise 38 cases of thoracoabdominal aortic aneurysm (TAAA) treated with the Multilayer Flow Modulator (MFM) outside indications for use, identified from the independent MFM global registry. All treatments were performed in Europe on compassionate grounds for patients whose comorbid disease severity precluded more invasive options. Material and Methods: There were 30 males and 8 females (mean age 70.2 years; mean TAAA diameter 7.1 cm). Ten patients were presented with rupture, and 23 had previous aortic intervention (20 thoracic endovascular, 3 open repair). One patient had both commercially available endografts and an MFM deployed at the same primary setting. Thirteen patients had chronic Stanford type B dissection with aneurysmal dilatation >6 cm. There were 6 mycotic aneurysms, and 4 saccular aneurysms; patients with TAAA Crawford type I, II, III and IV were 1, 7, 5 and 2, respectively. Results: No death, neurological or visceral compromise occurred perioperatively.

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Eighteen-month all-cause survival, freedom from aneurysm-related death and rupture-free survival were 17.5%, 25% and 31.5%, respectively. Eight visceral artery complications occured (6 superior mesenteric and 2 renal). Fourteen endovascular secondary interventions (37.8%) were required in 11 patients. All aneurysms expanded with mean diameter growth rate of 0.12±0.16 cm/month. Factors significantly influencing aneurysm-related death included maximum diameter (p=0.035), previous aortic intervention (p=0.03), number of MFMs deployed (p=0.05) and inadequate overlap between MFMs (p=0.0015). Conclusion: This study demonstrated the clinical scenarios in which MFMs do not perform well. MFMs should not be used indiscriminately in patients in whom other modalities of aortic repair are not feasible. This technology is still in its infancy; it requires technical development and more robust scientific and clinical data.

1407.6 Aortic arch endografting using brachiofemoral wire technique (platform) S. Raz1, D. Silverberg2, E. Atar3, D. Planer4, M. Goodman5; 1R&D, Endospan Ltd., Herzelia, Israel, 2Vascular Surgery, Shiba Medical Center, Ramat Gan, Israel, 3Radiology Department, Rabin Medical Center Hasharon Hospital, Petah Tikva, Israel, 4Cardiology, Hadassah Medical Center, Jerusalem, Israel, 5Vascular Surgery, Shiba Medical Center, Ramat Gan, Israel Purpose: Open reconstruction of the aortic arch is performed in specialized centers with good results, especially with techniques using staged grafting and partial bypass. However, medical morbidities, high costs, and limited access deny intervention to many. Current endovascular devices are limited to custom products. The aim of this study was to develop an off-shelf endovascular arch repair system: Nexus™, employing a right brachiofemoral “throughand-through” (T&T) wire technique to facilitate deployment and optimize cerebral perfusion. Material and Methods: Sixteen pigs underwent endovascular implantation of the Nexus™ device into the arch using the T&T wire technique to implant the stent graft from the brachiocephalic artery to the descending aorta, with modular extensions to the ascending aorta and the left carotid artery. Seven were acute implantations. Total follow-up for nine animals who were planned to survive was 481 days. Results: The T&T system minimized intra-arch manipulation and permitted rapid and accurate deployment of the main graft and modular extensions in all 16 animals. No major vascular complication occurred due to the insertion of the wire. An additional transbrachial latching control was effective by ensuring stent-graft position and stability throughout all stages of deployment. Cranial and distal perfusion was virtually uninterrupted. Imaging confirmed an accurate deployment. Conclusion: A modular device based on a brachiofemoral T&T wire system has the potential to reduce intra-arch manipulation allowing a rapid and accurate deployment. A range of modular components will permit compatibility to variations in arch and ascending aorta anatomy. The potential clinical benefits of the Nexus™ modular T&T system and implantation technique are supported by this study.

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Abstract Book treatments (n=4). Bridging was attained in 21 (MC) and 24 (UCSF) patients and downstaging in 6 (MC) and 3 (UCSF). A mean of 80% necrosis was attained, measured in liver explants. These patients waited for 307 days, on average. Conclusion: It is of utmost importance to have a global strategy for each patient. In our series, a large majority of patients transplanted for HCC had benefited from IR treatments, and they comprise about one fourth of all LTs.

Free Paper Session Combined therapy (ablation and embolisation) 1408.1 Survival rates after radiofrequency ablation and combined radiofrequency and drug-eluting bead transarterial chemoembolization in inoperable hepatocellular carcinoma M.C. Burgmans, J. Schaapman, R. Wolterbeek, C.S.P. van Rijswijk, M. Coenraad, A.R. van Erkel; Radiology, Leids Universitair Medisch Centrum, Leiden, Netherlands Purpose: Local tumor progression (LTP) rates after radiofrequency ablation (RFA) are significantly higher in hepatocellular carcinoma (HCC > 3 cm) compared with smaller HCCs. Combined RFA and drug-eluting bead transarterial chemoembolization (DEB-TACE) can achieve larger ablation zones compared with RFA alone. This retrospective study describes the results of RFA and combined RFADEBTACE in a European population. Material and Methods: Between January 2009 and July 2012, 54 patients [42 males; median age 66 years (range: 29-82)] were diagnosed with de novo unresectable HCC. Patients with HCC > 3 cm were scheduled to undergo RFA followed by DEB-TACE. All other patients would undergo RFA only. LTP-free survival and overall survival (OS) were evaluated. Results: Compared with the RFA group (n=39), patients in the RFADEB-TACE group (n=15) had larger tumors (mean maximal tumor diameter 45.7 mm versus 21.5 mm; p=0.026) and a more multifocal disease (46.7% versus 20.5%; p=0.04). Mean OS of all patients was 40.4 months (34.5-46.2 months; 95% CI). Mean OS in the RFA and RFA-DEBTACE group was 41.6 months (34.6-48.6 months; 95% CI) and 34.8 months (23.5-46.1 months; 95% CI), respectively; not statistically significant. Mean LTPFS for all patients was 30.7 months (23.937.5 months; 95% CI). Patients in the RFA group had better mean LTPFS compared with the RFA-DEB-TACE group: 38.3 months (31.145.5 months, 95% CI) versus 6.6 months (2.7-10.2 months, 95% CI); hazard ratio 0.2. Conclusion: In patients treated with RFA, prognosis is poorer in patients with HCC > 3 cm compared with patients with smaller tumors even when DEB-TACE is performed as an adjuvant treatment.

1408.2 Bridging and downstaging in hepatocellular carcinoma for liver transplant: a retrospective study

1408.3 Local hepatic tumor control in patients undergoing transarterial lipiodol embolization followed by microwave ablation R. Seidel, A. Massmann, P. Fries, G.K. Schneider, A. Buecker; Clinic for Diagnostic and Interventional Radiology, Saarland University Hospital, Homburg, Germany Purpose: To investigate local tumor control in patients with liver tumors undergoing lipiodol embolization and subsequent microwave ablation. Material and Methods: In all, 24 patients with 32 focal liver tumors (mean size 25 mm, 21 patients with HCC, 3 with metastasis of breast cancer, urothelial carcinoma, and angiosarcoma) underwent superselective transarterial embolization with lipiodol. Subsequently, percutaneous CT-guided microwave ablation of the tumors was performed using a 2.45-GHz generator (power output 80-120 W) with cooled tip probes (Acculis; Angiodynamics, USA). All patients were investigated before therapy by unenhanced and dynamic contrastenhanced MR or CT; follow-up was performed at 1, 3, and 6 months after treatment. Treatment was rated as successful in case of a complete rim of necrosis around the lesion. Patient data were evaluated retrospectively on a PACS workstation by two readers in consensus. Results: In 22 of 24 (92%) patients, a complete ablation was diagnosed on early follow-up imaging. The patients rated with incomplete ablation presented tumor progression on subsequent imaging. One patient initially rated as complete ablation presented lesion progression, and all patients with incomplete ablation demonstrated new intrahepatic or extrahepatic (1 patient) diseases. The overall complete ablation rate was 88% (21 of 24 patients). Conclusion: Microwave ablation in combination with lipiodol embolization is a valuable therapeutic procedure for smaller hepatic tumors. Especially the targeting potential of the retained lipiodol on CT scans contributes to a more reliable tumor access.

1408.4

F. Veloso Gomes1, M. Correia2, H. Rio Tinto2, E. Coimbra2; 1Radiology, Hospital de Faro, Faro, Portugal, 2Radiology, Hospital Curry Cabral, Lisbon, Portugal

Transarterial chemoembolization and thermal ablation combination therapy in HCC prior to liver transplant

Purpose: Interventional Radiology (IR) provides non-surgical therapies to reduce the dropout rates from liver transplant (LT) lists and to downstage tumors to meet the criteria for transplantation. The purpose of this study is to review our experience during 2013. Material and Methods: A retrospective study of all patients who underwent LT at our institution in 2013 due to cirrhosis and HCC, and those who underwent locoregional HCC treatments (TACE, RFA, or combined treatment). Treatments were decided at our multidisciplinary meeting. TACE was performed selectively using DC Beads® with Doxorubicin (100-300 μm) until the end-point, near stasis. RFA ablation was performed using the Covidien® Cool Tip Ablation System. CT was performed in all patients as a follow-up. Both Milan (MC) and San Francisco (UCSF) criteria were considered in this study. Results: In 2013, 109 patients underwent LT at our institution, 29 of those due to cirrhosis and HCC (26.6%). A total of 27 patients (93.1%), with a mean age of 58.3 ± 6.1 years, 25 males and 2 females, had been previously subjected to TACE (n=20), RFA (n=3), or to combined

T.G. Van Ha, M. Ginsburg, R. Vasani, B.S. Funaki; Radiology, University of Chicago, Chicago, IL, United States of America Purpose: To evaluate the safety and efficacy of combination therapy in patients with cirrhosis and hepatocellular carcinoma (HCC) and as a bridge to liver transplantation. Material and Methods: Over a six-year period, 89 patients (55 men, 34 women, mean age 65 years) with cirrhosis (70% Child-Pugh A and 30% Child-Pugh B) and HCC (29 patients with multiple tumors) received a combination therapy comprising transarterial chemoembolization followed by thermal ablation. Data were retrospectively reviewed for safety and efficacy, including overall survival (OS), progression-free survival (PFS), and number of patients who received liver transplant. Explanted livers were pathologically examined for tumor necrosis and tract seeding. Results: Median OS was 39 months (95% CI, 23.2-57.3), and median PFS was 9.2 months (95% CI, 7.0-16.6). There were no serious compli-

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cations and no major adverse events (AE-G3-5). The most common minor complication was pain, which resulted in prolonged hospitalization in five patients. There were 33 patients (21 men, 12 women, mean age 60 years) who underwent liver transplantation. A total of 40 lesions were treated in this group with the largest lesion measuring 5.5 cm. Pathological examination showed mean tumor necrosis of 88%. Statistical analysis showed no correlation between the tumor size and the extent of necrosis. No tumor seeding along the tract was noted. Conclusion: Combination therapy is safe and effective in treating HCC and in bridging patients to transplantation. Of note, no tract seeding was noted on imaging or on explanted specimens.

1408.5 Single-step treatment with combined radiofrequency and embolization in hepatocellular carcinoma: a 12-year prospective study J. Urbano, J. Cabrera, A. Alonso-Burgos; Vascular & Interventional Radiology, Jiménez Díaz Foundation University Hospital, Madrid, Spain Purpose: We show our results of combined treatment with radiofrequency and embolization in non-surgical HCC. Material and Methods: Institutional review board approval was obtained, and all patients signed informed consent. Between July 2001 and January 2014, we prospectively included 142 consecutive patients with HCC for simultaneous combined treatment with RF and embolization. In all, 93 men and 49 women (average age 67.4 years, range 43-85) were selected. Patients’ Child-Pugh score was B-7 or less. Tumor size ranged from 15 to 150 mm. For tumors of <3 cm, we combined RF and TAE. For recurrences of any size and for tumors of >3 cm, we combined RF and TAQE. We did not rule out RF in any subdiaphragmatic, subcapsular, or juxtavascular tumor location. Response was evaluated according to the mRECIST criteria. The survival curves were constructed with the Kaplan-Meier method and compared using the log rank test. R program was used for statistical analysis. Results: Complete response for tumors of <3 cm, 3-5 cm, and >5 cm was 100%, 79.6%, and 42.9%, respectively. Distant recurrence was 36.4%, and median survival was 37 months. The 1-, 2-, 3-, 5-, 8-, and 10-year overall survival was 92%, 77%, 62%, 42%, 31%, and 11%, respectively. Histopathology differentiation (p=0.0079), Child-Pugh (p=0.0003), initial response (p=0.0161), tumor size (p=0.0073), and number of tumors (p=0.0122) were survival significant prognostic factors. Major complications were 6.9% and 0.88% mortality. Conclusion: Single-step combined therapy increases the volume and intensity of ablation, providing a better response and fewer recurrences. The association of embolization and RF is safe. There is a trend towards survival improvement.

1408.6 Outcome of RFA combined with chemoradiation in managing inoperable NSCLC patients in Bangladesh M.R. Hassan1, A.S. Murshed2; 1Respiratory Medicine, NICRH, Dhaka, Bangladesh, 2Oncology, Gastro Liver Hospital and Research Institute, Dhaka, Bangladesh Purpose: Our study aimed to explore the efficacy of RFA on various tumor sizes and determine its outcome after combining radiation and/or chemotherapy. Material and Methods: Patients with unresectable nodule NSCLC underwent treatments in 2 different centers from 2000 to 2013. For patients with stage 1 disease, RFA followed by radiotherapy were performed; for stage 2, RFA followed by chemoradiation, and for stage 3, two doses of neoadjuvant chemotherapy followed by RFA

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and then by sequential chemoradiation. Patients’ symptom improvement, local recurrences, overall survival, disease-free survival, and the time of death were measured and compared. Results: Total 500 patients were included for the study. Follow-up range was from 2 to 52 months, median 23.5 months. The 1-, 2-, 3-, and 4- year survival rate of stage I (n=130) was 96%, 87%, 78%, 67%, respectively; in stage II (n=106) was 80%, 68%, 61%, and 57%, respectively; and in stage III (n=64), 71%, 52%, 25%, and 11%, respectively. Local recurrence was 2.8% in <5 cm tumors, while it was 21% in >5 cm tumors within a year. Nineteen patients developed pneumothorax, 35 had infections, and 7 were serious. Moreover, 95% infections were noted in tumors >5 cm. Twenty-four patients died of comorbid diseases, while 77 died of disease progression. Conclusion: RFA followed by EBRT along with adjuvant or neoadjuvant chemotherapy for inoperable NSCLC has a relatively higher rate of complete or partial treatment response and low rate of complications that are easily managed. Above all, survival has improved compared with other combination therapy i.e., chemoradiation or RFA alone.

Free Paper Session Clinical practice 1505.1 Pre-emptive analgesia for percutaneous microwave ablation of liver tumors under moderate sedation A. Vari1, R. Argiro’2, M. Rosignuolo2, M. Corona3, A. D’Adamo2, M. Bezzi2; 1Department of Surgery “Pietro Valdoni”, Sapienza University School of Medicine, Rome, Italy, 2Department of Radiology, Sapienza University School of Medicine, Rome, Italy, 3Vascular and Interventional Radiology Unit, Sapienza University of Rome, Rome, Italy Purpose: To evaluate the efficacy of pre-emptive non-opioid analgesia in reducing intraprocedural opioid use and post-operative pain for percutaneous microwave (MW) ablation of liver tumors under IV moderate sedation. Material and Methods: Patients undergoing percutaneous MW liver ablation under moderate sedation [midazolam (0.5 mg) + titrated boluses of IV fentanyl (20 mcg) to maintain BIS®>70-90 and NRS<3] were randomized to receive paracetamol (15 mg/kg IV) + ketorolac (0.5 mg/kg) either 30 min before (pre) or at the end (post). Contraindications to NSAIDs/paracetamol, cognitive function impairment, and severe chronic pain were excluded. A 0-10 graded numeric rate scale (before the procedure and at 1, 6 and 12 h after the procedure) was used to assess pain. Total procedural opioids, time taken for the first analgesic request, and the amount of supplemental non-opioids were recorded for both groups. Results: Out of the 83 patients, 40 and 43 were included in the pregroup and post-group, respectively. Both were similar for demographics, procedural time, and lesion numbers. Throughout the observation period, pre-group patients reported significantly lower pain scores compared with those of the post-group (P<0.004). Pregroup patients also reported a significantly longer time for the first post-operative analgesic request (10.9 h vs 3.8 h, P<0.003) and lesser analgesic demand (P=0.005). No statistically significant differences were found. Conclusion: Pre-emptive analgesia is initiated before painful stimuli to reduce sensitization of the central and peripheral pathways caused by transmission of pain signals and evoked by tissue damage. Although its role remains controversial, in our study, pre-emptive nonopioid analgesia resulted in a more effective peri-procedural pain control during IV moderate sedation for percutaneous MW liver ablation.

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1505.2 Value of pre-treatment MRI findings to predict the outcome of MRgFUS in ablating uterine fibroids. How much NPV do we need to predict clinical success? I. Mindjuk, M. Matzko; Abt. Radiologie, Klinikum Dachau, Dachau, Germany

Abstract Book Conclusion: PS and PSAT improved significantly after the implementation of an IR outpatient clinic for elective radiological cancer treatments. Patients undergoing such procedures should be observed prior to the procedure in an IR outpatient clinic.

1505.4 How good are we in teaching CT-guided interventions?

Purpose: To assess the dependency of treatment success in MRgFUS of uterine fibroids regarding volume, location, blood perfusion, consistency, and clinical success regarding NPV and the retreatment rate. Material and Methods: A total of 252 patients (mean age, 42.1 ± 6.92 years) suffering from uterine fibroids underwent MR-guided Focused Ultrasound (MRgFUS) treatment on an ExAblate 2100 system (Insightec Ltd, Haifa, Israel). Data was acquired by a 1.5-T MRI system (General Electric HealthCare, Milwaukee, WI). All patients underwent pre- and post-treatment CE-MRI. In addition, symptom severity score was obtained. In the pre-treatment MRI, location, volume, consistency as well as blood perfusion was determined. In the post-treatment MRI, the non-perfused volume (NPV) was measured and correlated to the original planned fibroid volume, which served as an MRI-marker for a successful treatment. All obtained fibroid characteristics were individually correlated with the NPV results. Results: The percentage of NPV was significantly (p<0.001) higher in lesions with a low signal intensity in CE-T1 imaging, lesions lacking septae, distance to the spine of >3 cm, a non-transmural affection, and intracavitary/submucosal and anterior location in the uterus. An NPV ratio of ≥85% is highly correlated to clinical success. Conclusion: The outcome of MRgFUS treatment of uterine fibroids regarding NPV and the clinical success is highly dependent on the location, volume, consistency, and blood perfusion of fibroids.

1505.3 Impact on patient safety and satisfaction of implementation of an outpatient clinic in interventional radiology (IPSI-POLI study) J. Lutjeboer, M.C. Burgmans, A.R. van Erkel; Radiology, LUMC, Leiden, Netherlands Purpose: Referring physicians often have no in-depth knowledge of interventional radiology (IR) procedures. Yet, in most centers, patients are informed and consented about such procedures by referring physicians and not the interventional radiologists. As a result, patients may not be informed adequately, receive incorrect preparation, and the informed consent may be illegitimate. In this study, the impact of an outpatient IR visit was evaluated on patient safety (PS) and patient satisfaction (PSAT). Material and Methods: Using a quasi-experimental design, elective oncological IR procedures were evaluated during 4 months before (n=110) and 4 months after the implementation (n=110) of an outpatient visit for PS and PSAT. The intervention comprised an outpatient visit 2-14 days prior to IR procedure, where procedural information was provided and screening on safety risk events were performed. PSAT was assessed by means of a questionnaire measuring three dimensions: interpersonal care aspects, information/communication, and patient participation. The CIRSE IR checklist was used to assess PS. Results: The average number of process deviations per patient was 0.39 in the control group compared with 0.06 in the experimental group (p<0.001). In 9.1% patients in the control group, no legal informed consent was obtained compared with 0% in the experimental group. Overall PSAT showed a significance difference between the control and experimental groups (p<0.001). Significant improvement was observed in the dimensions of interpersonal aspects (p=0.005) and information/communication (p<0.001).

M. Pradella1, T. Heye1, C.G. Trumm2, M. Takes1, A. Kircher1, C.J. Zech1; 1Klinik für Radiologie und Nuklearmedizin, University Hospital Basel, Basel, Switzerland, 2Institute for Clinical Radiology, LudwigMaximilians-University Hospital Munich, Munich, Germany Purpose: CT-guided biopsies and drainages are established by minimally invasive methods. The physicians’ experience was correlated with the procedure’s individual difficulty and efficiency in 1024 cases to evaluate the impact of experience on complications and clinical success. Material and Methods: In all, 1024 cases were evaluated retrospectively regarding lesion size, distance from the skin, procedure duration, radiation dose, complications and clinical success. Procedures were grouped into biopsies of lung, liver, remaining abdomen, musculoskeletal system (MSK) and drainages of any region. Efficiency was defined as the reciprocal of the procedure’s duration multiplied by its radiation and difficulty as distance from the skin divided by diameter. Results: Overall complication rate was 8.0% (6.4% minor, 1.6% major complications; experienced vs. inexperienced operators: 8.5% vs. 7.5%; p=0.58). Success rate was 93.3% (93.2% vs. 93.3%, p=0.81). Experienced radiologists performed significantly more difficult thoracic and liver biopsies (p=0.04 and 0.003, respectively), but only for liver biopsies, experience lead to significantly better clinical results (p=0.002). Abdominal biopsies were significantly more difficult in case of failure (p=0.04), whereas this was not seen in the other groups. Efficiency correlated positively with experience in all subgroups except MSK (abdominal p=0.007, thoracic p<0.0001, liver p=0.0004 and drainages p<0.0001; MSK p=0.11). Successful procedures by experienced physicians were likewise more effective (shorter, less radiation) in all subgroups except MSK (p=0.008, <0.0001, <0.0001 and 0.005, respectively; MSK p=0.14). Conclusion: Our data suggests that radiologists in training can achieve success rates which are almost equivalent to those of experienced operators; however, the procedures are longer and more radiation is required. Overall, CT-guided techniques remain a safe and successful option.

1505.5 Systematic review of aspirin, ticlopidine, clopidogrel, aspirin plus clopidogrel, and aspirin plus ticagrelor for prevention of cardiovascular events in patients with peripheral arterial disease: a Bayesian network meta-analysis of randomized controlled trials K.N. Katsanos1, S. Spiliopoulos2, A. Diamantopoulos1, M. Krokidis3, D. Karnabatidis2, D. Siablis2; 1Interventional Radiology, Guy’s and St. Thomas’ Hospitals, London, United Kingdom, 2Department of Diagnostic and Interventional Radiology, Patras University Hospital, Patras, Greece, 3Department of Radiology, Cambridge University Hospitals, Cambridge, United Kingdom Purpose: We conducted a network meta-analysis of all available randomized controlled trials (RCT) comparing aspirin (ASA), ticlopidine (TCD), clopidogrel (CLP), aspirin plus clopidogrel (ASA + CLP), and aspirin plus ticagrelor (ASA + TCG) with placebo or with each other for the prevention of cardiovascular events in patients with peripheral arterial disease (PAD).

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Material and Methods: Thirty RCTs comprising 21,700 patients with 68,500 person-years of follow-up were analyzed on an intentionto-treat basis. Bayesian random effects and Poisson models were employed for mixed treatment comparisons, and the primary endpoint was the composite of cardiovascular deaths, non-fatal myocardial infarction, and non-fatal stroke. Secondary endpoints were major amputations and major bleeding events. Pairwise rate ratios (RR) of absolute treatment effects were calculated (Markov Chain Monte Carlo simulation - WinBUGS) and reported as the posterior median and associated credible intervals (CrI). Results: With the exception of ASA, all ADP-inhibiting antiplatelet regimens produced a statistically significant reduction of the composite endpoint compared with the placebo (reference). CLP had the strongest effect (RR: 0.72, 95% CrI: 0.57-0.90). Dual antiplatelet therapy with ASA + CLP was the only treatment associated with a significant reduction of major amputations (RR: 0.46, 95% CrI: 0.460.99 compared with ASA). Major bleeding events were significantly increased with the use of TCD (number needed to harm; NNH = 10 person-years) and ASA + CLP (NNH = 255 person-years). Conclusion: ADP inhibitors prevent major cardiovascular events in patients suffering from PAD. Dual antiplatelet therapy with ASA + CLP may also reduce the incidence of major amputations but is related to an increased risk of major bleeding.

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Material and Methods: Between October 2012 and December 2013, 18 patients with LALC underwent CACBCT-guided IACH. All patients had locally advanced non-small cell lung cancer (NSCLC) except one patient who had a locally aggressive small cell lung cancer. Four patients had distant metastases that were under control. In all patients, through the femoral artery, multiple CACBCT angiographies were performed, and the feeding arteries of the tumors were identified. These arteries were then selectively catheterized, and cisplatin + docetaxel combination was infused. Patients were followedup with PET-CT, whenever possible, or with contrast CT. Results: In total, 35 sessions of IACH were performed in 18 patients (1-4 sessions per patient). No major complications occurred because of IACH procedures. Seven patients were excluded due to death (n=4) and chemotherapy intolerance (n=3). In the remaining 11 patients, 8 had follow-up images and were included in the evaluation. Among them, 4 had complete or near-complete response, 3 had partial response, and 1 had a stable disease. No patients had tumor progression. Of the four patients who had complete or near-complete response on PET-CT, 2 were operated, and a pathological examination revealed no viable tumor cells (complete pathologic response). Conclusion: Although the number of our patients is small and the follow-up duration is short, the results of our study suggest that CACBCT-guided IACH is quite safe and effective. However, our results should be confirmed with prospective series in a larger number of patients.

Anti-Müllerian hormone levels before and after uterine artery embolization: a preliminary report

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B. McLucas1, W.D. Voorhees III2; 1Obstetrics and Gynecology, UCLA, Beverly Hills, CA, United States of America, 2Med Institute, Inc., West Lafayette, IN, United States of America

Can we trust arterial calcium stimulation with hepatic venous sampling as a precise tool to locate insulinomas preoperatively?

Purpose: To determine the effects of uterine artery embolization (UAE) on Anti-Müllerian hormone (AMH) levels for women under 40 years. Material and Methods: This is a non-randomized, observational study of 14 women under 40 years and who underwent UAE. Hormone levels were measured prior to UAE and at least six months after UAE. Results: Statistical analysis from a paired t-test showed that AMH levels pre- and post-embolization of these women fell within the normal range. The average AMH level prior to embolization was 1.98 ± 1.50 ng/mL. The mean AMH concentration after embolization was 1.85 ± 1.36 ng/mL. The average change in AMH levels between preand post-embolization was −0.13 ± 0.96 ng/mL. There was no statistically significant difference between the pre- and post-UAE AMH levels (p = 0.62). Conclusion: No significant change in AMH levels before and after embolization suggests that UAE does not affect ovarian reserve in women under 40. Women who are of a reproductive age and have fibroids can consider UAE to adversely affect their fertility.

Free Paper Session Special vascular IR oncology 1506.1 C-arm cone-beam CT-guided selective intraarterial chemotherapy in locally advanced lung cancer S. Yilmaz, M. Ozdogan, N. Oz, M. Cevener, A. Kargi, A. Yildiz; Medstar Yildiz Hospital, The Mediterranean Integrative Oncology Group, Antalya, Turkey Purpose: To evaluate the safety and efficacy of C-arm cone-beam CT (CACBCT)-guided selective intra-arterial chemotherapy (IACH) in patients with inoperable locally advanced lung cancer (LALC).

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S. Lombardo Galera, L. Zurera Tendero, J.J. Espejo Herrero, I. Bravo Rey, M. Canis López; Interventional Radiology Unit, Hospital Reina Sofia, Cordoba, Spain Purpose: A selective arterial stimulation with calcium injection and hepatic venous sampling (ASVS) has been used as a localizing tool for insulinomas like other non-invasive localization modalities. The aim of this study is to assess the sensibility of ASVS in localizing insulin-secreting tumors. We measured the accuracy of CaStim for the localization of insulinomas preoperatively. Material and Methods: We retrospectively studied 33 patients with severe hyperinsulinemic hypoglycemia. The non-invasive localization techniques were nondiagnostic, and in all cases, ASVS was performed. Surgery was performed, and ASVS results were compared with the surgical findings, and these were considered as references for a statistical study. Results: The ASVS technique was performed in 33 patients. Surgery was performed in 24 patients, 22 with positive ASVS. Endogenous hyperinsulinism was performed in 19 patients, and all of these were detected in ASVS. The sensitivity of the ASVS test was 91.6%, and 100% of endogenous hyperinsulinism had a positive result on ASVS. This association was statistically significant (chi2 = 15.771; p < 0.001). A good and statistically significant agreement was obtained between histopathologic diagnosis and ASVS results. (k = 0.518, p < 0.001). Tumors were most frequently localized in body-tail (45%), head (37.5%), and tail (16.6%). Conclusion: ASVS is a very sensitive technique for preoperative localization of insulin-producing tumors and is superior to other localization modalities. ASVS allows to identify tumors in the pancreatic gland and help to plan a minimally invasive surgery.

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1506.3 Tumor degradation after complete tumor response following transarterial ethanol ablation for hepatocellular carcinoma S.C.-H. Yu; Imaging and Interventional Radiology, Chinese University of Hong Kong, Hong Kong, Hong Kong Purpose: Transarterial ethanol ablation (TEA) using a mixture of ethiodized oil and ethanol mixed in 2:1 ratio by volume is a hybrid of bland embolization and chemical ablation. We aimed to study the tumor degradation process of hepatocellular carcinoma (HCC) following complete tumor response to TEA. Material and Methods: Between 2001 and 2011, 184 patients with inoperable HCC (243 lesions) were treated with TEA. There were 154 lesions of size < 5 cm and 89 of size ≥ 5 cm. Tumor response of all lesions was followed with CT at 3-month intervals until death and assessed with the European Association for the Study of the Liver criteria. Lesions showing complete response throughout the follow-up period were selected for the study. The percentage of tumor volume compared with baseline was calculated for evaluating the process of tumor degradation over time. Results: The mean overall survival by Kaplan-Meier analysis was 36.1 months. Initial complete tumor response within 3 months occurred in 205 of 243 lesions (84.4%), and 131 of 243 lesions (53.9%) showed complete response throughout the follow-up period. The mean (interquartile range) percentage tumor volume compared with baseline at 6 months, 12 months, 24 months, and 48 months was 46% (30-66%), 29% (17-54%), 18% (13-38%), and 10% (0-30%), respectively for tumors of size < 5 cm, and 44% (34-67%), 34% (2853%), 27.4% (24-49%), and 22% (20-34%), respectively for tumors of size ≥ 5 cm. Conclusion: Complete tumor response is common following TEA for HCC, a continuous and substantial tumor degradation process that lasts for years, takes place afterwards, and leads to dramatic tumor volume reduction.

1506.4 Palliative embolotherapy for GI hemorrhage from malignant neoplasms J.C. Andrews, C.J. Fleming, A. Stockland; Radiology, Mayo Clinic, Rochester, MN, United States of America Purpose: To evaluate the safety and efficacy of selective embolotherapy for gastrointestinal hemorrhage secondary to malignant neoplasms. Material and Methods: Between February 1996 and August 2013, thirty eight patients with hemorrhage secondary to malignant neoplasms arising from or metastatic to the GI tract were referred for embolotherapy. Patients were included on an intent-to-treat basis, and interventions were performed at the discretion of the operating physician. Most common tumor types included renal cell carcinoma (9 patients) and pancreatic adenocarcinoma (6 patients). Patients were presented with hematemesis (7 patients), hematochezia (8 patients), or melena/anemia (23 patients). After diagnostic angiography to define the tumor blood supply, embolization was performed with a variety of materials. Follow-up was based on chart review. Results: Embolization was performed in 32/38 patients (84%); by site, in the esophagus (1/1), stomach (6/6), duodenum (21/22, 95%), small bowel/colon (4/8, 50%). Reasons to not embolize were: no tumor identified (1 case), extensive tumor with concern for bowel ischemia (4 cases), IMA dissection (1 case). The embolic agents used were: gelfoam (6 cases), PVA (27 cases), and coils (12 cases). Immediately following, embolization bleeding was controlled in 30/32 patients. Four patients were re-treated for recurrent bleeding. Survival after embolization was a mean of 144 days in the 24

Abstract Book treated patients with follow-up available. No complications related to embolization were encountered. Conclusion: Although survival is related to the biology of the patient’s tumor, embolotherapy can control GI hemorrhage secondary to malignant neoplasms and is most applicable to the stomach and duodenum.

1506.5 Improving survival and the quality of life in HCC patients with portal vein thrombosis using radio-interventional techniques R. D’Angelo1, F. Somma2, R. Galasso2, F. Izzo3, V. Albino3, F. Fiore1; Radiation Therapy and Nuclear Medicine, National Cancer Institute G.PASCALE, Naples, Italy, 2Radiology, Second University of Naples, Naples, Italy, 3Department of Surgical Oncology, National Cancer Institute, Naples, Italy 1Radiology,

Purpose: To estimate the possibility of improving the survival rate in HCC patients with portal vein thrombosis (PVT) using transarterial radioembolization (TARE) with Y-90 microspheres compared with no evidence of PVT and treated with similar techniques. Material and Methods: We performed 87 TARE between November 2005 and March 2013 in 77 patients (42% males; 58% females; age range 28-84 years) with unresectable HCC (BCLC advanced stage; size of lesions 1.1-5.5 cm; and bilirubin values up to 2.6 mg/dl). Among these, 23 patients had thrombosis of only one branch of portal vein (monolateral PVT). Pre-treatment work-up included multislice computed tomography and angiography, and 12 of them underwent embolization of the gastroduodenal artery using microcoils to avoid gastrointestinal side effects. The average dose administered was 1.7 GBq. Results: After the procedure, fever and abdominal pain were found in 29 and 19 patients, respectively. No other side effect was observed. A partial response was found in at least 69.3% and 89.8% patients at 3 and 9 months, respectively, after the procedure according to the mRECIST criteria. Conclusion: TARE was shown to be a safe and effective locoregional technique in BCLC advanced HCC patients, even in those with monolateral PVT. Indeed, a similar survival curve was showed by both patients with and without PVT. Moreover, a regression was evident in >50% patients with PVT, thus improving survival and the quality of life according to the ECOG scale.

1506.6 I-131-lipiodol therapy in local disease control and survival in patients with advanced hepatocellular carcinoma (HCC): an observational study S.S. Shivalingappa, I. Subbanna, K.G. Kallur, S. Malige; Imaging and Interventional Radiology, Health Care Global Enterprises, Bangalore, India Purpose: In this exploratory study, we aim to test the effectiveness of I-131-lipiodol in prolonging survival in patients with advanced HCC. Material and Methods: From March 2011 to November 2013, 59 patients with locally advanced/metastatic HCC (Childs A, B and C) were examined; the median survival was 3 months. Most patients had altered liver functions, which made them unsuitable for any therapy or have a failed standard line of therapy. The total serum bilurubin levels ranged 3-4 mg/dL. More than 50% patients had tumour thrombus in one or both portal veins. Patients had received prior chemotherapy, TACE therapy, sorafenib and had treatment refractory progressive disease. All patients received I-131-lipiodol therapy. We performed Kaplan-Meier analysis to evaluate median survival in this population. Results: In all, 50% patients had Childs A, 20% had Childs B and 30% had Childs C cirrhosis. Moreover, 50% patients had portal vein

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thrombosis. The Childs status did not influence median survival with I-131-lipiodol therapy. Median survival in patients without portal vein thrombosis was 195 days, 95% CI: 0-442 days, log-rank (MantelCox) χ 2 = 3.65, p=0.05 compared with those with portal vein thrombosis with a median survival of 71 days, 95% CI: 40-101 days. Results suggest that portal vein thrombosis is a prognostic predictor for median survival in patients with treatment-refractory HCC. Conclusion: I-131-Lipiodol is a useful local therapy in management of patients with advanced HCC and in providing a better quality of life. Randomized controlled trials are required to validate its findings in adjuvant and palliative settings.

Free Paper Session Peripheral arterial disease 2205.1 Relative importance of plantar arch integrity to crural runoff and angiosome-directed revascularization in predicting limb salvage in critical limb ischemia Z. Tan1, K.-H. Tay2, F.G. Irani3, A. Gogna3, S. Ramamurthy2, H.G.R. Lo2, A. Patel2, S.X.J.M. Chan2, C.W. Too2, J.P. Robertson2, S.Y.B. Chua4, S.G. Tan4, S.P. Chng4, S. Pasupathy4, T.T. Chong4, M.K. Pwint2, B.S. Tan2; 1Medical student, Duke-National University of Singapore Graduate Medical School Singapore, Singapore, Singapore, 2Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore, 3Department of Radiology, Singapore General Hospital, Singapore, Singapore, 4Vascular Surgery, Singapore General Hospital, Singapore, Singapore Purpose: To elucidate the importance of plantar arch integrity and compare it to crural runoff and angiosome-directed revascularization for predicting limb salvage in critical limb ischemia (CLI). Material and Methods: We retrospectively studied 693 limbs in 511 patients (age 67±11 years, 93% diabetes mellitus, 74% single angiosome tissue loss) presenting with CLI for angioplasty. From complete angiograms and medical records, the patient population was stratified according to crural runoff (n=639) [0 (7%), 1 (53%), 2 (32%), and 3 (9%) vessels], angiosome-directed revascularization (n=513) [indirect/IR (50%) and direct/DR (50%) revascularization), and plantar arch integrity (n=628) [absent/APA (8%), partial/PPA (73%), and complete/CPA (19%)]. Limb salvage rates were generated using Kaplan-Meier methodology and compared using the log-rank test. Multivariate analysis was conducted using the Cox proportional hazards model. Results: The overall 1-year limb salvage rate was 66±2%. One-year limb salvage rates were 50±10%, 65±3%, 68±4%, and 74±7%, respectively, for 0, 1, 2, and 3 crural runoff (p=.011); 52±6% and 70±3%, respectively, for IR and DR (p=.017); and 40±9%, 64±3%, and 86±4%, respectively, for APA, PPA, and CPA (p<.001). Single crural runoff improved limb salvage (p<.01), but additional crural runoff did not (1 and 2 vessels, p=0.444; 2 and 3 vessels, p=.548). DR improved limb salvage in APA and PPA (p=.021) but not in CPA (p=.285). On multivariate analysis, single-vessel runoff [hazard ratio (HR)=.515, 95% CI:.282-.941, p=.031], PPA (HR=.368, 95% CI:.229-.592, p=<.001), and CPA (HR=0.334 95% CI:.186-.602, p=<.001) were associated with improved limb salvage. Conclusion: Thus, a complete plantar arch offers the best limb salvage rates followed by direct revascularization and partial plantar arch.

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2205.2 Wound healing outcomes and health-related quality-of-life changes in the ACHILLES trial: 1-year results from a prospective randomized controlled trial of infrapopliteal balloon angioplasty versus sirolimus-eluting stenting in patients with ischemic peripheral arterial disease K.N. Katsanos1, S. Spiliopoulos2, A. Diamantopoulos1, D. Karnabatidis2, D. Scheinert3; 1Interventional Radiology, Guy’s and St. Thomas’ Hospitals, London, United Kingdom, 2Department of Diagnostic and Interventional Radiology, Patras University Hospital, Patras, Greece, 3Clinical and Interventional Angiology, Park Hospital Leipzig, Leipzig, Germany Purpose: The ACHILLES multicenter randomized trial has shown that sirolimus-eluting stents (SES) may achieve lower vessel restenosis and higher event-free survival rates compared with plain balloon angioplasty (PTA) for infrapopliteal lesions. The authors herein report the wound healing (WH) outcomes, health-related quality-oflife (HRQOL) changes, and quality-adjusted life years (QALYs) gains. Material and Methods: Two hundred patients were randomly assigned between SES and PTA for the treatment of infrapopliteal arterial occlusive lesions. Index-limb wound status was serially assessed by digital photography. The progression of wound healing was reviewed by a blinded independent diabetic foot specialist. HRQOL scores were assessed using the self-administered EuroQoL 5-D system (EQ-5D) up to 1 year from randomization. QALYs gained were calculated with a multiplicative model employing distributionfree Bayesian modeling. Results: In total, 99 open wounds were observed at baseline and evaluated up to 1 year. Wound closure rates improved in SES with a trend toward significance (72.9 vs. 55.6% closed wounds in PTA, P=0.088). The overall weighted EQ-5D score improved significantly up to 1 year in SES (P<0.0001) but not in PTA. There was a strong trend of more QALYs gained with SES compared with PTA up to 1 year after randomization. When analyzing the complete study arms, the relative QALY gain of SES compared with that of the PTA control group was 0.10 (95% CI:−0.01-0.21; P=0.08) at 1 year, and 0.17 (95% CI:−0.03-0.35; P=0.09) when analyzing the wound sub-groups only. Conclusion: Placement of SES in the infrapopliteal arteries seems to improve wound healing and the quality of life compared with plain balloon angioplasty.

2205.3 Randomized clinical trial favors the use of drug-coated balloons over plain balloons for post-dilatation of nitinol stents in SFA and PI segments to lower restenosis rate D. Kieselbach1, J. Tacke2; 1Clinical Department, Eurocor GmbH, Bonn, Germany, 2Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Klinikum Passau, Passau, Germany Purpose: Stents are required in up to 50% of all peripheral interventions where PTA with plain or drug-coated balloons alone will not reopen the vessel sufficiently. The restenosis rate of stents is still a major limitation of peripheral arterial interventions. Drug-coated balloons potentially overcome the problem of restenosis when used for post-dilatation after primary nitinol stenting in SFA and PI segments. Material and Methods: The Freeway Stent Study is a prospective, randomized, international trial initiated in 15 centers in Germany and Austria. In all, 200 patients will be enrolled and randomized equally to primary nitinol stenting followed by either DCB (Freeway™) or plain balloon post-dilatation. The primary endpoint is clinically driven TLR at 6 months, whereas secondary endpoints include shift in Rutherford classification and ABI, LLL, patency rate, and MAE.

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Results: Over 160 patients have been enrolled to date, of which 120 have completed 6 months and almost 100 have completed the 12-month follow-up. Results favor using Freeway™ DCB based on clinically driven TLR (only 3.5% at 6 months and 8.9% at 12 months). This is supported by a significantly better clinical outcome for PAD patients treated with DCB as a post-dilatation device regarding primary patency rate, ABI, and Rutherford classification. Conclusion: The use of DCB as post-dilatation device is investigated in a new approach to decrease the restenosis rate after stenting in SFA and PI segments. The interim results of the Freeway Stent Study show that DCB might lower the in-stent restenosis rate in the treatment of PAD patients.

2205.4 Angioplasty and stenting for radiation-induced carotid stenosis: a comparative study with atherosclerotic stenosis in 6-year clinical outcome and in-stent restenosis S.C.-H. Yu1, W. Zou2, Y. Soo2, W.Y.J. Hui3, A. Chan2, K.T. Lee3, V. Ip2, F. Fan2, L. Wong2, T. Leung2; 1Imaging and Interventional Radiology, Chinese University of Hong Kong, Hong Kong, Hong Kong, 2Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, Hong Kong, 3Department of Imaging & Interventional Radiology, Prince of Wales Hospital, Hong Kong, Hong Kong Purpose: We aimed to evaluate the safety of clinical and angiographic outcome of carotid angioplasty and stenting (CAS) for severe (≥70%) radiation-induced carotid stenosis (RIS) using atherosclerotic stenosis (AS) as a control. Material and Methods: In this 6-year prospective non-randomized study, we compared the CAS outcome of 65 consecutive patients (84 vessels) with RIS to that of a control group of 129 consecutive patients (150 vessels) with AS using Carotid Wallstent and filter-wire protection. Study endpoints were periprocedural stroke or death, ipsilateral ischemic stroke, technical success, procedure characteristics, in-stent restenosis of ≥50% (ISR), and symptomatic ISR. Results: Median clinical follow-up period was 47.3 months (95% CI: 26.9-61.6). One-year imaging assessment was available in 74 vessels (RIS) and 120 vessels (AS). Comparing the RIS group with the AS group, the rate of periprocedural stroke or death was 1.5% (1/65) versus 1.6% (2/129) (P = 1) and ipsilateral ischemic stroke rate was 4.6% (3/65) versus 4.7% (6/129) (P = 1). The annual risk of ipsilateral ischemic stroke were 1.2 % (3/254.7 patient-years) versus 1.2% (6/494.2 patient-years) (P = 0.89); technical success rate was 100% for both; stenting of common carotid artery and use of multiple stents were more common in the RIS group (P = 0 for both). ISR rate was 25.7% (19/74) versus 4.2% (5/120) (P < 0.001); symptomatic ISR rate was 6.8% (5/74) versus 0.8% (1/120) (P = 0.031). Conclusion: The safety, effectiveness, and technical difficulty of CAS for RIS are probably not different from that for AS, although it is associated with a higher rate of ISR.

2205.5 Randomized trials for endovascular treatment of infrainguinal arterial disease: systematic review and meta-analysis (part 1: above the knee) S. Jens1, A.P. Conijn1, M.J.W. Koelemay2, S. Bipat1, J.A. Reekers1; 1Radiology, Academic Medical Center, Amsterdam, Netherlands, 2Vascular Surgery, Academic Medical Center, Amsterdam, Netherlands Purpose: To evaluate the 1-36-month follow-up outcomes of different endovascular treatment strategies in above-the-knee (ATK) arterial segments in patients with intermittent claudication (IC) and critical limb ischemia (CLI).

Abstract Book Material and Methods: Studies indexed in Medline and Embase from 1980 to November 2013 were evaluated. Randomized controlled trials comparing balloon angioplasty (PTA) or drug-eluting balloon (DEB) with optional bailout stenting or primary stenting using a bare stent (BS) or drug-eluting stent (DES) to one another were included. Methodological quality of each trial was assessed using Cochrane Collaboration’s tool, and the quality of evidence was assessed using the GRADE system. Outcomes assessed were the quality of life, walking capacity evaluated by treadmill or questionnaire, change in Rutherford classification, target lesion revascularization (TLR), bypass, binary restenosis, late lumen loss, stenosis grade, amputation, death, major adverse cardiac events, or event-free survival with follow-up periods of at least 1 month. Results: Twenty-three trials including 3314 patients in total were identified, 85% patients had IC and 15% CLI. Fifteen trials showed no systematic benefit of BS over PTA. One trial comparing DES and PTA reported no significant differences in walking capacity or Rutherford classification. Four trials showed a beneficial effect on the TLR rate, but not on Rutherford classification of DEB compared with PTA. In four trials, DES did not systematically perform better than BS. Conclusion: In general, performing PTA with optional bailout stenting for ATK lesions is the preferred strategy in patients with IC. For CLI, further studies are required for recommending an optimal treatment strategy.

2205.6 Outcomes of endovascular first strategy in critical limb ischemia S. Jens1, A.P. Conijn1, F. Frans2, M.B.B. Nieuwenhuis1, R. Met2, M.J.W. Koelemay3, D.A. Legemate3, S. Bipat1, J.A. Reekers1; 1Radiology, Academic Medical Center, Amsterdam, Netherlands, 2Surgery, Academic Medical Center, Amsterdam, Netherlands, 3Vascular Surgery, Academic Medical Center, Amsterdam, Netherlands Purpose: To study a more real-life outcome of patients with critical limb ischemia (CLI) in an institution with a multidisciplinary team (MDT) approach with a preference toward endovascular intervention first. Material and Methods: A prospective observational cohort study was conducted between May 2007 and May 2010 on patients presenting with CLI. At baseline, MDT selected the optimal treatment, with a preference towards endovascular intervention first. Patients received endovascular treatment, surgical revascularization, primary major amputation, or conservative treatment. Primary endpoints were the quality of life and functional status 6 and 12 months after the initial intervention assessed by the VascuQol and ALDS questionnaire, respectively. Results: Overall, 150 patients were included; 98 had endovascular intervention, 36, surgery, 5, major amputation, and 11, conservative treatment. During follow-up, 40% underwent an additional ipsilateral revascularization procedure. For the total population and endovascular and surgery subgroups, VascuQol sum scores improved after 6 and 12 months (p<0.0001 for all outcomes) compared with baseline. The functional status improved (p=0.014) after 12 months compared with that of baseline for the total population. The functional status of the surgery subgroup improved after 6 (p=0.003) and 12 (p=0.011) months compared with baseline. The other subgroups did not show significant changes. Conclusion: Overall, the strategy of using MDT with a preference toward endovascular treatment first has comparable or even slightly better results than those of other cohorts. All vascular groups should consider implementing MDT to optimize patient outcomes, and discuss whether their treatment strategy should be aimed at treating CLI patients, preferably endovascular first.

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2205.7 The PACIFIER trial. A randomized multicenter trial evaluating prevention of restenosis with paclitaxel-coated PTA balloon catheters in stenosis or occlusion of femoropopliteal arteries: first report of the 3 year follow up results M. Werk1, T. Albrecht2, D.-R. Meyer3, Ö. Gögebakan4, A. Behne2, U. Dietz5, G. Eschenbach2, H. Hartmann3, C. Lange1, B. Schnorr6 , H. Stiepani1, G. Biondi Zoccai7, E.L. Hänninen1; 1Radiology, Martin-Luther-Krankenhaus, Berlin, Germany, 2Institut für Radiologie und Interventionelle Therapie, Vivantes - Klinikum Neukölln, Berlin, Germany, 3Diagnostic and Interventional Radiology, Hubertus-Hospital, Berlin, Germany, 4Department of Radiology and Interventional Therapy, Vivantes Clinic, Berlin, Germany, Berlin, Germany, 5Department of Cardiology, German Diagnostic Clinic, Wiesbaden, Germany, 6Department of Experimental Radiology, Charité, Universitätsmedizin Berlin, Berlin, Germany, 7Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy Purpose: Drug Eluting Balloons (DEB) have shown to safely and effectively reduce restenosis and reintervention rates versus standard PTA at 6 and 12 months after femoro-popliteal revascularization. This is the first report of the 3-year results of the PACIFIER randomized trial. Material and Methods: PACIFIER is a randomized multicenter trial testing DEB vs. standard PTA with provisional stenting in patients symptomatic for claudication and CLI due to femoro-popliteal disease. 85 patients (91 cases = interventional procedures) were randomized in 3 hospitals (44 to DEB and 47 to uncoated balloons). Baseline, procedural and 6 and 12 month outcomes were previously published (M.Werk et al. Circ Cardiovasc Interv 2012). Average lesion length was 7.0±5.3 and 6.6±5.5cm for DEB and PTA respectively. Results: Late lumen loss at 6 months (primary endpoint assessed by blinded angiographic corelab) was significantly lower in DEB versus PTA (−0.01mm vs. 0.65mm, P=0.001). Significant lower binary restenosis (8.6% vs. 32.4%, P=0.01) and target lesion revascularization (TLR) rates (7.1% vs. 27.9%, P=0.02) were reported at 6 and 12-month respectively for DEB versus PTA. At 2-year follow up (23.6±1.7 months) the TLR and major adverse events rates for DEB versus PTA were 16.7 % vs. 28.9% (P=0.2) and 21.4% vs. 37.8% (P=0.1) respectively. Exact numbers for the 3-year follow up will be available in September 2014. Conclusion: Safety and efficacy of IN.PACT DEB for the treatment of femoro-popliteal arterial disease is maintained at 2-years with lower reintervention and major event rates versus PTA. Exact numbers for the 3-year follow up will be available in September 2014.

Free Paper Session Cryo- and brachytherapy 2206.1 Efficacy and safety of image-guided cryoablation for stage 1 renal cell carcinoma: long-term results of a prospective study C.S. Georgiades1, M. Lessne2, R. Rodriguez3; 1Vascular & Interventional Radiology, American Medical Center, Nicosia, Cyprus, 2Interventional Radiology, Johns Hopkins University, Baltimore, MD, United States of America, 3Urology, University of Texas, San Antonio, TX, United States of America Purpose: Percutaneous cryoablation is a curative option for stage 1 renal cell carcinoma (RCC). Nonetheless, prospective data are lacking. We present the 5-year oncologic and safety outcomes of one such prospective trial.

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Material and Methods: In the 2006-2012 study period, we treated a total of 265 patients using CT-guided, percutaneous cryoablation for solid renal masses up to 7 cm. Of them, 134 patients had biopsy-proven RCC and were included in the study. The technical objective was for the “ice ball” to cover the lesion plus a minimum 5-mm margin. Efficacy was defined as the lack of enhancement and enlargement of a previously enhancing lesion on follow-up imaging. Safety was assessed using the CTCAE v.4.0 criteria. Patients were followed-up at 3, 6, 9, and 12 months and then annually with contrastenhanced CT or MRI. Results: The 1-, 2-, 3-, 4-, and 5-year efficacies of percutaneous cryoablation for RCC were 99.2%, 99.2%, 98.9%, 98.5%, and 97.0%, respectively. Though none from RCC, all-cause mortality during the study period was 3. The overall 5-year survival was 97.8% and cancer-specific 5-year survival was 100%. Median tumor size was 2.8 cm. There was one 30-day mortality unrelated to the procedure or the disease. No patient developed metastatic disease during the followup period. The overall significant CTCAE v.4.0 complication rate (>2) was 6% with the most frequent being hemorrhage (1.6%). Conclusion: Our study shows that the efficacy of CT-guided, percutaneous cryoablation for stage 1 A and B renal cancer can approach that of the gold standard with a lower complication rate.

2206.2 Determination and classification of hemorrhagic complications of percutaneous cryoablation for renal cancer from a prospective 5-year study C.S. Georgiades1, M. Lessne2, R. Rodriguez3; 1Vascular & Interventional Radiology, American Medical Center, Nicosia, Cyprus, 2Interventional Radiology, Johns Hopkins University, Baltimore, MD, United States of America, 3Urology, University of Texas, San Antonio, TX, United States of America Purpose: Theoretically, cryoablation is vulnerable to hemorrhagic complications as it does not coagulate any injured blood vessels. Our objective was to establish the risk of hemorrhagic complications of percutaneous cryoablation for renal cell carcinoma and classify them accordingly in a prospective and rigorous manner. Material and Methods: Over a 6-year period, we treated 246 patients with 261 renal masses with CT-guided percutaneous cryoablation. We documented all hemorrhagic complications whether symptomatic or not, as they appeared on the procedural and postprocedural CT and categorized them according to location, tumor size, patient age, probe number, and required intervention. Safety was assessed using the CTCAE v.4.0 criteria. Results: The significant CTCAE v.4.0 hemorrhage-related complication rate was 3.4%. Four patients required transfusion, 3 emergent angiograms, and 2 bladder irrigation due to bladder outlet obstruction from clot (a total of 9 significant complications). Hemorrhages were localized in three distinct locations: the perirenal, the pararenal space, and the collecting system. The former appeared more susceptible to clinically significant hemorrhage (CTCAE v.4.0 > 2). Although not statistically significant, in the significant hemorrhage risk group, there was a tendency for older age, larger tumor, malignant histology, and more probes. Procedure-related mortality was 0%. Conclusion: Percutaneous cryoablation carries a small risk of clinically significant hemorrhagic complications and similar to that reported for radiofrequency ablation and open or laparoscopic cryoablation. Older patients with larger, malignant tumors and perirenal space hemorrhage should be monitored more closely than others in the post-operative period.

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2206.3 Comparison of transarterial chemoembolization with radiofrequency ablation versus transarterial chemoembolization followed by stereotactic body radiation therapy for hepatocellular carcinoma C. Ahuja1, Y. Kharoti2, M. Chadha1, J. McLarty1, J.A. Kaufman2, K. Farsad2, C. Marquez2, K.J. Kolbeck2; 1Radiology, Louisiana State University, Shreveport, LA, United States of America, 2Dotter Interventional Institute, Oregon Health & Science University Hospital, Portland, OR, United States of America Purpose: To compare recurrence rates and survival in patients with hepatocellular carcinoma (HCC) treated with transarterial chemoembolization (TACE) and subsequent radiofrequency ablation (RFA) versus those treated with TACE followed by stereotactic body radiation therapy (SBRT). Material and Methods: This is a single institution retrospective review of patients with HCC treated with TACE + RFA (Group A) and TACE + SBRT (Group B). Patients were subdivided according to their clinical status (Child-Pugh score). Imaging response, complications, and survival were analyzed. Kaplan-Meier survival curves were compared with Cox proportional hazards regression for overall survival and time to progression. Progression is defined as recurrence or death. Other medical and interventional therapies were recorded. Results: There were 47 patients in Group A and 32 in Group B; median ages were 61 and 60 years, respectively. Mean survival in years was 54.2 months for Group A and 36.2 months for Group B with no statistically significant difference (p = 0.31) (adjusted according to age, sex, and Child-Pugh category). However, a statistically significant difference was observed in time to progression with a mean of 48.5 months for Group A and 26.1 months for Group B (p = 0.026). Complications were rare in both groups. Conclusion: Time to progression was significantly longer for patients treated with RFA. While there is no stastically significant difference in overall survival between regimens, there was a clear trend toward improved survival with TACE + RFA. While further investigation is required, TACE + RFA may confer a longer disease-free state compared with TACE + SBRT.

2206.4 Percutaneous renal cryoablation: feasibility under local anesthesia E. de Kerviler1, A. Coffin1, C. de Bazelaire1, P. Meria2, P. Mongiat-Artus2, F. Desgrandchamps2; 1Department of Radiology, Saint-Louis Hospital, Paris, France, 2Urology, Saint-Louis Hospital, Paris, France Purpose: The major advantages of cryoablation compared with other thermal ablative methods are the visual control of the ice ball and intrinsic anesthetic properties of cryoablation that result in less pain. The aim of this study was to evaluate the feasibility of cryoablation using only local anesthesia. Material and Methods: We prospectively evaluated CT-guided cryoablation procedures performed at our institution. Between 2009 and 2013, 150 renal cryoablations were performed in 141 consecutive patients under local anesthesia. Patients received only 1 g of paracetamol intravenously prior to the procedure. We recorded the size and location of the tumor, the number of cryoprobes, and the intraprocedural and post-procedural degree of pain and discomfort scored using an established visual analog pain score (0-10). Results: An interventional radiologist and a technologist, without the help of anesthesiologists, could perform all procedures. In all 150 cases, adequate analgesia could be achieved, without the need of WHO level II or III drugs on the analgesic ladder. Pre-procedure pain ranged from 0 to 8. Post-procedure pain was less, ranging from

Abstract Book 0 to 5. The level of pain increased with the size of the tumor and the number of cryoprobes, without significant correlation. Conclusion: Cryoablation has emerged as an effective treatment option in patients with small renal tumors who are not optimal surgical candidates. Elderly patients with multiple medical comorbidities mainly require nephron sparing procedures, but often have true contraindications to general anesthesia. This study demonstrates that cryoablation of renal tumors is feasible by interventional radiologists alone using a combination of IV paracetamol and local anesthesia.

2206.5 Portal vein stenting combined iodine-125 seeds implanted followed by transcatheter arterial chemoembolization in the treatment of hepatocellular carcinoma with portal vein tumor thrombus J.-H. Sun, T.-Y. Zhou, Y.-L. Zhang, C.-H. Nie, G.-H. Zhou, S.-S. Zheng; Hepatobiliary and Pancreatic Intervention Center, Department of Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China Purpose: To assess the therapeutic value of portal vein stenting (PVS) combined iodine-125 seeds strand endovascular implantation followed by TACE for treating patients with hepatocellular carcinoma (HCC) with main portal vein tumor thrombus (MPVTT). Material and Methods: The data of 26 patients (age 29-81, median 49 years) with HCC complicated by MPVTT, treated with PVS combined iodine-125 seeds strand endovascular implantation followed by TACE between March 2012 and March 2013 were retrospectively analyzed. Among them, 16 patients were with multiple scattered lesions and 10 with single lesions (8 in right liver and 2 in left), 6 patients with right portal vein tumor thrombus, 3 with left, 13 with main and right, and 4 with main and left. The liver function of 20 patients was Child-Pugh A and 6 was Child-Pugh B. Results: The technical success rate was 100% for placement of iodine-125 seeds strand and stents in the obstructed main portal vein. No serious procedure-related adverse events were recorded. Follow-up period ranged from 6 to 15 months. TACE times were 1-5 (total 55 times); the number of stents was 26, iodine-125 seeds strands was 28 with 520 seeds in total. The 3, 6, 9, 12, and 15 months survival rates were 100% (26/26), 61.5% (16/26), 53.8% (14/26), 30.8% (8/26), and 15.4% (4/26), respectively, and cumulative patency rates were 96.2% (25/26), 76.9% (20/26), 57.7% (15/26), 23.1% (7/26), and 7.7% (2/26), respectively. Conclusion: The combination therapeutic strategy of PVS combined iodine-125 seeds strand endovascular implantation followed by TACE improves the survival of HCC patients with MPVTT complication.

2206.6 Unresectable hepatocellular carcinoma: management with CT-guided high-dose-rate brachytherapy F. Collettini, N. Schreiber, B. Gebauer; Radiology, Charité – Universitätsmedizin Berlin, Berlin, Germany Purpose: To evaluate the clinical outcome of CT-guided high-doserate brachytherapy (CT-HDRBT) in patients with unresectable HCC. Material and Methods: Over a 6-year period, 98 patients with 212 unresectable HCC underwent CT-HDRBT at our institution. Radiation was from an iridium-192 source positioned in the tumor through afterloading catheters placed percutaneously under CT guidance. Magnetic resonance imaging (MRI) follow-up was performed 6 weeks after the intervention and then every 3 months. The primary endpoint was local tumor control (LTC); secondary endpoints included progression-free survival (PFS) and overall survival (OS).

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Results: Patients were available for MRI evaluation for a mean follow-up of 23.1 months (range 4-64 months; median 20 months). Mean tumor diameter was 5 cm (range 1.8-12 cm). Eighteen of 212 (8.5%) tumors showed local progression after a mean LTC of 21.1 months. Sixty-seven patients (68.4%) experienced distant tumor progression. Mean PFS was 15.2 months. Forty-six patients died during the follow-up period. Median OS was 29.2 months. Actuarial 1-, 2-, and 3-year OS rates were 80%, 62%, and 46%, respectively. Conclusion: CT-HDRBT is an effective local therapy for unresectable HCC. Reported local tumor control rates compare favorably to those reported with conventional therapies. To adequately explore the impact of CT-HDRBT on survival and to assess its role in the multidisciplinary armamentarium of HCC therapies, prospective randomized studies comparing CT-HDRBT with the standard treatments, RFA, and TACE in patients with unresectable HCC are mandatory.

Free Paper Session Vertebroplasty and cementoplasty 2207.1 Pain relief in VCF patients after treatment with a novel device: study results H.P. Hatten, Jr.; Radiology, Indian River Radiology, Vero Beach, FL, United States of America Purpose: To determine the safety and effectiveness of a novel device for the treatment of vertebral compression fractures (VCFs) that creates channels and allows targeted polymethylmethacrylate (PMMA) bone cement flow. Material and Methods: Thirty-five VCFs in 24 patients; mean collapse 26% were prospectively treated at a single site, by a single surgeon with a Blazer vertebral augmentation system (Benvenue Medical, Inc., Santa Clara, CA). Blazer offers targeted channel creation for a controlled PMMA bone cement delivery. Primary study endpoint was percentage of patients with reduction in pain at 3 months by >15 mm from baseline as measured on visual analog scale (VAS). Additional outcomes measured were extravasations, dysfunction on ODI, subsequent fracture rate, the quality of life, and adverse events. Follow-up time points assessment with clinical exam and X-rays and/or CT scans was 7 days and 3, 6, and 12 months. Results: Clinical utility of the Blazer system was excellent. Curvilinear vertebral channels were created and targeted PMMA delivery through bone channels was achieved. Sixteen patients were evaluated at a primary 3 month endpoint with 14 patients (88%) meeting success. Mean back pain decreased from 81.3 mm at pre-treatment to 16.3 mm and 13 mm at 3 and 12 months follow-up, respectively. No device-related adverse events reported. Conclusion: Clinical experience with the Blazer vertebral augmentation system suggests that this device is particularly useful in treating VCFs with targeted PMMA placement. Further studies are required to corroborate the findings of this early clinical experience.

2207.2 Percutaneous long bone cementoplasty of the limbs: experience in 51 non-surgical patients R.L. Cazzato, X. Buy, O. Eker, T. Fabre, J. Palussière; Department of Radiology, Institut Bergonié, Bordeaux, France Purpose: To review our 10-year experience with percutaneous long bone cementoplasty in poor surgical patients. Material and Methods: In all, 51 patients (20 males and 31 females, mean age 60.5 ± 16 years) were included.

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The investigated primary endpoints of the study were pain and functional outcomes one month following cementoplasty. Secondary endpoints dealt with factors predicting cement leakage. Delayed adverse events following the procedure and overall survival were also investigated. Fisher’s test was used to assess primary and secondary endpoints; p < 0.05 was considered as statistically significant. Kaplan-Meier analysis was used to estimate the overall survival. Results: In all, 66 lesions were treated. Local pain relief at one month occurred in 59/66 lesions (89.4%); pain improvement was significantly more common for lesions of the upper limb (p < 0.05). Limb functionality at one month improved in 46/64 lesions (71.8%); lesions ≤ 3 cm showed better outcomes in terms of function (p < 0.05). Cement leakage was minor and asymptomatic in 26 cases (26/66, 39.4%); in one case (1/66, 1.5%), symptomatic minor amount of intraarticular cement leakage occurred. Factors predicting cement leakage were diaphyseal location of the lesions, cortical bone disruption, and extra-bone tumor extension (p < 0.05). The most common delayed adverse event was fracture (6/66, 9.1%). Overall survival at one, two, and three years was 61.2%, 30.9%, and 23.0%, respectively. Conclusion: For poor surgical candidates, percutaneous long bone cementoplasty is safe and effective in terms of pain relief and functional improvement, and fracture is the most common delayed adverse event.

2207.3 VERTOS V: sham RCT for chronic osteoporotic vertebral compression fractures D. Carli, P.N.M. Lohle; Radiology, St. Elisabeth Hospital, Tilburg, Netherlands Purpose: VERTOS V is a sham-controlled randomised trial on vertebroplasty comparing clinical outcomes in patients with sustained pain for 3 or more months after osteoporotic vertebral compression fracture (VCF). Material and Methods: In March 2013, VERTOS V commenced at 4 centres in The Netherlands. Inclusion criteria were VCF at T5 or lower with focal tenderness at the fracture level, as assessed by an internist on physical examination, visual analogue scale (VAS) score ≥5 for 3 months or more, decreased bone density, defined as T score, less than −1 and age ≥50 years. Sixty patients were included, 30 in each arm. Crossovers were not allowed. Follow-up was at regular intervals during a 6-month period with VAS scores for pain as the primary endpoint. Secondary endpoints were back pain-related disability and the quality of life measured with the quality of life questionnaire of the European Foundation for Osteoporosis and physical function measured with the Roland-Morris Disability Questionnaire. Results: Clinically relevant pain relief is defined as a decrease in VAS score from baseline of 3 points or more. The trial and the baseline results of patients enrolled in the study between March 2013 and August 2014 will be presented. If already available, certain outcome results will also be presented. Conclusion: Vertos V is a methodologically sound multicentre randomised sham controlled trial on vertebroplasty in patients with pain for 3 months or more after vertebral compression fractures.

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2207.4 Percutaneous osteosynthesis plus cementoplasty for consolidation of impending pathological fracture of the proximal femur: 4 years’ experience F. Deschamps, T. de Baère; Department of Radiology, Institut Gustave Roussy, Villejuif, France Purpose: There is a risk of pathological fracture for osteolytic metastasis of the proximal femur. Percutaneous osteosynthesis plus cementoplasty (POC) has recently been developed for non-surgical patients. The purpose of this study was to report its feasibility and the risk of fracture thereafter. Material and Methods: We performed POC in 26 patients (7 males and 19 females) with metastasis of the proximal femur with a high risk of fracture (Mirels’ score > 7) between February 2010 and September 2013. Patients were not candidates for (or refused) standard surgery. POC was performed in an angio suite by an interventional radiologist. Three cannulated screws (diameter = 8 mm) were inserted in an inverted triangle configuration in the femoral neck through 3 skin incisions of <1 cm. Then cement was injected around the screws using 11-gauge needles. Results: The mean Mirels’ score was 10 (8-12). The feasibility was 100%. POC was performed under general anesthesia (n=17) or conscious sedation (n=9). The mean duration was 90 minutes (60-180). The average length of hospitalization was 4 days (2-7). We report 2 hematomas in 2 patients and no thromboembolic complications. One pathological fracture occurred at 3 weeks and required open surgery. At present, 9 patients are still alive (no fracture, median follow-up = 324 days), and 17 patients are dead (6% fracture, median follow-up = 187 days). Conclusion: POC is safe, highly feasible, and effective for prophylactic consolidation of impending pathological fracture of the proximal femur. It must be considered for non-surgical patients or for patients with intermediate risk of fracture.

2207.5 Percutaneous stabilization of metastatic disease of the acetabulum M.P. Hartung1, D. King2, J.C. Neilson1, S.B. White1, S.M. Tutton1; 1Interventional Radiology, Medical College of Wisconsin, Milwaukee, WI, United States of America, 2Orthopedic Surgery, Medical College of Wisconsin, Milwaukee, WI, United States of America Purpose: Patients with painful periacetabular metastases and impending or pathologic fractures have limited palliative treatment options. Surgical reconstruction can improve mobility but has high rates of complications and delays chemotherapy and radiation. Through the collaboration of orthopedic and interventional oncology, we have developed a minimally invasive approach to stabilize the pelvis. Material and Methods: Twelve patients underwent percutaneous screw fixation and polymethylmethacrylate augmentation for impending or non-displaced fractures of the acetabulum due to metastatic disease between 2011 and 2013. Adjuvant ablation was performed if indicated. Patients were evaluated for hospital course, complications, eligibility for chemotherapy and radiation, and functional scores before surgery and within 6 weeks postoperatively using the Musculoskeletal Tumor Society (MSTS) scoring system. Results: Twelve patients (median age, 57) comprised our cohort. Eight patients presented with pathologic fractures. Technical success rate was 100%, with no major complications and zero postoperative infections. All patients were eligible for immediate chemotherapy and radiation. Five patients were discharged within 24 hours with a mean hospital stay of 4 days.

Abstract Book The mean MSTS functional score improved from 5.9/30 (20%, range 1-15) to 13.3/30 (44%, range 6-25), indicating that patients achieved 44% of premorbid function after surgery. Pain and mobility improved for all patients. Conclusion: Percutaneous acetabular stabilization improves pain and mobility in patients with metastatic disease, has a low risk of complications, and allows immediate postoperative chemotherapy and radiation. Functional outcomes compare favorably with those reported for surgery. Therefore, patients with painful impending or pathologic pelvic fractures should be considered for stabilization with our minimally invasive approach.

2207.6 Effect of percutaneous vertebroplasty in the treatment of painful Schmorl nodes P. Li1, G.-J. Teng2; 1Department of Radiology, Zhongda Hospital, Jiangsu Key Laboratory of Molecular and Functional Imaging, Nanjing, China, 2Department of Radiology, Zhong-Da Hospital, Southeast University, Nanjing, China Purpose: Schmorl nodes are commonly observed in vertebral imaging of the normal adult population and usually remain asymptomatic. However, in some patients, Schmorl nodes result in chronic back pain. The purpose of our study was to determine the efficacy of percutaneous vertebroplasty in the treatment of back pain associated with painful vertebral body Schmorl nodes. Material and Methods: We reviewed the medical records of 35 patients treated from 2002 through 2013 affected by painful Schmorl nodes, who underwent percutaneous transpedicular injection of polymethylmethacrylate (vertebroplasty) at our department to relieve their back pain that was not responsive to medical and physical management. MR examinations were used to exclude other causes of back pain. The visual analog scale (VAS), a pain score with points assigned subjectively from patients pre- and post-procedure in a range between 0 (absence of pain) and 10 (maximum pain), was used to evaluate the pain symptoms. Furthermore, we stipulated a minimum period of 6 months for clinical symptoms and MR examinations follow-up after percutaneous vertebroplasty. Results: In all, 33 of 35 patients affected by painful Schmorl nodes treated with percutaneous vertebroplasty were analyzed in detail. Thirty (90.9%) patients reported improvement of the back pain and none reported a worsening of symptoms and serious complications in follow-up. The pain symptoms decreased from an average of 8.9 points on VAS to 2.5. Conclusion: We demonstrate that percutaneous vertebroplasty represents a safe, minimally invasive, and effective treatment option for patients with painful Schmorl nodes.

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Free Paper Session TIPS 2208.1 TIPS for refractory ascites in cirrhosis: a single-center experience using 8- and 10-mm diameter expandedpolytetrafluoroethylene covered stent A. Luca, R. Miraglia, L. Maruzzelli, G. Vizzini, S. Caruso, F. Tuzzolino; Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy Purpose: A single, small RCT showed that in cirrhotic patients with refractory/recurrent ascites, the use of an 8-mm diameter expandedpolytetrafluoroethylene (e-PTFE)-covered TIPS was associated with a significantly less efficient control of complications of portal hypertension. The aim of this study is to confirm these results in the clinical practice. Material and Methods: We retrospectively reviewed 171 consecutive cirrhotic patients with refractory/recurrent ascites treated with an 8-/10-mm diameter ePTFE-covered stent. An 8-mm diameter stent was used in 111 patients and a 10-mm diameter stent in 60. Mean follow-up was 16.2±8.5 months. Results: The two groups were comparable with regard to age, sex, etiology, Child-Pugh score, MELD, previous hepatic encephalopathy (HE), variceal bleeding (VB), spontaneous bacterial peritonitis (SBP), gastroesophageal varices, and baseline portosystemic pressure gradient (PPG). The prevalence of portal vein thrombosis was higher in the 10-mm group (43.3% vs. 5.4%; p<0.01). After TIPS, the decrease in PPG was significantly higher in the 10-mm group (10.4±4.2 vs. 8.7±3.5 mmHg; p=0.004). The 3-month need of paracentesis was not statistically different (23% vs. 18%; p=0.36); however, the longterm need of paracentesis was higher in the 8-mm group (58% vs. 31%; p=0.003). Overall HE, severe HE (grade III-IV), new episodes or worsening of HE, acute HE, chronic HE, and cumulative probability of developing the first episode of HE were similar in both groups. Similarly, no significant differences were observed in new episodes of VB, SBP, TIPS dysfunction, Child-Pugh score, MELD, need of liver transplantation, overall survival, and transplant-free survival. Conclusion: This study supports the use of 10-mm diameter ePTFEcovered stent in cirrhotic patients with refractory ascites.

2208.2 Early, unexpected liver failure after TIPS placement in cirrhotic patients with good liver function (MELD ≤ 12): incidence, outcome, and prognostic factors A. Luca, R. Miraglia, L. Maruzzelli, G. Vizzini, S. Caruso, F. Tuzzolino; Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy Purpose: To evaluate the incidence, outcome, and prognostic factors of early liver failure (LF) after TIPS placement in cirrhotic patients with good liver function. Material and Methods: We retrospectively reviewed 217 consecutive cirrhotic patients with baseline MELD ≤ 12 who underwent TIPS for portal hypertensive complications. Early LF was defined by death, liver transplantation (LT), or MELD > 18 within 3 months after TIPS. Results: TIPS indications were recurrent variceal bleeding (46.1%), refractory/recurrent ascites (41.5%), and others (12.4%). Twenty-one (9.7%) out of 217 patients developed early LF after TIPS (11 patients died, 1 patient required LT, and 9 patients increased MELD to >18). In the latter group, two patients died at 6, and 9.8 months, two

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underwent LT at 7.8 and 11.9 months, 4 patients normalized the MELD from 4.3 to 12 months after TIPS, and one maintained a stable MELD at 16 months. One patient undergoing TIPS for variceal rebleeding had a CT diagnosis of bi-segmental hepatic necrosis; no other procedure-related technical complications were observed. Patients who developed LF had a significantly lower transplantfree survival at 6 (97% vs. 40%; p<0.05) and 12 months (88% vs. 24%; p<0.0001) compared with patients without LF. Multivariate analysis revealed that refractory ascites (OR 4.6; CI: 1.37-15.5; p=0.01) and pre-TIPS MELD > 11 (OR 3.2; CI: 1.07-9.5; p=0.01) were independently associated with the risk of early LF. Conclusion: Early LF is not uncommon in cirrhotic patients with MELD ≤ 12 undergoing TIPS for refractory/recurrent ascites. In more than two-thirds of cases, early LF causes death or requires LT.

2208.3 VIATORR stent grafts do not self-expand to their nominal diameters in cirrhotic livers: good news from a computed tomography-based Italian multicentric study F. Schepis1, F. Vizzutti2, G. Marzocchi3, P. Quaretti4, A. Rampoldi5, R. Agazzi6 , R. Golfieri7, A. Luca8 , F. Fanelli9, C. Caporali3, S. Colopi3, M. De Santis3, L. Rega10, U. Arena10, I. Fiorina11, L.P. Moramarco4, A. Airoldi12, R. Nani6 , M. Renzulli13, C. Mosconi14, R. Bruno4, S. Fagiuoli15, A. Cannavale9, T. Di Maira1, E. Villa1; 1Department of Gastroenterology, University of Modena and Reggio Emilia, Modena, Italy, 2Internal Medicine, University of Florence, Florence, Italy, 3Department of Radiology, University of Modena and Reggio Emilia, Modena, Italy, 4Medical Physics Department, Fondazione Policlinico S.Matteo, Pavia, Italy, 5Department of Radiology, Niguarda Hospital, Milan, Italy, 6Department of Radiology, Papa Giovanni XXIII Hospital, Bergamo, Italy, 7Radiologia Albertoni, Azienda Ospadaliero-Universitaria di Bologna, Bologna, Italy, 8Diagnostic and Therapeutic Services, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy, 9Department of Radiology, University of Rome “La Sapienza”, Rome, Italy, 10 Department of Radiology, University of Florence, Florence, Italy, 11Interventional Radiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy, 12Department of Gastroenterology, Niguarda Hospital, Milan, Italy, 13Policlinico S.Orsola-Malpighi, Unità Operativa Radiologia Albertoni, Bologna, Italy, 14Department of Digestive Disease and Internal Medicine, Policlinico Sant’Orsola Malpighi, Bologna, Italy, 15Department of Gastroenterology, Papa Giovanni XXIII Hospital, Bergamo, Italy Purpose: Nitinol-based ePTFE covered-stent-grafts (VIATORR©) represent the standard option for TIPS creation in cirrhotic patients. No data exist on the VIATORR© ability to either self-expand to nominal diameter or maintain smaller calibers when under ballooned to avoid unwarranted portosystemic pressure gradient (PSPG) drop. To date, the ideal PSPG should be <12mmHg to avoid bleeding/ ascites recurrence but ≥10mmHg to avoid hepatic encephalopathy development. Our main objective is to measure the VIATORR© diameter in cirrhotic livers; secondary objective is to determine the relationship between stent-graft diameter and post-TIPS levels of PSPG. Material and Methods: CT scans of 196 cirrhotic patients (174 received 10mm nominal diameter stent-grafts; 22, 8mm) from 8 Italian centers were centralized and retrospectively analyzed. An average diameter of 3 orthogonal slices of VIATORR© intraparenchymal tract was obtained on liver images after 3D reconstruction with central lumen line detection. Results: Mean CT time-distance from TIPS positioning was 265.9±512.4 days (range 0-2282). Ballooning by semi-compliant devices was as follows: 6mm=33 patients, 7mm=21 patients, 8mm=91 patients, 9mm=15 patients, and 10mm=36 patients. Corresponding

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measured average diameters were 6.5±0.9mm, 7.1±0.9mm, 7.5±0.6mm, 8.4±0.5mm, and 7.8±0.8mm, and derived average distance from nominal diameters were −31.0±9.4%, −27.5±8.3%, −22.9±6.6%, −15.7±5.4%, −21.8±7.0%. After being grouped according to their stent-graft CT diameters (6mm, 7mm, 8mm, and 9mm groups only), proportions of patients reaching a PSPG target <12mmHg or <10mmHg were 43.3%, 63.0%, 84.8%, and 93.9% (p<0.0001) and 13.3%, 45.7%, 62.1%, and 87.5% (p<0.0001), respectively. Conclusion: VIATORR© do not self expand to their nominal diameters in cirrhotic livers. A clinically acceptable PSPG target is at a real caliber of <8mm. Developing a reliable ballooning technique will likely contribute to a complication-free use of the device in cirrhosis.

2208.4 Electromagnetically navigated TIPS procedure: phantom and in vivo evaluation P. Isfort1, H.-S. Na1, T. Penzkofer2, C. Wilkmann1, S. Osterhues3, A. Besting4, T. Schmitz-Rode5, C. Kuhl1, P. Bruners1; 1Department of Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany, 2Surgical Planning Laboratory, Brigham and Women's Hospital, Boston, MA, United States of America, 3Vygon GmbH & Co. KG, Aachen, Germany, 4SurgiTAIX AG, Herzogenrath, Germany, 5Institute of Applied Medical Engineering, RWTH Aachen University, Aachen, Germany Purpose: To evaluate the feasibility of electromagnetic tracking (EMT) transjugular intrahepatic portosystemic shunt (TIPS) placement in a phantom and in vivo setting. Material and Methods: A custom-designed TIPS set comprising a stainless steel stylet, a polypropylene catheter and a stainless steel outer canula was developed. In the tip of both stylet and outer canula, coils were integrated to allow tip detection through an electromagnetic tracking system (Aurora; Northern Digital, Waterloo, Canada). For navigation of the TIPS set, a software prototype was developed that allows visualization of both the stylet and the outer canula tip position in a previously acquired C-arm CT dataset. The EMT-TIPS procedure was performed in a custom-made gelwax phantom (n = 80 trials) and in 8 domestic pigs. Domestic pigs were selected as an animal model for challenging TIPS procedures. The time and number of punctures aiming at the portal vein were recorded. Results: In the phantom setting, intervention time to cannulate the portal vein (PV) was 144.0 ± 62.8 s. A mean of 1.2 ± 0.4 punctures were required for PV cannulation. In the in vivo trials, the TIPS procedure was successfully performed in 5 out of 8 animals. Time for a complete TIPS procedure including prosthesis placement ranged from 40 to 562 minutes with a notable learning curve between the trials. Conclusion: EMT-guided TIPS placement proved to be feasible in vitro as well as in vivo. The system holds promise to substantially facilitate challenging TIPS procedures.

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2208.5 Correlation of initial technical outcome and long-term patency to associated costs in the treatment of portal hypertension with a stent and a stent graft TIPS device T. Rodt1, J. Lauermann1, D.B. Hasdemir1, A. Potthoff2, S. Marquardt1, C. von Falck1, H.-P. Reiffen3, H. Rosenthal1, F. Wacker1, B.C. Meyer1; 1Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany, 2Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany, 3Anesthesiology, Hannover Medical School, Hannover, Germany Purpose: To compare the initial technical outcome and long-term patency between a stent and a stent graft device for transjugular intrahepatic portosystemic shunt (TIPS) in treating portal hypertension due to liver cirrhosis. Cost analysis was performed and correlated to initial technical outcome and long-term patency for both devices. Material and Methods: In all, 170 consecutive patients treated with TIPS for portal hypertension due to liver cirrhosis were reviewed. Eighty patients received a stent (group 1; Wallstent, Boston Scientific) and 83 a stent graft (group 2; Gore Viatorr). Analysis of technical and clinical data, periprocedural imaging, follow-up ultrasound was performed regarding initial technical outcome, long-term patency and group differences. Associated costs were calculated. Results: Technical success was 95.9%. Mean portosystemic gradient was 21.9 cmH2O before and 6.9 cmH2O after TIPS. Average fluoroscopy time was 15.4 min (SD 10.7), and mean dose-area product was 19407.3 cGy*cm2 (SD 12920.6). Follow-up ultrasound was available in 77.7% with a mean follow-up time of 244.7 d (SD 340.5). No significant differences in technical success and portosystemic gradient decrease between the two groups were observed. Kaplan-Meier analysis yielded significant differences in 14 d-patency (90/100%, p=0.004) and primary long-term patency (2 y; 83.3/93.1%, p=0.037). Costs to establish TIPS and maintain 2 y-patency were €8702 (€1444 material) and €9194 (€3823 material) for groups 1 and 2, respectively. Conclusion: Stent and stent graft allowed successful placement of TIPS with good initial technical results. Primary long-term patency was significantly higher in the stent graft group. However, stent graft is associated with higher costs to establish and maintain TIPS patency.

2208.6 Transjugular intrahepatic portosystemic shunt flow reduction with adjustable polytetrafluoroethylene-covered balloonexpandable stents using “sheath control technique” G.C. Lo1, S. Corelli1, E. Kim2, R. Patel2, F.S. Nowakowski2, R.A. Lookstein2, A.M. Fischman2; 1Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America, 2Interventional Radiology, Mount Sinai Medical Center, New York, NY, United States of America Purpose: A complication of transjugular intrahepatic portosystemic shunts (TIPS) placement is refractory portosystemic encephalopathy (PSE) requiring TIPS reduction. Numerous techniques have been described for TIPS reduction. We present the results of a technique utilizing constraining sheaths during deployment of polytetrafluoroethylene (PTFE)-covered balloon-expandable stents, minimizing stent migration and providing additional procedural control. Material and Methods: From January 2012 to July 2013, TIPS reduction was performed in 8 consecutive patients for PSE using iCAST covered stents (Atrium Maquet Getinge Group, Germany). In the indwelling Viatorr stents (W.L. Gore and Associates, Delaware), a 9 mm × 59 mm iCAST stent was deployed with 2 cm exposed from the sheath’s distal end and majority of the stent within the sheath to create the distal hourglass shape. During balloon retraction, the

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stent was buttressed by the sheath, which was retracted afterwards. The iCAST balloon then created the proximal hourglass shape of the stent, and the central portion of the stent was dilated to 5 mm. Demographics, laboratory values, and outcomes were recorded. Results: Eight patients (2 females, 6 males; mean age 65.7 years) underwent TIPS reduction with 100% technical success. There was no stent migration during stent deployment. All patients experienced improvement of encephalopathy with recurrent symptoms in 2 patients. The mortality rate at 30 and 180 days was 12.5% and 25%, respectively. There was no significant change in MELD score or bilirubin after the procedure (p > 0.05). Conclusion: TIPS reduction using PTFE balloon expandable stents using the “sheath control technique” is safe and effective while minimizing the risk of stent migration.

Free Paper Session Embolisation in the abdomen 2305.1 Splenic artery embolization for blunt splenic injury: impact on immune function D.W. De Boo1, H. Kavnoudias1, P. Foley2, P. Cameron3, K.R. Thomson1, S.M. Lyon1; 1Department of Radiology, The Alfred Hospital, Melbourne, VIC, Australia, 2Radiology, The Canberra Hospital, Canberra, ACT, Australia, 3Immunology, Alfred Hospital, Melbourne, VIC, Australia Purpose: To evaluate the splenic immune function after splenic artery embolization (SAE) for blunt abdominal injury using IgM memory B cells as a marker. Material and Methods: Between 2004 and 2010, patients with blunt splenic injury requiring SAE were prospectively enrolled. Indication for SAE was contrast extravasation, splenic artery pseudoaneurysm, splenic AV-fistula, splenic artery disruption, or cut-off and high-grade splenic injury with moderate-to-large hemoperitoneum, all diagnosed on MDCT. Splenic immune function was measured as percentage of IgM memory B cells within the B-cell population in peripheral blood samples after 6 months. This was compared with patients who underwent splenectomy for trauma and normal subjects. Institutional review board approval was obtained. Results: Overall, 77 patients underwent SAE during the study period; 26 patients were excluded from data analysis mainly because of loss to follow-up (14) or death from sustained injuries (7). Of the remaining 51 patients, 35 had proximal SAE and 16 distal SAE. There was a significant higher percentage of IgM memory B cell in both proximal and distal SAE as compared with splenectomised patients. There was no difference between the proximal and distal SAE groups. When compared with normal subjects, the percentage of IgM memory B cells was minimally but significantly lower in the proximal SAE group whereas it was not significantly lower in the distal SAE group. Conclusion: SAE for blunt splenic injury preserves the splenic immune function, measured by IgM memory B cells levels, as compared with splenectomy. Distal SAE might offer better preservation of splenic immune function compared with proximal SAE.

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2305.2 Transarterial embolization of renal arteries before transplantation in patients with polycystic kidney disease: long-term results F. Petitpierre, F. Cornelis, A.-S. Lasserre, E. Tricaud, M. Bouzagrou, Y. Lebras, N. Grenier; Radiology, CHU Bordeaux, Bordeaux, France Purpose: To retrospectively assess the tolerance and long-term outcomes of transarterial renal embolization (TAE) before renal transplantation in patients with polycystic kidney disease (PKD). Material and Methods: Between January 2008 and November 2013, 73 patients (47 males and 26 females; total 76 kidneys) with age ranging 34-72 years (mean: 53 years) underwent TAE. All patients presented terminal stage of PKD under hemodialysis and renal volume compromising kidney graft implantation. All patient data were retrospectively acquired, distribution of the quantitative variables was obtained and descriptive statistics were used. Results: TAE was considered as successful irrespective of the number of procedures in 88.2% embolized kidneys (67/76). Postembolization syndrome occurred after 15 procedures (18.3%). The severe complication rate was of 4.9%. A significant reduction was observed at 3 months with a mean decrease of 40% (range, 2-69) and 59 (35-86) thereafter (both p<0.001). It permitted to withdraw temporary contraindication in 5.6 months (2.8-24.3) after the procedure for 65 patients. Among patients in the waiting list, 43 patients were successfully grafted (67.2%) with a mean follow-up of 26.2 (1.859.5), the 1, 3, and 5 years graft survival were all 95.3% (41/43) (CI 95%: 82.7-98.8]. The survival rate of renal function >30 ml/min were 89.8% at 1 year (75-96.1), 89.8% at 3 years (75-96.1), and 62.7% at 5 years (29.6-83.6) after transplantation. Conclusion: TAE is a safe and effective alternative to nephrectomy to conduct renal transplantation in patients with PKD.

2305.3 Emborrhoid-embolization of the hemorrhoidal arteries: a new concept in the treatment of hemorrhoidal disease V. Vidal1, M.R. Sapoval2, G. Louis1, O. Pellerin2, V. De Parades3, I. Sielezneff4, J.-M. Bartoli5; 1Service de Radiologie, Hôpital Timone Adultes, Marseille, France, 2Interventional Radiology, Hopital Européen Georges Pompidou, Paris, France, 3Proctologie, Hopital Saint Joseph, Paris, France, 4Service de Chirurgie Viscérale, Hôpital Timone Adultes, Marseille, France, 5Radiologie Adulte – Pr Bartoli, APHM CHU La Timone, Marseille, France Purpose: Elective transanal Doppler-guided hemorrhoidal artery ligation has recently been shown to be effective in hemorrhoidal disease. It comprises ligating the terminal branches of the superior rectal artery under Doppler guidance to reduce the hemorrhoidal arterial blood flow and improve symptoms. By analogy, we propose performing this arterial occlusion using the “emborrhoid” technique (embolization of the hemorrhoidal arteries), in which arterial occlusion is achieved via the endovascular route using coils placed in the terminal branches of the superior rectal arteries. Material and Methods: Six patients (age: 41-85 years) with symptoms of hemorrhoidal disease (chronic and disabling rectal bleeding) were embolized after multidisciplinary discussion by a proctologist, a visceral surgeon, and a radiologist. Embolization of the terminal branches of the superior rectal arteries were performed via the inferior mesenteric artery using a microcatheter (0.018 inch) and coils (2 and 3 mm in diameter). Results: There were major differences in vascularization between the two patients with a proctologic surgical history and the four patients who had not undergone a transanal procedure. A single

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embolization procedure completely stopped hemorrhages for the four patients without a surgical history. A complete embolization (two and three sessions) for the two other patients was mandatory to obtain cessation of rectal bleeding. No ischemic complications or pain occured. Conclusion: This case study suggests that coil embolization of the superior rectal arteries is technically feasible, safe, and well tolerated. Further, studies are required to evaluate the efficacy of this new “emborrhoid” technique in the management of hemorrhoidal disease.

2305.4 Selective embolization strategy for non-variceal duodenal bleeding: is empiric embolization really required? S. Hur1, H.J. Jae1, M. Lee1, H.-C. Kim1, J.W. Chung1, J.D. Kim2, Y.H. So1; 1Radiology, Seoul National University, Seoul, Korea, 2Radiology, Eulji University Hospital, Daejeon, Korea Purpose: To assess the safety and efficacy of selective embolization strategy for non-variceal duodenal bleeding. Material and Methods: From 2006 to 2013, consecutive patients who underwent angiography for non-variceal duodenal bleeding were included in this single-center retrospective study. Embolization was performed only when positive angiographic sign was presented. In negative cases, repetitive angiography was performed on call as required instead of empiric embolization. Rates for technical success, rebleeding, clinical success (primary/secondary), complication, and mortality were determined. Several factors that may affect outcome were analyzed. Results: Ninety-three patients were included (76 endoscopic failure, 17 positive CT). Etiology was classified as peptic ulcer/Dieulafoy’s lesion (n=63), tumors (n=14), or endoscopic procedure (n=16). Positive angiographic findings were observed in the first angiography (n=60, group-A) or in the second (n=10, group-B). Outcomes were not different between them. N-butyl cyanoacrylate was the preferred embolic agent (n=57), while microcoils (n=7), or gelatin sponge pledgets (n=5) were also used. Technical success rate was 93% (n=65). Rebleeding, clinical success, and in-hospital mortality were 33%, 57% (primary), 71% (secondary), and 28%, respectively. There was no major complication. Patients without positive angiogram (20/23; 83%) recovered successfully with medical treatments (n=18) or endoscopic procedures (n=2). Iatrogenic etiology and negative angiogram were favorable prognostic factors, whereas the use of microcoil only, bleeding from pancreaticoduodenal arcade, coagulopathy, and spastic artery in the angiogram were unfavorable factors. Conclusion: Selective embolization strategy is safe and effective for non-variceal duodenal bleedings. Empiric embolization should be reserved for extremely unstable patients who do not respond to medical resuscitation, because majority of patients with negative angiogram recovered well with conservative treatments.

Abstract Book small arterial vessels to the fibroids were embolized. The large vessels and uterine artery trunk were left permeable. Contrastenhanced magnetic resonance imaging (MR) was performed before and 6 months after UAE. Results: Of the 224 women, 59.8% became spontaneously pregnant, 24 had 39 previous unsuccessful myomectomies, and 6 had 11 unsuccessful in vitro fertilization treatments. There were 127 successful pregnancies, with 109 successful live births (85.8%), 16 abortions, 1 stillbirth, 1 ectopic pregnancy, and 7 ongoing pregnancies. The mean weight of the newborns was 3.081 kg with a mean gestation time of 38.2 weeks and 10.1% preterm deliveries. There were 61.5% cesareans and 38.5% vaginal deliveries. Three cases of placenta previa, 1 placenta accreta, 2 postpartum hemorrhage, 2 pre-delivery hypertension, and 1 premature rupture of membranes were observed. The complication rate was the same as the general population with no significant neonatal problems. Uterine fibroids had an ischemia over 90% in 79.7% MR-controlled patients. The procedure was repeated in 22 patients with incomplete fibroid ischemia, and 7 of them had spontaneous and successful pregnancy embolization with live births. Conclusion: Incomplete UAE for women with uterine fibroids who can not conceive is an efficient outpatient procedure with high rates of spontaneous pregnancies (59.8%), live births (85.8%), and low morbidity.

2305.6 Clinical application of FlightPlan for Liver for the treatment of hepatocellular carcinoma S.-M. Joo, K.-H. Lee; Department of Radiology, Gangnam Severance Hospital, Seoul, Korea Purpose: To evaluate the clinical effectiveness of FlightPlan for Liver (FPFL) that is an automated tumor-feeding artery detection software in computed tomography (CT) angiography for the treatment of hepatocellular carcinoma (HCC) in identifying tumor-feeding arteries. Material and Methods: FPFL was used in transarterial chemoembolization of 40 HCCs (40 mm or smaller) in 25 patients. The detectability of the software was compared with that of nonselective digital subtraction angiography (DSA). Technical success of transarterial chemoembolization was evaluated on 1-month follow-up CT or magnetic resonance imaging. Results: Among the 49 tumor feeding vessels, 31 (63.3%) were identified with nonselective DSA and 48 (98.0%) with FPFL. The sensitivity of tumor feeding vessel detection was significantly better with FPFL than with nonselective DSA (P<0.001). One false negative was found with FPFL due to the small caliber of tumor-feeding vessel. Two false positive tumor-feeding arteries were found with FPFL. The accuracy of FPFL was 48 of 51 (94.1%). Conclusion: FPFL has a sufficient performance level to use in transarterial chemoembolization for HCC.

2305.5 Spontaneous and successful live birth pregnancy after uterine artery embolization for women with uterine fibroid: 109 live births J.M. Pisco, M. Duarte, F. Cirurgião, M. Forjaz, T. Bilhim, H. Rio Tinto, L. Fernandes, J.A. Pereira, A.G. Oliveira; Interventional Radiology, Saint Louis Hospital, Lisbon, Portugal Purpose: To evaluate the clinical efficacy and outcome of successful live birth pregnancy after uterine artery embolization (UAE) for patients with uterine fibroids. Material and Methods: Between 2004 and 2013, UAE was performed in 1514 patients. For the 224 women who wanted to conceive, only

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Free Paper Session MRgFUS (HIFU) & IRE 2306.1 Ablation of colorectal liver metastases by irreversible electroporation: results of the COLDFIRE-I ablate-and-resect study H.J. Scheffer1, K. Nielsen2, A.A. van Tilborg1, J.M. Vieveen1, A. Bouwman3, G. Kazemier2, H.W. Niessen4, S. Meijer2, C. van Kuijk5, P. van den Tol2, M.R. Meijerink5; 1Radiology, VU University Medical Center, Amsterdam, Netherlands, 2Surgery, VU University Medical Center, Amsterdam, Netherlands, 3Anaesthesiology, VU University Medical Center, Amsterdam, Netherlands, 4Pathology, VU University Medical Center, Amsterdam, Netherlands, 5Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, Netherlands Purpose: Irreversible electroporation (IRE) is a new, non-thermal ablation technique that relies on high-voltage electrical pulses. As opposed to thermal ablation, preclinical studies have shown that IRE is safe when applied close to vital structures such as the portal triad. This clinical study evaluates the pathological response of colorectal liver metastases (CRLM) treated with IRE as well as the clinical safety and feasibility of the technique. Material and Methods: Ten patients with resectable CRLM were included. Main exclusion criteria were cardiac arrhythmias and epilepsy. During laparotomy, metastases were ablated using ultrasound guidance and resected 60 minutes later. Safety and feasibility were assessed based on adverse events, laboratory values, technical success and ultrasound confirmation of the ablation zone. Tissue response was assessed using triphenyl tetrazolium chloride (TTC) vitality staining and (immuno) histochemical stainings (complement 3d and caspase-3). Results: Ten lesions with a mean diameter of 2.4 cm were successfully treated with IRE and resected, on average, 84 minutes later (range 51-153 minutes). One minor adverse event, a mild transient arrhythmia without haemodynamic consequences, occurred during IRE. Ultrasonography showed a sharply demarcated hypoechoic ablation zone around the tumour in all cases. TTC showed complete discolouration of the tumour in 8/10 lesions, indicating avitality. Immunohistochemistry confirmed irreversible cell damage in and around the tumour. Conclusion: This ablate-and-resect study demonstrated physiological and immunohistochemical cell death caused by IRE of liver metastases of colorectal origin in humans.

2306.2 Irreversible electroporation fails to demonstrate efficacy in a prospective multicenter phase II trial on lung malignancies J. Jürgens1, F. Deschamps2, K. Uhde1, L. Tselikas3, O. Kosiek1, J. Ricke1, T. de Baère3; 1Clinic for Radiology and Nuclear Medicine, University Hospital Magdeburg, Magdeburg, Germany, 2Department of Radiology, Institut Gustave Roussy, Villejuif, France, 3Dept. of Interventional Radiology, Institut Gustave Roussy, Villejuif, France Purpose: To assess the safety and efficacy of irreversible electroporation (IRE) for the treatment of lung malignancies. Material and Methods: Patients with primary and secondary lung malignancies and preserved lung function were included in this prospective single-arm trial. Primary and secondary endpoints were safety and efficacy. Recruitment goal was 36 subjects in 2 centers. Patients underwent IRE under general anesthesia with probe placement performed using Fluoroscopy-CT. The IRE system employed

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was NanoKnife® (Angiodynamics). System settings for the ablation procedure followed the manufacturer’s recommendations. The Mann-Whitney U test was used to evaluate the correlation of 9 technical parameters with local tumor control. Median follow-up duration was 12 months. Results: The expected efficacy was not met at interim analysis, and the trial was stopped prematurely after inclusion of 23 patients (13/10 between both centers). The dominant tumor entity was colorectal (n = 13). The median tumor diameter was 16 mm (8-27 mm). Pneumothoraces were observed in 11 of 23 patients with chest tubes required in 8 (35%). Frequently observed alveolar hemorrhage never led to significant hemoptysis. In all, 14/23 patients showed progressive disease (61%), and complete remission was found in 7 (30%). The relative increase of the current during ablation was significantly higher in the group treated successfully as compared with that of the group presenting local recurrence (p < 0.05). Needle tract seeding was found in 3 cases (13%). Conclusion: IRE is not effective for the treatment of lung malignancies. We hypothesize that the energy deposition with current IRE probes is highly sensitive to air exposure.

2306.3 Magnetic resonance-guided focused ultrasound surgery of primary pancreatic and hepatic cancer: a totally non-invasive treatment F. Zaccagna, F. Boni, L. Bertaccini, C. Palla, M. Anzidei, A. Napoli, C. Catalano; Department of Radiological, Oncological and Pathological Sciences, University of Rome La Sapienza, Rome, Italy Purpose: Hepatic tumors (HCC) and pancreatic cancer represent two of the most challenging abdominal tumors due to their vascular relationship and poor prognosis. Both these cancers have been successfully treated with focused ultrasound under conventional US guidance. Magnetic resonance-guided focused ultrasound (MRgFUS) introduces the advantage of real time monitoring, allowing a more precise lesion’s ablation and a more accurate in-treatment patient management. This technique has been widely used in other application while its use in treating HCC and pancreatic cancer is still in its preliminary phase. Therefore, our purpose was to evaluate the safety and effectiveness of high intensity MRgFUS treatment in pancreatic and HCC. Material and Methods: In all, 5 patients with pancreatic cancer and 1 with unresectable right lobe HCC underwent MRgFUS (ExAblate2100; InSightec). Treatments were performed in a single ambulatory session. To evaluate tumor control, perfusion T1-weighted images after contrast medium administration were obtained pre- and post-treatment. Follow-up examinations were scheduled at 1, 3, 6, and 12 months. Results: All patients well tolerated the treatment, and no heatrelated adverse event was recorded. Immediately after treatment, all patients showed coagulative necrosis with a mean non-perfused volume of 65.4 ± 16.6 (45-90). All patients with pancreatic cancer showed a significant decrease in pain. At follow-up, no local progression was recorded; after MRgFUS, 2 patients with pancreatic cancer underwent RT, meanwhile 1 required a second MRgFUS treatment. Conclusion: Our preliminary experience indicates that MRgFUS could be a promising non-invasive treatment modality in patients with unresectable pancreatic cancer and HCC.

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2306.4 Non-invasive focal therapy of organ-confined prostate cancer: phase I study using magnetic resonance-guided focused ultrasound technology and excision pathology for efficacy assessment M. Anzidei, A. Napoli, F. Boni, C. Palla, L. Bertaccini, A. Leonardi, C. Catalano; Department of Radiological, Oncological and Pathological Sciences, University of Rome La Sapienza, Rome, Italy Purpose: To assess the safety and effectiveness of non-invasive MRguided focused ultrasound surgery (MRgFUS) treatment of localized prostate cancer in a phase I, treat-and-resection-designed exploratory study. Material and Methods: Eleven patients with biopsy-proven focal T2 prostate cancer (low-to-intermediate risk: PSA < 12 and Gleason <3 ± 4), confirmed on a previous multiparametric MRI (Discovery 750HD; GE) including dynamic contrast enhanced imaging (Gd-BOPTA; Bracco), underwent MRgFUS ablation (ExAblate; InSightec). All patients were scheduled to undergo radical laparoscopic prostatectomy. MRgFUS treatment was performed on the MR identifiable lesion (<2) using a patient-specific energy (3000-8500 J) and real time MR thermometry. Non-perfused volume (NPV) in the post-treatment MRI was compared with that in excision pathology for necrosis assessment. Results: No significant complications were observed in all subjects during or immediately after the procedure. Treatment was validated by pathological examinations that demonstrated extensive coagulative necrosis at the site of sonication surrounded by normal prostatic tissue with inflammatory changes; these features were positively correlated with the immediate post-treatment MRI scan and NPV values. At histology, 10 patients were free of residual viable tumor within the treated area; in the remaining patients, 10% residual tumor was observed within NPV. There was a variable amount of isolated cancer tissue (Gleason < 6, 3 + 3) within the non-treated parenchyma that was identifiable neither at MRI nor at biopsy. Conclusion: Results of our phase I study suggest that MRgFUS is a safe and effective modality to determine a >90% necrosis of identifiable prostate cancer; further prospective studies are required to extend the success rate in larger cohort.

2306.5 Magnetic resonance-guided focused ultrasound surgery of bone metastases: from primary pain palliation to local tumour control V. Noce1, F. Zaccagna2, F. Boni2, C. Palla2, L. Bertaccini2, A. Napoli2, C. Catalano2; 1Department of Radiological Sciences, University of Rome La Sapienza, Rome, Italy, 2Department of Radiological, Oncological and Pathological Sciences, University of Rome La Sapienza, Rome, Italy Purpose: To evaluate the clinical performance of magnetic resonance-guided focused ultrasound (MRgFUS) in primary pain palliation of painful bone metastases and in local tumour control. Material and Methods: We enrolled 26 consecutive patients (females/males 12/14; age: 64.7 ± 7.5 years) with painful bone metastases. Before and 3 months after MRgFUS treatment (ExAblate2100 InSightec), pain severity and pain interference scores were assessed according to Brief Pain Inventory-Quality of Life criteria, and patients underwent both CT and MRI. Local tumour control was evaluated according to lesion size, density and perfusion at CT, dynamic contrast enhancement at MRI (Discovery 750HD, GE; Gd-Bopta, Bracco) and metabolic activity at PET or scintigraphy. Patients were classified as responders or non-responders.

Abstract Book Results: No treatment-related adverse events were recorded during the study. A statistically significant difference between baseline and follow-up values for both pain severity and pain interference scores was observed (p < 0.05). Increased bone density was observed in 9/26 (34.6%) patients. Non-perfused volume values ranged between 20% and 92%. There was no difference in NPV values between responders and non-responders [46.7 ± 24.2% (25-90%) vs. 45 ± 24.9% (20-93%); p = 0.7]. In 6 patients (5 prostate and 1 breast primary cancer), the metabolic activity was nearly absent after treatment (mean SUV = 1.2). Conclusion: MRgFUS can be safely and effectively used as the primary treatment for pain palliation in patients with painful bone metastases; moreover, our experience demonstrated a potential role of MRgFUS in local tumour control.

2306.6 Findings on computed tomography after irreversible electroporation of malignant liver tumors M. Dollinger, E.-M. Jung, L.P. Beyer, C. Niessen, C. Stroszczynski, P. Wiggermann; Institut für Röntgendiagnostik, Universitätsklinikum Regensburg, Regensburg, Germany Purpose: The purpose of this study was to describe the postablation findings on contrast-enhanced computed tomography (CT) of malignant hepatic tumors 24-72 hours after percutaneous ablation using irreversible electroporation (IRE) and in long-term follow-up. Material and Methods: A total of 54 malignant liver lesions ablated with IRE in 34 patients were retrospectively analyzed. Thirty cases of primary hepatic tumors and 24 hepatic metastases were treated. The ablation zones were evaluated by 2 examiners in consensus reading with dual phase CT (hepatic arterial and portal venous phase) after 24-72 hours after ablation and in long-term follow-up. Results: All 54 ablation zones were homogeneously hypodense in both phases, and 40/54 lesions included gas pockets. Peripheral contrast enhancement of the ablation defect was evident in 25/54 lesions in hepatic arterial and in 38/54 in portal venous phase. In 4 cases, intratumoral abscesses were detected after intervention. In long-term follow-up (mean, 4.7 months), after ablation, the mean volume of the ablation defects reduced to 29% of its initial value. Conclusion: Normal post-IRE findings on contrast-enhanced CT can be very similar to the classic descriptions of potential postablation complications such as liver abscesses. Consequently, CT scans must be carefully analyzed to avoid misinterpretation of normal findings related to the procedure with findings indicating complications requiring further treatment. In long-term follow-up there is a significant volume decrease of the ablation zone indicating a high regeneration capacity of the liver after IRE.

Free Paper Session Tumour ablation 3005.1 Radiofrequency ablation for chondroblastoma: a safe and effective technique or just a mirage? S.S. Kulkarni1, N.S. Shetty1, A.M. Polnaya1, A. Janu1, S.S. Patil1, K.B. Gala1, A. Kumar1, V.N. Bakare1, M. Thakur1, A. Gulia2, A. Puri2; 1Interventional Radiology, Tata Memorial Hospital, Mumbai, India, 2Surgical Oncology, Tata Memorial Cancer Hospital, Mumbai, India Purpose: To evaluate the clinical outcomes in chondroblastoma patients treated with radiofrequency (RF) ablation. Material and Methods: A retrospective analysis of prospectively

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maintained data of eight biopsy-proven chondroblastoma lesions treated in our institute from January 2010 to February 2014 using radiofrequency ablation were analysed. RF ablation was performed with multi-tined electrodes under computed tomography guidance. Lesion characteristics were determined from imaging studies (MRI/PET-CT). Symptoms were assessed before and at 24 hours and 6 weeks after the procedure. All patients were followed-up to assess the recurrence of pain or any complications. Follow-up MRI and PET-CT were done to evaluate post-RFA changes, growth plate and articular cartilage. Results: Eight male patients were treated (mean age, 17.5 years). Lesions were located in the proximal humerus (n = 1), proximal tibia (n = 3), proximal femur (n = 3) and distal femur (n = 1). Mean volume of lesions was 5.6 mL. All patients reported a relief of symptoms on day 1 post-procedure and on follow-up at 6 months. Mean follow-up was 28 months. A complete control of limb movements was found in all patients. Complete metabolic regression in the target lesion was obtained on PET-CT on follow-up. Follow-up MRI did not reveal growth plate abnormality. No major complication was noted in our patients. Conclusion: Percutaneous RF ablation appears to be a safe and effective minimally invasive alternative to open surgical method for chondroblastomas. Further research and long-term follow-up is required for substantiating long-term benefits of RFA in this subset of patients.

3005.2 Percutaneous radiofrequency ablation for children with small lung metastases F. Deschamps, T. de Baère; Department of Radiology, Institut Gustave Roussy, Villejuif, France Purpose: Despite percutaneous radiofrequency ablation (RFA) been proven as safe and effective for small lung metastases (LM), thoracotomy remains the gold standard for cancer children. Material and Methods: We prospectively analyzed all the children referred for RFA of LM at our institute. Indications and feasibility were discussed at multidisciplinary meeting. The goal was to treat all the LM patients using RFA to avoid thoracotomy. All procedures were performed under general anesthesia by an interventional radiologist under CT-guidance. Follow-up included a chest CT every 3 months. We report the complications and the rate of complete treatment per LM. Results: Between November 2011 and August 2013, 11 patients (12 years old, average 3.3-18) suffering from osteosarcoma (n = 7), hepatoblastoma (n = 2), and Ewing sarcoma (n = 2) were referred for RFA of 38 LM [mean diameter, 5 mm (2-14)]. One LM was contraindicated for RFA, because it was too close to the hilum and was surgically resected. Thirty-seven LM were successfully treated in 13 procedures. We experienced 6 patients with pneumothorax including 2 who required chest tube drainage. Patients did not experience any pain or dyspnea. The mean hospital stay was 3 days (1-8) after the procedure. After a median follow-up of 568 days (143-718), the complete treatment was 100% per LM. At present, 57% patients (n = 4/7) with osteosarcoma are still in complete remission [mean follow-up, 443 days (143-715)]. Conclusion: RFA is a safe and effective alternative to thoracotomy, even in children, and must be considered in managing small and potentially iterative lung metastases.

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3005.3 Microwave ablation of liver metastases from colorectal cancer: an Italian multicenter study G. Poggi1, L. Solbiati2, M.F. Meloni3, M. Bezzi4, B. Montagna1, D. Gasparini5, L. Carata6 , F. Antonella7, C. Gazzera8 , R.F. Grasso9, C.L. Mezzolla10, A. Noto11, S. Sartori12, F. Stacul13; 1UO Oncology, ICCP, Istituto Clinico Città di Pavia, Pavia, Italy, 2Division of Interventional Oncologic Radiology, General Hospital of Busto Arsizio, Busto Arsizio, Italy, 3Department of Radiology, San Gerardo Hospital Monza, Monza, Italy, 4Department of Radiological Science, University of Rome La Sapienza, Rome, Italy, 5Radiology - Vascular, Santa Maria Misericordia Hospital, Udine, Italy, 6Surgery, Osp Vito Fazzi, lecce, Italy, 7Radiology, Osp S. Annunziata, Chieti, Italy, 8Radiology, Molinette, Turin, Italy, 9 Radiology, Campus Bimedico, Rome, Italy, 10 Radiology, Clinica Città Verde, Taranto, Italy, 11Medicine, Osp Santa Annunziata, Cosenza, Italy, 12Gastroenterology, AOU Sant Anna, Ferrara, Italy, 13Radiology, AOU Riuniti, Trieste, Italy Purpose: The latest microwave (MW) technology is expected to obtain larger volumes and faster area of ablation than radiofrequency. We evaluated MW ablation in patients with unresectable liver metastases from colorectal cancer. Material and Methods: We have collected data from 14 Italian centers and treated 312 tumors in 178 patients. There were 116 patients with a single lesion; 15 of these developed another single metachronous lesion. Moreover, 40 patients presented two lesions, 18 presented three lesions, and 19 presented >three lesions. The mean diameter was 2.7 cm. Of them, 30% were deep lesions and 70% were superficial, and 30% lesions were close to the vessels. Results: Complete response (CR) was observed in 268 lesions (86%). CR was obtained in 97.5% lesions <2 cm, in 92.5% between 2 and 3 cm and in 89.5% between 3 and 4 cm. CR was not influenced by the distance between the lesion and the vessel. Median follow-up was 12 months. Overall, we observed 13% local tumor progressions. Intrahepatic distant recurrence was found in 40% patients. Local progression was 7% in lesions <3 cm and 12% lesions were large, i.e., between 3 and 4 cm. Only two major complications occurred: a biloma and a hemoperitoneum. Minor complications occurred in 7% patients. Conclusion: This study demonstrates that this new microwave device has achieved a substantial rate of complete necrosis of liver metastases even in a short-term treatment with only few major complications.

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3005.4 Immediate post-liver tumor ablation biopsy can predict local tumor progression C.T. Sofocleous1, L.M. Petrovic2, D.S. Klimstra3, A.R. Garcia4, M. Gonen5, S.B. Solomon1, E. Vakiani6 , S. Fujisawa7, Y. Romin7, A. Barlas7, M. Turkekul7, N. Fan7, K.T. Brown1, A.M. Covey1, W. Alago1, L.A. Brody1, R.P. DeMatteo8 , K. Manova-Todorova7, N.E. Kemeny9; 1Interventional Radiology Suite H118, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America, 2Pathology, University of Southern California-Keck Medical Center, Los Angeles, CA, United States of America, 3Pathology C563F, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America, 4Interventional Radiology H201, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America, 5EpidemiologyBiostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America, 6Pathology Z469, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America, 7Molecular Cytology Core Facility, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America, 8Surgical Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America, 9Gastrointestinal Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America Purpose: To validate the pathological examinations of the ablation zone immediately after liver radiofrequency ablation (RFA) as predictors of local tumor progression-free (LPFS) and overall survival (OS). Material and Methods: A prospective NIH supported, IRB- and HIPAA-compliant study enrolled 69 RF-ablated colon cancer liver metastases in 47 patients with at least 16 months follow-up. Ablated tissue was evaluated live by fluorescent stains and then fixed. Tumor cells were immunohistochemically assessed with proliferation protein Ki-67, mitochondrial viability marker OxPhos Antibody (OXP) and apoptotic markers caspase-3 and/or TUNEL. Kaplan-Meier and log-rank tests evaluated LPFS and OS. Multivariate analysis assessed tumor size and tissue characteristics. Results: Fifty-three post-ablation biopsied tumors were classified as coagulation necrosis (CN). Sixteen were viable (Ki-67, OXP positive tumor cells). Mean tumor sizes were 1.88 vs. 2.48 cm in the CN vs. V group. For the CN and V groups, LTP occurred in 12/53 (23%) and 11/16 (69%) tumors, with median and 2 year LPFS not reached (NR) vs. 11.2 months and 86% (76-96%) vs. 26% (10-64%) (p<0.001), respectively. V was significant (p=0.003, HR=3.7) but not tumor size (p=0.25, HR/cm=1.3). V remained significant for small (≤3 cm, p=0.004) and large (>3 cm, p=0.014) tumors. Overall median and 2 year LPFS were NR (71%; 60-83%). In total, 15/34 (44.1%) CN and (6/13) 46.2% V patients died. Overall median and 2 year OS was 36 (24 NR) and 62% (49-79%), respectively. Conclusion: OXP- and/or Ki67-positive ablated cells are independent LPFS predictors. This validated our preliminary data and indicated that biopsy of the ablation zone immediately after RFA may be clinically useful.

3005.5 Lung metastases of colorectal carcinoma: percutaneous radiofrequency ablation under C-arm cone-beam CT guidance G. Weber-Donat1, A. Boronat2, J.-C. Boucherie3, G. Amouyal2, J.-P. Hubsh3, R. Piracchio3, B.P. Cholley3, M.R. Sapoval2, O. Pellerin2; 1Radiology Department, Military Hospital Percy, Clamart, France, 2Interventional Radiology, Hopital Européen Georges Pompidou, Paris, France, 3Anesthesiology, Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France

Abstract Book an environment that is not fully adapted to the interventional radiology and anesthesiology team. Conversely, C-arm cone-beam CT (C-arm CBCT) occurs in a dedicated IR room. We tried to assess the feasibility of lung ablation using CBCT guidance alone. Material and Methods: This monocentric pilot study included consecutive patients referred for percutaneous lung radiofrequency ablation (RFA) between August 2012 and September 2013. All patients were administered general anesthesia with selective unilateral ventilation while the pathologic lung was expended by continuous positive pressure. iGuide® needle path guidance software (Artis Zee Siemens Healthcare Forchheim G.) was used to place the RF needle in the center of targeted metastasis. The primary endpoint was clinical and technical feasibility and safety; secondary endpoint was imaging results at 3 months. Results: Ten patients [age: 62.8 ± 11.1 years (47-80)] and 11 lung metastasis were treated in a single session. The tumor mean diameter was 24 ± 2.7 mm (18-29). Time to insert the needle was 12 min (9-25) median time. Median number of needles repositioning and C-arm CBCT acquisition/patient was 1 (0-3) and 5 (4-7), respectively. Only 1 pneumothorax occurred and required drainage. At 3 months, all patients were alive and had non-significant FDG activity on the PET scanner follow-up. Conclusion: Percutaneous lung RFA under C-arm CBCT guidance is feasible and safe with similar immediate and short-term results to conventional CT guidance.

3005.6 Single-center experience of radiofrequency ablation, cryoablation, and transarterial embolization of adrenal metastasis R.F. Grasso, G. Luppi, E. Faiella, F. Giurazza, R.L. Cazzato, S. Mercurio, B. Beomonte Zobel; Radiology, Campus Biomedico University of Rome, Rome, Italy Purpose: We describe our experience in the treatment of adrenal metastasis with radiofrequency ablation (RFA), cryoablation, and transarterial embolization (TAE). Material and Methods: From January 2012 to July 2013, 10 patients were treated with a mini-invasive approach; 5 had lung cancer, 4 had renal cancer, and 1 had neuroendocrine cancer. Four lesions were treated with RFA, 4 with cryoablation, and 1 with TAE. For each procedure, anesthetists performed a deep sedation and continuously monitored blood pressure levels. In all cases, a final CT scan was performed immediately after the procedure and then at 1 and 3 months follow-up. The average size was 31 mm (25-42 mm). The 6-month survival rate was 100%. During the procedures, 6 hypertensive crisis occurred with a maximum value of 300/200 mmHg. No further complications were detected during or immediately after the procedure. Results: The 3-month follow-up CT scans showed residual disease in 3 cases, estimated as 20% (patient treated with TAE) and 15% (2 patients treated with thermal ablation) of residual pathologic tissue. In other cases, no residual/recurrent disease was identified at followup imaging. Conclusion: Mini-invasive approach to secondary adrenal cancer is a valid alternative to surgery in terms of therapeutic outcome and procedural safety. Based on our experience, cryoablation appears to be the technique with the highest rate of success at 3-month follow-up.

Purpose: Percutaneous lung tumor ablation is an expanding procedure. The most accepted imaging guidance technique is conventional CT. However, its drawbacks are a poor patient accessibility and

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Free Paper Session Venous lysis and stenting 3006.1 Hybrid treatment with angiographic catheter in massive pulmonary embolism: mechanical fragmentation and fibrinolysis S. Pieri, A. Paolo; Cardioscienze, Az Osp S.Camillo Forlanini, Rome, Italy Purpose: Massive pulmonary embolism is a severe clinical condition that requires prompt therapeutic intervention. Medical and surgical interventions are ineffective. We report our experience with a hybrid treatment involving systematic fragmentation of the embolus with an angiographic catheter associated with fibrinolytic therapy over the following days. Material and Methods: From 1999 to 2012, we treated 235 patients with massive pulmonary embolism. We used the same angiographic catheter for mechanical fragmentation and for administration of the fibrinolytic agent (24-72 hours). Results were assessed on the basis of changes in the mean pulmonary artery pressure. Results: After fragmentation with the angiographic catheter, we observed four types of haemodynamic behaviour: in 114 patients (48.6%), mean pulmonary pressure fell rapidly below 30 mmHg, in 57 patients (24.3%), two passes were required to achieve the same result and in 37 patients (15.8%), three passes were required. In the remaining patients, at no time did the mean pulmonary pressure fall below 35 mmHg. The only four deaths occurred in this last group. Conclusion: Mechanical fragmentation with the angiographic catheter and administration of fibrinolytic agent effectively brought a rapid improvement in the clinical status of patients by moving the embolus towards the periphery.

3006.2 Transvenous SVC biopsy during SCV stenting in patients with SVC-obstructing intrathoracic malignancy F. Kovacs1, W. Sprenger De Rover2, G. Pollock1, P.M. Bungay1, P. Thurley1; 1Radiology, Royal Derby Hospital, Derby, United Kingdom, 2Radiology, Nottingham University Hospitals, Nottingham, United Kingdom Purpose: Superior vena cava (SVC) obstruction can occur in patients with intrathoracic malignancies. Malignant SVC obstruction is observed in up to 30% of lung cancer patients at presentation, and stenting is a well-established palliative measure to reduce distressing symptoms. Transvenous biopsy during stent placement is rarely performed with few published series. We share our experience, modiefied procedural technique and results. Material and Methods: We retrospectively analysed data between 2006 and 2013 using our radiology information system, electronic patient records and consultant interventional log books. Results: 20 SVC biopsies were performed over 7.5 years by three interventional radiologists in 20 patients with a mean age of 69 years (range 58-80). All stenting procedures were technically successful with significant symptom resolution and no major procedural complications. Tissue samples were obtained in all cases. Initial results in the first three patients were disappointing with negative histology, but after changing the technique by switching to spiked endoscopy forceps and solely using the transjugular route, we have since achieved a 90% positive biopsy yield. Our results are comparable to the previously published series. Conclusion: Transvenous SVC biopsy is a safe technique to gain histological diagnosis whilst treating malignant superior vena caval

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obstruction simultaneously with stent insertion when other biopsy routes are deemed higher risk or inaccessible. Simultaneous SVC stenting and trans-SVC biopsy allows safe prompt histological diagnosis and symptomatic treatment in this palliative cohort of patients.

3006.3 Pulmonary embolism response to fragmentation, embolectomy, and catheter thrombolysis (PERFECT): initial results from a prospective multicenter registry W.T. Kuo1, P.S. Kim2, A. Banerjee1, F.J. DeMarco3, J.R. Levy4, F.R. Facchini5, K. Unver1, M.J. Bertini6 , A.K. Sista7, M.J. Hall8 , M.A. de Gregorio9; 1Vascular and Interventional Radiology, Stanford University Medical Center, Stanford, CA, United States of America, 2Vascular and Interventional Radiology, Maine Medical Center, Portland, OR, United States of America, 3Pulmonary-Critical Care, Northside Hospital, Atlanta, GA, United States of America, 4Vascular and Interventional Radiology, Northside Hospital, Atlanta, GA, United States of America, 5Vascular and Interventional Radiology, Adventist Health Partners, Hinsdale, IL, United States of America, 6Family Medicine, Adventist Hinsdale Hospital, Hinsdale, IL, United States of America, 7Interventional Radiology, Weill Cornell Medical Center, New York, NY, United States of America, 8Vascular and Interventional Radiology, Memorial Hospital of South Bend, South Bend, IN, United States of America, 9Interventional Radiology, Clinico Universitario Zaragoza, Zaragoza, Spain Purpose: Systemic thrombolysis for acute PE carries up to a 20% risk of major bleeding, including a 2-5% risk of hemorrhagic stroke. We evaluated the safety and effectiveness of catheter-directed therapy (CDT) as an alternative treatment for acute PE. Material and Methods: Overall, 101 consecutive patients receiving CDT for acute PE were prospectively enrolled in a multicenter registry. Massive PE (n=28) and submassive PE (n=73) were treated with immediate catheter-directed mechanical or pharmacomechanical thrombectomy and/or catheter-directed thrombolysis via a lowdose hourly drug infusion with tPA or urokinase. Clinical success was defined as meeting all criteria: stabilization of hemodynamics, improvement in pulmonary hypertension and/or right heart strain, and survival to hospital discharge. Primary safety outcomes were major procedure-related complications and major bleeding events. Results: There were 53 men and 48 women with an average age of 60 years (range, 22-86) and mean BMI of 31.03±7.20 kg/m2. The average thrombolytic doses were 28±11 mg tPA (n=74) and 2,697,101±936,287 IU for urokinase (n=23). Clinical success was achieved in 24/28 (85.7%) (95% CI, 67.3-96.0%) patients with massive PE and 71/73 (97.3%) (95% CI, 90.5-99.7%) with submassive PE. The mean PA pressure improved from 51.17±14.06 mmHg to 37.23±15.81 mmHg (n=92) (P<0.0001). Among patients monitored with followup echocardiography, 56/64 (87.5%) (95% CI, 76.8-94.4%) showed improvement in right heart strain. There were no major procedure-related complications, major hemorrhages, and hemorrhagic strokes. Conclusion: Catheter-directed therapy improves clinical outcomes in acute PE patients while minimizing the risk of major bleeding. At experienced centers, CDT is a safe and effective treatment for both acute massive and submassive PE.

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3006.4 Deep blue something: catheter-directed thrombolysis of iliofemoral vein thrombosis – a single-center experience P. Staunton, S. McHugh, D. Moneley, A.L. Leahy, M.F. Given, F. McGrath, A. Keeling, P. Naughton, M.J. Lee; Vascular Centre, Beaumont Hospital, Dublin, Ireland Purpose: To evaluate the practice of catheter-directed thrombolysis of iliofemoral vein thrombosis in our center. Material and Methods: Data was retrospectively collected on all cases treated from 2006 to 2013. Outcomes were assessed using follow-up out-patient consultation notes and via a direct survey of patients. Results: Fifteen patients underwent intervention. Median age was 48 years with a female to male ratio of 9:6. Mean duration of presenting symptoms prior to intervention was 7.4 days (range 1-17). Known risk factors included OCP (n=2), SLE (n=2), active carcinoma (n=2), hypercoagulable state (n=3), and recent major surgery (n=1). Diagnosis was conducted using duplex (n=12), CT abdomen (n=2), or CT venogram (n=1). IVC filter was deployed pre-procedure in 14 cases. Procedures included tPa alone (n=4), tPa with mechanical thrombectomy (n=4), tPa with mechanical thrombectomy and aspiration (n=7). Stenting was performed in 7 cases. Duration of tPa post bolus was procedural only (n=4), 12-15 hours post procedure (n=10), or 24 hours (n=1). The overall reintervention rate was 40% (n=6). One patient developed compartment syndrome post-intervention. All patients were anticoagulated prior to discharge with grade 2 compression stockings. Mean follow-up was 15 months (range 2-24 months). Post-thrombotic syndrome has been reported by 2 patients. Follow-up imaging showed patency in 13/15 cases, with evidence of non-occlusive common femoral vein thrombus in one patient at 21 months (asymptomatic). Conclusion: Iliofemoral thrombosis should be considered a very different entity than infrainguinal thrombosis and urgent percutaneous intervention should always be considered in acute presentations.

3006.5 Aggressive endovascular treatment of deep vein thrombosis: PEARL registry outcomes demonstrate favorable improvement over published reports M.J. Garcia1, R.A. Lookstein2, A. Amin3, L. Blitz4, D. Leung1, E. Simoni5, P. Soukas6; 1Interventional Radiology, Christiana Care Health, Newark, DE, United States of America, 2Interventional Radiology, Mount Sinai Medical Center, New York, NY, United States of America, 3Vascular Surgery, Reading Medical Center, Reading, PA, United States of America, 4Cardiology, Chilton Memorial Hospital, Pompton Plains, NJ, United States of America, 5Vascular Surgery, Hershey Medical Center, Hershey, PA, United States of America, 6Cardiology, Miriam Hospital, Providence, RI, United States of America

Abstract Book extremity DVT (187 males, mean age 52) with the AngioJet system. Adjunctive therapies included CDT (61%) and stenting (35%). Of them, 33% were completed in 1 session, 73% in <24 h, and 86% in ≤2 sessions. The mean CDT drip time was 17 h with a 5% bleeding complication rate (major and minor), which compares favorably to the Venous Registry (48 h, 27%) and CaVenT Trial (57.6 h, 22%) results. The freedom of rethrombosis rate at 6 months was 88%, which is promising when compared with the primary patency rates of the Venous Registry (65%) and CaVenT (65.9%). Conclusion: Rheolytic thrombectomy with adjunctive therapies is a safe and effective strategy for DVT management with significant improvement in the endpoints of lytic drip time and bleeding complications when compared with the Venous Registry and CaVenT Trial.

3006.6 Endovascular management of chronic deep venous thrombosis: clinical and imaging outcomes C.J. Grilli, C. Wrigley, D. Leung, G. Kimbiris, K. Lie, D. Agriantonis, M.J. Garcia; Interventional Radiology, Christiana Care Hospital, Newark, DE, United States of America Purpose: Post thrombotic syndrome (PTS) can be a devastating complication of deep venous thrombosis (DVT). A goal for both acute and chronic DVT management is the prevention of PTS and its progression. We report the clinical benefit and imaging outcomes following aggressive endovascular recanalization of chronic, occlusive DVT. Material and Methods: A single-center retrospective review of patients suffering from chronic, occlusive DVT and PTS treated in 2013. Clinical and imaging data was collected including pre- and post-procedure Vilalta scores and ultrasound (US) follow-up at 1, 3, 6, and 12 months. Results: In all, 31 patients were treated, including 20 males and 11 females (mean age 52; range 19-86). The femoropopliteal segment was affected in all patients with iliac and IVC involvement in 14 and 6 patients, respectively. All patients had symptoms for >1 month. Technical success (defined as the ability to cross the occlusion and restore flow) was achieved in 100% (31/31) of cases. Clinical success was quantitatively measured by the Vilalta score. The mean pre-procedural Vilalta score was 13.1 (range 3-40). Post-recanalization mean Vilalta scores were 5.2, 2.6, 2.1, and 1.9 at 1, 3, 6, and 12 months, respectively. The US patency was 97% at 1 month (30/31), 93% at 3 months (25/27), 86% at 6 months (12/14), and 75% at 12 months (6/8). Conclusion: Patients suffering from chronic, occlusive DVT and PTS can safely and effectively undergo venous recanalization with excellent short- to mid-term clinical and imaging outcomes.

Purpose: Aggressive endovascular therapies, such as pharmacomechanical thrombectomy, are employed for early thrombus removal in an effort to preserve valves while reducing post-thrombotic syndrome risk. The PEARL Deep Vein Thrombosis (DVT) Registry evaluated the procedural and clinical benefits of rheolytic thrombectomy and compared them with published reports on DVT management. Material and Methods: The PEARL registry captured DVT history, procedural information, and clinical follow-up, with phase 1 patients (n = 145) followed for 3 months and phase 2 patients (n = 184) followed for 12 months. Symptomatic improvement was documented by the SF12 questionnaire. Procedural outcomes were then compared with published data from the Venous Registry and CaVenT Trial. Results: In all, 329 patients (32 centers) were treated for lower

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Free Paper Session TACE 3007.1 Transarterial chemoembolization with irinotecan drug-eluting beads in patients with unresectable colorectal liver metastases refractory to multiple lines of standard systemic therapy: our single-center multidisciplinary study A. Guerra, R. Iezzi, M. Nestola, A. Posa, E.G.M. Antonuccio, L. Bonomo; Department of Radiological Sciences, Institute of Radiology, “A. Gemelli” Hospital – Catholic University, Rome, Italy Purpose: To evaluate the safety and efficacy of transarterial chemoembolization with irinotecan drug-eluting beads (DEBIRI) combined with systemic therapy in patients with unresectable liver metastases from colorectal cancer (CRC) refractory to multiple lines of standard chemotherapy. Material and Methods: Twenty patients with liver-dominant metastatic CRC (12/20, 60% with bilobar disease; 8/20, 40% with unilobar disease), who have failed two or more lines of standard systemic chemotherapy, were enrolled in our single-center multidisciplinary study. The treatment schedule comprised TACE 100 mg of irinotecan loaded into 2 ml of 70-150 μm drug-eluting beads, every 4 weeks in patients with unilobar disease (total of 2 treatments) and every 2 weeks in patients with bilobar disease (total of 4 treatments). A concomitant systemic chemotherapy with capecitabine was administered. Adverse events, intra/periprocedural complications, and overall mean survival were assessed. Results: Technical success was achieved in all patients. No intra/periprocedural death or major complications occurred. A total of 54 procedures were performed (54/64, 84.3%). The scheduled treatment was interrupted in 6 patients (30%) because of capecitabine toxicity (2/6), refractory progression (3/6), or lack of compliance (1/6). An overall mean survival of 238 ± 54 days was calculated using KaplanMeier analysis. Only performance status correlated with overall survival in multivariate analysis (p = 0.006). Conclusion: TACE using DEBIRI combined with systemic chemotherapy is a safe and effective treatment option in the management of patients with chemorefractory metastatic CRC with liver-dominant disease. In particular, it seems to be an appropriate palliative therapy after chemotherapy failure allowing to control disease progression and improving patients’ overall survival.

3007.2 Chemoembolization of hepatocellular carcinoma with M1 drug-eluting beads: safety and effectiveness A.F. Nicolini1, S. Crespi1, A. Bellobuono1, M. Triolo2, L. Martinetti1, M. Iavarone2, A. Sangiovanni2; 1Interventional Radiology, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy, 2Division of Gastroenterology Center for Liver Disease, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy Purpose: TACE is SOC treatment for intermediate stage HCC. We assessed the safety and efficacy of TACE using 70-150 μm drug-eluting beads (DC-BeadM1, Biocompatibles UK), an embolizing device with a narrower distribution, which avoids premature proximal occlusion of tumor-feeding vessels and increases drug delivery to the tumor. Material and Methods: All patients consecutively subjected to DC-BeadM1-TACE were studied with at least one sizable and untreated HCC node at baseline CT. Clinical and analytical data were recorded at 24 and 48 h and 7, 14, and 30 days after the first TACE. Quality of life was evaluated by the FACT Hepatobiliary Symptom

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Index at baseline and after 7 days. Response was assessed by CT after 1 month according to mRECIST. In patients achieving a complete response (CR), a new CT was performed after 3 months. Patients who failed to reach CR received a second DC-BeadM1-TACE. Results: Fifty-seven cirrhotics (81% males, 72 years, 68% HCV, 76% Child-Pugh A) with unresectable HCC (24% BCLC A4 and 35% BCLC B) were treated. No major complications occurred, 26% patients had abdominal pain after 20 minutes-3 hours, 7% had transient hypertension, and 9% had post-TACE syndrome. The quality of life evaluation did not show any significant change. After 1 month, 22% patients had CR, 54% had partial response, 11% had stable disease, and 9% had progression. CT scan after 3 months was available in 9/13 patients who achieved a complete response, and 46% maintained CR. Conclusion: TACE with DC-BeadM1 is a safe and effective technique facilitating CR or partial response in a majority of patients with unresectable tumors.

3007.3 Anatomical and functional imaging methods to assess c-TACE efficacy in a hepatocellular carcinoma animal model W. Gonzalez, E. Vaudon, C. Hollenbeck, J.-F. Mayer, C. Robic, P. Robert, S. Catoen, S. Ballet, C. Corot; R&D, Guerbet Inc., Roissy CdG Cedex, France Purpose: To evaluate the robustness and the complementarity of anatomical and functional imaging methods for assessing cytotoxic drug delivery and anti-tumor effect of conventional transarterial chemoembolization (c-TACE) procedure in HCC rat model. Material and Methods: A total of 106 N1-S1 cells were placed in the left hepatic lobes of 20 female Sprague-Dawley rats. Rats were randomly divided into two groups: the first group underwent c-TACE via the hepatic artery with saline (n=10, control group), and the second group was infused with 0.1-mL lipiodol + 0.5-mg doxorubicin emulsion (c-TACE group). Treatment efficacy was followed by anatomical magnetic resonance imaging (MRI) 7 days after the chemoembolization procedure in both groups. Tumor growth ratios were measured by MRI, and necrosis was evaluated by histology (haematoxylin and eosin staining, H & E). Results: HCC was induced in all animals, and c-TACE was successful. H & E staining revealed hypervascular tumor with a pattern that mimics human HCC lesions. MRI showed that tumors are homogenous, and volume and diameter were determined. Seven days after c-TACE, tumor sizes were significantly smaller in c-TACE vs control groups (8.2±5.2 mm vs. 14.7±3.9 mm, p<0.01). H & E staining revealed higher necrosis (% of total tumor surface) in TACE vs control groups (59±23 vs 26±9.0%, p<0.05). Conclusion: HCC rat model is suitable for studying the therapeutic effect of lipiodol-based transarterial chemoembolization and seems to be a valuable screening tool in investigating cTACE-based innovative therapies. Imaging methods can be applied to characterize and follow-up anti-tumor effect of c-TACE procedure in HCC rat model.

3007.4 Transcatheter arterial chemoembolisation of intermediate stage hepatocellular carcinoma with drug-eluting beads under cone-beam computed tomography control P. Popovic, M. Garbajs, M. Stabuc, D. Nuredini, P. Kavcic, D. Kuhelj; Clinical Institute of Radiology, University Medical Centre Ljubljana, Ljubljana, Slovenia Purpose: The purpose of our study was to evaluate the results of drug-eluting bead-transarterial chemoembolisation (DEB-TACE) performed under cone-beam computed tomography (CBCT) in patients with intermediate stage hepatocellular carcinoma (HCC).

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Material and Methods: Between February 2010 and June 2012, 47 patients were treated with DEB-TACE. Inclusion criteria for our analysis was intermediate stage disease according to the Barcelona Clinic Liver Cancer (BCLC) staging classification. Overall, 37 of 47 patients were analysed (34 males, 3 females; average age, 67.5 ± 7.6 years; 23 patients Child-Pugh class A, 9 class B). Superselective catheterisation of feeding vessels was followed by embolisation with 100-300 microspheres loaded with 50-100-mg doxorubicin. In all cases, CBCT was used during chemoembolisation. Patients underwent follow-up CT or magnetic resonance imaging (MRI) every 3 months. Results: Overall, 94 procedures were performed in 37 patients (mean, 2.5 per patient). There were 35 minor and 2 major complications (one liver abscess and one cerebrovascular insult). After a median followup of 15 months (range, 1.0-26.4 months), 34 of 37 (91.9%) patients achieved objective response (13 patients with complete response, 21 with partial response). Mean time to progression was 11.2 months (5.8-24.8 months). Mean overall survival was 31.1 months (range, 4.427.6 months), and 1-year overall survival was 91.9%. Conclusion: DEB-TACE with CBCT is a safe and effective method for patients with intermediate stage HCC.

3007.5 Hepatic metastases from uveal melanoma treated with transarterial drug-eluting beads loaded with irinotecan U. Carling1, E.J. Dorenberg1, S.P. Haugvik2, N.A. Eide3, D.T. Berntzen1, B. Edwin4, B. Røsok2, S. Dueland5; 1Dep. for Radiology and Nuclear Medicine, Oslo University Hospital Rikshospitalet, Oslo, Norway, 2Dep. of Hepatobiliary Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway, 3Dep. of Ophtalmology, Oslo University Hospital Ullevål, Oslo, Norway, 4Intervention Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway, 5Dep. of Oncology, Oslo University Hospital Radiumhospitalet, Oslo, Norway Purpose: To report the treatment effect of transarterial chemoembolization (TACE) with drug-eluting beads loaded with irinotecan (DEBIRI) in patients with hepatic metastases from uveal melanoma. Material and Methods: Fourteen patients (6 men, median age 64) diagnosed with hepatic metastases from uveal melanoma were treated with DEBIRI TACE (100-300 microns loaded with 100-mg irinotecan), in 2010-2013. Each patient received 4 treatments, 2 in each lobe (except three cases where 1 and 3 treatments were provided; total 55 procedures). Treatment response according to RECIST 1.1 was assessed using contrast-enhanced computed tomography obtained at median 1.5 months (range 1.2-3.7) post-treatment. Overall survival was calculated from the time of diagnosis of metastatic disease (OS1), and the time of the first DEBIRI (OS2). Complications were registered retrospectively and categorized according to the Society of Interventional Radiology (SIR) classification for complications by outcome. Results: Radiological response showed 11 cases of progressive disease and 2 cases of a stable disease (one patient was not evaluated). Median OS1 was 13.3 months (range 3.9-47.5; 3 patients were alive at 10, 12, and 11 months), and median OS2 was 8.9 months (1.7-39; 3 patients were alive at 8, 9, and 7 months). We registered 8 major complications (including one death in <30 days). Conclusion: Even at early follow-up, progressive disease occurred following DEBIRI TACE, and overall survival was similar to reports from other transarterial methods in this patient group. Major treatment-related complications were registered.

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3007.6 DEB-TACE for unresectable hepatocellular carcinomas: results from a tertiary cancer care centre in India S.S. Kulkarni1, N.S. Shetty1, A.M. Polnaya1, S.S. Patil1, V.N. Bakare1, A. Kumar1, A. Janu1, K.B. Gala1, M. Thakur1, S. Shrikande2, M. Goel2, S. Mehta3, P. Patil3, B. Shirroi4; 1Interventional Radiology, Tata Memorial Hospital, Mumbai, India, 2Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India, 3Department of Gastroenterology, Tata Memorial Hospital, Mumbai, India, 4Medical Oncology, Tata Memorial Hospital, Mumbai, India Purpose: To evaluate the safety and efficacy of drug-eluting beads (DEB-TACE) in patients with unresectable hepatocellular carcinomas. Material and Methods: In all, 113 patients with unresectable hepatocellular carcinomas who have undergone single/multiple sessions of DEB-TACE between June 2008 and December 2013 were retrospectively analyzed. The tumor response was classified according to modified RECIST criteria as complete response (CR), partial response (PR), stable disease (SD), and progressive disease (PD). Median survival was calculated. Results: A total of 113 patients underwent 214 TACE sessions at our institute during the study period. Of them, 66% patients had a solitary lesion. The patients were followed-up with MRI/CT at 6 and 12 weeks for imaging response and later for survival analysis. The mRECIST criteria were used for assessing tumor response. At 6 weeks, CR, PR, SD, and PD were 8.8, 71.6, 11.5, and 6.2%, respectively, and at 12 weeks, they were 14.1, 56.6, 5.3, and 11.5%, respectively. The median survival was 2.1 years. Post-embolization (24.7%) was the most common morbidity in our study group while one patient succumbed to chemotherapy-induced neutropenia. Conclusion: DEB-TACE is a safe and effective palliative locoregional therapy in the management of unresectable hepatocellular carcinomas. Tumor response and median survival appears to closely follow the global trend even in the Indian population.

Free Paper Session Experimental work (transarterial) 3008.1 Pharmacokinetics and antitumor efficacy of chemoembolization using novel 40- μm irinotecan-loaded microspheres in a rabbit liver tumor model T. Tanaka1, H. Nishiofuku1, Y. Hukuoka1, T. Sato1, T. Masada1, J. Ren2, C.W. Gilbert2, K. Kichikawa1; 1Radiology, Nara Medical University, Kashihara, Japan, 2Technology Officer, CeloNova BioSciences, Inc., San Antonio, TX, United States of America Purpose: To evaluate the pharmacological and histological advantages of newly developed 40-μm irinotecan-loaded drug-eluting microspheres, Embozene TANDEM® Microspheres (TANDEM-IRI). Material and Methods: In all, 24 VX2 rabbits were divided into 3 groups: Group 1, full-dose (50 mg irinotecan/1 mL TANDEM) loaded/ high-dose (1 mg irinotecan/kg) injection; Group 2, full-dose (50 mg/mL) loaded/low-dose (0.5 mg/kg) injection, and Group 3, halfdose (25 mg/mL) loaded/low-dose (0.5 mg/kg) injection. Irinotecan and SN-38 in plasma and tumors were measured within 72 hours. Histological examinations were conducted on days 1, 3, and 7. Results: The serum irinotecan levels remained near the CMAX values for 180 minutes after TACE; in Group 1, at 351.4, 329.0, and 333.5 ng/mL at 30, 60, and 180 minutes, respectively. The AUC0-24 h values of irinotecan in Group 1 were approximately 2 times higher than those of Groups 2 and 3. High irinotecan and SN-38 concentrations

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in tumors were measured at 24 and 72 hours. After TACE, liver enzymes of AST and ALP levels in Group 1 elevated significantly higher than Group 2 and Group 3. Histological findings showed that microspheres had deeply penetrated into tumors. Significantly higher tumor necrosis ratios in Group 1 (86.6-90.0%) and Group 3 (90.0100%) were observed when compared with those of Group 2 (63.370%) (P = 0.031 and 0.016). Conclusion: The 40-μm TANDEM-IRI has the advantages of slow drug release and can achieve high tumor drug concentrations with high antitumor response. The dose of irinotecan loaded on 40-μm TANDEM could be reduced while maintaining efficacy when complete arterial embolization is performed.

3008.2 Feasibility, safety and efficacy of intra-arterial delivery of autologous bone marrow-derived stem cells in treating diabetes mellitus S. Sharma1, S. Kumar1, P. Jagia1, G.S. Gulati1, B. Bhargava2, S. Mohanty3; 1Dept of Cardiac Radiology, All India Institute of Medical Sciences, Delhi, India, 2Dept of Cardiology, All India Institute of Medical Sciences, Delhi, India, 3Stem Cell Facility, All India Institute of Medical Sciences, Delhi, India Purpose: The feasibility, safety and therapeutic efficacy of the intraarterial delivery of autologous bone marrow-derived stem cells in pancreaticoduodenal arteries for improving glycemic control was assessed in a group of patients. Material and Methods: Ten patients were enrolled with uncontrolled diabetes (requiring >0.6 U of insulin/kg/day for glycemic control). Clearance from the Institute Ethics Committee and informed written consent were obtained. All patients underwent anatomic (ultrasound and CT for pancreas) and biochemical (fasting blood sugar, C-peptide, serum amylase and HbA1C levels) assessment before and after treatment. Each patient received 30 million autologous bone marrow-derived stem cells, injected intra-arterially in the pancreaticoduodenal branches of the gastroduodenal artery. The primary endpoint was >15% improvement in baseline HbA1c levels at 3 months; secondary endpoints included >30% improvement in fasting blood sugar level and reduction in number/dose of drugs for glycemic control. Results: Median age was 45 (18-65 years). Technical success, as defined by uneventful delivery of stem cells in target area, was achieved in 100% cases. Mean follow-up period was 24 (3-45 months). There were no complications. Seven (70%) patients achieved primary endpoint (mean HbA1C before treatment was 11% (7.5-13%) and after treatment was 7.8% (5.9-12.2%). Fasting blood sugar improved from 236 mg/dl (190-310 mg/dl) to 149 mg/dl (100-307 mg/dl). There was significant reduction in insulin requirement for glycemic control (mean before treatment was 48 U/day (38-54 U/ day) and after treatment was 25 U/day (0-32 U/day). Conclusion: This pilot study confirms the feasibility, safety and efficacy of the local intra-arterial delivery of autologous stem cells to treat patients with uncontrolled diabetes.

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3008.3 Initial evaluation of the arterial recanalization and ischemic effect after embolization of the uterine artery with a new degradable microsphere in a sheep model J. Bengtsson1, I. Keussen1, E. Karlstam2, D. Gavier-Widén2, W. Cwikiel1; 1Center for Medical Imaging and Physiology, Lund University Hospital, Lund, Sweden, 2Department of Pathology and Wildlife Diseases, National Veterinary Institute, Uppsala, Sweden Purpose: To evaluate revascularization and local effects of a new degradable calibrated microsphere in a short-term experimental study. Material and Methods: All procedures were performed under general anesthesia. Unilateral transarterial embolization of the uterine artery was performed in six ewes using new 500-700-μm biodegradable microspheres. The absence of blood flow after embolization was confirmed by angiography. The animals were observed in the animal research facilities and euthanized following angiography at different intervals (1-65 hours after embolization). Gross and histopathological evaluations were performed of the uterus and other organs of interest. Results: Successful embolization was achieved in all animals. Recanalization increased with time and was completed in the evaluated sheep at 65 hours. At gross examination, edema and discoloration, indicating ischemia, on the embolized side of the uterus were observed. At histopathological examination, different stages of sphere degradation were observed in arteries in both the myometrium and the endometrium. Mild-to-moderate vasculitis and mildto-extensive ischemic changes were present along with the degeneration of endometrial glandular structures in all sheep except the one evaluated after one hour. No spheres were found in other examined organs. Conclusion: This pilot study confirmed the degradability of microspheres with the restoration of blood flow in the embolized arteries within 2-3 days with acute local ischemic changes. Evaluation of longer-term effects and comparison with non-degradable microspheres is intended.

3008.4 Liver percutaneous isolated localized perfusion: interim results of the first-in-man trial G.A. Maleux1, P.P. Goffette2, L. Defreyne3, S. Heye1, J.J. Fierens4, E.J. Bartholomé4, K. Geboes5, M. Van den Eynde6 , E. Van Cutsem7; 1Department of Radiology, University Hospitals Leuven, Leuven, Belgium, 2Radiologie Interventionnelle et Vasculaire Neuroangiographie Thérapeutique, Cliniques Universitaires SaintLuc-UCL, Brussels, Belgium, 3Vascular and Interventional Radiology (VINRAD), UZ Gent, Gent, Belgium, 4Clinical Affairs, Medical Device Works, Brussels, Belgium, 5Gastroenterology, UZ Gent, Gent, Belgium, 6Gastroenterology, Cliniques Universitaires Saint-Luc-UCL, Brussels, Belgium, 7Department of Gastroenterology, University Hospitals Leuven, Leuven, Belgium Purpose: To evaluate the feasibility, repeatability, and safety of a liver percutaneous isolated localized perfusion (liver-PILP) kit. Material and Methods: Patients with colorectal cancer with unresectable liver metastasis refractory to chemotherapy were included in a multicenter, phase I prospective trial in 3 centers in Belgium. The innovative liver-PILP kit was used to create an isolated perfusion circuit between the hepatic veins, the hepatic artery and the portal vein. The hepatic artery collaterals were occluded. IVC flow was not interrupted by a newly designed IVC-covered stent, allowing selective hepatic venous blood aspiration. Eloxatin (40 mg/m2) was injected in the closed liver circuit and allowed to circulate for 1 hour.

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Isolated perfusion was performed every 3 weeks with a maximum of 3 procedures/patient. Results: Twelve procedures performed on 7 patients are reported here. Based on angiographic results, the performance criteria were reached in 11 (92%) interventions. Despite optimal angiographic closure of all hepatic vessels, isotopic monitoring disclosed communication with the systemic circulation during half of the procedures, indicating undetected collaterals. When optimal isolation was achieved, eloxatin concentration in the liver (15.0-31.0 mg/ml) was 11.5 times (median) higher than that in the systemic blood (1.5-2.2 mg/ml). Partial right portal vein thrombosis and non-obstructive hepatic artery dissection were observed in 1 and 2 patients, respectively, without clinical effects. Anemia, transient elevation of liver enzymes, puncture site pain, and fatigue were the most common side effects. One patient developed a systemic inflammatory response syndrome. Conclusion: These results demonstrate the ability of the liver-PILP kit to safely achieve percutaneous liver isolation and perfusion with highly concentrated chemotherapy.

3008.5 Next generation multimodal-visible embolization particles: a feasibility study in rabbit and pig animal models J. Budjan1, E. Appel1, T. Nguyen2, S. Diehl1, S. Schönberg1, C. Reis2, S. Bartling1; 1Institute of Clinical Radiology and Nuclear Medicine, University Hospital Mannheim, Mannheim, Germany, 2Fraunhofer IPA, Fraunhofer IPA, Mannheim, Germany Purpose: The aim of this study is to produce and test next generation multimodal-visible (X-ray, CT, and MRI) embolization particles with a narrow particle-size distribution and synthesize them in a new automated process under 100% quality control and to assess the visibility, manageability, and ability to perform controlled, selective embolization with the particles in vivo. Material and Methods: Particles with a 200-μm diameter and a narrow particle-size distribution (±5% deviation in diameter) are synthesized in a closed-loop automated microfluidic process. An optimized monomer blend of an iodine-containing monomer with an additional cross-linker is polymerized. The monomer blend contains superparamagnetic iron oxide particles. A kidney embolization model was used. Four rabbits and 3 pigs were embolized in an X-ray angiography/DynaCT setup (Siemens Artis Zeego) under live image control. The animals were examined using clinical MRI (Siemens Magnetom Trio, T1 VIBE, T2* and T2) and CT (Siemens Somatom Definition, 120 kV, 260 mAs, 0.6-mm collimation) scanners directly before and after embolization. Results: The particles were visible in CT, MRI, and during embolization in X-Ray/DynaCT. A controlled segmental kidney embolization could be achieved. Peri-interventional imaging demonstrated particles in all 3 imaging modalities and in positive correlation to histology, which showed proper thrombogenesis. Conclusion: The automated synthesis process allows the creation of high quality MR-, CT-, and X-ray-visible embolization particles with a narrow particle-size distribution that will allow novel approaches to personalize treatment concepts and therapy monitoring.

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3008.6 Automatic 3D detection of prostatic arteries using cone-beam computed tomography during prostatic arterial embolization: a feasibility study M. Chiaradia1, J. Mayer1, A. Campeggi2, L. Novelli1, M. Bouanane1, A. De La Taille2, A. Radaelli3, H. Kobeiter1; 1Service d’Imagerie Médicale, CHU Henri Mondor, Créteil, France, 2Service d’Urologie, CHU Henri Mondor, Créteil, France, 3Interventional X ray, Philips Healthcare, Best, Netherlands Purpose: To evaluate the feasibility of automatic 3D detection of prostatic arteries from cone-beam computed tomography (CBCT) using a vessel-tracking software (Emboguide software; ES) during prostatic arterial embolization (PAE). Material and Methods: Six patients underwent PAE for benign prostatic hyperplasia between December 2012 and January 2014. All patients underwent intra-procedural dual-phase CBCT with selective contrast injection in each internal iliac artery. Prospectively, ES was applied to the CBCT datasets to facilitate the detection of prostatic arteries (PA). The candidate vessels were assessed by two interventional radiologists and validated by selective angiography and CBCT. Results: PA were detected for each patient on both sides except for one case. The information provided by ES impacted clinical decisions on PAE in three of the six patients (50% cases). One false-negative (due to a technical error, i.e., injection in the posterior trunk of the internal iliac) and 3 false-positive cases were observed (related to the over-segmentation of the prostate gland: the artery supplying seminal vesicles, right pudendal artery, and pelvic bone). The operators successfully detected and corrected all false-positive cases using the selective CBCT images after distal catheterization. Conclusion: Automatic detection of prostatic arteries from CBCT using ES is feasible and may be used to facilitate catheterization of the prostatic arteries during PAE and to avoid non-target embolization.

Free Paper Session Radioembolisation 3104.1 Feasibility of combining capecitabine and temozolomide with yttrium-90 radioembolization (CapTemY90) for intermediategrade metastatic neuroendocrine tumors M.C. Soulen1, G. Deitrick1, D. van Houten1, J.I. Mondschein1, S.W. Stavropoulos1, B. Giantonio2, U. Teitelbaum2; 1Radiology, University of Pennsylvania, Philadelphia, PA, United States of America, 2Medical Oncology, University of Pennsylvania, Philadelphia, PA, United States of America Purpose: Grade 2 NETs have an intermediate proliferative rate and progress more aggressively than low-grade NETs. Capecitabine + temozolomide (CapTem) has shown 61% response rate. Capecitabine is a radiosensitizer. We investigated the safety and tolerability of combining CapTem with Y90 for progressive grade 2 NETs with liverdominant metastases. Material and Methods: Patients were prescribed capecitabine (600 mg/m2 BID) for 14 days and temozolomide (150-200 mg/m2) in 2 doses on Days 10-14 with 14 days between cycles. Y90-planning angiography was performed during the first cycle. During the second cycle, resin Y90 radioembolization was performed on one lobe on Day 7. The other lobe was treated if required on Day 7 of the 4th cycle. CapTem was continued every month, and clinical and laboratory toxicities were assessed every month. Imaging was performed 3 months after the first radioembolization and thereafter, every 3 months.

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Results: Ten patients were treated. Primary NETs were pancreatic in 5 patients, bronchial in 2, and in the gut in 3. Overall, 9/10 patients completed the prescribed combination of chemotherapy and radioembolization. One patient developed grade 2 hyperbilirubinemia after the first radioembolization and did not have the other lobe treated, 1 stopped CapTem on Cycle 3 because of grade 4 thrombocytopenia, 1 required dose interruption for ITP, and 1 required dose reduction for grade 3 fatigue. Six patients had 3-month imaging with 4 PR, 1 SD, and 1 PD. Conclusion: CapTemY90 is a tolerable regimen with toxicities similar to those of CapTem alone. Early responses are encouraging and support further evaluation in a formal phase 2 trial.

3104.2 Radioembolization for hepatocellular carcinoma using yttrium-90 resin microspheres: general experiences in Korea Y.H. Kim1, E. Chung1, G.M. Kim2, C.W. Kim3, H.J. Chun4, D.I. Kwon5, K.-H. Lee6 , J.Y. Won7, J.K. Kim8 , J.W. Chung9, Korean Radioembolization Association; 1Radiology, Korea University Anam Hospital, Seoul, Korea, 2Department of Radiology, Yonsei University College of Medicine, Seoul, Korea, 3Radiology, Pusan National University Hospital, Busan, Korea, 4Radiology, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea, 5Department of Radiology, Ulsan University College of Medicine, Seoul, Korea, 6Department of Radiology, Gangnam Severance Hospital, Seoul, Korea, 7Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea, 8Department of Radiology, Chonnam National University College of Medicine, Seoul, Korea, 9Radiology, Seoul National University Hospital, Seoul, Korea Purpose: Radioembolization using yttrium-90 microsphere (Y-90) is a new treatment option for hepatocellular carcinoma (HCC). We assessed clinical outcomes of patients treated with Y-90 in Korea. Material and Methods: We treated 154 HCC patients with Y-90 in 7 university-affiliated hospitals and prospectively analyzed these patients. Toxicities of treatment were assessed using Common Terminology Criteria for Adverse Events version 3.0. The response was analyzed using modified Response Evaluation Criteria in Solid Tumors (mRECIST). Results: At baseline, there were 144 (93.5%) and 10 (6.5%) patients with Child-Turcotte-Pugh score A and B. At the Barcelona Clinic Liver Cancer (BCLC) stage, there were 12.3%, 48.7%, 38.3%, and 0.6% patients in A, B, C, and D, respectively. Thirty-four patients (22.0%) had extrahepatic metastasis. Complete response, partial response, stable disease, and progressive disease were observed in 28 (18.2%), 9 (5.8%), 38 (24.7%), and 48 (31.2%) patients during median 8-month follow-up period, respectively, and disease control rate was 48.7%. Abdominal pain (17.5%), nausea or vomiting (12.9%), anorexia (5.2%), and fever (5.1%) were observed, and 0.6% patients had grade 3/4 fever. Median hospital stay was 3 days (range 1-10). There was no therapy-related death. Two-year survival rates were 68.3%, and 3 year survival rates were 62.0%. Conclusion: Y-90 is a safe and effective tool for HCC. Survival may be worse for advanced HCC but Y-90 can still be considered as an important treatment option.

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3104.3 Prospective randomized comparison of selective internal radiotherapy versus transarterial chemoembolization for the treatment of hepatocellular carcinoma R. Kloeckner1, W. Eichhorn1, M.A. Wörns2, G.M. Wirth1, G. Otto3, C. Düber1, M.B. Pitton1; 1Diagnostic and Interventional Radiology, University of Mainz, Mainz, Germany, 2Internal Medicine – Hepatology, University of Mainz, Mainz, Germany, 3Hepatobiliary, Pancreatic and Transplant Surgery, University of Mainz, Mainz, Germany Purpose: To prospectively compare selective internal radiotherapy (SIRT) and drug-eluting bead-transarterial chemoembolization (DEB-TACE) for treating hepatocellular carcinoma (HCC). Material and Methods: From April 2010 to July 2012, 24 patients with histologically proven unresectable N0, M0 HCCs were randomized 1:1 to receive SIRT or DEB-TACE. SIRT was repeated once in case of recurrence; whereas, TACE was repeated every 6 weeks until no viable tumor tissue was detected by MRI or contraindications prohibited further treatment. Patients were followed-up by MRI every 3 months; the final evaluation was performed in May 2013. Results: Both groups were comparable in demographics (SIRT: 8 males/4 females, mean age 72±7 years; TACE: 10 males/2 females, mean age 71±9 years), initial tumor load (in 1 patient ≥25% in each group), and Barcelona Clinic Liver Cancer stage (SIRT: 12xB; TACE 1xA, 11xB). Median progression-free survival (PFS) was 180 days for SIRT versus 216 days for TACE patients (p=0.6193), median time to progression (TTP) was 371 days versus 336 days (p=0.5764), and median overall survival (OS) was 592 days versus 788 days (p=0.9271). Seven patients died in each group. Causes of death were liver failure (n=4 SIRT group), tumor progression (n=4 TACE group), cardiovascular events, and inconclusive (n=1 in each group). Conclusion: No significant differences were found in median PFS, OS, and TTP. The lower rate of tumor progression in the SIRT group was nullified by a greater incidence of liver failure. Our study is the first prospective randomized trial comparing SIRT and TACE for treating HCC, and results can be used for sample size calculations of future multicenter studies.

3104.4 Carcinoembryonic antigen response after initial single- or multi-session radioembolization for colorectal cancer: analysis of cumulative delivered radioactivity and dose D. Goldin1, S. Reich2, D. George2, L. Bahoura2, S. Emerson2, J. Campbell2, M. Savin2; 1Radiology, Division of Interventional Radiology, Medical University of South Carolina, Charleston, SC, United States of America, 2Radiology, Division of Interventional Radiology, William Beaumont Health System, Royal Oak, MI, United States of America Purpose: To investigate whether administered radioactivity and dose correlate with changes in carcinoembryonic antigen (CEA) levels after initial radioembolization for metastatic colorectal cancer (mCRC). Material and Methods: Retrospective review of patients treated with radioembolization for liver-dominant mCRC between June 2009 and February 2013 was conducted. Multivariate analysis included age, sex, disease stage, number of prior chemotherapy lines, and initial presentation with stage IV disease. Multisession therapy variables were calculated including total radioactivity administered, lobe dose of most disease-burdened lobes, total radioactivity delivered to the tumor, multi-session liver, and tumor doses. Response variables included progression-free survival, absolute and relative changes of CEA levels at 4-6 weeks and 12 weeks after completion of initial radioembolization. Statistical correlations

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and robust regression models were used to investigate the significance of findings after therapy. Results: Thirty subjects treated with radioembolization for mCRC were included. CEA level follow-up was at 4-6 week (n=28) and 12 week (n=17) intervals. Analyzing the entire cohort, there were no significant correlations at α=0.05; however, nearly significant correlations were observed in total radioactivity administered compared with progression-free survival (p=0.055) and total activity delivered to tumor compared with CEA change at 12 weeks (p=0.064). Total radioactivity delivered to tumor in liver-only mCRC patients (excluding extrahepatic patients) was significantly correlated with a decrease in CEA both at 4-6 and 12 weeks post radioembolization with estimated Spearman correlations of −0.66 (p=0.01) and −0.60 (p=0.022), respectively. Conclusion: Total radioactivity delivered to tumor in liver-only mCRC disease was the only variable correlated with change in CEA levels after radioembolization.

3104.5 Radioembolization for portal vein tumor thrombosis using yttrium-90 resin microspheres: general experiences in Korea Y.H. Kim1, G.M. Kim2, H.J. Chun3, D.I. Kwon4, J.Y. Won5, K.-H. Lee6 , Korean Radioembolization Association, J.K. Kim7, J.W. Chung8 , E. Chung1; 1Radiology, Korea University Anam Hospital, Seoul, Korea, 2Department of Radiology, Yonsei University College of Medicine, Seoul, Korea, 3Radiology, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea, 4Department of Radiology, Ulsan University College of Medicine, Seoul, Korea, 5Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea, 6Department of Radiology, Gangnam Severance Hospital, Seoul, Korea, 7Department of Radiology, Chonnam National University College of Medicine, Seoul, Korea, 8Radiology, Seoul National University Hospital, Seoul, Korea Purpose: Radioembolization using yttrium-90 microspheres (Y-90) is emerging as a new treatment option for hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT). We investigated the clinical outcomes of Y-90 in this setting. Material and Methods: We treated 154 HCC patients with Y-90 in 7 university-affiliated hospitals, and among them, 47 patients with PVTT were analyzed. Toxicities of treatment were assessed using Common Terminology Criteria for Adverse Events version 3.0. Response was analyzed using modified Response Evaluation Criteria in Solid Tumors (mRECIST). Results: At baseline, there were 41 (87.2%) and 6 (12.8%) patients with Child-Turcotte-Pugh score A and B. Fifteen patients (31.9%) had extra-hepatic metastasis. Complete response, partial response, stable disease, and progressive disease were observed in 3 (6.4%), 3 (6.4%), 12 (25.5%), and 24 (51.1%) patients during median 6-month follow up period, respectively, and the disease control rate was 38.3%. Moreover, abdominal pain (19.1%), nausea or vomiting (17.0%), and anorexia (5.2%) were observed. Median hospital stay was 2 days (range 1-10). There was no therapy-related death. The median overall survival was 10.3 months (95% confidence interval, 5.69-14.83). Conclusion: Compared with other systemic therapies, Y-90 shows a comparable outcome, and toxicities were tolerable. We believe Y-90 can be considered as an important treatment option for HCC with PVTT.

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3104.6 Prospective, randomized study of coiling vs surefire infusion system in Y-90: clinical outcomes in HCC patients – subgroup analysis of safety and efficacy from the COSY Trial A.M. Fischman1, S.C. Lewis1, R. Patel2, E. Kim3, F.S. Nowakowski3, R.A. Lookstein1, A. Arepally4; 1Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America, 2Interventional Radiology, Mount Sinai Medical Center, New York, NY, United States of America, 3Division of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America, 4Interventional Radiology, Piedmont Healthcare, Atlanta, GA, United States of America Purpose: To prospectively evaluate the preliminary clinical response in patients with non-operative hepatocellular carcinoma (HCC) undergoing selective internal radiation therapy (SIRT) using a surefire anti-reflux infusion system (SIS) without coil embolization (CE) of non-target vessels. Material and Methods: Over a 9-month period, 30 consecutive patients were randomized into 2 groups. Of these, a subgroup of 16 patients with intermediate- or advanced-stage HCC (BCLC B/C) was analyzed. Group CE (n=7) underwent SIRT after CE with a standard microcatheter. Group SIS (n=9) underwent SIRT only with SIS (Surefire Medical, Westminster, CO) without CE. Both groups were treated with SIR-Spheres (Sirtex Medical, Woburn, MA). Clinical outcomes in Group SIS were assessed using mRECIST criteria on followup CT or MRI. Tumor characteristics and adverse events (AEs) were recorded. Results: Nine patients (mean age 67±9) were evaluated. Tumor types included: multifocal (n=4), infiltrative (n=2), focal hypervascular (n=2), and focal hypovascular (n=1). Mean lesion size was 5.5 cm (range 1.2-10.2). Tumor lobe location included right (n=6), left (n=1), and both (n=2). Branch portal vein invasion was noted in 44.4% cases (4/9). There were no cases of non-target deposition of SIRT. Two patients are awaiting initial follow-up imaging. Mean time to follow-up imaging was 76±31 days. Initial mRECIST response rates (CR, PR, SD, and PD) were 0%, 43%, 57%, and 0%, respectively. Disease control rate (CR+PR+SD) was 100%. There were no major or minor AEs at 30 days. Conclusion: Use of SIS without CE during SIRT was clinically feasible and resulted in promising preliminary tumor response at short-term follow-up in patients with BCLC stage B/C HCC.

Free Paper Session IR oncology and/versus non-IR therapies 3105.1 Usefulness of RENAL nephrometry scoring system for predicting outcomes of percutaneous ablation: comparison between radiofrequency ablation and microwave ablation C. Floridi1, W. Prevoo2, E. Macchi1, M. Petrillo3, A.M. Ierardi1, F. Fontana1, G. Carrafiello1; 1Radiology Department, Interventional Radiology Unit, Varese, Italy, 2Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands, 3Section of Radiology, Department ‘‘Magrassi-Lanzara’’, Second University of Naples, Naples, Italy Purpose: We applied RENAL (radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior and location relative to polar lines) nephrometry scoring system to renal tumors treated with percutaneous ablation to determine whether this score is associated with oncological outcomes comparing radiofrequency ablation (RFA) with microwave ablation (MWA) outcomes.

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CIRSE 2014 Material and Methods: A total of 250 renal tumors were treated with percutaneous ablation at two different institutions between 2008 and 2013. Of these renal masses, 145 (58%) were treated with RFA and 105 (42%) with MWA. RENAL tumor scores were analyzed to determine the association of the score with ablation treatment outcomes. Clinical success was measured on the first follow-up contrast-enhanced CT/MR (complete or incomplete tumor ablation). Results: The mean ± SD RENAL nephrometry score of all ablated tumors was 7.5 ± 2.1. Those treated with MWA had higher scores than those treated with RFA. We identified 12 local treatment failures (4.8%) during computerized tomography/magnetic resonance imaging follow-up. There was a significant association between RENAL nephrometry score and local treatment failure. There was also a significant association between RENAL nephrometry score and complications. Conclusion: The RENAL nephrometry scoring system predicts the treatment efficacy and complications following percutaneous renal ablation. In our experience, MWA was more effective in the treatment of more complex lesions (higher RENAL scores).

3105.2 Retrospective comparison between renal tumors treated with radiofrequency ablation and laparoscopic partial nephrectomy – theatre time, hospital stay length, complications and treatment results V. Acosta Ruiz1, P. Dahlman1, E. Brekkan2, A. Magnusson1, M. Häggman2, S. Ladjevardi2, M. Lönnemark1; 1Dept. of Radiology, Uppsala University Hospital, Uppsala, Sweden, 2Dept. of Urology, Uppsala University Hospital, Uppsala, Sweden Purpose: Conventional treatment of small renal masses (SRM) is performed using laparoscopic partial nephrectomy (LPN). Less invasive treatment methods such as radiofrequency ablation (RFA) have been described for the treatment of SRM. Few studies have compared the results of LPN and RFA. To compare RENAL nephrometry score (RNS)-matched RFA and LPN-treated SRM with respect to treatment results, theatre time, hospital stay length and complication rates. Our hypothesis was that RFA-treated patients would have fewer complications, shorter hospital stay and same final treatment results compared with those of LPN-treated patients. Material and Methods: In all, 52 and 38 SRM have been treated with RFA and LPN, respectively, and followed up for 6 years. Patients were followed up with routine contrast-enhanced CT scans at 3, 6 and 12 months and annually after treatment. Data collection included patient information (age, gender and previous renal tumour treatment), tumour data (RNS, tumor size and histopathological diagnosis), treatment data (RFA electrode placement, operation info, hospital stay length, complication rate, ablative and operative success) and follow-up results (tumour relapse). Results: Complete ablation success rate was 79% after a single treatment session. Second treatment of the incomplete ablated tumors increased the success rate to 90%. LPN showed 73% radically operated tumors. Compared with RFA-treated patients, LPN-treated patients had longer hospital stay (7 days vs 3 days), more complications (8 major and 8 minor vs 8 minor) and longer theatre time (217 min vs 127 min). Conclusion: RFA is a safe procedure for patients treated for SRM and has comparable results with LPN.

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3105.3 Radiofrequency ablation versus non-anatomical resection: long-term results in 580 patients with a single small hepatocellular carcinoma of ≤3cm T.W. Kang, H. Rhim; Department of Radiology, Samsung Medical Center, Seoul, Korea Purpose: To compare the long-term therapeutic outcomes of radiofrequency ablation (RFA) with non-anatomical resection (NAR) in patients with a single small hepatocellular carcinoma (HCC; ≤3cm). Material and Methods: From January 2006 to October 2010, 580 patients with a single HCC (≤3cm) underwent ultrasonographyguided percutaneous RFA (n=438) or NAR (n=142) as a first-line treatment. Local tumor progression (LTP), intrahepatic distant recurrence (IDR), disease-free survival (DFS) and overall survival (OS) rates were compared with propensity score matching before and after adjustment. Cox proportional hazard models were used to compare the two groups. Results: Median follow-up period in both groups was 50.9 months. Before propensity score matching, cumulative LTP and OS rates were comparable between both groups while cumulative IDR and DFS rates in the NAR group were significantly higher than those in the RFA group. After this adjustment, all therapeutic outcomes were comparable between the two groups (p<0.05). Conclusion: All therapeutic outcomes of RFA were comparable to those of NAR for patients with a single small HCC (≤3cm) as a firstline treatment.

3105.4 Negative-balance isolated pelvic perfusion for uterine cervical cancer S. Onozawa1, S. Murata1, T. Mine2, F. Sugihara1, D. Yasui1, H. Yamaguchi1, T. Ueda1, I. Miki1, S. Kumita1; 1Radiology/Center for Advanced Medical Technology, Nippon Medical School, Tokyo, Japan, 2Radiology, Nippon Medical School, Tokyo, Japan Purpose: Negative-balance pelvic perfusion (NIPP) could establish a higher concentration of anticancer drug (CDDP) in pelvic area and lower toxicity in systemic area. The purpose of this study was to assess the efficacy and toxicity of NIPP for uterine cervical cancer. Material and Methods: Thirty-one patients with uterine cervical cancers were treated by NIPP from 2001 to 2013 in our institute. The overall survival after the first NIPP was compared between with and without distant metastases, prior chemoradiation therapy, and squamous cell carcinoma and adenocarcinoma. We also assessed the toxicity of NIPP. Results: NIPP was performed 1-5 times per patient (median: 2) and the CDDP dose used per patient ranged from 140 mg/m2 to 220 mg/m2. The overall survival was 59.3% in 1 year, 44.9% 3 years, and 26.9% 5 years (mean: 59.7 months). The overall survival of cases with or without distant metastases (n=12 vs 19) were 49.5% vs 63.1% in 1 year, 0% vs 46.5% 3 years [mean 88.2 vs 10.9 months (P<0.001)] and of cases with or without prior chemoradiation therapy (n=22 vs 9) were 52.9% vs 75.0% in 1 year and 0% vs 75.0% 3 years and 0% vs 45% in 5 years [mean: 19.1 months vs 104.0 months (P=0.006)]. The mean survival of squamous cell group (n=20) was 65.3 months and adenocarcinoma group (n=11) was 41.3 months (P=0.065). There were 6 cases of toxicity > grade 3 (2 nausea, 2 renal dysfunction, and 2 bone marrow suppression). Conclusion: NIPP for cervical cancer could facilitate longer survival and less toxicity.

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3105.5 Robot-assisted partial nephrectomy versus percutaneous radiofrequency ablation for the treatment of small renal cell carcinoma M. Pantelidou1, K.N. Katsanos1, B. Challacombe2, P.M. Kitrou3, M. Brown2, A. Adam1; 1Interventional Radiology, Guy’s and St Thomas’ Hospitals, NHS Foundation Trust, London, United Kingdom, 2Urology, Guy’s and St Thomas’ Hospitals, NHS Foundation Trust, London, United Kingdom, 3Department of Interventional Radiology, University Hospital of Patras, Patras, Greece Purpose: A single-center comparison of radiofrequency ablation (RFA) with robot-assisted partial nephrectomy (RPN) for the treatment of T1 renal cell carcinoma (RCC) in terms of oncological and functional outcomes. Material and Methods: RPN was performed using the daVinci robot and RFA under CT-guided radiofrequency electrodes. Data collected included baseline demographics, PADUA score, and tumor size. Perioperative complications and oncological outcomes were compared. Results: In total, 126 cases were audited. Baseline demographics were well matched, and comorbid conditions were more pronounced in RFA. Tumour size was greater in the RPN group (2.88 cm vs. 2.11 cm, p=0.0003), but PADUA score showed no significant difference (7.38 RPN vs. 7.27 RFA). More single kidneys were treated with RFA (15/63 vs. 1/63, p=0.0002). There were no conversions to open surgery and no blood transfusions. Follow-up was longer in the RFA group due to the recent commencement of RPN (4 years vs. 0.5 years, p<0.0001), and the length of stay was significantly shorter in this group (1 day vs. 3 days, p<0.0001). More minor complications were recorded in the RPN group (10/63 vs. 4/63, p=0.15), and local recurrence was also more frequent in this group (6/63 vs. 1/63, p=0.11). Disease-free survival (DFS) was not significantly different in the two groups (HR ratio=0.91, p=0.92). Tumor size had a significant effect on DFS (HR= 1.7; 95% CI: 1.1-2.6; p=0.02). Conclusion: RPN and RFA offer excellent oncological outcomes for treating T1 RCC with low perioperative morbidity. RFA was associated with less perioperative complications, whereas RPN had a lower local recurrence rate. Therefore, RFA should be offered alongside RPN for selected cases.

3105.6 Effect of liver cirrhosis on portal vein embolization before right hepatectomy in patients with primary liver cancer J.-H. Sun, Y.-L. Zhang, C.-H. Nie, G.-H. Zhou, T.-Y. Zhou, S.-S. Zheng; Hepatobiliary and Pancreatic Intervention Center, Department of Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China Purpose: To evaluate the clinical value of portal vein embolization (PVE) prior to surgery in primary liver cancer (PLC) patients, and the effect of liver cirrhosis on compensatory hypertrophy of the future liver remnant (FLR) after PVE. Material and Methods: Overall, 21 patients were retrospectively selected with right liver cancer who underwent right hepatic resection successfully after PVE. All patients were divided into non-cirrhosis group (n=9) and cirrhosis group (n=12) according to the absence or presence of cirrhosis. All patients underwent transcatheter arterial chemoembolization (TACE) treatment 1-3 sessions before PVE. Left liver remnant volumes were assessed by computed tomography before and after PVE. We retrospectively investigated whether statistical differences were detected in left hepatic lobe volume of the two groups, and serious complications occurred after PVE.

Abstract Book Results: PVE was successfully performed in all patients at the 2nd 4th week after the final TACE. There was significant difference in the left hepatic lobe volume (FLR) of all patients before and 4-6 weeks after PVE (P<0.001). The 4-6 weeks after PVE and FLR in each group showed that PVE induced significant compensatory hypertrophy (P=0.002, and <0.001, respectively). However, there was no significant difference between the two groups in terms of the left liver volume enlargement 4-6 weeks after PVE (P=0.373). Liver function damage in all patients was minor and transient after PVE, and no severe complications occurred. Conclusion: Sequential TACE and PVE before surgery can make the remnant liver compensatory hypertrophy and increase the resectable rate of primary liver cancer. Liver cirrhosis had no significant effect on liver lobe hyperplasia after PVE.

Free Paper Session Filters and ports 3106.1 Percutaneous re-positioning of displaced port catheters in patients with dysfunctional central venous port systems A. Massmann1, P. Jagoda1, N. Kranzhoefer2, A. Buecker1; 1Department for Diagnostic and Interventional Radiology, Saarland University Hospital, Homburg, Germany, 2Department for Internal Medicine, Saarland University Hospital, Homburg, Germany Purpose: Observational analysis of percutaneous re-positioning of displaced port catheters in patients with dysfunctional central venous port systems. Material and Methods: In all, 286 patients (76 males, mean 58.8±12.1 years; 210 females, 57.1±12.6 years) with dysfunctional venous port systems underwent port angiography. Malpositioned port catheters were identified in 31 (10.8%) patients (11 males, 58.1±7.2 years; 20 females, 57.8±12.1 years). Percutaneous endovascular repositioning was performed using transfemoral (5-F pigtail, 4-F sidewinder) catheter maneuvers or snaring. Primary endpoint was to restore port function; secondary endpoint was repositioning success rate. Safety endpoints included incidence of port damage or procedure-related complications. Follow-up encompassed routine clinical and radiological controls [mean follow-up duration 12.9±17.9 (1-81) months]. Results: Clinical signs of port dysfunction due to port catheter displacement included difficult blood aspiration in 10 (32.3%) patients, resistance or inability to inject saline-solution in 12 (41.9%), and pain in 1 (3.2%). Primary technical success for repositioning displaced port catheters was 96.8% (30/31 patients). In 1 (3.2%) patient, repositioning failed due to extensive chronic jugular vein thrombosis that prevented capturing the port catheter. Redisplacement occurred immediately after the repositioning procedure in 2 of 30 (6.7%) patients due to a twisted port catheter; in 2 patients, within 1 month due to a too short port catheter (two-tailed Fisher’s exact-test, p=0.0138); and in 2 patients, with appropriate catheter length after 18 months. There were no procedure-associated complications, e.g., port catheter disconnection or disruption. Conclusion: Repositioning of displaced port catheters or dysfunctional central venous port catheters with appropriate catheter length is safe and effective. Thus, scheduled port usage is not unnecessarily delayed. However, repositioning of port catheters located peripherally with its tip is ineffective.

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3106.2 Local low-dose thrombolysis for safe and effective treatment of venous port catheter thrombosis P. Jagoda1, T. Probst1, A. Rostam1, N. Kranzhoefer2, G.K. Schneider1, A. Buecker1, A. Massmann1; 1Department for Diagnostic and Interventional Radiology, Saarland University Hospital, Homburg, Germany, 2Department for Internal Medicine and Hematology, Saarland University Hospital, Homburg, Germany Purpose: To evaluate local low-dose thrombolysis for venous port catheter thrombosis. Material and Methods: In all, 1031 patients with dysfunctional port systems underwent port angiography indicating 181 patients with thrombosis around the port catheter. Of them, 165 patients [35 males, mean age 58.2±13.1 (25-83) years; 130 females, mean 57.0±12.9 (20-83) years] underwent thrombolysis by single 3-mg alteplase injection into the port system with clinical and angiographic port controls the following day. Results: Thrombosis occurred 10.1±19.3 (median 2.9) months after port implantation and was clinically evident by either difficult blood aspiration in 146/181 (80.7%) or high resistance to inject fluids in 75 (41.4%) patients. A strong predictor for port catheter thrombosis was a combination of both in 73 (40.3%) patients (Fisher’s exact test p<0.0001; PPV 0.8977), or suboptimal (not cavoatrial) port catheter position in 92 (50.8%) patients (p=0.0047; PPV 0.8276). Cumulative success rate of thrombolysis was 92.7%. Initial thrombolysis was effective in 127 (76.4%) patients. Repeated (up to 6) thrombolysis was effective in 26/31 patients after the second or third thrombolysis. Extensive central venous thrombosis (9 patients) strongly predicted ineffective thrombolysis (p<0.0001). Rethrombosis occurred in 27 patients after mean 4.4±6.6 (median 1.8) months. Cumulative success rate of rethrombolysis was 100%, and primary rethrombolysis was effective in 22 (81.5%) patients. There were no procedurerelated complications. Conclusion: The combination of difficult blood aspiration with high resistance to inject fluids, and suboptimal port catheter position are independent predictors for port catheter thrombosis. Local lowdose rethrombolysis is safe and very effective in the absence of large central venous thrombosis.

3106.3 Managing malfunctioning ports: revise or replace? W.M. Pabon-Ramos, R.A. Ruberte Thiele; Department of Radiology, Duke University Medical Center, Durham, NC, United States of America Purpose: Techniques used to manage malfunctioning ports include port revision (fibrin sheath disruption by stripping, angioplasty, or catheter exchange) and port replacement (concurrent removal of a malfunctioning port and the placement of a new port through a different venotomy site). The purpose of this study was to determine if there is a difference in the time of ports remaining functional after being revised versus after being replaced. Material and Methods: The medical records of adults who underwent port revisions or replacements by interventional radiology between July 1, 2002 and June 30, 2012 were retrospectively reviewed. Patient demographics, indications, and procedural details were recorded. Kaplan-Meier analysis of survival curves were calculated for the time when ports remained functional after being revised, and for the time when ports remained functional after being replaced. The log-rank test was used to determine if there was a significant difference (p<0.05) between the survival curves for the two groups.

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Results: There were 46 port revisions and 36 port replacements. Based on the log-rank test, there was no significant difference (p=0.28) between the survival curve for the time when ports remained functional after being revised and the survival curve for the time when ports remained functional after being replaced. Conclusion: There is no significant difference in the duration for which ports remain functional after being revised versus after being replaced.

3106.4 Intermediate-term experience with the ALN optional filter in a large US tertiary institute – deployment, safety, and retrievability R.C. Zvavanjanja, L. Sedrak, N. Clark, A.M. Cohen; Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, Houston, TX, United States of America Purpose: The ALN IVC filter has been available in the European market for over a decade. In the USA, few centers have extensive experience with this filter, and our center is one of them. We present our experience with this filter. Material and Methods: A retrospective review of ALN filters placed from August 2010 to January 2014 was conducted. Data were obtained from EMR and PACS. The filters placed were evaluated for safety, deployment success, and tilt angle. Filters retrieved were assessed for dwelling time, tilt angle, fluoroscopy time, and associated complications. Results: In all, 170 ALN filters were placed in 170 patients (10 IVUS and 160 fluoroscopically). A majority (120/170 patients) were deployed via the femoral access and the remaining with the jugular approach. There was 100% deployment success. The median tilt angle at the time of placement was 11.6° (range 0-27°). Eighteen (10.6%) attempted retrievals were made with 100% success. The mean time between placement and retrieval was 7.7 months (range 1-24 months). During retrieval, median filter tilt angle was 10.5° (range 2.5-27°) and median fluoroscopy time was 5.9 minutes (range 1.4-20.6 minutes). Only 1 filter demonstrated significant penetration (duodenum), incidentally diagnosed on CT; this was retrieved uneventfully. Among the retrieved filters, there was no evidence of filter fractures. Conclusion: Our experience with ALN filters demonstrated good deployment success and a relative ease of retrieval even up to 24 months. The safety profile so far appears acceptable. Longer followup and larger multicenter data are required to validate our current experience.

3106.5 Optional vena cava filter placement and 3 months retrievability: results of the PREPIC 2-randomized multicenter trial O. Pellerin1, F.G. Barral2, O. Sanchez3, G. Meyer3, P. Mismetti4, M.R. Sapoval1; 1Interventional Radiology, Hopital Européen Georges Pompidou, Paris, France, 2Interventional Radiology, CHU Saint Etienne Hopital Nord, Saint Etienne, France, 3Pneumonology, Hopital Européen Georges Pompidou, Paris, France, 4Pneumonology, CHU Saint Etienne Hopital Nord, Saint Etienne, France Purpose: To report the implantation and retrieval vena cava filter success rate of the ALN filter in the setting of a PREPIC 2 subgroup. Material and Methods: PREPIC 2 is a prospective, open, and randomized study that compared retrievable ALN filter maintained for 3 months with no filter insertion in patients receiving anticoagulant therapy for acute symptomatic PE associated with DVT. Filter retrieval was systematically scheduled at 3 months. The goal of this

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ancillary study is to report the technical success rate of implantation removal and related complications. Results: Between August 2006 and July 2012, 399 patients (76 years) were enrolled with acute PE and no contradiction to anticoagulation. Of them, 193 patients received a filter after randomization plus anticoagulation therapy, using femoral (162), basilic (15), or jugular vein (16) access. The filter was not implanted because of technical failure (n=2, 1%), non-confirmation of PE diagnosis after randomization (n=3, 1.5%), and patients’ death before implantation (n=2, 1%). Implantation tilting (>15°) occur in 19 (9.8%) cases. In 20 (11.9%) cases, minor complications occurred: <20 mm migration (n=4, 2%), >3 mm filters IVC penetration (n=10, 5.2%), puncture site hematoma (n=3, 1.6%), and tilt increase (n=5, 2.6%) were reported. Among the 166 (92.2%) patients who were referred for extraction after 3 months [3 days (89-98)], retrieval was successfully performed in 92.2% (n=153). Moreover, 3 (1.8%) cases of asymptomatic filter thrombosis were observed. Failure of extraction was observed in 13 (7.8%) cases, because of >15° tilt (n=9, 5.4%) or non-removable fibrotic bridge to IVC (n=4, 2.4%). Filter removal was successfully performed in a median of 20 min (15-40). Conclusion: The ALN filter was successfully extracted in 92.2% cases in this multicenter experience with a lower complication rate.

3106.6 Suprarenal vena cava filter placement and removal: technical and clinical outcomes O. Pellerin1, F.G. Barral2, B. Hag Mohamed Ali2, G. Amouyal1, M.R. Sapoval1; 1Interventional Radiology, Hopital Européen Georges Pompidou, Paris, France, 2Interventional Radiology, CHU Saint Etienne Hopital Nord, Saint Etienne, France Purpose: Suprarenal IVC filter placement remains unstable. However, some clinical situation such as PE occurring in the last pregnancy trimesters require filter placement. The goal of this study is to report the technical and clinical outcome of suprarenal IVC filter placement and removal. Material and Methods: Between Jan 2008 and Jan 2014, 36 consecutive patients were referred for suprarenal ALN® (ALN Implants Chirurgicaux) IVC filter placement in 2 academic institutions. Implantation was performed either by jugular or brachial access, while removal was performed only by jugular approach, when indicated with the dedicated grasping device. Results: In all, 36 filters were successfully implanted without any complication. Filters were indicated because of a coexisting PE and pregnancy (n=15), infrarenal IVC abnormality [extrinsic compression (n=2), VCI duplication (n=2), and VCI thrombosis (n=9)], or renal vein thrombosis prior to renal surgery (n=8). No clinical PE recurrence was observed. All filters were successfully removed with a mean duration of 28 days after implantation. Additional manoeuvers were required in 7 cases. >15° tilt was observed in 2 cases. Neither proximal migration nor removal complications were observed. Conclusion: These retrospectives results confirm the safety of the ALN® filter use in a suprarenal placement in some selected indications.

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Free Paper Session Aortic interventions 3107.1 Endovascular aneurysm repair versus open repair for patients with a ruptured abdominal aortic aneurysm: a systematic review and meta-analysis S.C. van Beek1, A.P. Conijn2, M.J.W. Koelemay1, R. Balm1; 1Vascular Surgery, Academic Medical Centre, Amsterdam, Netherlands, 2Radiology, Academic Medical Center, Amsterdam, Netherlands Purpose: There is a clinical equipoise whether open (OR) or endovascular aneurysm repair (EVAR) is the best treatment for patients with a ruptured abdominal aortic aneurysm (RAAA). We conducted a systematic review and meta-analysis to estimate the short-term (combined 30-day or in-hospital) survival after EVAR and OR for patients with RAAA. Material and Methods: PRISMA guidelines were followed. Medline, Embase and the WHO International Clinical Trials Registry were searched on 13 January 2014, and the methodological quality of all studies was assessed. The results of RCTs, of observational studies and of administrative registries were pooled separately and analysed with a random effects model. Results: From a total of 3769 articles, 3 RCTs, 21 observational studies and 8 administrative registries met the inclusion criteria. In RCTs, the risk of bias was lowest and the pooled odds ratio for death after EVAR versus OR was 0.90 (95% CI: 0.65-1.24). Most observational studies had a high risk of bias and the pooled odds ratio for death was 0.44 (95% CI: 0.37-0.53). Most administrative registries had a high risk of bias and the pooled odds ratio for death was 0.54 (95% CI, 0.47-0.62). Conclusion: In head-to-head comparisons, there is no short-term survival benefit of EVAR over OR in patients with RAAA. However, studies selecting patients for intervention show a reduced risk of death after EVAR, indicating that proper selection reduces the risk of death.

3107.2 Endovascular repair of acute and chronic aortic type B dissections: impact on aortic remodeling and clinical outcome A. Cannavale1, F. Fanelli2, M. Corona3, P. Lucatelli4, C. Cirelli4, A. D’Adamo3, F.M. Salvatori3; 1Vascular and Interventional Radiology Unit, Sapienza University of Rome, Rome, Italy, 2Interventional Radiology Unit, Department of Radiological Sciences, Sapienza University of Rome, Rome, Italy, 3Department of Radiological Sciences, Sapienza University of Rome, Rome, Italy, 4Radiological Sciences, Vascular and Interventional Radiology Unit, University of Rome Sapienza, Rome, Italy Purpose: To evaluate the clinical outcome, morphologic changes, and behavior of acute and chronic type B aortic dissection after endovascular repair (TEVAR). Material and Methods: Sixty cases of TEVAR were retrospectively reviewed for complicated acute (AAD, n=29) and chronic (CAD, n=31) type B dissection with a minimum follow-up of 3 years. True (TL) and false (FL) lumens and total aortic short axis diameter were evaluated at seven different levels. Endoleaks and false lumen thrombosis rates were also assessed in relation to the dilation and oversizing of the endograft. Results: Mean number of stent-graft patients in the AAD group was 1.5 ± 0.5 and in the CAD group was 1.9 ± 0.8 (P=0.01). Aorta remodeling comprised FL thrombosis with a decrease in diameter (mean, 18.8-9.5 mm; P=0.002, ANOVA), and an increased TL diameter (mean,

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22.5-28 mm; P=0.001, ANOVA), which was higher in AAD, especially within the first 18 months. In the AAD group, stent-graft dilation (in 18 patients, 62% of the AAD group and in 18 patients, 58% of the CAD group) was correlated with a higher FL thrombosis. Complications occurred in 4/29 patients (AAD) and in 3/31 patients (CAD). Endoleaks were recorded in 17 patients (28%; 8 in the AAD group and 9 in the CAD group), but they did not appear related either to stent-graft dilation or oversizing. Conclusion: A good knowledge of the clinical outcome, morphologic changes, and behavior of AAD and CAD after endovascular repair is a milestone for the correct treatment of complicated aortic dissections.

3107.3 Acute kidney injury in ruptured abdominal aortic aneurysms: an underestimated problem S.C. van Beek1, D.A. Legemate1, A. Vahl2, C.S.C. Bouman3, L. Vogt4, W. Wisselink5, R. Balm1; 1Vascular Surgery, Academic Medical Centre, Amsterdam, Netherlands, 2Vascular Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands, 3Intensive Care, Academic Medical Center, Amsterdam, Netherlands, 4Internal Medicine, Academic Medical Center, Amsterdam, Netherlands, 5Vascular Surgery, VU University Medical Center, Amsterdam, Netherlands Purpose: Acute kidney injury (AKI) is a serious complication after repair of a ruptured abdominal aortic aneurysm (RAAA) with an incidence estimated between 20% and 34%. In 2004, the consensual multidisciplinary RIFLE classification for AKI was introduced and subsequently validated in over half a million patients. Patients are classified in a ‘Risk’, ‘Injury’ or ‘Failure’ category based on their serum creatinine and/or urine output. The objective of the present study was to assess the incidence of AKI as defined by the RIFLE criteria (AKIRIFLE) in patients with RAAA. Material and Methods: Observational cohort study in 362 consecutive surgically treated patients with RAAA in three hospitals between 2004 and 2011. The primary endpoint was the incidence of AKIRIFLE and the combined 30-day or in-hospital death rate. Results: AKIRIFLE occurred in 74% (267/362, CI: 69-78%), with 27% of these patients categorised as ‘Risk’ (71/267, CI: 22-62%), 39% categorised as ‘Injury’ (104/267, CI: 33-45%) and 34% categorised as ‘Failure’ (92/267, CI: 29-40%). After multivariable adjustment for shock profile, the risk of death in patients categorised as AKIRIFLE ‘Failure’ was higher than in those without AKI RIFLE (adjusted odds ratio: 6.360, CI: 2.231-18.130). Conclusion: The incidence of AKIRIFLE was much higher (74%) than anticipated (34%), and the ‘Failure’ patients had a higher risk of death. These results indicate that the problem of AKI is graver than expected and that minimising injury to the kidney could be a focus of future research on reducing the death rate after RAAA repair.

3107.4 Complications and secondary interventions following Nellix sac-anchoring endoprosthesis for abdominal aortic aneurysm repair S. Ameli-Renani1, A. Weller1, I. Loftus2, M. Thompson2, R.A. Morgan1; 1Radiology, St Georges Hospital NHS Trust, London, United Kingdom, 2Vascular Institute, St George’s Healthcare NHS Trust, London, United Kingdom Purpose: To assess the technical success, complications and reintervention rates following Nellix sac-anchoring endoprosthesis for abdominal aortic aneurysm (AAA). Material and Methods: In a single-centre retrospective study, 48 patients who underwent Nellix sac-anchoring endoprosthesis for

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AAA in the preceding year were evaluated by CT angiography and review of electronic patient records. The immediate technical success, complication rates and re-intervention approaches were assessed. Results: The study group comprised 46 elective and 2 emergency repairs for ruptured aneurysms. Immediate technical success of stent-graft implantation was achieved in all cases. There were no mortalities at the latest follow-up (average 3 months, range 1-11 months). There were 5 complications (10%), and 4 cases (8%) required reintervention. Two cases were reported of stenosis/kinking of the distal Nellix limb and 1 of type 2 endoleak from internal iliac artery. All three cases were treated with extension iliac endografts. A type 1a endoleak was embolised with Onyx. This was complicated by a contrast reflux into the proximal left Nellix stent remedied by the placement of a covered stent within the proximal left Nellix stent to isolate the displaced Onyx. There was 1 case of complete occlusion of the left Nellix stent with preserved perfusion of the left leg, which was managed conservatively. Three cases (6%) of partial renal infarcts with preserved renal function were noted but were not included in the complications category. Conclusion: Nellix sac-anchoring endoprosthesis is a novel and increasingly utilised device for aortoiliac aneurysm repair with only 1 previously reported case of reintervention. Awareness of the potential complications and indications for reintervention are important.

3107.5 Endovascular repair of mycotic aortic aneurysms: experience in a tertiary centre B.A. Conrad1, D. Roi1, C.M. Sullivan2, A. Gordon2, I.M. Williams3, D.C. Bosanquet3, A.M. Wood2, C.P. Twine3, R.D. White2; 1Medical School, Cardiff University, Cardiff, United Kingdom, 2Interventional Radiology, University Hospital Wales, Cardiff, United Kingdom, 3Vascular Surgery, University Hospital Wales, Cardiff, United Kingdom Purpose: Mycotic/inflammatory aneurysms of the thoracic and abdominal aorta (MAA) have been treated by endovascular repair (EVAR) at our centre for the last 17 years. However, there is little evidence on it in the literature. This retrospective analysis aims to evaluate our experience and assess whether EVAR should be a standard approach for such patients. Material and Methods: All patients who underwent EVAR at our centre between 2007 and 2013 for MAA (n=21) were included in this study. Radiological and clinical data were scrutinised for information such as demographics, anatomy, procedural information and followup (including reintervention, morbidity and mortality). Results: There were 19 male and 2 female patients, mean age 73 (range 54-84), with 7 thoracic MAA and 14 abdominal MAA. Primary technical success was 100% with no immediate complications. Mean follow-up was 24.8 months (range 0-59 months). There was one case (4.7%) of 30-day mortality (abdominal EVAR) considered due to the underlying disease processes rather than the procedure. Reintervention was required in 5 (23.8%) patients (2 abdominal, 3 thoracic EVAR). No cases required EVAR explant. Conclusion: To date, this is the largest reported series of MAA treated with EVAR in the world. Patients with MAA are often critically ill, and open surgical repair has significant associated morbidity and mortality in these patients. Although there are no randomised controlled trials comparing open and endovascular repair of MAA, our experience with EVAR in these patients is favourable and adds to the growing body of evidence to support EVAR as a viable treatment option for MAA.

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3107.6 Morphological determinants of EVAR failure with chimney and periscope grafts M.J. Glenck1, G. Puippe1, F. Pecoraro2, M.L. Lachat1, T. Frauenfelder1, T. Pfammatter1; 1Interventional Radiology, University Hospital of Zurich, Zurich, Switzerland, 2Chirurgia, Università degli studi di Palermo, Palermo, Italy Purpose: To identify the possible determinants of failure of endovascular aortic aneurysm repair (EVAR) with chimney and periscope grafts (CPG). Material and Methods: Follow-up CTAs of 44 consecutive patients (mean age=73.2 years, SD=9.0 years, male:female=35:9) with EVARs with at least one CPG treated at our institution between January 2011 and January 2013 were analyzed. There was one CPG in 12 (27%), two in 28 (64%) and three in 4 patients (9%). The diameter of the aortic stent-graft was selected according to the following formula: dm (trunk)=dm (landing zone)+∑perigraft diameters/2+10%. Failure was defined as secondary CPG-occlusion or perigraft endoleak. The morphological determinants analyzed were the anatomy of the landing zone diameter, the brand, and the number of main body and CPGs. Relative risk analysis was performed using the Mann-Whitney test and ROC analysis. Results: There were 11 perigraft or “gutter” leaks. Inadvertent aortic stent graft oversizing (n=2, range=3.4-4.25 mm) or more often, undersizing (n=9, mean=4.8 mm, range=3.05-6.9 mm) relative to the formula’s “optimal” diameter highly increased the risk of these endoleaks (P=0.001). CPG occlusions occurred in 7.8% (7/90) cases, and only if the minimal diameter of the stent graft (measured in postoperative CT) was 4 mm or less (ROC=0.85). Conclusion: A choice of the aortic stent graft diameter based on the suggested mathematical formula prevents perigraft leaks of EVAR with CPG. Compression of CPGs in the anchoring segment is associated with thrombosis, and an increase in the CPG radial strength by adding a coaxial bare stent may prevent this complication.

Free Paper Session Experimental work (new techniques) 3108.1 Experimental study on treatment of transplanted VX2 tumor of rabbit with intratumoral ozone injection J. Yang, Q. Wei; Interventional Radiology, Changhai Hospital, Shanghai, China Purpose: To investigate the effect of intratumoral injection of O3 for the treatment of transplanted VX2 tumor of rabbit Material and Methods: In all, 120 rabbits bearing VX2 tumors (2 weeks after inoculation) were randomly divided into 4 groups: group A for control, whose tumors were only punctured, and groups B, C, and D for treatment, whose tumors were punctured and injected 3 times the volume of 20%, 40%, and 60% O3 under direct vision. Perfusion CT scan was performed at the beginning of the operation and on the 4th and 8 days after treatment to measure the size of tumors. On the 8th day, all tumors were removed for pathological observation. Results: The tumor growth rates of groups A, B, C, and D showed that V4/V0 was 2.06±1.10, 1.43±0.80, 1.54±0.82, and 1.62±0.92; V8/V4 was 2.47±2.31, 1.80±0.72, 1.98±1.28, and 1.56±0.86, and V8/V0 was 4.58±3.14, 2.64±1.59, 2.93±1.56, and 2.27±1.34, respectively. For all groups, the V4/V0 and V8/V4 rates showed no significant difference.

Abstract Book By comparing the control and treatment groups, V8/V0 rate of group A was markedly higher than that of groups B, C, and D (A/B, P=0.008; A/C, P=0.029; and A/D, P=0.001). Among groups B, C, and D, the growth rates had no significant difference (P>0.05). Conclusion: The intratumoral injections of 20%, 40%, and 60% O3 can effectively inhibit the growth of VX2 tumor of rabbits, and with an increasing O3 concentration, more obvious and longer inhibitory effect could be achieved.

3108.2 New intravascular elution device for the interventional radiological treatment of pancreatic neoplasm: in vitro and in vivo early results R. Lopez-Benitez1, G.M. Cruise2, M.J. Constant2, J. Heverhagen1, Y. Wu2; 1Diagnostische, Interventionelle und Pädiatrische Radiologie, Inselspital – Universitätsspital Bern, Bern, Switzerland, 2Interventional Development, MicroVention Inc., Tustin, CA, United States of America Purpose: To characterize gemcitabine-loaded hydrogel-elution devices (GLH elution devices) using in vitro and in vivo methods as first intravascular prototypes for local treatment in pancreatic tumors. Material and Methods: To determine in vitro gemcitabine elution, GLH-elution devices were placed in 0.9% saline at 37°C. The saline was periodically collected and analyzed for gemcitabine content using liquid chromatography. To determine in vivo gemcitabine elution, a 10-cm, 35-system gemcitabine-loaded hydrogel device was placed into the gastroduodenal artery of every pig. Blood samples were periodically collected for gemcitabine and 2ƍ, 2ƍ-difluoro-2ƍ-deoxyuridine quantitation using liquid chromatography or mass spectroscopy. A follow-up angiography was performed at 30 days after embolization; the harvested tissues were histologically evaluated. Results: All the evaluated devices demonstrated a certain degree of gemcitabine elution, both in vitro and in vivo. In vitro elution of gemcitabine from the embolic device was rapid as elution ceased after 2 hours. All 6 pigs were successfully embolized; they survived the 30-day period. Similar to in vitro elution, the plasma levels of gemcitabine spiked within 15 minutes of embolization and returned to baseline levels by 1 week after embolization. As expected, the plasma levels of 2ƍ, 2ƍ-difluoro-2ƍ-deoxyuridine peaked later than gemcitabine, between 1 and 3 hours after embolization. No evidence of inflammatory changes was observed. Conclusion: The first local elution devices designed for porcine models with possible future applications in pancreatic neoplasm cases showed a positive local drug elution during the first experimental phase. With this model, it will be feasible to deliver a targeted therapy near pancreatic tumoral areas with a sustainable local drug release.

3108.3 Evaluation of the cooling effect of liver vessels in microwave ablation: an experimental pig liver model K.I. Ringe1, C. Lutat1, C. Rieder2, F. Wacker1, H.-J. Raatschen1; 1Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany, 2Institute for Medical Image Computing, Fraunhofer MEVIS, Bremen, Germany Purpose: To evaluate and quantify the cooling effect (also known as 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 37 mm) were inserted parallel to the non-perfused and perfused (700 and 1400 ml/min) glass tubes (diameter 5 mm) at different distances (10, 15, and 20

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mm). Using dedicated software, ablation zones (radius and area) were analyzed and compared (Kruskal-Wallis test). In addition, temperature close to the glass tubes was measured continuously throughout the ablation cycle (10 min). Results: Maximum temperature during ablation decreased significantly with increasing flow and distance (p<0.05). Compared with non-perfused glass tubes, ablation zones were significantly deformed by perfused tubes within 15 mm distance (p<0.05). Using a flow of 700 ml/min, minimal radius was reduced to 39% and 81% and lesion area was reduced to 56% and 90% at 10 and 15 mm tube distance, respectively, in comparison with non-perfused glass tubes. At a flow of 1400 ml/min, minimal radius was reduced to 37% and 74% and lesion area was reduced to 51% and 78% at 10 and 15 mm tube distance, respectively. Conclusion: Significant changes in the morphology of the ablation zone were demonstrated in a pig liver model. Considerable heat sink effect was observed at MWA within 15 mm distance to simulated hepatic vessels. Heat sink effect was dependent on flow rate in “vessels.” This has to be considered when ablating liver lesions that are close to vessels.

3108.4 Retrospective computer simulation can predict magnetic resonance imaging and clinical outcomes following ultrasound-guided irreversible electroporation of the prostate F. Cornelis1, G. Srimathveeravalli2, J. Coleman3, S.B. Solomon2; 1Radiology, CHU Bordeaux, Bordeaux, France, 2Section of Vascular & Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America, 3Urology, MSKCC, New York, NY, United States of America Purpose: To retrospectively perform computer simulations that model the ablative electric field distribution in the prostate during IRE ablation and to compare simulation findings with those of follow-up magnetic resonance imaging (MRI) to assess the predictive value of computer simulation for determining the ablation adequacy and safety of IRE ablation of the prostate. Material and Methods: Intraoperative ultrasound images from 8 patients who underwent IRE ablation of the prostate were used to create 3D finite element simulations. An in vitro study was performed to estimate the susceptibility of prostate cancer cells to increasing electric field strength delivered at clinically used pulse parameters. The simulation predicted in vivo electric field distribution was correlated to the ablation defect seen on postoperative MRI and results from the in vitro study to identify the critical electric field strength threshold. Results: The in vitro study suggested that prostate cancer cells undergo acute necrosis at 1250 V/cm. Comparison of the simulation estimation of the electric field distribution and the postoperative MRI suggested 700 V/cm to be the threshold between the ablated and untreated tissues. Measurement of the predicted ablation area (mean: 475 mm2, range: 176-735 mm2) correlated well with the postoperative imaging findings (mean: 477 mm2, range: 95-849 mm2, p=0.52). Conclusion: Computer simulation of IRE may predict therapeutic outcomes after ultrasound-guided ablation of the prostate. IRE ablation in the prostate is susceptible to local variations in electrical conductivity, and needle placement must be scrutinized to avoid these effects and the redistribution of the electric field to non-targeted zones.

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3108.5 Time-resolved perfusion imaging in the angio suite: comparison of a new flat-panel detector-based assessment of tumor perfusion with CT perfusion in rabbit VX2 tumors J. Jürgens1, N. Schulz1, M. Seidensticker1, C. Wybranski1, S. Streit1, J. Brauner1, Y. Kyriakou2, J. Ricke1, O. Dudeck1; 1Clinic for Radiology and Nuclear Medicine, University Hospital Magdeburg, Magdeburg, Germany, 2Imaging & Therapy Division, Siemens AG – Healthcare Sector, Forchheim, Germany Purpose: To compare the parameter maps of a new flat-panel detector application for time-resolved perfusion imaging in the angiography lab (FD-P) with CT perfusion (CT-P) in an experimental tumor model. Material and Methods: In all, 24 VX2 tumors were implanted into the hind legs of 12 rabbits. For each lesion, an FD-P (Artis Zeego; Siemens) and a CT-P (Somatom Definition AS; Siemens) were performed after 3 weeks. FD-P data were acquired by performing a native reference to 200° rotation of the flat panel C-arm (rotation time: 3 s) followed by 10 additional rotations after administering IV contrast media (1 ml/s). FD-P parameter maps were generated using a prototype software. For CT-P data acquisition, a standard CT perfusion protocol with zigzag scan over 30 s after administering IV contrast media (1 ml/s) was used. CT-P parameter maps were generated with VPCT-body software on a dedicated workplace (syngoMultiModality; Siemens). Corresponding perfusion parameters were compared using Pearson’s correlation coefficient and linear regression analysis. Results: Statistical analysis showed good correlations of the two perfusion imaging modalities for the following parameters: blood volume (Pearson’s correlation coefficient: 0.848, p<0.01; linear regression equation: y=4.44x+36.72, p<0.01) and blood flow (Pearson’s correlation coefficient: 0.698, p<0.01; linear regression equation: y=0.75x+14.61, p<0.01). Conclusion: This standardized experimental trial revealed FD-P to allow a time-resolved (dynamic) perfusion imaging of tumors comparable with CT-P. These findings provide the prerequisite for a clinical application, which could be, for example, the assessment of tumor response to local endovascular therapies in the angio suite.

3108.6 Effect of substituting sterile water with 50% isovue as the delivery medium for SIR-spheres: improved percentage delivery and decreased administration time C. Chao, M.C. Soulen, J.I. Mondschein, M. Dagli, D. Sudheendra, S.W. Stavropoulos; Radiology, University of Pennsylvania, Philadelphia, PA, United States of America Purpose: To evaluate the effect of substituting sterile water with 50% isovue as the injection medium during SIR-spheres radioembolization on percentage delivery of the radioembolic agent and administration time. Material and Methods: Radioembolizations were reviewed at our facility using SIR-spheres from 1 January 2011 to 11 February 2014. From 1 May 1 2013, one experienced proctor used 50% isovue in saline instead of sterile water in the “B” and “D” lines of the infusion set. We compared the prepared and administered doses using sterile water versus contrast and the administration times. We recorded if embolization was terminated because of stasis. Results: In all, 175 radioembolizations were analyzed: 75% using sterile water and 25% (43 cases) with 50% isovue. The mean percentage of Y-90 dose administered was 97.6% using contrast versus 86.6% cases using water (p < 0.01). Of all, 95% cases using contrast resulted in ≥90% delivery of the Y-90 dose versus 59% cases

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using water (p < 0.01). For cases using water, 17% were terminated because of stasis versus 2% cases (1 case) using contrast. The average administration time was 7 minutes using contrast versus 22 minutes using water (p = 0.015). Conclusion: Using dilute contrast resulted in a significantly greater percentage of the radioembolization dose delivered. Termination for stasis occurred less frequently. The administration time was approximately 2.8 times less when using contrast. Moreover, using contrast as the delivery medium allowed continuous real-time monitoring of the microsphere administration, mitigating the chance of reflux and non-target radioembolization.

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Glasgow, UK

September 13-17

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Abstracts of Posters sorted by presentation numbers

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Aortic intervention P-1 Acute aortic syndrome: is routine cardiac-gated CTA necessary? D. Saunders1, B. Adams1, S. Puppala2; 1Leeds Radiology Academy, Leeds General Infirmary, Leeds, United Kingdom, 2Radiology, Leeds Teaching Hospitals, Leeds, United Kingdom Purpose: Trans-oesophageal echo (TOE) and computed tomographic angiography (CTA) share similar accuracy in the diagnosis of acute aortic syndrome (AAS). CTA is increasingly accessible and is often the first-line investigation in most centres. Cardiac-gated CTA decreases motion artefact, thus providing an improved cardiac resolution. We investigated whether this should be the initial investigation of AAS. Material and Methods: We retrospectively audited the diagnostic accuracy of standard non-gated CTA in patients with suspected AAS over one year in a tertiary vascular center. Provisional reports were compared with finalised consultant reports to assess concordance. All images were reviewed by a vascular radiologist. We reviewed technical scan parameters to differentiate technical from human error. Results: In all, 146 CTAs were performed with a female preponderance. Mean age was 60 (range 14–96). Of them, 18% cases (n=27) had radiological evidence of AAS. There were 4 (3%) significant reporting errors with none leading to an adverse patient outcome. All cases were considered to be human errors. Total sensitivity and specificity was 93%. Although not within our study population, we observed one negative sternotomy resulting from motion artefact being misreported as dissection. There were some discrepancies from locally agreed scan protocols, which did not affect the diagnostic quality of the scan. Conclusion: Cardiac-gated CTA can provide an improved resolution of the ascending aorta; however, it often has a scan time and radiation dose penalty. A standard CTA that is performed adequately yields diagnostic accuracies approaching 100%, although it is operator-dependent. Cardiac-gated CTA should be reserved for the cases of diagnostic uncertainty secondary to cardiac motion artefact.

P-2 Covered endovascular reconstruction of aortic bifurcation: a haemodynamically proven technique for treating extensive aortoiliac occlusive disease P. Goverde1, K. Lauwers1, F.A.B. Grimme2, M. Reijnen2; 1Vascular & Endovascular Surgery, Vascular Clinic ZNA, Antwerp, Belgium, 2Surgery, Rijnstate Hospital, Arnhem, Netherlands

Abstract Book Results: The present study was a two-centre physician-initiated, prospective, non-randomised follow-up. We treated >80 patients with acute, chronic, or recurrent aortoiliac occlusive diseases. Technical success was almost 95%. During follow-up (3-60 months), 6 patients died of non-interventional causes. Six patients reoccluded mainly due to progressive distal peripheral diseases. They received treatment of the outflow problems. The other patients showed no complications. Conclusion: CERAB is safe and feasible and can be performed completely percutaneous. However, a larger population and a longer follow-up is required; distal peripheral outflow should be sufficient. It can be combined as a ‘hybrid’ procedure. CERAB can be used for the treatment of recurrent or in-stent disease. A haemodynamic in vitro investigation showed a superior outcome compared with other techniques.

P-3 Onyx embolization in the management of type I endoleaks R. Chung, R. Das, R.A. Morgan; Department of Radiology, St. George’s Hospital, London, United Kingdom Purpose: To evaluate the role of transarterial Onyx embolization in the management of type I endoleak (EL1). Material and Methods: A single-center, retrospective review of transarterial Onyx embolization procedures performed for EL1 was undertaken. Eleven procedures to date have been performed at our institution consisting of 10 proximal and 1 distal EL1. None of the patients were suitable for conventional therapy for EL1. Six patients had aneurysm sac enlargement and 1 had a contained rupture. Average time from EVAR to embolization was 28 months, and average sac size at embolization was 86 mm. Results: The overall immediate technical success rate was 100%. Detachable coils were used in addition to Onyx in one procedure. There were no early major complications.There was one small selflimiting haematoma after brachial artery access. Mean imaging follow-up was 10.2 months (range 2–23 months). Of the 10 patients in whom follow-up imaging was available, 3 had a reduction in sac size, 4 had a stable sac diameter, and 2 had an increase in sac size of up to 1 cm. Conclusion: Transarterial embolization remains a viable treatment option in the management of EL1 when standard therapy is not feasible. Careful case selection is necessary to ensure optimum outcomes.

P-4 Promoting false lumen thrombosis after TEVAR in type B aortic dissections by selectively excluding true lumen reentry points

Purpose: We developed and tested the covered endovascular reconstruction of aortic bifurcation or CERAB technique for extensive and/or recurrent aortoiliac occlusive disease using V12 covered balloon expandable stents (Atrium Maquet Getinge Europe BV) to rebuild the aortic bifurcation. Material and Methods: Endovascular bifemoral recanalisation of the aortoiliac axes was performed, and a 12-mm V12 LD was placed and expanded in the distal aorta (9-Fr). The already expanded V12 stent was picked with a large balloon (adapted to the aortic diameter). The balloon was so positioned that the distal marker was approximately 15 mm proximal to the distal stent margin. After positioning and expansion, the distal stent part became funnel-shaped. Two iliac covered stent grafts were then placed in this segment in a “kissing stent” configuration and inflated. Both stents were tightly linked and moulded together with the aortic stent, simulating a new bifurcation.

M. Wojtaszek, R. Maciag, K. Korzeniowski, O. Rowinski; 2nd Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland Purpose: Thoracic endografting (TEVAR) is the mainstay of treatment in type B aortic dissections (BAD). While proving beneficial for aortic remodelling in the thoracic region, further concern remains regarding the false lumen at the level of the juxta and infrarenal aorta. We present various secondary endovascular procedures that we employed in order to promote false lumen thrombosis, prevent aortic dilatation and avoid rupture. Material and Methods: Between 2002 and 2013, 11 patients (9 men and 2 women; mean age, 52) from 62 undergoing TEVAR for BAD were treated. The main indication for treatment was dilatation of the false lumen more than 5 mm/year with persistent turbulent flow. Different techniques were employed alone or in combination:

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1. occlusion of a reentry point at the level of detached visceral artery ostia using a covered peripheral stent, 2. occlusion of a major entry tear using an occlusion device and 3. occlusion of reentry points with a straight or bifurcated aortic endograft. Results: Four patients underwent a single-stage and 7 underwent a two-stage procedure to exclude one or more than one false lumen reentry point. The mean clinical follow-up was 42 months. During this time, 5 patients (55%) had complete false lumen thrombosis and 2 patients had near-complete false lumen thrombosis. Two deaths occurred during follow-up. Conclusion: Using various endovascular techniques, we were able to limit false lumen expansion and promote thrombosis in the majority of treated patients. The method proves to be an effective ancillary procedure which promotes aortic remodeling and may prevent aortic rupture.

Background: In endovascular repair of the descending thoracic aorta, the role of segmental artery occlusion and the changes in the blood flow to the spinal cord in the postoperative period are not clear. A better knowledge of the response of the spinal cord blood supply to segmental artery sacrifice should help us understand the possible risk of neurologic complications after endovascular repair of the descending thoracic aorta. Clinical Findings/Procedure: The spinal cord vascular network was studied before and after endovascular repair of the descending thoracic aorta in patients undergoing this procedure using MD-CT. The purpose of this poster is to illustrate (1) vascular anatomy and (2) possible new vascular networks. Conclusion: After endovascular repair of the descending thoracic aorta, there is a remodelling of the spinal cord blood supply by a complex vascular network. This network is responsible for the absence of neurologic complications after the repair.

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Regional cooperation improves survival in ruptured abdominal aortic aneurysms

Tips and tricks for optimal EVAR planning in “hostile” necks

S.C. van Beek1, J. Reimerink1, A. Vahl2, W. Wisselink3, J.A. Reekers4, D.A. Legemate1, R. Balm1; 1Vascular Surgery, Academic Medical Centre, Amsterdam, Netherlands, 2Vascular Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands, 3Vascular Surgery, VU University Medical Center, Amsterdam, Netherlands, 4Radiology, Academic Medical Centre, Amsterdam, Netherlands Purpose: Care for patients with a ruptured abdominal aortic aneurysm (RAAA) in the Amsterdam ambulance region (population, 1.38 million) was concentrated into three hospitals (“vascular centers”) with a 24-h full emergency vascular service in cooperation with seven referring regional hospitals. Previous 30-day survival after admission in the Netherlands was 46% [95% confidence interval (CI) 43–49%]. We hypothesized that regional cooperation improves survival. Material and Methods: Prospective observational cohort study in all consecutive patients with RAAA between 2004 and 2011 in all ten hospitals of the Amsterdam ambulance region was conducted. Primary outcome was the 30-day survival after admission. Multivariable logistic regression, including age, sex, comorbidity, intervention (endovascular or open repair), preoperative systolic blood pressure, cardiopulmonary resuscitation, and year of intervention, was used to assess the influence of hospital setting on survival. Results: Of 453 patients with RAAA in the ambulance region, 61 did not undergo intervention, 352 patients were surgically treated at a vascular center, and 40 at a referring hospital. The regional admission survival rate was 59% (265/453, CI 54–63%). After multivariable adjustment, patients surgically treated at a vascular center had a higher survival rate (adjusted odds ratio 3.176, CI 1.433–7.040) than those surgically treated at a referring hospital. Conclusion: After regional cooperation, the overall survival of patients with RAAA was better than anticipated. Most patients were treated in a vascular center and in these patients, the survival was even better.

P-6 MD-CT imaging of spinal cord vascular network before and after endovascular repair of the descending thoracic aorta: what the interventional radiologist needs to know U.G. Rossi, P. Rigamonti, M.A. Politi, P. Reganati, C. Uggetti, M. Cariati; Radiology and Interventional Radiology, San Carlo Borromeo Hospital, Milan, Italy Learning Objectives: To evaluate the spinal cord vascular network changes before and after endovascular repair of the descending thoracic aorta by multi-detector computed tomography (MD-CT) imaging.

U.G. Rossi, P. Rigamonti, C. Redaelli Spreafico, E.C. Resta, D.F. Candito, M. Cariati; Radiology and Interventional Radiology, San Carlo Borromeo Hospital, Milan, Italy Learning Objectives: We illustrated specific problems that can be encountered during preoperative planning related to endovascular aneurysm repair (EVAR) deployment in “hostile” necks, and explained potential solutions for these problems. Background: An increasing number of patients with abdominal aortic aneurysm (AAA) with short and angulated necks are being treated with EVAR. Accurate imaging planning of the AAA morphology and possible landing zones (especially the proximal one) are essential for successful EVAR in these patients. Clinical Findings/Procedure: The purpose of this poster is to illustrate the tips and tricks for optimal EVAR planning in “hostile” necks, with emphasis on (i) setting of the aortic center line, (ii) evaluation of the “functional neck,” (iii) determination of the best access site, (iv) correct orientation of the C-arm, and (v) proximal stent orientation. Conclusion: Endovascular exclusion of an AAA in patients with “hostile” necks is the greatest challenge in EVAR. Optimal imaging planning of the AAA morphology with particular attention to the possible problems that may occur during implantation are needed to achieve a correct and successful EVAR.

P-8 Use of non-fluoroscopic, intra-aortic balloon occlusion for acute severe haemorrhage K. Khanna1, L. Childs2, D.E. Low1; 1Interventional Radiology, The Royal London Hospital, London, United Kingdom, 2Radiology, The Royal London Hospital, London, United Kingdom Learning Objectives: 1. To define the specific indications that may require intra-aortic balloon occlusion in acute, massive haemorrhage. 2. To describe the procedural sequence for intra-aortic balloon insertion in the absence of fluoroscopy, often in the emergency room resuscitation setting. 3. To review the current evidence on the efficacy of this procedure in life-threatening haemorrhage. 4. To discuss the potential training opportunities and implications for this procedure to be performed by non-interventional radiologists. Background: Intra-aortic balloon occlusion without image guidance is a life-saving procedure for patients with severe, life-threatening haemorrhage.

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This has been utilised particularly in the setting of traumatic or obstetric haemorrhage which is not adequately controlled through traditional measures. Despite studies to suggest its potential life-saving benefits, intraaortic balloon occlusion is still not universally available in trauma centres in the United Kingdom. Clinical Findings/Procedure: This presentation will provide the following: 1. Introduction on the current use and evidence for intra-aortic balloon occlusion in acute, massive haemorrhage. 2. Diagrammatic/pictorial demonstration of the procedural sequence and relevant anatomy. 3. Indications for intra-aortic balloon occlusion with recent clinical examples from a level 1 trauma centre in central London. 4. Description of training opportunities for non-interventional radiologists along with service development implications. Conclusion: By the end of the review, the viewer should 1. Understand the current uses and indications for non-fluoroscopic, intra-aortic balloon occlusion 2. Be familiar with the procedural sequence and important anatomical landmarks 3. Appreciate the possible future development of this service and its possible implications in the management of acute haemorrhage.

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P-11 Capture and repositioning of an erroneously positioned abdominal aortic stent U.G. Rossi1, M. Dahmane2, C. Ferro2, M. Cariati1; 1Radiology and Interventional Radiology, San Carlo Borromeo Hospital, Milan, Italy, 2Radiology, IRCCS San Martino, University Hospital, Genoa, Italy We describe the case of a 48-year-old female who underwent primary abdominal aortic stenting as a treatment for focal atherosclerotic abdominal aortic stenosis. The stent was erroneously released; it was subsequently captured and repositioned with “goose-neck” snare and balloon catheter.

P-12 Endovascular rescue of the narrowed extra-anatomical aortic bypass graft leading to heart failure in a patient with Takayasu’s arteritis J.H. Kim1, J.H. Park1, S.S. Byun1, C.K. Lee2; 1Division of Cardiovascular Imaging and Interventional Radiology, Gacheon University Gil Hospital, Incheon, Korea, 2Sejong Heart Institute, Sejong Hospital, Bucheon, Korea We report a case of a 59-year-old female who presented with heart failure caused by extra-anatomical bypass graft obstruction. Because she had many risk factors for open surgical correction, we successfully performed stent grafting for revascularization of the narrowed extra-anatomical bypass graft.

A novel technique utilising trans-IMA (inferior mesenteric artery) SAFARI (subintimal arterial flossing with antegrade– retrograde intervention) method for re-entry into the true lumen during subintimal aortic revascularisation for long segment aorto-iliac occlusive disease G.W.L. Tan1, U. Pua2, L.H.H. Quek 2; 1General Surgery, Tan Tock Seng Hospital, Singapore, Singapore, 2Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore, Singapore

P-13 Endovascular treatment of recurrent type I endoleak

We attempted crossing long aortic occlusion with bilateral femoral and left brachial artery access; antegrade and retrograde wires could not re-enter the true lumen but passed into IMA. Goose-neck snare was advanced in IMA using through-and-through wire (SAFARI). Bilateral iliac kissing stents were deployed.

P-10 Atrial septal defect closure device to salvage an aortic rupture patient C.S. Georgiades, G. Georghiou, M. Soteriou; Vascular & Interventional Radiology, American Medical Center, Nicosia, Cyprus

F.L. Ruales, P. Escudero, C.A. Diaz; Interventional Radiology, Hospital Universitario San Vicente Fundacion, Medellin, Colombia We report a case of type I endoleak refractory to conventional treatment that required reintervention using coils and Onyx as a trap to prevent migration into the aneurysm sac. We describe a different technique – low cost with excellent results.

P-14 Intimal angiosarcoma of the descending aorta that caused heart failure: treatment with endovascular stent grafting N. Alishev, M. Barburoglu, B. Acunas, M. Ugurlucan, U.I. Alpagut; Radiology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey

Patient presented with acute aortic rupture 2 months after surgical repair for TAA. Because of lack of other options, an endovascular apprach was selected. Anatomic considerations obviated endograft. An ASD device was used as salvage intervention. Patient was stable at 3-month follow-up.

We report a case of a patient with mass lesions in bilateral adrenal glands and descending aorta that caused progressive heart failure. During TEVAR, tumor fragments occluded the distal aorta; balloon embolectomy specimen revealed angiosarcoma, which was same as in adrenal biopsies.

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Repair of an ascending aortic pseudoaneurysm caused by vomiting using Gore Excluder stent grafts

(n=6) were detected in the N group. On reviewing the arteriograms obtained before the removal of drainage catheter in the W group, vascular compression was observed in 3 patients and negative in 2; a close contact of the drainage catheter to the artery with lesions was observed in 2 patients. Technical success and 30-day mortality rate after embolization were 88.6% (n=31) and 31.4% (n=11), respectively. Nine patients with vascular compression showed no significant difference in technical success and 30-day mortality rate as compared with the patients without compression. Two patients (14.3 %) who underwent non-selective embolization (n=14) showed hepatic failure. There were no other complications. Although poorer pre- and post-embolization laboratory values were observed in patients with 30-day mortality, only post-embolization ALT was statistically higher (P=0.031). Conclusion: Transarterial embolization is an effective treatment for iatrogenic hemobilia. Meticulous analysis of angiograms helps in preventing additional manipulations in detecting vascular lesions.

M. Hennessy1, S. Chandramohan2; 1Radiology, Yorkhill Hospital, Glasgow, United Kingdom, 2Radiology, Gartnavel General Hospital, Glasgow, United Kingdom

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P-15 Percutaneous retrieval of embolized atrial septal occluder device from the abdominal aorta C. Khouri Chalouhi1, F. Melchiorre1, M. Montechiari1, T. Donati2, M. Crippa2, G.P. Cornalba1; 1Diagnostic and Interventional Radiology, San Paolo Hospital, Milan, Italy, 2Vascular Surgery, San Paolo Hospital, Milan, Italy We report a rare case of late embolization of an atrial septal occluder device in the abdominal aorta at the level of the celiac trunk. This is one of the few cases of totally percutaneous retrieval.

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We present the case of exclusion of an ascending aortic pseudoaneurysm with an unusual aetiology. Tachycardia pacing and transoesophageal echocargiography facilitated the deployment of Gore Excluder stent grafts with access via the left common carotid artery due to the short delivery system.

P-17 Type II endoleak embolization after endovascular aortic repair (EVAR) using direct percutaneous puncture of the endoleak sac via the vertebral arch pedicle Y. Ogawa1, H. Nishimaki2, Y. Kon1, K. Chiba2, S. Hamaguchi1, Y. Arai1, T. Miyairi2, H. Makuuchi2, Y. Nakajima1; 1Radiology, St. Marianna University School of Medicine, Kawasaki, Japan, 2Cardiovascular Surgery, St. Marianna University School of Medicine, Kawasaki, Japan With the patient in the prone position, a 13-G bone biopsy needle was inserted through the vertebral arch pedicle; then, a 20-G needle was advanced into the endoleak sac. NBCA-lipiodol mixture was injected, and the endoleak sac was filled.

Biliary intervention P-18 Iatrogenic hemobilia: a new arteriographic feature and interventional management H.G. Lee1, J.S. Oh1, H.J. Chun1, B.G. Choi1, Y.S. Lim2; 1Radiology, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea, 2Radiology, Bucheon St. Mary’s Hospital, Bucheon, Korea Purpose: To investigate arteriographic features and the interventional management of iatrogenic hemobilia. Material and Methods: A total of 35 consecutive patients were retrospectively evaluated. Results: The causes of hemobilia were percutaneous drainage (n=31), endoscopic manipulation (n=3), and biopsy (n=1). Lesions were detected on arteriograms with drainage catheters (C group) in 19 patients, wires (W group) in 7, and none (N group) in 9. Pseudoaneurysm, vascular compression by catheter, arteriobiliary fistula, arteriovenous fistula, and negative findings were diagnosed in 9, 6, 1, 1, and 2 patients in the C group and in 0, 1, 5, 0, and 1 the W group, respectively. Ateriobiliary fistula (n=3) and pseudoaneurysm

Percutaneous biliary drainage in a tertiary referral center: safety and efficacy K.A. Pennycooke, P. Thanaratnam, S. Shaikh, M.F. Given, A. Keeling, M.J. Lee; Department of Radiology, Beaumont Hospital, Dublin, Ireland Purpose: Percutaneous biliary drainage (PBD) has been associated with a high in-hospital mortality of 19.8% and morbidity of 7.9% for major complications and 26% for minor complications in a recent BSIR registry of 833 patients. We reviewed PBD procedures at our institution to determine morbidity and 30-day mortality. Material and Methods: A total of 119 patients (67 males and 52 females; age range 47–100 years, mean age 70.6 years) undergoing 193 PBD procedures were identified over a 6-year period. In all, 8 patients (6.7%) had stone disease, 75 (63%) had been diagnosed with a malignancy, and 29% were diagnosed with other pathologies. The standard techniques of PBD stenting were performed with 73 patients (61%) and all undergoing gelfoam embolization of percutaneous tracts. All patients received intravenous (IV) penicillin/tazobactam and 2 L of IV fluid before the procedure. Results: Technical success rate was 97%. The mean drop between pre- and post-procedure bilirubin was 105 Umol/L. Twelve patients (10%) had hilar obstruction. Thirty-day mortality was 4% (5 deaths). Major complications included sepsis in 4 patients (2%), major hemorrhage in 3 (1.5%), and renal failure in 3 (1.5%). Minor complications included a 7.3% minor sepsis rate. Two patients (1.7%) were septic pre-procedure, and less than 1% was complicated by bile leak. Conclusion: This study confirms that PBD is a safe and effective technique that improves biliary function and provides a successful symptomatic relief.

P-20 Percutaneous dual stent placement for advanced malignant hilar obstruction: Y versus criss-cross configuration C.H. Jeon, C.J. Yoon, Y.-J. Kim, Y.N. Woo, S.W. An, N.J. Seong; Radiology, Seoul National University Bundang Hospital, Gyeonggi-do, Korea Purpose: To compare the clinical outcomes of percutaneous biliary stent placement between Y and criss-cross configured stent placements in patients with an advanced malignant hilar obstruction. Material and Methods: Between April 2006 and December 2013, 44 patients (mean 68.4 years, range 42–84) with advanced malignant hilar obstructions (Bismuth type III or higher) were included in this retrospective study. Two metallic self-expandable stents were percutaneously placed with Y (n=23, group A) or criss-cross

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configuration (n=21, group B). Technical/functional success, complications, and stent patency were compared between the two groups. Results: Stent placement was technically successful in all patients of the two groups. No procedure-related complications were observed. Initial functional success (decrease of serum bilirubin to <75% of pretreatment level) was achieved in 20 (87.0%) patients of group A and 17 (80.9%) of group B (p=0.90). Stent occlusion by tumor ingrowth, with or without overgrowth, occurred in 13 (56.5%) patients of group A and 4 (19.0%) of group B. There was no difference in primary stent patency between the two groups (median, 185 days in group A and 315 days in group B; p=0.22). Conclusion: Percutaneous dual stent placement is safe and effective for biliary drainage in patients with advanced malignant hilar obstruction. There was no difference between Y and criss-cross configuration stent placement in functional success and primary stent patency.

P-21 Percutaneous dual stent placement for malignant hilar obstruction: comparison between T and criss-cross configuration C.H. Jeon, C.J. Yoon, Y.-J. Kim, Y.N. Woo, S.W. An, N.J. Seong; Radiology, Seoul National University Bundang Hospital, Seongnam, Korea Purpose: To compare the clinical outcomes of percutaneous biliary stent placement between T and criss-cross stent placements in patients with malignant hilar obstruction. Material and Methods: Between April 2009 and December 2013, 51 patients (mean 69.3 years, range 42–88 years) with malignant hilar obstructions (Bismuth type III or higher) were included in this retrospective study. Two metallic self-expandable stents were percutaneously placed with T (n=30, group A) or criss-cross configuration (n=21, group B). Technical/functional success, complications, and long-term clinical outcomes were compared between the two groups. Results: Stent placement was successful in all patients of the two groups. Massive hemobilia caused by tumor bleeding occurred in 2 patients of group A (6%, p=0.51). Initial functional success (decrease of serum bilirubin by <75% of pretreatment level) was achieved in 25 patients (83.3%) of group A and 17 (80.9%) of group B (p=0.55). Stent occlusion by tumor ingrowth, with or without overgrowth, occurred in 14 patients (46.6%) of group A and 4 (19.0%) of group B. The median primary stent patency was longer in group B (315 days) than group A (132 days) (p=0.03). There was no difference in median survival between the two groups (164 days in group A and 392 days in group B; p=0.73). Conclusion: Percutaneous dual stent placement is safe and effective for biliary drainage in patients with an advanced malignant hilar obstruction. Criss-cross configuration was better than T configuration in primary stent patency.

P-22 Study on application value of percutaneous transhepatic cholangiobiopsy in the pathologic diagnosis of anastomotic stenosis after cholangiojejunostomy for malignant obstructive jaundice in 24 cases

Abstract Book Material and Methods: Using biopsy forceps, specimens were collected from the stenosis sites of patients with recurrent jaundice (n=24) who had previously undergone cholangiojejunostomy for malignant obstructive jaundice. Results: Stenosis occurred in all patients at the biliary–enteric anastomosis based on percutaneous transhepatic cholangiography and was the location of the biopsy. Satisfactory specimens were obtained from 22 of 24 patients. Sensitivity was 91.7% (22/24). Tumour tissue was obtained in 18 cases and tumour recurrence was confirmed. Pathological changes in four patients were diagnosed as fibroplasia and/or inflammation. These were considered as cicatricial stenosis based on pathological, imaging and laboratory findings. The remaining two histopathology-negative patients were proven to have recurrent tumour based on imaging, laboratory and followup data. No complications occurred during biopsy, including gastrointestinal haemorrhage or perforation. Either cholangial drainage and/or an inner stent was used following biopsy, resulting in a noticeable decrease in jaundice postoperatively (p<0.05). Conclusion: The present procedure is easy to perform, safe and highly sensitive. Interventional therapies, such as percutaneous transhepatic cholangial drainage and stent placement, can be performed concurrently and can markedly improve the symptoms of patients with obstructive jaundice with fewer complications.

P-23 Usefulness and safety of biliary percutaneous transluminal forceps biopsy: our experience F.A. Vizzari1, D. Laganà2, G. Carrafiello3, A.M. Ierardi1, D. Lumia3, N. Lucchina2, C. Fugazzola1; 1Radiology, Uninsubria, Ospedale di Circolo, Varese, Italy, 2Radiologia, Ospedale di Circolo e Fondazione Macchi, Varese, Italy, 3Radiology, University of Insubria, Varese, Italy Purpose: To evaluate the usefulness and safety of percutaneous transluminal forceps biopsy in patients suspected of having a malignant biliary obstruction. Material and Methods: Forty consecutive patients (21 men and 19 women; mean age, 71.9 years) underwent forceps biopsy through percutaneous transhepatic biliary access performed to drain bile. Lesions involved the common bile duct (n=8), common hepatic duct (n=18), hilum (n=6), ampullary segment of the common bile duct (n=8) and were biopsied with 7-F biopsy forceps. Final diagnosis was confirmed with pathologic findings at surgery, or clinical and radiological follow-up. Results: Twenty-one of 40 biopsies resulted in correct diagnosis of malignancy. Thirteen biopsy diagnosis were proved to be true-negative. There were six false-negative and no false-positive diagnoses. Sensitivity, specificity, and accuracy in aspecific biliary obstructions were 85%, 100%, and 88.7% respectively. Sensitivity of biopsy in malignancies was higher than in benign obstructions (100% vs 68.4%, CI = 95%). Sensitivity was lower in the hilar tract and common bile duct than in other sites (CI = 95%). No major complications related to biopsy procedures occurred. Conclusion: Percutaneous transluminal forceps biopsy is a safe procedure, easy to perform through a transhepatic biliary drainage tract, providing high accuracy in the diagnosis of malignant biliary obstructions.

T.-F. Li, X.-W. Han, Z. Li; Interventional Radiology, First Affiliated Hospital, Zhengzhou University, Zhengzhou, China Purpose: The aim of the present study was to investigate the feasibility and advantages of cholangiobiopsy during percutaneous transhepatic cholangiography and in the histopathological diagnosis of anastomotic stenosis after cholangiojejunostomy for malignant obstructive jaundice.

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P-26

Endobiliary biopsy in patients with biliary steno-occlusion: technical advantages and limitations

Interventional procedures in common liver transplant-related vascular and non-vascular complications

D.F. Candito1, S. Brambilla1, C. Redaelli Spreafico1, E.C. Resta1, U.G. Rossi2, M. Cariati1; 1Radiology and Interventional Radiology, San Carlo Borromeo, Milan, Italy, 2Radiology, San Carlo Borromeo Hospital, Milan, Italy

L.-M.N.J. Boucher, T. Cabrera, C.I. Torres, K. Muchantef, F.A. Toonsi, S. Cooper, P.P. Rao, K. Ho, D.A. Valenti; Radiology, McGill University Health Centre, Montreal, QC, Canada

Learning Objectives: To describe the technique, advantages and limitations of endobiliary biopsy after transhepatic percutaneous biliary drainage (TPBD) in patients with biliary steno-obstruction. Background: TPBD is currently the first-line therapy in patients with biliary steno-occlusion after the failure of endoscopic retrograde cholangiopancreatography (ERCP) or in case of proximal lesions. These patients need a specific diagnosis for the most correct therapeutic algorithm. Endobiliary biopsy (cytologic and hystologic) can be performed during percutaneous drainage or during its followups as a safe and less invasive technique. Clinical Findings/Procedure: The purpose of this poster is to describe all the technical steps (from “A” to “Z”) of endobiliary biopsy during TPBD in patients with biliary steno-occlusion, with particular reference to methods and times of procedure execution. Conclusion: Endobiliary biopsy during TPBD, if well performed, appears to be safe and effective, with low risk of complications and highly sensitive technique for the final diagnosis in patients with biliary steno-occlusion.

P-25 Endoluminal ablation for malignant biliary duct stenosis T. Andrašina1, V. Bernard2, J. Panek1, J. Hlavsa3, J. Boudny1, V. Válek4; 1Radiology, Faculty Hospital Brno, Brno, Czech Republic, 2Department of Biophysics, Masaryk University Brno, Brno, Czech Republic, 3Surgery, Faculty Hospital Brno, Brno, Czech Republic, 4Department of Radiology, University Hospital Brno, Masaryk University, Brno, Czech Republic Learning Objectives: Endoluminal radiofrequency ablation is a useful palliative method for patients with malignant stenosis of the bile ducts. It can be used for ablation before self-expandable metal stent placement and in dealing with stent occlusion. Thermal injuries of the bile ducts and surrounding vasculature are possible complications. Background: The optimal palliative method for patients with bile duct malignancies is metal stent placement. The use of covered selfexpanding stents does not seem to be an appropriate solution for resolving hilar strictures. However, the most frequent complication of uncovered self-expandable metal stents is their closure. To prolong metal stent patency, photodynamic techniques and brachytherapy are used. Nowadays, endoluminal radiofrequency ablation is another possibility. Clinical Findings/Procedure: After the endoluminal ablation procedure, a lower rate of stent occlusion and early stent occlusion (up to 2 months of stent placement) is found. In addition, the intervention is not associated with higher rates of complications compared with brachytherapy or photodynamic therapy. In ex vivo testing using thermometric and thermographic studies, we propose an optimal protocol of ablation for the clearance of occluded stents considering patient safety. Conclusion: Local ablation techniques such as endoluminal radiofrequency ablation with simple and one-time application are potentially useful in palliating endoluminal tumours, preventing early ingrowth of the tumours through the stent mesh and even helping to resolve stent occlusion. However, there are still no randomised, prospective studies for these applications. The work was supported by grant from the Ministry of Health of the Czech Republic (NT14586).

Learning Objectives: To understand the liver transplantationrelated complications that require the help of interventional radiology as well as hurdles specifically associated with these complications and how to overcome them. Background: Complications after liver transplantation can be divided as vascular and non-vascular. Apart from rejection, vascular complications are the most common cause of transplant failure. Most vascular and biliary complications are related to ischemia, often secondary to anastomotic injuries leading to stenosis or thrombosis. Because of the nature of the transplant leading to marked changes in liver physiology, these complications often present in an atypical fashion and are associated with their own specific treatment hurdles. Among these, the lack of biliary dilatation, tortuosity of anastomosed vessels, and difference in post-surgical vascular and biliary anatomy play an important role. Clinical Findings/Procedure: A review of vascular complications, including hepatic arterial, hepatic venous, and portal venous stenoses, are discussed with case examples and types of treatment that can be offered. Specific non-vascular complications related to biliary injury are also discussed with case examples and treatment options. Advice regarding specific difficulties that can be encountered and how to overcome them is provided. Conclusion: Liver transplantation is a procedure that leads to marked changes in liver physiology and is associated with specific complications. In liver transplantation centers, interventional radiology assumes a central role in the post-transplantation care. Understanding the difficulties that can be encountered in treating these complications is critical to an interventional radiologist working in such centers.

P-27 Percutaneous management of bile leaks and biliary strictures associated with laparoscopic cholecystectomy and biliary reconstructive surgery A. Erbahceci Salik1, F. Islim1, D. Akinci2; 1Radiology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey, 2Radiology, Hacettepe University School of Medicine, Ankara, Turkey Learning Objectives: To illustrate and discuss the role of the interventional radiology techniques for the management of bile leaks and biliary strictures associated with laparoscopic cholecystectomy (LC) and biliary reconstructive surgery. Background: Open cholecystectomy has been largely replaced by LC for the treatment of symptomatic gallstone disease; however, LC has been associated with significant increase in the incidence of bile duct injuries. Bile leaks and biliary strictures are the most common biliary complications of biliary reconstructive surgery. Early recognition and appropriate management are crucial because a delay in the diagnosis may have severe consequences, such as sepsis, cholangitis, cirrhosis and death. Radiological imaging modalities and percutaneous interventional radiology techniques play a key role in the treatment. Clinical Findings/Procedure: We present a few illustrative cases to demonstrate the role of percutaneous interventional radiology techniques such as collection drainage, transhepatic cholangiography, biliary drainage and balloon dilatation for the management of bile leaks and biliary strictures as palliative or definitive treatment options.

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Conclusion: Clinical management of these complications requires a multidisciplinary approach. Interventional radiology treatment options may, in part, provide definitive treatment of these complications with minimally invasive approach; furthermore, they may save time for surgical biliary tract reconstruction by relieving septic symptoms. Excellent long-term outcomes can be achieved through the teamwork of experienced hepatobiliary surgeons and interventional radiologists in this patient group.

P-28 Percutaneous treatment of extrahepatic bile duct stones assisted by balloon sphincteroplasty and occlusion balloon: the “A” to “Z” of the technique P. Rigamonti1, U.G. Rossi1, F. Alberghini2, P. Torcia3, F. Melchiorre4, G. Cornalba5, M. Cariati1; 1Radiology and Interventional Radiology, San Carlo Borromeo Hospital, Milan, Italy, 2Anesthesiology, San Carlo Borromeo Hospital, Milan, Italy, 3Radiology and Interventional Radiology, San Giovanni Addolorata Hospital, Rome, Italy, 4Interventional Radiology, AO San Paolo, Milan, Italy, 5Diagnostic and Interventional Radiology, S. Paolo Hospital, Milan, Italy Learning Objectives: To provide a step-by-step description of the percutaneous extrahepatic technique for biliary stone removal by balloon sphincteroplasty and occlusion balloon pushing. Background: Various methods, including surgical and non-surgical techniques, have been used to remove bile duct stones. Endoscopic sphincterotomy with stone removal has been recognized as the first-line modality in extrahepatic duct stones. However, the use of endoscopic technique may be impossible in some clinical situations. In these situations, the percutaneous extrahepatic technique with balloon dilatation of the papilla and clearing biliary ducts stones by pushing with occlusion balloon is a valuable alternative. Clinical Findings/Procedure: The purpose of this poster is to illustrate the indications and the “A” to “Z” of the percutaneous extrahepatic technique as well as its possible failures and complications. Conclusion: Percutaneous extrahepatic biliary stone removal by balloon sphincteroplasty and subsequent stone pushing with occlusion balloon is an alternative method in patients in whom endoscopic biliary stone removal cannot be used or has failed.

P-29 Sphincteroplasty technique for biliary stone removal via the PTBD tract: results of a single-center study of 695 patients H.J. Shim1, J.S. Shin2, B.K. Kwak1; 1Radiology, Chung-Ang University Hospital, Seoul, Korea, 2Radiology, Inje University Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, Korea Learning Objectives: We report our experience of a single-center analysis of 695 patients (total 732 cases) in whom percutaneous biliary stone removal was performed via the PTBD tract. Balloon sphincteroplasty with the flushing technique – our novel method – was investigated to evaluate the technical feasibility and usefulness as well as success rate and complications. Background: From 2002 to 2012, 695 patients (M:F = 368:327; mean age, 65 years) with 37 recurred cases (i.e., a total of 732 cases) were enrolled in this study. Biliary stone removal via the PTBD tract was performed using a combination of balloon sphincteroplasty with the flushing technique, i.e., pushing after sphincteroplasty after basket stone fragmentation. Clinical Findings/Procedure: Location of biliary stone was extrahepatic (CBD) in 68%, intrahepatic (IHD) in 15%, and both CBD and IHD in 17%. Success rates were complete removal in 667 cases (91.1%), clinical success in 59 (8%), failure in 6 (0.08%). Total success rate was

Abstract Book 99.2%. Most frequently used interventional technique (82%) was balloon sphincteroplasty with flushing into the duodenum after stone fragmentation with basket. No major complications such as arterial hemobilia and critical pancreatitis were observed. Minor complications such as nausea, vomiting, pain, minor subcapsular hemorrhage, minimal hemobilia, and fever and chills (cholangitis) were observed in 14% cases and controlled by conservative measures. Conclusion: Percutaneous biliary stone removal via the PTBD tract is safe and effective, especially in cases where it is difficult to proceed with ERCP. Balloon sphincteroplasty with the flushing technique was feasible and useful method to remove biliary stones, and it was tolerated without any major complications.

P-30 Biliary stent placement for the management of acute obstructive jaundice secondary to uncovered gastroduodenal stent placement S.H. Kwon1, J.H. Oh1, S.W. Park2, T.-S. Seo3; 1Radiology, Kyung Hee University Medical Center, Seoul, Korea, 2Radiology, Konkuk University Hospital, Seoul, Korea, 3Radiology, Korea University Guro Hospital, Seoul, Korea WITHDRAWN

Biopsy and drainage P-31 Cone beam CT-guided percutaneous core biopsy of mediastinal masses: safety and accuracy in 21 patients S. Yilmaz, N. Oz, G. Asal, M. Cevener, A. Kargi, S. Oztekin, A. Yildiz, M. Ozdogan; Medstar Yildiz Hospital, The Mediterranean Integrative Oncology Group, Antalya, Turkey Purpose: Although percutaneous CT-guided biopsy has advantages over bronchoscopic or surgical biopsies, it is rarely performed because of concern for injury to mediastinal structures. The aim of our study was to evaluate the safety and accuracy of cone beam CT (CBCT)-guided percutaneous core biopsies of the lesions located in the mediastinum. Material and Methods: Between June 2012 and December 2013, 21 patients with suspected mediastinal mass lesions underwent percutaneous core biopsy under cone beam CT guidance. The lesions were 10–28 mm in diameter and located in the anterior (n=7), middle (n=6), and posterior mediastinum (n=8). After local anesthesia, an 18-gauge needle was advanced to the lesion via a trans-sternal (n=3), parasternal (n=8), or paravertebral (n=10) approach. In 16 patients, mediastinum was widened with dextrose or saline injection during needle advancement to avoid lung and prevent pneumothorax. After the lesion was reached, a 20-gauge fully automated biopsy needle was advanced through the 18-gauge needle and multiple samples were obtained. Results: In all patients, the biopsy procedure was technically successful. There was no pneumothorax, bleeding, or infection. All samples yielded diagnostic results. The results were malignant (lymphoma, lung cancer, thymic carcinoma) in 18 patients and benign in 3. Conclusion: Our study suggests that CBCT-guided percutaneous core biopsy is safe and accurate for mediastinal masses. Using CBCT imaging and special maneuvers, it is possible to obtain high-quality core biopsy samples without passing the lung parenchyma and injuring the mediastinal structures.

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P-32 Cone beam-CT (CBCT) is a safe and effective single imaging technique to guide percutaneous biopsies A. Cannavale, C. Cirelli, M. Corona, P. Lucatelli, A. Wlderk, A. D’Adamo, F.M. Salvatori, F. Fanelli; Department of Radiological Sciences, Vascular and Interventional Radiology Unit, Sapienza University of Rome, Rome, Italy Purpose: To evaluate the feasibility of cone beam-CT (CBCT) as a single technique to guide percutaneous biopsy. Material and Methods: Sixty-nine consecutive patients (28 vertebral bodies, 15 intervertebral discs, 5 pelvic masses, 6 retroperitoneal masses, 10 pelvic bone lesions, and 5 muscles lesions) underwent biopsy under CBCT and fluoroscopy guidance with 11–20gauge biopsy needles. All procedures were performed in the same angiosuite (Artis zee; Siemens, Erlangen, Germany). Rotational acquisitions were directly elaborated by a dedicated workstation (Leonardo) processing CT-like images and 3D reconstructions were employed to guide the biopsy and to asses potential post-procedure complications. Technical success, procedure time, fluoroscopy time, mean number of rotational acquisitions, dose area product (DAP), image quality (categorized as optimal, sufficient, insufficient), procedural complications, and histological analysis of biopsy samples were recorded. Results: Technical success was 100%, mean procedure time was 29.2 ± 9.1 min, mean fluoroscopy time was 4.24 ± 0.002 min, mean number of rotational acquisitions were 6.12 ± 2.7, and mean DAP was 37833.5 ± 24431.6 μGym². Image quality was considered optimal in 49 cases (71%) and sufficient due to the presence of beam hardening artifacts in 20 (29%). In no case was the procedure suspended because of poor quality of CBCT. Minor complications (pain, small hematoma) were observed in three cases (4.34%). In seven cases (10.1%), biopsy samples were inadequate for histological diagnosis. Conclusion: In all cases, CBCT permitted a safe and an accurate control of the needle insertion with high-quality CT-like images and 3D reconstruction with no significant increase in complication rate or procedure failure rate.

P-33 Flow mechanics of common body fluids, the catheters that drain them, and the stopcocks that intervene M.M. Morshedi1, H. Aryafar 2, K. Nakanote1, M.T. Gudmundsson1, H. Aryafar1; 1Department of Radiology, UCSD Medical Center, San Diego, CA, United States of America, 2Mechanical and Aerospace Engineering, UCLA, Los Angeles, CA, United States of America Purpose: Percutaneous drainage of intracorporeal fluid collections revolutionized treatment and reduced morbidity. Single-lumen pigtail catheters are selected based on collection size and other factors, including user preference. Stopcocks allow access while maintaining patency and decreasing occlusion and contamination. Poiseuille’s law is proportional to the fourth power of catheter lumen radius for Newtonian fluids like water, suggesting that flow rate is dependent on the system’s smallest diameter. Ex vivo vacuum pump studies with Newtonian fluids show that drainage catheter efficacy varies with internal diameter and stopcock internal diameter affects efficiency; however, the rheology of intracorporeal fluid collections has not been extensively studied. We evaluate common drainage catheter and unisize connector performance characteristics and measure commonly drained fluids’ flow mechanics evaluating Newtonian versus non-Newtonian characteristics and their effects on catheters. Material and Methods: We compare 8–12-French single-lumen pigtail drainage catheters from five manufactures using a gravitybased model with and without various intervening connectors. A

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rheometer was used to characterize the fluid dynamics of representative intracorporeal fluid collections. Results: The physical characteristics of the catheters and intervening connectors, including inner diameters, were evaluated with a pictorial overview. Significant flow rate variability between companies and catheter sizes was noted with the flow rate gradient not corresponding to catheter sizes. Stopcocks reduced flow through all sizes of catheters from 0–40% with largest catheters affected most. Body fluid rheological analysis show non-Newtonian characteristics that could alter flow mechanics and efficiency during drainage. Conclusion: Intracorporeal fluid collections may not follow Newtonian flow mechanics; optimal catheter selection and stopcock use is essential for drainage.

P-34 Percutaneous CT fluoroscopy-guided abdominal and pelvic abscess drainage: comparison of one-step and Seldinger techniques K. Kajiwara, T. Yamagami, R. Yoshimatsu, M. Ishikawa, K. Awai; Diagnostic Radiology, Institute and Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan Purpose: To evaluate and compare the one-step technique and Seldinger technique in percutaneous computed tomography (CT) fluoroscopy-guided abdominal and pelvic abscess drainage. Material and Methods: Fifty consecutive patients (31 men, 19 women; mean age, 60 years; range, 19–84 years) with abdominal or pelvic abscess were included in this study. Drainage was performed with the one-step (n=23) or Seldinger (n=45) technique between September 2012 and December 2013. Results: The technical success and clinical success rates were 95.7% and 90.9%, respectively, in the one-step group, and 100% and 95.6%, respectively, in the Seldinger group. The mean procedure time was significantly shorter (p<0.05) in the one-step group (17.0±5.3 minutes, 10–29 minutes) than in the Seldinger group (23.6±9.6 minutes, 13–54 minutes). Additional treatment was performed in 6/16 patients (drainage, n=3; surgery, n=3) in the one-step group and 10/36 patients (drainage, n=5; surgery, n=5) in the Seldinger group. There were no procedure-related complications. The mean diameter of the abscess was 78.8±40.3 mm in the one-step group and 64.0±22.7 mm in the Seldinger group. The mean depth of the abscess was 46.3±19.9 mm in the one-step group and 40.3±20.8 mm in the Seldinger group. Conclusion: The results suggest that the one-step technique is simpler and quicker than the Seldinger technique. The effectiveness of the one-step technique was similar to that of the Seldinger technique in percutaneous CT fluoroscopy-guided abdominal and pelvic abscess drainage.

P-35 Preliminary clinical experience with a dedicated robotic system for CT-guided biopsies of thoracic and abdominal lesions M. Anzidei1, R. Argirò1, A. Porfiri1, F. Boni1, A. Napoli1, M. Bezzi1, C. Catalano2; 1Department of Radiological Sciences, Sapienza University of Rome, Rome, Italy, 2Radiology, University La Sapienza Policlinico Umberto I, Rome, Italy Purpose: To evaluate the clinical performance of a robotic system for CT-guided biopsies of thoracic and abdominal lesions in comparison with conventional manual approach. Material and Methods: Sixty patients referred for CT-guided biopsies of thoracic (n=41) and abdominal (n=19) lesions were randomly assigned to robot-assisted (group A) or manual procedure (group B). Robot-assisted biopsies were performed with the Robio EX system

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(Perfint Healtcare) by two radiologists (8 years and 3 years of experience). Dose length product (DLP), procedure duration, accuracy in needle placement, complications, diagnostic accuracy of biopsy and operator preference were assessed using the paired t-test, Wilcoxon test and McNemar test to evaluate significant differences (p<0.05) between the two groups. Results: All biopsies were successfully performed under CT guidance. DLP and procedure duration were significantly reduced using the robot-assisted system (p 0.01), being 237 mGy-cm and 16±2 min in group A and 373 mGy-cm and 26±3 min in group B. No major complications occurred in the study population, and minor procedure-related complications (pneumothorax, pleural effusion and self-limiting haemorrhage) occurred in 10% of patients in both groups, without statistically significant differences (p 0.05). The diagnostic accuracy of the biopsy sampling was similar in the two groups (p 0.05). The more expert operator preferred the manual approach, while the robot-assisted system was preferred by the less experienced radiologist. Conclusion: The robot-assisted system is safe and adequately accurate in performing CT-guided biopsies of thoracic and abdominal lesions with reduction in procedure duration and radiation dose to the patient compared with the manual approach.

P-36 Radiology-guided forceps biopsy and airway stenting in severe airway stenosis Z.-M. Li, X.-W. Han, G. Wu, K. Ren; Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China Purpose: To determine the feasibility, safety, and effectiveness of radiology-guided forceps biopsy and airway stenting in patients with severe airway stenosis. Material and Methods: This study involved 28 patients with severe airway stenosis who underwent forceps biopsy between October 2006 and September 2011. Chest multi-slice CT was used to determine the location and extent of stenosis. Sixteen patients had tracheal stenosis, two had stenosis of the tracheal carina, six had stenosis of the left main bronchus, and four had stenosis of the right main bronchus. Forceps biopsy and stenting of the stenosed area were performed under fluoroscopic guidance in digital subtraction angiography (DSA) and the biopsy specimens were analyzed histopathologically. We contacted the patients via phone call and utilized a standardized questionnaire to interview them regarding the medical situation during the postoperative 3-month follow-up. Results: The technical success rate of radiology-guided forceps biopsy was 100%. Biopsy specimens were obtained in all patients. Dyspnea was relieved immediately after stent placement. No serious complications occurred, including tracheal hemorrhage or perforation, mediastinal emphysema, and asphyxia. Conclusion: Radiology-guided forceps biopsy and airway stenting can be used for the emergency treatment of severe airway stenosis. This method appears to be safe and effective and may be an alternative therapeutic option in patients who cannot tolerate fiberoptic bronchoscopy.

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P-37 Tract embolization with ultrasound-guided percutaneous liver biopsy in patients without coagulopathy: does it make a difference? R. Arya, P. Nene, J. Xiao, R. Vilvendhan; Department of Radiology, Boston Medical Center, Boston, MA, United States of America Purpose: To evaluate for a statistically significant difference in complication rates between patients who underwent tract embolization with US-guided percutaneous liver biopsy (UGPLB) versus those who did not. Material and Methods: In this IRB-approved retrospective study, clinical charts and PACS reports were reviewed for patients who underwent UGPLB over a period of four years. Complications (subcapsular hematoma, hemoperitoneum, and skin-site hemorrhage), coagulation profile, size of coaxial biopsy system used, biopsy indication, and active anticoagulation medications were compared between the study and control groups. Tract embolization was performed using either D-Stat Thrombin Flowable or Gelfoam. Results: Among 714 patients who underwent UGPLB, 46 were excluded (incomplete clinical information). Of the 673 patients included, 209 underwent UGPLB with tract embolization and 459 without; 198 of the study group and 162 of the control group had a follow-up 2-hour post-procedure US. The overall rate of subcapsular hematoma and hemoperitoneum was 1.5% (n=8), one diagnosed clinically and seven detected on post-procedure US. There was no statistically significant difference in the rate of subcapsular hematoma and hemoperitoneum between the two groups (p=1.0). There was a statistically significant but clinically insignificant difference in the number of skin-site hemorrhages (p=0.035). There was no statistically significant difference in coagulation panel, active anticoagulation medications, biopsy indication, and size of coaxial biopsy system used. There were no complications related to tract embolization. Conclusion: In patients without coagulopathy, there is no statistically significant difference in subcapsular hematoma and hemoperitoneum between patients who undergo tract embolization with UGPLB versus those who do not.

P-38 Transjugular renal biopsy using a 19-gauge Quick-Core blunt-tip needle A.T. Chen, V. Keluth Chavan, J. Soni, U.C. Turba, J. Tasse, P.G. Smith, N. Khurana, B. Arslan; Section of Interventional Radiology, Rush University Medical Center, Chicago, IL, United States of America Purpose: To evaluate the safety and tissue adequacy when using the 19-gauge Quick-Core blunt-tip needle for transjugular renal biopsy (TJRB) in patients at high risk for percutaneous renal biopsy. Material and Methods: A retrospective review of all TJRB procedures performed between May 2011 and Jan 2014 was performed for indication, number of glomeruli, specimen adequacy, and complications. The number of passes was not universally documented. Indications for TJRB included coagulopathy or thrombocytopenia, anticoagulation that could not be reversed or discontinued, obesity or inability to achieve appropriate position for percutaneous biopsy. Complications were evaluated primarily based on the patient’s clinical condition; post-procedure hemoglobin levels; and relevant imaging, including ultrasound and/or CT. Results: A total of 39 TJRB procedures were performed on 37 patients. Two patients underwent repeat procedures due to the inadequacy of initial specimens. TJRB was technically successful in 36 of 37 patients (97%); one patient could not undergo the

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procedure due to the renal vein angulation. Thus, 38 TJRB procedures were performed. Adequate tissue for diagnosis was obtained in 35 of 38 biopsies (92%). Mean number of glomeruli obtained for evaluation were 10.7 ± 7.9, 4.3 ± 4.1, and 0.66 ± 0.48 for light microscopy, immunofluorescence, and electron microscopy, respectively. Major complication occurred in 1 patient (2.6%) consisting of large perinephric hematoma requiring additional management. Minor complications occurred in 4 patients (10%), primarily small perinephric hematoma that did not require increased level of care. Conclusion: TJRB is safe and provides adequate diagnostic tissue when using a 19-gauge Quick-Core blunt-tip needle.

P-39 Can mediastinal tumors be diagnosed by CT-guided percutaneous biopsy with registration of prior PET/CT images? O. Ikeda1, K. Kawanaka1, K. Yokoyama1, S. Inoue2, Y. Tamura1, Y. Nakasone1, Y. Yamashita1; 1Diagnostic Radiology, Kumamoto University Graduate School of Life Sciences, Kumamoto, Japan, 2Diagnostic Radiology, Kumamoto University Hospital, Kumamoto, Japan Learning Objectives: If positron emission tomography (PET) information could be integrated into computed tomography (CT)-guided biopsy procedures, more lesions could be biopsied and diagnostic accuracy may be improved. We compared the diagnostic value of CT-guided percutaneous biopsy with and without registration of prior PET/CT images in patients with mediastinal tumors. Background: CT-guided transthoracic needle biopsy is the initial diagnostic procedure in many patients with mediastinal masses. Nonenhanced CT is performed to guide percutaneous biopsies, but it may return false-negative results because of sampling error. Some lesions detected using PET yield few or no correlative CT findings, and it may be impossible to perform biopsy based on PET findings alone. Clinical Findings/Procedure: We performed clinically indicated CT-guided percutaneous biopsy with (group 1, n=56) or without (group 2, n=50) registration of prior PET/CT images in 106 patients. The registered images were used to plan the procedure and help target the tumors. CT-guided needle biopsy yielded adequate samples in 101 of 106 (95%) patients (group 1, n=53; group 2, n=48); in 95 (94%), the diagnosis was confirmed by specific histological typing (group 1, n=51; group 2, n=44). Diagnostic accuracy with and without registration of prior PET/CT images was not significantly different (group 1, 96%; group 2, 93%; p=0.324). Conclusion: CT-guided percutaneous biopsy is an easy and safe procedure that can provide a precise diagnosis in most mediastinal tumors. PET/CT-guided biopsy yielded no diagnostic advantages.

P-40 CT-guided interventional strategies for the management of intra-/peri-pancreatic collections in pancreatitis S. Kumar, A. Gupta, R. Yadav; Radio-diagnosis, SGPGIMS, Lucknow, India Learning Objectives: To evaluate the role, efficacy and safety of CT-guided transgastric percutaneous drainage (PCD) in cases of intra-/peri-pancreatic collections in pancreatitis. Background: From January 2011 to December 2013, 42 patients with clinical and contrast-enhanced CT (CECT) findings of intra-/ peri-pancreatic collections due to pancreatitis underwent transgastric PCD with the placement of 10-F/12-F locking-loop catheter(s) using the Seldinger technique. Patients were followed up with ultrasonography and CECT during hospital stay and after discharge. Clinical Findings/Procedure: Out of 42 cases, 59.5% were males and 40.5% were females. Catheter deployment was successful in

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40/42 (95.2%). It could not be performed in one case due to multiple vascular channels in the wall of collection and in another because the catheter could not be manipulated across the posterior gastric wall. PCD was performed at an interval of 2–32 weeks after pancreatitis onset (5 cases within 4 weeks and the rest beyond 4 weeks). Outcome on follow-up was clinical and radiological resolution of collection where drainage catheter was placed in 33 (82%) cases. Two cases required catheter upsizing, 6 (15%) required further surgical necrosectomy, and 5 (12.5%) patients died with PCD catheter in situ. Catheter internalization was attempted in 4 cases and successful in 2. Post-procedural complications included pseudocyst infection in 2 cases, bleeding within catheter lumen in 1, and posterior gastric wall erosion in 1; these complications resolved on conservative management. Conclusion: Transgastric PCD is safe and effective, much less invasive than pancreatic necrosectomy, and has become an integral part of the management protocol in pancreatitis-related intra-/peri-pancreatic fluid collections.

P-41 CT-guided transthoracic biopsy of lung mass: technique, complications and factors affecting the occurrence of complications A.R. Aktas, E. Gozlek, B. Degirmenci, M. Kayan, O. Yilmaz, N. Unlu; Interventional Radiology, Süleyman Demirel University Medical Faculty, Isparta, Turkey Learning Objectives: Transthoracic image-guided percutaneous biopsies play an important role in the diagnosis and treatment of thoracic masses. We aimed to investigate transthoracic CT-guided lung nodule biopsy technique and risk factors for the development of complications. Background: CT-guided transthoracic biopsy technique and complications were retrospectively evaluated in 85 patients. In nine patients, the biopsy was repeated because of the clinical requirement. Thus, a total of 94 CT-guided percutaneous transthoracic biopsies were performed: 87 Tru-cut and 7 FNA. Data were analyzed by Chi-square test and independent sample t test. Clinical Findings/Procedure: The pathology results were evaluated as malignant in 54 patients, suspected malignant in 3, benign in 5, and nonspecific in 17. Specific diagnoses were obtained from 59 patients (62.8%) using Tru-cut biopsy, but there was no specific diagnosis using FNA. Twenty-seven patients (28.7%) developed pneumothorax and 8 (8.5%) developed parenchymal hemorrhage during and after the procedure. A significant correlation was observed between the development of pneumothorax and lesion size (p = 0.040) and the length of the parenchyma traversed (p = 0.001). There was significant difference between parenchymal hemorrhage and lesion size and the length of the parenchyma traversed (p = 0.021 and 0.008, respectively). An increased incidence of parenchymal hemorrhage and pneumothorax was observed at small size and deep-seated lesions. Conclusion: CT-guided percutaneous transthoracic needle biopsy has high accuracy rate with respect to the histopathological diagnosis of thoracic masses. Lesion size and the length of the parenchyma traversed on biopsy are the most important factors that influence the development of complications.

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P-42 GPS: guiding procedures safely using navigation systems in interventional radiology M.R. Akhtar1, H. du Preez1, N. Khan2; 1Diagnostic Imaging, Royal London Hospital, London, United Kingdom, 2Cardiology, Calderdale and Huddersfield NHS Foundation Trust, Huddersfield, United Kingdom Learning Objectives: 1. To discuss the uses of navigational systems in interventional radiology-guided biopsy procedures. 2. To review the types and configurations of navigation systems currently available. 3. To discuss the advantages and disadvantages of navigational systems over traditional needle trajectory planning. Background: Biopsy yield is an important measure of performance in interventional radiology. Navigation systems, such as image fusion or optical tracking, offer the potential to overcome factors which can limit yield, such as unpredictable needle trajectory and limited size of a target. We will discuss the different types of navigation systems available, their potential uses and their advantages and disadvantages. Clinical Findings/Procedure: 1. Advantages of the navigational systems include the ability to target smaller lesions and potential to shorten procedure times and radiation exposure. 2. Physiological functions, such as respiratory movement, pose a significant challenge to the use of this technology. 3. An optimal use of navigational systems requires training and expertise. Conclusion: Though not yet part of mainstream radiological practice, navigation systems are a form of rapidly evolving technology with many potential benefits.

Abstract Book Mediastinal – right paravertebral, anterior Pleural – effusion, pneumothorax, empyema Parenchymal – abscess, collection Pericardial – effusion Below the diaphragm: Abdomen and pelvis – transhepatic, transgastric, gastrosplenic, left anterior pararenal, paravertebral, right anterior pararenal, transduodenal, transgluteal, transvaginal, transrectal Subphrenic – subcostal anterior Ascitis Clinical Findings/Procedure: While placing the catheter, care should be take not to traverse the pancreas, spleen, gallbladder, small and large bowel, urinary bladder, uterus, ovaries, prostate, blood vessels, neural foramina, trachea, esophagus, lung and major nerves. Traversing of the liver, stomach and duodenum can be done provided there is no access available. We used the Seldinger technique for all patients. Complications: Ooze – pericatheter Bleeding – hematoma at the puncture site in the skin and subcutaneous tissue or internal bleeding if inadvertent injury to blood vessel Pain – at the site or injury to nerve bundles Injury to bowel Injury to lung – pneumothorax, pleural effusion, empyema Contraindications: Uncorrected coagulation profile Lack of percutaneous access Uncooperative patient Conclusion: Percutaneous image-guided drainage of collection is safe and effective technique through a key hole for the treatment of thoracic, abdominal or pelvic sepsis in postoperative or oncological patients with collection, and major surgery is thus avoided.

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Radiation dosage as a function of lesion and patient morphology in CT-guided liver biopsy

Management of symptomatic lymphoceles after renal transplant: emerging minimally invasive approaches

C. Ahuja, H. Poonawala, M. Chadha; Radiology, Louisiana State University, Shreveport, LA, United States of America

D. Wells1, K. Kondo1, M. Smith1, R. Gupta1, C.E. Ray, Jr.2, J. Durham1, M. Gipson1; 1Radiology, University of Colorado, Aurora, CO, United States of America, 2Radiology, University of Illinois at Chicago, Chicago, IL, United States of America WITHDRAWN

P-44 Pictorial review: percutaneous image-guided drainage procedures K.B. Gala1, S.S. Kulkarni1, N.S. Shetty1, A. Polyana1, A. Kumar2, A. Janu2, S.S. Patil1, V.N. Bakare2, P. Velayutham1, A. Andhare2, M. Thakur 2, U. Zende1, K.U. Gaikwad2; 1Interventional Radiology, Tata Memorial Hospital, Mumbai, India, 2Radiodiagnosis, Tata Memorial Hospital, Mumbai, India

Learning Objectives: To assess CTDI variation with changes in patient weight, lesion depth, and lesion size for CT-guided liver biopsy performed using a single CT scanner. Background: Both lesion and patient characteristics were analyzed, alone and in combination. Clinical Findings/Procedure: Two hundred patients were identified who underwent CT-guided percutaneous biopsy of the liver. Effective radiation dose was calculated for each lesion. This was statistically analyzed as a function of patient weight. Effective radiation dose per lesion was also calculated as a function of lesion size and depth. Conclusion: Significant statistical correlation was observed for effective CT dose and all variables – patient weight, lesion size, and lesion depth.

Learning Objectives: Percutaneous image-guided (ultrasound/CT) drainage (aspiration/catheter) of collection technique for the treatment of patients with cardiothoracic, abdominal or pelvic sepsis in postoperative or oncological patients with collection, thus avoiding major surgery. Background: Various techniques are used for the drainage of the collection under ultrasound or CT guidance depending on the position of the collection. Above the diaphragm:

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Bone, spine and soft tissue intervention

Trans-sternal percutaneous CT-guided needle biopsy for mediastinal and pulmonary lesions: how and when

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H. Fujisawa, K. Matsunari, K. Watanabe, N. Hashizume, T. Kushihashi; Department of Radiology, Showa University Northern Yokohama Hospital, Kanagawa, Japan Learning Objectives: 1. To learn how to access mediastinal and pulmonary masses using trans-sternal computed tomography (CT)-guided coaxial needle biopsy. 2. To evaluate the efficacy and review the technical and clinical outcomes of the procedure. 3. To discuss CT anatomy, indications, technical aspects, and potential complications. Background: CT-guided needle biopsy using trans-sternal approach is used for mediastinal and pulmonary masses that are not safely accessible with parasternal or pulmonary approaches. It will be useful for interventional radiologists to learn this procedure. Clinical Findings/Procedure: This exhibit includes illustrative examples of the procedures, discuss the cases we experienced, and provide a review of the literature. In 12 cases, we performed trans-sternal percutaneous CT-guided needle biopsy. Enough pathologic specimens were taken to obtain pathologic diagnosis in all cases. In no case, we observed critical complications such as injury to major vessels, pneumothorax, mediastinitis, osteomyelitis, and pathologic fracture. In some cases, contrast media was used to clearly distinguish target lesion from vessels. The needle support device was also used in some cases to ensure precise needle placement in the craniocaudal and mediolateral oblique angles. Conclusion: The trans-sternal percutaneous CT-guided coaxial needle biopsy is a safe and effective method for mediastinal and pulmonary masses that are not accessible with traditional approaches.

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Cryoablation of extra-abdominal desmoid tumours: a report of 11 cases G. Tsoumakidou1, J. Garnon1, M.A. Thenint1, J.P. Bergerat2, A. Gangi1; 1Non Vascular Interventional Radiology, University Hospital of Strasbourg, Strasbourg, France, 2Oncology, University Hospital of Strasbourg, Strasbourg, France

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Purpose: To present our experience with image-guided cryoablation of extra-abdominal symptomatic desmoid tumours in 11 patients. Material and Methods: Since 2009, we have treated 11 patients (mean age, 42 years) with desmoid tumours. All patients presented with local recurrence after surgical excision that was refractory to all conventional treatments. Lesions were located in the neck, shoulder, thoracic/posterior abdominal/pelvic wall and extremities. Lesion size ranged from 6.2 to 26 cm. No patient received radiotherapy. Follow-up ranged from 1 to 52 months. Results: We performed 12 cryoablation procedures in 11 patients (1 patient was treated in 2 consecutive sessions). CT guidance was used in 4 cases and MR guidance in 8. In the case of the pelvic wall lesion and due to its proximity to the pelvic organs and sciatic nerve, a combined open surgical and CT-guided approach during the same session was used. Protection of the skin from thermal damage was necessary in all cases. Hydro-dissection of the brachial plexus and radial nerve was used in 2 cases. All patients experienced significant tumour size (>75%) and pain reduction post treatment. One patient had a residual lesion that was retreated successfully. Four patients were treated for residual evolving lesions with NSAIDs, anti-estrogens or anti-angiogenic medications. Complications included skin burn (n=1) and skin necrosis (n=1). Conclusion: Image-guided cryoablation is an alternative for the treatment of extra-abdominal desmoid tumours when conventional treatments have failed. Significant tumour size reduction and symptom regression can be safely achieved.

CT-guided puncture navigated by gyroscope-equipped smartphone

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M. Hirata, H. Tanaka, N. Fukuyama, N. Kawaguchi, T. Mochizuki; Radiology, Ehime University School of Medicine, Toon Ehime, Japan

Doxycycline sclerotherapy in children with lymphatic malformations

We developed a smartphone application to support CT-guided puncture. While holding the smartphone at any angle, this application shows the accurate puncture line by automatically rotating reference CT image. We will report the usefulness of this handy tool with clinical cases.

P-48 Percutaneous abscess drainage of an aortoesophageal fistula after endovascular stent grafting for thoracic aortic aneurysm N. Alishev1, M. Barburoglu1, B. Acunas1, M. Ugurlucan2, U.I. Alpagut2; 1Radiology, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey, 2Cardiovascular Surgery, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey We report the case of a patient with thoracic aortic aneurysm treated with TEVAR in 2006 who developed aortoesophageal fistula that led to abscess formation in the thrombosed aneurysm sac. Due to severe comorbities, percutaneous drainage was performed.

M. Teixidor Vinas1, P.A. Patel2, A.M. Barnacle3, D.J. Roebuck3; 1Interventional Radiology, Saint George’s Hospital, London, United Kingdom, 2Interventional Radiology, Great Ormond Street Hospital, London, United Kingdom, 3Radiology, Great Ormond Street Hospital, London, United Kingdom Purpose: To evaluate the efficacy of doxycycline as a sclerosing agent in children with lymphatic malformations (LM). To determine if localisation or type of LM can predict the efficacy of treatment. Material and Methods: A retrospective study collecting data for patients treated with percutaneous doxycycline sclerotherapy for LM from 2010 to 2013 was performed. Ultrasound allowed classification of patients with LM as macrocystic, microcystic or mixed. Clinical follow-up was used to determine the efficacy of treatment as excellent, satisfactory or poor. Results: In all, 173 doxycycline sclerotherapy procedures in 94 children with LM were included (mean procedures per patient, 1.9 ± 2.1). Mean age was 10.0 ± 8.6 years, and 58% were girls. The most frequent localisation was head and neck (55%), followed by upper limb (14%); 53% were macrocystic LM, and 17% were microcystic. The mean volume of doxycycline used per procedure was 16.7 ± 12.6 mL, and mean dose was 12 ± 12 mg/kg. No clinically significant complications were observed. There was no clinical follow up for 7 patients. An excellent clinical result was observed in 51% of the patients and

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a poor result in 31%, but there was no statistically significant difference between macrocystic, microcystic or mixed groups. Although patients with LM in the head and neck region responded better than other localisations, this was not statistically significant. Conclusion: Doxycycline sclerotherapy treatment is a safe procedure for LM in children. Approximately half of children had an excellent clinical result. It will be important to identify widely accepted outcome measures to support prospective multicentre research.

P-51 Effectiveness of ultrasound-guided platelet rich plasma (PRP) injections after needle tenotomy in the treatment of chronic tendinopathies: a prospective study J.-C. Brichaux; Radiology, Clinique Saint Etienne, Bayonne, France

Abstract Book Surgeons (ASES) scores were assessed at 1 week and at 1, 3, and 6 months after the procedure. Results: Abnormal neovessels were identified at the rotator interval in all cases. No major or minor adverse events were related to the procedures. TAE rapidly decreased nighttime pain scores from 69 ± 12 mm to 29 ± 14 mm at 1 week after the procedure, with further improvement at 1 and 6 months (7 ± 8 mm and 1 ± 4 mm, respectively). ASES score significantly improved from 17.5 ± 4.2 to 41.8 ± 12.2 at 1 month and to 78.2 ± 4.6 at 6 months. Conclusion: Abnormal neovessels were observed at the rotator interval in all patients with frozen shoulder. TAE of this lesion was feasible, effectively relieved unrelenting pain, and restored shoulder function.

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Purpose: To prospectively evaluate the effectiveness of ultrasound (US)-guided needle tenotomy followed by autologous platelet rich plasma (PRP) injection in reducing pain and functional improvement for chronic tendinopathy. Material and Methods: Fifty patients referred for PRP injection with a clinical diagnosis of tendinosis and refractory to conservative therapy for ≥6 months. Inclusion criteria were symptoms of lateral epicondylitis (n=28, group 1), medial epicondylitis (n=4, group 2), Achilles tendinopathy (n=6, group 3) or plantar fasciitis (n=12, group 4). All patients were previously evaluated according to the visual analogue scale (VAS) scores and activity level, and they all underwent US of the tendon before and after PRP injection (4, 10 and 24 weeks). All studies were performed using IU22 Matrix Sonographer (Philips Healthcare) and the PRP injectate was obtained using the SmartPReP 2+ procedure pack (Harvest Technologies). Results: In groups 1, 2 and 3, maximum clinical benefits occurred after 10 weeks and after 14 weeks in group 4. PRP-treated patients reported functional and clinical improvements (pain scores) in respectively 89% (25/28, group 1), 75% (3/4, group2), 83% (5/6, group 3) and 67% (8/12, group 4). Conclusion: Our preliminary results (follow-up of at least 6 months) of US-guided PRP injection after needle tenotomy in epicondylitis and Achilles tendinopathy show significant improvement of clinical symptoms and functional improvements. US-guided PRP injection enables direct targeting of a specific lesion and thus increases the accuracy of the procedure. In all cases, US-guided PRP injection is a safe procedure with no complications.

New robot system Maxio for performing minimally invasive spine interventions with CT S. Zangos, K. Eichler, B. Schulz, E. Mbalisike, C. Czerny, T.J. Vogl; Department of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Johann Wolfgang Goethe, Frankfurt, Germany Purpose: The aim of the study was to evaluate the use of the new robotic system Maxio during spine interventions with CT. Material and Methods: Within a body, 24 pins using the new robotic system Maxio (Perfint, India) were introduced into the pedicles of T2– L5. For this, a CT dataset was acquired in each of the corresponding vertebral body and the planning of the access path was done with the associated workstation using the navigation software. The software of the system automatically positions the guiding arm, and displays the table position to be set. The modified needle holder of the positioning system was then used for the introduction of the pins. The post-interventional CT data were then used to check the accuracy of pin placement. Results: The interventions were technically successfully performed in all cases. The pins could be safely positioned in the pedicles without additional X-rays. The mean planning time with Maxio was 2:53 min and the positioning time of the pin was 2:12 min. Through the use of the robot, a precise guidance of the pins with a mean deviation of 0.85 mm was achieved by the planned access over a distance of 8.06 cm. Also, double-angulated access routes could be easily implemented by the system. Conclusion: The use of the new robot Maxio allows safe percutaneous insertion of the pins into the pedicle, resulting into easier intervention workflow. In particular, the reduction of radiation exposure shows a high potential for further clinical applications.

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Feasibility and effects of transcatheter arterial embolization for frozen shoulder refractory to non-surgical management

Preoperative transarterial embolization of malignant spinal tumors: how does it make a difference?

Y. Okuno; Radiology, Edogawa Hospital, Tokyo, Japan

G. Anil, P. Gahlot, N.S. Kumar, K. Yeong, L. Tan; Diagnostic Imaging, National University Hospital, Singapore, Singapore

Purpose: Neovessels and accompanying nerves are possible sources of pain. Our previous work demonstrated that transcatheter arterial embolization (TAE) for patients with painful tendinopathy and enthesopathy resulted in excellent pain relief. We hypothesized that abnormal neovessels play an important role in frozen shoulder and that TAE can relieve pain associated with this condition. Material and Methods: TAE using imipenem/cilastatin sodium as an embolic agent was performed in ten patients with frozen shoulder. All patients had night shoulder pain and previous conservative therapies applied for at least 3 months and persistent moderateto-severe pain (visual analog scale > 50) before treatment. Adverse events, changes in visual analog scale scores of night pain and overall shoulder pain, and changes in American Shoulder and Elbow

Purpose: To assess the impact of preoperative transarterial embolization of malignant spinal tumors. Material and Methods: Between December 2007 and December 2012, 36 patients underwent preoperative transarterial embolization for malignant spinal tumors. The perioperative blood loss, duration of surgery (DOS, in minutes) and postoperative length of hospital stay (LOS, in days) were compared with that in 62 other patients who underwent similar surgeries without embolization. Embolized and non-embolized patients were stratified according to tumor type and surgery type (I: cervical corpectomy and stabilization, II: thoracolumbar laminectomy/tumorectomy decompression and instrumentation, and III: thoracolumbar corpectomy and stabilization).

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Results: In patients with myeloma/lymphoma, embolization significantly reduced the blood loss (mean difference 1317 ml, p=0.04) and DOS (94.5, p=0.04). Preoperative embolization significantly reduced LOS (38.6, p=0.04) and DOS (212, p=0.03) in patients with spinal metastases from colorectal carcinoma. Meanwhile, for metastases from pulmonary malignancy, embolization significantly reduced DOS (123.1, p=0.009). Embolization reduced LOS and DOS in type II surgery (8.42, p=0.02; 66.8, p=0.02) and DOS in type I surgery. At combined stratification by tumor and surgery type, embolization significantly reduced blood loss (2985 ml, p<0.01) in patients with myeloma/lymphoma undergoing type II surgery. There were no embolization-related major complications.

P-55 Survival and cost comparison of kyphoplasty and percutaneous vertebroplasty using German claims data P. Brasseur1, A. Lange2, S. Braun3; 1Health Economics, Medtronic International, Tolochenaz, Switzerland, 2Center for Health Economics Research Hannover, University of Hannover, Hannover, Germany, 3Claims database analysis, Herescon, Hannover, Germany Purpose: To examine the overall survival and treatment costs from a third payer perspective for patients with osteoporotic vertebral compression fractures (OVCF) treated by vertebral augmentation or conservative treatment in Germany. Material and Methods: Claims data from a major German health insurance fund were used. Mortality risk differences between operated [balloon kyphoplasty (BKP) or percutaneous vertebroplasty (PVP)] and non-operated patients were assessed using Cox regression. Operated patient groups were established by propensity score matching, adjusting for covariates. For the matched operated OVCF patients (2006– 2010), survival was estimated by the Kaplan–Meier method. Results: A total of 598 newly diagnosed OVCF patients were operated out of 3,607 OVCF patients. The operated cohort were 43% less likely to die than non-operated one in the 5-year study period (HR = 0.57; p<0.001). BKP patients had higher 60-month adjusted survival rate (66.7%) than that of PVP patients (58.7%; p = 0.68). Cumulative 4-year mean overall costs after first diagnosis were lower for the BKP cohort. Initial upfront higher costs driven by the surgical treatment for BKP patients were offset by considerable pharmacy costs in PVP patients. Differences were found for painkiller consumption (PVP: €3,321 vs. BKP: €2,224). Conclusion: Results suggest a higher overall survival for the operated patients than the non-operated OVCF patients, and indicate a potential survival benefit for BKP compared with PVP. The reasons merit further investigation. Total costs after 4 years were lower for patients who received BKP than those who received PVP due to lower consumption of pharmaceuticals.

P-56 Technical outcome, complications and effective patient dose of percutaneous CT fluoroscopy-guided screw placement for the fixation of unstable injuries of the posterior pelvic ring F.F. Strobl1, S.M. Haeussler1, P.M. Paprottka1, R.-T. Hoffmann2, T.A. Sandner1, M.F. Reiser1, C.G. Trumm1; 1Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital Munich, Munich, Germany, 2Inst. u. Pk. f. Radiologische Diagnostik, Medizinische Fakultät Carl-Gustav-Carus, TU Dresden, Dresden, Germany WITHDRAWN

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P-57 Transcatheter arterial embolization as a treatment for mild-tomoderate knee osteoarthritis Y. Okuno; Radiology, Edogawa Hospital, Tokyo, Japan Purpose: Osteoarthritis is a common cause of pain and disability. The management of knee osteoarthritis that is resistant to non surgical options and not severe enough to warrant joint replacement is challenging. Based on the hypothesis that neovessels and accompanying nerves are possible sources of pain, we previously reported that transcatheter arterial embolization (TAE) for chronic painful conditions resulted in excellent pain relief. We hypothesized TAE can relieve pain associated with knee osteoarthritis. Material and Methods: TAE for mild-to-moderate knee osteoarthritis using imipenem/cilastatin sodium or 75-μm calibrated microspheres (Embozene) as an embolic agent was performed in ten and three patients, respectively. We assessed adverse events and changes in Western Ontario and McMaster University Osteoarthritis Index (WOMAC) scores. Results: Abnormal neovessels were identified at soft tissue, including synovium and fat pad surrounding knee joint, in all cases. No major adverse events were related to the procedures. Transcatheter arterial embolization rapidly improved WOMAC pain scores from 11.7 ± 1.9 to 4.6 ± 2.5 at 1 week after the procedure, with further improvement at 1 and 4 months (3 ± 1.7 and 1.7 ± 1.8, respectively) and WOMAC total scores from 47.3 ± 5.8 to 19.9 ± 10.7 at 1 week and to 6.7 ± 5.9 at 4 months. These improvements were maintained in all patients at the final follow-up examination at a mean of 12 ± 5 (range, 4–19) months. Conclusion: TAE for mild-to-moderate knee osteoarthritis was feasible, rapidly relieved unrelenting pain, and restored knee function.

P-58 Vertebral augmentation with titanium T6 endoprosthesis: a preliminary experience E. Piras, S. Marini, S. Marcia; Radiologia - P.O. SS. Trinità, ASL Cagliari, Cagliari, Italy Purpose: The aim of this study was to evaluate the effectiveness of a titanium vertebral augmentation system for the treatment of painful vertebral compression fractures. Material and Methods: Twenty-one consecutive patients (6 males, 15 females; average age, 74.9) with painful vertebral compressive fractures underwent titanium vertebral augmentation system procedure. Patients had been previously evaluated with clinical examination and X-Ray, CTms and MRI-T2wSTIR. All procedures were performed under local anaesthesia and bilateral approach under digital fluoroscopic guidance. A total of 23 vertebras were treated. Clinical evaluation and the assessment of pain using an 11-point visual analogue scale (VAS, 0–10) and of functions using the Oswestry disability scale (ODI, 0–100%) were performed at baseline and at 1 month after the procedure. Height restoration using volume calculation with CTms as well as the Cobb angle was performed before and after the procedure. Results: We obtained a progressive reduction in pain in all patients (mean VAS pre: 8.3, post 2.7; difference: 5.6), an improvement of function (ODI baseline: 56%, at 1 month: 24%; difference: 32%), a good restoration of height (mean height pre: 11.3 mm, post: 16.7 mm; difference: 5.4 mm) and a good increase of the volume of the vertebral bodies (mean volume pre: 13.74 cm3, post: 22.42 cm3; difference: 8.68 cm3). The Cobb angle increased 3.6°. No major complications or device migration was noted. Conclusion: From our preliminary studies, the implant of vertebral

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augmentation with titanium T6 endoprosthesis resulted to be safe and effective for the treatment of painful vertebral compression fractures, providing pain relief and anatomical restoration.

P-59 Botulinum toxin is not just for cosmesis: a review of applications M.-G. Knuttinen1, J. Karrow1, J. Minocha1, J.T. Bui1, R.C. Gaba1, C.E. Ray, Jr.2; 1Radiology, University of Illinois Hospital and Health Sciences System, Chicago, IL, United States of America, 2Radiology, University of Illinois at Chicago, Chicago, IL, United States of America Learning Objectives: 1. To describe the mechanism for botulinum toxin (BTX-A) in the treatment of excessive salivation. 2. To describe the indications, contraindications and potential side effects of Botox injection into the salivary glands. 3. To present illustrative cases on the successful use of Botox in hypersalivation states. Background: Excessive salivation, or drooling, as a consequence of swallowing impairments either due to pharyngeal muscle weakness or neurological disorders is a disabling condition that contributes to poor quality of life. The parotid, submandibular and sublingual glands contribute 90% of all salivary production. Systemic anticholinergic agents are the standard first-line treatment, but they are often ineffective and can lead to significant systemic side effects. Injection of BTX-A can be used as a safe and effective treatment for excessive salivation. Clinical Findings/Procedure: Intraglandular injection of Botox is frequently performed under ultrasound guidance. Local injections of Botox reconstituted with 0.9% sodium chloride was performed in several unique cases of hypersalivation, including chronic sialadenitis from an impacted parotid ductal stone, a salivary gland fistula following parotid gland surgery and the neurologic disorder amyotrophic lateral sclerosis. A review of the technique and follow-up is described in this exhibit. Conclusion: Local intraglandular injection of Botox into the major salivary glands leads to a significant reduction of salivary flow. This technique is safe and effective and should be considered in a variety of pathologies causing excessive salivation.

P-60 Distension arthrography in the treatment of adhesive capsulitis of the shoulder M. Golli1, A. Zrig1, M. Cheguirim2, W. Mnari1, M. Maatouk1, B. Hmida1, W. Harzallah1, R. Salem1, M. Zrig3; 1Radiology, CHU Fattouma Bourguiba University of Monastir, Monastir, Tunisia, 2Rhymatology, CHU Fattouma Bourguiba University of Monastir, Monastir, Tunisia, 3Surgery, CHU Fattouma Bourguiba Monastir, Monastir, Tunisia Learning Objectives: 1. To describe the technical approach of distension arthrography of the glenohumeral joint in the treatment of 50 adults with adhesive capsulitis (AC) of the shoulder. 2. To discuss the mechanism of action and long-term clinical results of the distension arthrography for AC. Background: Primary AC is characterized by spontaneous onset of shoulder pain accompanied by progressive loss of both active and passive range of motion. More than 2% of the general population is known to have the disease. Magnetic resonance imaging may show characteristic findings. Nonsurgical treatments include analgesics, oral prednisone, and intra-articular corticosteroid injections. Home exercise regimens and physical therapy are often prescribed. Surgical treatments include manipulation of the joint under anesthesia and capsular release.

Abstract Book Clinical Findings/Procedure: Between 2011 and 2013, we have explored and treated with capsular distension 50 patients with primary AC in only one shoulder. We excluded patients with rotator cuff tear or rheumatic disease and those who had received a steroid injection or undergone previous shoulder surgery in the affected shoulder. Under fluoroscopic guidance with intra-articular contrast injection, the diagnosis of AC was confirmed in all cases. Capsular distension was obtained by intra-articular injection of a 25-mL mixture of 1% lidocaine, corticosteroid (Altim*), and saline solution. The rupture was confirmed by the leakage of contrast outside the capsule. The success rate of the procedure was 80%. Conclusion: Arthrographic distension of the constricted capsule appears to be an excellent therapeutic intervention to achieve rapid symptomatic relief from AC.

P-61 Facet joint syndrome: the role of the radiologist from diagnosis to treatment H. Brat1, T. Tancredi1, D. Fournier1, T. Bouziane2; 1Radiology Department, Institut de Radiologie de Sion, Sion, Switzerland, 2Centre Radiologique de Tournai, Tournai, Belgium Learning Objectives: 1. To understand the complexity of facet joint syndrome. 2. To differentiate facet joint-related pain and disability from other causes. 3. To use appropriate diagnostic modalities. 4. To propose an age-related management algorithm for back pain. 5. To appreciate treatment options for facet joint syndrome. Background: Facet joint-related back pain and disability often reflect a combination of mechanical, inflammatory and neuropathic processes, and represent a diagnostic and therapeutic challenge. The lifetime prevalence is estimated at 60–70% in industrialised countries with an average incidence of 5% per year. Clinical Findings/Procedure: Related to facet joint syndrome, this exhibit presents the following: - Main causes, red and yellow flag signs, risk factors, physiopathology and clinical symptoms with their spine and non-spine differential diagnosis - Diagnostic options, including physical examination, pain and disability evaluation, facet block, SPECT/CT and MRI - Current treatment options from conservative to invasive that including the following: * an age-related management algorithm * physical treatment * medication strategy * radiofrequency CT-guided neurotomy * multidisciplinarity and follow-up of the patient Conclusion: This exhibit allows - a better understanding of facet joint-related pain - choosing the correct evaluation methods and diagnostic imaging modalities - understanding current treatment options with their limitations and success rates

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P-62 Percutaneous radiofrequency thermoablation of osteoid osteoma: how I do it M. Golli, M. Zrig, A. Zrig, W. Mnari, M. Maatouk, B. Hmida, W. Harzallah, R. Salem; Radiology, CHU Fattouma Bourguiba University of Monastir, Monastir, Tunisia Learning Objectives: To describe the steps of radiofrequency ablation (RFA) in osteoid osteoma (OO) and to discuss the benefits and disadvantages of RFA versus traditional open surgery. Background: OO is the third-most-common benign bone neoplasm after osteochondroma and nonossifying fibroma. The classic presentation is pain that is worse at night and ameliorated by nonsteroidal anti-inflammatory drugs. Computed tomography is the imaging modality of choice for visualisation of the nidus and treatment planning. Therapies include surgery with local excision, percutaneous CT-guided cryotherapy and RFA. Clinical Findings/Procedure: The method we use may be summarised in the following ten steps: 1) epidural or general anaesthesia, 2) lesion localisation, 3) approach planning, 4) placement of grounding pads, 5) skin entry with bone biopsy system, 6) superficial bone entry and drilling, 7) needle biopsy of the nidus, 8) cannula and probe placement, 9) electrode connection and 10) radiofrequency thermal ablation. The procedure was performed in approximately 60 minutes. Clinical success was obtained in 90%. Conclusion: Computed tomography-guided percutaneous RFA is a highly effective, efficient, minimally invasive and safe method for the treatment of OO.

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Conclusion: Preoprative transarterial embolization of vertebral tumors makes vertebral body procedures safer and reduces intraoperative blood loss. Correct knowledge of this procedure, including its indications and proper technique, leads to a good clinical outcome with a low rate of complications.

P-64 Aneurysmal bone cyst of the cervicothoracic spine treated with cryoablation J. Griauzde, J.J. Gemmete, V. Vadlamudi; Department of Radiology, University of Michigan Health System, Ann Arbor, MI, United States of America A 13-year-old female presented with back pain. She was diagnosed with a biopsy-proven aneurysmal bone cyst extending from the posterior elements of C6 to T1. This was treated with embolization followed by cryoablation, and the patient’s symptoms resolved.

P-65 C-arm CT robotic-guided sclerotherapy of an aneurysmal bone cyst using a 2-needle technique G. Widmann, P. Schullian, R. Bale; Department of Radiology, Innsbruck Medical University, Innsbruck, Austria A rotational C-arm CT and an interventional trajectory alignment robot are used for percutaneous sclerotherapy of a 32 × 15-mm aneurysmal bone cyst in the left humerus in a 10-year-old boy using two 16-G coaxial needles.

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Preoperative embolization of spinal tumors

Diffusion-weighted MRI demonstrates partial tumor response following palliative embolization of extra-axial plasmocytomas

T. Dionísio1, B. Gonçalves1, H. Duarte2, A. Machado Carvalho3, M.J. Sousa1; 1Interventional Radiology, IPO Porto, Porto, Portugal, 2Radiology, IPO Porto, Porto, Portugal, 3Neurosurgery, IPO Porto, Porto, Portugal Learning Objectives: 1. To summarize the main indications and advantages of this procedure. 2. To describe the technique of vertebral embolization. 3. To recognize possible complications and discuss how to avoid them. Background: Spinal destruction or lysis caused by neoplasic lesions can lead to mechanical instability, intractable pain, radiculopathy, and cord compression symptoms, strongly affecting patients’ quality of life. Vertebral spread occurs in 30–70% of metastatic tumors, most commonly from primary tumors of the breast, kidney, lung, and prostate, sometimes presenting as hypervascular lesions. Primary tumors occur less frequently. These metastases can be treated surgically using corporectomy and vertebral body replacement. However, these procedures have the risk of massive intraoperative blood loss, because tumorous vertebrae show much more vascularization than normal vertebrae, especially metastases from the kidney and thyroid carcinoma. This can lead to life-threating hemorrhage and massive blood transfusions if preoperative embolization is not performed. Preoperative transarterial embolization of spinal tumors reduces bleeding complications. Clinical Findings/Procedure: A review of preoperative transarterial embolization performed for vertebral primary and secondary tumors is presented along with step-by-step description of the procedure. The following are reported: tumor location, histological diagnosis, number of embolized arteries, whether complete or partial embolization was performed, and the respective clinical outcomes.

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P.N. Kaposi1, G. Mikala2, L.R. Kozák3, T. Györke4, I. Kalina1, G. Rudas3, V. Bérczi1; 1Radiology and Oncotherapy, Semmelweis University, Budapest, Hungary, 2Haematology, St. László Hospital, Budapest, Hungary, 3MRI Research Center, Semmelweis University, Budapest, Hungary, 4Nuclear Medicine, Semmelweis University, Budapest, Hungary We performed palliative embolization of plasmocytomas, which had been unresponsive to radiation and chemotherapy. The shoulder and rib lesions were embolized with PVA. Both patients reported improvement of symptoms following embolization. Diffusionweighted MRI and CT demonstrated partial therapeutic response.

P-67 Kummell’s disease treated with vertebroplasty  H.-D. Zhu, G. Deng, S.-C. He, G.-J. Teng; Department of Radiology, Zhongda Hospital, Southeast University, Nanjing, China An old woman with Kummell’s disease (T6, T7, T8) underwent vertebroplasty, during which pathologic motion in T7 was found to coincide with breathing and bone cement was found to leak from T7 to T6. Pathologic motion disappeared and pain was relieved rapidly.

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P-68 Percutaneous radiofrequency ablation of osteoblastoma of the C2 vertebra in a 7-year-old girl A.A. Nassef, H.G. Khira; Diagnostic and Interventional Radiology, Cairo University, Cairo, Egypt A 7-year-old girl with an 11-mm, painful, expanded mass in the right lateral C2 vertebra, diagnosed as osteoblastoma, was treated with RFA leading to complete pain relief without post-procedure sensorimotor neurological deficit. She was pain-free at 6-month follow-up.

Clinical practice development P-69 Assessing patient awareness of interventional radiology D. Heister1, E. Olson1, K. Richman1, I. Newton2; 1Department of Radiology, University of California San Diego, San Diego, CA, United States of America, 2Department of Radiology, Veterans Affairs Hospital, La Jolla, CA, United States of America Purpose: We hypothesize that a lack of patient awareness of interventional radiology (IR) may result in patients’ favoring surgery over unfamiliar minimally invasive IR procedures (MIIP) despite the lower associated risks and faster recovery time of the latter. If true, then public education campaigns and practice changes to increase IR physician visibility could improve patient desire for MIIP and subsequent outcomes. Material and Methods: Outpatients in the UCSD Radiology Department waiting room received surveys to assess patient familiarity with and impression of IR, preference of MIIP versus open surgery, and familiarity with IR physician expertise (N=80; 53% females, 29% males, 19% no response; aged 53.1 ± 18.3 years, 19% no response). Results: Only 35% of patients surveyed were familiar with IR; of them, 57% had a positive impression and 39% had a neutral or no impression of IR. Of the 11% of patients presenting for an IR procedure, 63% had a positive impression of IR. Of the 84% of patients presenting for imaging procedures, only 17% had a positive impression of IR and 77% had a neutral or no impression of IR. Information about IR physician training made 71% of all patients more confident in their expertise. Moreover, 75% of all patients would consider a MIIP if recommended by their primary physician. Conclusion: Despite a general lack of awareness of IR and MIIP options, most patients in our study would prefer MIIP to surgery, especially if recommended by their primary physician. These data suggest that efforts to increase public awareness about IR could improve patient access to MIIP.

P-70 Experience with clinical skills-based simulation and a process for improvement E.J. Hohenwalter, S.B. White, P.J. Patel, M. Mulligan, R.A. Hieb, S.M. Tutton, W.S. Rilling; Radiology, Medical College of Wisconsin, Milwaukee, WI, United States of America Purpose: Technical simulation is an established model in IR; however, with the increasing emphasis of clinical IR, clinical simulation may also have an important role in the fellowship training. We have developed and implemented a fellowship clinical simulation program for the past 4 years. Our purpose is to share lessons learned from an analysis of this simulation curriculum.

Abstract Book Material and Methods: Beginning in 2010, we piloted two clinical skills-based objective structured clinical evaluation (OSCE) simulations. This was expanded in 2011 to 4 clinical OSCEs (2 clinical assessment-based; 2 clinical communication-based), and again in 2012 to two repetitions of the 4 OSCEs. As a part of a larger improvement process, retrospective evaluation was performed via a survey with past fellows, with analysis conducted by an IR faculty and a PhD educator. Results: Analysis showed that clinical scenarios contributed to IR education. Of particular importance was the feedback that the clinical communication-based OSCEs permitted learning in a controlled setting with critique from experienced faculty and experienced standardized patients (SP). Additionally, process and structural improvements were identified and integrated into OSCE cases to mirror clinical experiences. Conclusion: Training fellows in clinical IR is crucial. Training in the clinic about interactions with patients in the IR department is important but can be inadequate. Our clinical simulation program has improved fellow education by enhancing their confidence and communication skills. The important lessons we have learned may benefit other programs considering a clinical simulation curriculum.

P-71 Exploring attitudes towards the Cancer And Venous Access (CAVA) study – a qualitative study of patient and clinical staff attitudes to venous access devices for the delivery of long-term chemotherapy and participation in randomised controlled trials M. Ritchie1, J.G. Moss2, R. Shaw1; 1Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom, 2Department of Radiology, North Glasgow University Hospitals, Gartnavel General Hospital, Glasgow, United Kingdom Purpose: The CAVA study is the first randomised controlled trial to compare three venous access devices for chemotherapy delivery. The pre-trial qualitative research was carried out to deliver tailored recruitment strategies and materials in order to maximise recruitment to the study. Material and Methods: Focus groups with patients and interviews with clinical staff examine attitudes towards the three devices, views on equipoise and barriers to trial participation and randomisation. Interviews and focus group discussions were digitally recorded, transcribed verbatim, anonymised, uploaded to the QSR NVivo10 qualitative software programme and thematically analysed. Results: Clinical staff interviews revealed the following themes: getting the staff on board, suitability of devices, logistics of device insertion and experience and training. Consequently, several interventions have been implemented, including defining the role of a trial ‘Champion’, undertaking a service review of device insertion appointments, modifying trial materials to aid visibility and reviewing education and training. Analysis of focus group interviews highlighted cancer patients’ desire to be informed about research, preconceptions regarding the devices, pain and discomfort, fear of stigma and the need to avoid disruption to daily life and retain control. This analysis will allow clinical staff to elicit and address patients’ concerns and counsel potential participants on the impact of the three devices. Conclusion: The pre-trial qualitative research has allowed study personnel to anticipate and address practical and logistical issues that are likely to negatively impact on recruitment in a timely fashion, to allow recruiters to clearly identify patient concerns and to present equipoise and randomisation consistently, ensuring informed consent.

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P-72 Islet cell transplantation: investigation of technique and postoperative complications in Newcastle upon Tyne A. Zahed1, R. Jackson2; 1Medical School, University of Bristol, Bristol, United Kingdom, 2Department of Interventional Radiology, Freeman Hospital, Newcastle upon Tyne, United Kingdom Purpose: Islet cell transplantation (ICT) is a minimally invasive procedure which involves the infusion of purified donor islet cells into the recipient’s portal venous system under fluoroscopic guidance. The primary aim is to reduce the symptoms of severe hypoglycaemia in patients with type 1 diabetes. This has several advantages over whole pancreas transplantation such as reduced rates of re-intervention. The primary aim of this study was to evaluate the safety of the procedure by looking at post-ICT complications and observe if any correlation exists between technique/equipment employed. Material and Methods: A full list of 14 patients and 23 transplant procedures obtained from departmental records. Archived procedural sheets were investigated for each transplant to ascertain the equipment used. The PACS Infinitt© system was used to review abdominal imaging results. Full blood counts and coagulation screens were also analysed on the Diadem © system. Results: There were 2 cases of haematoma and no cases of portal venous thrombosis on post-operative ultrasound. Portal pressure changes were common (12/22 recorded cases) with an average increase of 1.1 mmHg (range 0–3 mmHg). There was no relationship between technique and complications. Five of 14 patients developed hepatic steatosis, but the significance of this is unknown. Conclusion: This study demonstrated that certain complications can occur post-ICT. The development of specific patient selection criteria and reviewing the pre-operative protocols may be useful in limiting these. Larger, national studies need to be performed to assess if there is a true link between procedural methodology and complications. This in turn will help construct uniform guidelines for ICT.

P-73 Role of interventional radiology in trauma care: a single-center experience N.Y. Yim1, H.O. Kim1, J.K. Kim1, Y.T. Kim2, Y.J. Kang1, S.H. Kim1; 1Radiology, Chonnam National University Hospital, Gwangju, Korea, 2Radiology, Mokpo Hankook Hospital, Mokpo, Korea Purpose: Although interventional management is now regarded as essential in trauma care, its effect on clinical results remain uncertain. We conducted this retrospective study to determine the role of interventional management in trauma care. Material and Methods: Medical records of patients who were enrolled in the trauma database of our trauma center were reviewed for the period of January 2009–December 2012. During this period, we evaluated the number of interventional procedures conducted and the clinical effect of interventional procedures on trauma care. Results: On the basis of our institutional trauma database, medical records of 2,170 patients were reviewed (m:f = 1475:542; mean age, 50.03 years). Their mean Injury Severity Score (ISS) was approximately 26.28. In all, 110 patients were treated with interventional procedures. The number of interventional procedures increased significantly over time up to 15% (p<0.005). During the same period, the overall survival rate did not show a significant change. The survival rate of the patients treated with interventional procedures for traumatic vascular injuries was higher than the estimated possibility of survival (86.4% vs. 65.59%). Conclusion: The need for interventional procedure in trauma care is increasing. Although interventional procedures did not affect the

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overall survival rate in trauma care, they appeared to remarkably improve the survival rate in patients with traumatic vascular injuries.

P-74 Safety and effectiveness of Wirsung duct percutaneous interventions – drainage, endoluminal biopsy, balloon dilatation, stenting, endoluminal RFA and stenting and balloon-assisted percutaneous descending litholapaxy (BAPDL) M. Mizandari1, N. Habib2; 1Diagnostic and Interventional Radiology, Tbilisi State Medical University, Tbilisi, Georgia, 2Division of Surgery, Oncology, Reproductive Biology & Anaesthetics, Imperial College London, London, United Kingdom Purpose: The techniques of Wirsung duct percutaneous interventions are outlined. Material and Methods: In all, 16 patients were analysed: 9 with pancreatic tumor, 6 with pancreatitis (2 with wirsungolithiasis and 1 with pancreas divisum) and 1 with papilla of Vater tumor. Percutaneous drainage was performed in all patients: endoluminal biopsy in 1, balloon dilatation in 1, stenting in 1, endoluminal RFA and stenting in 4 and BAPDL in 2. Drainage procedure was performed using the guidewire technique under combined ultrasound and fluoroscopy (n=9) or CT and fluoroscopy (n=7) guidance. All other procedures were performed under fluoroscopy guidance. Endoluminal biopsy was performed using 5-Fr endobiliary forceps biopsy set. Balloon dilatation was performed using conventional technique applying 6–10-mm balloons. Endoluminal RFA and stenting was performed using 5-Fr novel RF endoluminal device and 6-mm metal stent. BAPDL was performed by original technique using 6–10-mm balloons. Results: Adequate pancreatic duct drainage was achieved in all cases; Wirsung duct dilation-related problems (pancreatitis and hyperglycemia) showed significant improvement shortly after the drainage. Wirsung duct patency restoration procedures were effective in 7 of 8 cases; no procedure-related complications were detected. Conclusion: The wide spectrum of percutaneous Wirsung duct interventions might be safely applied to selected patients when adequate imaging guidance and devices are used. The safety key point for pancreatic duct patency restoration is the pancreatic duct drainage, performed in advance. Pancreatic duct interventions should be routinely included in the list of probable treatment options.

P-75 Vascular intervention in trauma: a teaching hospital experience H. Cliffe1, J.V. Patel1, D.O. Kessel2, A.A. Nicholson3, C.J. Hammond4, S.J. McPherson3, S. Puppala5, K. Flood2; 1Leeds General Infirmary, Radiology Academy, Leeds, United Kingdom, 2Department of Radiology, St. James’s University Hospital, Leeds, United Kingdom, 3Department of Radiology, Leeds General Infirmary, Leeds, United Kingdom, 4Department of Vascular Radiology, Leeds General Infirmary, Leeds Teaching and University Hospitals NHS Trust, Leeds, United Kingdom, 5Vascular Radiology, Leeds Teaching Hospitals, Leeds, United Kingdom Purpose: Leeds General Infirmary (LGI) is a city centre teaching hospital, which became a Major Trauma Centre in 2013. This study aims to assess the volume, nature, efficiency and outcomes of vascular intervention in trauma at LGI from 2009 to 2011. Material and Methods: Using the Computerised Radiology Information System (CRIS), trauma scans performed at LGI from 2009 to 2011 were reviewed. Records were analysed for vascular injury

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and intervention. In vascular intervention cases, subsequent imaging and online patient management system entries were assessed for the type and timing of intervention, outcome, complications and discharge date. Results: In all, 770 trauma scans were performed; 137 demonstrated a vascular injury. Thirty-one patients (age range, 16–91 years; median age, 55 years; 65% males, 35% females) underwent diagnostic and/or therapeutic vascular intervention; in them, the mechanisms of trauma included road traffic accident (46%), pedestrian hit by vehicle (19%) and fall from height (19%). Median time to intervention was 120 minutes. Only 4 patients commenced intervention within 1 hour of CT. Intervention was most commonly performed for splenic (34%) and pelvic (28%) arterial bleeding. Two patients (6%) returned to interventional theatre for successful re-embolisation. Five (16%) post-procedure deaths occurred, unrelated to the intervention. Median duration of stay was 34 days. Conclusion: This study demonstrates the important role of vascular intervention in trauma. We hope to provide focus for improvement as LGI gains experience as a Major Trauma Centre. Only 13% of cases demonstrated commencement of intervention within 1 hour of CT. Further investigation of delays may help to improve future vascular intervention in trauma.

P-76 Vessel catheterization with the new steerable microcatheter Direxion compared with standard microcatheters: a prospective preclinical trial of safety and effectiveness O. Dudeck; Radiology and Nuclear Medicine, University Hospital Magdeburg, Magdeburg, Germany Purpose: To assess the potential of a new steerable microcatheter in a comparative preclinical trial. Material and Methods: A total of 100 small target vessels of the lower limbs with a maximum diameter of 3 mm were prospectively randomized to catheterize with either a steam-shaped RenegadeTM (Boston Scientific, Natick, USA) or a preshaped steerable DirexionTM microcatheter (Boston Scientific) in a porcine model. Catheterization was first performed together with a microguidewire (FathomTM; Boston Scientific) and later wirelessly as well. Results: No significant differences were found for the mean vessel diameter catheterized with either the Renegade (1.62 ± 0.43 mm; n = 50) or Direxion (1.53 ± 0.44 mm; n = 50; p = 0.350) microcatheter. Guidewire-assisted catheterization was successful in all target vessels, but access was achieved in most cases using the guidewire. Whenever it became necessary to steer with the angled tip of Direxion, this was found to be very helpful in order to obtain vessel access. Guidewire-less vessel catheterization was significantly more successful in the Direxion group (88%; n = 44) than in the Renegade group (32%; n = 16; p < 0.0001). Guidewire-less catheterization with Direxion was also significantly faster in terms of mean fluoroscopy time (14.6 ± 14.7 s vs. 110.6 ± 62.8 s; p < 0.0001) as well as mean catheterization time (16.1 ± 14.4 s vs. 122.4 ± 59.0 s; p < 0.0001). Conclusion: The Direxion microcatheter demonstrated unique steerability characteristics, which makes it a promising new tool especially for complex coaxial endovascular procedures.

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P-77 Sciatic nerve block to facilitate lower limb endovascular revascularisation  S. Quigley1, I. Reed2, K. Khanna1, T. Egan1, D.E. Low1; 1Radiology, Barts Health NHS Trust, London, United Kingdom, 2Anaesthetics, Queen Victoria Hospital, London, United Kingdom Learning Objectives: 1. To understand the principles behind regional anaesthesia 2. To appreciate the role of sciatic nerve block in critical limb ischaemia 3. To learn the techniques behind ultrasound-guided anterior and popliteal sciatic nerve block 4. To appreciate the potential impact of regional anaesthesia on patient safety and satisfaction and unit productivity Background: Regional anaesthesia is increasingly used across surgical specialties. It enables treatments to be offered to patients who would otherwise be medically unfit, and allows adequate analgesia in groups with severe comorbidities without resorting to general anaesthesia. Anaesthetic practice is trending towards the use of regional anaesthesia whenever possible. Clinical Findings/Procedure: Lower limb vascular interventions, in particular critical limb revascularisation, can be performed safely following sciatic nerve block. This improves complicance in patients with severe rest pain during often prolonged procedures and also facilitates pedal access in chronic total occlusions where antegrade access has been unsuccessful. Sciatic nerve block reduces requirements for opiate analgesia and obviates the need for general anaesthesia in patients in whom typical risk factors render these options undesirable. Regional anaesthesia using ultrasound guidance is a skill which is easily learned by interventional radiologists. It maximises resource and staff utilisation as well as patient throughput by reducing the need for anaesthetic staff support or nurse-led sedation. Conclusion: Sciatic nerve block is safe and useful in providing analgesia and facilitating endovascular revascularisation procedures in patients in whom sedation or general anaesthesia is undesirable due to comorbidities. Furthermore, it allows better use of existing resources and reduces demands on anaesthetic staff.

P-78 Direct puncture embolization under CBCT guidance of postoperative chylous leakage C. Floridi1, W. Prevoo2, F. Piacentino3, M. Petrillo4, G. Carrafiello3; 1Radiology Department, Interventional Radiology Unit, Varese, Italy, 2Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, Netherlands, 3Radiology, University of Insubria, Varese, Italy, 4Radiology, Second University of Naples, Naples, Italy We present a case of percutaneous embolization of chylous fistulas occurring after neck surgery. After lymphography demostrated chylous leakage, we performed direct puncture embolization under CBCT guidance using XperGuide navigation, which led to a cessation of the leakage.

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Dialysis intervention and venous access P-79 Radiation risk and role of routine chest X-ray after ultrasound and fluoroscopy-guided central venous portcatheter implantation V. Chovanec1, M. Rek1, O. Renc1, J. Raupach1, P. Zak 2, L. Slovacek3, R. Malý4, A. Krajina5; 1Radiology, Faculty Hospital, Hradec Králové, Czech Republic, 2Haematology, Faculty Hospital, Hradec Králové, Czech Republic, 3Oncology, Faculty Hospital, Hradec Králové, Czech Republic, 4Department of Cardiovascular Medicine I, University Hospital, Hradec Králové, Czech Republic, 5Department of Radiology, University Hospital, Hradec Králové, Czech Republic Purpose: The aim of this retrospective study is to evaluate procedural radiation risk and to determine whether postprocedural chest X-ray is mandatory after ultrasound and fluoroscopy-guided central venous portcatheter insertion. Material and Methods: From January 2013 to Decebr 2013, 511 patients (286 males, 225 females, age from 20 to 86 years, median 64 years) underwent 514 procedures under sonograhic and fluoroscopic guidance. Indications for central venous portcatheter implantation were solid tumor in 424 patients, hematologic malignancy in 81 patients and non-malignant disease in 9 cases. Postoperative chest X-ray was available in 485 patients. Radiation dose measurements were generated automatically by the interventional angiography units or digital radiography units and statistical analysis was performed. Results: The procedure was successful in all patients. There was no pneumothorax detected on the postprocedural chest X-ray. The port chamber caudal migration and catheter dislocation to the brachiocephalic vein was seen in 8 cases (1.6%) and one patient suffered from large pocket hematoma. The findings on the chest X-rays did not lead to port system extraction or exchange. Fluoroscopy during central venous port system insertion respective postprocedural chest X-ray produced exposition of patient to a median DAP (dose area product) 919 mGycm2 respective 175 mGycm2. The difference was statistically significant (p< 0.001). Conclusion: Sonography and fluoroscopy-guided central venous portcatheter implantation is safe method with 100% technical succes rate. There was statistically significant higher radiation dose compared to chest X-ray in our series. Routine use of postprocedural chest X-ray seems to be redundant.

P-80 Randomised trial comparing Hickman lines with ports for chemotherapy: a pilot study to inform a larger trial J.G. Moss1, R. Kasthuri2, J. Paul3, O. Wu4, E. McCartney3, M. Ritchie4, J. Dixon3; 1Department of Radiology, North Glasgow University Hospitals, Gartnavel General Hospital, Glasgow, United Kingdom, 2Radiology, Gartnavel General Hospital, Glasgow, United Kingdom, 3Oncology, Cancer Research UK, Glasgow, United Kingdom, 4Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom Purpose: Centrally inserted venous access devices are commonly used for chemotherapy. It is unclear which is most effective from a clinical or cost perspective. Material and Methods: This trial gathered data to inform the design of a larger randomised trial. Hundred patients requiring a venous access device for chemotherapy were randomised from a single UK site: 74 to a Hickman line and 26 to a port. The primary endpoint was complication rate. Secondary endpoints included chemotherapy interruption and device removal rates.

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Results: Seventy-three patients received a Hickman line, and 24 received a port. The study arms were well matched at baseline. Outcome data were available for the 97 patients receiving a device; no patients were lost to follow-up. Thirty-five (47%) Hickman patients and seven (27%) port patients suffered one or more complication (p = 0.044). The most frequent complication in the Hickman arm was bloodstream infection (BSI) accounting for 23 (46%) of 50 complications. There were no BSIs in the port arm. Line occlusions were the most common complication in the port arm accounting for 9 (64%) of 14 complications. Of the devices removed, 17 (32%) and 1 (9%) were removed due to complication in the Hickman and Port arms, respectively. A pilot device-specific questionnaire indicated favourable results for 12 of 16 questions. The EQ-5D data from a health economic perspective showed ports to be associated with lower costs but fewer QALYs than Hickman lines. Conclusion: Ports appear to be more cost effective. A larger trial is needed to confirm these preliminary findings.

P-81 Thromboaspiration of arteriovenous hemodialysis graft thrombosis using Desilets-Hoffman sheath: a single-center experience D.E. Goo1, S.B. Yang2, Y.J. Kim1, W.-H. Lee3, J.M. Lee4, D. Song5, S.C. Yoon5; SoonChungHyang University, Seoul, Korea, 2Radiology, SoonChungHyang University Hospital, Gumi, Korea, 3Radiology, Soonchunhyang Hospital, Cheonan, Korea, 4Radiology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea, 5Vascular Surgery, SoonChungHyang University, Seoul, Korea 1Radiology,

Purpose: The purpose of this study was to evaluate the feasibility, efficacy, and safety of percutaneous thromboaspiration with a 7-F Desilets-Hoffman sheath compared with previously established percutaneous mechanical thrombectomy techniques in occluded hemodialysis grafts. Material and Methods: One thousand three hundred five patients (767 women, 538 men; mean age, 61.04±13.09 years; mean graft age, 36.64±30.80 months) with 2531 episodes of hemodialysis graft thrombosis underwent percutaneous thromboaspiration with a 7-F Desilets-Hoffman sheath using the criss-cross or apex puncture technique. Technical success rate, procedure time, complications, and patency rates were analyzed. Results: Technical success was achieved in 2426 of 2531 procedures (95.9%). The average procedure time of the intervention was 42.87 ± 22.77 minutes. Primary patency rate was 61.9% at 3 months, 41.2% at 6 months, and 19.6% at 1 year. Major complications occurred in 4.1% of cases (23 graft outflow rupture; 68 arterial emboli; 1 arterial dissection; 3 symptomatic pulmonary embolism; and 1 stent migration) and minor complications occurred in 7.7% of cases (196 cases). These results were comparable to previously reported mechanical thrombectomy techniques in occluded hemodialysis grafts. Conclusion: Percutaneous thromboaspiration of occluded hemodialysis grafts with a Desilets-Hoffman sheath is an effective and safe method.

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P-82 Ultrasound-guided supraclavicular brachial plexus block for analgesia during the treatment of failed hemodialysis fistulas by interventional radiology M. Gedikoglu1, C. Andic1, H.E. Eker 2, I. Guzelmansur3, L. Oguzkurt1; 1Radiology, Baskent University School of Medicine, Adana, Turkey, 2Anaesthesiology, Baskent University School of Medicine, Adana, Turkey, 3Radiology, Mozaik Hospital, Hatay, Turkey Purpose: To prospectively evaluate the feasibility, technical problems, safety, and efficacy of an ultrasound-guided supraclavicular brachial plexus block for analgesia during the treatment of failed hemodialysis fistulas by interventional radiology. Material and Methods: Ultrasound-guided supraclavicular brachial plexus block was performed to provide analgesia during the treatment of failed hemodialysis fistula in 40 consecutive patients. After the blocks, standard interventional procedures were performed for the treatment of failed hemodialysis fistulas. A visual analogue scale (0–10) was used to assess block performance-related pain immediately after the treatment procedure. Patient satisfaction and operator satisfaction with this anesthetic technique were also assessed after the procedure. Results: Satisfactory procedural regional anesthesia and analgesia was achieved in all patients who could be treated without patient discomfort or the need for supplemental intravenous sedation and analgesia. Pain scores were 0 (no pain) in 26 patients, 1–3 (mild, annoying pain) in 14 patients. Patients never experienced any pain higher than 3. Patient satisfaction with pain control was recorded as satisfied (very well) in all cases. Operator satisfaction with this anesthetic technique was also recorded as satisfied (very well) in all cases. No side effects or complications related to block procedure occurred in any patient. Conclusion: Ultrasound-guided supraclavicular brachial plexus can be used as a durable alternative method to provide considerable analgesia during the treatment of failed hemodialysis fistulas with endovascular interventions. It can enhance patient satisfaction and protect the patients with end-stage renal disease from the side effects of sedoanalgesia or general anesthesia.

P-83 Venous outflow stenosis: a single entity or is the cephalic arch different?  A.J. Jackson1, E.L. Aitken1, R. Kasthuri2, D.B. Kingsmore1; 1Western Infirmary, Department of Renal Transplant, Glasgow, United Kingdom, 2Radiology, Gartnavel General Hospital, Glasgow, United Kingdom Purpose: Cephalic arch stenosis (CAS) is emerging as an important cause of brachiocephalic fistula (BCF) failure. We compare the outcomes of angioplasty in CAS to other venous stenoses causing BCF dysfunction. Material and Methods: Fifty-nine patients with dysfunctional BCF were identified and proceeded to angioplasty. Lesions were categorised anatomically: 16 CAS, 22 venous outflow and 21 swing segment (<3cm of anastomosis). Anastomotic stenoses were excluded. Endovascular intervention was carried out in a standard fashion. Patients were followed up prospectively by regular clinical and venous pressure monitoring of the fistula. Re-intervention was performed on clinical suspicion of recurrence. Results: Mean follow-up duration was 402 days. Patient demographics were comparable across the three groups except a lower incidence of diabetes in the cephalic arch cohort (15.7% vs. 28.2% vs. 25.0%). Swelling and aneurysmal fistulae were more common presenting complaints in CAS (15.7% vs 2.6% vs. 0%). Mean length of cephalic arch stenosis was shorter (1.6 cm vs. 3.1 cm vs. 3.3 cm).

Abstract Book Primary patency of cephalic arch angioplasty was 68.8%, 43.7% and 31.0% at 3, 6 and 12 months, respectively. Primary-assisted patency was 87.5%, 81.0% and 43.0%, respectively. There was no significant difference in primary or primary-assisted patency compared to other outflow stenoses. Moreover, 2.3 interventions/patient were required to preserve the access in the CAS cohort vs. 1.1 interventions/patient for venous outflow stenosis and 1.3 interventions/patient for swingsegment stenoses. Conclusion: CAS bears a different clinical presentation to other venous outflow stenoses. The hallmark is a requirement for repeated intervention compared to other venous stenoses causing BCF dysfunction.

P-84 Doppler ultrasonography of arteriovenous fistulae in hemodialysis patients: far more than just for diagnosis J.R. Fortuño, E. Criado, A. Alguersuari, J.F. Falco-Fages, J. Perendreu, J. Branera; Interventional Radiology, UDIAT-CD. Corporacio Parc Tauli, Sabadell, Spain Learning Objectives: To pictorially demonstrate how we can use Doppler ultrasound to evaluate arteriovenous fistulae for diagnostic, prognostic, and therapeutic purposes. Background: Doppler ultrasound (US) is an established technique for the diagnosis of vascular access dysfunction in hemodialysis patients. The aim of this exhibit is to illustrate that US can be used in hemodialysis patients not just for diagnostic purposes. An accurate arteriovenous fistula (AV) US examination has great therapeutic and prognostic implications and plays a key role in the management of these patients. Clinical Findings/Procedure: Pictorial description of US findings and their angiographic correlation showing that in case of AV access, US can be used for the following: 1. Monitoring the access, including flow measurement 2. Diagnosing fistula dysfunction 3. Determining the best therapeutic option (surgical interventions vs endoluminal treatment) 4. Determining the optimal puncture site and access (venous retrograde vs anterograde) 5. Providing guidance for accessing an immature fistula 6. Planning the procedure (type of sheath, wire, catheter, angioplasty balloon, and stent/stent graft) 7. Providing guidance during the angioplasty procedure alone or in combination with fluoroscopy 8. Assessing the short- and medium-term outcomes of the procedure and evaluating morphologic and hemodynamic residual stenosis Conclusion: Doppler US examination of dysfunctional AV fistulae is useful not only in determining the cause of access dysfunction but also in the overall planning, monitoring, and assessing the outcome of any intravascular intervention.

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P-85 Image-guided permanent central venous catheters: evaluation of complications and strategies using different accesses M.D. Ferrer-Puchol, E. Esteban Hernández, P. Montesinos García, E. Taberner López, R. Ramiro Gandía, A. Cervera Araez, E. García Oliver, N. Úbeda Morant; Radiology, Hospital de la Ribera, Alzira, Spain Learning Objectives: 1. To review central venous access (tunneled catheter for dialysis and implanted port) and describe major and minor complications. 2. To review technical approaches and unconventional venous accesses in difficult procedures using different strategies. 3. To present our experience in 2,212 image-guided permanent central catheters over the last 13 years. We describe our complications and solutions in these difficult accesses. Background: A permanent central line is a tunneled catheter placed in order to gain venous or dialysis access. Tunneled catheters are defined as catheters that travel through a subcutaneous tract via a small incision in the skin. Implanted ports are similar to tunneled catheters; however, they do not exit the skin, but terminate with the device buried in the subcutaneous tissue. Central venous catheterization is an essential tool for many physicians. Despite the potential for serious complications, the procedure is generally safe and successful. Conventional access is via the jugular and subclavian veins. However, in patients who have undergone multiple previous catheter placements, venous access can be a technical challenge. Once the usual access sites are no longer available, it may be necessary to use an unconventional access method such as the following: Catheterization of the common femoral vein Catheterization of collateral vessels Recanalization of the occluded vein Translumbar inferior vena cava/hepatic vein catheter placement Clinical Findings/Procedure: We present our experience describing different complications that occurred and descriptions of these unusual access techniques that offer successful alternatives. Conclusion: Venous access can be challenging for most interventional radiologists. It may be necessary to know possible complications and unconventional access routes.

P-86 Malfunction of arteriovenous dialysis shunt in patients with ipsilateral pacemaker: endovascular treatment considerations F. Petrocelli1, M. Dahmane1, L. Patrone1, G. Gola1, G. Bovio1, U.G. Rossi2, C. Ferro1; 1Radiology, IRCCS San Martino, University Hospital, Genoa, Italy, 2Radiology and Interventional Radiology, San Carlo Borromeo Hospital, Milan, Italy Learning Objectives: To describe our experience in the management of arteriovenous dialysis shunt malfunction due to occlusion of the central veins in presence of a permanent pacemaker. Background: A close relationship exists between cardiovascular and renovascular pathology. Patients requiring haemodialysis are often elderly and have cardiac pathological conditions that frequently require permanent pacing. Central vein occlusion is not uncommon after implanting permanent cardiac stimulators or creating arteriovenous shunt; if ipsilateral placement is unavoidable, the combination of the two should be avoided because it may result in functional impairment of the shunt and/or arm edema. The targets of endovascular treatment are functional recovery of the shunt and resolution of symptoms without damaging the electrodes.

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Clinical Findings/Procedure: Twelve patients with dialysis shunt malfunction for central vein occlusion with ispilateral pacemaker underwent angioplasty. Stents were not used. Affected areas included subclavian and anonymous veins. Common indications for stent placement were treated with repeated prolonged angioplasty. The functionality of the shunt was restored, and no pacemaker malfunction was observed. Conclusion: The endovascular treatment of angioplasty without stent deployment is the first-line treatment of symptomatic stenoocclusions of the central veins in the presence, on the same side, of cardiac stimulator and arteriovenous dialysis shunt. The possible rupture of the stent could cause damage to the electrodes and infection. In addition, to ensure an adequate venous drainage of the shunt, long-term patency of the central veins may not be necessary because of the formation of collaterals.

P-87 No access? Strategies for achieving venous access in long-term haemodialysis patients R.S. Malliwal, S. Quigley, K. Khanna, T. Fotheringham, D.E. Low; Interventional Radiology, The Royal London Hospital, London, United Kingdom Learning Objectives: 1. To understand alternative strategies for dealing with long-term haemodialysis patients who have exhausted conventional routes of access. 2. To learn useful tips and tricks for achieving alternative access. 3. To recognise potential pitfalls and complications when using alternative, technically challenging access routes. Background: - Our institution serves approximately 1,000 haemodialysis patients of whom 44% dialyse via a central venous line (jugular, subclavian and femoral routes) as opposed to arteriovenous fistulas or grafts. - Line access is associated with numerous complications, including infection, malfunction and ultimately line and vessel thrombosis and occlusion. - We manage approximately 200 line ‘incidents’ per year. Alternative routes of access are obviously imperative for survival when common access sites are occluded. - The insertion of CVC in these patients is technically challenging and has a greater complication rate. Clinical Findings/Procedure: - Alternative routes of access that we successfully use are as follows: transhepatic venous access, translumbar access and sharp recanalisation of SVC. - Case examples of each access with consideration of why and how this access was chosen and achieved. - Tips and tricks in achieving and maintaining this access together with potential complications and how to avoid them. - Our technical success, complication and patency rates for each type of unconventional access. Conclusion: Line complication rates are high and usual access sites can become compromised. Alternative routes of venous access are imperative for survival. Unconventional line access can be successfully achieved with good patency rates, but potential complications must be considered.

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P-88

Embolotherapy (excluding oncology)

Safety of transhepatic route of permanent catheter in patients receiving hemodialysis

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A. Uçar, G. Yildirim, E. Agolli, A. Sulovari; Interventional Radiology Department, Istanbul University Faculty of Medicine Hospital, Istanbul, Turkey Learning Objectives: To retrospectively review our experience with respect to the safety and functionality of hemodialysis catheters placed via the transhepatic route. Background: In all, 21 patients (6 men, 15 women) aged 28–81 years (average, 50) underwent transhepatic hemodialysis catheter placement from January 2010 to June 2013. Transhepatic route was chosen to obtain vascular access in the absence of an available peripheral venous site in all our patients. By reviewing dialysis records and the patients’ hospital files as well as by maintaining communications and contacts between radiologists and patients, transhepatic catheters safety and functionality was assessed. Clinical Findings/Procedure: The procedure was technically successful in all patients. The catheters remained fully functional for approximately 6 months, and there was no gender-related difference. Seven patients (33%) died because of complications not related to the catheters, and all catheters were functional at the time of their death. One (4%) patient died 1 week after catheter placement due to sepsis, and catheter was considered to be the source of the infection. Thirteen (63%) patients are alive and well, and the catheters have remained fully functional since their placement. Only one case needed exchange 2 months after its initial placement – the device failed because its tip was occluded with thrombus. One catheter was dislodged 2 months after its initial placement and required an additional access procedure to a different hepatic vein. Conclusion: Transhepatic route can be considered as an alternative for patients having exhausted other vascular access routes.

ACE multicenter study: preliminary results with the Penumbra Ruby TM Coil in the peripheral vasculature C. Teigen1, H. Moyle2, R. Patel2, A.M. Fischman2, E. Kim2, B. Baxter3, S. Quarfordt3, D. Heck4, R. Klucznik5, O. Diaz6 , A. Reeves7, M. Abraham8 , E. Madarang7, B. Zwiebel9, M. Brant-Zawadzki10, W. Peck11, B. Nguyen11, L. Whitaker12, P. Gailloud13, R. Hagino14, E. Luong15, J. Lai15, S.S. Kuo15, H. Buell15, A. Bose15, S.P. Sit15; 1Interventional Radiology, Sanford Medical Center, Fargo, ND, United States of America, 2Mount Sinai Medical Center, New York, NY, United States of America, 3Interventional Radiology, Erlanger Health System, Chattanooga, TN, United States of America, 4Vascular & Interventional Radiology, Forsyth Medical Center, Winston-Salem, NC, United States of America, 5The Methodist Hospital Research Institute, Houston, TX, United States of America, 6Interventional Radiology, The Methodist Hospital Research Institute, Houston, TX, United States of America, 7Radiology, University of Kansas Medical Center Research Institute, Kansas City, KS, United States of America, 8University of Kansas Medical Center Research Institute, Kansas City, KS, United States of America, 9 Interventional Radiology, Tampa General, Tampa, FL, United States of America, 10Hoag Neurosciences Institute, Hoag Hospital, Newport Beach, CA, United States of America, 11Interventional Radiology, Hoag Hospital, Newport Beach, CA, United States of America, 12Hoag Hospital, Newport Beach, CA, United States of America, 13Interventional Neuroradiology, Johns Hopkins University, Baltimore, MD, United States of America, 14Vascular Surgery, Essentia Health, Duluth, MN, United States of America, 15Penumbra Inc., Alameda, CA, United States of America Purpose: Penumbra Ruby TM Coils are platinum detachable coils designed for arterial and venous embolizations in the peripheral vasculature. The initial outcomes of the multicenter Ruby Coils study of patients with peripheral aneurysms/malformations and vessel sacrifices – an Aneurysm Coiling Efficiency (ACE) registry subset – are reported herein. Material and Methods: Data were compiled from March 2012 through January 2014 at 10 centers. The first 38 cases of peripheral aneurysms/malformations and vessel sacrifices comprised 5 splenic and 6 renal artery aneurysms, 5 AVMs, 2 fistulae, 1 varicocele, 1 varix, and 18 vessel sacrifices treated with Ruby Coils. Results: Aneurysms located at the splenic and renal arteries had volumes from 120 to 4351 mm3 and neck diameters from 4 to 11 mm. A mean of 8 coils was placed per aneurysm, with a mean packing density of 33% in the aneurysms/malformations (N=20). Mean fluoroscopy time was 30 minutes. Ninety-five percent had no procedural complications. Aneurysms/malformations with data exhibited Raymond class 1 occlusion after treatment (N=13). Seven patients with 6-month follow up revealed stable complete class I occlusion. The peripheral vessel sacrifices (N=18) included 10 patients with complete obliteration and 6 patients having successful coil placement with decreased flow or absence of reflux through the involved vessel. No procedural SAEs were observed. A median of 2 coils was placed, and mean fluoroscopy time was 17 minutes. Conclusion: The initial findings in the multicenter Ruby Coils study show encouraging results. Using Ruby in the periphery showed complete occlusion immediately post-procedure, and they remained stable at follow-up. Additional cases are necessary to corroborate these findings.

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P-90 Cone beam CT: an essential adjunct to prostatic artery embolisation for benign prostatic hypertrophy? Experience from the first UK trial D. Flowers1, J. Coyne1, T.J. Bryant2, L.M. Ingram1, J. Dyer3, M. Harris3, B. Somani3, N. Hacking4; 1Interventional Radiology, University Hospital Southampton, Southampton, United Kingdom, 2Radiology, Southampton General Hospital, Southampton, United Kingdom, 3Urology, University Hospital Southampton, Southampton, United Kingdom, 4Department of Clinical Radiology, University Hospitals Southampton, Southampton, United Kingdom Purpose: To assess the value of cone beam CT in performing prostatic artery embolisation. Material and Methods: Between April 2012 and November 2013, 42 patients underwent prostatic artery embolisation for benign prostatic hypertrophy; of them, 24 patients underwent cone beam CT assessment of the vascular supply of the prostate for the sites of potential non-target embolisation and prostatic enhancement pattern. Results: In 9 (37.5%) patients, cone beam CT confirmed good hemiprostatic enhancement and/or no adverse collaterals. In 15 (62.5%) patients, significant findings were found that led to a change in the procedure. Of these cases, potential sites of non-target embolisation included the bladder, rectum, seminal vesicles and penis in 60%; minimal prostatic or central prostatic supply in 26.7%; cross-filling in 6.7% and entire prostatic supply from a single prostatic vessel in 6.7%. Conclusion: In our experience, cone beam CT is of considerable value in PAE and helps reduce the risk of non-target embolisation.

P-91 Deliverability, efficacy of occlusion and acute histopathological evaluation of novel radiopaque embolic microspheres (OccluRad) in a rabbit auricular artery model R. Abraham1, S. Kehoe2, C. Daly 2, D. Boyd3; 1Diagnostic Imaging and Interventional Radiology, QE II Health Sciences Centre/Dalhousie University, Halifax, NS, Canada, 2ABK Biomedical Inc, ABK Biomedical Inc, Halifax, NS, Canada, 3Applied Oral Sciences, Dalhousie University, Halifax, NS, Canada Purpose: Using a rabbit auricular artery as an initial in-vivo feasibility model, we assessed the deliverability and efficacy of occlusion and performed an acute histopathological evaluation of a novel radiopaque embolic microsphere (OccluRad). Material and Methods: Bilateral auricular artery (Aur. Art.) embolization was performed on three New Zealand white rabbits directly comparing novel radiopaque OccluRad 45–150-μm, 150–300-μm and 300–500-μm microspheres on the left to Embosphere 40–120μm, 100–300-μm and 300–500-μm microspheres on the right. Angiography and embolisation were performed using 22-G angiocatheters placed in the proximal Aur. Art., and the degree of stagnation was assessed using the Thrombolysis in Myocardial Infarction (TIMI) scale. Animals were sacrificed, and gross and microscopic histopathologic evaluation was performed on the embolized auricular tissue. Micro CT imaging was performed on target specimens. Statistical analysis was not performed. Results: Embolisation was successfully performed for all OccluRad particle size ranges and Embosphere 40–120 μm and 100–300 μm size ranges. Embolisation with Embosphere 300–500 μm size range was not successful because of failed arterial access. OccluRad particles were readily radiopaque on fluoroscopy. Deliverability was demonstrated to the peripheral arterial branches. OccluRad-embolised arteries showed TIMI 0 flow, and Embosphere-embolised arteries

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showed TIMI 1 (40–120 μm) and TIMI 2 flow (100–300 μm). Ischemia of the embolised tissue was noted on necropsy. Histopathological evaluation confirmed arterial occlusion but did not demonstrate inflammation or other microscopic abnormality. Micro CT confirmed OccluRad radiopacity and demonstrated stacked contiguous microspheres positioned within the occluded arteries. Conclusion: OccluRad microspheres demonstrated deliverability, arterial occlusion and no inflammation in a rabbit auricular artery model similar to Embosphere control.

P-92 Embolic effects of transcatheter mesenteric arterial embolization with microspheres of the small bowel in a dog model K. Kishimoto1, K. Osuga1, N. Maeda1, Y. Higashi2, A. Hayashi2, Y. Hori3, M. Nakamura1, K. Tanaka1, Y. Ono1, H. Higashihara1, F. Ohashi2, E. Morii3, N. Tomiyama1; 1Department of Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine, Osaka, Japan, 2Laboratory of Veterinary Surgery, Department of Graduate School of Life and Environmental Sciences, Osaka Prefecture University, Osaka, Japan, 3Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan Purpose: To assess the optimum particle size and safety of microsphere embolization of the small bowel in a dog model. Material and Methods: In ten dogs, selective microsphere embolization was performed in six branches of the superior mesenteric artery. Microspheres were allocated into three size ranges (100– 300 μm, 300–500 μm, and 500–700 μm) and four sediment volumes (0.00625 mL, 0.0125 mL, 0.025 mL, and 0.05 mL). For each size and sediment volume of the microspheres, five branches were embolized at the level of the marginal artery. Angiographic findings were categorized into two groups: Group A (only the vasa recta disappeared) and Group B (the marginal artery or more proximal branches disappeared). The range and severity of ischemic changes were pathologically evaluated. Results: The range of ischemic changes among the three size ranges and among the four sediment volumes was significantly different (p=0.004 and p<0.0001, respectively). In Group A, no ischemic change was observed for 500–700 μm, and no stripping of endothelial cells was observed for 300–500 μm and 500–700 μm. The range of ischemic changes between Group A and B for 500–700 μm was significantly different (p=0.001). The severity of ischemic changes between Group A and B for 300–500 μm and 500–700 μm was significantly different (p=0.049 and p=0.0036, respectively). Conclusion: Embolization limited to the vasa recta in response to 300–500-μm and 500–700-μm microspheres reduced the range and severity of ischemic changes and was suitable for mesenteric artery embolization.

P-93 Embolization of a wide-neck aneurysm using N-butyl cyanoacrylate-ethanol-lipiodol under balloon inflation: occlusive potency of the mixture and its adhesion characteristics to the balloon M. Sato, F. Tanaka, H. Sanda, N. Kawai; Radiology, Wakayama Medical University, Wakayama, Japan Purpose: Ethanol accelerates the polymerization of N-butyl cyanoacrylate (NCBA), causing least adhesion to a catheter and enabling repeated and slow injections. This study aimed to evaluate the occlusive potency of NBCA-ethanol-lipiodol (NEL) for a wide-neck aneurysm under balloon inflation.

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Material and Methods: The NEL mixture was prepared with an NBCA:ethanol:lipiodol ratio of 1:2:1 and the NL mixture, used as a control, was prepared with an NBCA:lipiodol ratio of 1:1. Under general anesthesia, aneurysms of 10-mm diameter with 8-mm neck size were created at carotid arteries using removed jugular veins. Percutaneous transluminal angioplasty (PTA) balloon catheter was advanced via a femoral approach to the carotid artery and a microcatheter was inserted into the aneurysm from another femoral artery. Under balloon inflation, NEL or NL was injected into aneurysm via the microcatheter, and the balloon at the carotid artery was inflated for 10 minutes and then attempted to be retrieved. Results: In three aneurysms of the NL group, NL stayed in the aneurysm and strongly adhered to the balloon catheter and microcatheter, resulting in difficulty in retrieving the catheters, whereas in seven aneurysms of the NLE group, NLE formed a round shape in the aneurysm; thus, they could pack the full lumen and caused least adhesion to the balloon catheter and microcatheter, leading to the easy retrieval of catheters. Conclusion: NL adhered to the balloon catheter and microcatheter, whereas NLE did not and adequately packed and occluded the wide-neck aneurysm under balloon inflation.

P-94 Embolotherapy of trauma-associated pelvic arterial hemorrhage: feasibility of superselective catheterization in heavily injured patients N.Y. Yim1, H.O. Kim1, S.H. Kim1, J.K. Kim1, Y.T. Kim2; 1Radiology, Chonnam National University Hospital, Gwangju, Korea, 2Radiology, Mokpo Hankook Hospital, Mokpo, Korea Purpose: To determine the efficacy of embolization with superselective catheterization of internal iliac arterial branches to treat heavily injured trauma patients with pelvic arterial bleeding. Material and Methods: Retrospective analsysis was performed using the medical records of patients who underwent embolotherapy for trauma-associated pelvic arterial hemorrhage in a regional trauma center between July 2010 and July 2013. Results: Thirty-seven patients underwent embolotherapy for trauma-associated pelvic arterial bleeding. Among them, 29 patients underwent embolization after superselective catheterization (more than 2nd order branch of the internal iliac artery) using microcatheter. Mean Injury Severity Score (ISS) of enrolled patients was 25 ± 8.45. Mean procedure time was 34 minutes. After the procedure, angiographic hemostasis was established in all patients. Six patients died after embolization due to additional traumatic injury rather than pelvic hemorrhage. In addition, 23 patients recovered and were discharged. None of the patients suffered from complications related to pelvic embolization. Conclusion: Pelvic arterial embolization with superselective catheterization is safe and effective treatment method for heavily injured patients with trauma-associated pelvic arterial bleeding.

P-95 Evaluation of renal artery embolization for the management of post-partial nephrectomy bleeding A. Dmytriw1, R. Rendon2, C. Lightfoot3; of Radiology, Dalhousie Medical School, Halifax, NS, Canada, 2Department of Urology, QEII Health Sciences Centre, Halifax, NS, Canada, 3Department of Radiology, QEII Health Sciences Centre, Halifax, NS, Canada 1Department

Purpose: Renal cell carcinomas represent 80%–85% of primary renal neoplasms. With renal-sparing surgery, postoperative bleeding may occur and lead to significant morbidity. Superselective renal artery embolization has shown promise for the management

Abstract Book of hemorrhagic complications. We evaluated the angiographic characteristics and utility of superselective renal artery embolization for post-partial nephrectomy bleeding. Material and Methods: We retrospectively analyzed patients who underwent partial nephrectomy between 2002 and 2012. In all, 244 patients were evaluated. Preoperative imaging was assessed with RENAL score [1, radius (maximum diameter in cm); 2, exophytic/endophytic; 3, proximity of the tumor to the sinus or collecting system; 4, anterior/posterior; 5, location relative to the polar lines]. Embolization imaging and technique were reviewed and categorized. Results: A total of 18 patients had bleeding that was managed with embolization. Nine patients had active contrast extravasation/ bleeding; 6, pseudoaneurysm; 1, arteriovenous fistula; 1, abrupt vessel cutoff sign; and 1, arterial dissection. The average RENAL score for patients undergoing embolization was 8 (range: 6–10) and for patients managed conservatively was 6.4 (range, 5–9). Embolizations were technically successful. One patient required a second embolization for persistent bleeding. Two others were readmitted for suspected bleeding and managed conservatively. The average hospital stay for those embolized was 9.6 days (range, 2–29) and for those managed conservatively was 13.4 days (range, 4–30). No significant complications related to embolization occurred. Conclusion: Hemorrhage following partial nephrectomy is associated with significant morbidity and protracted stay in hospital. Superselective arterial embolization is safe and effective, and should be strongly considered in patients with post-partial nephrectomy bleeding.

P-96 Fibered platinum coils vs vascular plugs in pelvic varices embolization for the treatment of pelvic congestion syndrome: 1-year follow-up randomized study A. Laborda1, M. Sanchez Ballestin1, I. De Blas2, M.A. de Gregorio1; University of Zaragoza, Zaragoza, Spain, 2Epidemiology, University of Zaragoza, Zaragoza, Spain 1GITMI,

Purpose: To compare the safety and efficacy of two embolic agents for the treatment of pelvic congestion syndrome: Nester coils (NS; Cook Medical) and Amplatzer vascular plugs (AVP; St. Jude Medical). Material and Methods: From May 2010 to September 2012, 55 consecutive patients (mean age 43.07±7.56 years; range 29–60) diagnosed of pelvic congestion syndrome due to pelvic varices (>6 mm pelvic venous caliber and venous reflux in ultrasonography) were randomized in 2 groups and treated with either NC (n=28) or AVP (n=27). Median cubital or jugular approach was used interchangeably, using 5F for NC and 6F for AVP. Both ovarian and hypogastric veins were targeted. Safety, efficacy, procedure time, fluoroscopy time, and radiation dose were compared. Results: In both groups, all veins were successfully embolized with no differences. The mean number of coils per case was 17.82±1.39 (NC) vs 4.18±0.48 (AVP). There were 6 re-embolizations due to no improvement in NC and 2 in AVP. At 1-year follow-up, there were no significant differences in clinical success (complete disappearance or improvement of symptoms 89.3% vs 92.6%) or in subjective improvement self-assessment (by VAS). Two coils migrated in the NC group and were retrieved without complications. Procedure time (45.24±3.89 vs 32.55±7.00 min), fluoroscopy time (33.71±8.83 vs 21.13±7.08 min) and radiation dose (PDA 348.66±81.84 Gycm2 vs 199.31±183.64 Gycm2) were significantly higher in the NC group (all p<0.0001). Conclusion: AVP embolization is as safe and efficient as NC embolization. AVP significantly reduces procedure and fluoroscopy time and radiation dose. Device migration and incomplete embolization is more frequent with NC, but larger studies would be necessary.

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P-97 Initial evaluation of hemodynamic changes in the liver during B-TACE using double-balloon catheters S. Ota, N. Nitta, S. Misaki, A. Inoue, K. Aoki, S. Mori, Y. Tomozawa, S. Watanabe, Y. Murakami, H. Otani, A. Sonoda, K. Murata; Radiology, Shiga University of Medical Science, Otsu, Japan Purpose: Microballoon catheters (MBs) have been recently used for TACE (B-TACE). Unexpected lipiodol distribution often described during B-TACE has been attributed to hemodynamic changes secondary to balloon occlusion. In this study, the hemodynamic changes during B-TACE was investigated and evaluated using CT angiography (CTA) using double-balloon occlusion technique. Material and Methods: Eight patients (average age, 70.4; M:F=5:3) with HCCs were enrolled in this study. A 5-Fr balloon catheter (PB) was placed in the central artery (CHA, 3; PHA, 4; RHA, 1), and an MB was placed in the segmental artery (RHA/LHA, 5; posterior branch, 1; sub-segmental branch, 2). CTA from MB under 3 different conditions (MB/PB:−−,+−,++) and CTA from PB under 2 different conditions (MB/PB:+−,++) (+ indicates balloon occlusion) was performed. The hemodynamic changes in the tumors was evaluated using contrast enhancement on CTA, depending on the presence or absence of the balloon occlusions. Results: Contrast enhancement increased in 4 cases, reduced in 2, and no changes were seen in 2 on CTA from MB (MB+, PB−). CTA from PB (MB+, PB−) showed additional tumor vessels in 3 cases. Conclusion: Tumor hemodynamic characteristics change with balloon occlusion technique. A proper understanding and application of balloon catheters during B-TACE is necessary. CTA is an important tool during B-TACE to manage case-related variations in hemodynamics.

P-98 Oral–perioral and orbital–periorbital vascular malformations sclerotherapy in children S.M. Nihayah, J. Amaral, P.R. John; Image Guided Therapy/Interventional Radiology, The Hospital for Sick Children, Toronto, ON, Canada WITHDRAWN

P-99 Preoperative superselective transarterial embolization of renal tumors: a method to improve perioperative outcomes in partial nephrectomy Y.-T. Lin1, S.-W. Hung1, C.-K. Yang2, Y.-C. Ou2, C.C.-C. Chen1; 1Radiology, Taichung Veterans General Hospital, Taichung, Taiwan, 2Division of Urology, Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan Purpose: To compare the perioperative outcomes of partial nephrectomy between patients who underwent preoperative superselective transarterial embolization (TAE) of renal tumors and those who did not. Material and Methods: From January 2012 to February 2014, 46 patients who underwent partial nephrectomy (conventional, laparoscopic, and robotic-assisted laparoscopic) were classified into two groups: those who underwent preoperative superselective TAE and those who did not. The duration between partial nephrectomy and preoperative TAE was ≤2 days. Their perioperative outcomes, including operation methods, blood loss, and hospitalization, were compared. Results: Twenty-one patients (13 males, 8 females) underwent preoperative superselective TAE before partial nephrectomy, and 25

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patients (14 males, 11 females) who did not undergo preoperative TAE. There was no significant intergroup difference in renal tumor and patient characteristics, including age, sex, tumor size, tumor location, and RENAL nephrometry score. The intraoperative ischemic time was significantly lower in the preoperative superselective TAE group (mean, 13.6 min vs. 28.9 min; p = 0.001) as was blood loss (mean, 174.8 ml vs. 320.8 ml; p = 0.04). In addition, hospitalization duration was significantly shorter in the preoperative superselective TAE group (mean, 6.1 days vs. 8.4 days; p = 0.007). Conclusion: Superselective TAE of renal tumor before partial nephrectomy may be beneficial because of decreased intraoperative ischemic time, blood loss, and hospitalization duration.

P-100 Reverse medical microplug: a new embolic material for hepatic arterial skeletonization O. Pellerin1, G.A. Maleux 2, A. Boronat1, C. Déan1, J. Golzarian3, M.R. Sapoval1; 1Interventional Radiology, Hopital Européen Georges Pompidou, Paris, France, 2Department of Radiology, University Hospitals Leuven, Leuven, Belgium, 3Department of Interventional Radiology & Vascular Imaging, University of Minnesota, Minneapolis, MN, United States of America Purpose: To report the first clinical use of a new detachable microplug that is suitable for hepatic artery skeletonization of 1–3 mm vessels. Material and Methods: This is a bicentric pilot study. From April 2013 to June 2013, all consecutive patients referred for hepatic artery skeletonization before radioembolization or intrahepatic artery port catheter placement (HAPCP) were considered eligible for microplug use as an embolic material. The microplug is a controlled detachable embolic material, designed as a nitinol cage covered by PTFE. The microplug bottom is connected to a 0.018-inch guide wire by resorbable welding, and its delivery is performed through a 2.7-F microcatheter. This device is attached to a 1–3-mm diameter vessel. Results: Fourteen consecutive patients with the mean age of 62 years were referred to radioembolization work-up or to HAPCP. The target arteries were right gastric (n=12), pancreaticoduodenal (n=3), or segment IV (redistribution; n=1). The average vessel diameter was 2.1 mm. Only one microplug was used per target artery. All devices, irrespective of their structures, were successfully inserted and deployed. No microcatheter dislodgments from the target site were reported. An immediate occlusion occurred in all cases. The release event occured at an average of 38 seconds. The last angiography control (22 days) confirmed the permanent artery occlusion. Conclusion: This bicentric pilot study demonstrates that reverse medical microplug is a useful tool in achieving satisfactory permanent occlusion of small arteries through a microcatheter. Further technical development employing large devices to allow larger arteries are pending; more clinical evaluation is required to define its real place in the armamentarium of interventional radiology.

P-101 Safety and efficacy of transarterial embolization of the vesical arteries in refractory hemorrhagic cystitis N.G. Macias, M. Burrel, M. Barrufet, F.M. Gómez, J. Guitart, X. Montañá; Interventional Radiology, Hospital Clínic, Barcelona, Spain Purpose: To evaluate the safety and efficacy of the transarterial embolization of the vesical arteries (TAEVA) to control bleeding in patients with refractory hemorrhagic cystitis (HC). Material and Methods: This study retrospectively reviewed 11 patients (8 men and 3 women; age range 21–85 years, mean 67 years) with the clinical diagnosis of refractory HC treated at our

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institution with TAEVA between February 2002 and February 2014. The following technical and clinical endpoints were evaluated were: technical success, bleeding control, presence of major complications, and clinical success (considered as technical success without recurrent bleeding or major complications). Results: The main two causes of HC in all patients evaluated were radiation cystitis (7 patients) and hematopoietic cell transplantation (4 patients). Technical success was achieved in 9 patients (81.82%). Bleeding was controlled in 5/9 patients with technical success (55.55%), and one major complication was reported (bladder perforation) after the procedure. Clinical success was achieved in 5 patients (45.45%). Conclusion: TAEVA appears to be a feasible, safe, and beneficial treatment in the complex management of patients with refractory HC reaching bleeding control in a considerable number of patients. This therapy is useful as an alternative to surgery or in poor surgical candidates. Prospective studies with a larger number of patients are necessary to confirm these result.

P-102

Abstract Book Reperfusion was assessed using follow-up arteriography and CT at least 6 months after embolization. On angiography, reperfusion was defined as persistent flow through the coils or from the adjacent normal pulmonary arteries. On CT, PAVMs were considered as reperfused, undefined, or occluded if the respective diameter reductions of the aneurysmal sac were <30%, 30%–70%, and >70%. Results: Between June 2009 and November 2013, 18 patients had 61 PAVMs embolized with 0.018-inch FIDC. Technical success was 100%. No short- or long-term complications were noted. Two patients (2 PAVMs) were lost to follow-up. Median follow-up duration of remaining 16 patients (59 PAVMs) was 14.2 months. Follow-up pulmonary angiography showed 15/32 (46.9%) PAVMs reperfusions; 14 (93.3%) of these were re-embolized and 7/14 (50%) were re-embolized more than once. Follow-up CT of the 27 PAVMs not assessed by angiography demonstrated 6 (22.2%) reperfused, 13 (48.2%) undefined, and 8 (29.6%) occluded PAVMs. Therefore, depending on the true status of undefined PAVMs on CT, reperfusion rate is between 21/59 (35.6%) and 34/59 (57.6%). Conclusion: PAVM embolization with FIDC was safe and effective but was associated with high reperfusion and re-embolization rate.

Advantages of using Amplatzer Vascular Plug 4 in percutaneous embolisation of lung sequestration

P-104

U.G. Rossi1, P. Rigamonti1, F. Petrocelli2, C. Ferro2, M. Cariati1; 1Radiology and Interventional Radiology, San Carlo Borromeo Hospital, Milan, Italy, 2Radiology, IRCCS San Martino, University Hospital, Genoa, Italy

Use of HydroCoil for embolization of pulmonary arteriovenous malformation to prevent recanalization

Purpose: To describe our experience with and the possible advantages of Amplatzer Vascular Plug 4 (AVP 4) in percutaneous embolization of lung sequestration. Material and Methods: Three patients were diagnosed with intralobar pulmonary sequestration. One patient presented with haemoptysis, and all of them suffered from recurrent episodes of severe pulmonary infections. All patients were treated with percutaneous proximal endovascular embolisation using AVP 4. Results: Technical success was achieved in all 3 patients, with complete exclusion of the pathological systemic artery after embolisation (mean duration, 5 minutes). Follow-up till 24 months revealed no recurrence of symptoms, and MD-CT scan revealed total occlusion of vascular supply and regression of the sequestered lung tissue. Conclusion: AVP 4 seems to be quick, safe and effective for occluding the aberrant vessel in lung sequestration. AVP 4 can be deployed through a diagnostic catheter following angiography control of its correct position. These properties minimise possible intra- and postprocedural complications.

P-103 Treatment of pulmonary arteriovenous malformations by fibered interlock detachable coils: safety, efficacy, and reperfusion rate  S. Tantawi1, G. Soulez1, P. Gilbert1, M.-F. Giroux1, M. Faughnan1, S. Larrivée2, V.L. Oliva1, É. Thérasse1; 1Radiology, Centre Hospitalier Universitaire de Montréal, Montreal, QC, Canada, 2Biostatistics, CRCHUM, Montreal, QC, Canada

M. Shimohira, T. Hashizume, T. Kawai, K. Ohta, H. Nishikawa, Y. Shibamoto; Department of Radiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan Purpose: The aim of this study was to evaluate the usefulness of the HydroCoil for the embolization of pulmonary arteriovenous malformation (PAVM) to prevent recanalization. Material and Methods: Coil embolization was performed in 16 patients with 25 PAVMs (2 males and 14 females; median age, 54 years; range, 16–72 years) between May 2011 and August 2013. Coil embolization was performed without HydroCoil in 12 PAVMs (conventional group) and with HydroCoil in 13 PAVMs (HydroCoil group). In all embolization procedures, immediate postembolic complete cessation of blood flow was confirmed using digital subtraction angiography. For follow-up examination, contrast-enhanced MRI or pulmonary angiography was performed after embolization in all cases. We reviewed follow-up images, and evaluated whether recanalization occurred or not. Results: The median size of the feeding artery of PAVM was 3.1 mm in the conventional group and 4.2 mm in the HydroCoil group. The median size of the venous sac of PAVM was 7.4 mm in the conventional group and 8 mm in the HydroCoil group. The median coil length was 132.5 cm in the conventional group and 160 cm in the HydroCoil group. The median follow-up period was 6.5 months (range, 1–15) in the conventional group and 5 months (range, 2–9) in the HydroCoil group. Recanalization was found in 42% (5/12) in the conventional group and in 0% (0/13) in the HydroCoil group. Conclusion: To prevent recanalization, HydroCoil appears to be useful in the embolization of PAVM.

Purpose: To evaluate the technical success, safety, efficacy, and reperfusion rate of 0.018-inch fibered interlock detachable coils (FIDCs) for the treatment of pulmonary arteriovenous malformations (PAVMs). Material and Methods: The institutional review board approved this retrospective study that included all consecutive patients with simple PAVMs treated with 0.018-inch FIDC. Re-embolizations and PAVMs with multiple feeders were excluded. Technical success was defined as complete PAVM occlusion after embolization attempt.

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P-107

Bleomycin–lipiodol embolization of giant hepatic hemangiomas: is it really effective?

Onyx embolisation of renal angiomyolipomas

Z. Bayramoglu1, N. Alishev1, F. Bicen1, G. Yıldırım1, B. Acunas2; 1Radiology, Istanbul University İstanbul Faculty of Medicine, Istanbul, Turkey, 2Interventional Radiology Department, Istanbul University Faculty of Medicine Hospital, Istanbul, Turkey Learning Objectives: To evaluate the effectiveness of transcathater arterial embolization with bleomycin–lipiodol emulsion along with radiological and clinical follow-up of patients with giant symptomatic liver hemangiomas. Background: We performed transcatheter arterial embolization with bleomycin–lipiodol emulsion in 15 patients between January 2012 and December 2013; in addition, the patients underwent contrast-enhanced MRI. Clinical Findings/Procedure: 15-mg bleomycin sulphate was dissolved in 5-ml saline and then mixed with 10-ml lipiodol; this emulsion was injected, and feeding arteries were embolized. Conclusion: Bleomycin–lipiodol embolization of symptomatic giant liver hemangiomas is safe and effective treatment modality with very good radiological and symptomatic response.

P-106 Dual-lumen Scepter balloon for flow control in the treatment of extracranial arteriovenous malformations J. Griauzde, J.J. Gemmete, D.M. Williams; Radiology, University of Michigan, Ann Arbor, MI, United States of America Learning Objectives: To describe the Scepter balloon and present its advantages in the treatment of extracranial arteriovenous malformations (AVMs). Background: Sclerosant materials provide a viable option for the treatment of extracranial AVMs; however, targeted delivery can be challenging. AVMs are high-flow lesions and often have multiple small feeding vessels, leading to short sclerosant target time. The Scepter balloon (MicroVention; Tustin, CA, USA) is a dual-lumen balloon occlusion device that was initially developed for balloonassisted treatment of intracranial aneurysms. Clinical Findings/Procedure: Four extracranial AVMs were treated with absolute alcohol and a Scepter C or XC balloon. Two were located in the pinna of the ear, one involved the submental region, and one involved the chest wall. The Scepter balloon (4 x 10 mm or 4 x 11 mm) was advanced into a feeding pedicle and was inflated. In treating the chest wall AVM, two Scepter balloons were advanced into separate feeding pedicles and were inflated simultaneously. Once near-flow arrest was achieved, absolute alcohol mixed with contrast material was injected under negative roadmap. In three cases, final angiograms showed no residual filling of AVM. In one case, a large AVM required several staged embolizations secondary to maximum amount of absolute alcohol being used. Conclusion: The small size and compliance of the Scepter balloon allows for more distal access and increased flow control in extracranial AVMs. By facilitating simultaneous flow control and injection of sclerosant, these devices decrease sclerosant wash-out, improving targeted AVM therapy.

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A. Shaw1, K.N. Katsanos2, A. Parthipun1, I. Ahmed2, T. Sabharwal3; 1Interventional Radiology, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom, 2Interventional Radiology, Guy’s and St. Thomas’ Hospitals, London, United Kingdom, 3Department of Radiology, Guy’s and St. Thomas’ Hospital, London, United Kingdom Learning Objectives: The aim is to provide an educational presentation and pictorial illustration of the indications, imaging evaluation, endovascular technique, embolisation material Onyx and its potential advantages in the treatment of renal angiomyolipomas (AMLs). Background: Renal AML is a benign hamartoma of the kidney consisting of predominantly lipid, myoid and angioid elements. AMLs greater than 4 cm have a propensity to bleed due to aneurysmal vessel components. Nephron-sparing percutaneous transcatheter embolisation is currently the preferred treatment of symptomatic or ruptured renal angiomyolipomas. Alcohol, microparticles and coils are usually used. Onyx is a non-adhesive liquid embolic agent and is well established in the treatment of arteriovenous malformations. Onyx is beneficial in providing both complete peripheral devascularisation of the tumour and occlusion of proximal feeding vessels. Furthermore, because a vascular cast is formed, the chance of recanalisation of the pathological vessels and long-term recurrence is potentially eliminated. Clinical Findings/Procedure: Computed tomography is initially performed to define the renal arterial anatomy and allow pre-operative planning. Superselective catheterisation and embolisation is performed of the multiple vessels supplying the angiomyolipoma with a slow controllable injection of Onyx, forming a vascular cast. Follow-up imaging is performed with magnetic resonance imaging demonstrating complete tumour necrosis with no recurrent vascularity. A pictorial review is provided along with presentation of multiple cases with cross-sectional imaging and angiographic findings. Conclusion: Onyx embolisation of renal angiomyolipomas is a safe and effective minimally invasive technique and is an alternative for successful percutaneous embolisation of AMLs achieving complete tumour devascularisation.

P-108 Percutaneous embolisation in the management of intractable postpartum haemorrhage M.D. Ferrer-Puchol1, E. Esteban Hernández1, C. Lanciego2, J.J. Ciampi Dopazo2, R. Ramiro Gandía1; 1Radiology, Hospital de la Ribera, Alzira, Spain, 2Radiologia Intervencionista, Hospital Virgen de la Salud, Toledo, Spain Learning Objectives: 1. To define postpartum haemorrhage (PPH); classify PPH as primary (early) or secondary (delayed), showing the relevance of this classification; know the aetiologies of primary and secondary PPH and choose the best embolisation material. 2. To describe percutaneous techniques applicable to PPH including vascular embolisation for uterine atony or vessel injury and prophylactic procedures in patients with anomalous placentation. 3. To determinate factors associated with failure of embolisation. 4. To show our results in 35 women who experienced PPH and underwent arterial embolisation. Background: Postpartum haemorrhage is an unpredictable and serious complication of labour and a major worldwide cause of maternal mortality. Delayed recognition and insufficient management are important factors that contribute to morbidity and mortality. Primary treatment methods include correction of hypovolaemic shock and coagulation abnormalities, pharmacological measures,

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uterine balloon tamponade and vaginal packing. If these measures fail, embolization with absorbable gelatine sponge with particles or coils can be performed as a lifesaving treatment. Clinical Findings/Procedure: We present our experience with different type of PPH and show the selection of embolisation material. In addition, we show the embolisation technique for uterine atony, arterial tears and pseudoaneuryms as well as prophylactic balloon occlusion in patients with anomalous placentation. We discuss different procedures and clinical outcomes. Conclusion: The interventional radiology techniques play a key role in the prevention and management of PPT. Transcatheter embolisation has been proven to be safe and effective. An in-depth knowledge of this entity is crucial to obtain successful outcomes.

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P-111 Concomittant transarterial and transvenous embolization of a complex pelvic AVM using a new embolic agent Squid®-12 and detachable coils A. Erbahceci Salik1, F. Islim1, A. Akgul2, B.E. Cil1; 1Radiology, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey, 2Cardiovascular Surgery, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey We describe a complex congenital pelvic AVM feeding from the side branches of the right internal iliac artery in a male patient. Concomitant transarterial and transvenous embolization with Squid®-12 and detachable coils enabled a complete embolization in a single session.

P-112

Prostatic artery embolization – where does it stand in the management of the end point? L. Fernandes, T. Bilhim, H. Rio Tinto, J.A. Pereira, M. Duarte, J.M. Pisco; Interventional Radiology, Saint Louis Hospital, Lisbon, Portugal Learning Objectives: To review prostatic artery embolization (PAE) end points using digital subtraction angiography (DSA), and the importance of performing selective and safe prostatic artery embolization and knowing when to stop. Background: PAE has gained special attention in the past years as a potential minimally invasive technique for benign prostatic hyperplasia (BPH). PAE may be performed safely with minimal morbidity and without associated mortality. Its major advantages are its minimally invasive nature, which causes a significant improvement in symptom severity associated with prostate volume reduction and a slight improvement in the sexual function. Clinical Findings/Procedure: Several technical points regarding PAE are noteworthy. The end point of embolization continues to evolve as interventionalists gain experience. Initially, embolization was performed to achieve stasis. At the completion of the procedure, there was a static column of contrast in the prostatic artery. Now, as techniques and embolic materials change, several other end points are considered appropriate indications of adequate interruption of flow to the prostate. Conclusion: Recognizing the end point and knowing when to stop the embolization plays a crucial role in avoiding unnecessary complications and optimizing clinical results.

Double balloon-assisted glue injection for renal arteriovenous malformation: introducing a new method for the treatment of vascular lesion supplied by multiple arteries J. Otaka1, T. Saguchi1, K. Saito1, D. Yunaiyama1, T. Funatsu1, S. Akata1, K. Tokuuye1, Y. Ohno2, M. Tachibana2; 1Radiology, Tokyo Medical University, Tokyo, Japan, 2Urology, Tokyo Medical University, Tokyo, Japan By injecting NBCA under arterial flow control with double balloon occlusion, multiple feeding arteries to the nidus can be occluded simultaneously from a single artery. We present 5 cases of renal AVM successfully and conveniently treated with double balloon occlusion technique.

P-113 Embolization for massive bleeding from buttock ulcer caused by untreated pelvic AV malformation to achieve successful gluteoplasty K. Kuntelia; Diagnostic and Interventional Radiology, Tbilisi State Medical University, Tbilisi, Georgia Untreated giant high-flow pelvic AV malformation caused massive bleeding from the right buttock ulcer. Embolization of AV malformation via brachial approach using Amplatzer plug and coils facilitated successful gluteoplasty.

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P-110 Aberrant ovarian artery originating from the iliolumbar artery J.M. Lee1, J. Ohm2; 1Radiology, Soonchunhyang University Bucheon Hospital, Bucheon, Korea, 2Radiology, Chungnam National University Hospital, Daejeon, Korea Uterine artery embolization is effective for the control of postpartum hemorrhage. However, ovarian artery is one of the bleeding sources. We present the case of an aberrant ovarian artery originating from the iliolumbar artery in a 30-year-old woman with postpartum hemorrhage.

Embolization of a type II endoleak using image fusion technique O. Francois1, J. De Coster 2; 1Interventional Radiology, ASZ CAMPUS AALST, Aalst, Belgium, 2Vascular Surgery, ASZ AALST, Aalst, Belgium A type II endoleak was treated using image fusion technique (with CT angiography) during fluoroscopy. We were able to embolize the endoleak via the lumbar arteries and inferior mesenteric artery using less than 30cc of contrast medium.

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SS/FC/HL/HTS/CM Posters

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P-120

Embolization via a percutaneous transhepatic approach for portal venous laceration caused by blunt hepatic injury

Giant right main pulmonary artery aneurysm from a gunshot wound treated with coil embolization

T. Mine, S. Murata, F. Sugihara, H. Yamaguchi, S. Onozawa, S. Kumita; Radiology, Nippon Medical School, Tokyo, Japan

A. Kumar1, J. Yoon1, P. Kisza2, S.G. Contractor1; 1Radiology, Rutgers New Jersey Medical School, Newark, NJ, United States of America, 2Division of Interventional Radiology, Department of Radiology, Rutgers New Jersey Medical School, Newark, NJ, United States of America

A 66-year-old woman suffered from blunt hepatic injury and hemorrhagic shock due to massive bleeding from the laceration of portal venous branches. Glue embolization of portal venous branches via a percutaneous transhepatic approach was successfully performed, and promising outcome was achieved.

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A 38-year-old female suffered a gunshot wound to the right chest and developed a giant right main pulmonary artery pseudoaneurysm along the bullet tract. The pseudoaneurysm was successfully treated with endovascular coil embolization.

Embolotherapy of a bronchial artery aneurysm presenting as life-threatening mediastinal hematoma

P-121

J.H. Kim1, J.H. Park1, S.S. Byun1, C.K. Lee2;

Large pulmonary artery pseudoaneurysm: endovascular treatment

1Division

of Cardiovascular Imaging and Interventional Radiology, Gacheon University Gil Hospital, Incheon, Korea, 2Sejong Heart Institute, Sejong Hospital, Bucheon, Korea

F. Petrocelli, F. Camerano, G. Gola, G. Bovio, A. Utili, C. Ferro; Radiology, IRCCS San Martino, University Hospital, Genoa, Italy

We reported a case of a 56-year-old male who presented with sudden chest pain and dyspnea. CT examination showed large mediastinal hematoma with a tiny bronchial artery aneurysm. We successfully embolized the aneurysm using microcoils and glue.

This unusual case describes massive hemoptysis caused by a large pulmonary artery pseudoaneurysm of a posterior basal branch due to infection. The patient underwent selective endovascular embolization with Amplatzer Vascular Plug 4.

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Endovascular coil embolization for steal syndrome in a hemodialysis patient with brachioaxillary arteriovenous graft

Percutaneous direct-puncture embolization using glue under manual compression of the drainage vein for a superficial forehead arteriovenous malformation (AVM)

J.H. Kim1, J.H. Park1, S.S. Byun1, C.K. Lee2; 1Division of Cardiovascular Imaging and Interventional Radiology, Gacheon University Gil Hospital, Incheon, Korea, 2Sejong Heart Institute, Sejong Hospital, Bucheon, Korea We report the case of a 56-year-old male hemodialysis patient who had a brachioaxillary arteriovenous graft. He developed steal syndrome due to iatrogenic arteriovenous fistula (AVF) after balloon angioplasty. We successfully treated AVF with coil embolization.

P-118 Endovascular embolization of a ruptured bronchial artery aneurysm in a patient with Ehlers–Danlos syndrome type IV M. Leyva Vásquez-Caicedo1, J.V. Mendez Montero2, J.E. Armijo Astrain2; 1Vascular and Interventional Radiology, Hospital Universitario Clínico San Carlos, Madrid, Spain, 2Radiology, Hospital Clinico San Carlos, Madrid, Spain We report the case of massive hemothorax from a ruptured bronchial artery aneurysm in a 38-year-old woman with vascular Ehlers– Danlos syndrome (type IV). Transcatheter artery embolization with Amplatzer vascular plug was performed successfully.

P-119 Endovascular embolization of intralobar pulmonary sequestration in an adult female P. Popovic, J. Avsenik; Clinical Institute of Radiology, University Medical Centre Ljubljana, Ljubljana, Slovenia Pulmonary sequestration is a rare entity, and is conventionally managed surgically. A 43-year-old female with haemoptysis in whom intralobar pulmonary sequestration was diagnosed using computed tomography was successfully treated with endovascular embolization using metallic coils and Amplatzer® vascular plug.

M. Inoue1, S. Nakatsuka2; 1Radiology, Hiratsuka City Hospital, Kanagawa, Japan, 2Diagnostic Radiology, School of Medicine, Keio University, Tokyo, Japan We report a case of a 37-year-old male with a complex AVM of the forehead. After transarterial glue embolization, the nidus was visualized via the orbital artery. Direct-puncture glue embolization under manual compression of the drainage vein was performed with good results.

P-123 Percutaneous transvenous retrograde cannulation of the thoracic duct and cisterna chyli for the embolisation of a lymphoperitoneal fistula W.M. Pabon-Ramos; Department of Radiology, Duke University Medical Center, Durham, NC, United States of America A 52-year-old female developed chronic chylous ascites after liver/ pancreas/small bowel transplant. Considering that the foramen ovale was patent, percutaneous transvenous retrograde cannulation of the thoracic duct and cisterna chyli with abdominal lymphangiography and embolisation of a lymphoperitoneal fistula were performed.

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Sandwich coil embolization of a pulmonary artery pseudoaneurysm secondary to metastatic breast cancer

Transvenous embolization of a pelvic arterio-venous fistula (AVF) after internal iliac artery (IIA) endoaneurysmorrhaphy using Amplatzer vascular plug (AVP)

N. Ptohis1, S. Lechareas1, L. Poulou1, M. Pagoni2, G. Karydas1, V. Georgountzos1; 1Interventional Radiology Department, Athens General Hospital, Athens, Greece, 2Internal Medicine Department, Athens General Hospital, Athens, Greece

M. Inoue1, T. Akiyoshi2, J. Tsukada3; 1Radiology, Hiratsuka City Hospital, Kanagawa, Japan, 2Vascular Surgery, Hiratsuka City Hospital, Kanagawa, Japan, 3Diagnostic Radiology, Keio University Hospital, Tokyo, Japan

We report the successful use of the sandwich coil embolization technique for the treatment of a complex pulmonary artery pseudoaneurysm caused by extensive collateral anomalous tumor vessels feeding the distal vascular bed of the pseudoaneurysm.

P-125 Sclerosing therapy for neck lymphangioma using doxycycline in a 3-month-old infant E. Guedes Pinto, D. Penha, A. Costa; Radiology, Hospital Professor Doutor Fernando Fonseca E.P.E., Amadora, Portugal We report two attempted procedures of sclerosing treatment of a massive bilateral neck lymphangioma with airway compression in a 3-month-old infant using doxycycline. The patient was referred after a failed surgical attempt at disease control.

P-126 Transhepatic arterial cannulation and embolization of hepatic artery pseudoaneurysm S. Punamiya; Diagnostic Radiology, Tan Tock Seng Hospital, Singapore, Singapore Interventional treatment of hepatic artery pseudoaneurysm can be challenging when the proximal artery is occluded. We describe a case of transhepatic retrograde arterial access and embolization of an inaccessible hepatic artery pseudoaneurysm.

A 52-year-old male with a pelvic AVF between persistent IIA and iliac vein after IIA endoaneurysmorrhaphy due to impending rupture presented with fatigue. After coil embolization failed, AVP was successfully inserted into the arterial side of the fistula transvenously with good results.

P-129 Uretero-arterial fistulae: a case series L. Monzon1, A. Alsafi1, E. Kashef 2, M.S. Hamady3; 1Interventional Radiology, Imperial College Healthcare NHS, London, United Kingdom, 2Radiology, Imperial College Healthcare NHS, London, United Kingdom, 3Interventional Radiology, St Mary’s Hospital, London, United Kingdom We present a case series of 3 uretero-arterial fistulae with relevant CTA imaging and post-embolisation imaging along with an overview of clinical presentations and overall management.

P-130 Usefulness of 0.010-inch microcatheter and microcoils in embolizing lower gastrointestinal haemorrhage – sometimes you need to go further J.E. Armijo Astrain1, M. Leyva Vásquez-Caicedo2, J.V. Mendez Montero2; 1Radiology, Hospital Clinico San Carlos, Madrid, Spain, 2Vascular and Interventional Radiology, Hospital Universitario Clínico San Carlos, Madrid, Spain We explain the usefulness of being open-minded. Instead of using our usual 0.018-inch system, we borrowed some neuro-interventionalist material. Our patient had an extensive bowel resection requiring ultraselective embolization. Success could only be achieved using 0.010-inch microcatheter and coils.

P-127 Transthoracic embolization of a candida lung abscess and associated pseudoaneurysm P. Delli Fraine, P.P. Rao, A. Bessissow, C.I. Torres, T. Cabrera, L.-M.N.J. Boucher, D.A. Valenti; Department of Radiology, McGill University Health Center, Montreal, QC, Canada

EVAR and TEVAR

A 76-year-old man presenting with hemoptysis was found to have an RLL lesion with active extravasation. Transthoracic ultrasoundguided puncture of the intra-lesional pseudoaneurysm was achieved, allowing for successful fluoroscopic-guided embolization. BAL cultures grew candida species, and cytology was negative.

P-131 Advanced EVAR techniques (CHIMney, Periscope, Sandwich graft; CHIMPS) for juxtarenal abdominal aortic aneurysms (ju-AAA) – midterm results: a single-center experience F. Pozzi-Mucelli1, R. Pozzi Mucelli1, L. De Paoli1, R. Adovasio2, M.A. Cova1; 1Struttura Complessa di Radiologia, Azienda OspedalieroUniversitaria Ospedali Riuniti di Trieste, Trieste, Italy, 2Struttura Complessa di Chirurgia Vascolare, Azienda OspedalieroUniversitaria Ospedali Riuniti di Trieste, Trieste, Italy Purpose: To report the results of advanced EVAR techniques for the treatment of ju-AAA with the deployment of parallel stents in the renal arteries (RA) and/or superior mesenteric artery (SMA) using the “chimney”, “periscope” or “sandwich graft” (CHIMPS) techniques after 3 years of experience.

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Material and Methods: Twenty-four consecutive patients (21 males, 3 females) underwent the CHIMPS techniques. Thirty-two RAs and 5 SMAs were stented (chimney, n=30; periscope, n=7). Follow-up CT was performed at 1, 6, and 12 months and annually thereafter). The patency of deployed stents, freedom from reintervention (FFR), and type 1 endoleak (EL1) related to the CHIMPS techniques were evaluated. Results: Stent-graft and RA/SMA stent deployments were successful in all cases except 2 renal stents. Four patients died in the postoperative period (<30 days): 2 because of acute bowel ischemia due to acute SMA stent occlusion (in 1, the stent was positioned in the right RA, which covered the SMA ostium), 1 due to acute heart failure (after 9 h), and 1 due to acute myocardial infarction (after 4 days). During the follow-up (1–38 months; average 15.6 months) 2 occlusions of renal stents and 3 EL1 related to CHIMPS occurred, 2 which required reintervention (FFR, 91.6%). Conclusion: In our experience, the CHIMPS techniques were possible in almost all cases but with high perioperative death rate. Although the patient selection in this series was suboptimal, the findings demonstrated the negative impact of acute SMA occlusion. Mid-term results appear to be favorable, but the possibility of EL1 due to inadequate “sealing” caused by the stent positioned externally to the graft must be considered.

P-132 Diagnosis of endoleaks and reintervention with Endologix stent graft D. Wells1, M. Smith1, M. Gipson1, C.E. Ray, Jr.2, J. Durham1, K. Kondo1, O. Jazaeri3, J. Greenberg3, D. Kuwayama3, R. Gupta1; 1Radiology, University of Colorado, Aurora, CO, United States of America, 2Radiology, University of Illinois at Chicago, Chicago, IL, United States of America, 3Vascular Surgery, University of Colorado, Aurora, CO, United States of America Learning Objectives: 1. Review the unique construction and imaging appearance of the Endologix endograft. 2. Review the challenges of endoleak diagnosis and repair unique to this endograft design. Background: New endograft technologies have expanded options for EVAR, but mandate a knowledge of their construction and imaging appearance. The Endologix endograft, unique from other EVAR devices, has mobile graft material outside a metal endoskeleton with fabric attachment at each end. The detection of endoleaks often requires correlation to dynamic imaging. Clinical Findings/Procedure: With the Endologix endograft, smooth contoured flow outside the metal components may be a normal imaging finding due to billowing of the ePTFE fabric. Differentiating type I endoleaks from normal fabric billowing may require attention to signs such as antegrade filling of lumbar arteries and the lack of expected fabric constriction of the proximal extension at the junction with the main body. Repair is typically with graft extension, Palmaz stent placement, or other more advanced maneuvers. Since the fabric may billow out from the endoskeleton, there may be greater risk for inadvertent graft puncture resulting in a type III endoleak, which may be more difficult to treat because additional endografts placed within the existing endoskeleton will be constricted and fabric may no longer cover the tear. When reintervening, the working wire must never pass between endoskeleton and fabric. This can be verified using intravascular ultrasound or balloon dilation. Conclusion: The Endologix endograft is different from other endografts. Familiarity with the construction of this device is essential to the diagnosis and treatment of endoleaks.

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P-133 Thoracic endovascular aortic repair (TEVAR) for the treatment of acute aortic syndrome: post-operative imaging, complications and secondary interventions S. Ameli-Renani, R. Das, R. Chung, L. Mailli, M. Gonsalves, R.A. Morgan; Radiology, St Georges Hospital NHS Trust, London, United Kingdom Learning Objectives: 1. To understand follow-up imaging modalities and protocols 2. To describe early and late complications 3. To outline evaluation strategies and management options for common complications Background: Thoracic endovascular aortic repair (TEVAR) is an increasingly utilised treatment for aortic dissection. CT angiography (CTA) remains the standard imaging modality. Persistent false lumen perfusion (FLP) is the most common complication. This poster presents an updated literature-based assessment of the current status on imaging and complications post-TEVAR using clinical examples from our extensive institutional experience (tertiary referral centre). Clinical Findings/Procedure: We will evaluate and discuss the following: 1. Imaging modalities (including protocols) following TEVAR: primarily CTA; occasionally MRA; angiography used for problem solving. 2. Normal CTA appearances and review areas: FLP (proximal/distal fenestration leak or secondary to retrograde perfusion from the left subclavian or intercostal arteries); changes in aortic size and integrity, position and coverage of the endograft. 3. Early complications: persistent FLP, retrograde type A dissection, organ ischaemia, aorto-bronchial fistulation, access site-related. 4. Late complications: type A dissection, increased FLP, endograft collapse/separation/fabric tear. 5. Assessment and management of complications: diagnostic approach, including role of angiography; treatment strategies including endovascular, surgical and hybrid interventions. 6. Challenges and pitfalls: aortic aneurysm after TEVAR, thoracoabdominal aneurysmal dissection and role of fenestrated/ branched endografts. Conclusion: Familiarity with CTA appearances post-TEVAR, including normal and abnormal findings, is important and enables prompt diagnosis and timely intervention when required.

P-134 Chronic type B dissection – endovascular repair with branched device R.S. Cunha; Cirurgia Endovascular, Hospital Federal da Lagoa, Rio de Janeiro, Brazil 2007: surgical repair of acute aortic dissection. 2008: endovascular repair of descending aortic dissection + LSA stenting + stenting for TAD in the abdominal aorta. 2012: deterioration and fracture of the stent, endovascular treatment with a custom-made 4-branch stent graft.

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P-139

Deliberate stent-graft extension and endotacking straightens the hyperangulated aortic neck during endovascular aneurysm repair

TEVAR and EVAR complications: a single-center experience

K. Morgan Bates, A. Chaudhuri; Bedfordshire - Milton Keynes Vascular Centre, Bedford Hospital NHS Trust, Bedford, United Kingdom

V. Kovacevic1, D. Sagic1, Z. Antonic1, B. Petrovic1, D. Radak 2; 1Interventional Radiology, Institute for Cardiovascular Disease “Dedinje”, Belgrade, Serbia, 2Vascular Surgery, Institute for Cardiovascular Disease “Dedinje”, Belgrade, Serbia

A 90-year-old woman underwent EVAR using a Cook LP endograft for an 8-cm AAA with 67° neck angulation. Deliberate neck endotacking along the outer curve with deployment of a Cook RENU cuff stiffened/constrained the neck with angle reduction to <30°.

Between 2002 and 2013, we performed 130 endovascular procedures on the aorta (38 TEVARs and 92 EVARs). This report details the complications encountered in 11 procedures that were not endoleak type II, including endoleak type Ia, graft fracture, and graft migration.

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Experimental work in IR

Management of bronchial compression due to thoracic aortic aneurysm using endovascular and endobronchial stent placement

P-140

M.I. Generalov1, B.V. Fadin2, S.D. Chernyshov1, V.E. Sherstobitov1, A.A. Tarkhanov1, D.N. Maystrenko2; 1Department of Angio/Interventional Radiology, Russian Research Center for Radiology and Surgical Technologies, Saint-Petersburg, Russian Federation, 2Department of Vascular Surgery, Russian Research Center for Radiology and Surgical Technologies, SaintPetersburg, Russian Federation We report the use of an endovascular stent graft for a large thoracic aortic aneurysm and a bronchial stent for airway compression in a 54-year-old patient at high risk for open surgery.

P-137 Periaortic fibrosis post-endovascular aortic aneurysm repair: spontaneous improvement of periaortic fibrosis following the treatment of type II endoleak S.-Y. Song1, J.Y. Oh2; 1Department of Radiology, Hanyang University Hospital, Seoul, Korea, 2Radiology, Hanyang University Guri Hospital, Guri si, Korea A patient developed a persistent type II endoleak that was associated with de novo periaortic fibrosis (PAF) 5 months after undergoing EVAR. After coil embolization for endoleak, 6-month follow-up CT scan revealed a significant reduction in PAF.

P-138 Post-surgery AAA revascularization: endovascular treatment U.G. Rossi1, P. Rigamonti1, F. Alberghini2, A. Settembrini3, P. Mingazzini3, M. Cariati1; 1Radiology and Interventional Radiology, San Carlo Borromeo Hospital, Milan, Italy, 2Anesthesiology, San Carlo Borromeo Hospital, Milan, Italy, 3Vascular and Endovascular Surgery, San Carlo Borromeo Hospital, Milan, Italy We describe the case of a 77-year-old male who developed, 3 years after aorto-bisiliac AAA repair, a symptomatic supra-anastomotic aneurysm (4.8 cm) with native AAA revascularization. The patient was treated with embolization and EVAR.

A new experimental model and application of endograft for lethal hemorrhage of juxtahepatic inferior vena cava injury in a swine model K. Idoguchi1, M. Yamaguchi1, K. Sofue1, T. Okada1, E. Ueshima1, N. Katayama1, A. Muradi1, K. Sugimoto1, T. Iseri2, A. Hayashi3, K. Mie3, T. Matsuoka4; 1Department of Radiology and Center for Endovascular Therapy, Kobe University Hospital, Kobe, Japan, 2Animal Medical Center, Tokyo University of Agriculture and Technology, Tokyo, Japan, 3Laboratory of Veterinary Surgery, Osaka Prefecture University, Osaka, Japan, 4Senshu Trauma and Critical Care Center, Rinku General Medical Center, Osaka, Japan Purpose: Juxtahepatic inferior vena cava (Jh-IVC) injury is rare but highly lethal even though various methods have been proposed. This study aimed to develop a new animal model to evaluate the hemostatic effect of endograft application for lethal Jh-IVC injury. Material and Methods: In seven anesthetized pigs (mean weight, 48.8 kg), following pre-procedural contrast-enhanced CT (CECT; mean Jh-IVC diameter, 19.1mm), laparotomy was performed. Ultrasound-guided transhepatic puncture of Jh-IVC was then performed with a 19-G needle while evading major intrahepatic vessels. After insertion of a guidewire, liver parenchyma and Jh-IVC were injured using a PTA balloon (10-mm diameter) inflation. To mimic coagulopathic trauma model, heparin was administered (activated clotting time >250 s). Immediately after cavography, suitable commercially available endografts were deployed in the injured Jh-IVC via iliac vein access. Perihepatic gauze packing was applied if concomitant intrahepatic vessel injury occurred. Post-procedural angiography and CECT with and without packing were used to evaluate extravasation, hepatic injury, Jh-IVC injury, and endograft. Results: Lethal Jh-IVC injury was successfully created and hemostasis was achieved in all pigs, but it was associated with mild (n=3) and moderate (n=2) intrahepatic vessel injury. Two aortic cuff endografts (mean oversizing, 21.5%; mean proximal and distal landing zone, 15.1 mm and 24.1 mm) were needed on average to control the injured Jh-IVC. Post-procedural imaging showed no contrast extravasation from the injured Jh-IVC or endograft-related complications such as migration, fracture, infolding, and collapse. Conclusion: Lethal Jh-IVC injury could be created successfully in the swine model. Endograft application seems to be safe and effective to control the hemorrhage and useful as a damage control strategy.

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P-141 Bioinert properties of coronary nanostructured carbon-coated stents I.B. Kovalenko, M.I. Boyarintsev, M. Filatov; Medical Faculty, Belgorod National Research University, Belgorod, Russian Federation Purpose: To evaluate nanostructured carbon-coated stents for implantation in coronary arteries. Material and Methods: Twenty-seven experimental samples of coronary nanostructured carbon-coated stents, 3-mm diameter and 15-mm width, were evaluated on sheep. The control group comprised 27 bare-metal stents. The implantation sites were anterior interventricular artery (AIVA) and circumflex artery (CA). On the 14th, 28th, and 180th days, intravascular ultrasound (IVUS) and optical coherence tomography (OCT) were performed. Results: Up to 28 days in both groups, the presence of neointimal proliferation on the stent surface was ultrasonographically determined, with uniform thickness and area of 1% arterial lumen. Intimal dissection on the border of stented segment was not observed. Mural thrombus detected in 3 (11.1 %) stented segments in the control group (2 on the 14th day and 1 on the 28th day). In the experimental group, thrombus was not detected. Mural thrombus did not lead to occlusion (thrombosis) or distal embolism. On the 180th day, there was no thrombus in either group. On the 180th day, IVUS showed significant neointimal proliferation on the stent surface in both groups. AIVA/CA in-stent stenosis was 9.75±1.03/9.2±0.3% (IVUS) and 9.63 ±1.2/9.5±0.9%, (OCT) in the experimental group and 25.1±1.63/22.03±2.7% % and 24.2±1.3/21.03±3.5%% (P>0.01) in the control group. Restenosis was 9.5±0.3% (IVUS) and 9.55±0.05 (OCT) in the experimental group and 23.6±1.53% and 22.8±0.6 in the control group. Conclusion: The implantation of nanostructured carbon-coated stents does not prevent the repair processes and does not cause thrombus formation under standard doses of anticoagulants. In-stent stenosis was significantly lower in experimental stents, indicating their higher bioinertness.

P-142 Comparing the visual-spatial skills of the interventional radiology team M.A. Ghouri1, S. Razvi2, D. Birchall3; 1Interventional Radiology, Northern Deanery School of Radiology, Newcastle upon Tyne, United Kingdom, 2Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom, 3Neuroradiology, Royal Victoria Infirmary, Newcastle upon Tyne, United Kingdom Purpose: Interventional radiology (IR) relies on internal representation and transformation of spatial information (visual-spatial skills, VS) where the operator must develop a mental picture of the 3D anatomy based on 2D views, and must devise a visual-spatial plan to navigate to the organ or site of interest. It is unknown whether the members of the IR team have differing VS skills and which factors influence them. Material and Methods: We examined and compared the VS skills of the IR team professionals including consultants (C), residents (SpR), radiographers (R) and nurses (N). VS skills were assessed by Perceptual Aptitude Test utlilising the paper-folding origami task – a widely used and validated process. Briefly, the task involved making a paper penguin using special two-sided coloured paper and 15-step 2D-diagrams instruction sheet. Scoring was based on a 15-point scale based on the number of correct steps achieved by evaluating colour orientation. Statistical analyses were performed using SPSS™ software.

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Results: A total of 135 participants (C=42, SpR=35, R=33 and N=25) participated in the study. Participants with correct colour orientation had higher VS scores (mean±SD, 10.8±3.4 vs 8.4±3.9, p<0.001). In multiple linear regression analysis, factors that predicted higher VS scores were lower age, higher experience, correct colour orientation and job position (C, SpR and R having similar scores but each were higher than N, p<0.05). Conclusion: VS scores are higher in individuals involved in performing IR procedures, and are influenced by factors that could yield important information about capability to perform these procedures. Further studies are required to investigate the use of such techniques in the selection of personnel involved in these procedures.

P-143 Evaluation of the plasmatic and parenchymal elution kinetics in a domestic pig model using irinotecan-loaded drug-eluting beads D. Gnutzmann1, J. Mechel2, A. Schmitz1, N. Bellemann2, C.M. Sommer1, T.L. Gockner1, T. Mokry1, N. Kortes1, U. Stampfl1, H.-U. Kauczor1, B.A. Radeleff1; 1Diagnostic and Interventional Radiology, University of Heidelberg, Heidelberg, Germany, 2Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany Purpose: Irinotecan is an effective chemotherapeutic agent for local therapy of hepatic metastases caused by colorectal cancer, applied intraarterially by drug-eluting beads (DEB). The severity of systemic side and adverse effects may be linked to different elution kinetics depending on the type of DEB. The purpose of our study was to compare two commercially available types of DEB regarding their elution kinetics by measuring plasma and tissue concentration. Material and Methods: Sixteen domestic pigs were treated with superselective embolization of the left lateral liver lobe receiving 1-ml DC Bead®M1 (70–150 μm, DEBIRI®; Biocompatibles, UK) or TANDEM® Microspheres (75 μm, CeloNova, USA) containing each 50-mg irinotecan. Plasma levels were measured at 0, 10, 20, 30, 60, 120, 180, and 240 minutes after completed embolization and at the time of sacrifice (1 day, 48 h, 72 h, and 7 days for each group, respectively). After sacrifice, samples (approximately 5 grams each) were taken for tissue concentration at 3 different sites of the left lateral liver lobe. Results: For the first 4 h, irinotecan blood levels were higher in the DEBIRI group than in the TANDEM group. Significant differences were detected at 10 and 20 min p.i. with significantly higher Cmax (median 158.3 ng/mL) in the DEBIRI arm at 10 min compared with TANDEM Cmax (median 90.13 ng/mL) at 20 min. No significant difference was found at later time points. AUC for the first 30 min was significantly lower for TANDEM. Total AUC showed no significant difference. Conclusion: For the first 4 post-embolization hours, irinotecan is released significantly faster from DEBIRI than from TANDEM Microspheres in a pig model.

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P-144 Idarubicin-loaded TANDEM® for chemoembolization of HCC: in vitro loading and release and in vivo pharmacokinetics B. Guiu1, A. Schmitt 2, S. Reinhardt3, T. Pohl3, M. Wendremaire4, A. Denys5, J. Blümmel3, M. Boulin6; 1Department of Radiology, Saint-Eloi Hospital - University Hospital of Montpellier, Montpellier, France, 2Pharmacy, CGFL, Dijon, France, 3Scientific Department, Celonova, San Antonio, TX, United States of America, 4Pharmacology, CHU Dijon, Dijon, France, 5Radiology and Interventional Radiology, CHUV, Lausanne, Switzerland, 6Pharmacy, CHU Dijon, Dijon, France Purpose: Idarubicin has been shown as the most effective drug for chemoembolization of HCC in vitro. We aimed to assess in vitro loading and release of idarubicin from TANDEM® microspheres as well as in vivo pharmacokinetics of idarubicin-loaded TANDEM® in humans. Material and Methods: In vitro study: We used 6 samples of 100-μm TANDEM® loaded with 5-mg idarubicin-HCl (1 mg/ml, Zavedos®; Pfizer)/ml microspheres. Idarubicin loading was monitored. Particle sizes were measured by optical microscopy. In vitro drug releases were performed with a SOTAX flow cell apparatus at 37°C and 5 ml/min saline and were evaluated using HPLC. In vivo study: Two BCLC B patients were treated with lobar TACE using 2 ml of 100μm TANDEM® loaded with 10-mg idarubicin. Peripheral blood samples were collected at baseline and at 5, 10, 15 and 30 min 2 and 24 h after completion of the TACE procedure. Results: In vitro study: Idarubicin loading was completed within 10 min. Unloaded particle size was 99±12 μm. Calibration of idarubicin-loaded TANDEM® was excellent. TANDEM® exhibited a sustained release of idarubicin; 87.4±1.4% was released after the second period of release. In vivo study: PK data demonstrated a very low and sustained systemic exposure: Tmax of idarubicin was 10 and 5 min for each patient; Cmax of idarubicin was 2.5 and 6.1 ng/ml. The AUC0-24 for idarubicin were 16 and 22 ng·h/ml, respectively. Conclusion: The 100-μm TANDEM® microspheres allow a fast and complete loading of 5-mg idarubicin/ml microspheres as well as a slow and sustained release. In vivo, they exhibit a very favorable PK profile.

P-145 Initial evaluation of the performance of a developed accelerometer-based assisting device for CT-guided interventions N. Ito1, C. Wilkmann2, P. Isfort2, H.-S. Na2, T. Penzkofer 2, T. Schmitz-Rode3, P. Bruners4; 1Radiology, National Hospital Organization, Tokyo Medical Center, Tokyo, Japan, 2Diagnostic and Interventional Radiology, RWTH Aachen University Hospital, Aachen, Germany, 3Institute of Applied Medical Engineering, RWTH Aachen University, Aachen, Germany, 4Applied Medical Engineering/Diagnostic Radiology, RWTH-Aachen University, Aachen, Germany Purpose: To evaluate the initial performance of a developed puncture-assisting device for CT-guided interventions. Material and Methods: An easy-to-use accelerometer-based guidance device, composed of a small sensor cube with dimensions of approximately 2 x 2 x 2 cm and a weight of 11 g was developed. The device was mounted on the needle’s rear end and real-time visualization of the needle’s orientation angles was achieved using a standard personal computer. Its initial performance was tested by puncturing lumbar facet joints (FJs, n=108) of pig cadavers laid on the CT table. Three fixed in-plane angles of 15°, 30°, and 45° as well as

Abstract Book out-of-plane angles of 20/15°, 20/30°, and 20/45° (transversal/sagittal) were chosen to standardize the evaluation; in addition, puncture plans for each angle were made on pre-procedural CT images. After that, punctures were performed under sole device guidance, and accuracies and skin-to-target time were compared with 48 control punctures performed under CT-fluoroscopy guidance. Results: Out of 84 punctures achieved with sole use of the device, the deviation from targets was 5.27 ± 2.72 mm, at a mean skin-totarget distance of 43.09 ± 5.41 mm and a mean skin-to-target time of 33.89 ± 17.17 s. Under CT-fluoroscopy guidance, a deviation of 5.41 ± 3.57 mm at puncture lengths of 51.24 ± 7.53 mm was achieved. Conclusion: The developed device demonstrated tolerable accuracy in the ex vivo animal study considering that no intermittent CT control scans were performed during the trials.

P-146 Intraarterial therapy using a novel vascular disrupting agent dissolved in iodized oil in a hepatocelluar carcinoma (HCC) model Y.I. Kim1, J.W. Chung1, M. Lee1, J.S. Park1, S.J. Kim2, H.J. Jae1; 1Radiology, Seoul National University College of Medicine, Seoul, Korea, 2Chong Kun Dang Research Institute, CKD Pharmaceuticals, Yong In, Korea Purpose: Our study aims to evaluate the efficacy of a novel vascular disrupting agent (CKD-516) dissolved in lipiodol as a therapeutic agent for intraarterial (IA) therapy in an orthotopic HCC model. Material and Methods: VX2 carcinoma was implanted in the liver of 20 rabbits. When the tumor diameter reached 15–20mm, the animals were randomly divided into 4 groups as follows: group A (IV of CKD-516, n=6), group B (IA of CKD-516, n=7), group C (IA of lipiodol, n=3), and group D (IA of CKD-516 dissolved in lipiodol, n=4). DCEMRI was performed to measure the changes of kinetic parameters in tumors before CKD-516 administration for baseline, and at days 1 and 7 post-injection. A two-tailed p value <0.05 was considered to indicate a significant difference using Mann–Whitney test. Results: Serial DCE-MRI showed decreases in K-trans parameters from baseline at day 1 post-treatment (70.1% in group B, 66.5% in group C, and 31.9% in group D) except group A (101.7%). However, different recoveries at day 7 (132.4% in group A, 105.4% in group B, 103.4% in group C, and 48% in group D) were observed. Therefore, group D showed a marked decrease in tumor vascularity at day 7 post-treatment compared with other groups with a statistical significance (p<0.05); this suggests a better therapeutic effect of the IA injection of CKD-516 dissolved in lipiodol. Conclusion: In an orthotopic HCC model, the IA injection of CKD516 showed a therapeutic benefit when dissolved in lipiodol. The application of CKD-516 to conventional TACE may open a new therapeutic strategy to treat HCC patient.

P-147 Multipolar radiofrequency ablation of adrenal gland with bipolar ablation device: ex vivo and in vivo experimental studies in porcine and bovine models T. Kinoshita1, K. Seiji1, S. Takahashi1, K. Takase1, F. Sato2, R. Morimoto2, Y. Ono2, M. Inaba3; 1Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan, 2Department of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai, Japan, 3Development Department, Olympus Medical Systems Co., Tokyo, Japan Purpose: The aim of this study was to evaluate the efficacy and safety of the bipolar radiofrequency ablation (RFA) system for the treatment of adrenal aldosterone-producing adenomas (APAs) in ex vivo and in vivo studies.

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Material and Methods: Ex vivo studies (n=18) were performed using bovine adrenal glands with a single applicator (group ex-A, n=6), or two applicators (groups ex-B, n=6 and ex-C, n=6). Positions of electrodes were different between groups ex-B and ex-C. In vivo studies (n=4) were performed using poccine adrenal glands with a single applicator (group in-A, n=2) or two applicators (group in-B, n=2). After the ablations, the areas of coagulative necrosis were measured with two directions (D1, along the applicator axis; D2, perpendicular to D1). We also examined heat-induced damage of the organs adjacent to the adrenal glands. Results: In ex vivo studies, the mean D1 and D2 respectively were 10.96 ± 1.50 mm and 11.99 ± 1.16 mm in group ex-A, 10.0 ± 1.65 mm and 12.66 ± 2.40 mm in group ex-B, and 22.10 ± 2.00 mm and 23.37± 1. 95 mm in group ex-C. In in vivo study, the mean D1 and D2, respectively, were 9.03 mm and 12.23 mm in group in-A and 9.52 mm and 16.38 mm in group in-B. No heat-induced damage was histologically evident in the adjacent organs. Conclusion: The bipolar ablation system achieved sufficient coagulation zones to treat most of adrenal APAs, 97% of which are less than 25 mm in diameter in our previous study. Moreover, no heatinduced damage was histologically evident in the adjacent organs.

P-148 Pilot study of percutaneous isolated pancreas perfusion chemotherapy: pharmacokinetic and histological assessment in a pig model S. Murata1, S. Onozawa1, T. Mine1, T. Ueda1, F. Sugihara1, D. Yasui1, S. Kumita1, M. Satake2; 1Radiology/Center for Advanced Medical Technology, Nippon Medical School, Tokyo, Japan, 2Diagnostic Radiology, National Cancer Center East, Chiba-ken, Japan Purpose: Pancreatic cancer is one of the most lethal cancers, with a low response rate to systemic chemotherapy. The aim of this study was to evaluate the feasibility of percutaneous isolated pancreas perfusion (PIPP) using a pig model. Material and Methods: All animal experiments were approved by the Animal Experiment Ethics Committee of our university. PIPP was performed in 15 female pigs, weighing 38–43 kg (mean, 41 kg), by redirecting pancreatic outflow through the portal vein. Blood containing cisplatin (1.5 mg/kg) in an extracorporeal circuit was circulated through the pancreas at 3 infusion rates, 40, 60, and 80 ml/min, under isolation with balloon catheters. The organs were examined angiographically and histopathologically, and the maximum platinum concentration (Cmax), the area under the concentration–time curve (AUC), and chronologic laboratory data were measured. Results: Angiography confirmed the patency of the PIPP system. Histopathological examinations showed no abnormalities in the pancreas and other organs at an infusion rate of 40 ml/min. However, edematous changes in the pancreas were observed in animals infused at 60 and 80 ml/min. The pancreatic Cmax (52.3 mg/L) was 74.7-fold greater than the systemic Cmax (0.7 mg/L), and the pancreatic AUC (754.5 min·mg·L-1) was 58.2-fold greater than the systemic AUC (12.8 min·mg·L-1) at an infusion rate of 40 ml/min. Within 1 week, the chronologic laboratory data attained normal range or pre-treatment values. Conclusion: The PIPP technique at an infusion rate of 40 ml/min appears safe and feasible for the perfusion of the pancreas.

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P-149 Pre-clinical evaluation of the caterpillar device for peripheral embolisation in a porcine model W. Allen1, L. Mullins1, M.K. Razavi2, F. Sharif 3, C. Forde1; 1Embo Medical, Galway, Ireland, 2Interventional Radiology, St. Joseph Vascular Institute, Orange, CA, United States of America, 3Interventional Cardiology, University Hospital Galway, Galway, Ireland Purpose: Despite recent developments in coils and plugs, vessel embolization still requires the use of multiple devices for vessel length treatment, and risks persist in terms of vessel recanalisation and migration. The objective of this study was to evaluate a novel embolisation device in a porcine model. Material and Methods: The caterpillar device consists of a stem with a high density array of radiating fibres intended to anchor the device while inducing vessel occlusion. The device is available in lengths up to 20 cm, is detachable and does not require any adjustment in-situ. Four Yorkshire swine (50–60kg) were implanted with the caterpillar device (test) or fibred coils (control). All vessels in the test group were treated with one caterpillar size (diameter). Three animals were survived for 30 days. Histopathology was conducted on one animal. Results: One caterpillar device was deployed per vessel in the test group, while in the control group, 4–5 coils were deployed per vessel. Peripheral veins and arteries were implanted ranging in diameter from 4 to 11 mm. Angiography demonstrated enhanced vessel occlusion in the caterpillar device compared with the controls. At 30 days, histology demonstrated the test device was associated with uniform, extensive device dispersion in the vessel lumen, while the control device was associated with variable device dispersion and incidences of mild/moderate recanalization. Recanalization in the coil group was also present angiographically. Conclusion: The caterpillar device may be an effective option for peripheral embolization, enabling full vessel length and diameter treatment using one device.

P-150 Translational experience in the treatment of duchenne muscular dystrophy (DMD) by intra-arterial mesoangioblasts (MABs) transplantation: from a toxicity study in 10 beagle dogs to the first phase-1 study in 5 dystrophic children M. Venturini1, G. Cossu2, M. Colombo1, F. De Cobelli1, A. Del Maschio1; 1Radiology, Vita-Salute University, San Raffaele Hospital, Milan, Italy, 2Stem Cells Department, Vita-Salute University, San Raffaele Hospital, Milan, Italy WITHDRAWN

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Usefulness of 3D/3D fusion technology in image-guided procedures:  a step-by-step display of its creation and a review of its utilization in various scenarios

Mission creep with Angioseal: what else can we do?

R.K.R. Gurajala1, C. Martin III1, R. Setser 2, A. Gill1, G. Mclennan1, M.J. Sands3, K. Karuppasamy1; 1Interventional Radiology, Cleveland Clinic, Cleveland, OH, United States of America, 2Seimens, Seimens, Cleveland, OH, United States of America, 3Radiology, Cleveland Clinic, Cleveland, OH, United States of America Learning Objectives: 1. To demonstrate innovative uses of 3D/3D fusion technology in image-guided procedures. 2. To provide a step-by-step practical guide and tips to achieve reliable fusion. Background: With advancements in 3D/3D fusion technology coupled with increasing use of cone-beam CT, prior MRI and CT data can be merged more reliably during procedures to provide new information on anatomical relationships. This allows for better pre-procedural planning and improved guidance for any procedure, especially more complex procedures. Clinical Findings/Procedure: A step-by-step guide on fusing data and techniques for fine adjustments improving reliability during procedures is shown in the following scenarios: 1. Color coding the intricate relationship between SMA branches and SMV tributaries in a live small bowel donor was demonstrated by fusing two c-arm CT scans obtained following a single SMA injection. 2. Adequate filling of gastric varices was confirmed during balloon-occluded retrograde transvenous obliteration by fusing a C-arm CT with prior venous phase CT. 3. A pathway for recanalizing a central hilar biliary stricture was demonstrated after fusing a unilateral C-arm CT cholangiogram with prior MRCP. 4. Real-time graphical representation of the portal system was achieved prior to TIPS creation by fusing a C-arm CT with prior MRI/CT, providing additional options for access without repeated portograms. 5. During CT-guided mediastinal mass biopsy, limited chest CT with the needle in place was fused with prior PET for confirmation of the needle tip in the metabolically active component. Conclusion: Various uses of 3D/3D fusion technology are reviewed. A simplified guide to achieve fusion is likely to extend its use and enable further innovations.

P-152 Closing neo-esophageal pleural fistula with Amplatzer ASD closure device – it works! S.S. Kulkarni1, A.M. Polnaya2, N.S. Shetty 2, A. Janu2, S.S. Patil2, K.B. Gala2, A. Kumar 2, M. Thakur 2; 1Radiology, Tata Memorial Hospital, Mumbai, India, 2Interventional Radiology, Tata Memorial Hospital, Mumbai, India A 67-year-old male who had undergone transthoracic esophagectomy for T3N1M0 esophageal carcinoma presented with persistent pleural drainage secondary to gastric tube pleural fistula at the upper anastomatic site. The defect was successfully closed using atrial septal defect device augmented with N-butyl cyanoacrylate.

W. Sprenger De Rover, W. Al-Obaydi, S. Whitaker, H. White, S. Travis; Radiology, Nottingham University Hospitals, Nottingham, United Kingdom This case report demonstrates a relatively novel use in the treatment of arterial pseudo-aneurysms successfully with an already wellknown closure device called Angioseal. In the correct clinical setting and indications, it may be more useful than you think.

GI tract intervention P-154 Efficacy of transcatheter arterial embolization for colonic diverticular hemorrhage T. Iraha1, H. Takara1, W. Higashiura1, E. Yamada1, W. Tamaki1, T. Kubota2, M. Arashiro2, K. Kikuchi2, T. Yasutani1; 1Radiology, Okinawa Prefectural Chubu Hospital, Uruma, Japan, 2Gastrointestinal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Japan Purpose: To evaluate the efficacy of transcatheter arterial embolization (TAE) for colonic diverticular hemorrhage (CDH). Material and Methods: A retrospective review of all patients who presented to the emergency department and underwent angiography for CDH from February 2008 to November 2013 was performed. TAE was performed using microcoils at the level of the vasa recta or the marginal artery when microcatheter wasn’t positioned into the vasa recta. Short-term outcomes (≤30 days from the procedure) identified including technical success (defined as immediate cessation of extravasation as identified by a post-procedural angiography), clinical success (defined as the termination of bleeding per rectum and the stabilization of hemoglobin levels that required no more than 2U of packed red blood cells), complication, surgical intervention, and mortality rate. Long-term outcomes including readmission for rebleeding and/or surgical operation were also evaluated. Results: Forty-five patients underwent angiography. A total of 36 patients (median age 77 years) underwent TAE, while 9 patients were managed conservatively because of no extravasation detected by angiography. Technical and clinical success rates were 89% and 81%, respectively. Mild colonic ischemia was noted in 3 patients, and they did not need further intervention. There was no patient with surgical intervention, and 30-day mortality rate was 0%. Five of 36 patients had a new episode of bleeding, 4 of which were treated with TAE and one was successfully managed conservatively. No patients needed surgical intervention during follow-up. Conclusion: TAE for CDH has an acceptable short-term outcome with low complication rates; moreover, it is also effective for rebleeding in the long-term period.

P-155 Endovascular thromboaspiration in acute superior mesenteric artery thromboembolic occlusion U.G. Rossi1, P. Rigamonti1, F. Petrocelli2, M. Dahmane2, C. Ferro2, M. Cariati1; 1Radiology and Interventional Radiology, San Carlo Borromeo Hospital, Milan, Italy, 2Radiology, IRCCS San Martino, University Hospital, Genoa, Italy Purpose: To describe our experience in the management with Endovascular thromboaspiration in acute superior mesenteric artery (SMA) thromboembolic occlusion.

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Material and Methods: We treated 21 patients with MD-CT diagnosis of acute SMA thromboembolic occlusion and initial signs of bowel ischemia. In all, 15/21 (71%) patients underwent endovascular thromboaspiration through femoral access with co-axial technique (6-8-Fr sheath, 5-Fr guiding catheter, 0.035 hydrophilic guide-wire) for the treatment of the SMA trunk and its collaterals. In the remaining 6/21 (29%) patients underwent the same endovascular technique with consequent transcatheter (5 Fr) selective thrombolytic therapy (12 hours) for the treatment of small distal branches residual thrombus. Results: Technical success was achieved in 20/21 patients (95%). 15/21 (71%) patients had post-procedural patency of the main trunk of the SMA and its distal branches, with no bowel resection. 4/21 (19%) patients underwent partial bowel resection, and 2/21 (8%) patients died after massive bowel ischemia. Conclusion: Acute SMA thromboembolic occlusion is potentially fatal vascular emergency that requires rapid restoration of mesenteric blood flow as well as early diagnosis. Percutaneous endovascular revascularization techniques are a valuable alternative to surgical thrombectomy as a first-line therapy.

P-156 Percutaneous radiologic gastrostomy using the one-anchor technique in patients with a history of partial gastrectomy J.H. Shin1, J.-H. Park1, H.-Y. Song1, E.-Y. Kim2; 1Radiology, Asan Medical Center, Seoul, Korea, 2Medical Device Development Center, Osong Medical Innovation Foundation, Chungbuk, Korea Purpose: The purpose of our study was to assess the feasibility and safety of performing percutaneous radiologic gastrostomy (PRG) in patients who had undergone partial gastrectomy and to evaluate the factors associated with the technical success. Material and Methods: Nineteen patients with a history of partial gastrectomy, and who were referred for PRG, were included in our study between April 2006 and April 2012. The remnant stomach was punctured using a 21-gauge Chiba-needle. A single anchor was used for the gastropexy, and a 12–14 F gastrostomy tube was inserted. Data were collected regarding the technical result of the procedure, the procedure time, and any complications. Univariate analyses were performed to determine the factors related to the technical success. Results: There was technical success of PRG in 10 patients (53%), while a failed attempt and failure without an attempt were seen in five (26%) and four (21%) patients, respectively. Percutaneous radiologic jejunostomy (PRJ) was successfully performed in nine patients who experienced technical failure. In ten patients with technical success, the mean procedure time was 6.35 minutes. Major complications occurred in two patients, including tube passage through the liver and pneumoperitoneum requiring tube removal, and severe hemorrhage. The success rate was significantly higher in patients with Billroth I gastrectomy (100%, 6/6) than in patients with Billroth II gastrectomy (31%, 4/13) (P=0.011). Conclusion: PRG could be successfully performed using the oneanchor technique in more than half of the patients who had previously undergone partial gastrectomy. The success rate was significantly higher in patients with Billroth I gastrectomy than in patients with Billroth II gastrectomy.

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P-157 Pharmacokinetics of gelatin sponge particles in a rabbit VX2 liver tumor model of hepatic arterial embolization Y.W. Zhang; Interventional Radiology, Affiliated Zhong shan Hospital of Dalian Medical University, Dalian, China Purpose: To investigate pharmacokinetics of gelatin sponge particles (GSMs) combined with epirubicin in a rabbit VX2 liver tumor model of hepatic arterial chemoembolization (TACE). Material and Methods: Eighteen successful models of VX2 in New Zealand white rabbits was established, which were divided into three groups randomly, HAI group (n = 6): the epirubicin solution (epirubicin 10mg mixed with normal saline 10ml into the hepatic artery; GSMs-TACE group(n=6): GSMs (20mg) mixed with epirubicin solution (1mg/ml) Lipiodol-TACE group (n=6): epirubicin (10mg) mixed with Lipidol (10ml). Samples collected from femoral vein at 5, 10, 20, 30, 40, 60, 90, 120 min after therapy after 120 min,rabbit was killed and tumor and peritumoral normal liver tissue was excised .epirubicin concentrations in plasma and tumor and peritumoral liver tissue were measured. Results: The epirubicin concentration in plasma was significantly lower in GSMs-TACE group than in HAI group. Cmax in there groups was at 5min after administration was 28.77±7.15μg/ ml for Lipiodol-TACE group, 83.84±32.28μg/ml for GSMs-TACE group,and 238.46±23.44μg/ml for HAI group. The epirubicin concentration in tumor tissue was 53.06±19.6μg/g for LP-TACE group, 44.49±16.80μg/g for the GSMs-TACE group and 18.32±8.30μg/g for HAI group, epirubicin concentration of GSMs-TACE group was significantly higher than that of HAI group (p<0.05). The AUC (μg.min/ ml) at 0–120 min in Lipiodol-TACE, GSMs-TACE, and HAI groups were 1815±889.88)μg.min/ml, 3 416±799.90, and 11 899±2 717.17, respectively, was lower in GSMs-TACE group than in HAI group (p<0.05). Conclusion: Compared with HAI, GSMs-TACE has higher epirubicin concentrations in tumor and lower concentrations in plasma. The results show GSPs-TACE has a feature of slow drug release – it may be one of the mechanisms of GSPs-TACE for HCC.

P-158 Treatment of esophagopleural fistulae using covered retrievable expandable metallic stents J.H. Shin1, T.-H. Kim2, J.H. Kim1, E.-Y. Kim3; 1Radiology, Asan Medical Center, Seoul, Korea, 2Radiological Science, Kangwon National University, Kangwon, Korea, 3Medical Device Development Center, Osong Medical Innovation Foundation, Chungbuk, Korea Purpose: To evaluate the clinical efficacy of the placement of covered retrievable expandable metallic stents for esophagopleural fistulas (EPFs). Material and Methods: Between 1997 and 2013, nine patients with EPF were treated using covered retrievable expandable metallic stents. The underlying causes of EPF were esophageal carcinoma (n=6), lung cancer (n=2), and postoperative pyothorax for Boerhaave syndrome (n=1). Results: Technical success was achieved in eight patients (88.9%). In one patient, incomplete EPF closure was due to incomplete stent expansion. Complete EPF closure, clinical success, within seven days, was achieved in five patients (55.6%). Overall fistula persistence (n=1) or reopening (n=4) occurred in five (55.6%) 0–15 days after stent placement. The causes of reopening were due to the gap between the stent and the esophagus (n=3) or stent migration (n=1). For fistula persistence or reopening, additional interventional management, such as gastrostomy, stent removal or stent reinsertion, was performed. Stent migration occurred as a complication in one

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patient with benign-cause EPF secondary to postoperative pyothorax. In the eight patients who died during the follow-up period, the mean and median survival times were 78.8 and 46 days, respectively. Conclusion: Placement of covered expandable metallic esophageal stents for the palliative treatment of EPF is technically feasible, although the rate of clinical success seen was poor due to fistula persistence or reopening. Fistula reopening was caused by the gap between the stent and the esophagus or by stent migration, and additional interventional treatment was useful in order to ensure enteral nutritional support.

P-159 Celiac ganglion neurolysis: an underused palliative procedure M.-G. Knuttinen1, M. Salahi1, R.C. Gaba2, J. Minocha1, J.T. Bui3, P. Giulianotti4, C.E. Ray, Jr.3; 1Radiology, University of Illinois Hospital and Health Sciences System, Chicago, IL, United States of America, 2Radiology, University of Illinois Hospital, Chicago, IL, United States of America, 3Radiology, University of Illinois at Chicago, Chicago, IL, United States of America, 4Minimally Invasive Surgery, University of Illinois Hospital and Health Sciences System, Chicago, IL, United States of America Learning Objectives: 1. To review the anatomy of the celiac plexus. 2. To describe the current indications and contraindications for celiac plexus neurolysis. 3. To illustrate the techniques used and various tips to ensure a successful outcome. Background: The management of cancer-related abdominal pain can be difficult and challenging. The majority of such patients require chronic use of narcotics, which can lead to several adverse side effects. The celiac plexus is the largest visceral plexus, and is the main target point of pain transmission from the upper abdominal organs. Celiac plexus neurolysis refers to the permanent destruction of the celiac plexus with the use of a sclerosant. When performed, this treatment has been reported to have a long-lasting benefit, with up to 70%– 90% clinical efficacy in patients with various abdominal cancers. Clinical Findings/Procedure: After careful pre-procedure and patient evaluation, CT guidance has been the preferred modality used for celiac plexus neurolysis as the plexus can be frequently identified during diagnostic abdominal CT. Various approaches (anterior vs. posterior; temporary vs. permanent) have been described in using this technique and will be discussed in this exhibit. In addition, the role of non-radiologic guidance (e.g., endoscopic ultrasound) will also be discussed. Finally, prognostic indicators for clinical and technical success will be identified. Conclusion: Celiac plexus neurolysis should be considered a palliative care intervention for patients with advanced abdominal cancers and significant abdominal pain. Interventional radiologists should be familiar with the indications, technical considerations, complications, and outcomes of this highly effective procedure.

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P-160 Colonic stenting: everything that a resident needs to know J.R. Fortuño, J.F. Falco-Fages, E. Criado, A. Alguersuari, J. Perendreu, J. Branera; Interventional Radiology, UDIAT-CD. Corporacio Parc Tauli, Sabadell, Spain Learning Objectives: Based on our experience with more than 850 colonic stents, the purpose of the pictorial review is the following: 1. To familiariarize radiology residents with the accepted indications and contraindications of colonic stenting. 2. To give the residents an overview of the stenting procedure and its technical tricks and tips, and to provide an overview of all radioprotection concerns. 3. To illustrate the post-procedure management, possible complications, and ways to deal with them. 4. To emphasize uncommon indications and new technical developments in the field. Background: Colonic stenting is a highly accepted treatment for colonic cancer prior to surgery or as a defintive treatment of palliative care patients. Although it was initially a pure radiological technique, nowadays it has an endoscopic approach. We believe that we, as interventional radiologists (IRs) who perform the technique, must explain our experiences to the future IRs in order to continue performing colonic stenting in our departments. Clinical Findings/Procedure: In this exhibit, we illustrate the following points in a case-based style: -Indications and contraindications -Pre-procedure management -Technical tricks and tips -Radioprotection concerns -Post-procedure management -Complications and how to deal with them -New developments in the technique Conclusion: Colonic stenting is an effective method of relieving colonic obstruction as a palliative treatment and as a pre-operative bridge to one-stage oncology surgery. Most of the times, this technique is away from radiology departments. This exhibit describes all the basic information that a radiology resident needs to know in order to understand the procedure and to establish a colonic stenting program in his/her future career.

P-161 Percutaneous radiological gastrostomy: from “A” to “Z” U.G. Rossi1, P. Rigamonti1, P. Torcia2, F. Alberghini3, F. Petrocelli4, M. Cariati1; 1Radiology and Interventional Radiology, San Carlo Borromeo Hospital, Milan, Italy, 2Radiology and Interventional Radiology, San Giovanni Addolorata Hospital, Rome, Italy, 3Anesthesiology, San Carlo Borromeo Hospital, Milan, Italy, 4Radiology, IRCCS San Martino, University Hospital, Genoa, Italy Learning Objectives: To describe the step-by-step procedure of percutaneous radiological gastrostomy (PRG). Background: PRG consists of creating an artificial gastrocutaneous fistula between the anterior wall of the stomach and the anterior abdomen. PRG is now widely recognised as a safe procedure, which has a low risk of complications and is well tolerated by patients. Since PRG was first described in 1981, the procedure has undergone many technical modifications. In early reports, it was carried out with the Seldinger technique alone, whereas nowadays it is performed using gastropexy – the fixation of the anterior gastric wall to the anterior abdominal wall using a T-shaped fastener, known as an anchor.

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Clinical Findings/Procedure: The purpose of this poster is to illustrate the “A” to “Z” of the PRG technique. Conclusion: Percutaneous gastrostomy techniques (radiological and endoscopic) have replaced surgical gastrostomy. A perfect knowledge of all PRG steps is mandatory to perform it in a fast, safe and effective manner.

P-162 Single-puncture pull-through gastrostomy tube: a step-bystep review C. Kaufman, K. Quencer, H.R. Mojibian; Department of Radiology, Yale New Haven Hospital, New Haven, CT, United States of America Learning Objectives: 1. To review the indications and contraindications of pull-through percutaneous gastrostomy tube placement. 2. To provide a step-by-step review of how to place a pull-though gastrostomy tube. Background: Gastrostomy tube placement is crucial for patients who are unable to receive sufficient oral nutrition. Traditionally, gastrostomy tubes were placed surgically; this has since been surpassed by percutaneous placement. There are two main types of techniques for placing percutaneous gastrostomy tubes: the “push” technique and the “pull” technique. The “push” technique entails direct placement of the gastrostomy tube into the stomach using a gastropexy with T-fasteners through which the gastrostomy tube is placed. The “pull” technique involves a single puncture of the stomach and the placement of a catheter and snare up the esophagus and into the mouth. Subsequently, the mushroom-tipped gastrostomy tube is pulled into the stomach. The “pull” technique facilitates the placement of a larger diameter tube, lessening the rate of clogging as well as allowing for the decompression of bowel in cases of chronic obstruction. Additionally, the mushroom tip makes the tube much less prone to dislodgement. Clinical Findings/Procedure: This poster will review the indications and contraindications as well as provide illustrated step-by-step instructions for the placement of a “pull” gastrostomy tube. Conclusion: The single-puncture pull-through technique is not commonly used in interventional radiology but facilitates the placement of larger diameter gastrostomy tubes with a lower risk of clogging and dislodgement. This poster will provide an image-based review of the procedure technique.

P-163 Endovascular treatment of a gastric arteriovenous malformation (AVM): a rare cause of upper gastrointestinal bleed (UGIB) S. Ilyas, N. Shaida, B. Koo; Radiology, Addenbrookes Hospital, Cambridge, United Kingdom Haemorrhage from gastric AVMs is an extremely rare cause of UGIB, especially in the young. We report the first case (a 28-year-old male) in which a gastric AVM was successfully embolised using a liquid embolic agent (Onyx).

P-164 Percutaneous transhepatic aproach to fundal varices and embolisation V. Marinkovic, M. Scepanovic, M. Mihajlovic, S. Rusovic; Institute of Radiology, Medical Military Academy, Belgrade, Serbia Transhepatic percutaneous approach to the portal vein in a patient with bleeding fundal varices and coil embolisation of oesophageal–fundal varices. MDCT arteriography and DSA findings revealed excellent outcome.

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P-165 Successful transcatheter embolization of a superior mesenteric arteriovenous fistula: comprehensive imaging assessment and 3-year follow-up A.S. Awad, I.Y. Wassal, I.A. Shehata, A.A. Nassef; Diagnostic and Interventional Radiology, Kasr Alainy, Cairo, Egypt Successful transarterial coil embolization of an iatrogenic superior mesenteric arteriovenous fistula in a 24-year-old patient with a history of bowel resection 9 years ago. We present the pre- and postprocedural findings using different imaging modalities.

P-166 Unusual cause of massive colonic haemorrhage successfully treated with embolisation of the splenic artery S. Ameli-Renani1, S. Mahalingam2, K. Burney3; 1Radiology, St Georges Hospital NHS Trust, London, United Kingdom, 2Surgery, Epsom and St Helier Hospital, London, United Kingdom, 3Radiology, Epsom and St Helier Hospital, London, United Kingdom A 50-year-old man with a history of pancreatitis presented with collapse and frank bleeding per rectum. CTA showed a 2-cm splenic artery pseudoaneurysm fistulating into the colon. The splenic artery was selectively catheterised and embolised with coils and Gelfoam with good angiographic and symptomatic results.

Gynaecological intervention (including UFE) P-167 Antero-retrograde sclerotherapy in the treatment of vulvoperineal varicosity F. Colucci1, S. Giuliani1, S. Pillon2, V. Miele1, L. de’Medici3; 1U.O. Radiologia Vascolare Interventistica, Azienda Ospedaliera S. Camillo-Forlanini, Rome, Italy, 2U.O.S. Angiologia, Azienda Ospedaliera S. Camillo-Forlanini, Rome, Italy, 3Centro Studi Raolu Gueze, Centro Studi Raolu Gueze, Rome, Italy Purpose: To evaluate the efficacy of antero-retrograde varices sclerotherapy in the treatment of vulvo-perineal varicosity. Material and Methods: Between March 2008 and December 2012, 19 patients (42.3 ± 6.7 years) with dyspareunia and vulvo-perineal varicosity were examined. Patients who had undergone percutaneous veins sclerosis with 2% atossisclerol during the previous year presented with recurrence of symptoms and vulvo-perineal varicosity. Pelvic varices were found in all patients by transvaginal Doppler ultrasonography. Percutaneous sclerotherapy was performed either by retrograde or anterograde approaches. The retrograde approach was used to treat utero-ovarian ectasic veins and any pelvi-perineal collaterals revealed by phlebography. Anterograde sclerotherapy was achieved through direct puncture of the vulvo-perineal varicosity, filled with contrast media refluxed from perineal incontinent veins, using the Valsalva maneuver under fluoroscopic control. Trans-vaginal ultrasonography follow-up was performed at 6–12 months Results: Phlebography of the ovarian veins confirmed pelvic varices and showed pathologic retrograde flux in pelvis-perineal shunts through perineal and clitoridian points. Antero-retrograde technique allowed us to reach pelvi-perineal shunts from both sites and block the reflux permanently. The procedure was well tolerate and no major complications were observed. No evidence of pelvic varices was found after 6–12 months by transvaginal ultrasonography. No recurrence of vulvoperineal varicosity was detected by the

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gynecologist or the vascular surgeon up to 24 months, and improvement of dyspareunia was reported by all patents. Conclusion: Antero-retrograde varices sclerotherapy is a safe and effective technique for the treatment of vulvoperineal varicosity and must always be considered when pelvic congestion syndrome is associated.

P-168 Do apparent pretreatment diffusion coefficient measurements predict the response to uterine artery embolisation for adenomyosis? M.D. Kim1, D.Y. Lee2, Y. Park1, D.C. Jung1, S.J. Lee1, I.J. Kim1, S.I. Park3, J.Y. Won3, Y. Yoon4; 1Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea, 2Radiology, Yonsei University College of Medicine, Seoul, Korea, 3Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea, 4Radiology, National Medical Center, Seoul, Korea Purpose: To determine the usefulness of the apparent diffusion coefficient (ADC) to predict the response to uterine artery embolization (UAE) for symptomatic adenomyosis. Material and Methods: Twenty-five patients who underwent diffusion-weighted (DW) magnetic resonance imaging (MRI) before UAE between June 2011 and December 2012 were included. All patients underwent a 3-month follow-up MRI after UAE using polyvinyl alcohol (PVA) particles as the embolic agent. Quantitative measurement of ADC was performed for each adenomyosis. Complete response and incomplete response were defined as ≥90% or <90%, respectively, of the non-perfusion area with adenomyosis following UAE at the 3-month follow-up MRI. The ADC values were compared between patients who achieved a complete or incomplete response after UAE. Results: Nineteen patients showed a complete response, and 6 showed an incomplete response. The ADC value ranged from 0.842 to 1.346×10 -3 mm2/s (mean 1.075±0.117). The mean ADC of the complete response group was 1.043±0.237 and that of the incomplete response group was 1.176±0.429 (p=0.012). Using a threshold of <1.147×10 -3 mm2/s, the sensitivity and specificity of ADC to predict success after UAE were 83.3% and 84.2%, respectively. Conclusion: ADC of uterine adenomyosis can be used to predict successful response to UAE for adenomyosis.

P-169 MRgFUS treatment of uterine fibroids: three years of experience F. Ciolina, F. Boni, C. Palla, F. Zaccagna, A. Napoli, C. Catalano; Radiological Sciences, Oncology and Anatomo-pathology, Policlinico Umberto I-Sapienza University of Rome, Rome, Italy Purpose: To retrospectively evaluate the non-perfused volume (NPV) necessary to obtain an optimal ablation of uterine fibroids using magnetic resonance-guided focused ultrasound (MRgFUS). Material and Methods: In all, 147 fibroids (52±19 mm) in 124 symptomatic women (average age 39±5) were treated using MRgFUS (ExAblate 2100) combined with a 3-T MR unit (GE). Symptoms were scored using Symptoms Severity Score (SSS) and quality of life was determined using the UFS-QOL score. Immediately after treatment, non-perfused volume (NPV) was calculated from T1-weighted contrast-enhanced MR sequences. The average volume of treated fibroids was 90.27±80.4 mm3. Follow-up (FU) images were obtained at 3 and 12 months after treatment and served to determine leiomyoma shrinkage and at each FU, patients were asked to answer the same questionnaire used before treatment. The NPV volume after treatment was correlated to leyomioma shrinkage and relief of symptoms.

Abstract Book Results: MRgFUS-treated patients demonstrated a significant change in USF-QoL score: mean SSS values were 48.6±13.4 (pretreatment), 25.1±8.9 (3-month FU) and 19.3± 6.8 (12-month FU). Fibroids volume changed from 90.27±80.4 mm3 (pre-treatment) to 54±66.1 mm3 (12-month FU). We encountered a statistically significant difference between the two values (p=0.001). Mean posttreatment VNP was 57,65±52.9 mm3, about 63% of total fibroid volume (p=0.001). We observed a significant improvement in USF-QoL and a major shrinkage of treated myoma when the NPV was >60% (p=0.001). Conclusion: MRgFUS therapy is effective in symptom relief and volume shrinkage when >60% of leyomioma was treated.

P-170 Potentially relevant MRI findings in patients who became pregnant after uterine artery embolization for symptomatic fibroids: comparison with myomectomy M.D. Kim1, D.Y. Lee2, J.T. Lee3, S.J. Lee2, I.J. Kim1, S.I. Park1, J.Y. Won1, Y. Yoon4; 1Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea, 2Radiology, Yonsei University College of Medicine, Seoul, Korea, 3Radiology, CHA Bundang Medical Center, Seongnam, Korea, 4Radiology, National Medical Center, Seoul, Korea Purpose: To evaluate the MRI findings of fibroids in women who became pregnant after uterine artery embolization (UAE) and compare them with the MRI findings of myomectomy patients. The aim of the study was to determine whether MRI findings can narrow down the indication of UAE for patients who desire future pregnancy. Material and Methods: Among 900 patients who underwent UAE, MRI findings of women who became pregnant after UAE (UAE group; n=20) were retrospectively analyzed and compared with those of patients after myomectomy (Myomectomy group; n=10). The location and size of the predominant fibroid and involvement of the fundus were evaluated. The maximum length of endometrial displacement by the fibroid from the imaginary line of the endometrium was measured. Results: The mean size of the fibroid was 10.3 cm in the myomectomy group, which was significantly larger than that of the UAE group. In the UAE group, women with submucosal fibroids > 5 cm that were completely pedunculated or with >50% of the fibroid located in the endometrial cavity achieved pregnancy. Women with an intramural myoma that displaced the endometrium by <17 mm became pregnant, whereas a woman with intramural myoma that displaced the endometrium >30 mm was not fertile. This patient underwent myomectomy, followed by a successful pregnancy. The displacement of the endometrium was significantly more severe in the myomectomy group than in the UAE group (14.3 mm vs. 5.3 mm; p=0.044). Conclusion: MRI assessment might be helpful in patient selection when considering UAE in patients who desire future pregnancy.

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P-171 Pre-procedure and post-procedure administration of Oxycodone improves pain management after uterine fibroid embolization G.M.G. Freire1, J.M. Motta-Leal-Filho1, R.N. Cavalcante2, B.D. Fina1, R.D. Rocha1, M.D.L. Messina2, I.D.P. Posso1, M.D. May1, M.L. Pinheiro Oliveira1, F.L. Galastri2, B.B. Affonso2, F. Nasser 2; 1Radiologia Intervencionista e Cirurgia Endovascular, Hospital Israelita Albert Einstein, São Paulo, Brazil, 2Radiologia Vascular Intervencionista, Hospital Israelita Albert Einstein, São Paulo, Brazil Purpose: To evaluate if standard anesthesia in combination to preand post-procedure administration of controlled-release oxycodone (CRO) improves pain control and decreases the amount of required post-procedure opioids in uterine fibroid embolization (UFE). Material and Methods: Between January 2009 and March 2010, 60 consecutive women were prospectively randomized in two groups for UFE: Group CRO, 30 patients that underwent standard anesthetic procedure plus Oxycodone and Group C (control group), 30 patients that underwent standard anesthetic procedure (combination of morphine intrathecal, sedation with propofol, intravenous analgesia with ketoprofen, and metamizole). Age, pain, nausea/vomiting, use and dose of morphine (PCA device), pre-procedure fibroid volume, and length of hospital stay were evaluated and compared in both groups. We also measured the fibroid volume by MRI and correlated with post-embolization pelvic pain over the first 24 hours. Results: A significant difference was seen in pain scores at 24 hours (p=0.029), with less pain in the CRO group. Morphine was administered at higher levels (p=0.130) and in more patientes in the C group (p=0.017). Pruritus was lower in the CRO group (p=0.029). No correlation was seen between leiomyoma volume and pain levels over 24 hours. Hospital stay duration was not different between the two groups. Conclusion: The addition of CRO to standard analgesia for UFE provides better analgesia with lower pain scores in 24 hours, use of a lesser amount of morphine, and decreased incidence of pruritus.

P-172 Prophylactic internal iliac balloon placement prior to caesarean section in patients with placenta accreta P.J. Nicholson, K. James, J. Murphy, F. Moloney, L. Spence, J. Buckley, D. Tuite; Radiology, Cork University Hospital, Cork, Ireland Purpose: To report on maternal and foetal outcomes following the use of prophylactic internal iliac artery occlusion balloons in the management of patients with placenta accreta or a variant thereof. Material and Methods: We undertook a retrospective chart review of all patients with abnormal placentation who underwent prophylactic internal iliac balloon placement prior to elective caesarean section. We also looked at foetal outcomes following the procedure. Results: Over a 44-month period, 22 patients with placenta accreta or a variant thereof underwent caesarean section after first undergoing prophylactic placement of bilateral internal artery occlusion balloons. Average follow-up duration was 2.08 years. Technical success was achieved in 100%. The average gestational age was 37 weeks 6 days, and mean gravidity was 2.8. Mean number of previous caesarean sections was 2.4, while mean maternal age was 35 years. Mean intraoperative blood loss was 1.4 litres, and mean number of blood units transfused was 2. Mean duration of surgery was 90 minutes, mean total length of hospital stay 7.5 days, and mean duration of ICU/HDU stay was 1.2 days. The balloons were inflated in 80% of cases, and 1 patient underwent subsequent hysterectomy.

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There were no major maternal complications due to the procedure. Foetal outcomes were also satisfactory, with no foetal acidosis or injury secondary to the procedure. Conclusion: Prophylactic placement of arterial balloons prior to caesarean section in patients with accreta is well tolerated and leads to satisfactory maternal outcomes with minimal complications. Uniquely, we have also demonstrated that this technique results in excellent foetal outcomes.

P-173 Radial versus femoral artery access for uterine fibroid embolization Y. Khairutdinov1, I. Vorontsov 2, E. Kravchenko3, O. Tsygankova3; 1Interventional Radiology, Botkin Hospital, Moscow, Russian Federation, 2Department of Interventional Radiology, BSMP №1, Omsk, Russian Federation, 3Obstetrics and Gynaecology, OSMA, Omsk, Russian Federation Purpose: We aimed to assess whether radial artery access was superior to femoral artery access in patients undergoing uterine fibroid embolization (UFE). Material and Methods: Fifty patients with symptomatic uterine fibroid were enrolled in our study. Radial approach was used in 22 patients and femoral approach in 28 patients. The duration of UFE, time needed for catheterization of both uterine arteries, and radiation exposure were assessed during the procedure. In the radial approach group, compression bands were used to achieve hemostasis. In the femoral approach group, manual compression was used in 23 patients and closure devices in 5 patients. Major vascular complications were evaluated after the procedure. Discomfort during and after UFE was assessed using specific questions. Results: UFE was successfully performed in all patients from both groups. The duration of the procedure (27.6 and 32.3 minutes, p>0.05) was lower in the radial approach group. The time needed for catheterization of both uterine arteries (7.9 and 15.2 minutes, p=0.003) and radiation exposure (0.32 and 0.58 mZv, p=0.002) were significantly lower in the radial approach group. Major vascular complications were not seen in any group. Radial approach was associated with a significant reduction in procedural discomfort (40.9% and 67.8%, p=0.002). Conclusion: Radial approach is associated with a significant reduction in the duration of the UFE, time needed to catheterize both uterine arteries, and radiation exposure. The radial approach provides a significant reduction in procedural discomfort and allows early mobilization of the patients.

P-174 Radiation dose and contrast reduction during uterine fibroid embolization using 3D MRA guidance versus conventional 2D technique N.D. Nadkarni1, V.S. Dravid2, A. Syal2, A. Gupta1; 1Interventional Radiology, Paoli Hospital, Main Line Health, Paoli, PA, United States of America, 2Department of Radiology, Bryn Mawr Hospital, Bryn Mawr, PA, United States of America Purpose: To compare physician dose, patient dose, procedure time, contrast and fluoro time using the conventional 2D technique for uterine fibroid embolization (UFE) versus a novel 3D MRA guided UFE technique. Material and Methods: Ten UFE procedures were performed using the same imaging equipment at 2 hospitals in the same health system by 2 interventional radiologists, each with over 10 years of experience. 5 were performed using the conventional 2D guidance technique and 5 were performed using a novel 3D MRA guidance technique, which allows real time fusion of a preexisting MRA with the

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live fluoroscopy stream to create a visual roadmap during UFE. The physician dose (μSv), patient dose (DAP), procedure time (min), nonembolic contrast (mL), and fluoro time (min) were compared. Results: There was a 94% reduction in average physician dose using 3D MRA guidance (18.6 μSv) versus conventional 2D technique (308.6 μSv). There was 83% reduction in average patient radiation dose using 3D MRA guidance (68.5 Gy·cm2) versus 2D technique (401.6 Gy·cm2). A 49% reduction in procedure time was noted using 3D MRA guidance (40 min) versus 2D technique (78 min). A 55% reduction was noted in non-embolic contrast utilized using 3D MRA technique (39 ml) versus 2D technique (86 ml). There was a 57% reduction in fluoroscopy time using 3D MRA guidance (10.8 min) versus 2D technique (24.9 min). Conclusion: There is a notable and statistically significant reduction (p < 0.05) in physician and patient radiation dose, procedure time, non-embolic contrast utilized, and fluoro time using 3D MRA guidance for UFE.

P-175 Randomised controlled trial of Particles used in Uterine fibRoid Embolisation (PURE) – non-spherical polyvinyl alcohol (Contour PVA; Boston Scientific, USA) versus calibrated hydrogel microspheres with polyzene coating (Embozene; CeloNova Biosciences, USA): interim results R. Das1, I. Manyonda2, A.-M. Belli1; 1Department of Radiology, St George’s Hospital, London, United Kingdom, 2Department of Gynaecology, St George’s Hospital, London, United Kingdom Purpose: The PURE study is a randomised controlled trial designed to evaluate clinical, MRI and technical outcomes between two embolic agents in uterine artery embolisation (UAE): non-spherical polyvinyl alcohol (ns-PVA) and calibrated hydrogel microspheres (Embozenes). Material and Methods: Prospective, ethically approved non-sponsored randomised controlled trial in a UK tertiary IR unit. The study is designed to recruit 80 patients with a 6-month follow-up. UAE was performed via bilateral arterial access and following a standardised embolisation protocol and a single-blinded design. Primary outcome: Assessment of symptomatic improvement using the validated Uterine Fibroid Symptom and Health-related Quality of Life questionnaire (UFS-HRQOL). Secondary outcomes: Using contrast-enhanced MRI performed before and at 6 months after UAE 1. Percentage fibroid infarction of total fibroid burden and dominant fibroid. 2. Uterine and dominant fibroid volume reductions. 3. Uterine artery recanalisation and presence of ovarian collaterals. 4. Volume of embolic agent required, fluoroscopy time and radiation dose. Results: Forty patients have currently enrolled in the study and the full 6-month follow-up with interim comparative statistical analysis will be complete for CIRSE congress in September 2014. Analysis of volumes of embolic agent has demonstrated a statistically significant difference with a mean volume of 5.5 syringes (range, 1–12) of Embozenes used versus 3.8 vials of ns-PVA (range, 2–8) (p=0.05). No significant difference was detected with respect to fluoroscopy time or radiation dose. Conclusion: The study involves comprehensive clinical and MRI outcome assessment to evaluate two contemporary and widely used particulate embolic agents. The PURE study will guide IR practitioners regarding the relative efficacy of embolic agents in UAE.

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P-176 Role of prophylactic occlusion balloons in patients with morbidly adherent placenta to prevent postpartum haemorrhage and caesarean hysterectomy: a systematic review and meta-analysis M. Teixidor Vinas1, R. Das2, A.-M. Belli2; 1Interventional Radiology, Saint George’s Hospital, London, United Kingdom, 2Department of Radiology, St George’s Hospital, London, United Kingdom Purpose: To conduct a comprehensive systematic review of the available literature, assessing the efficacy of prophylactic occlusion balloon catheters (POBC) in caesarean section delivery (CS) in the management of patients with morbidly adherent placenta (MAP), and to determine the clinical value of POBC in decreasing the estimated blood loss (EBL) and to avoid caesarean hysterectomy. Material and Methods: PubMed (Medline), EMBASE and conference abstracts were searched in November 2013 for eligible studies according to the preferred reporting criteria for systematic reviews and meta-analysis (PRISMA). Endpoints were estimated blood loss, hysterectomy requirement, uterine artery embolisation or blood transfusion during the procedure. The odds ratio and risk difference were calculated using the Mantel–Haenszel fixed-effects model. Results: The systematic review included 6 articles involving 97 patients. Within the total patient population studied, the weighted average EBL was 2.1 L. In all, 15.5% patients required UAE and 22.7% required hysterectomy. Only three cohort studies comparing CS with or without POBC placement were found, and two studies were suitable for meta-analysis (TAN and PANICI trials). The standard mean difference in EBL between CS and POBC vs CS only demonstrated an odds ratio of −2.49 (−6.2 to 1.30) but was not statistically significant (p=0.20). There was a statistically significant difference in the prevention of hysterectomy in patients with POBC and CS vs CS only [OR −0.48 (−0.69 to −0.35)] (p=0.00001). UAE requirement was not statistically significant between both groups [0.22 (−0.39, 0.82)]. Conclusion: POBC placement for patients with MAP treated with CS delivery demonstrated a trend towards reduction in EBL and statistically significant reduction in the hysterectomy rate.

P-177 Selective pelvic arterial embolization in the management of postpartum hemorrhage H. Kondo, Y. Tanahashi, M. Kanematsu, S. Goshima, K. Sakurai, Y. Noda, H. Kawada; Radiology, Gifu University Hospital, Gifu, Japan Purpose: A retrospective evaluation of pelvic arterial embolization for the treatment of severe postpartum hemorrhage. Material and Methods: In all, 71 consecutive patients (age 21–43, mean 32.8 years) who presented postpartum hemorrhage and underwent selective pelvic arterial embolization (PAE) between January 2006 and December 2013 were included. Among them, 31 patients had a vaginal delivery and 35 had a caesarean section. The underlying causes of postpartum hemorrhage were uterine atony (n=49), vaginal injury (n=8), retained placenta (n=4), ectopic pregnancy (n=3), placenta accreta (n=2), abdominal wall hematoma (n=2), inevitable abortion (n=2), and uterine rupture (n=1). Eighteen patients had disseminated intravascular coagulation on admission, which was managed with blood transfusion therapy. Treatment efficacies, angiographic image findings, complications, and fertility were assessed. Results: An overall bleeding control was achieved in 97.2% (69 of 71) patients. PAE was performed using gelatin sponge alone in 48 of 71 (68%) patients, or in association with metallic coils in 6 of 71 (8%) patients, or N-butyl-2-cyanoacrylate in 17 of 71 (24%) patients.

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Two patients underwent hysterectomy after PAE. The most frequent vessel embolized was the uterine artery. The angiogram showed an active contrast material extravasation in 61 patients and pseudoaneurysm in 13 patients. There were no severe complications associated with arterial embolization. Five pregnancies were observed after the procedure. Conclusion: Pelvic arterial embolization is the best therapeutic choice for severe postpartum hemorrhage.

P-178 Transbrachial approach for uterine leiomyoma embolization S. Pieri, A. Paolo, B. Sessa, M.G. Buquicchio, V. Miele; Cardioscienze, Az Osp S.Camillo Forlanini, Rome, Italy Purpose: To investigate the characteristics associated with transbrachial approach in uterine artery embolization. Material and Methods: Of 85 patients treated for uterine artery embolization between 2009 and 2013, 7 were treated with transbrachial approach. A 4-Fr introducer and only one angiographic catheter were used. The time of selective catheterization, procedure duration, and X-ray exposure were evaluated. Results: Uterine artery catheterization was easily performed in all patients (100%) with the multipurpose catheter, and the catheterization time for this group was less than that for the femoral group; 1.4 minutes was the median time for each uterine artery catheterization as compared with 3.4 minutes for the femoral group (4.1 minutes for the omolateral artery). Mean procedure time, from the first uterine artery catheterization to the second, was 16 minutes for the former group and 31 minutes for the latter one, and X-ray exposure was 21 minutes for the former group and 36 in the latter one. Conclusion: Transbrachial approach for uterine artery embolization was quick and easier than femoral approach; it permits deambulation after 2 or 3 hours from the procedure, easier observation of the percutaneous access, and hospitalization for fewer days.

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Conclusion: Although bleeding control rate is lower in postpartum bleeding with DIC than without DIC and it may be required to simultaneously correct DIC with TAE to increase bleeding control rate, we believe that TAE is still an effective method for postpartum bleeding with DIC.

P-180 Usefulness of ovarian protection by selective coil embolization of utero-ovarian anastomosis before uterine artery embolization S.B. Yang1, W.-H. Lee2, D.E. Goo3; 1Radiology, SoonChungHyang University Hospital, Gumi, Korea, 2Radiology, Soonchunhyang Hospital, Cheonan, Korea, 3Radiology, Soonchunhyang University Hospital, Seoul, Korea Purpose: We evaluate the usefulness of ovarian protection by superselective coil embolization of distal uterine artery collateral pathways (utero-ovarian anastomosis) to the ovary before uterine artery embolization. Material and Methods: A retrospective study was conducted of 314 women who underwent uterine artery embolization for symptomatic uterine fibroid or cornual pregnancy from March 2003 to June 2011 to identify patients who had type Ib utero-ovarian anastomosis during uterine artery embolization. In 11 of these patients, selective coil embolization of utero-ovarian anastomosis was performed before uterine artery embolization. The data collected included symptom recurrence, procedure-related complications, temporary or permanent amenorrhea, and future pregnancy. Results: There were no significant procedure-related complications and temporary or permanent amenorrhea. Two patients were pregnant at the 12-month follow-up. Conclusion: Selective coil embolization of utero-ovarian anastomosis before uterine artery embolization is a safe and feasible procedure to avoid non-target embolization of ovaries. It may be a useful procedure for future pregnancy and for reducing temporary or permanent amenorrhea.

Transcatheter arterial embolization for intractable postpartum bleeding: long-term results

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C.S. Kim1, Y.H. Kim1, S.H. Kim1, H. Kim1, U.R. Kang2;

The effect of uterine artery embolization using gelatin sponge particles on ovarian function

1Radiology,

Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea, 2Radiology, Daegu Catholic University Medical Center, Daegu, Korea Purpose: To evaluate the clinical efficacy and long-term results of transcatheter arterial embolization for intractable postpartum bleeding and to determine the factors associated with clinical outcomes. Material and Methods: Between February 2005 and December 2013, 182 female patients from a tertiary-care center were enrolled in this study. The mode of delivery, parity, cause of bleeding, interval between delivery and bleeding, detailed laboratory and angiographic findings, embolic materials, and clinical outcomes were recorded. Of these patients, follow-up data of more than 6 months were available for 83 patients. Univariate and multivariate analyses were performed to determine the factors associated with clinical success. Results: TAE failed to control bleeding in 21 patients despite technical success (11.5%). Among these, 3 underwent repeat TAE, 5 underwent remnant placenta evacuation, and 13 underwent additional surgery. The overall mortality was 0.5% (1/182) after additional hysterectomy. Among the 83 patients with long-term follow-up, a regular menstrual cycle resumed in 81 patients (97.6%) and 12 were pregnant. Disseminated intravascular coagulation (DIC) emerged as the only significant predictive factor related to the failed TAE via univariate and multivariate analyses (odds ratio, 2.981; 95% CI, 1.096–8.111; P=0.03).

Y. Song1, J.R. Juhn2; 1Interventional Radiology, Samsung Changwon Hospital, Sungkyunkwan University School, Chang Won, Korea, 2Interventional Radiology, College of Medicine, Inje University, Busan Paik Hospital, Busan, Korea Learning Objectives: To evaluate the effect of uterine artery embolization (UAE) using gelatin sponge particles on ovarian function Background: There has been no previous evaluation of vascular occlusion using temporary embolic material causing ovarian ischemia in UAE. Clinical Findings/Procedure: Methods: From March 2011 to December 2013, this study of ovarian reserve in 32 women (mean age, 39.4 ± 4.8 years) with symptomatic fibroid who underwent UAE using gelatin sponge particles was conducted. At baseline and at 3and 12-month follow-up after UAE, the serum level of anti-Mullerian hormone (AMH), follicle-stimulating hormone (FSH), estradiol (E2), and ovarian volume of the patients were evaluated. Results: At 12-month follow-up, there was no statistically significant difference in AMH and FSH levels (P = 0.8614 and P = 0.4766, respectively) and serum E2 and LH levels (P = 0.8194 and P = 0.3976, respectively). Moreover, there was no significant difference in ovarian volume (P = 0.6822). Conclusion: UAE using gelatin sponge particles did not result in a change in ovarian function at 12 months compared with that at baseline.

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P-185

Uterine artery embolization in cervical and cesarean scar ectopic pregnancies

Particulate embolisation-induced ovarian failure for endometriosis: a novel approach to a challenging condition

T.H. Balli1, E. Aksungur2, E. Akgul2, I. Ürünsak2, A.B. Güzel2; 1Interventional Radiology, Cukurova University Balcali Hospital, Adana, Turkey, 2Medical Faculty, Cukurova University, Adana, Turkey

J. Coyne, D. Beckett; Interventional Radiology, Royal Bournemouth Hospital, Bournemouth, United Kingdom

Learning Objectives: The aim of the study is to show that uterine artery embolization (UAE) is an effective and reliable method for cervical and cesarean scar ectopic pregnancies. Background: Between January 2012 and December 2013, 9 patients (mean age 37, range 34–41) diagnosed with cervical or cesarean ectopic pregnancy were referred to our department for UAE and were evaluated retrospectively. Ectopic pregnancy site was confirmed by pelvic magnetic resonance scan prior to embolization. Clinical Findings/Procedure: We performed digital subtraction angiography via the femoral artery approach and detected the feeding arteries of the gestational sac. Eight (89%) bilateral uterine arteries and 1 (11%) left uterine artery were embolized with microspheres ranging 250–900 μ via microcatheter until total or near-total devascularization of the gestational sac. Technical success rate was 100%. In 6 patients, intravenous methotrexate as a chemotherapeutic agent was also applied in addition to UAE. Subsequently, all patients underwent curettage or laparotomic ectopic gestational sac excision by surgeons. Conclusion: Cervical or cesarean scar ectopic pregnancies are rare but life threatening. Uterine protective management is topical and important in order to protect fertility. Therefore, UAE with or without chemotherapeutic agent administration is an effective treatment modality, and it reduces the possibility of hemorrhage.

Endometriosis is challenging: symptom recurrence and side effects are common with medications; surgery is invasive, risky and disease may still recur. A 47-year-old female intolerant to medications with surgical contraindications underwent ovarian artery embolisation. At follow-up, she was clinically and biochemically menopausal with resolved symptoms.

P-183 K.

Mori2,

Y.

Uchikawa1,

S.

Hoshiai1,

M.

Shiigai1,

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Placental chorioangioma embolization with glue: 2 cases J. Soussan1, U. Scemama1, F. Bretelle2, J.-B. Haumonté3; 1Imagerie Médicale, CHU Nord, Marseille, France, 2Service de Gynécologie-obstétrique, CHU Nord, Marseille, France, 3Gynécologie, CHU Nord, Marseille, France A placental chorioangioma >5cm in size is associated with fetal complications. We report two antenatal embolizations with acrylic glue (Glubran 2) using US-guided approach to the feeding vessel. Delivery occured at 6 and 14 weeks after intervention with no associated complications.

Imaging P-187

Angiographically treated ruptured aneurysm of the uterine artery in a pregnant patient T. Konishi1, M. Minami1;

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Ohara3,

1Diagnostic

and Interventional Radiology, Tsukuba University Hospital, Tsukuba-shi, Ibaraki-ken, Japan, 2Radiology, Graduate School of Comprehensive Human Sciences, University of Tsukuba, Tsukuba, Japan, 3Obstetrics and Gynecology, Tsukuba University Hospital, Tsukuba-shi, Ibaraki-ken, Japan A 6-month pregnant woman presented with abdominal pain and hemoperitoneum. Dynamic CT scan identified a ruptured left uterine artery aneurysm. We embolized the aneurysm using the isolation technique with interlocking coils and NBCA-lipiodol. No major fetal complication was observed.

P-184 Infected necrotic fibroid: a rare complication of uterine artery embolization J.T. Soares1, J. Ressurreição1, T. Pereira2, P. Portugal1; 1Radiology Department, Centro Hospitalar de Vila Nova de Gaia/ Espinho, Vila Nova de Gaia, Portugal, 2Serviço de Imagiologia, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal Infected uterine fibroid necrosis is a rare but well-established serious complication of uterine fibroid embolization (UAE). We describe the case of a patient with an infected necrotic uterine fibroid after UAE, which was treated conservatively, who ultimately underwent an emergency myomectomy.

Accuracy of registration for fusion imaging with ultrasound navigation system T. Andrašina1, O. Kala2, J. Foukal1, V. Válek3; 1Radiology, Faculty Hospital Brno, Brno, Czech Republic, 2 Student of High School Brno, Brno, Czech Republic, 3Department of Radiology, University Hospital Brno, Masaryk University, Brno, Czech Republic Purpose: The Philips iU22 PercuNav 4.0 (Koninklijke Philips Electronics N.V.) is an image navigation system, which provides realtime, three-dimensional visualization, and navigation tools for all stages of diagnosis and intervention. In this study, we analyze the accuracy of different registration methods for fusion imaging using the Percunav system on a phantom model. Material and Methods: A preprocedural CT dataset was obtained using interventional triple modality phantom (Fluke Biomedical). Three different methods were used for the registration of real-time ultrasound images with CT datasets (registration patch match, ultrasound plane match, and US point match). For each method, variable distance of matching points to the target lesion was evaluated. Each subgroup fusion comprised 12 attempts with two operators. The real deviation of the target lesion depicted on CT scan and ultrasound in an anterior approach (approach for fusion), and the lateral approach were measured. Student’s t test and F test were used for statistical analyses. Results: The real accuracy of CT fusion and ultrasound is not linearly dependent on the overall fit, counted by navigation systems after 3D data registration. US plane match registration is less timeconsuming compared with 3 points match; it shows a good correlation between the overall fit and the target lesion in the anterior approach for distant lesions in the anterior and lateral approaches. There is a statistically significant difference in accuracy for depicting the target lesion from the anterior and lateral approaches (p<0.05).

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Conclusion: All registration methods have comparable precision for targeting lesions in fusion imaging. Using different approaches for fusion registration and navigation could lead to significant inaccuracy of systems.

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92% and 98%, respectively. The sensitivity and specificity of CE-MRA were 96% and 98%, respectively. Conclusion: CE-MRA after selective embolization of intracranial aneurysm is useful and comparable with DSA in the assessment of aneurysmal recanalization. Agreement with the gold standard is stronger in CE-MRA than in TOF-MRA.

Is reduction of testicular vein diameter predictive of clinical outcomes post-varicocele embolization?

P-190

K.W.H. Chiu, R. Lakshminarayan, P. Scott; Radiology, Hull and East Yorkshire NHS Trust, Hull, United Kingdom

PET-CT after radiofrequency ablation of colorectal liver metastases: suggestions for duration and image interpretation

Purpose: To investigate the diagnostic value of testicular vein measurement post-varicocele embolization. Material and Methods: A retrospective review of all patients who underwent testicular vein embolization between 2007 and 2013 at our institute. Patients who had undergone ultrasound of the testes before and after the procedure were identified from a radiology database, and case notes were reviewed. Their demographics, presenting symptoms, testicular vein diameter and clinical outcomes were analysed. Results: Twenty-eight out of 111 men who underwent this procedure fulfilled the criteria. All 28 had radiologically successful varicocele embolisation. Their mean age was 33 years (range 15–60). Of them, 21 (75%) men presented with groin or scrotal pain, 6 (21%) with infertility and 1 (4%) for cosmetic reasons. The mean duration of ultrasound before the procedure was 7 months (range 5–13 months) and after the procedure was 3 months (range 2–35 months). Twentyfour had a clinical follow-up. Clinical success, as defined by the resolution of symptoms or subsequent successful pregnancy, were observed in 17 (71%) men. There was a significant difference in the size of the testicular vein post-embolisation between men with clinical success and non-responders (mean diameter 2.4 mm vs 3.7 mm, p=0.0003). Receiver operating curve analysis showed a cut-off value of 0.5 mm in the reduction of testicular vein diameter and has a sensitivity of 86% and specificity of 88% of predicting clinical success. Conclusion: Our findings support the hypothesis that successful varicocele embolization is associated with a reduction in the testicular vein diameter using a cut-off value of 0.5 mm.

P-189 Evaluation of endovascular coiled intracranial aneurysms using magnetic resonance angiography A. Levent1, I. Yuce2, S. Eren1, M. Kantarci1; 1Radiology, Ataturk University Medical Faculty, Erzurum, Turkey, 2Radiology, Regional Training and Research Hospital, Erzurum, Turkey Purpose: The purpose of our study is validate the coherence of contrast-enhanced magnetic resonance angiography (CE-MRA) with three-dimensional time-of-flight (3D-TOF) MRA in detecting the recanalization status of aneurysms by comparing the results with digital subtraction angiography (DSA). Material and Methods: Sixty-seven patients with 79 coiled aneurysms underwent TOF-MRA, CE-MRA, and catheter-angiography 6 months after coiling. Recanalization status was classified on images as neck or body remnant or no recanalization by two independent observers. For TOF-MRA and CE-MRA, intermodality agreement, interobserver agreement, and correlation with angiography were assessed. Results: Of the 67 patients, 3 aneurysms could not be detected on TOF-MRA and were excluded from the study. Interobserver agreement was very good for TOF-MRA and CE-MRA (κ: 0.87 and 0.94, respectively). The correlation of TOF-MRA with angiography was good (κ: 0.76), and the correlation of CE-MRA with angiography was excellent (κ: 0.91). The sensitivity and specificity of TOF-MRA were

A.A. van Tilborg1, K. Nielsen2, H.J. Scheffer1, P. van den Tol2, E. Comans1, S. Meijer 2, M.R. Meijerink1; 1Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, Netherlands, 2Surgery, VU University Medical Center, Amsterdam, Netherlands Purpose: The reported accuracy of PET-CT in detecting local site recurrence (LSR) is high compared with morphological imaging alone, but no internationally accepted criteria for image interpretation have been defined. Our aim was to assess the criteria for FDG PET-CT image interpretation following RFA and to define a schedule for follow-up detection of LSR. Material and Methods: Patients who underwent RFA for colorectal liver metastases between 2005 and 2011 with FDG-PET followup within 1 year after treatment were included. The results of repeat FDG-PET scans were evaluated until LSR was diagnosed. Results: In all, 170 scans were obtained for 79 patients (179 lesions) and 57 scans (72%) within 6 months of treatment. Thirty patients developed local recurrence and 29 (97%) within 1 year. Only 2% lesions of <1 cm and 4% of <2 cm showed LSR. Conclusion: The majority of local site recurrences can be diagnosed within 1 year after RFA. Regular follow-up using FDG PET-CT within this period is advised so that treatment can be repeated. To avoid false positives, the initial PET-CT should be performed at 3 months, although inflammatory uptake may be present till 4–6 months, thereby complicating evaluation. The benefit in the follow-up of lesions of <2 cm may be limited.

P-191 Quantitative perfusion using contrast-enhanced magnetic resonance angiography with multi-echo and radial k-space sampling to evaluate perfusion changes following Y-90 radioembolization for hepatocellular carcinoma J.D. Collins1, N. Chatturjee1, R.J. Lewandowski2, E. Semaan1, R. Salem1, F. Miller1, T. Carroll1, J.C. Carr1; 1Radiology, Northwestern University, Chicago, IL, United States of America, 2Interventional Radiology, Northwestern University, Chicago, IL, United States of America Purpose: To evaluate hepatocellular carcinoma, adjacent liver, and remote liver perfusion following yttrium-90 radioembolization (RAE) using a novel highly accelerated contrast-enhanced MR angiography (MRA). Material and Methods: Quantitative MR perfusion was performed to evaluate 12 HCC lesions in 11 patients (6 men, average age 66 years) via a peripheral IV injection. The MRA perfusion sequence utilized radial sampling with a sliding window reconstruction to achieve an effective frame rate of 16 ms with a voxel size of 1.9 × 1.9 × 2.2 mm3. MR perfusion was performed using glass beads before, immediately after, and at 1 month following RAE. The peak slope of the signal intensity curve was ascertained for the target lesion, adjacent liver (L adj), and remote liver (Lrmt) and normalized to the peak slope of the aorta as a measure of perfusion. Target lesion response to therapy was assessed using the mRECIST criteria on routine MR imaging; responses were defined as stable disease, partial response,

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or complete response. Target lesion perfusion was compared at each time point using the Student’s t-test. Results: Follow-up was available for an average of 3.9 (1–8) months. No lesions progressed. Target lesions average was 2.9 (1.3–6.8) cm. Target lesion perfusion decreased from 0.33 to 0.26 immediately after and was 0.18 at 1 month following RAE (p>0.05). Ladj perfusion increased from 0.25 to 0.41 immediately after RAE and remained elevated at 0.36 1 month following RAE (p>0.05). Lrmt perfusion was similar across all time points (0.13, 0.15, and 0.16) (p>0.05). Conclusion: Following RAE, responding HCC target lesions demonstrate reduced perfusion with regional hyperemia consistent with local hepatic radiation injury.

P-192 Reference-less PRF thermometry during MR-guided focused ultrasound (MRgFUS) for liver treatment in a preclinical Thielembalmed human cadaver model I. Karakitsios, N. Le, X. Xiao, A. Melzer; University of Dundee, Institute for Medical Science and Technology (IMSaT), Dundee, United Kingdom Purpose: MR-guided focused ultrasound (MRgFUS) is a safe, controlled, and non-invasive option that utilizes proton resonance frequency (PRF) MR thermometry for real-time temperature mapping. Reference-less thermometry is more robust to motion and displacement of the tissue than the standard phase-referenced thermometry. The aim of the present study was to demonstrate reference-less PRF thermometry on preclinical Thiel-embalmed human cadaver. Material and Methods: Liver treatment was conducted on MRgFUS patient table (ExAblate 2100 Conformal Bone System; InSightec Ltd., Tirat Carmel, Israel) embedded in a 1.5-T MR scanner (Signa HDx; GE Medical Systems, Milwaukee, WI, USA) for MR imaging. The liver was sonicated for 20 seconds with acoustic energies (1000 and 2000 J; Fig.1). Reference-less PRF thermometry was used for treatment monitoring. Results: A region of interest (ROI) was selected around the heated area. The real and imaginary parts of ROI were interpolated using a 2D polynomial, and they were fitted to the inside (heated) area. A series of reconstructed temperature maps were generated, showing the maximum temperature rise and the temperature distribution over time during MRgFUS treatment. Conclusion: We demonstrated that reference-less thermometry is suitable on the entire Thiel-embalmed human cadaver for liver treatment under respiratory motion. The fitting and interpolation was based on real and imaginary parts separately, using a 2D polynomial. The quality of both the fitting and the interpolation was found to be satisfactory.

P-193 Role of contrast-enhanced ultrasound in the detection of carotid plaque vulnerability: a pilot study M.F. la Torre, R. Iezzi, A. Guerra, A. Contegiacomo, E.G.M. Antonuccio, L. Bonomo; Department of Radiological Sciences, Institute of Radiology, “A. Gemelli” Hospital - Catholic University, Rome, Italy Purpose: To assess the relationship between contrast-enhanced ultrasound (CEUS) and immunohistological evaluation of carotid artery “inflammatory vulnerable plaque.” Material and Methods: Fifty consecutive patients (18 symptomatic and 32 asymptomatic) referred to our department for carotid endarterectomy were enrolled. Ultrasound examination was performed using a high-frequency (8–14 MHz) linear probe and a non-linear pulse inversion technique during a double contrast media injection (2–4 ml, Sonovue; Bracco, Italy). Two videotapes were recorded for

Abstract Book every injection: early “dynamic” phase and late “flash” phase, performed with 6 high mechanical index impulses. Movies were evaluated in terms of intraplaque enhancement and proliferation of adventitial vasa vasorum both qualitatively, on the basis of a 4-point scale, and quantitavely using Esaote Qontrast 4.0 software. After surgical resection, plaque specimens were immunohistologically evaluated to assess neovascularization. Qualitative and quantitative evaluation were statistically compared with immunohistological results, considered as the gold standard. Results: Qualitative CEUS evaluation yielded high statistical results compared with immunohistological results with sensitivity, specificity, positive predictive value, negative predictive value (NPV), and diagnostic accuracy values as 94%, 68%, 87%, 85%, and 86%, respectively, which increased if only asymptomatic patient were considered (NPV of 91%). Nevertheless, quantitative software evaluation proved less effective and could not reach similar results. Conclusion: Carotid plaque enhancement assessed with CEUS correlates well with histological density of neovessels, which is associated with plaque vulnerability. CEUS may provide valuable information for plaque risk stratification and may play a role in indicating appropriate treatments for patients with carotid stenoses, particularly, in asymptomatic population.

P-194 Transcatheter CT arterial portography and CT hepatic arteriography for liver tumor visualization during percutaneous ablation A. van Tilborg1, H.J. Scheffer 2, K. Nielsen3, J.H. van Waesberghe2, E. Comans2, P. van den Tol3, C. van Kuijk 2, M.R. Meijerink1; 1Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, Netherlands, 2Radiology, VU University Medical Center, Amsterdam, Netherlands, 3Surgery, VU University Medical Center, Amsterdam, Netherlands Purpose: This prospective study evaluated the feasibility of combining transcatheter CT arterial portography (CTAP) or transcatheter CT hepatic arteriography (CTHA) for optimized and repeated tumor exposure with percutaneous liver ablation. Material and Methods: Twenty patients were included (13 males and 7 females, mean age 59.4 years, range 40–76 years) with unresectable liver-only malignancies (14 with colorectal liver metastases, 29 lesions; 5 with hepatocellular carcinoma, 7 lesions; and 1 with intrahepatic cholangiocarcinoma, 2 lesions), obscure on nonenhanced CT. A catheter was placed within the superior mesenteric artery (CTAP) or in the hepatic artery (CTHA). CTAP/CTHA was repeatedly performed after injecting 30–60 ml 1:2 diluted contrast media to plan, guide, and evaluate ablation. The operator confidence levels and the liver-to-lesion attenuation differences, needle-to-target mismatch distance, technical success, and technique effectiveness were assessed after 3 months. Results: Technical success rate was 100%, and there were no major complications. Compared with conventional non-enhanced CT, operator confidence increased significantly for CTAP/CTHA cases (p<0.001). The liver-to-lesion attenuation differences between unenhanced CT, CECT, and CTAP/CTHA were statistically significant (mean attenuation difference 5 HU vs. 28 HU vs. 70 HU; p<0.001). Mean needle-to-target mismatch distance was 2.4±1.2 mm (range 0–12 mm). Primary technique effectiveness at 3 months was 87% (33/38 lesions). Conclusion: In patients with technically unresectable liver-only malignancies, single-session CTAP/CTHA-guided percutaneous tumor ablation enables repeated contrast-enhanced imaging and real-time contrast-enhanced CT fluoroscopy, improving lesion conspicuity.

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P-195 Value of a standardized angiographic reporting system in correlation with kidney parameters to predict the outcomes in patients with non-occlusive mesenteric ischemia P. Minko1, M. Klingele2, J. Stroeder 3, H. Groesdonk4, S. Wagenpfeil5, H.-J. Schäfers6, A. Buecker1, M. Katoh7; 1Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg, Germany, 2Internal Medicine IV Nephrology and Hypertension, Saarland University Medical Center, Homburg, Germany, 3Diagnostic and Interventional Radiology, Saarland University Hospital, Homburg, Germany, 4Department of Anaesthesiology, Saarland University Medical Center, Homburg, Germany, 5Institute of Medical Biometry, Epidemiology and Medical Informatics, Saarland University Medical Center, Homburg, Germany, 6Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany, 7Diagnostic and Interventional Radiology, HELIOS Klinikum Krefeld, Krefeld, Germany Purpose: To correlate angiographic findings with kidney parameters and to investigate the predictive value of angiography with respect to the outcomes in patients with non-occlusive mesenteric ischemia (NOMI). Material and Methods: In this prospective study, 63 consecutive patients (mean age: 73±8 years) suspected of NOMI after cardiac or major thoracic vessel surgery underwent catheter angiography of the superior mesenteric artery. Images were assessed by two experienced radiologists on consensus basis using a previously published standardized reporting system (Homburger NOMI score). These data were correlated to kidney-specific parameters like FGF-23, cystatin, cystatin C, creatinin and glomerular filtration rate (GFR), outcome data (death and acute renal failure) using linear and logistic regressions, nonparametric tests, and ROC analyses. Results: Significant correlations were found between FGF-23 and the overall NOMI score (comprising five categories, i.e., vessel morphology, reflux of contrast medium into the aorta, contrast enhancement, distension of the intestine, and time to portal vein filling; p=0.05) as well as the modified NOMI score (comprising three categories, i.e., vessel morphology, reflux of contrast medium into the aorta, and time to portal vein filling; p=0.02). No significant correlation was found for creatinin (p=0.07), cystatin (p=0.27), cystatin C (p=0.83), and GFR (p=0.23). Logistic regression revealed a significant correlation between death and the overall NOMI score (p=0.006) as well as the modified NOMI score (p<0.001). No significant correlation was found for the development of acute renal failure (p=0.268). Conclusion: FGF-23 significantly correlates with the development of NOMI. Furthermore, the applied scoring system allows to predict fatal outcomes in NOMI patients.

P-196 Anterolateral thigh flap: anatomic variations and preoperative imaging technique for surgical planning T. De Beule1, W. Van Deun2, J. Vranckx 2, G.A. Maleux1, S. Heye1; 1Department of Radiology, University Hospitals Leuven, Leuven, Belgium, 2Department of Plastic and Reconstructive Surgery, University Hospitals Leuven, Leuven, Belgium Learning Objectives: The anterolateral thigh has a complex local vasculature with inherent anatomic variations. Important variations to preoperatively aid the reconstructive surgeon are highlighted, and a tool to calculate perforator localization is presented. Background: The anterolateral thigh flap (ALT-flap) has a widespread use throughout the body because of the many engineering options. The flap receives its perfusion from the branches of the lateral circumflex femoral artery (LCFA), which have a large anatomic variance.

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Clinical Findings/Procedure: The perforators to the ALT-flap skin originate most commonly from the descending branch of LCFA. The course of these perforators can be determined preoperatively with the use of computed tomography angiography (CTA). With the aid of our local software, we can automatically calculate coordinates for these perforators with respect to a reference point on the anterolateral thigh used by surgeons in preoperative skin measurements. The most prominent LCFA perforator and the course of the perforator (septocutaneous, musculoseptocutaneousm or musculocutaneous) can also be determined. Preoperative anatomic knowledge of the main branches of LCFA can result in a longer pedicle length, aids in ideal flap design, and can reduce harvest time. Conclusion: ALT-flap is one of the most ideal soft-tissue flaps because of its versatility. Preoperative knowledge of the anatomic variations of the blood supply are important for surgical planning due to the risk of flap loss. We determined perforator coordinates with regards to the standard surgical reference point using a 3D reconstruction software program.

P-197 Contrast-enhanced ultrasound in interventional radiology – the mover and shaker D. Penha, E. Guedes Pinto, A. Costa, E. Coimbra; Radiology, Hospital Professor Doutor Fernando Fonseca E.P.E., Amadora, Portugal Learning Objectives: 1. To briefly review the technical aspects of contrast-enhanced ultrasound (CEUS) 2. To illustrate the potential applications of CEUS in interventional radiology (IR) 3. To discuss the role of CEUS in IR as a problem-solving technique Background: CEUS is a rapidly growing technique. Ultrasound microbubble contrast agents have distinct advantages such as being purely intravascular, providing an accurate display of the vascularity and being non-nephrotoxic. The advantages of ultrasound guidance include its inherited real-time and multiplanar approach allowing an accurate evaluation of enhancement. In the last 5 years, some preliminary reports of the use of CEUS in IR have been published focusing on guidance for biopsy and ablation procedures or post-ablation evaluation. Clinical Findings/Procedure: Describing our institution’s experience, we will present several selected cases of CEUS application in the field of IR, explaining techniques such as CEUS-guided biopsy, drainage, and tumor ablation. We will also demonstrate the utility of this imaging modality in localizing active bleeding sites in superficial lesions or intra-abdominal organs. We will discuss how the dynamic and real-time nature of CEUS can further add to the diagnostic accuracy of a given lesion and how it can have an impact on decision making in relation to interventional procedures. Conclusion: CEUS is a real-time, functional, and low-cost evaluation technique with robust and versatile performance. The advantage of using a purely intra-vascular pool contrast technique adds value to the IR practice. Based on our experience, CEUS is an essential problem-solving tool not only to guide procedures but also to help in the diagnostic approach of complex cases.

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P-200

Leap Motion Controller implementation for touchless PACS integration in the interventional radiology suite

Primitive superior vena cava tumor mimicking thrombosis

Z.L. Bercu, V.V. Patil, R. Patel, E. Kim, F.S. Nowakowski, R.A. Lookstein, A.M. Fischman; Division of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America Learning Objectives: 1. To evaluate the implementation of a low-cost, dynamic device for hands-free PACS control in the interventional radiology suite. 2. To demonstrate how hands-free interaction may result in decreased procedure time and likelihood of re-intervention as well as increased technical success. 3. To demonstrate ease-of-use with respect to operator training. Background: Review of prior imaging is ubiquitous in the angiography suite during complex procedures. Examples of intra-procedural PACS use include catheter position confirmation, tumor localization, and small vessel assessment. In-case PACS review decreases the likelihood of incomplete treatment and reduces patient radiation dose. Existing systems require an expensive setup, two-handed gestures, non-native drivers, and software limitations. The Leap Motion Controller (Leap Motion, Inc., San Francisco, CA) is inexpensive (ERP: $79.99), portable, natively designed for workstation use, and more gesture-sensitive than alternatives. Mapping allows for universal PACS interaction. Clinical Findings/Procedure: The device is connected directly to a PACS workstation. A single training session is performed prior to inprocedure use. PACS images are reviewed on a monitor in the angiography suite or in the control room depending on the institutional setup. At the time of procedure, the device is covered with a transparent sterile cover and placed on a clear surface with adhesive. Device operators are surveyed, and the software is tailored as per user preferences. Conclusion: Leap Motion Controller is a feasible, portable, and inexpensive alternative to other touchless PACS integration systems. The replacement of the keyboard and mouse enables maintaining sterility. Ease-of-use permits reduced table time for patients with low operator training times and decreased need for reintervention.

P-199 Aortic intramural hematoma with extension into pulmonary arteries and hemopericardium C. Kaufman1, K. Quencer1, H. Song2, J.A. Kaufman3; 1Department of Radiology, Yale New Haven Hospital, New Haven, CT, United States of America, 2Department of Cardiothoracic Surgery, Oregon Health & Science University Hospital, Portland, OR, United States of America, 3Dotter Interventional Institute, Oregon Health & Science University Hospital, Portland, OR, United States of America A 59-year-old hypertensive male presented in cardiac tamponade due to a spontaneous type A intramural aortic hematoma (IMH) that extended into pulmonary arteries and pericardium. The management and underlying anatomy of this rare presentation of IMH will be reviewed.

F. Cousin1, D. Henroteaux1, P.-J. Bruyère2; 1Medical Imaging, CHR Citadelle, Liège, Belgium, 2Interventional Radiology, CHR Citadelle, Liège, Belgium We report the case of a primitive tumor of the superior vena cava (SVC) presenting as thrombosis on CT. Catheter-directed thrombolysis was ineffective; MRI and endovascular biopsy revealed a primitive tumor of SVC, which is a rare pathology.

P-201 Segmental arterial mediolysis: a case requiring prompt imaging diagnosis and image-guided intervention R. Fernando1, N.I. Fotiadis2, B. Roberton1; 1Radiology, Chelsea & Westminster Hospital, London, United Kingdom, 2Interventional Radiology, Royal Marsden Hospital, London, United Kingdom We present a rare case of segmental arterial mediolysis. Imaging with CT-angiography and formal angiography provided an unsuspected and prompt diagnosis. Trans-catheter intervention successfully managed the acute complications. We also review the pathology, imaging findings and IR management.

Neuro and carotid intervention P-202 Balloon dilatation and thrombus extraction for the treatment of cerebral venous sinus thrombosis T.-F. Li, S. Shui, X.-W. Han; Interventional Radiology, First Affiliated Hospital, Zhengzhou University, Zhengzhou, China Purpose: This study aimed to investigate the efficacy and safety of balloon dilatation and thrombus extraction for the treatment of cerebral venous sinus thrombosis (CVST). Material and Methods: Twenty-six cases of DSA-confirmed CVST were treated with balloon dilatation and thrombus extraction. An active treatment of primary disease was provided after cerebral venous sinus recanalization, and subsequent anticoagulant therapy lasted for 6 months. Results: Recanalization of the cerebral venous sinus was achieved in all patients, and no endovascular treatment-related complications occurred during or after the procedure. At discharge, the Glasgow Coma Scale of the patients had improved from an average of 12.3 points to 15 points, and clinical symptoms improved in 100% of the patients. Follow-up duration ranged from 12 to 62 months (mean follow-up duration of 42.3 months), and no thrombus re-formation or new neurological deficits occurred during that time. Conclusion: Based on our small study population, balloon dilatation and thrombus extraction appears to be a safe and effective treatment for cerebral venous sinus thrombosis. However, further research is required to confirm this hypothesis.

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P-203 Clinical treatment result of carotid artery stenting in Japan: comparsion of periprocedual ischemic complication by embolic protection devices K. Takayama1, K. Myochin1, T. Wada2, H. Nakagwa2, K. Kichikawa2, S. Kurokawa3; 1Radiology and Interventional Neuroradiology, Ishinkai Yao General Hospital, Yao city, Japan, 2Radiology, Nara Medical University, Nara, Japan, 3Neurosurgery, Ishinkai Yao General Hospital, Yao city, Japan Purpose: Carotid artery stenting (CAS) was formally approved in Japan in October 2007. Since then, several embolic protection devices (EPDs) and stents for CAS have become available. We investigated the clinical treatment results and periprocedural ischemic complications of CAS by using a standard procedure. Material and Methods: We retrospectively analyzed 297 patients (257 men, age 39–97 years, mean 73.7 years) with 321 carotid artery stenoses and symptomatic stenosis (137 lesions, mean 82.1%) who underwent CAS from October 2007 to January 2014. Technical success rate, periprocedural ipsilateal ischemic stroke, and ischemic lesions by diffusion-weighted images (DWIs) were assessed within 48 h after CAS. Results: All cases of CAS were successful. Among 9 patients (2.8%) who suffered a stroke, major stroke occurred in 1 patient (0.3%) and minor stroke in 8 patients (2.5%). The EPDs and stents were used as follows: Angioguard XP/RX (AG), 141; Filterwire EZ (FW), 127; MoMa Ultra (MU), 47; Spider FX, 2; PercuSurge, 2; Precise (PS), 209; Carotid Wallstent (CW), 95; Protege (PT), 14; PS and CW, 2; and PS and PT, 1. Over 40 cases of stroke and new ischemic lesions by EPD were observed in AG, 2.8% (4/141) and 33.1% (46/139); FW, 2.4% (3/127) and 21.4% (27/126); and MU, 4.3% (2/47) and 41.3% (19/46), respectively. Conclusion: CAS by standard procedure showed very good clinical treatment results. The incidence of ischemic lesions on DWI was much lower in FW than in other EPDs.

P-204 Mechanical thrombectomy in acute ischemic stroke: predictors of clinical outcomes S.M. Protto1, T. Kau1, A. Weissenbacher1, M. Niedermayer1, J.R. Weber 2, S.-M. Obmann1, K.A. Hausegger1; 1Radiology, General Hospital Klagenfurt, Klagenfurt, Austria, 2Neurology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria Purpose: To evaluate the factors that may be helpful in predicting the clinical outcome in patients with acute ischemic stroke treated with mechanical thrombectomy (MTE). Material and Methods: In a retrospective study, 37 consecutive patients with acute ischemic stroke in the anterior circulation were analyzed. All patients had an occlusion of the internal carotid and/ or middle cerebral artery proven by CTA. All patients got CT and CTA before and a MR examination within 24 h after MTE. MTE was performed with stent retrievers. ASPECT score, visual graduation of the collateral flow in CTA, recanalization grade (TICI flow), extent of MR-diffusion impairment after MTE, and time window were correlated to the clinical outcome (mRS after 1 and 3 months) Results: TICI IIb/III flow was achieved in 97%. Good clinical outcome (mRs ≤ 2) after 1 and 3 months was seen in 45.5% and 51% patients. Strong predictors of good clinical outcomes were grade of recanalization (p=0.05), good collateral flow on CTA (p=0.02), younger patients (p=0.02), and a stronger smaller diffusion defect on the post-interventional MR (p=0.000). Outcomes were better with a shorter time window (p=0.09). Conclusion: Good clinical outcome after MTE can be expected in younger patients, those with good collateral flow seen on base line

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CTA, after successful recanalization, and in patients with smaller post-interventional DWI defects. Time window was not a very strong predictor.

P-205 Optical frequency domain imaging provides useful endoluminal microstructural information in patients treated with carotid angioplasty with stenting M. Jeromel; Department of Diagnostic and Interventional Neuroradiology, Institute of Radiology, Ljubljana, Slovenia Purpose: Optical frequency domain imaging (OFDI) enables a high resolution intravascular imaging. The aim of our study was to test the feasibility, safety, and practical value of OFDI in the carotid artery during angioplasty with stenting (CAS) procedure. Material and Methods: In 12 patients with asymptomatic and symptomatic carotid artery disease (70–90% stenosis), OFDI was used during CAS procedure. In 9 patients, OFDI was performed before and after the elective CAS procedure, while in 3 patients, OFDI was used for restenosis evaluation after previous endovascular or surgical treatments. The passage with 2.6-Fr OFDI microcatheter through the stenotic segment (performed after the placement of embolic protection device filter or proximal occlusion) resulted in 24 high resolution images of arterial inner wall surface. Results: The microcatheter passage was safely created in all patients without any intra- or periprocedural device-related adverse event. OFDI enabled information regarding the degree and length of the stenosis and plaque composition. In all 3 already treated patients, OFDI showed severe (hemodynamically important) stenosis that failed to be proved with preoperative noninvasive imaging evaluation. Therefore, OFDI had a decisive impact on CAS. Conclusion: OFDI is feasible and can be safely used for intraprocedural assessment of arterial inner surface in patients treated with CAS. This method is quick and provides useful endoluminal microstructural information that helps in uncertain carotid artery disease cases.

P-206 Preoperative endovascular balloon-assisted embolization with glubran and lipiodol of high-flow head and neck arteriovenous malformations: preliminary results F. Melchiorre1, M. Montechiari1, C. Khouri Chalouhi1, F. Allevi2, G. Colletti2, U.G. Rossi3, M. Cariati3, G.P. Cornalba1; 1Diagnostic and Interventional Radiology, San Paolo Hospital, Milan, Italy, 2Maxillo-Facial Surgery Department, San Paolo Hospital, Milan, Italy, 3Radiology and Interventional Radiology, San Carlo Borromeo Hospital, Milan, Italy Purpose: To evaluate short-, mid-, and long-term results of the combined technique of endovascular balloon-assisted embolization with glubran plus lipiodol of head and neck (H and N) arteriovenous malformations (AVMs) on the day before surgery. Material and Methods: From 2009 to 2014, 9 patients (4 males and 5 females, mean age 29±17 years) with high flow H and N AVMs were treated with endovascular balloon-assisted embolization with glubran and lipiodol. After reaching the external carotid artery, a compliant occlusion balloon catheter was placed and inflated to modulate the flow, reducing the high blood flow of AVM. We continued with superselective micro-catheterization of the AVM nidus and a mixture of glubran and lipiodol (1:3) was injected with significant reduction/occlusion of arterial flow to avoid non-target embolization. The next day, a maxillofacial surgical procedure was performed in all patients. H and N MRI was performed after the procedure.

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Results: A complete preoperative endovascular embolization was obtained in 6 of 9 patients, whereas a complete surgical removal was obtained in all cases. No recurrences were found in the treated patients according to the MRI scan and clinical evaluations with a mean follow-up duration of 34 months. Conclusion: AVMs are characterized by the presence of nidus, a central mass of arteriovenular shunts, the true cause of the disease and responsible for a high relapse rate. Although our results are limited to a small number of cases, this combined approach (endovascular balloon-assisted embolization and surgical procedure) is an effective and promising therapy for AVMs. The compliant occlusion balloon is the key point of the endovascular procedure.

P-207 Endovascular management of symptomatic, vulnerable, and inflamed carotid plaques: a 1-year single-center experience R. Gandini1, D. Morosetti1, A. Chiaravalloti1, E. Salvatori2, G. Loreni1, G. Simonetti1; 1Diagnostic and Interventional Radiology, Policlinico Tor Vorgata, Rome, Italy, 2Department of Diagnostic Imaging and Interventional Radiology, University Hospital “Tor Vergata”, Rome, Italy Learning Objectives: To evaluate the short-term safety and the intermediate-term efficacy of carotid artery stenting in preventing cerebrovascular accidents in patients with highly inflamed vulnerable plaques, acute symptoms, and high surgical risk. Background: Ischemic stroke is responsible for 10% of all deaths, and carotid artery stenosis represents a major risk factor for this pathology. Plaques characterized by inflammation and neovascularization by the vasa vasorum have a higher vulnerability than do noninflamed plaques. Clinical Findings/Procedure: Between January 2008 and December 2009, 102 patients were evaluated with duplex-ultrasound; 31 of them were evaluated with computed tomographyangiography and with high resolution magnetic resonance (HR-MRI). All patients underwent CAS with a closed-cell stent and, on the basis of the preprocedural MR examination, were divided in two groups. Group 2 patients, who had unstable inflamed plaques on HR-MRI, were treated with Mo.Ma protection device. Technical success was obtained in all treated patients. One episode of TIA (5.2%) was observed in the group in which a Mo.Ma protection device was employed; however, there were no signs of acute ischemia on subsequent MRI examination. No major adverse cerebrovascular events during hospital stay and during follow-up were observed in either group. Conclusion: HR-MRI can help in the identification of inflamed and high-risk carotid artery plaques and can aid in choosing an appropriate stent and cerebral protection device in patients at high surgical risk. CAS can be considered as a safe alternative treatment for unstable plaques.

P-208 Intracranial atheromatous disease treatment with the Wingspan stent system: evaluation of clinical and procedural outcomes and restenosis rate in a single-center series of 21 consecutive patients with acute and mid-term results R. Gandini, A. Chiaravalloti, D. Morosetti, G. Loreni, E. Salvatori, G. Simonetti; Diagnostic and Interventional Radiology, Policlinico Tor Vorgata, Rome, Italy

Abstract Book 40% of strokes in some populations. After an ischemic event due to intracranial atherosclerosis, patients have a 12% annual risk of stroke recurrence, mainly in the first year. Clinical Findings/Procedure: Twenty-one Caucasoid patients were enrolled. Inclusion criteria were high-grade, symptomatic, intracranial atherosclerotic lesions; current antithrombotic therapy; and high stroke risk. All patients were treated with the Wingspan stent system. Technical success rate was 100%, and all target lesions were reduced to <50%. No stroke or death was observed at 30 days. The mean percent of stenosis was reduced from a median value of 84% to 17% after stent placement. Median follow-up duration was 19.5 months (range 6–36 months). No stroke or death occurred in any patient. No patient presented with a stent patency rate of <50% at follow-up. Conclusion: The short-term results and follow-up analysis provide evidence demonstrating the safety of the Wingspan system when used in high-risk patient population. Due to concerns regarding long-term stent patency and ischemic events occurrence that emerged from clinical trials such as SAMMPRIS, intracranial angioplasty and stent using the Wingspan system should be considered only for high-risk patients in whom it may be the only viable therapeutic option.

P-209 Intravascular ultrasound-assisted carotid artery stenting: preliminary results of a randomized controlled trial involving 60 patients R. Gandini, D. Morosetti, A. Chiaravalloti, E. Salvatori, G. Loreni, G. Simonetti; Diagnostic and Interventional Radiology, Policlinico Tor Vorgata, Rome, Italy Learning Objectives: The primary aim is the evaluation of the usefulness of intravascular ultrasound (IVUS) in the identification of otherwise unnoticed complications during carotid artery stenting (CAS). The secondary aim is to evaluate the impact of IVUS assistance in the procedural outcomes and long-term patency rates of CAS. Background: Carotid artery stenosis may be the underlying pathology in up to 21% of ischemic strokes, but may account for approximately 40% of strokes in some populations. Clinical Findings/Procedure: Sixty patients who underwent CAS during a 14-month period were prospectively evaluated; of them, 30 underwent IVUS-assisted CAS and 30 underwent angiographyguided CAS as a unique diagnostic tool. Mean follow-up was 23 months. No periprocedural or late complications were observed. No statistical significance was observed in long-term stent patency between the two groups. Virtual Histology (VH)-IVUS evaluation of plaque morphology led to a different stent choice in three patients. In two patients, IVUS assessment revealed a suboptimal stent deployment, which was managed by angioplasty; in one patient, VH-IVUS revealed plaque protrusion through stent cells, which was immediately treated with manual aspiration. Conclusion: Though not recommended as a routine intraprocedural evaluation, IVUS may be useful for real-time CAS control when treating challenging plaques such as soft, lipidic, or those that are prone to rupture; when an intraprocedural morphologic evaluation is required for the appropriate stent choice; or when embolic risk is high.

Learning Objectives: To evaluate the procedural safety, clinical outcome, and restenosis rate of Wingspan stent placement. Background: Intracranial atherosclerosis is the underlying pathology in up to 15% of ischemic strokes, but accounts for approximately

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Virtual histology-intravascular ultrasound as a diagnostic alternative for morphological characterization of carotid plaque: comparison with histology and high-resolution magnetic resonance findings

Endovascular treatment of a traumatic direct carotid– cavernous fistula with flow-diverter stents in addition to stentassisted coiling

R. Gandini, E. Salvatori, D. Morosetti, A. Chiaravalloti, G. Loreni, G. Simonetti; Diagnostic and Interventional Radiology, Policlinico Tor Vorgata, Rome, Italy Learning Objectives: The primary aim was to validate virtual histology-intravascular ultrasound (VH-IVUS) as a diagnostic tool for carotid plaque characterization by histological comparison through ex vivo evaluation of carotid plaques. The secondary aim was to compare VH-IVUS with high resolution-MRI (HR-MRI) through in vivo evaluation of carotid plaques. Background: Stroke is the third most common causes of death and one of the most common cause of long-term disability in the western world. Carotid plaque morphology, more than stenosis degree, is the main predictor of cerebrovascular accidents. Clinical Findings/Procedure: In the ex vivo study, data was acquired from six carotid arteries explanted from six symptomatic male patients. Sectional images obtained with the IVUS catheter were compared with digitalized histological images. Twelve consecutive patients for carotid artery stenting were included in the in vivo study. All histological and HR-MR images were converted to digital format, and the exact percentages of the four plaque components were determined. Forty-two images were used. Quantitative analysis of different plaque components revealed a good concordance (0.82) between the two methods (95% CI, 0.69–0.92). Precision rate of VH-IVUS for concordance with true histology of different plaque components was 99.4% for fibrous tissue, 85.9% for fibrolipid tissue, 71.4% for calcium, and 83.4% for necrosis. Comparison between HR-MRI and VH-IVUS was performed on 27 images. Concordance between the two methods was 0.84 (95% CI, 0.69–0.92), and respective precision rates were 85.3%, 95.2%, 90.2%, and 82.0%. Conclusion: VH-IVUS is useful for intraprocedural evaluation of a carotid plaque before/after stent placement is required but unsuitable for accurate in vivo differentiation between stable and unstable plaques prone to rupture.

O. Ergun1, S. Berk Ergun2, H.A. Durmaz1, C. Gurdal3, B. Hekimoglu1; 1Radiology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey, 2Ophthalmology, Ankara Numune Training and Research Hospital, Ankara, Turkey, 3Ophthalmology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey We present the case of a 14-year-old male with a traumatic direct high-flow carotid–cavernous fistula treated with five flow-diverter stents after inadequate stent-assisted coiling.

P-213 Extraction of a lost coil using a stent retriever device E.R. Gizewski1, A.E. Grams1, W. Poewe2; 1Neuroradiology, Medical University Innsbruck, Innsbruck, Austria, 2Neurology, Medical University Innsbruck, Innsbruck, Austria This case shows that a lost coil can be extracted even out of small vessels (distal MCA) using a stent retriever device (initially designed for thrombus extraction). In this case, the more asymmetrically designed Revive® device was better than Solitair®.

P-214 Intracerebral pial arteriovenous fistula with an associated feeding artery aneurysm: a rare case report S. Keskin1, E. Gökmen1, O. Koc2, .Ş.L. Cengiz3; 1Radiology, Necmettin Erbakan University, Meram School of Medicine, Konya, Turkey, 2Radiology, Necmettin Erbakan University, Konya, Turkey, 3Neurosurgery, Necmettin Erbakan University, Meram School of Medicine, Konya, Turkey A 17-year-old female presented to the emergency department. A pial arteriovenous fistula and additional pseudoaneurysm arising from the feeding artery were detected. The feeding artery aneurysm and arteriovenous fistula were embolized using detachable microcoils in the interventional radiology department.

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Common carotid artery stenting with Atrium covered stent following inadvertent catheterisation of the right common carotid artery

Management of delayed coil migration with flow-diverter stent

C. Kachramanoglou1, T. Hampton2, D. Evans1, D. Huang1, C.J. Wilkins1, P. Sidhu1, H. Rashid3, T. Ammar1; 1Department of Radiology, King’s College Hospital, London, United Kingdom, 2Department of Neuroradiology, King’s College Hospital, London, United Kingdom, 3Vascular Surgery, King’s College Hospital, London, United Kingdom We report an uncomplicated case of common carotid arerty stenting with an Atrium covered stent, following inadvertent cannulation of the common carotid artery with a dialysis catheter in a patient with complete occlusion of the contralateral internal carotid artery.

M. Gok1, C. Cinar 2, H. Bozkaya2, I. Oran2; 1Radiology, Kafkas University, Kars, Turkey, 2Interventional Radiology, Ege University Department of Medicine, Izmir, Turkey A patient had incidental paraophthalmic aneurysm, which was embolized 3 years ago. At follow-up, recurrence of aneurysm and delayed coil migration was detected. The management of recurrence and delayed coil migration using flow-diverter stent and its long-term result are reported.

P-216 Spontaneous carotid–superior petrosal sinus arteriovenous fistula in a patient with Marfan’s syndrome R. Shimada, H. Kiyosue, S. Tanoue, H. Mori; Radiology, Oita University Faculty of Medicine, Oita, Japan Cerebral arteriovenous fistula is a rare complication of Marfan’s syndrome. We present a case of a patient with spontaneous carotid– superior petrosal sinus fistula with cerebellopontine edema. AVF was successfully treated with transarterial embolization, and the patient fully recovered without complications.

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Successful treatment for central retinal artery occlusion (CRAO) – carotid artery stenting (CAS) followed by local thrombolysis of the ophtalmic artery

Chemoembolization of extrahepatic collateral arteries for hepatocellular carcinoma in the caudate lobe of liver

M. Lewandowski, A. Modrzejewski, I. Kossuth, J. Gorący; Clinic of Cardiology, Pomeranian Medical University, Szczecin, Poland A case of sudden blindness due to CRAO was diagnosed. Using a proximal protection device, CAS was performed, followed by selective ophthalmic arteriography and local thombolysis. Excellent clinical result was observed with regard to regaining of vision.

Oncologic intervention P-218 A prognostic score for survival of salvage patients after Y-90 radioembolization of liver metastases from colorectal carcinoma R. Damm, R. Seidensticker, M. Seidensticker, K. Mohnike, H. Amthauer, M. Pech, J. Ricke; Radiology and Nuclear Medicine, University of Magdeburg, Magdeburg, Germany WITHDRAWN

P-219 Angled cool-tip electrode for radiofrequency ablation of small superficial subcapsular tumors in liver D.Y. Lee1, S.J. Lee1, M.D. Kim1, Y.E. Chung1, J.Y. Won1, S.I. Park1, I.J. Kim1, Y. Yoon2; 1Severance Hospital, Yonsei University College of Medicine, Department of Radiology, Research Institute of Radiological Science, Seoul, Korea, 2Radiology, National Medical Center, Seoul, Korea Purpose: To evaluate the feasibility and results of using angled cooltip electrode to traverse non-tumorous liver parenchyma for radiofrequency ablation of small superficial subcapsular tumors in liver. Material and Methods: From January to December 2013, angled cool-tip electrode was used for radiofrequency ablation of 8 superficial subcapsular tumors of ≤3 cm in 8 patients (male:female=6:2, mean age 49.4±8.7 years). The tumors were hepatocellular carcinoma (n=6), metastasis from cholangiocarcinoma (n=1), and rectosigmoid cancer (n=1) with a diameter of 9–26 mm (mean 16.0±6.1 mm). The junction of insulated/non-insulated segment of the electrode was manually bent to an angle of 25–40°. Under an ultrasonographic guide, non-tumorous liver parenchyma was punctured at about 1–2 cm apart from the tumor. The tip of the angled electrode was adjusted and advanced to penetrate the index tumor for radiofrequency ablation. Follow-up CT/MRI was performed at 1–3 months after treatment. Radiological images and medical records were retrospectively evaluated for success rate and complications. Results: Technical success of obtaining complete necrosis of the index tumors was 100%. There were no immediate procedurerelated complications including subcapsular hematoma. CT/MRI follow-up performed at 29–267 days revealed no local recurrence including seeding, but distant recurrence was noted in 3 patients with hepatocellular carcinoma. Conclusion: Using angled cool-tip electrode for radiofrequency ablation of small superficial subcapsular tumor is a feasible alternative technique that may lower the incidence of complications related to the direct penetration of tumors.

J.D. Kim1, G.M. Kim2, H.-C. Kim3, S. Hur4, H.J. Jae5; 1Radiology, Eulji University Hospital, Daejeon, Korea, 2Radiology, Korea University Medical Center Anam Hospital, Seoul, Korea, 3Radiology, Seoul National University Hospital, Seoul, Korea, 4Radiology, Seoul National University, Seoul, Korea, 5Department of Radiology and Emergency Medicine, Seoul National University Hospital, Seoul, Korea Purpose: To evaluate the safety and efficacy in performing chemoembolization of extrahepatic collateral arteries (EHC) for hepatocellular carcinoma (HCC) in the caudate lobe of the liver. Material and Methods: Between January 2006 and November 2013, chemoembolization via EHC was performed in 35 patients with 35 caudate HCCs. Preprocedural and follow-up CT or MR scans, angiograms, and medical records were retrospectively reviewed by consensus. Chi2 analysis was used to evaluate the relationship between tumor characteristics and the type of EHC and that between tumor response and the characteristics of the tumor and chemoembolization. Results: EHCs supplying the caudate HCC originated from the right inferior phrenic artery (RIPA) in 31 patients (88.6%). The remaining 4 HCCs were supplied by the gastroduodenal artery, dorsal pancreatic artery, and right and left gastric arteries. Superselective catheterization of tumor-feeding vessels from the EHC was achieved in 27 patients (77.1%). There were no major complications. Individual tumor response supplied by EHC at follow-up enhanced CT were complete response (n=18), partial response (n=9), stable disease (n=3), and progressive disease (n=3). Non-RIPA EHCs were significantly more common in patients who had previously received chemoembolization via RIPA (50%) than those who had not (6.5%; P=0.010). There were no significant predictive factors associated with tumor response. Conclusion: HCC in the caudate lobe can be supplied by several EHCs. Chemoembolization via these arteries can be performed safely and effectively.

P-221 Clinical effectiveness of Y-90 transarterial radioembolization in liver metastases R. D’Angelo1, R. Galasso2, F. Somma2, L. Aloj1, S. Lastoria1, F. Fiore1; Radiation Therapy and Nuclear Medicine, National Cancer Institute G.PASCALE, Naples, Italy, 2Radiology, Second University of Naples, Naples, Italy 1Radiology,

Purpose: The purpose of this study was to assess the safety and usefulness of intra-arterial Y-90 SIR-sphere treatment in patients with liver metastases. Material and Methods: Between 2005 and 2013, radioembolization was performed in 123 patients with non-surgical liver metastases in progression after chemotherapy (74 with colorectal tumor, 28 with breast cancer, 5 with melanoma, 5 with NET, 4 with pancreatic tumor, 4 with gastric tumor, and 3 with ovarian tumor). The administered dose was calculated with body surface area method. All patients underwent PET/TC before and after treatment. PET-Y-90 was performed to check the microsphere distribution. Work-up also included embolization of gastroduodenal artery and other arteries using micro-coils. A shunting study was conducted with Tc-99MAA after positioning of 3-French microcatheters. Results: The mean administered dose was 1.55 GBq. A partial/complete response was achieved in 37 patients, stability was obtained in 54, and progressive disease in 31 patients. No significant side-effects of treatment were observed; 45 patients developed fever that lasted

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up to a week. In all, 53 patients also experienced abdominal pain controlled by oral analgesia. Prophylaxis treatment was used for 1 month after PPI. Conclusion: Our experience suggests that radioembolization is effective and safe for the local treatment of non-surgical hepatic metastasis in progression after systemic chemotherapy.

P-222 Cone-beam CT vs CT in lung ablation procedure: which is faster? J.B. Battistuzzi1, R.L. Cazzato1, S. Al-Amari1, J.T. Perez1, C. Ziade1, X. Buy 2, J. Palussière2; 1Imagerie Medicale, Institute Bergonie, Bordeaux, France, 2Department of Radiology, Institut Bergonié, Bordeaux, France Purpose: To compare the duration of targeting and positioning of radiofrequency electrode on lung tumors using different modalities [cone-beam CT (CBCT) vs CT]. Material and Methods: Patients were randomized in 2 groups – group A, 19 lung tumors (mean size 15 mm, range 6–38.7 mm) treated in 16 patients under CBCT and group B, 13 lung tumors (mean size 13.5 mm, range 4–32 mm) in 13 patients under CT. Both groups were compared in terms of time required to correctly deploy electrode tips within the target lesion and to check its positioning. If electrode reposition occurred, time required for it was recorded. Results were stratified according to lesion size (<10 mm vs 10–20 mm vs >20mm). Student’s t test was used to compare both groups. Results: For lesions of <10mm, mean time needed for electrode deployment and positioning control was 19 minutes with CT vs 7.1 minutes with CBCT (p<0.05); electrode repositioning occurred 14% times (mean 8 minutes) with CT vs 25% times (mean 1.5 minutes) with CBCT. For lesions of 10–20 mm, mean time needed for electrode deployment and positioning control was 13.2 minutes with CT vs 6.6 minutes with CBCT (p<0.05). Electrode repositioning occurred 36% times (mean 4 minutes) with CT, and no electrode repositioning was required with CBCT. For lesions of >20 mm, mean time needed for electrode deployment and positioning control was 27.7 minutes with CT vs 10.6 minutes with CBCT (p<0.05); electrode repositioning occurred 100% times (mean 5.3 minutes) with CT vs 80% times (mean 4.5 minutes) with CBCT. Conclusion: Despite lesion size, CBCT allows a faster lung ablation procedure than CT.

P-223 Cryotherapy combined with intra-arterial chemoembolization in advanced cancer patients: feasibility and clinical gains  J.H. Kim; Radiology, G SAM Hospital, Gunpo, Korea Purpose: To evaluate the practical feasibility and clinical gains of cryotherapy combined with intra-arterial chemoembolization (IACE) in the palliative treatment of advanced cancer patients. Material and Methods: From January 2009 to July 2013, 42 advanced cancer patients (18 males and 24 females) underwent oncolytic intervention to control their clinical problems that were unable to control with standard treatments. Patients’ current problems, practical feasibility, and expected clinical gains were discussed with the consulting oncologists. Cryotherapy adapting usual technique and IACE using cytotoxic agents and 50-150 um temporary embolic materials were performed simultaneously, consecutively, or alternatively for target lesions. Post-procedural clinical gains were evaluated in 5–10 days and 20 days, including assessment for clinical improvement, laboratory and radiological changes. Results: The consulting purposes for the procedures could be categorized into 3 groups according to the clinical manifestations and

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clinical situations – rescue (control of lesions and symptoms, impossible in other treatment modalities, n=22: control of pain and discomfort in 15, control of rapidly growing lesions in 5, old age in 1, refusal in 1), supporting (adjuvant to consolidate main treatments, n=18), and bridging (improving general condition to take systemic treatments, n=2). Clinical gains concurred with oncologists were obtained in 15 patients in the rescue group (69%), 13 in the support group (75%), and 2 in the bridging group (100%). Results were all statistically significant (p<0.05). Complications developed in 5 patients (major in 1). Conclusion: Combination of cryotherapy and IACE could induce locoregional control and clinical palliation in advanced cancer patients, which would be a helpful option in the palliation of advanced cancer patients.

P-224 Early changes in apparent diffusion coefficient and contrast enhancement after cryoablation of renal tumors E. de Kerviler1, F. Mantagui2, A. Coffin2, C. de Bazelaire2; 1Department of Radiology, Saint-Louis Hospital, Paris, France, 2Radiology, Saint-Louis Hospital, Paris, France Purpose: To compare the apparent diffusion coefficient (ADC) and enhancement pattern of renal tumors before, at 1 day, and at 1 month after successful cryoablation. Material and Methods: Twenty-five patients with renal carcinoma underwent MRI before and after cryoablation at 1 day (D1) and 1 month (M1) using DWI-weighted MR sequences and contrastenhanced T1-weighted images at 20 s and 60 s after injection of 0.1 mmol/kg of dotarem. We measured ADCs and calculated the percentage enhancement using two different regions of interest (ROIs), one in the tumor bed and the second in the ablated area around the tumor. Changes in ADCs and percentage enhancement were compared between time points with Wilcoxon’s tests Results: ADC in the tumor was 1.290±0.4 mm2s-1 at baseline and 0.973±0.299 mm2s-1 at D1 (p<0.001), and 0.768±0.262 mm2s-1 at M1 (p<0.001). ADC in the ablated area was 1.863±0.093 mm2s-1 at baseline, 0.973±0.299 mm2s-1at D1 (p<0.001), and 1.090±0.401 mm2s-1at M1 (p<0.001). The early (20 s) and late (60 s) enhancement in the tumor was 181%±115% and 217.2%±130% at baseline, 22%±54% and 59.9%±105% at D1, and 15%±49 and 41.2%±112% at M1 (p=0.001), respectively. The early and late enhancement at baseline in the ablated area was 179%±111% and 250%±83% at baseline, 19%±18% and 8%±24% at D1,and 17%±37% and 8%±24% at M1 (p=0.001), respectively. Conclusion: ADC and the percentage enhancement of malignant renal tumors successfully treated by cryoablation show a predictable evolution and may help radiologists to monitor tumor response after treatment. Early changes in both diffusion and enhancement are consistent with a prominent occurence of ischemia.

P-225 HCC treatment with 40-μm drug-eluting microspheres: early results R. Nani, C. Villa, R. Agazzi; Radiology, HPG 23 Bergamo, Bergamo, Italy Purpose: Transarterial chemoembolization (TACE) is the current standard of care for patients with intermediate-stage hepatocellular carcinoma (HCC) and relatively preserved liver function. The introduction of an embolic drug-eluting bead (DEB) has been shown to substantially improve the pharmacokinetic profile of TACE. We report our preliminary experience with calibrated 40-μm drug-eluting beads in treating nodular HCC.

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Material and Methods: Since June 2013, we have treated 14 HCC (15–70 mm, median size 31 mm). In 11 patients (6 males and 5 females, age 48–79 years), using small microspheres (Tandem; CeloNova BioSciences, Newnan, USA) loaded with 50 (3 patients)–100 mg (8 patients) epirubicin. Three patients had been treated previously with cTACE and one with RF. Results: No procedure-related complications occurred. Postembolisation symtoms were mild or absent. CT and MR evaluation showed complete necrosis at 1 and 3 months in all but 2 nodules. One nodule presented a partial (20%) necrosis but a persistent vascolarisation from the phrenic artery was observed. The last one, a lesion with partially infiltrative pattern, appeared widely hypodense with peripheral vascular ring and was closely controlled. Conclusion: In this small series, we registred impressive short-term results. TACE using calibrated, small, drug-eluting microspheres could have a stronger effect than conventional TACE. The selection of the size of the beads could be a key issue. Deb-TACE with 40-μm particles appear to be safe and effective.

P-226 In vitro characterization of drug-eluting HepaSphere designed for chemoembolization N. Maeda, K. Osuga, K. Tanaka, K. Kishimoto, M. Nakamura, Y. Ono, H. Higashihara, N. Tomiyama; Diagnostic and Interventional Radiology, Osaka University Graduate School of Medicine, Suita, Japan Purpose: To review in vitro characterization of anticancer drug (epirubicin, cisplatin, irinotecan)-loaded HepaSphere designed for chemoembolization. Material and Methods: HepaSphere is a calibrated microsphere designed for chemoembolization with an ability to absorb any kind of anticancer drug. Various concentrations of solution was made from anticancer drugs (including epirubicin, cisplatin, irinotecan) and solvating media (including non-ionic contrast media; NICM, ionic contrast media; ICM, normal saline; NS, injection solvent; IS). After HepaSphere absorbed various drug solutions, elution kinetics was assessed and the mean diameter of microspheres before and after the drug elution was measured. Results: 1. HepaSphere could not absorb epirubicin when mixed with ICM. The concentration of epirubicin eluted from HepaSphere increased until 4–8 hours and was then constant thereafter under conditions of no flow. HepaSphere in epirubicin solution was expanded by 3–4 times. 2. When mixed with NICM, HepaSphere carried ten times larger dose of cisplatin than when mixed with ICM. Cisplatin-loaded HepaSphere with any kind of solvating media showed a similar elution profile and elute more than 90% within almost 24 hours. It expanded by 2 times, 4.5 times with ICM, NICM, respectively. 3. In solutions of higher NaCl concentrations, the elution rate of irinotecan becomes higher. NaCl is likely to promote elution of irinotecan from HepaSphere. HepaSphere in irinotecan solution was expanded by 2.5–6 times. When mixed with irinotecan solutions of higher concentration, the diameter was relatively smaller. Conclusion: When HepaSphere was mixed with anticancer drugs, these characteristics must be considered.

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P-227 Intraarterial lutetium dotatate receptor therapy for neuroendocrine tumors S. Yilmaz, A. Yildiz, M. Ozdogan, M. Cevener, A. Kargi; Medstar Yildiz Hospital, The Mediterranean Integrative Oncology Group, Antalya, Turkey Purpose: Intravenous administration of radiolabelled somatostatin analogues is a novel and effective therapy for neuroendocrine tumors. The efficacy of this therapy may theoretically be increased with selective intraarterial administration. The aim of our study is to evaluate the safety and efficacy of intraarterial 177 lutetium-labelled somatostatin analogue (IA 177Lu-DOTATATE) infusion for the treatment of inoperable or metastatic neuroendocrine tumors. Material and Methods: Between March and December 2013, 8 patients (2 females, 6 males aged 33-64 years) with inoperable or metastatic neuroendocrine tumors underwent 1-3 sessions of IA 177Lu-DOTATATE. Seven patients had primary tumors in the pancreas, 1 in the larynx and 3 had hepatic metastases. Treatment response was evaluated in 7 patients according to the RESIST criteria using 68Ga-DOTATATE PET-CT in 4 and post-therapy 177Lu-DOTATATE scintigraphy plus MRI in 3. Results: In all patients, the procedure was technically successful. The catheter was placed into the celiac trunk (n=2), proper hepatic artery (n=4), left hepatic artery (n=1) and external carotid arteries (n=1). After the infusions, there was no evidence of local or systemic toxicity, but one patient had flushing and another had mild abdominal pain. The post-treatment follow-up images revealed partial response in 6 and stable disease in 1. In one patient with laryngeal tumor who had no follow-up images, there was significant clinical improvement (hoarseness disappeared after the first session). Conclusion: Our study suggests that selective intraarterial infusion of 177Lu-DOTATATE is safe and effective in patients with neuroendocrine tumors. The relatively high response rate in our series warrants comparison with the standart intravenous administration in a prospective randomized trial.

P-228 Irreversible electroporation for non-thermal tumor ablation in the clinical setting: a systematic review of safety and efficacy H.J. Scheffer1, K. Nielsen2, M.C. de Jong1, A.A. van Tilborg1, J.M. Vieveen3, A. Bouwman3, S. Meijer 2, C. van Kuijk1, P. van den Tol2, M.R. Meijerink1; 1Radiology and Nuclear Medicine, VU University Medical Center, Amsterdam, Netherlands, 2Surgery, VU University Medical Center, Amsterdam, Netherlands, 3Anaesthesiology, VU University Medical Center, Amsterdam, Netherlands Purpose: Irreversible electroporation (IRE) is a novel, non-thermal tumor ablation technique that uses electrical pulses to induce cell death, whilst preserving structural integrity of bile ducts and vessels. The aim of this systematic review was to provide an overview of current clinical results. Material and Methods: All in-human literature on IRE reporting safety and/or efficacy was included. All adverse events were recorded. Tumor response on follow-up imaging from 3 months onwards was evaluated. Results: In sixteen studies, 221 patients had 325 tumors treated in liver (n=129), pancreas (n=69), kidney (n=14), lung (n=6), lesser pelvis (n=1) and lymph node (n=2). No major adverse events during IRE were reported. IRE caused only minor complications in the liver, but three major complications in the pancreas (bile leak n=2, portal vein thrombosis n=1). Complete response at 3 months was 67-100% for hepatic tumors (93-100% for tumors <3cm). Pancreatic IRE combined with surgery lead to prolonged survival compared to control (20 vs 13 months) and significant pain reduction.

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Conclusion: Where other techniques are unsuitable, IRE is a promising modality for the ablation of tumors near bile ducts and blood vessels. This review gives an extensive overview of the available evidence, which unfortunately is limited in terms of quality and quantity. With this in mind, IRE of central liver tumors seems relatively safe without major complications, whereas complications after pancreatic IRE appear more severe. The available limited results for tumor control are generally good. Overall, the future of IRE for difficult-to-reach tumors appears promising.

P-229 Microwave ablation of pancreatic tumors N. Lucchina1, A.M. Ierardi2, M. Petrillo3, C. Floridi1, E. Duka2, F.A. Vizzari2, G. Carrafiello1, C. Fugazzola2; 1Radiology, University of Insubria, Varese, Italy, 2Radiology, Uninsubria, Ospedale di Circolo, Varese, Italy, 3Radiology, Second University of Naples, Naples, Italy Purpose: To evaluate the safety, efficacy, and survival after microwave (MW) ablation treatment in locally advanced, non-resectable pancreatic tumors. Material and Methods: We present our experience and describe our technique about MW ablation in 13 patients with pancreatic tumors. Of them, 6 patients with adenocarcinoma were treated with percutaneous approach; 5 with adenocarcinoma and 2 with neuroendocrine tumors underwent a laparotomic approach. MW generator used (45 Watt, 915 MHz) was connected by a coaxial cable to 14-gauge straight MW antennas with a 3.7 cm or 2 cm radiation section. One or two antennae were used with an ablation time of 10 minutes. The US guide was used in 8 patients and combined US/ cone-beam CT-guidance were used in 5 patients. Follow-up was performed by CT after 1, 3, 6, 12, 16, and 24 months.Tumor response was assessed according to Response Evaluation Criteria In Solid Tumors and Choi criteria.The feasibility, safety, complications associated with quality of life (QOL) and overall mean survival were recorded. Results: The procedure was feasible in all patients. A late major complication was observed in one patient. No patient had further surgery and all minor complications were resolved during the hospital stay. Improvement in QOL was observed in all patients despite a tendency to return to preoperative levels in the months following the procedure. No repeat treatment was performed. Overall mean survival was 19 months for adenocarcinoma and 29.5 months for neuroendocrine tumors. Conclusion: In our experience, even if associated with self-limited complications, MW ablation seems to be feasible for the treatment of pancreatic tumors in terms of local disease and pain control.

P-230 Percutaneous CT-guided cryoablations of renal masses: a safe and effective treatment G.-A. Kock1, A. Montauban van Swijndregt1, B. Lagerveld2; 1Interventional Radiology, OLVG Hospital Amsterdam, Amsterdam, Netherlands, 2Urology, OLVG Hospital Amsterdam, Amsterdam, Netherlands Purpose: To evaluate the safety and the efficacy of CT-guided cryoablation of renal masses. Material and Methods: In this retrospective study, 45 patients who underwent CT-guided cryoablation for a total of 48 renal masses between 2007 and 2012 were included. The reports were checked for treatment-related complications during and/or after the cryotherapy and for efficacy with at least 1-year follow-up with CT. The patients were divided in 3 groups by the size of the mass: <3 cm (group I), 3–4 cm (group II), and 4–5 cm (group III). A biopsy was taken from the renal mass for evaluation by the pathology department.

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Results: Fifty-five ablations were performed on 48 masses (7 recryotherapy in case of unsuccessful initial result or recurrence). Only minor complications were reported: hematoma and probe-site paresthesia. Thirteen masses (27%) turned out to be benign; these were excluded from further evaluation. Follow-up was performed in 34 proven RCCs: 22 in group I, 8 in group II, and 4 in group III. Efficacy after 1 treatment: group I 73% (16), group II 88% (7), and group III 75% (3). Efficacy after 2 treatments: group I 96% (21), group 2 100% (8), and group III 75% (3). Total efficacy after 2 treatments was 94%. Conclusion: Cryotherapy is a safe and effective method for treating renal masses up to 5 cm. No major complications were reported. Total efficacy was 94%. Additional finding: biopsy of the mass prior to the treatment is advocated to reduce the unnecessary treatment of benign lesions.

P-231 Percutaneous hepatic perfusion (chemosaturation) of cholangiocarcinoma with second-generation hemofiltration system: a technical note M. Zeile1, K.J. Oldhafer 2, A. Stang3, G.A. Stavrou2, U. Koch1, C.-U. von Seydewitz3, M. Beumer4, R. Bruening1; 1Radiology (Röntgeninstitut), Asklepios Clinic Hamburg Barmbek, Hamburg, Germany, 2General and Visceral Surgery, Asklepios Clinic Hamburg Barmbek, Hamburg, Germany, 3Oncology, Asklepios Clinic Hamburg Barmbek, Hamburg, Germany, 4Anestesiology, Asklepios Clinic Hamburg Barmbek, Hamburg, Germany Purpose: Intrahepatic cholangiocarcinoma (ICC) is the second most common intrahepatic primary malignancy. Treatment options besides resection are limited and have a poor prognosis. An alternative treatment is percutaneous hepatic perfusions (PHP), which combines hepatic arterial perfusions of chemotherapy with venous hemofiltration to limit systemic toxicity. Material and Methods: Three patients (F:M=2:1; age 38, 56, and 55 years) with unresectable ICC were treated with melphalan delivered by PHP combined with a second-generation hemofiltration system (Hepatic CHEMOSAT® Delivery System; Delcath Systems Inc., USA). The targeted aggregated clotting time during treatment was >400 s. All individuals showed tumor progression following standard chemotherapy. Treatments were approved by the local tumor board. Liver transplantation was not considered an option in any patient. At the time of evaluation for therapy, Karnofsky indices were 100%, 90%, and 100%, respectively. Comorbidities were excluded in all patients, particularly cardiac diseases and extrahepatic metastases. Results: Patients received a single dose of melphalan (median 187 mg, range 162–220 mg). Following the procedure, all patients remained in intensive care for 24 hours, and then catheters were removed. Two patients were discharged within 3 and 18 days, while the third patient required an extended hospital stay (because of leucopenia and thrombocytopenia). There were no peri-procedural complications. Tumor status will be evaluated in all patients 8 weeks after treatment. Conclusion: High-dose melphalan delivered by PHP combined with an advanced filtration system is a technically feasible and apparently safe technique.

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P-232 Pre-transplant transarterial chemoembolization in an outpatient setting: a single-center retrospective review R.J. Pierami Neto, J.M. McKinney, R. Paz-Fumagalli, D. Sella, G. Frey; Interventional Radiology, Mayo Clinic, Jacksonville, FL, United States of America Purpose: Unexpected admissions and hospital days of pre-transplant transarterial chemoembolization (TACE) managed by sameday discharge (outpatient setting) were reviewed. Material and Methods: Our procedural database for pre-transplant TACE/DEB TACE performed between September 2011 and September 2013 was reviewed. In all, 127 pre-transplant hepatic TACE procedures at a single hepatic transplant center were identified; 104 TACE procedures were managed with intent of same-day discharge and 23 TACE procedures were managed with overnight observation (20 patient in 2011/2012 and 3 patients in 2012/2013). The following data was analyzed for each patient: unexpected admissions, admission diagnoses, and hospital days. Results: A total of 102 conventional TACE and 25 drug-eluting bead TACE were performed on 108 patients (mean age, 62 years). The outpatient group (mean MELD score, 8.2) had 7 unexpected admissions (length of hospitalization, 2.54 days). Unexpected admission diagnoses for the same-day discharge group included pain, nausea/vomiting, confusion, hematochezia, and spontaneous bacterial peritonitis. The 23-hour observation group (mean MELD score, 6.4) had 4 unexpected admissions (length of hospitalization, 2.75 days). Unexpected admission diagnoses for the 23hour observation group included pain, fever, encephalopathy, and hypotension. In all, 93% (97/104) of the same-day discharge group were discharged on the day of the procedure without unexpected admissions or hospital days. Conclusion: Same-day discharge following hepatic transarterial chemoembolization is safe and well tolerated in pre-transplant population. Rate of unexpected admission and hospital days are comparable to the overnight observation group.

P-233 Radial versus femoral artery access for transarterial chemoembolization Y. Khairutdinov, V. Tsurkan, A. Arablinskiy; Interventional Radiology, Botkin Hospital, Moscow, Russian Federation Purpose: We aimed to assess whether radial artery access was superior to femoral artery access in patients undergoing transarterial chemoembolization (TACE). Material and Methods: Sixty-two patients with unresectable hepatocellular carcinoma or metastatic colorectal cancer were enrolled in our study. Radial approach was used in 30 patients and femoral approach in 32 patients. The duration of TACE, time needed for catheterization of the target artery, and radiation exposure were assessed during the procedure. In the radial approach group, compression bands were used to achieve haemostasis. In the femoral approach group, manual compression was used in 21 patients and closure devices in 11 patients. Major and minor vascular complications were evaluated after the procedure. Discomfort during and after TACE was assessed using specific questions. Results: TACE was successfully performed in all patients from both groups. The duration of the procedure (37.4 and 36.1 minutes, p>0.05), time needed for catheterization of the target artery (7.8 and 8.2 minutes, p>0.05) and radiation exposure (0.43 and 0.51 mZv, p>0,05) were comparable between the two groups. In the radial approach group, major vascular complications were not seen and 2 (6.7%) patients had local hematoma. In the femoral approach group, 1 (3.1%) patient had pseudoaneurysm and 6 (18.7%) patients had

Abstract Book local hematoma. Radial approach was associated with a significant reduction in procedural discomfort (43.3% and 65.6%, p=0.0026). Conclusion: The duration of TACE and radiation exposure are comparable between the radial and femoral approach groups. The radial approach provides a significant reduction in the rate of vascular complications and procedural discomfort.

P-234 Radiofrequency ablation in fibromatosis: a new modality of treatment in refractory cases S.S. Kulkarni1, N.S. Shetty1, A. Polyana1, K.B. Gala1, A. Kumar 2, S.S. Patil1, A. Janu2, V.N. Bakare2, P. Velayutham1, K.U. Gaikwad2, A. Andhare2, A. Puri3, A. Gulia3, S. Banavali4, M. Thakur 2; 1Interventional Radiology, Tata Memorial Hospital, Mumbai, India, 2Radiodiagnosis, Tata Memorial Hospital, Mumbai, India, 3BST, Tata Memorial Cancer Hospital, Mumbai, India, 4Oncology, Tata Memorial Cancer Hospital, Parel, Mumbai, India Purpose: To describe the technique, safety and efficacy for performing radiofrequency ablation. Material and Methods: Retrospective evaluation of 22 patients from January 2008 to December 2013 was done. Inclusion criteria include fibromatosis refractory to primary treatmen, i.e. surgery, RT, CT or immunotherapy. The presenting complains of 13/22 had swelling and restriction of movements, 7/22 had restriction of movements and pain and 2/22 had dyspnea. Response evaluation was done clinically by improvement in the range of movements (ROM) and radiologically by change in volume of the lesion at 6-week follow-up, and percentage decrease were calculated. Results: A total of 61 sessions of percutaneous RFA was done in 22 patients with fibromatosis with median number of 3.7/22 sessions had upper limb involvement, 5/22 had lower limb involvement, 5/22 chest wall involvement, 2 of mediastinum, 2 retroperitoneum and 1 of pelvis. Quantification of reduction of size was 0-25% in 10/22 patients, 4 in each 26-50% and 51-75% in 5 and 76-99 in 3. Mean reduction of the volume was reduced from 858 to 503 cc, and pain score reduction of patients having pain and restriction of movements from 6.52 to 2.06. Complications: 51 session patients had post procedural pain; 1 each had neurological deficit and blister and 2 had necrosis. Limitation: Larger prospective study with long follow-up. Endpoint of number of sessions of RFA cannot be objectively stated and is a subjective decision. Conclusion: Radiofrequency ablation of fibromatosis is a potentially safe and effective treatment.

P-235 Robotic high-intensity focused ultrasound for the treatment of prostate cancer in 1008 patients: a 7-year single-center experience V.A. Solovov1, M.O. Vozdvizhenskiy 2, Y.S. Matyash3, D.V. Fesenko3, R.Z. Khametov3; 1Interventional Radiology, Samara Oncology Centre, Samara, Russian Federation, 2Surgery, Samara Oncolody Centre, Samara, Russian Federation, 3Interventional Oncology, Samara Oncology Centre, Samara, Russian Federation Purpose: To report the results of the HIFU treatment for the prostate cancer and failure after external beam radiotherapy (EBRT) and radical prostatectomy (RPE), stratified by tumor recurrence risk according to the D’Amico risk classification. Material and Methods: In all, 1008 patients were treated in our center in 2007–2014: 251 with low-, 375 with intermediate-, and 340 with high-risk progression, 42 – after the EBRT and RPE failure. Further,

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873 patients underwent TURP+HIFU and 135 only HIFU (volume prostate <40cc). Mean follow-up was 51 months (range 3-82). Mean age was 69.2 (52-89) years and mean prostate volume was 38.5 (5.5108) cc. Results: Median PSA level 72 months after HIFU treatment were 0.6 (0.0-3.9) ng/ml – low-risk progression group, 1.1 (0.2-6.8) ng/ml – intermediate-risk, for high-risk group - 3,4 (0-24,5) ng/ml, with failure after EBRT and RPE - 1,8 (0.0-9.9) ng/ml. Patients with low risk had 6.1% progression, with intermediate risk had 8.2%, and with high risk had 14,5%, with failure after EBRT being 19.6%. Kaplan-Meier analyses of the total group indicated that the risk of progression at the 6-year follow-up was 86.5%. Conclusion: Robotic HIFU ablation is minimally invasive treatment for prostate cancer and effective in 86.5%. HIFU-therapy can also use in patients with local recurrence after RPE and EBRT.

P-236 Selective internal radiotherapy (SIRT) using resin yttrium-90 microspheres for chemotherapy-refractory metastatic colorectal cancer: a UK cost-effectiveness analysis B. Pennington1, L. Bester 2, H. Wasan3, B. Sangro4, A.S. Kennedy5, K. Sennfält6; 1Cost-effectiveness, BresMed, Sheffield, United Kingdom, 2Interventional Radiology, University of New South Wales, Sydney, Australia, 3Medical Oncology, Hammersmith Hospital, London, United Kingdom, 4Liver Unit, Clinicia Universidad de Navarra, Pamplona, Spain, 5Radiation Oncology, Sarah Cannon Research Institute, Nashville, TN, United States of America, 6Market Access / Reimbursement, Sirtex Medical Limited, Sydney, Australia Purpose: Treatment options for chemotherapy-refractory liver metastases resulting from colorectal cancer are limited. The safety and efficacy of SIRT using resin yttrium-90 microspheres was studied in this population. The objective of this analysis was to assess the cost-effectiveness of SIRT compared to best supportive care (BSC) from the perspective of the UK NHS. Material and Methods: A state-transition model was constructed, based on survival curves from a retrospective cohort study of yttrium-90 resin microspheres (SIR-Spheres; Sirtex, Sydney, Australia) vs. BSC in chemotherapy-refractory mCRC. The model included costs for treatment acquisition, pre-treatment work-up and delivery of microspheres, and chemotherapy. Additionally, costs of managing AEs and a cost of death were included. Utility data were taken from a recent NICE economic evaluation in metastatic colorectal cancer. Results: The results showed an increase in survival for patients receiving SIRT compared to BSC (2.09 vs 0.97 years), with a corresponding increase in quality adjusted life years (1.50 vs 0.69). The associated costs were £35,487 vs £12,730 for SIRT and BSC, respectively. The additional costs were due to the SIRT treatment and the cost associated with extension to life. The cost per QALY was £28,216 (cost per life year £20,323). The results were robust to alternative assumptions tested in scenario analyses; survival functions, utilities or the time spent pre- and post-progression. Conclusion: The analysis demonstrates that SIRT using resin yttrium-90 microspheres has the potential of being a cost-effective option in the treatment of patients with chemotherapy-refractory liver metastases resulting from colorectal cancer.

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P-237 Selective internal radiotherapy (SIRT) using resin yttrium-90 microspheres for chemotherapy-refractory metastatic colorectal cancer: an Italian cost-effectiveness analysis B. Pennington1, K. Sennfält2, M. Cosimelli3, R. Golfieri4; 1Cost-effectiveness, BresMed, Sheffield, United Kingdom, 2Market Access / Reimbursement, Sirtex Medical Limited, Sydney, Australia, 3Surgical Oncology, Regina Elena National Cancer Institute, Rome, Italy, 4Digestive Disease and Internal Medicine, Sant’OrsolaMalpighi Hospital, University of Bologna, Bologna, Italy Purpose: SIRT using resin microspheres of yttrium-90 can be used to treat liver metastases resulting from colorectal cancer (CRC). A retrospective cohort study found a survival advantage from SIRT compared to standard care in chemotherapy-refractory patients. This study was used in to model the cost-effectiveness of SIRT vs best supportive care (BSC) in this indication. Material and Methods: A state-transition model was developed, with three health states, based on survival outcomes from the retrospective cohort study. The model was developed from the perspective of the National Health Service in Italy. The model included costs for treatment acquisition, pre-treatment work-up and delivery of microspheres, and chemotherapy. In addition costs of managing AEs and a cost of death were included. Costs were obtained from the University Hospital in Bologna, Agenzia Italiana del Farmaco, and the literature. Utility data was not available from the study, so was taken from a recent NICE economic evaluation in the same indication. Results: SIRT increased survival resulting in a life-year gain of 1.35 (2.12 vs 0.98) life years and a quality-adjusted life year (QALY) gain of 0.83 (1.52 vs 0.70). Overall, SIRT lead to an increase in costs of €24,626 (€39,973 vs €15,347), resulting in a cost/QALY of €29,850. Probabilistic sensitivity analysis showed a 97% chance of SIRT being cost-effective at a threshold of €50,000/QALY. Conclusion: The analysis demonstrates that SIRT using resin yttrium-90 microspheres has the potential of being a cost-effective option in the treatment of patients with chemotherapy-refractory liver metastases resulting from colorectal cancer.

P-238 Single-center experience with percutaneous CT-guided cryoablation of renal neoplasms M.M. Ali1, C. Fedele2, O. Tahir 2, M.K. McGarry3, A. Graif1, C.J. Grilli1, C. Wrigley1, D. Agriantonis1, K. Lie1, G. Kimbiris1, M.J. Garcia3, D. Leung1; 1Interventional Radiology, Christiana Care Hospital, Newark, DE, United States of America, 2Vascular and Interventional Radiology, Christiana Care Health System, Newark, DE, United States of America, 3Interventional Radiology, Christiana Care Health System, Newark, DE, United States of America Purpose: To evaluate our institution’s experience with percutaneous CT-guided cryoablation of renal neoplasms. Material and Methods: Retrospective analysis was performed of 95 renal lesions in 88 consecutive patients (55 males, 33 females) treated with CT-guided cryoablation between December 2008 and August 2013. Average lesion size was 2.73 cm. Fifty-two lesions demonstrated medullary involvement (54.1%) and 9 lesions (9.4%) contained a cystic component. Technical success was defined as complete ablation of the target lesion(s) with an “iceball” margin of 5 mm by CT. Average number of cryoablation probes required for treatment was 2.7. Biopsy was performed before cryoablation in 18 of 95 lesions (19%). Follow-up imaging was obtained at 3, 6, and 12 months, and annually thereafter.

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Results: Technical success was achieved in all patients. Hydrodissection was required in 13 lesions (14%) due to proximity of bowel. Follow-up ranged from 1–48 months. Recurrence was noted in 1 of 88 patients (1.1%) at 42 months. Secondary lesions in the contralateral kidney were seen in 2 patients (2.2%). Recurrent and secondary lesions were treated by percutaneous CT-guided cryoablation. Complications were seen in 11 patients (12%). Perinephric hematomas were identified immediately post-treatment in 8 patients, with one patient requiring hemodynamic support and blood transfusion. Two additional patients demonstrated delayed hemorrhage requiring transfusion. One procedure was prematurely terminated secondary to sedation-related respiratory depression; follow-up imaging demonstrated no residual disease. There was a single 30-day mortality as a complication of coronary bypass surgery involving a patient with underlying ischemic cardiomyopathy. Conclusion: Percutaneous CT-guided cryoablation is safe and effective for treating renal neoplasms.

P-239 Transarterial  chemoembolization  of hepatocellular carcinoma with 70–150 μm doxorubicin-loaded drug-eluting beads K.B. Marashi, M.A. Cura, J.D. Sacks, J.D. Meler; Interventional Radiology, Baylor University Medical Center, Dallas, TX, United States of America Purpose: To evaluate the response and patient tolerability of transarterial chemoembolization (TACE) with 70–150 μm doxorubicinloaded drug-eluting beads (DEB) in patients with hepatocellular carcinoma (HCC). Material and Methods: Sixteen consecutive patients (12 males, mean age 63.5 years, range 50–77 years) who underwent 18 TACE sessions with 70–150 μm doxorubicin-loaded DEB for unresectable HCC were retrospectively reviewed. Of them, 11 patients (68.75%) were classified as Barcelona Clinic Liver Cancer stage A, 4 (25%) were stage B, and 1(6.25%) was stage C. Tumor size ranged from 1.3 cm to 7 cm (8 focal and 8 multifocal). Two patients were re-treated with 70–150 μm DEB. Doxorubicin dose infused ranged from 50 mg to 150 mg. Follow-up MRI was obtained in 13 of 16 patients and was evaluated using mRECIST. Results: Fourteen patients received a single session and 2 patients underwent 2 sessions. Final hepatic arteriogram showed slow forward flow. One procedural complication was encountered. Patients were discharged within 24 hours after 16 sessions. Two patients required admission for more than 24 hours, 1 for nausea, fever, and emesis and both for epigastric pain. In 14 patients with follow-up MRI, 4 resulted in complete response (28.57%), 4 in partial response (28.57%), 4 in stable disease (28.57%), and 2 in progressive disease (14.29%). Mean time of last follow-up was 156 days (range 22–940 days). No late complications or deaths were recorded during follow-up. Conclusion: TACE with 70–150 μm doxorubicin-loaded DEB appears safe and effective for treatment of patients with unresectable HCC. In our study, the procedure was tolerated well by the majority of patients showing favorable-to-stable tumor response.

P-240 Transcatheterarterial chemoembolization using HepaSphere microspheres™: preliminary results of a monocentric study F. Pedrazzini, A. Antonietti, A. Balderi, D. Sortino, E. Roberto, C. Vinay, M. Grosso; Radiology, Ospedale Santa Croce e Carle, Cuneo, Italy Purpose: To present our experience with TACE using HepaSphere microspheres™ (Biosphere Medical) loaded with doxorubicin in patients with unresectable hepatocellular carcinoma. Material and Methods: From December 2005 to December 2013, 200 patients (157 males and 43 females, mean age 72 years) were

Abstract Book treated by selective TACE using HepaSphere microspheres™ loaded with doxorubicin. Lesion diameters ranged from 25 to 176 mm with a mean diameter of 64.2 mm from single to multinodular lesions. Before treatment, 75.5% patients had a Child–Pugh A, 24.5% had Child–Pugh B, 33.5% had stage A (BCLC staging), 64,5% had stage B, and 2% had stage C. In all, 131 patients were HCV positive, 21 were HBV positive, 29 had an alcohol-related liver disease, and 19 had a non-alcoholic steatohepatitis. Results: Technical success rate was 100% with complete devascularization of lesions at the end of all procedures. Subdividing the sample according to the BCLC staging provided a 6-month survival of 89% for stage A, 86% for stage B, and 50% for stage C, a 12-month survival of 70% for stage A and 71% for stage B, a 24-month survival of 61% for stage A, and 60% for stage B, while at 36-month, survival of 59% for stage A and 45% for stage B. Conclusion: Our experience demonstrates that TACE using HepaSphere™ is feasible, with a low complication rate and promising efficacy. Comparing with conventional TACE, randomized studies are mandatory to confirm these preliminary results.

P-241 Unresectable neuroendocrine liver metastases treated by transcatheter intraarterial therapy: results of a Japanese multicenter study O. Ikeda1, Y. Sato2, Y. Baba3, T. Yasumoto4, K. Osuga5, D. Abo6, H. Gobara7, K. Yamakado8, S. Hirota9, T. Minami10; 1Diagnostic Radiology, Kumamoto University Graduate School of Life Sciences, Kumamoto, Japan, 2Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya, Japan, 3Radiology, Kagoshima University, Kagoshima, Japan, 4Radiology, Toyonaka Municipal Hospital, Toyonaka, Japan, 5Department of Radiology, Osaka University Graduate School of Medicine, Osaka, Japan, 6Radiology, Hokkaido University Graduate School of Medicine, Sapporo, Japan, 7Radiology, Okayama University Medical School, Okayama, Japan, 8Interventional Radiology, Mie University School of Medicine, Tsu, Japan, 9Department of Radiology, Hyogo College of Medicine, Nishinomiya, Japan, 10Radiology, Kanazawa University, Kanazawa, Japan Purpose: To evaluate the technical success, effectiveness, complications, survival, and prognostic factors in patients with unresectable neuroendocrine liver metastases treated by transcatheter intra-arterial therapy (TIT). Material and Methods: We evaluated 93 patients who underwent 309 TIT procedures at 12 institutions. They underwent c-TACE with lipiodol (n=107), TAE (n=111), TACE without lipiodol (n=65), and TAI with infusion chemotherapy (n=28) (groups 1–4). Overall survival from the first treatment, factors affecting survival, and efficacy of TIT based on the tumor reduction ratio (%) were determined by MRI, and the side-effects were analyzed. Complete and partial responders and non-responders were classified based on RECIST, mRECIST, and EASL. Results: Mean overall and 5-year survival were 2611±271 days and 59%, respectively. Mean overall survival in the absence and presence of extrahepatic disease was 2787±351 and 2459±377 days, respectively, (p = 0.02); other factors had no significant effect. The response ratio was 54%, 84%, and 86% for groups 1, 2, and 3, respectively. By RECIST, EASL, and mRECIST, 28%, 36%, and 44% group 1, 19%, 40%, and 43% group 2, 17%, 26%, and 32% group 3, and 17%, 0%, and 17% group 4 patients responded. By EASL, the response was significantly worse in group 4 TAI (p<0.03). In 3 procedures, we encountered complications exceeding grade 3 (liver abscess, groups 1 and 2, n=2 and acute cholecystitis, group 1, n=1). Conclusion: The presence of extrahepatic metastasis should not limit the use of TIT. Groups 1, 2, and 3 had better tumor response ratios, but their difference was not significant.

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P-242 Virtual thermometry software during cone-beam CT-guided pulmonary radiofrequency ablation: advantages of a new tool R.L. Cazzato1, F. Texeira Jr.1, R.F. Grasso2, V. Catena1, N. Alberti1, X. Buy3, J. Palussière3; 1Imagerie Medicale, Institute Bergonie, Bordeaux, France, 2Radiology, Campus Biomedico University, Rome, Italy, 3Department of Radiology, Institut Bergonié, Bordeaux, France Purpose: To evaluate the technical feasibility of a software (virtual thermometry; VT) that predicts ablation area in lung radiofrequency ablation (RFA) performed under cone-beam CT (CBCT) guidance. Material and Methods: In our center, we have a 10-year experience in lung ablation with 4-year experience in CBCT-guided lung ablation. We prospectively enrolled 16 patients (9 males and 7 females, mean age 64.7 years). Seventeen tumors (2 primary lung cancers, 15 lung metastases) were treated with RFA in 16 sessions. VT was used before and after probe deployment into the lesion to predict the optimal 3D coverage. When VT did not show optimal tumor coverage, the electrode was repositioned according to VT indications. Tumor size, technical success, procedural time, and complication rate were assessed. It was also noted if VT changed the initial RFA planning by an additional needle repositioning. A 2-day MPR CT scan was used to assess the optimal tumor coverage (ground glass opacity; GGO, entirely covering the lesion with a 1 cm safe margin). Results: Mean size of the lesions was 10 mm (range 6–38 mm). All procedures were performed successfully within the mean procedural time of 48.75 min (range 45–60 min). According to VT indications, 50% RFA required an additional needle deployment and 50% did not. The most common complication was PNX (6/16, 37.5%). In all cases, the 2-day CT scan showed perfect tumor coverage by GGO. Conclusion: VT was highly effective in predicting the extent of the ablation area as assessed on a 2-day CT scan following CBCT-guided lung RFA. This software may be helpful in centers initiating in lung ablation.

P-243 Visualization of lipiodol-marked renal tumor under fluoroscopy for percutaneous cryoablation H. Tomimatsu, Y. Arai, M. Sone, H. Ishii, S. Sugawara, S. Morita, D. Okamoto; Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan Purpose: The purpose of this study was to assess the feasibility and safety of lipiodol marking prior to percutaneous cryoablation for renal tumors under fluoroscopy. Material and Methods: In this retrospective study, patients who underwent percutaneous cryoablation with lipiodol marking between April 2012 and December 2013 were included. However, patients requiring additional procedures such as spacer placement were excluded. A superselective transarterial injection of lipiodol was administered to the branch of renal artery followed by embolization with a small amount of gelatin sponge particles. Percutaneous cryoablation was performed next day under fluoroscopy and CT using an angio-CT system. The visibility of tumor under fluoroscopy, technical success, the number of needles, procedural time, adverse events (AEs) (CTCAE ver4.0), and local recurrence were evaluated. Results: In all, 23 patients (26 tumors) were included (17 males, median age, 68; range, 35–88 years). The average diameter of the tumor was 2.0 cm (range, 0.8–3.7 cm). All tumors were visible under fluoroscopy and technical success was achieved in all. The average number of punctured needles was 1.7 (range 1–4). Mean procedural time was 85 minutes (range, 60–160 minutes). AEs occurred in 4

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patients [grade 2 retroperitoneal hematoma (n=3), grade 3 iliopsoas abscess (n=1)]. No local recurrence was identified in any patient on contrast-enhanced CT during a mean follow-up time of 9 months (range, 2–22 months). Conclusion: Lipiodol marking prior to percutaneous cryoablation under fluoroscopy and CT is technically feasible without major complications and useful in terms of accurate puncture with real-time monitoring under fluoroscopy.

P-244 CT-guided percutaneous cryoablation: everything the radiologist needs to know E. de Kerviler, C. de Margerie, C. de Bazelaire, A. Coffin; Department of Radiology, Saint-Louis Hospital, Paris, France Learning Objectives: Cryoablation is feasible in almost every organ. However, treatment protocols and precautions differ between organs. The aim of this exhibit is to present the main characteristics of cryoablation in various organs, with emphasis on success and safety issues. Background: Drawing from our experience of more than 200 CT-guided cryoablation procedures, we present the treatment protocols in various organs, including the kidney, lung, breast, bone, adrenal and soft tissues along with take-home points important for the interventional radiologist. Clinical Findings/Procedure: In every organ except the lung, the treatment protocol comprises a double-freeze technique (10-minute freeze, 10-minute thaw and 10-minute freeze). In the lung, a triple freeze technique (3-minute freeze, 3-minute thaw, 7-minute freeze, 7-minutes thaw, 10-minute freeze and 10-minute thaw) ensures a more effective cytotoxicity. In the kidney, sparing of nephrons and preservation of the ureter and digestive structures is mandatory. In the adrenal gland, premedication with alpha-adrenergic blockade is necessary to prevent hypertensive crisis. In breasts and superficial structures, protection of the skin is the essential. In the bone and soft tissues, preservation of the nerves is necessary. Conclusion: Cryoablation is an effective treatment option in many cancer patients. Care should be taken to use the correct treatment protocol, which depends on the organ, and consider the surrounding tissues and metabolic consequences of the ablation.

P-245 Delirium following chemoembolization: the role of inflammation in post-embolization syndrome C.E. Ray, Jr.1, D. Wells2, J. Alisky3, J. Minocha1, M.-G. Knuttinen1, R.C. Gaba1, J.T. Bui1; 1Radiology, University of Illinois at Chicago, Chicago, IL, United States of America, 2Radiology, University of Colorado, Aurora, CO, United States of America, 3Gerontology, IPC/Senior Care of Colorado, Aurora, CO, United States of America Learning Objectives: 1. To understand the incidence and proposed etiologies of postembolization syndrome (PES) and delirium in patients following chemoembolization. 2. To understand the current treatment methods used for the prevention and treatment of PES. 3. To discuss the opportunities for research for delirium as a component of PES, particularly as it relates to hepatic chemoembolization. Background: Post-embolization mental status changes – often attributed to hepatic encephalopathy but more likely due to delirium – are particularly lifestyle-altering in these patients. The incidence of delirium following chemoembolization (TACE) is unknown, although an association between delirium and elevated

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inflammatory markers has been noted in other post-procedural patient populations. Prevention and treatment algorithms are widespread but largely based on anecdotal evidence or small case series. Clinical Findings/Procedure: Results from a literature review will be presented, focusing on the incidence, proposed causes, algorithms for prevention and treatment, and current areas of research interest in PES. In addition to standard PES signs and symptoms, special attention will be paid to the occurrence of delirium following hepatic chemoembolization. Data as determined from a retrospective medical record review performed at the authors’ institution will be presented; moreover, an outline for future studies will be proposed. These future studies will focus on the use of markers (IL-2, IL-6, other cytokines, and insulin-like growth factor) in the recognition of post-TACE delirium. Conclusion: Understanding the current status of PES and postTACE delirium is vital to any physician performing embolization procedures. Exciting research opportunities exist in the diagnosis and treatment of this common yet lifestyle-altering side effect.

P-246 Extrahepatic collateral blood supply to hepatocellular carcinoma (HCC): the anatomical and imaging features of extrahepatic collateral arteries and procedural complications related to transcatheter arterial chemoembolization (TACE) through these arteries S. Kanasaki1, T. Hirose1, Y. Hamanaka1, K. Fumoto1, S. Ota2, A. Furukawa3; 1Radiology, Koseikai Takeda Hospital, Kyoto, Japan, 2Radiology, Shiga University of Medical Science, Otsu, Japan, 3Radiological Science, Tokyo Metropolitan University, Tokyo, Japan Learning Objectives: 1. To review the anatomical potentials for the pathways of collateral blood supply to HCC; commons and uncommons. 2. To learn relations of the pathways of collateral supply to intrahepatic locations of HCC. 3. To learn the typical procedural complications of TACE related to each pathway of collateral artery catheterized. Background: Extrahepatic collateral supply to HCC develops in various conditions, and often occurs in patients with a history of multiple TACE treatments. A knowledge of common as well as rare pathways of collateral blood supply and their relation to intrahepatic locations of HCC is essential. There are several typical procedural complications of TACE related to each pathway of collateral blood supply to HCC. Clinical Findings/Procedure: Conditions leading to the development of extrahepatic collateral vessels to HCC are described. The relations of developed pathways of collateral supply to intrahepatic locations of HCC are expounded. Illustrative CT and angiographic appearances of various pathways of collateral arteries to HCC are demonstrated with key findings for recognition. Collateral arteries that supply HCC may arise from the following arteries: inferior phrenic, adrenal, intercostal, subcostal, lumbar, renal or renal capsular, cystic, gastric, gastroepiploic, internal mammary, or others. Typical procedural complications of TACE related to each collateral pathway to HCC are discussed along with some representative cases. Conclusion: The presence and anatomy of collateral vessels should be correctly assessed from the key imaging findings on CT and angiography prior to TACE. A knowledge of procedural complications related to TACE due to collateral vessels is essential for their prevention.

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P-247 Bilateral prostatic artery embolization for intractable hematuria in prostate cancer J.M. Gimenez1, I.M. Kably1, P. Okolo1, G. Narayanan2; 1Radiology, University of Miami, Miami, FL, United States of America, 2Interventional Radiology, University of Miami, Miami, FL, United States of America A 69-year-old male with intractable hematuria due to prostate cancer was treated with bilateral prostatic artery embolization using 300–500-μ beads. Dyna-CT comfirmed that no rectal or vesical branches were embolized. Patient’s hematuria resolved, and transfusions were no longer required.

P-248 Biliary stricture as a complication of transcatheter arterial chemoembolization after hemihepatectomy: a report of 3 cases D. Flowers1, C. Mansbridge2, J. Coyne1, T.J. Bryant3, B. Stedman4, T. Armstrong2, D.J. Breen3, N. Hacking5; 1Interventional Radiology, University Hospital Southampton, Southampton, United Kingdom, 2Surgery, University Hospital Southampton, Southampton, United Kingdom, 3Radiology, Southampton General Hospital, Southampton, United Kingdom, 4Radiology, Southampton University NHS Trust, Southampton, United Kingdom, 5Department of Clinical Radiology, University Hospitals Southampton, Southampton, United Kingdom We report 3 cases of biliary injury in patients with different underlying pathologies but who had in common normal background liver and previous hepatic surgery. This will be followed by a literature review on biliary injury following TACE.

P-249 HIFU therapy for pancreatic cancer: 3-year follow-up V.A. Solovov; Interventional Radiology, Samara Oncology Centre, Samara, Russian Federation A 35-year-old woman with pancreatic cancer (2 cm, head) underwent six sessions of HIFU ablation with the FEP-BY system. Three years after treatment, MRI revealed pseudocyst with no contrast enhancement. No additional treatment was required. The patient has an excellent quality of life.

P-250 Multiple mininvasive interventional procedures of renal cell carcinomas and pancreatic metastasis in a patient with a solitary kidney R.F. Grasso1, F. Orsi2, G. Luppi1, E. Faiella1, F. Giurazza1, R.L. Cazzato1, S. Mercurio1, B. Beomonte Zobel1; 1Radiology, Campus Biomedico University of Rome, Rome, Italy, 2Unit of Interventional Radiology, IEO Istituto Europeo di Oncologia, Milan, Italy A 64-year-old woman underwent ten RFAs and six cryoablations of recurrent and multifocal renal cell carcinomas in a solitary, partially resected kidney. Three pancreatic metastasis were treated with HIFU and intra-operative thermal ablations. Serum creatinine levels did not show significant variations.

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P-251 Post-transplantation diaphragmatic recurrence of hepatocellular carcinoma treated with chemoembolization C. Garcia Alba, J. Cazejust, B. Bessoud, Y. Menu; Radiology, Saint Antoine Hospital, Paris, France We present a case of unifocal recurrence of hepatocellular carcinoma (HCC) in the right diaphragmatic cupola after LT for HCC meeting the Milan criteria. We performed chemoembolization via the right phrenic artery with good lipiodol uptake and mRECIST complete response on MRI.

P-252 Radiofrequency ablation of adrenal metastases of hepatocellular carcinoma in a post-liver transplant patient complicated by vascular injury managed endovascularly D. Jain, A.K. Kapoor, A.H. Khandelwal, V. Jain, S.S. Baijal; Radiology, Medanta-the Medicity, Gurgaon, India A 51-year-old post-liver transplant male with HCC had a 1.5-cm arterially enhancing right adrenal nodule with raised AFP. RFA was performed under robotic guidance; the adrenal artery was injured during RFA but managed endovascularly. The patient was tumor-free, and AFP was normal at 8-month follow-up.

Others P-253 Catheter-directed embolization of extracranial high-flow arteriovenous malformations with Onyx: safety, efficacy, and long-term outcomes T. De Beule1, J. Vranckx 2, I. Fourneau3, S. Heye1, G.A. Maleux1; 1Department of Radiology, University Hospitals Leuven, Leuven, Belgium, 2Department of Plastic and Reconstructive Surgery, University Hospitals Leuven, Leuven, Belgium, 3Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium Purpose: To retrospectively assess the safety, efficacy, and longterm outcomes of catheter-directed Onyx embolization for the treatment of symptomatic extracranial high flow arteriovenous malformations (exHFAVM). Material and Methods: From January 2006 to March 2012, 22 patients (6 males and 17 females, age range 2–76 years, and mean age 37 years) were included. Regional distribution was in the head and neck (n=9), thorax (n=4), upper limb (n=4), or lower limb (n=5). Embolization with Onyx (n=13) or Onyx followed by adjunctive embolic agents (n=9) was performed in one (n=17) or two sessions (n=5). Follow-up duration ranged from 1 year to 7 years (median, 6.5 years). Results: The complete angiographic exclusion of exHFAVM was obtained in 9 patients (41%). Moreover, 21 patients showed a complete disappearance or major improvement of initial symptoms (45% and 50%, respectively). One patient had no improvement at all (5%). In the long-term follow-up, 4 patients (18%) presented with mild worsening of recurrent, initial exHFAVM-related symptoms. In 2 patients, an additional Onyx embolization session was performed resulting in symptomatic improvement in 1 patient. Major procedure-related complications were encountered in 3 patients (ischemic skin ulceration, n=2; non-target embolization, n=1). Minor complications were encountered in 8 patients (36%) (mild pain to local epidermolysis). Conclusion: Onyx seems to be a relatively safe and efficient embolic agent for transcatheter treatment of exHFAVM with a durable

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symptom control in a large number of patients, although complete angiographic exclusion of the exHFAVM could be obtained in <50% of the treated patients.

P-254 CT-assisted sympathicolysis as an additional minimally invasive therapeutic option in primary focal plantar hyperhidrosis F. Scheer1, P. Wiggermann2, P. Kamusella1, C. Wissgott1, R. Andresen1; 1Institute of Diagnostic and Interventional Radiology/ Neuroradiology, Westkuestenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Luebeck and Hamburg, Heide, Germany, 2Radiology, University Hospital Regensburg, Regensburg, Germany Purpose: The aim of this retrospective study was to evaluate the benefit of lumbar computed tomography-assisted sympathicolysis (CTSy) in patients with primary focal hyperhidrosis of the feet. Material and Methods: A lumbar CTSy was conducted on 35 patients (mean age 36.6 ± 11.9 years) with a primary focal hyperhidrosis of the feet who experienced persistent symptoms after all conservative treatment options had been exhausted. The severity of the symptoms of patients were evaluated prior to the intervention, 2 days after the intervention, and 6 and 12 months after the intervention on the basis of a Dermatology Quality of Life Index© (DLQI), and side effects were experienced. Results: The interventions performed led to a statistically significant decrease in the pre-interventional severity of symptoms 2 days after the intervention, and 6 and 12 months after CTSy (p<0.05). No major complications occurred. Twelve patients reported compensatory sweating as the most common side effect. Conclusion: After conservative measures have been exhausted or as a complement to the existing therapy regimen, CT-assisted sympathicolysis represents a therapeutic option that is low in side effects and provides a marked benefit to patients with primary focal hyperhidrosis.

P-255 Effectiveness and safety of a pneumatic compression device for hemostasis of femoral catheterization J.H. Kwon, S.W. Kim, Y.H. Han; Department of Radiology, Dongguk University Ilsan Hospital, Goyang-si, Korea Purpose: To report the usefulness and safety of pneumatic compression device for hemostasis in patents undergoing a puncture of the femoral artery. Material and Methods: This study included 173 patients in whom hemostasis after transfemoral catheterization was performed by pneumatic compression device comprising an inflatable bulb containing a main body and four pieces of supplementary tape. Pneumatic compression devices were applied for 4 hours in 51/173 patients (group A) and additional 2 hours bed rest was advised. In 122/173 patients (group B), the devices were applied for 2 hours and additional 2 hours bed rest was advised. Medical records were retrospectively reviewed for the clinical result and complications. Clinical success was defined as the ability to ambulate after 4 or 6 hours of bed rest without any complications. Complications comprised hemostasis-related problems such as the oozing of blood or hematoma. Results: Clinical success was achieved in 157 (91%) of 173 patients: 45 (88%) in group A and 112 (92%) in group B. Sixteen (9%) patients [6 (12%) in group A and 10 (9%) in group B] required additional sand bag placement to control the mild oozing of blood or hematoma. No major complications were noted in groups A and B. No patient had late complications.

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Conclusion: The pneumatic compression device provides a safe and effective hemostasis for patients undergoing transfemoral catheterization. There were no differences in the effectiveness and safety between groups A and B.

P-256 Efficacy and safety of ExoSeal vascular closure device positioned under ultrasound guidance: a 6-month singlecenter prospective registry R.F. Grasso, G. Luppi, E. Faiella, R.L. Cazzato, F. Giurazza, S. Mercurio, B. Beomonte Zobel; Radiology, Campus Biomedico University of Rome, Rome, Italy Purpose: To retrospectively evaluate the feasibility and effectiveness of an ExoSeal vascular closure device (VCD) for vascular closure of the femoral artery. Material and Methods: Between January 2013 and June 2013, 91 patients (60 males and 31 females, mean age 70 ± 12 years, range 23–87 years) underwent retrograde or antegrade arterial transfemoral access closure using the ExoSeaL VCD. This study focused on technical success, procedural success and complication rates of ExoSeaL VCD in relation to the calibre of the closure device, the type of arterial access, the type of interventional procedure, anti-platelet therapy, the thickness of the adipose tissue between the arterial wall and the skin layer and presence of calcifications on the arterial walls near the sheath entry site. Results: The technical and procedural success rate of ExoSeal VCD were optimal with 5-Fr (100%) and 7-Fr (96.2%–100%) devices while performing carotid artery stenting (100%) and abdominal tumour embolisation (97.6%–100%) in patients not being under double antiplatelet therapy (94.3%–100%), in those with a thicker subcutaneous tissues (96.7%–98.4%) and in those without arterial wall calcifications near the sheath entry point (97.4%–98.7%). No cases of major complications were observed. Minor complications (2.1%) included two cases of pseudoaneurysms. Conclusion: The present study suggests that the ExoSeal VCD is a safe and effective device applied with high rates of technical and procedural success. Poor results in terms of efficacy may be expected in patients under double antiplatelet therapy, in those with a thin inguinal subcutaneous tissue and in those with vascular calcifications near the sheath entry site.

P-257 Endovascular embolisation as a primary treatment for spinal dural arteriovenous fistulae: a 10-year retrospective review J.G. McGarry1, J. Thornton2, P. Brennan2, A. O’Hare2, S. Looby 2; 1Department of Academic Radiology, Beaumont Hospital Dublin, Dublin, Ireland, 2Department of Neuroradiology, Beaumont Hospital Dublin, Dublin, Ireland Purpose: Spinal dural arteriovenous fistulae (SDAVFs) are rare entities that result in a retrograde perfusion of perimedullary veins, leading to cord oedema and ischaemia. If untreated, 50% patients are wheelchair bound within 3 years. A 2004 meta-analysis demonstrated 97% fistula obliteration with surgery versus 46% with primary embolisation. We aimed to determine the procedural success and clinical benefits of primary embolisation of SDAVFs over a 10-year period. Material and Methods: Clinical records were reviewed from 2002 to 2012. Pre- and post-embolisation Aminoff–Logue Scale (ALS) disability scores were determined (stable or improved scores were considered successful). The influence of pre-treatment ALS, symptom duration, angiographic occlusion and SDAVF location on the outcome was determined using bivariate analysis (p<0.05).

Abstract Book Results: Fourteen patients (10 males and 4 females, mean age 60) had angiographically confirmed SDAVFs. One patient was unsuitable for treatment due to proximity to the artery of Adamkiewicz. Three patients were unsuitable for embolisation due to difficulty in accessing the feeding artery. Ten patients (79%) received primary embolisation without complications. Seven patients (70%) had successful outcomes, although the benefit was transient in one patient who proceeded to surgery at 9 months. Three patients (30%) continued to deteriorate. All 4 patients requiring secondary surgery stabilised or improved. There was a trend towards correlation between the outcome and angiographic occlusion only (p=0.13). Conclusion: Our success rate of 70% is among the highest to date, which we attribute to the refined case selection and experience with technology. Limitations include a small cohort and variability in follow-up. Our 10-year experience strongly confirms the benefits of multidisciplinary management with primary embolisation of SDAVFs.

P-258 Evaluation of medical students’ knowledge of interventional radiology (IR) before and after adoption of the CIRSE undergraduate IR curriculum K.A. Pennycooke, S. Shaikh, S.S. Alnafisee, M.J. Lee; Radiology, Beaumont Hospital, Dublin, Ireland Purpose: IR is generally taught by other specialties in medical school programmes. We have recently introduced the CIRSE IR undergraduate medical curriculum. We assessed the knowledge of students before and after the delivery of the IR lecture series. Material and Methods: Prior to IR lecture curriculum delivery, 309 senior medical students were requested to fill a web-based questionnaire testing their knowledge of IR. The questionnaire comprised 22 questions with a combination of closed- and open-ended questions that collected qualitative and quantitative data on the students’ knowledge of common procedures performed by interventional radiologists. The questionnaire was readministered to the class upon completing a 6-hour IR didactic course. Results: A 76% response rate was achieved initially. Pre- and postIR curriculum delivery, the negative responses for the selected IR procedures reduced from 30% to 10% for venous access, 22% to 0% for uterine fibroid embolization, 25% to 4% for GI bleeding embolization, 40% to 12% for trauma embolization, 29% to 8% for tumor ablation, and 19% to 6% for angioplasty/stenting in peripheral arterial disease. For IR clinical roles, the selected negative responses were 58% to 45% for OPD review of patients and 58% to 57% for ward rounds, but the rate reduced from 40% to 22% for considering a future career in IR. Conclusion: Delivery of an IR curriculum by interventional radiologists improves undergraduate medical students’ knowledge of IR. However, the clinical role of IR is yet to be studied.

P-259 Frequency and risk factors of innominate artery stent fractures E. Dósa1, B. Nemes1, V. Bérczi2, H. Sarkadi1, K. Hüttl1; 1Vascular Surgery, Semmelweis University, Budapest, Hungary, 2Department of Radiology and Oncotherapy, Semmelweis University, Budapest, Hungary Purpose: Stenting is the preferred minimally invasive treatment for innominate artery (IA) stenosis or occlusion. Stent fractures in IA have not been assessed in larger cohorts. In this retrospective study, we examined the frequency and risk factors of IA stent fractures. Material and Methods: The final analysis included 32 patients (15 women; mean age, 59.4±12.0 years) with 32 balloon-expandable

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stents (from 2000 to 2009). In the year 2010, patients were asked to return for a fluoroscopic examination of the implanted stents. Stent fractures and their relationship to atherosclerotic risk factors, lesion characteristics, post-procedural symptoms, and in-stent restenosis were analyzed. Fisher’s exact test and univariate Cox regression analysis were used in the statistical evaluation. Results: Lesions were longer than 20 mm in 14 patients (44%) or heavily calcified in 13 patients (41%). Mean follow-up duration was 33.4±21 months. Post-procedural symptoms were noted in nine patients (28%). Significant restenosis was detected in 22% of the implanted stents. Eleven stent fractures (34%) were observed. The prevalence of heavily calcified lesions, post-procedural symptoms, and in-stent restenosis did not differ significantly between the fractured and non-fractured groups. The presence of long lesions was associated with an increased incidence of stent fractures (hazard ratio, 5.09; 95% CI, 1.33–19.48; P=0.017). No correlation has been observed between stent fractures and old age (>70 years), females, smoking, hypertension, hyperlipidemia, or diabetes mellitus. Conclusion: IA stent fractures are common, but they seem to have no impact on symptoms and in-stent restenosis rate.

P-260 Image-guided percutaneous treatment of chylous leaks: a single-center experience of 30 patients E. Santos Martín1, K.M. McCluskey1, C.J. Friend1, R. Bandi1, K. Ching2, V. Gavrilovic2; 1Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America, 2Radiology, University of Pittsburgh, Pittsburgh, PA, United States of America Purpose: To evaluate the efficacy of image-guided percutaneous procedures in the management of chylous leaks. Material and Methods: A retrospective review was performed of 30 patients with chylous leaks. The etiology of the chylous leaks was post-operative in 25 patients (81%) and non-traumatic in 6 patients (19%). One patient with lymphangioleiomyomatosis had post-operative chylothorax and a spontaneous chylothorax one year later. In the post-operative group, the chylous leaks had the following clinical presentations in patients: chylothorax, 65%; retroperitoneal leak, 10%; and chylous ascites, 6%. Five patients with chylothorax underwent thoracic duct ligation prior to attempting percutaneous treatment. Thirty-four intranodal lymphangiograms (IL) were attempted. Within the chylothorax group, 45% patients underwent thoracic duct embolization/needle disruption. Additional CT/US guided coiling/glue embolization was performed in 5 patients (16%), in which the leak was not sealed after IL or thoracic duct embolization. Any patient who required additional surgery to treat the chylous leak was considered a treatment failure. Results: The technical success of IL was 97%. Lymphangiography detected a leak in 15 patients (48%). A post-lymphangiography CT scan demonstrated a leak in 3 more patients (10%). In the post-operative group, IL and thoracic duct embolization/disruption was successful in sealing the lymphatic leak site in 11 patients (55%). In the non-traumatic group, IL was therapeutic in 2 patients (33%). CT/ US-guided procedures for targeted treatment were successful in all 5 patients. The overall success of image-guided treatment for chylous leaks was 68%. There were no complications. Conclusion: Image-guided percutaneous therapies are safe and effective in the management of patients with chylous leaks.

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P-261 Left axillary artery access for angiography: indications and outcomes in current practice R.D. White1, A. Wells2, S. Chakraverty 2, J.G. Houston3, R. Bhat4, M. Flett3, I. Zealley 2; 1Department of Clinical Radiology, University Hospital of Wales, Cardiff, United Kingdom, 2Medical School, Ninewells Hospital and Medical School, Dundee, United Kingdom, 3Clinical Radiology, Ninewells Hospital, Dundee, United Kingdom, 4Radiology, Ninewells Hospital, Dundee, United Kingdom Purpose: Left axillary artery (LAxA) access is a lesser used upper limb arterial access site. We analysed the indications, procedure and outcomes of consecutive cases using LAxA access in the last 10 years at our centre, hypothesising that it is a safe route with a high technical success rate. Material and Methods: In all patients undergoing LAxA, demographics, procedure, indication for LAxA access, technical success and complications were tabulated using data from Radiology Information System and computerised laboratory/clinical communication systems; 219 consecutive LAxA access cases over 10 years till November 2012 were identified. Results: The mean age of patients was 68 years (range 32–90, 89 females and 130 males). In 2002–2004, 19% LAxA access cases were interventional, increasing to 82% by 2010–2012. The indications were failure of common femoral approach (CFA; 20%) or non-feasibility (55%). LAxA access was considered as anatomically favourable (20%) and as an adjunctive access for EVAR (5%). Technical success was 90%. The success rate was 74% in cases in which CFA access failed initially. There were 21 (10%) complications including 10 (4%) 30-day mortalities, 2 (1%) likely left arm access-related (e.g. brainstem infarct) but none specific to LAxA access. Of the remaining complications, 8 (3.7%) were due to left arm access and 5 (2.2%) specifically due to LAxA access. Conclusion: LAxA access is employed in challenging cases of advanced arterial disease, cases in which a CFA approach has been unsuccessful or where surgery is contraindicated or undesirable due to the risk of complications. Despite this, the procedural success rate is high and the complication rate is low.

P-262 Patient radiation doses and reference levels in interventional radiology: a national approach in Korea S. Hur1, H.J. Jae2, B. Kang1, H.-C. Kim1, M.S. Lee1, J.W. Chung1; 1Radiology, Seoul National University, Seoul, Korea, 2Department of Radiology and Emergency Medicine, Seoul National University Hospital, Seoul, Korea Purpose: To survey the radiation exposure data in patients who underwent interventional radiology (IR) procedures in Korea and to propose national reference dose levels. Material and Methods: The survey of radiation exposure in patients who underwent IR procedures was conducted in 24 nationwide hospitals in Korea. The radiation dose data of patients who underwent 11 types of IR procedures were included. The selected procedures were as follows: transcatheter arterial chemoembolization (TACE), arteriovenous fistula (AVF) intervention, lower extremity artery intervention, transfemoral cerebral angiography (TFCA), brain aneurysm embolization, percutaneous transhepatic biliary drainage (PTBD), biliary stenting, percutaneous nephrostomy (PCN), Hickman catheter insertion, chemoport insertion, and tunneled hemodialysis catheter insertion. The fluoroscopy time and dose–area product (DAP) value of each procedure were recorded. Results: A total of 8145 IR procedures were included. The reference dose levels were 383.5 Gy cm2 for brain aneurysm embolization, 237.7

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Gy cm2 for TACE, 188.5 Gy cm2 for TFCA, 114.1 Gy cm2 for lower extremity artery intervention, 64.6 Gy cm2 for biliary stenting, 37.5 Gy cm2 for PTBD, 22.4 Gy cm2 for PCN, 17.3 Gy cm2 for AVF intervention, 4.4 Gy cm2 for tunneled hemodialysis catheter insertion, 4.3 Gy cm2 for Hickman catheter insertion, and 2.8 Gy cm2 for chemoport insertion. Conclusion: The present study is the first nationwide survey of patient radiation dose data in Korea. It provides foundational data necessary to understand the current status of radiation doses related to IR procedures in Korea and can support efforts to manage and reduce radiation doses.

P-263 Role of interventional radiology in management and prevention of complications with islet transplantation after pancreatic surgery: a 13-year single-center experience on 1634 patients G. Agostini1, M. Venturini2, F. Morelli1, A. Palmisano1, F. De Cobelli2, A. Del Maschio2; 1Radiology, San Raffaele Hospital, Milan, Italy, 2Radiology, VitaSalute University, San Raffaele Hospital, Milan, Italy Purpose: Despite the improvement in technique and expertise, pancreatic surgery remains burdened with a high complication rate. Our aim was to report our 13-year single-center experience regarding the clinical relevance and management of interventional radiology (IR) of post-operative complications (treatment/prevention) on 1634 patients submitted to pancreatic surgery. Material and Methods: In 2000–2013, 1634 patients were subjected to pancreatic surgery. Post-operative course was classified according to the Clavien–Dindo classification (0=no complication, I-II=conservative treatment, IIIa=endoscopy/IR, IIIb=surgery, IV=intensive care, V=death). IR management was based on US/ CT-guided percutaneous drainage of abdominal collection, percutaneous transhepatic cholangiography (PTC) with percutaneous biliary drainage (PBD) of biliary fistula, transarterial embolization (TAE, with coils/PVA-particles), or covered stenting (Viabahn; Gore) in late severe bleeding. Since 2009, percutaneous intraportal islet autotransplantation (PIPIAT) was performed in total/subtotal pancreatectomy to prevent pancreatogenic diabetes. Results: Patients were classified as follows: 0, 36.1%; I, 18.9%; II, 29.9%; IIIa, 5.8%; IIIb, 4.2%; IV, 2.2%; V, 2.9%. In all, 108/1485 underwent IR; 60 fluid collections were treated with percutaneous drainages (12/60 CT-guided) and 44 biliary fistulas with PTC/PBD (only one artero-biliary fistula as a complication). Eighteen arterial bleedings with 14/18 TAE and 4/18 with covered stenting (surgery avoided in 56% cases; survival rate, 78%). Moreover, 23/1485 underwent PIPIAT, and no complications occurred in 87%. Total graft function at a median of 546 days was 63%. Conclusion: IR provides a less invasive approach to such life-threatening complications occurring after pancreatic surgery, thereby avoiding reintervention, decreasing recovery duration, and minimizing morbidity. PIPIAT represents a valid therapeutic option to prevent pancreatogenic diabetes.

P-264 Strategy for the treatment of spontaneous isolated visceral artery dissection H. Yamaguchi, S. Murata, S. Onozawa, T. Mine, T. Ueda, F. Sugihara, D. Yasui, H. Hayashi, S. Kumita; Radiology/Center for Advanced Medical Technology, Nippon Medical School, Tokyo, Japan

Abstract Book this problem. The objective of this study is to analyze the need for treatment. Material and Methods: We retrospectively analyzed the 38021 cases that underwent an examination for abdominal contrastenhanced computed tomography (CE-CT) at our hospital from January 2004 to December 2013. Thirty patients were diagnosed with spontaneous isolated dissection of superior mesenteric artery and 5 patients with celiac artery (32 males and 3 females). Eighteen patients had acute abdominal symptoms. We analyzed the need for treatment, the onset of complications, symptoms, and CE-CT changes during follow-up. Results: There was SIVAD in 0.09% cases (n=35) of abdominal CE-CT and in 0.75% (n=18) of abdominal CE-CT for acute abdominal symptoms at our hospital. All asymptomatic 17 patients received no treatment and were followed up. There were no complications, and SIVAD disappeared in only 2 patients during follow-up. All symptomatic 18 patients were hospitalized and followed up. Six patients with continued symptoms underwent endovascular treatment, and the remaining patients received conservative treatment because the symptoms disappeared. The patency of the stent or true lumen was maintained, and no complications were observed in the symptomatic patients after discharge. Conclusion: Asymptomatic patients can be managed without treatment. However, symptomatic patients must be hospitalized, because organ ischemia or expansion of false lumen may develop; the treatment differed based on symptom disappearance.

P-265 Effectiveness of bronchial artery embolisation for haemoptysis in a cystic fibrosis population N. Shaida1, S. Ilyas1, M. Krokidis2, C. Cousins1; 1Department of Radiology, Addenbrookes Hospital, Cambridge, United Kingdom, 2Department of Radiology, Cambridge University Hospitals, Cambridge, United Kingdom Purpose: Haemoptysis is a common complication of cystic fibrosis (CF) seen in up to 9% of patients; it is associated with significantly high mortality. Bronchial artery embolisation (BAE) is a well-established treatment for haemoptysis of all causes; however, limited data exists on its effectiveness in the CF population with reported recurrence rates as high as 80%. We set out to evaluate the effectiveness of BAE in our CF patient population and to identify the causes for ‘early recurrences’, which was defined as the need for further procedures within 12 months. Material and Methods: The local radiology database at our tertiary referral centre was searched to identify BAE procedures performed over the past 10 years. Retrospective analysis of anatomy, technical considerations and outcomes was performed. Results: Between 2003 and 2013, 34 procedures were performed in 27 patients (mean age, 27 years). Initial technical success was seen in 91% (31/34) procedures. PVA particles (82%) were the most commonly employed embolic agent followed by microspheres (6%). The most commonly employed size of PVA particles was 250–355 μ. Variant anatomy was observed in 19% (5/27) of cases. There was 1 procedure-related mortality due to systemic embolisation. Overall recurrence rate was 26% (9/34) with early recurrence seen in 3 cases. On review, the causes for the early recurrences could be identified as due to variant anatomy (1 case) and very small particle size (2 cases). Conclusion: BAE provides an effective treatment for haemoptysis in CF patients. In cases of early recurrence of symptoms, an underlying cause should be sought.

Purpose: Spontaneous isolated visceral artery dissection without aortic dissection (SIVAD) is rarely encountered. There is no consensus regarding the pathology or optimal therapy related to

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P-266 Treatment of benign cystic thyroid nodules with ethanol ablation: comparison of ethanol retention and aspiration H.S. Park1, J.H. Baek1, E.J. Ha2, J.H. Lee1, Y.K. Shong3, W.B. Kim3, T.Y. Kim3; 1Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea, 2Department of Radiology, Ajou University School of Medicine, Suwon, Korea, 3Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea Purpose: The retention of injected ethanol could cause ethanol leakage, leading to pain and perithyroidal fibrosis. If the aspiration of injected ethanol shows noninferior efficacy compared with retention, then injected ethanol should be aspirated because of its potential complications. This study compared the efficacy of aspiration and retention for treating benign cystic thyroid nodules. Material and Methods: This noninferiority study prospectively enrolled 120 patients with ethanol retention from January 2011 to January 2012 and then compared with retrospectively enrolled 120 patients with ethanol aspiration from February 2009 to February 2011. Primary endpoint was VRR at last follow-up; the noninferiority margin was chosen as −8% (ethanol aspiration minus retention). Secondary endpoints included improvement of symptoms and cosmetic problems, vascularity, pain, and presence of major complication. A one-sided 95% confidence interval (CI) for the mean difference in VRR at last follow-up was calculated to test for noninferiority. Results: All demographic data of both groups showed no differences, except vascularity (P = 0.013). The mean VRR was 83.2% in the retention group and 86.1% in the aspiration group (difference, 2.858%; 95% CI, −4.156 to 9.873), thus demonstrating the noninferiority of ethanol aspiration to retention. Intergroup differences in mean symptoms and cosmetic scores were not significant (P= 0.677 and P = 0.277, respectively). Pain was significantly higher in the retention group (P = 0.001). There were no major complications (P > 0.99). Conclusion: VRR of the aspiration group was noninferior to that of the retention group; however, pain was significantly higher in the retention group. Therefore, ethanol aspiration is preferred for treating benign cystic thyroid nodules.

P-267 Ultrasound-guided PICC placement: evaluation of economic and non-economic repositioning costs at an academic medical center E. Semaan, J. Lee, E. Rose, H. Molina, R. Salem, S. Resnick, H. Chrisman, J.D. Collins; Radiology, Northwestern University, Chicago, IL, United States of America Purpose: To assess repositioning rate and analyze the associated economic and non-economic costs following ultrasonography (US)guided PICC insertion at an academic medical center. Material and Methods: A retrospective evaluation of 400 consecutive US-guided PICC procedures (150 outpatients and 250 inpatients) was performed. Initial and final PICC locations were determined with chest radiograph review or fluoroscopy, where appropriate. The need for PICC repositioning was left at the discretion of the mid-level operator, with interventional radiology consultation as needed. The efforts expended for repositioning and delays regarding PICC placement, which were mentioned in the electronic medical record, were noted. Outpatient costs above the PICC charge associated with repositioning were estimated using Medicare reimbursement rates; in-patient non-economic costs were determined using an operator survey.

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Results: Initial PICC tip position was unsatisfactory in 64 (16%) procedures. PICC procedures in the inpatient cohort accounted for 80% of repositioning events. Due to delays in catheter repositioning, 22 PICCs (6%) could not be used the day of the insertion procedure. Medicare costs associated with catheter repositioning averaged $269 and $82 per in- and outpatient, respectively. The average time expended by staff to determine inpatient PICC positioning was 15 minutes, with an average of 36 minutes spent arranging repositioning procedures. Conclusion: Initial PICC tip location was unsatisfactory in 16% of US-guided insertion procedures. Repositioning was more costly for inpatients. The lack of an in-procedure verification of PICC location is associated with significant non-economic costs measured in staff time, averaging up to 36 minutes in cases requiring repositioning.

P-268 A new university radiology ‘app’ for medical students and junior doctors M.S. Shaikh, M.J. Lee, K.A. Pennycooke, M. Mirza; Department of Radiology, Beaumont Hospital (RCSI), Dublin, Ireland Learning Objectives: To demonstrate the salient features of a new iPhone™ and iPad™ radiology and interventional radiology app. Background: Education at all levels has dramatically progressed from classroom- and lecture-based teaching to more proactive information technology-based distance learning. Radiology teaching is imparted in last three years of medical school at our institution. A significant portion of radiology education is delivered online through our university portal. We developed an iOS™ ‘app’ for iPhone™ and iPad™ targeting medical students and junior doctors. Clinical Findings/Procedure: The contents of the app are divided between the topics of diagnostic radiology with a specific section on interventional radiology (vascular, including neurointervention, and non-vascular topics). The IR topics are in line with the recently released CIRSE IR curriculum for students. We demonstrate the salient features of the app, its user-friendliness and its detailed content delivered through bullet-points and high-resolution images. We also discuss the potential for further development of this app. Conclusion: The new app would assist in making undergraduate radiology education a more interactive and intuitive experience. This will likely result in junior doctors being better informed about radiology in general and interventional radiology in particular.

P-269 Anesthetics, analgesics, and sedatives: a pocket guide E. Guedes Pinto, D. Penha, A. Costa; Radiology, Hospital Professor Doutor Fernando Fonseca E.P.E., Amadora, Portugal Learning Objectives: 1. To review the core knowledge of anesthetics, analgesics, and sedatives and potential interaction between different commonly used agents. 2. To review peri- and post-procedure evaluation regarding the effects of these agents. 3. To discuss the variability of responses to sedatives and analgesics and how they relate to patient characteristics and concurrent medication. 4. To propose a systematic approach to analgesic and sedation needs in the form of an easily consulted pocket guide. Background: Patient comfort is a priority during planned or emergency IR procedures and contributes to the safety of both patient and interventionist. Synergic effects between different agents must be understood because they can result in added cardiovascular and respiratory

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depression, making the ability to titrate doses and evaluate patient response paramount and part of the core knowledge of every interventionist. Paradoxical reactions are frequent and occasionally difficult to manage, thereby compromising patient’s and interventionist’s safety. Clinical Findings/Procedure: Prescribing analgesics and sedatives as per individual patient’s needs is a daily requirement for any IR procedure. The repetition and apparent simplicity of the decision makes common practice easy and appropriate in most cases. Personal preference is established based on frequently repeated experiences, even if the pathophysiological and pharmaceutical mechanisms involved are easily forgotten. This makes it difficult to handle infrequent responses. Conclusion: By providing an easy-to-use pocket guide regarding analgesia and sedation management that interventionists can carry in their pockets or smartphones, we expect to facilitate concise and precise consultation and improve the overall safety of the procedures.

P-270 High-frequency jet ventilation for CT-guided radiofrequency ablation of lung and solid organs: is it an unnecessary luxury? A. Alsafi1, A. Zia1, E. Kashef 2, M.S. Hamady1, R.H. Thomas1; 1Interventional Radiology, Imperial College Healthcare NHS, London, United Kingdom, 2Radiology, Imperial College NHS Trust, London, United Kingdom Learning Objectives: 1. Basics of high-frequency jet ventilation (HFJV) 2. Uses, advantages and complications of HFJV 3. Current evidence supporting HFJV use in image-guided ablative procedures Background: HFJV is a ventilation technique used in the context of general anaesthesia (GA), whereby small tidal volumes are delivered from a high-pressure jet at supra-physiologic frequencies, often with the intention to reduce motion artefacts associated with conventional ventilation. HFJV is traditionally used during some ENT procedures, providing unimpeded views of the larynx (due to small catheter size c.f. ET tubes) as well as relative immobility of the vocal cords. HFJV is also employed in thoracic surgery and critical care, and increasingly used during image-guided radiofrequency ablation (RFA) of the lung and solid abdominal organs. Clinical Findings/Procedure: When performing RFA under sedation or conventional GA, respiratory motion can preclude accurate ablation catheter placement. Current evidence shows that HFJV is a safe and effective mode of ventilation with clear advantages in reducing target organ movement, making RFA less technically challenging and reducing non-target injury. Small, non-randomised case series have shown HFJV to reduce procedure time and radiation exposure. It remains to be seen, however, whether this translates into better patient outcomes in larger studies. HFJV is not without complications, which range from barotrauma, pneumothorax and CO2 retention to loss of cardiac output in patients with pre-existing right ventricular dysfunction. Conclusion: In this poster, we present some of the current evidence on using HFJV during image-guided ablative procedures of the lung and solid abdominal organs.

Abstract Book

P-271 How to perform safe spinal and pelvic thermal ablations G. Tsoumakidou, J. Garnon, I. Enescu, M.A. Thenint, F. Bing, A. Gangi; Non-Vascular IR, University Hospital of Strasbourg, Strasbourg, France Learning Objectives: 1. To describe with rich illustrations the anatomic considerations as per the treatment area 2. To elucidate the existing thermal insulation and temperature monitoring techniques used during ablation procedures 3. To discuss the significance of the functional monitoring of the neural structures at risk Background: Percutaneous thermal ablation has been increasingly used for the therapeutic and palliative treatment of benign and malignant lesions. Spinal and pelvic thermal ablations can be risky because of the proximity of sensitive anatomic structures (peripheral nerves, spinal cord, and spinal artery). Clinical Findings/Procedure: The peripheral spinal nerves, spinal cord, and spinal artery can be at risk when performing spinal and pelvic ablations. Different neuroanatomic considerations should be taken into account during procedure planning. The existing techniques of active and passive insulation should be used. - Hydrodissection offers thermal insulation and can also cool or warm the tissue. - Gas dissection creates an excellent insulation blanket by displacing the organs at risk away from the ablation zone, with minimal cooling or warming effect. The temperature can be monitored using thermocouples or fiberoptic temperature sensors. Nerve electrostimulation offers a functional assessment along the whole length of the peripheral nerve at risk. Conclusion: Profound knowledge of the regional cross-sectional anatomy is mandatory in order to avoid serious neurologic complications. The existing thermal insulation, temperature, and functional (electrostimulation) monitoring techniques should be used when appropriate to avoid major complications and increase the indications.

P-272 Interpretation of blood flow patterns in femoral pseudoaneurysm Y.H. Choi1, Y.H. So1, H.-H. Kim2; 1Department of Radiology, Seoul National University Boramae Hospital, Seoul, Korea, 2Department of Mechanical Engineering, Soongsil University, Seoul, Korea WITHDRAWN

P-273 Non-surgical treatment of benign thyroid nodules: management strategies according to nodule composition E.J. Ha1, J.H. Baek2, H.S. Park 2; 1Department of Radiology, Ajou University School of Medicine, Suwon, Korea, 2Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea Learning Objectives: To comprehensively review the efficacies in ethanol, laser, and radiofrequency (RF) ablation and conduct the best treatment option according to nodule characteristics based on current evidences.

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Background: Non-surgical treatment of benign thyroid nodules is classified into two types: chemical ablation (e.g. ethanol ablation) and thermal ablation (e.g. laser and RF ablation). Although chemical ablation is safe and cost-effective for cystic nodules, it is of limited use for solid nodules. Therefore, thermal ablation should be used for nodules as the solid component increases. Clinical Findings/Procedure: The current results of ethanol, laser, and RF ablation of benign thyroid nodules will be described based on efficacy and complications. Efficacy will be explained according to volume reduction rate, therapeutic success rate, number of the treatment sessions, and changes of the symptom/cosmetic score. All results will be discussed focusing on the nodule characteristics. Based on current evidence, we will propose a 3-step approach for non-surgical treatment according to nodule composition: cystic (solid portion < 10%), predominantly cystic (solid portion 10%–50%), and solid (solid portion ≥ 50%). We will introduce the concept of “step-by-step management” and/or “combination therapy” for the treatment of nodules with solid component, and present examples of practical cases to aid reader comprehension. Conclusion: The best treatment modality of benign thyroid nodules should be established according to the proportion of solid component. Understanding of proper management strategies of benign thyroid nodules will be useful.

P-274 Paracentesis-induced circulatory dysfunction: a primer for the interventional radiologist A. Lindsay1, C.E. Ray, Jr.2, J.T. Bui2, J. Minocha2, R.C. Gaba2, M.-G. Knuttinen2; 1Department of Interventional Radiology, University of Colorado Denver, Aurora, CO, United States of America, 2Radiology, University of Illinois at Chicago, Chicago, IL, United States of America Learning Objectives: To understand the pathophysiology, clinical presentation, diagnosis and prevention/treatment of paracentesisinduced circulatory dysfunction. Background: Therapeutic paracenteses are routinely performed by interventional radiologists. Paracentesis-induced circulatory dysfunction (PICD) is a complication of large-volume paracentesis that leads to early reaccumulation of ascites, hyponatraemia, renal impairment and decreased survival. In this exhibit, the pathophysiology, clinical presentation, diagnosis and prevention/treatment of PICD are reviewed. Clinical Findings/Procedure: The aetiology of PICD is largely related to the accentuation of arteriolar vasodilation and compensatory increased activation of the renin–angiotensin–aldosterone (RAA) pathway. The accentuated arteriolar vasodilation is probably related to rapid decrease in intra-abdominal pressure and reflexive vasodilation related to increased cardiac output and increased release of nitric oxide. Patients with PICD reaccumulate ascites faster, are at greater risk for developing hyponatremia and renal failure and have decreased survival. PICD is diagnosed by increases of more than 50% of plasma renin activity on the fifth or sixth day after paracentesis. Strategies to reduce the incidence and severity of PICD include the following: decreasing the total volume of ascites removed, reducing the rate of removal, using plasma volume expanders (albumin, dextran 70, polygeline and saline), and using vasoconstrictors (e.g. terlipressin, a vasopressin type 1 receptor agonist, and midodrine, an alpha-1 agonist). Other strategies such as the use of propanolol, a non-selective beta blocker, and vaptans, vasopressin type II receptor antagonists, reportedly increase the incidence of PICD and mortality, respectively. Conclusion: Knowledge of the pathophysiology, clinical presentation, diagnosis and prevention/treatment of PICD is essential for the safe care of patients undergoing frequent paracenteses.

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P-275 Percutaneous fluorosopic guidewire manipulation of malfunctioning peritoneal dialysis catheters S.H. Kwon1, J.H. Oh1, S.W. Park2; 1Radiology, Kyung Hee University Medical Center, Seoul, Korea, 2Radiology, Konkuk University Hospital, Seoul, Korea Learning Objectives: To review the fluoroscopic guidewire manipulation in patients with malfunctioning peritoneal dialysis (PD) catheters. Background: Continuous ambulatory PD is an increasingly popular alternative to hemodialysis in the treatment of chronic renal failure. The number of patients on PD is increasing worldwide. Catheter malfunction develops in 3.9%–33% of patients with a PD catheter; malfunction is a cause of serious morbidity because it precludes a further continuation of dialysis, and leads to incomplete or painful dialysis unless the catheter is replaced or repaired. Clinical Findings/Procedure: a. The concept of PD b. Preprocedure evaluation (indications and contraindications) c. Percutaneous radiologic placement of PD catheters d. Postprocedure management e. Complications f. Fluoroscopic manipulations for malfunctioning PD catheters Conclusion: Fluoroscopic guidewire manipulation in patients with malfunctioning PD catheters is a relatively simple procedure, an effective way of prolonging PD catheter life, and a recommended procedure prior to invasive surgical procedures.

P-276 Pictorial review of transcatheter management of submassive pulmonary emboli using ultrasound-accelerated thrombolysis S. Pal, H.M. Ireland, J. Gordon-Smith, C. Hay; Radiology, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom Learning Objectives: To illustrate our experience of ultrasound liquefaction as an adjunct to catheter-directed thrombolysis (CDT) in the treatment of life-threatening pulmonary embolism in patients with relative contraindications to systemic thrombolysis. Background: CDTs, both mechanical and pharmaco-mechanical, have had limited success and uptake historically. They have not been demonstrated to improve mortality compared with surgical thrombectomy. More recent reviews have alluded to its use in submassive and massive PE. New pharmaco-mechanical devices have also been developed that show promise in this difficult area. Ultrasound liquefaction has been demonstrated in vitro to produce an 84% greater uptake of tissue plasminogen activator (TPA). We present two cases of submassive PE with relative contraindications to systemic thrombolysis successfully treated with CDT augmented with ultrasound liquefaction. Clinical Findings/Procedure: We present the clinical and radiological history of two severely compromised patients with submassive PE who could not be treated with systemic thrombolysis. Both underwent pharmaco-mechanical CDT with the EkoSonic Endovascular System. Side-hole infusion catheters were placed across the thrombus bilaterally. The ultrasound device was then inserted via the central lumen of the infusion catheter. Infusion with recombinant TPA with concurrent ultrasound augmentation was performed for 18 and 22 h. Rapid improvement of clinical and echocardiographic indices was observed in both patients. Conclusion: Our experience to date of CDT with ultrasound liquefaction for submassive PE has been positive. In a selected group of patients, CDT may enable safe and effective therapy, avoiding the need for surgical thrombectomy.

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P-277 Safe and efficient treatment of peripheral vascular malformations: the twin butterfly needle technique A. Pantos; Interventional Radiology, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom Learning Objectives: The purpose of this report is to describe our methodology approach in the percutaneous treatment of the peripheral vascular malformations in a safe and efficient way. This method can be combined with a transluminal access. The goal is complete obliteration of the lesion. Background: The aim of foam sclerotherapy for peripheral vascular malformations is to damage the endothelial surface of the vein causing scarring, leading to the blockage of the treated vessels. Clinical Findings/Procedure: The procedure may be carried out with local anaesthesia and conscious sedation. A tourniquet applied to the arm is necessary for vascular stasis within the peripheral vascular malformation. The first needle, usually 19–21 gauge, is advanced under real-time US guidance at the most distal segment of the vein pouch. A second needle is placed in the most proximal segment of the vein pouch, working as a pressure relief valve. Once correct placement has been achieved with the distal needle, we slowly inject contrast to fill up the lesion and determine its volume. Sclerosant in the form of foam is injected under fluoroscopic guidance, and the disappearance of contrast is observed. The de-staining of the lesion occurs as the sclerosant replaces the contrast; thus, the extent of treatment can be seen. Compression bandages are applied. Conclusion: Combined use of US- and fluoroscopy-guided percutaneous injection of sclerosant in form of foam for the sclerosis of peripheral vascular lesions is simple, effective and safe. This technique is especially effective in cases of soft tissue venous malformation and lymphangioma.

P-278 Safety in interventional radiology – time to shake things up! F. Rawf1, A. Alsafi2, A. Zia2, A. Darzi1, C. Bicknell3, M.S. Hamady4; 1Department of Surgery & Cancer, Imperial College London, London, United Kingdom, 2Interventional Radiology, Imperial College Healthcare NHS, London, United Kingdom, 3Vascular Surgery, Imperial College Healthcare NHS, London, United Kingdom, 4Radiology, St Mary’s Hospital, London, United Kingdom Learning Objectives: This systematic review aimed to amalgamate the available evidence on procedural error in IR to identify knowledge gaps requiring further investigation. Background: Over the past three decades, interventional radiology (IR) has experienced exponential growth with a variety of novel procedures and treatments with increasing complexity. These have widened the therapeutic options for a multitude of disease processes and patient populations. Like surgical disciplines, IR circles have become increasingly concerned with patient safety and improving outcome. Clinical Findings/Procedure: We conducted a comprehensive literature search using the OVID interface and supplemented this with Cochrane library and Google Scholar searches to compile articles quantitatively assessing IR errors. Titles, abstracts and papers were reviewed by two independent assessors using specific inclusion/ exclusion criteria, with discrepancies resolved by a third assessor. From the initial 80 citations, 15 were concerned with procedural errors in IR and were selected for full text review. Only two papers performed quantitative analysis of IR errors. One article

Abstract Book retrospectively assessed insurance claims filed by interventional radiologists, while a more recent paper prospectively assessed the incidence of errors in an IR suite with a root cause analysis and resultant outcomes. The authors implemented a planned intervention during a modified WHO “time-out” in the angiography suite with a significant reduction in preventable errors. Conclusion: There is a distinct paucity of articles quantitatively and qualitatively assessing procedural errors in IR. We urge IR practitioners to systematically report and analyze errors in order to draw up lessons and ultimately enhance patient safety and outcome.

P-279 Training in interventional radiology: developing hands-on courses in an animal cathlab A. Laborda, C. Serrano, R. Fernández-Parra, C. Lahuerta, M.A. de Gregorio; GITMI, University of Zaragoza, Zaragoza, Spain Learning Objectives: Developing hands-on courses for IR training is a difficult but exciting work. After eight years of experience, we want to share our results. The main objective of this e-poster is to learn about the organization and management of training courses in an animal lab. Background: We mainly conduct courses a day-and-a-half long (three cathlab sessions) with two operating rooms working at the same time, in groups of four with a dedicated professor. Each session is preceded by 45 minutes of theoretical introduction or clinical case discussion in which the students are actively involved. Professors are requested to let the students do all the practical work, guiding them to solve any situation but not interfering with the animal. E-learning introductory courses, virtual simulators, and in vitro testing have also been used, especially in medical representatives’ training, to compare different devices. Clinical Findings/Procedure: During these 8 years, we have developed 103 courses in different topics, embolization and leg therapies being the most demanded. In our facilities, we have trained 725 attendees from 34 different countries and specialties. Physicians, nurses, and sales and marketing representatives have attended these sessions. Students’ satisfaction was assessed through a quality questionnaire, and achieved an average score of 9.2/10. Conclusion: In IR, there is a wide gap between watching and performing a procedure. Our fellows-in-training can benefit from training on simulators and animal hands-on courses before performing procedures on patients. This is equally important for an experienced operator when learning to use a new complex device.

P-280 Transcatheter embolization of visceral artery pseudoaneurysms O. Ikeda1, S. Inoue2, Y. Tamura1, Y. Nakasone1, Y. Yamashita1; 1Diagnostic Radiology, Kumamoto University Graduate School of Life Sciences, Kumamoto, Japan, 2Diagnostic Radiology, Kumamoto University Hospital, Kumamoto, Japan Learning Objectives: To describe our experience with the treatment of visceral artery pseudoaneurysms (VAPA) using transcatheter embolization and to propose treatment options for the treatment of VAPA. Background: Pseudoaneurysms are contained vessel-wall ruptures; they can produce massive, life-threatening hemorrhage. Emergency transcatheter embolization of VAPA is an alternative to surgery with a high success rate and lower morbidity and mortality rates. Transcatheter coil embolization of vessels distal and proximal to the pseudoaneurysm – the isolation technique – is an effective alternative treatment and N-butyl cyanoacrylate-lipiodol (NBCA-Lp) is

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CIRSE 2014 useful to embolize and eradicate arteriovenous malformations, fistulae, and pseudoaneurysms. Clinical Findings/Procedure: We endovascularly treated 66 patients with VAPA (22 pancreaticoduodenal arcade, 17 hepatic, 8 renal, 5 splenic, 5 left gastric, 4 gastroduodenal, 2 superior duodenal, 1 gastroepiploic, 1 adrenal, and 1 superior mesenteric artery). Transcatheter coil embolization with the isolation technique was technically successful in 56 (85%); however, in 3, we experienced difficulties. Consequently, 9 patients (14%) were treated without the isolation technique, 6 of whom were injected with NBCA-Lp or thrombin via the catheter. None of these 9 patients developed recanalization. Conclusion: Transcatheter coil embolization using the isolation technique is an effective alternative treatment in patients with VAPA. Patients with VAPA in whom there are difficulties with the isolation technique may benefit from transcatheter embolization using NBCA-Lp.

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P-282 Intraoperative angiography and endovascular treatment of massive bleeding during open necrosectomy following heterotopic pancreas transplantation M. Gawlitza1, M. Bartels2, T.-O. Petersen1, J. Fuchs1, M. Moche1; 1Department of Diagnostic and Interventional Radiology, Leipzig University Hospital, Leipzig, Germany, 2Department of Visceral, Transplantation, Vascular and Thoracic Surgery, Leipzig University Hospital, Leipzig, Germany We present the case of two patients who developed severe, necrotizing pancreatitis shortly after pancreas transplantation. During open necrosectomy, uncontrollable hemorrhage occurred. In both cases, emergency intraoperative angiography with endovascular embolization helped identify the bleeding site and treat the bleeding.

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Understanding regression analyses – a primer

Low-invasive percutaneous treatment of pancreas divisuminduced recurrent pancreatitis by pancreatic duct drainage and subsequent balloon dilatation of Wirsung and Santorini ducts

C.E. Ray, Jr., R.C. Gaba, J. Minocha, M.-G. Knuttinen, J.T. Bui; Radiology, University of Illinois at Chicago, Chicago, IL, United States of America Learning Objectives: 1. To understand the basis of regression analyses (RA) as they relate to medical research. 2. To understand when RA should be used in clinical and translational studies. 3. To identify the pitfalls and drawbacks of using RA, and identify other statistical methods that might be more appropriate for specific study designs. Background: RA is a statistical method using which the relationship between an outcome (dependent) variable and one or more predictor (independent) variables is determined. Using RA, an investigator is able to predict an average outcome given specific combinations of predictor variables. RA has many applications in medicine and interventional radiology, including predicting outcomes for a population of patients undergoing different therapies or who present with diverse predictor variables. Clinical Findings/Procedure: RA methods are themselves widely disparate in terms of the data used in the model as well as the information that may be gleaned from the analyses. This poster will discuss the most commonly used models in the interventional radiology literature (assumptions used in regression models; linear vs. logistic regression; fixed effects vs. random effects models; and goodness of fit and R-squared test). In addition, common mistakes while using RA will be discussed, including when the tests are inappropriate and what tests would be better performed for specific scenarios. Conclusion: Whether authors perform their own statistical analyses or have others perform them, a basic understanding of RA is vital for any investigator or reader of the literature.

M. Mizandari1, N. Habib2, G. Asatiani1, G. Nemsadze1; 1Diagnostic and Interventional Radiology, Tbilisi State Medical University, “High Technology Medical Center - University Hospital”, Tbilisi, Georgia, 2Division of Surgery, Oncology, Reproductive Biology & Anaesthetics, Imperial College London, London, United Kingdom A patient with recurrent pancreatitis due to pancreas divisum with severe dilatation of the pancreatic ductal system was successfully treated percutaneously. Pancreatic duct drainage enabled resolution of pancreatitis, and the treatment was completed with balloon dilatation of Wirsung and Santorini ducts.

P-284 Mechanical thrombus aspiration in a case of massive pulmonary thromboembolism M. Bossalini, F.C. Bodini, B. Rossi, E. Michieletti; Radiology, Piacenza Hospital, Piacenza, Italy A patient with clinical history of recurrent high-grade cerebral astrocytoma developed an acute and serious respiratory insufficiency caused by massive pulmonary thromboembolism. He was successfully treated in the emergency room with mechanical thrombus aspiration using the AngioJet system.

P-285 Three cases of recanalization after arterial embolization with NBCA-lipiodol for traumatic hemorrhage K. Hashimoto1, T. Yamada2, S. Hamaguchi1, Y. Ogawa1, Y. Arai1, K. Murakami2, Y. Nakajima1; 1Radiology, St. Marianna University of Medicine, Kawasaki, Japan, 2Radiology, St. Marianna University of Medicine Yokohama City Western Hospital, Yokohama, Japan We present three cases of recanalization following arterial embolization using NBCA-lipiodol mixture for traumatic hemorrhage. Each case had lower concentration of NBCA-lipiodol (<20%), shock index >1, DIC, and severe vasospasm; these factors could be responsible for the hemorrhage.

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Unusual case of acute internal carotid artery (ICA) bleeding which presented as a late complication of radiotherapy

A previously undefined accessory great saphenous vein: an ultrasonogaphy study

I.U. Din, I. Ahmed, I. Sherman, S. Lea; Interventional Radiology, Wirral University Teaching Hospital, Liverpool, United Kingdom

S. Deniz1, D. Unal1, E. Hatipoglu1, M. Gedikoglu2, L. Oguzkurt2; 1Radiology, Baskent University, Adana Teaching and Medical Research Center, Adana, Turkey, 2Radiology, Baskent University School of Medicine, Adana, Turkey

The patient developed ulceration and bleeding following radiotherapy for squamous cell cancer on the neck. CT and catheter angiograms showed pseudoaneurysm with active bleeding from ICA, which was successfully treated with a covered stent. Surgery was not an option.

Peripheral vascular disease intervention P-287 A 100-case single-center experience with OUTBACK-assisted subintimal recanalization P.M. Kitrou, A. Parthipun, P. Gkoutzios, I. Ahmed, N. Karunanithy, A. Diamantopoulos, T. Sabharwal, K.N. Katsanos; Interventional Radiology, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom Purpose: To report the experience of our department in using the OUTBACK device for subintimal recanalization. Material and Methods: From February 2011 to July 2013, 104 OUTBACK devices were employed in 93 patients for subintimal recanalization of 100 vessels with chronic total occlusions after initial failure of spontaneous re-entry. Fifty-two cases involved retrograde approach of total chronic aorto-iliac occlusions (Group AO), and 48 were re-entry attempts of infrainguinal occluded arteries (Group II). Points of re-entry were treated with or without pre-dilation, followed by the placement of uncovered or covered stents or just standard balloon angioplasty (PTA) for definite lesion treatment. Endpoints were set at technical failure, defined as failure to reenter at the desired distal true lumen, and re-entry distance, defined as the distance between the point of true vessel reconstitution and the eventual re-entry point. Secondary endpoints included minor or major complications. Results: In total, 7 (7%) cases failed to re-enter the true lumen [5/52 (9.6%), Group AO vs 2/48 (4.16%), Group II; p=0.44]. Re-entry distance was similar in both groups [11.5±0.8mm vs 12.6±1.1mm, respectively; p=0.40]. Overall, there were 17 minor complications [9/52 (17.3%) vs 8/48 (16.7%), respectively; p=0.93], including 5 vessel perforations, 5 significant vessel dissections, 5 embolic events, and 2 others; all were treated successfully. There were no major complications. PTA of the re-entry point was associated with significantly more complications than primary stent placement (Odds Ratio 4.1, 95%CI 1.3– 14.2; p=0.02). Conclusion: The OUTBACK device is safe and has a high technical success rate in achieving targeted re-entry after failed spontaneous re-entry of standard subintimal recanalization.

Purpose: To define a new variation to the accessories of the great saphenous vein (GSV). Material and Methods: Ultrasonographic mapping of 568 limbs with GSV insufficiency in 318 patients was evaluated retrospectively. After defining the new accessory GSV, we prospectively mapped the saphenous anatomy. The definition of the accessory GSV was based on the new nomenclature of the International Union of Phlebology. The accessory GSV was categorized anatomically into 3 types with respect to the exit and entrance to the saphenous compartment. The frequency, anatomic types, and distribution of the insufficiency of the new variant of the accessory GSV was investigated. Results: The newly defined accessory GDV was bow-shaped. The normal and patent GSV lied in the saphenous compartment all along its course, and the accessory GSV left the compartment distally and always joined the compartment more proximally. This accessory GSV was present in 29 of 586 limbs (5.1%). Insufficiency of the accessory GSV was seen in 25 of 29 limbs (86.2%). Conclusion: In all, 318 patiens (216 women, 102 men; 18–83 years, mean ± sd 44.6 ± 11.7 years) were enrolled in our study with a total of 568 limbs with GSV insufficiency. The new accessory GSV, althought not frequent, had a very high rate of insufficiency in limbs with GSV insufficiency. It is therefore important to recognize this accessory GSV; else, treating GSV alone can lower the treatment success of these patients.

P-289 Acute thrombosis of covered stents in the peripheral arteries: an underestimated phenomenon A. Parthipun, S. Al-Lamki, Y. Gupta, A. Diamantopoulos, T. Sabharwal, K.N. Katsanos; Interventional Radiology, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom Purpose: Little is known about the incidence of acute thrombosis and limb ischemia after covered stent placement in the peripheral arteries. We report the results of a single-centre retrospective audit investigating the phenomenon in the aortoiliac and infrainguinal arteries. Material and Methods: Patients with supra- and infrainguinal peripheral arterial occlusive disease were eligible for VIABAHN stent placement following balloon pre-dilation as required. Relevant patient archives were retrospectively audited and scrutinised for any events of acute limb ischemia with angiographically confirmed covered stent thrombosis. Correlation of thrombotic events with baseline anatomical and clinical variables was performed. Results: The study covered a period of over 5 years (July 2008– December 2013). Patient notes of 100 cases that had undergone covered stent (VIABAHN, Gore Medical; 137 stents) placement during that period were analysed. In 29 cases, VIABAHN stents were placed in the aortoiliac arteries and in 71 cases, in the infrainguinal vessels without any peri-procedure or short-term (30-day) major complications. After a median follow-up duration of 1 year (range, 0.1–5.5), there were 12 events of acute covered stent thrombosis presenting with acute limb ischemia symptoms. Thrombosis rate in the aortoiliac segment was 0%. All acute thromboses occurred in the femoropopliteal segment (rate 16.9%, incidence of 15 events per 100 person-years). Among them, 8 resulted in a bypass graft or amputation and 4 were successfully thrombolysed.

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Conclusion: Acute thrombosis of VIABAHN covered stents in the femoropopliteal arteries is a true phenomenon with an underestimated incidence. Patients present with acute limb ischemia and may end up with major amputations.

P-290 Belgian remedy registry: 1-year results of bioabsorbable stents in superficial femoral artery lesions P. Goverde1, K. Lauwers1, H. Schroe2, F.E. Vermassen3; 1Vascular & Endovascular Surgery, Vascular Clinic ZNA, Antwerp, Belgium, 2Limburgs Vaatcentrum - ZOL, ZOL Sint-Jan Genk, Genk, Belgium, 3Department of Vascular Surgery, University Hospital Ghent, Ghent, Belgium Purpose: In the treatment of superficial femoral artery (SFA) lesions, nitinol stents are commonly used with good results. But the incidence of in-stent stenosis or occlusion is increasing, and their treatment remains a difficult and yet unresolved issue. We wanted to investigate if the placement of a “temporary” bioabsorbable stent can be a solution. Material and Methods: The Belgian multi-centre prospective follow-up study used the bio-absorbable semi-self-expandable Remedy stent (Kyoto Medical Planning Co Ltd, Kyoto, Japan) for the treatment of short (≤8 cm) SFA lesions. This stent is made of a biodegradable polymer and has a zig zag helical coil stent design. At the moment, it is available in 2 lengths, 36 and 78 mm, on a 7-Fr device. Results: We have treated 100 patients with TASC II A and B lesions in the SFA region. Mean lesion length was 35 mm (2–80 mm). Technical success rate was 98 %. There were no intervention-related deaths. Follow-up ultrasound at 6 months revealed primary patency rate 70.2%, assisted patency rate 88.5% and target lesion revascularisation rate 17.9%. At 12-month follow-up, primary patency rate was approximately 65%. Conclusion: Bioabsorbable stent technology might improve the mid- and long-term durability of the SFA endovascular treatment. The early results were encouraging, but the 12-month results were rather disappointing. The combination of drug-coated balloon and Remedy stent is under investigation to see if this could improve the results. A better understanding and even adjustments of the kinetic and mechanical characteristics of the stent structure are nescessary and under investigation.

P-291 BIOLUX P-II: a randomized clinical trial of Passeo-18 Lux DRB vs. POBA for the treatment of infrapopliteal artery lesions K. Deloose1, T. Zeller 2, M. Brodmann3, M. Bosiers1, P. Peeters4, K.-L. Schulte5, D. Scheinert6, U. Beschorner 7, E. Pilger3; 1Department of Vascular Surgery, AZ Sint-Blasius, Dendermonde, Belgium, 2Angiology, Universitäts-Herzzentrum Freiburg Bad Krozingen, Bad Krozingen, Germany, 3Universitätsklinikum Graz, Division of Angiology, Graz, Austria, 4Surgery, Imelda Ziekenhuis, Bonheiden, Belgium, 5Vascular Center Berlin, Ev. Hospital Königin Elisabeth Herzberge, Berlin, Germany, 6Clinical and Interventional Angiology, Park Hospital Leipzig, Leipzig, Germany, 7Medical Quality Analysis Center, CoreLab Bad Krozingen GmbH, Bad Krozingen, Germany Purpose: Drug-eluting balloons have shown promising results in femoropopliteal disease; however, adequate evidence demonstrating improved outcomes in infrapopliteal arteries is currently lacking. BIOLUX P-II assesses the safety and performance of the Passeo-18 Lux paclitaxel-releasing balloon (DRB) vs. the uncoated Passeo-18 balloon (POBA) in the treatment of infrapopliteal lesions.

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Material and Methods: BIOLUX P-II is a prospective, international, multicenter, randomized trial with follow-ups at 30 days and 6 and 12 months. Safety and performance primary endpoints are major adverse events (MAE) at 30 days and target lesion primary patency at 6 months (assessed by an independent angiographic core laboratory). Results: Seventy-two subjects, 79.2% men, mean age 71.3±9.7 years were randomized 1:1 at six European sites. At baseline, subjects presented with hypertension (86.1%), hyperlipidemia (68.1%), diabetes (66.7%), and critical limb ischemia (77.8%). At 30 days, MAE were 0.0% for DRB vs. 8.3% for POBA (p=0.239). At 6 months, target lesion primary patency showed a trend in favor of DRB (84.3%) vs. POBA (75.9%; p=0.330), and major amputations were 3.3% for DRB vs. 5.7% for POBA (p=0.655). Clinical improvement at 6 months, reflected by improvement in Rutherford class, was 59% for DRB vs. 47% for POBA, with 0% DRB subjects worsening vs. 6% POBA subjects (p=0.326). Clinical improvement in Rutherford 5 subjects was significant in the DRB group (p=0.002) compared with the POBA group (p=0.058). Conclusion: DRB, as compared to POBA, is associated with favourable functional and clinical outcomes and results in significant clinical improvement of Rutherford 5 subjects in the treatment of infrapopliteal artery lesions.

P-292 Covered stents for the treatment of aorto-iliac occlusive disease F.A.B. Grimme1, P. Kasprzak 2, P. Goverde3, M. Reijnen1; 1Surgery, Rijnstate Hospital, Arnhem, Netherlands, 2Vascular Surgery, University Hospital Regensburg, Regensburg, Germany, 3Vascular & Endovascular Surgery, Vascular Clinic ZNA, Antwerp, Belgium Purpose: Endovascular treatment options for the aorto-iliac occlusive disease include plain balloon angioplasty and stent placement. Covered stents may improve patency rates compared with bare metal stents because of the prevention of tissue ingrowth. Furthermore, they may reduce the risk of complications such as vessel wall rupture and embolization. We evaluated the safety and durability of single covered stents for isolated infrarenal occlusive lesions and of the covered endovascular reconstruction of the aortic bifurcation (CERAB) technique. Material and Methods: In three clinics, the data of all patients treated with the CERAB technique or with covered stents for isolated aortic lesions were analyzed. Follow-up consisted of clinical examination, duplex sonography, ankle–brachial index, and plain abdominal X-ray. Results: Between November 2008 and January 2014, 36 covered stents were placed for isolated aortic lesions and 94 CERAB procedures were performed. For isolated stents, the primary patency rate was 100% after a median follow-up of 22 months. Technical success rate of CERAB was 96% with primary and secondary patency rates at one year of 85% and 95%, respectively. No distal embolizations occurred. Two iliac ruptures occurred in the CERAB group, and both were treated endovascularly. Conclusion: Covered stents for aorto-iliac occlusive disease are safe and effective. Patency rates are excellent, and their use may provide an alternative for open surgical reconstruction. Long-term results have to be awaited.

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P-293 Differentiation of superficial femoral artery restenosis with optical coherence tomography (OCT) M. Brodmann1, A. Dorr1, T. Gary1, H.A. Deutschmann2, E. Pilger1, P. Eller1; 1Internal Medicine, Division of Angiology, Graz, Austria, 2Radiology, Medical University of Graz, Graz, Austria Purpose: We tried to evaluate the morphological nature of the first restenosis in the superficial femoral artery (SFA) as a consequence of initial treatment with plain old balloon angioplasty (POBA) versus primary stenting by OCT. Material and Methods: We conducted a single-center non-randomized observational study to evaluate 10 consecutive patients who presented with symptomatic restenosis after endovascular treatment of SFA. To guarantee a homogenous nature of restenosis, we only included patients with a first high-grade restenosis of SFA. The 10 patients were divided into two groups according to their initial treatment: POBA or bare metal stent placement. Results: Ten consecutive patients with a mean age of 75.7 ± 4.5 years were evaluated. The mean lesion length was 9.7 ± 3.6 cm, and the mean duration since primary treatment was 8.6 ± 3.7 months. Concerning the modality of restenosis in relation to the primarily applied endovascular technique, we identified in the POBA group the classic atherosclerotic plaques with mixed features of lipid pool areas, calcium deposits, calcified plaques, necrotic areas, and fibrosis. In contrast, we were able to show massive neointimal hyperplasia with purely fibrotic features in all cases of in-stent restenotic lesions with considerable neovascularization in one of them. Conclusion: Our data show for the first time a clear morphological difference of restenotic lesions in SFA depending on the primary treatment. We were able to show a clear relationship of the primary endovascular treatment (either POBA or bare metal stent placement) with the morphology of restenosis.

P-294 Drug-coated balloon (DCB) angioplasty versus conventional angioplasty for the treatment of the superficial femoral artery (SFA) and PI segment in PAD patients: first interim results of the FREERIDE study K.-L. Schulte1, B. Fernandez-Tresguerres2, R. Langhoff 3; 1Vascular Center Berlin, Ev. Hospital Königin Elisabeth Herzberge, Berlin, Germany, 2Clinical Department, Eurocor GmbH, Bonn, Germany, 3Vascular Center, Sankt Gertrauden-Krankenhaus, Berlin, Germany Purpose: Paclitaxel DCB during percutaneous transluminal angioplasty (PTA) for femoropopliteal lesions in PAD patients might result in a significantly reduced restenosis rate. Thus, the FREERIDE study investigates the inhibition of restenosis by the FREEWAY DCB versus standard balloon (POBA) in the treatment of de-novo occluded, stenotic lesions or re-occluded and restenotic lesions in SFA and popliteal arteries (PI segment). Material and Methods: In all, 280 patients will be randomized either to FREEWAY DCB or POBA in 23 centers worldwide. The primary endpoint is clinically driven target lesion revascularization rate (TLR) at 6 months. Further, several secondary endpoints like late lumen loss and patency rate at 6 months; TLR at 12, 24 months follow-up (FU); improvement in Rutherford classification and ankle– brachial index (ABI); and MAE at FU will be investigated. Results: So far, 71 patients have been enrolled; 51 of them completed the 6-month FU, and 3 were not available for FU. At 6-month FU, positive trends were observed for the TLR rate (6.6% vs. 9.5% after POBA; p=0.7) and MAE (6.7 % vs 14.3 % after POBA; p=0.36). Furthermore, there are positive trends in the patency rate and improvement of

Abstract Book Rutherford classification after FREEWAY PTA vs. POBA. Conclusion: The first interim results indicate that FREEWAY DCB might provide an advantage for angioplasty in SFA and PI segment lesions. DCB might overcome the existing limitations in the treatment of PAD.

P-295 Endovascular treatment with percutaneous transluminal angioplasty in patients with Buerger’s disease L. Oguzkurt1, M. Gedikoglu1, N. Koca1, C. Andic2; 1Radiology, Baskent University, Adana Teaching and Medical Research Center, Adana, Turkey, 2Radiology, Baskent University School of Medicine, Adana, Turkey Purpose: To evaluate the outcome of endovascular intervention with percutaneous transluminal angioplasty in patients with Buerger’s disease (thromboangiitis obliterans). Material and Methods: Between 2002 and 2014, we treated 202 limbs in 142 patients with Buerger’s disease having long segment chronic occlusion in the lower extremity arteries. Diagnostic criteria included (1) smoking history, (2) onset before the age of 50 years, (3) infrapopliteal arterial occlusions, and (4) absence of atherosclerotic risk factors other than smoking. Percutaneous transluminal angioplasty was the primary treatment modality. Percutaneous mechanical thrombectomy and aspiration thrombectomy was used as needed. The data on the index procedures were retrospectively evaluated to demonstrate the distribution of arterial involvement, outcome of percutaneous transluminal angioplasty, and complications. Results: Patients were 138 males (97.2%) and 4 females (mean age, 41 years). Femoropopliteal as well as below-knee arteries were invloved. All patients were Rutherford class 3 and 5. Technical success – defined as the patency of at least one target artery from the groin to the ankle level with less than 30% residual stenosis – was achieved in 147 limbs (72.7%). Almost all patients required repeated intra-arterial nitroglycerine injection during the procedure. Arteriovenous fistula after PTA developed in 26 limbs (12.8%). Conclusion: Endovascular treatment with PTA had a modest outcome. The arterial involvement and response to PTA in Buerger’s disease was very different from atherosclerosis and had characteristic features such as intra-arterial spasm in response to any manuplation in the artery and PTA, postangioplasty arteriovenous fistula formation, and poor response to PTA.

P-296 Evaluation of infrapopliteal blood flow changes during endovascular revascularization using 2D X-ray perfusion software: a pilot study  M. Meeks1, J. Mayer 2, P. Desgranges2, Y. Ketsakin2, J.-F. Deux 2, H. Kobeiter 2; 1Clinical Science, Interventional X-ray, Philips Healthcare, Best, Netherlands, 2Department of Radiology and Medical Imaging, Henri Mondor Hospital, Créteil, France Purpose: To evaluate a 2D X-ray perfusion software to quantify infrapopliteal blood flow changes during endovascular revascularization of femoropopliteal lesions. Material and Methods: Fifteen patients undergoing endovascular revascularization were included in this study. Forty-one vessels were analyzed using 2D perfusion software (Philips Healthcare, Best, The Netherlands). 2D perfusion images could be collected after regular DSA without additional radiation or contrast usage. A region of interest was drawn in the distal part of the 3 tibial arteries. The following parameters were calculated: time to peak (TTP), wash in rate (WIR), and arrival time (AT). Parametric differences before and after revascularization and between Rutherford classes were

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CIRSE 2014 statistically compared using paired and one-sample Student’s t-test, respectively. Results: Eight patients had Rutherford class <3, and 7 had Rutherford class ≥3. Ten patients underwent SFA stent placement, the remaining five were treated with balloon angioplasty of SFA and/or popliteal/tibial arteries. Results demonstrated significant differences after revascularization in TTP (7% decrease), WIR (41% decrease), and AT (35% increase). Sub-analysis showed a significant difference (p = 0.004) in the arrival time in CLI patients compared with PAD patients – a 40% decrease and 2.7% increase, respectively, after revascularization. Conclusion: 2D perfusion software enables hemodynamic measurement of flow differences after endovascular revascularization. CLI patients at rest demonstrate a faster arrival time after revascularization than PAD patients. This could be explained by the symptomatic appearance of vascular disease in PAD patients during physical exercise. Further research is needed to prove whether these hemodynamic differences are related to clinical outcome and tissue reperfusion.

P-297 Exercise or intervention? Contrasting non-surgical options in the management of claudicants T.M. Aherne1, S. McHugh2, M.J. Lee1, A.L. Leahy3, D. Moneley 2, P. Naughton2; 1Vascular and Interventional Surgery, Beaumont Hospital, Dublin, Ireland, 2Vascular Surgery, Beaumont Hospital, Dublin, Ireland, 3Department of Surgery, Beaumont Hospital, Dublin, Ireland Purpose: Peripheral arterial disease (PAD) is a common condition, and it is associated with considerable morbidity and mortality. At present, conflicting views exist as to the optimal non-surgical management of PAD. While studies to date are supportive of supervised exercise training (SET), the incorporation of SET into PAD treatment protocols is varied. We aim to compare the merits of endovascular revascularization (EVR) and SET in the management of PAD. Material and Methods: A systematic literature search was performed using the PubMed database. Randomized studies directly comparing exercise with invasive procedures were included. Intermittent claudication distance (ICD), maximum walk distance (MWD), and ankle–brachial pressure index (ABPI) were the primary markers of walking performance. Results: Fifteen trials including 1,374 patients were identified. When reviewed, SET offered similar walking outcomes to EVR at 6 and 12 months. Endovascular intervention consistently resulted in higher ABPI measurements. A combination of both appeared to offer significantly superior walk performance and quality of life with an associated reduction in re-intervention rates. No morbidity was reported in patients undergoing SET with compliance in that cohort incompletely reported. Procedural morbidity following EVR varied widely with reported rates of complication and failure up to 15.8% and 20.6%, respectively. Conclusion: Exercise is effective and safe. SET should be advocated in the initial care of PAD. In those failing conservative management, a combination of SET and EVR appears to offer superior outcomes to monotherapy. Unfortunately, to date SET programs remain inaccessible to many interventionists.

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P-298 Feasibility of direct imaging of perfusion in the foot in patients with critical limb ischemia S. Jens1, M.J.W. Koelemay 2, H.A. Marquering1, J.A. Reekers1; 1Radiology, Academic Medical Center, Amsterdam, Netherlands, 2Vascular Surgery, Academic Medical Center, Amsterdam, Netherlands Purpose: Absolute systolic blood pressure, toe pressure, and transcutaneous oxygen pressure are indicative of critical limb ischemia (CLI), but are not helpful in quantifying disease severity. Therefore, we studied the feasibility of a new imaging technique, i.e., 2D perfusion assessment during digital subtraction angiography (DSA), to evaluate perfusion in the foot before and after revascularisation in CLI patients. Material and Methods: Ten consecutive CLI patients undergoing crural angioplasty were included for this phase II study. Postprocessed 2D perfusion images and curves were acquired with DSA imaging of the foot. DSA of the foot was performed in a standardized manner with a standard catheter position and contrast injection and the foot fixated in a foot support. 2D perfusion images and curves before and after revascularisation were compared. Results: Perfusion changes between pre- and post-angioplasty were seen. 2D perfusion imaging of the foot seems to be an effective modality to monitor angioplasty success in CLI patients. The technique and the phase II patients results will be discussed. Conclusion: 2D perfusion imaging of the foot is feasible and contains important information to learn more about why some patients do better than others after percutaneous revascularisation. It might also help to select which vessel(s) to treat in CLI.

P-299 Lower limb amputation and the fate of the contralateral limb in patients with critical limb ischemia (CLI) P.M. Khin1, K.-H. Tay1, F.G. Irani2, A. Gogna1, S. Ramamurthy1, C.W. Too1, S.X.J.M. Chan1, A. Patel1, H.G.R. Lo1, J.P. Robertson1, S.K. Sanamandra1, S.Y.B. Chua3, S.G. Tan3, S.P. Chng3, S. Pasupathy3, C.T. Tec3, B.S. Tan1; 1Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore, 2Department of Radiology, Singapore General Hospital, Singapore, Singapore, 3General Surgery, Singapore General Hospital, Singapore, Singapore Purpose: To determine the rates and associated risk factors of contralateral lower limb amputations following initial amputation for CLI. Material and Methods: A retrospective review of patients with CLI who underwent lower limb angioplasty and subsequently had lower limb amputation from January 2005 to December 2012 was conducted. The proportions of subsequent ipsilateral and contralateral major and minor amputations at 1 and 3 years were calculated. Cox proportional hazards regression was performed to determine the predictors of contralateral major amputation. Results: We identified 805 patients (males: 55%, females: 45%; mean age: 66.5 years). Of them, 94% had diabetes and 32% had end-stage renal failure (ESRF). There were 265 (33%) and 540 (67%) patients who underwent an initial major and minor amputation, respectively. After major amputation, 11.3% and 16.7% had a contralateral major amputation at 1 and 3 years, respectively. After minor amputation, 28.5% and 32.2% had an ipsilateral major amputation, whereas 6.7% and 12.2% had a contralateral major amputation at 1 and 3 years, respectively. Cox proportional hazards regression showed that ESRF (hazard ratio [HR], 2.4; 95% confidence interval [CI], 1.6–3.5; p<0.001), stroke (HR, 1.6; 95% CI, 1.0–2.4; p=0.03), and initial major amputation (HR, 1.4; 95% CI, 1.0–2.1; p=0.04) were independent predictors of subsequent contralateral major amputation.

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Conclusion: Our data suggest that the contralateral limb is at risk of amputation following initial major amputation. All patients with amputations, particularly those with ESRF or stroke, should be closely monitored and treated early to prevent subsequent contralateral amputations.

P-300 Percutaneous thrombosuction for acute lower limb ischemia A. Katsargyris1, K. Oikonomou1, B. Möhner 2, R. Wolfgang2, M. Pedraza de Leistl1, E. Verhoeven1; 1Department of Vascular and Endovascular Surgery, Klinikum Nürnberg Süd, Nuremberg, Germany, 2Department of Radiology, Klinikum Nürnberg Süd, Nuremberg, Germany Purpose: Conventional treatment of acute limb ischemia (ALI) consists of heparinization and delayed surgery for grade I (viable) ischemia, and prompt embolectomy/bypass surgery for grade II (threatened) ischemia. Intra-arterial thrombolysis is a less invasive option, but it is less suitable for grade II ischemia as it requires long treatment duration. Percutaneous thrombosuction can actively remove the clot aiming for prompt revascularization. In addition, it does not preclude immediate open surgery in case of failure. Material and Methods: We conducted a retrospective review of all consecutive patients treated with percutaneous thrombosuction for ALI from January 2009 to December 2012 at a single institution. Evaluated outcomes included initial technical success, operative mortality, 30-day amputation, late mortality, amputation, and reintervention during follow-up (FU). Results: A total of 205 patients (48% males, mean age 75.1 ± 10.6 years) were treated. Seventy-six percent patients presented with grade I (viable) ischemia and 24% with grade II (threatened) ischemia. Technical success was 94% and perioperative mortality 2.4%. Additional open surgery was required in 4.4%. The 30-day amputation rate was 2%, including only one (0.5%) major amputation. Mean FU was 25.3 ± 15 months. Estimated freedom from reintervention was 91 ± 2.1% and 83.4 ± 3.3%, at 1 and 3 years, respectively. Estimated freedom from amputation was 94.1 ± 1.7% and 93.5 ± 1.8% at 1 and 3 years, respectively. Conclusion: Percutaneous thrombosuction is an effective treatment for selected patients with ALI. It is associated with high initial technical success and good mid-term durability.

P-301 Prospective, multicenter Tack optimized balloon angioplasty (TOBA) study for femoropopliteal arteries using the Tack-It Endovascular SystemTM: preliminary results C. Wissgott1, C. Luedtke1, O. Lorenzen2, F. Scheer1, P. Kamusella1, R. Andresen1; 1Institute of Diagnostic and Interventional Radiology/ Neuroradiology, Westküstenklinikum Heide, Academic Teaching Hospital of the Universities of Kiel, Lübeck and Hamburg, Heide, Germany, 2Albertinen Krankenhaus, Klinik für Gefäß- und Endovaskuläre Chirurgie, Hamburg, Germany

Abstract Book all, 138 subjects (mean age 68.3±9.8 years) were enrolled; of them, 130 were treated with the Tack-It Endovascular System™ after angioplasty of femoropopliteal arteries. The Tack, which is made of nitinol, is 6-mm long and has low outward force; it is indicated for vessel diameters from 2.5 to 5.5 mm. Results: The technical success rate was 98.5%. The mean lesion length was 50.1±28.8 cm. A median number of 1.7±1.0 dissections after angioplasty were observed, and 3.7±2.1 Tacks were implanted per subject. The ankle–brachial index (ABI) improved from baseline 0.66±0.20 to 0.98±0.16 after 1 month (p<0.05). The pain free walking distance improved from 144.5±131.5 m to 461.4±562.6 m. There were no major adverse events or amputations during follow-up. Conclusion: The preliminary results of the study demonstrate that the Tack-It Endovascular System™ is a safe and effective treatment option to optimize the results of angioplasty. Long-term clinical evidence is needed to confirm the clinical benefits of this novel technology.

P-302 Randomized trials for endovascular treatment of infrainguinal arterial disease: systematic review and meta-analysis (part 2: below the knee) S. Jens1, A.P. Conijn1, M.J.W. Koelemay 2, S. Bipat1, J.A. Reekers1; Academic Medical Center, Amsterdam, Netherlands, 2Vascular Surgery, Academic Medical Center, Amsterdam, Netherlands 1Radiology,

Purpose: To evaluate 1–48-month follow-up outcomes of different endovascular treatment strategies in below-the-knee (BTK) arterial segments in critical limb ischemia (CLI) patients. Material and Methods: Medline and Embase were last searched on 5 November 2013. Randomized controlled trials comparing either balloon angioplasty (PTA) or drug-eluting balloon (DEB) with optional bailout stenting or primary stenting using a bare stent (BS) or drug-eluting stent (DES) to one another were included. Methodological quality of each trial was assessed using Cochrane Collaboration’s tool, and quality of evidence was assessed using the GRADE system. Outcomes assessed were wound healing, quality of life, change in Rutherford classification, amputation, death, target lesion revascularization (TLR), bypass, binary restenosis, late lumen loss, stenosis grade, and event-free survival with follow-up periods of at least 1 month. Results: Twelve trials including 1145 patients were identified, and 90% of patients had CLI. Six BS versus PTA and two DES versus PTA trials showed low-quality evidence of equal efficacy. One trial comparing DEB with PTA showed moderate-quality evidence of improved wound healing, improvement in Rutherford classification, and lower TLR and binary restenosis in diabetic patients after 12 months. Amputation and death rate did not differ significantly. For DES versus BS, most trials showed equal efficacy between strategies. Conclusion: Based on low- to moderate-quality evidence, PTA with optional bailout stenting using BS should remain the preferred strategy in treating CLI patients with BTK arterial lesions. Before other strategies can be implemented, larger and high-quality RCTs assessing clinically relevant outcomes are needed.

Purpose: Dissection or tissue flaps often occurs after angioplasty, which requires stent placement to prevent restenoses or reocclusions that occur if left untreated. The aim of this study was to evaluate the safety and effectiveness of the Tack-It Endovascular System™(Intact Vascular, Wayne, PA), which is indicated for tissue apposition to optimize balloon angioplasty instead of normally used stents. Material and Methods: The primary endpoints were safety and device technical success at 30 days. Safety included major devicerelated adverse event(s), including device embolization, emergency revascularization, amputation, or clinically-driven TLR at 30 days. In

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P-303 Safety and efficacy of ticagrelor in patients with critical limb ischemia and high on-clopidogrel platelet reactivity: initial experience from a platelet function test-guided individualized antiplatelet therapy study S. Spiliopoulos1, K.N. Katsanos2, P.M. Kitrou1, A. Diamantopoulos2, D. Siablis1, D. Karnabatidis1; 1Department of Diagnostic and Interventional Radiology, Patras University Hospital, Patras, Greece, 2Interventional Radiology, Guy’s and St. Thomas’ Hospitals, London, United Kingdom Purpose: To report the safety and efficacy of ticagrelor in patients with critical limb ischemia (CLI) and high on-clopidogrel platelet reactivity (HCPR) undergoing complex, limb-salvage, peripheral endovascular procedures (PEP). Material and Methods: Consecutive patients with HCPR undergoing peripheral angioplasty or stenting for CLI were included. HCPR was defined as platelet reaction units (PRU)>234 measured using the VerifyNow P2Y12 assay. Patients with HCPR were prescribed with ticagrelor 90 mg twice daily and aspirin 100 mg daily for 6 months followed by ticagrelor 90 mg twice daily thereafter. Primary safety endpoint was total major bleeding, and primary efficacy endpoint was the composite of cardiovascular death and major amputation. Secondary endpoints included the level of platelet inhibition achieved and target limb revascularization (TLR)-free survival rate. Results: In total, 37 CLI patients (40 limbs) were investigated. Mean follow-up duration was 11.3±5.0 months (range, 6–21), and mean treated lesion length was 229.2±71.4 mm for the femoropopliteal axis and 179.3±83.9 mm for infrapopliteal arteries. No major/minor bleeding was detected. There were four peri-procedural minor adverse events (10.8%); in two cases (5.4%), ticagrelor was discontinued. Kaplan–Meier-estimated primary efficacy endpoint and TLRfree survival rates were 92.0% and 69.5%, respectively, at 12 months. In all patients, ticagrelor exhibited platelet inhibition below the cutoff value. Mean PRU during clopidogrel therapy was 308.4±41.8 (range, 257–422) vs. 65.0±52.4 (range, 2–189) when changed to ticagrelor; p<0.0001. Conclusion: In this series of CLI patients with HCPR undergoing complex PEP, ticagrelor was proven safe and efficient as it achieved abundant platelet inhibition and satisfactory clinical outcomes without major complications.

P-304 To identify the source and journal of publication for studies on endovascular interventions in lower limb peripheral arterial disease over the past 5 years P.N. Thanaratnam, E. Carmody, R.J. Lee, D.M. Lee, S.S. Alnafisee, M.J. Lee; Radiology, Beaumont Hospital, Dublin, Ireland Purpose: To identify the source of publications and journal of publications related to endovascular interventions, in patients suffering from Peripheral Arterial Disease. Material and Methods: Twenty keywords related to PAD and endovascular interventions in the lower limb were identified, and a literature search was carried out through PubMed database from October 2013 to January 2014. Major inclusion criteria for the study required publications to be published in the last 5 years from English language journals, include study populations with greater than 5 patients, and publications on endovascular interventions in the treatment of PAD. Eligible articles were then added to a database and classified by journal of publication, PubMed identification number, article title, date of publication, associated department, country of origin, and first/last authors.

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Results: 787 articles from 106 different journals were identified: Forty-nine percent (384 articles) originated from Vascular Surgery, 16% (125 articles) from Interventional Radiology, 9% (70 articles) from Cardiology, 4% (34 articles) from Angiology, 5% (54 articles) from Medicine, and 2.4% (19 articles) from research institutions. Thirty articles (3.8%) were published in CVIR, and 14 articles (2.3%) in JVIR. 703 articles (89%) were published in non-IR journals. IR departments published 125 articles, and 54 (43%) of them were published in non-IR journals. Conclusion: Research in endovascular intervention in PAD continues to be produced by IR, but increasinly, these studies are being published in non-IR journals. Vascular surgery is the most active specialty in terms of endovascular intervention research.

P-305 Ultrasonography-guided retrograde tibial artery access in patients with failed antegrade recanalization of femoropopliteal and crural artery occlusions D. Unal1, S. Deniz1, C. Andic2, E. Hatipoglu1, L. Oguzkurt1; 1Radiology, Baskent University, Adana Teaching and Medical Research Center, Adana, Turkey, 2Radiology, Baskent University School of Medicine, Adana, Turkey Purpose: To evaluate the success for retrograde tibial artery puncture and recanalization after failed antegrade recanalization of chronic femoropopliteal and crural artery occlusions. Material and Methods: Ultrasound-guided retrograde tibial artery access was performed in 37 tibial arteries of 35 patients (86.5% males, 13.5% females; mean age 63.2) with a failed antegrade recanalization. Technical results were evaluated retrospectively. Access was obtained by using a 21-G needle with a 13-MHz ultrasound transducer. Technical success for access (successful guidewire placement into the artery) for traversing the occlusion through retrograde route (successful passage through the occlusion with a guidewire) and for obtaining a patent artery (a residual stenosis less than 30%) after endovascular treatment were reported. Results: Retrograde recanalization was attempted for failed antegrade femoropopliteal artery occlusion recanalization (n=12), crural artery occlusion (n=19), and both (n=6). A guidewire was placed successfully in 36 of 37 tibial arteries (97.3%). A sheath was placed in only two cases. The occlusion could be traversed in 31 of 36 tibial arteries (86.1), and the artery was successfully recanalized in 24 of 36 tibial arteries (66.6%). One artery at the tibial puncture site had temporary thrombosis (2.7%), which resolved with anticoagulation. There were no other complications related to the access site. Hemostasis was achieved with 3–5-minute finger pressure in each case. Conclusion: Ultrasound-guided retrograde tibial artery access is safe and effective. A very high rate of patients with failed antegrade recanalization for femoropopliteal and crural artery chronic occlusions had successful recanalization.

P-306 Ultrasound-accelerated vs. standard catheter-directed thrombolysis in patients with acute and subacute limb ischemia: a single-center retrospective experience in 102 patients M.B. Schernthaner1, S.L. Samuels2, P. Biegler 2, J.F. Benenati2, H. Uthoff 2; 1Radiology, Medical University Vienna, Vienna, Austria, 2Diagnostic Radiology, Vascular & Interventional Radiology, Baptist Cardiac & Vascular Institute, Miami, FL, United States of America Purpose: To compare the safety and efficacy of ultrasound-accelerated thrombolysis (UAT) and standard catheter-directed thrombolysis (CDT) in patients with acute and subacute limb ischemia.

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Material and Methods: Medical records of all patients presenting with acute and subacute limb ischemia and treated with thrombolysis between August 2005 and January 2012 at a tertiary care center were reviewed. Co-primary (ABI increase and degree of lysis) and secondary endpoints (technical success, distal embolization, bleeding complications, and need for additional interventions) were assessed by an independent interventional radiologist. UAT was performed in 75 patients and CDT in 27 patients. Patients’ baseline demographic and clinical parameters as well as procedure details including lytic drug infusion rate, total infusion time, and use of adjunctive procedures did not differ significantly between the groups. Results: Complete lysis was achieved in 72.0% (UAT) and 63.0% (CDT) patients (p=0.542) and hemodynamic success in 91.8 % and 92.3% (p=0.956), respectively. Overall major and minor bleeding complications were observed in 6.9% and 3.9% patients. The calculated combination of minor and major bleeding was significantly lower in UAT versus CDT: 6.7% versus 22.2%, p=0.025. Overall target vessel patency after 0.67 (0.13–1.71) years was 73.5% (UAT: 75.9% versus CDT: 64.3%, p=0.379). Median long-term survival was not significantly different between UAT and CDT: 3.6 (2.42–5.33) versus 1.8 (1.33–4.92) years, p=0.061. Conclusion: Both UAT and CDT proved to be safe and efficient treatment modalities for patients with acute and subacute limb ischemia. The observed lower risk of total bleeding for UAT versus CDT should be examined in a prospective trial.

P-307 Use of a new hybrid nitinol ring stent (TIGRIS) in the popliteal artery A. Parthipun1, P.M. Kitrou2, A. Diamantopoulos3, I. Ahmed3, P. Gkoutzios4, N. Karunanithy1, K.N. Katsanos3; 1Interventional Radiology, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom, 2Department of Interventional Radiology, University Hospital of Patras, Patras, Greece, 3Interventional Radiology, Guy’s and St. Thomas’ Hospitals, London, United Kingdom, 4Department of Radiology, Guy’s and St. Thomas’ Hospital, London, United Kingdom Purpose: To report the interim results of a single-centre prospective study investigating a novel hybrid heparin-bonded nitinol ring stent (TIGRIS; Gore Medical) in the popliteal artery. Material and Methods: Patients with de-novo or restenotic popliteal arterial obstructive disease (Rutherford–Becker class 3–5) were eligible for primary TIGRIS stent placement following balloon predilation, as necessary. Outcome measures included immediate technical and procedural success, vascular restenosis (evaluable by duplex ultrasound on the 50% threshold; PSVR>2.0), freedom from target lesion revascularisation (TLR) and limb salvage. Results: Between August 2012 and February 2014, 46 TIGRIS popliteal stents were implanted in 43 patients (23 males, 75±11 years old). Chronic total occlusions were in 26 of 43 cases (60%). Treated lesion length was 10.7±4.7cm (range, 5–20cm), and stent diameter was 6–7 mm. Technical and procedural success were achieved in all cases at the time of the procedure (46/46), and no in-hospital major adverse events occurred. After a median follow-up period of 6 months (range, 5–13 months), 5 patients died. Overall freedom from TLR was 33/38 (87%). One patient underwent a major amputation, and 2 had a femoropopliteal bypass because of stent re-occlusion. A 6-month duplex was performed in 27 arteries (29 stents). Binary restenosis rate (≥50% on duplex scan as well as the re-occlusions) was 8/30 (73%) at 6 months. Collection of 1-year follow-up data is ongoing. Conclusion: The new hybrid heparin-bonded TIGRIS stent may represent a potentially safe and effective endovascular option for the femoropopliteal artery.

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P-308 A beginner’s guide to vascular stents K. Khanna1, S. Quigley2, O.S. Jaffer 2; 1Interventional Radiology, The Royal London Hospital, London, United Kingdom, 2Radiology, Barts Health NHS Trust, London, United Kingdom Learning Objectives: 1. To provide an overview of current stent materials and their vital chemical properties. 2. To describe key steps in the manufacturing process and their clinical relevance. 3. To define key terminology and physical characteristics of vascular stents. 4. To outline general principles of stent deployment and choice of stent based on specific disease entities and anatomical locations. Background: What is the difference between radial force and radial strength? Why is nitinol used as a stent material? Why and when should I use a self-expanding stent rather than a balloon-expandable stent? The subject of vascular stents can appear both broad and daunting for a new IR fellow. The relevant scientific terminology, material nomenclature and choice of stent are often learned as a ‘process of osmosis’ with large operator variability. Understanding the key principles is vital for safe, evidence-based clinical practice and future development. Clinical Findings/Procedure: This presentation provides the following: A description of stent materials and their key chemical properties. Images of different stent types, demonstrating key manufacturing differences, such as woven stents, laser cut stents and open/closed cell systems. Definitions of key terms and physical characterisics. Guidelines on choice of stent based on disease entity and anatomical location. Conclusion: By the end of the presentation, the viewer should: Understand why certain materials and manufacturing processes have been developed for vascular stents. Understand commonly used terminology and its clinical relevance in relation to stents. Be familiar with the key ‘do’s and don’ts’ of vascular stenting and have a framework for choice of stent based on disease entity and anatomical location.

P-309 Drug-eluting stent placement in the bifurcation and trifurcation of the tibial arteries: how I do it S.G. Prabhudesai1, A. Parthipun2, A. Diamantopoulos1, I. Ahmed1, N. Karunanithy 2, K.N. Katsanos1; 1Interventional Radiology, Guy’s and St. Thomas’ Hospitals, London, United Kingdom, 2Interventional Radiology, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom Learning Objectives: To describe and familiarise interventional radiologists with the following techniques of drug-eluting stent placement for the treatment of complex lesions affecting the bifurcation and trifurcation of the tibial arteries. 1. Culotte technique 2. Kissing-stent technique 3. T-stenting technique 4. Crush stenting technique Background: The management of complex tight stenotic lesions involving the bifurcation of the tibial arteries has always been challenging. Elastic recoil and acute dissection following balloon angioplasty are the commonest problems encoutered.

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Drug-eluting stent placement in the bifurcation of the tibial arteries has been gaining popularity following evidence gathered from the interventional cardiology community. Long-term clinical outcomes based on previous studies have been promising.The various techniques and steps will be illustrated on a case-based presentation. Clinical Findings/Procedure: Culotte technique: the less-angulated branch of the tibial artery is stented. A wire is passed through the strut in the side branch vessel. A second stent is placed behind the proximal part of the previously deployed main stent with simultaneous kissing balloon inflation. Kissing-stent technique: simultaneous advancement of two stents positioned side by side into each tibial bifurcation branch. T-stenting technique: after stent deployment in the tibial side branch, the main branch is stented. The side branch is rewired and post-dilated. Crush-stenting technique: two stents are simultaneously advanced into both tibial bifurcation branches but with nonsimultaneous deployment such that a portion of one stent is crushed inside the proximal segment. The crushed stent is rewired with simultaneous kissing balloon inflation. Conclusion: Coronary techniques for drug-eluting stent placement can be adapted to successfully treat complex ostial lesions located in the bifurcation and trifurcation of the tibial arteries.

P-310 Illustrated complications of peripheral arterial intervention: identification and management R. Das, R. Chung, S. Ameli-Renani, L. Mailli, L. Ratnam, G.J. Munneke, M. Gonsalves, R.A. Morgan; Department of Radiology, St George’s Hospital, London, United Kingdom Learning Objectives: To outline the variety of complications of peripheral arterial intervention and specific management strategies with illustrated examples. Background: Peripheral arterial intervention is safe and widely practiced in interventional radiology. Complications are low in prevalence but require prompt and decisive management. The rapid recognition of arterial complications is of paramount importance, and will be addressed in this educational article. Clinical Findings/Procedure: Complications will be categorised as immediate, early and late in nature. The following aspects are addressed: access site haemorrhage, arterial dissection, in-situ thrombosis, distal embolus and arterial rupture with illustrated clinical examples. Immediate management will be described, including stent-grafting, control of haemorrhage and embolisation and aspiration thrombectomy/embolectomy with a practical management strategy. Early complications include the use of stents in arterial dissection and the management of early acute thrombosis. The use of newer devices such as mechanical thrombectomy catheters is also described. Closure device-specific complications will also be outlined with appropriate management. Late complications will be addressed and include restenosis and occlusion; in addition, the use of cutting balloon angioplasty, drugeluting balloon angioplasty and drug-eluting stenting will be discussed. Stent occlusion and recanalisation will be illustrated with technical tips and strategies. Conclusion: Interventional radiologists and vascular specialists continue to make great progress in the endovascular management of peripheral arterial disease. This educational presentation will comprehensively describe a systematic approach to arterial complications with detailed illustrated description and practical strategies for their management.

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P-311 Infrared thermographic imaging based on the angiosome concept as a screening modality for below-the-knee arterial insufficiency H.J. Shim1, J.S. Shin2, B.K. Kwak1; 1Radiology, Chung-Ang University Hospital, Seoul, Korea, 2Radiology, Inje University Ilsan Paik Hospital, Goyang-si, Gyeonggi-do, Korea Learning Objectives: Infrared thermographic imaging and its quantitative measurement could be a screening modality in patients with below-the-knee arterial insufficiency. Background: Infrared thermographic imaging has been used as a sensitive modality to quantify skin temperature changes in relation with breast cancer detection, pain evaluation, and blood flow and muscular performance assessment. The purpose of this study was to establish appropriate infrared thermographic images of the foot and ankle as per the angiosome concept and evaluate the results of its pilot clinical application as a screening modality. Clinical Findings/Procedure: In all, 24 healthy volunteers were enrolled in this study. Various thermographic images of the foot and ankle using infrared thermography (IRIS-5000, Medicore™) were taken. Six regions of interest (ROI) were placed in territories of three major below-the-knee arteries based on the angiosome concept and correlation with pulse palpation. Stress test was performed using a low-velocity treadmill (AP3126; Apsun Inc.). The quantitative parameters were statistically evaluated between pre- and post-stress test using Wilcoxon signed strength test (PASW Statistics 18.0, IBM Corporation). Temperature ranges of preand post-stress test were 26.06–30.19°C and 26.03–29.72°C. The mean pre- and post-stress test temperatures (with standard deviation) of the volunteers were 27.66 ± 1.30°C and 27.24 ± 1.14°C, respectively. There was significant difference of the mean surface temperature between pre- and post-stress test (P < 0.05). The result of pilot clinical application showed an average increase of 0.7°C in temperature post-PTA. Conclusion: Infrared thermography and its quantitative measurement demonstrate valuable correlation of arterial insufficiency, and could be clinically applied as a screening modality.

P-312 Introduction of J guidewire as a deformable guide for ultrasound-guided antegrade access during lower limb angiographies B. Shaygi, R. Guiness; Interventional Radiology, Royal Devon & Exeter NHS Foundation Trust, Exeter, United Kingdom Learning Objectives: This article demonstrates the use of a J guidewire as a deformable guidewire for re-positioning from the profunda femoris artery (PFA) into the superficial femoral artery (SFA) during the antegrade access for lower limb angiographies. Background: During the US-guided antegrade access for lower limb angiographies, it is not infrequent that the guidewire advances into PFA instead of the intended SFA. We are describing a manoeuvre (video link will be provided) to reposition the guidewire from PFA into the intended SFA. Clinical Findings/Procedure: In the event of the guidewide proceeding into PFA, the guidewire should be withdrawn to the level of the bifurcation of the common femoral artery (CFA), and the J-tip should be partially straightened into the desirable angle by stretching the wire just proximal to the J-tip, thus increasing the density of the externally wrapped coil spring wire at the tip. As the tip is now located along SFA, it can be advanced into SFA with minimal steer. Conclusion: Using the aforementioned manoeuvre, we are able to relocate the guidewire from PFA back into SFA during the US-guided antegrade access in lower limb angiographies.

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Acute lower limb ischaemia in a patient with bilateral persistent sciatic arteries

Transradial cardiac catheterization in a patient with primary Raynaud’s phenomenon – complication and treatment

S. Ilyas1, N. Hilliard2, M. Gohel1, B. Koo2; 1Radiology Department, Addenbrooke’s Hospital NHS Trust, Cambridge, United Kingdom, 2Radiology, Addenbrookes Hospital, Cambridge, United Kingdom

N.C. Figueroa1, R. Baker2, R.T. Gandhi3, B.T. Katzen4; 1Surgery, Mount Sinai Medical Center, Miami, FL, United States of America, 2Interventional Radiology, University of Miami, Miami, FL, United States of America, 3Interventional Radiology, Miami Vascular Specialists, Miami, FL, United States of America, 4Baptist Cardiac & Vascular Institute, Baptist Hospital of Miami, Miami, FL, United States of America

Persistent sciatic artery (PSA) is a rare anatomical variant with an incidence of 0.05%. We present a case of bilateral PSAs with associated aneurysm and acute ischaemia of the right lower limb.

A 72-year-old woman with Raynaud’s phenomenon underwent radial artery cardiac catheterization. She developed progressive hand pain over three months. After conservative therapy failed, diagnostic angiogram revealed ulnar occlusion and a flow-limiting radial artery dissection. Radial angioplasty resolved symptoms.

P-314 Contrast-enhanced ultrasound (CEUS)-guided direct percutaneous thrombin injection for a type II endoleak in an enlarging internal iliac aneurysm M.A. Husainy, P. Sidhu, D. Huang; Department of Radiology, King’s College Hospital, London, United Kingdom

Radiation Safety

An 87-year-old patient presented with an 18-cm, enlarging internal iliac aneurysm, previously treated with a graft across the origin and embolisation of branches. A type II endoleak was successfully targeted for percutaneous thrombin injection under CEUS guidance without angiography or CT.

Analysis of radiation dose in varicocele embolization using a latest-generation C-arm: what is the hereditary risk?

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P-315 Crossing over the abyss – should we do this more often? W. Sprenger De Rover, W. Al-Obaydi, F. Kovacs, G. Pollock, J. Kirk; Radiology, Royal Derby Hospital, Derby, United Kingdom An interesting case of trans-collateral retrograde sub-intimal recanalisation of a moderate length segment tibio-peroneal trunk occlusion via the anterior tibial artery with great results. This technique is rarely performed; in our case, it was the only option, with a great outcome.

P-316 Endovascular management of accidentally separated balloonexpandable stent from its balloon catheter at the aortic bifurcation P. Celtikci, O. Ergun, H.A. Durmaz, E. Birgi, B. Hekimoglu; Radiology, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey A balloon-expandable stent accidentally separated from its balloon catheter at the aortic bifurcation during left iliac artery stenting from the right side. Unopened stent was caught, pulled to the proper position with a snare, and opened with another balloon catheter from the left side.

P-317 Jetstream atherectomy for the treatment of heavily calcified SFA occlusions using a “no guidewire” technique T. Balázs, R. Bažík, I.P. Vulev; Clinic of Diagnostic and Interventional Radiology, National Institute of Cardiovascular Diseases, Bratislava, Slovak Republic

A. Gioppo1, F. Melchiorre2, R. Azzeroni1, G. Cornalba2; 1Department of Diagnostic and Interventional Radiology, University of Milan, San Paolo Hospital, Milan, Italy, 2Diagnostic and Interventional Radiology, San Paolo Hospital, Milan, Italy Purpose: Varicocele embolization is performed in young men in good health with normal life expectancy. The aim of this study is to evaluate the gonad radiation dose and estimate hereditary risk and lifetime fatal cancer risk. Material and Methods: From September 2012 to date, 20 patients underwent percutaneous embolization of the spermatic vein, using a “low-dose” protocol. A double transmission chamber was used to measure the entrance surface dose and the dose area product. Three thermoluminescent dosimeters (TLD) were placed adjacent to the scrotum to directly measure the gonad dose. A PC-based Monte Carlo program was used to estimate the effective dose from recorded DAP. Results: The mean fluoroscopy time was 3 min 12 s with a mean DAP of 4.21 Gy·cm2. Effective gonad dose, directly measured with TLD, was 1.64 mSv. The mean hereditary risk was 1.6 x 10 -5, obtained by combining the gonad doses with the risk factor of 2.6 x 10 -2 Gy-2 for reproductive population. The mean total fatal cancer risk was 2.8 x 10 -4, estimated by multiplying each organ dose with the respective risk factor. Conclusion: The gonad dose was definitely below the lower threshold corresponding to deterministic effect of temporary sterility (1.64 mSv vs. 150 mSv). Hereditary effects were very low (order of 10 -5). The total fatal cancer risk resulted as a “minor risk descriptor”, and only in a “moderate benefit” required to justify the procedure, according to the National Council on Radiation Protection & Measurements guidelines. In our experience, adequate field-limiting measures, including never using radiography and using limited fluoroscopy, are the most significant to optimise exposure.

We report the case of two patients with heavily calcified SFA occlusions and critical limb ischemia. After an unsuccessful attempt at conventional endovascular revascularization, the patients were successfully treated with the Jetstream atherectomy device using a “no guidewire” technique.

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P-320 Interventional neuroradiology procedures – diagnostic reference levels and occupational exposure: a Portuguese department analysis G. Paulo, I. Cardoso, S. Pereira, J. Santos; Radiology, Coimbra Health School- ESTESC, Coimbra, Portugal Purpose: Establishment of local diagnostic reference levels (DRLs) in neuroradiology interventional procedures and evaluation of the occupational exposure using real-time active dosimeters in a Portuguese excellence department. Material and Methods: This study was conducted in two phases: a retrospective dose data collection of the most frequent neuroradiology procedures (related to 2013) was obtained from the Picture Archiving and Communication System (PACS) in order to establish local DRLs, based on the 75th percentile of the dose descriptors and a prospective data collection of staff exposure during 41 procedures using Raysafe i2 real-time dosimeters. Results: The most frequently performed procedures were cerebral embolization (20%), cerebral angiography (19%), interventional spine procedures (16%), and ozone therapy and vertebroplasty (12%). The obtained local DRLs were 135 Gy.m2, 62 Gy.cm2, 37 Gy.cm2, and 34 Gy.m2 and 78 Gy.cm2, respectively. During the 41 procedures, the neuroradiologist was exposed to an average of 49 μSv and the nurse to 8 μSv. The anesthetists were the professionals the least exposed because they were outside the room most of the times. Conclusion: This study in interventional neuroradiology procedures was the first one made in Portugal. The obtained local DRLs are in line with the ones published in literature. Despite the fact that the values of occupational exposure are similar to the ones found in literature, the professionals became more aware of the necessity of individual radiation protection because of the influence of the use of real-time active dosimeters.

P-321 Radiation dose considerations and the methods of dose reduction in prostate artery embolisation for benign prostatic hypertrophy: experience from the first UK trial D. Flowers1, J. Coyne1, T.J. Bryant2, L.M. Ingram3, J. Dyer4, M. Harris4, B. Somani4, N. Hacking5; 1Interventional Radiology, University Hospital Southampton, Southampton, United Kingdom, 2Radiology, Southampton General Hospital, Southampton, United Kingdom, 3Radiology, University Hospital Southampton, Southampton, United Kingdom, 4Urology, University Hospital Southampton, Southampton, United Kingdom, 5Department of Clinical Radiology, University Hospitals Southampton, Southampton, United Kingdom Purpose: To assess the intra-procedural radiation dose involved in the performance of PAE for BPH, and to determine methods to minimise this. Material and Methods: Information on intra-procedural radiation dose was prospectively collected. The procedures were then assessed to determine best methods to ensure that radiation dose is kept to a minimum. Results: Forty-two procedures were performed. The dose area product average dose was 27576.74 cGycm2. The indicated skin dose average was 1956.57 mGy. Screening time (minutes:seconds) average was 33:14. Cone beam CT was used in 24 cases with an average acquisition dose of 4250 cGycm2. Four patients received locally notifiable doses of >3000 mGy. Conclusion: Little has been published on radiation dose in PAE. Dose is acceptable, but due to procedure complexity has the potential for high radiation doses. Methods for dose reduction include

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pre-procedural CT angiogram planning, low-dose fluoroscopic protocols and optimal use of projections that best demonstrate the prostatic arteries.

Renal and visceral artery intervention P-322 DENER-HTN trial: a prospective randomized control trial of the efficacy of renal artery denervation in resistant hypertension M.R. Sapoval1, M. Monge2, H. Pereira3, The DenerHTN investigators4, M. Azizi2; 1Interventional Radiology Department, Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Paris, France, 2Clinical Investigation Center, Hôpital Européen Georges Pompidou, Paris, France, 3Unité de Recherche Clinique, HEGP, Paris, France, 4Radiology, HEGP, Paris, France Purpose: The DENER-HTN trial is a multicenter, prospective, open, randomized, controlled study with blind end-point evaluation of the efficacy, safety, and cost-effectiveness of renal denervation (RDN) using the Symplicity Catheter System in addition to standardized optimal medical treatment (RDN group) compared with standardized optimal medical treatment alone (control group) in patients with resistant hypertension (RH). The primary outcome is change in SBP assessed by ABPM at 6 months. Cost-effectiveness evaluation is performed at 1 year. We will report the 6-month results. Material and Methods: Patients were included when they had essential RH to ≥3 antihypertensive drugs, including a diuretic (office BP ≥ 140 and/or 90 mmHg), and were receiving a 4-week standardized triple therapy. Main exclusion criteria were non-suitable renal artery anatomy, secondary hypertension, and estimated glomerular filtration rate (eGFR) < 40 ml/min. After 4 weeks of the standardized triple therapy regimen, patients with a mean baseline daytime ambulatory SBP/DBP (dASBP/dADBP) ≥ 135 mmHg or 85 mmHg were randomized to the RDN or control group. In each group, antihypertensive treatment was reinforced by sequentially adding a new antihypertensive drug. Results: From 06/01/2012 to 10/15/2013, 106 were randomized at visit 1 after 4-week standardized triple therapy regimen. The clinical and biological characteristics of the two groups did not significantly differ at baseline. The 6-month results will be presented. Conclusion: The patients included in the DENER-HTN trial had confirmed essential RH. This superiority trial aimed at showing a 10-mmHg difference in dASBP with a 17-mmHg SD, an alpha risk of 5%, and a beta risk of 20%.

P-323 Endovascular treatment of renal artery aneurysms: a single-center experience based on 44 aneurysms R. Maciag, M. Wojtaszek, K. Korzeniowski, M. Januszewicz, O. Rowinski; 2nd Department of Clinical Radiology, Medical University of Warsaw, Warsaw, Poland Purpose: Renal artery aneurysms (RAAs) may be more common than previously thought, with a prevalence of 0.1% of the general population and a female predilection (male:female = 1:1.75). Rupture rates are low but with mortalities up to 80%. The aim of this study was to evaluate the technical feasibility and long-term efficacy of endovascular treatment of RAAs. Material and Methods: Between 2009 and 2012, 40 patients underwent endovascular treatment of 44 RAAs. Thirteen patients underwent a single-stage procedure, whereas the remaining underwent

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several stages (mean, 2.7 procedures). Mean treated RAA diameter was 2.3 mm (range, 1.6–3.3 mm). Stent-assisted coiling was used for 28 aneurysms, and simple coiling was used for 10 aneurysms. Five aneurysms were excluded because of covered stents. In 1 patient, an embolization polymer was used in adjunct to stent-assisted coiling. The follow-up protocol consisted of Doppler ultrasound and conventional angiography. Results: Technical success was achieved in 43 RAAs. Intraprocedural complications occurred in 12 patients (i.e., acute main renal artery thrombosis or dissection, stent migration into the aneurysm sac, loss of coils in side branches, and thrombosis of peripheral renal artery branches). Perirenal hematomas were observed in 5 patients. Mean follow-up duration was 34 months. On follow-up, 2 patients had acute renal artery thrombosis. No aneurysm ruptures occured. Conclusion: RAA embolization is a technically challenging therapeutic option with a high risk of procedural complications. Keeping this in mind, this minimally invasive treatment can become a valid treatment option and an alternative to surgery in experienced centers with a high patient load.

P-324 Isolated spontaneous celiac trunk dissection: diagnosis and management R.N. Cavalcante, B. De Fina, F.B. Travassos, B.B. Affonso, F.L. Galastri, J.M. Motta-Leal-Filho, N. Wolosker, J.E. de Amorim, F. Nasser; Radiologia Vascular Intervencionista, Hospital Israelita Albert Einstein, São Paulo, Brazil Purpose: The purpose of this study is to evaluate clinical presentation, diagnosis, treatment, and outcomes of nine cases of isolated spontaneous celiac trunk dissection (ISCTD) treated at our institution. Material and Methods: A retrospective search was performed from 2009 to 2012, and nine patients with ISCTD without aortic and/or other visceral artery dissection were included in the study. The following information was collected from each case: sex, age, associated risk factor, symptoms, diagnostic method, anatomic dissection pattern, treatment modality, and outcome. Results: All patients were male (average age 44.8 years) and symptomatic. Diagnosis was made with computed tomography identifying an intimal flap. Dissection was limited to the celiac trunk in two patients, extended to celiac branches in six, and was limited do the hepatic artery in one. Initial conservative treatment was successful in eight patients. In two of them, there was late progression of the dissection to aneurysmal dilatation and endovascular treatment was performed. In one case, initial conservative treatment was unsuccessful and coil embolization of the dissection was performed. Mean follow-up was 21 months. Conclusion: Conservative treatment was adequate for most patients with ISCTD. Due to the risk of complications, such as aneurysm dilatation, long-term follow-up is mandatory.

P-325 One-year and preliminary 18-month efficacy and safety results from the REDUCE-HTN trial E. Wyffels1, U. Hoppe2, I. Ott3, J. Diaz-Cartelle4, M. Mazor4; 1Cardiology, Onze Lieve Vrouw Hospital, Aalst, Belgium, 2Department of Internal Medicine, Paracelsus Medical University, Salzburg, Austria, 3Cardiovascular Diseases, German Heart Center, Munich, Germany, 4Peripheral Interventions, Boston Scientific Corporation, Natick, MA, United States of America

Abstract Book Material and Methods: Patients were required to have office-based systolic blood pressure (BP) ≥160 mmHg despite compliance with ≥3 antihypertensive medications at maximally tolerated doses. Longterm follow-up includes office-based BP measurements at 1 year and 18 months, and 24-hour ambulatory BP monitoring at 1 year. Safety, including renal function (estimated glomerular filtration rate [eGFR]), continues to be monitored throughout the follow-up period. Results: Mean baseline office BP was 182.4±18.4/100.2±14.0 mmHg among enrolled patients (n=146; age 58.6±10.5 years, 61% men, 28.1% with type 2 diabetes). Among 67 patients with 12-month data, mean office BP was reduced to 157.3±26.8/86.6±17.7 mmHg; a mean reduction of 27.8±22.2 /11.6±12.9 mmHg (P<0.0001). Officebased BP reductions at 1 year were also significant within subgroups of patients with diabetes, those with treated accessory renal arteries, and for both sexes (P<0.05). Mean baseline ambulatory BP was 153.0±15.1/87.5±13.2 mmHg (n=103); at 12 months the mean reduction was 10.1±15.3/6.2±8.3 mmHg (n=32; P<0.001). Mean eGFR decreased 6.0±19.8 mL/min/1.73 m2 at 12 months. One-year results for the full cohort of enrolled patients and 18-month partial-cohort results are expected to be available at the time of presentation. Conclusion: Long-term results from the REDUCE-HTN trial demonstrate that the Vessix System is a safe and efficacious method for treating resistant hypertension, with significant blood pressure reductions sustained for 1 year.

P-326 Percutaneous embolization of iatrogenic renal vascular injuries A.M. Ierardi1, E. Duka1, M. Petrillo2, C. Floridi1, F. Piacentino1, E. Kehagias3, D.K. Tsetis4, G. Carrafiello1; 1Radiology, Uninsubria, Ospedale di Circolo, Varese, Italy, 2Radiology, Second University of Naples, Naples, Italy, 3Department of Radiology, Heraklion University Hospital, Iraklion, Greece, 4Unit of Angiography and Interventional Radiology, University Hospital Heraklion, Iraklion, Greece Purpose: The aim of our study was to report our experience and the long-term follow-up in the treatment of iatrogenic renal vascular injuries using transcatheter embolization (RAE). Material and Methods: Twenty-one patients underwent RAE for iatrogenic arterial kidney bleeding. Seven patients presented with haemodynamic instability requiring blood transfusion (33.3 %), the remaining were haemodynamically stable (66.7 %). Diagnostic renal angiography revealed 9 actively bleeding vessels, 6 pseudoaneurysms, 4 arteriovenous fistulas and 1 arteriocalyceal fistula. In one patient, selective renal arteriography was negative probably because the bleeding observed at CT-angiography was self-limited. Twenty-one embolization procedures were performed in 20 patients; one patient required a second embolization 3 hours after the first one. Results: Technical success rate was 100%. The overall clinical success rate was 95%. Apart from a patient who died due to disseminated intravascular coagulation, no major complications requiring intensive care treatment were encountered during or after the procedures. No patient required emergency surgery or subsequent surgical treatment. No statistically significant differences in eGFR or renal function stage appeared after RAE. Conclusion: Percutaneous treatment can be proposed as a first-line treatment in iatrogenic renal arterial injuries. Further studies with greater numbers of patients are necessary to validate this method.

Purpose: The REDUCE-HTN clinical study – a prospective, multicenter, single-arm study – is being conducted to evaluate the performance of the Vessix Renal Denervation System (Boston Scientific, Natick, MA) in treating medication-resistant hypertension.

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P-327 Renal angiomyolipoma: a systematic review of transarterial embolisation T.É. Murray, M.J. Lee; Radiology, Beaumont Hospital, Dublin, Ireland Purpose: We performed a systematic review to assess the efficacy of transarterial embolisation (TAE) in angiomyolipoma (AML) using the MOOSE Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies. Material and Methods: A MEDLINE search identified 1793 studies, of which 1762 were excluded. Exclusion criteria included non-English language publications, lack of electronic edition, case reports, nephron-sparing surgery, nephrectomy, chemotherapy or histopathology and abstracts with unpublished full text. Thirty-one English language studies investigating the efficacy of TAE were identified. Results: In all, 883 patients (F:M, 3.5:1; mean age, 47 years) with AML were included. Mean size of AML at presentation was 5.17 cm; 21.9% of patients presented with haemorrhage or rupture with a mean size of 11 cm (range, 8.6–20.3 cm). Furthermore, 36% of patients had tuberous sclerosis (TS), presenting at a younger age (mean, 27 years) and with larger tumors (mean, 7.57 cm vs 4.89 cm in sporadic AML). TAE was performed in 645 cases: in 42%, ethanol mono-therapy was employed; 5%, foam or microparticle therapy; 6%, coil mono-therapy and 47%, combined agents. Mean technical success was 93% with no mortality and morbidity of 43% (of which 83% was self-limiting post-embolisation syndrome). Mean size reduction was 38%; 18% required retreatment during the follow-up period (mean, 37 months). Conclusion: TAE of renal AML has a high technical success but with significant morbidity and a retreatment rate of 18%. The accepted threshold size for the intervention of 4 cm is questionable given the mean size of AML with rupture of 11 cm and lowest mean size of 8 cm.

P-328 Safety and efficacy of sympathetic renal artery denervation using a multi-electrode renal artery denervation catheter in patients with drug-resistant hypertension: results of two firstin-human, multicenter studies C. Tsioufis1, S.G. Worthley 2; 1First Cardiology Clinic, University of Athens, Hippokration Hospital, Athens, Greece, 2Cardiovascular Res Ctr, Royal Adelaide Hosp and Dept of Med, Univ of Adelaide, Adelaide, Australia Purpose: Percutaneous sympathetic renal artery denervation is emerging as an approach for the treatment of patients with drugresistant hypertension who do not respond adequately to optimal medical therapy. We investigated the safety and efficacy of a multi-electrode catheter ablation system (EnligHTN) developed by St. Jude Medical, designed to create a pre-determined stereotactic lesion pattern in two separate first-in-human studies. Material and Methods: The EnligHTN renal denervation system has 4 electrodes attached on a basket mounted at the tip of the catheter, activated to achieve the desired lesion pattern. The EnligHTN-I (Gen 1 system; n=46) and EnligHTN-III (Gen 2 system; n=39) first-inhuman studies were designed to assess the safety and efficacy of this multi-electrode ablation system in patients with drug-resistant hypertension using sequential and simultaneous electrode activation, respectively. Results: Similar inclusion criteria resulted in similarly enrolled patients between the studies; baseline average office and 24-hour ambulatory blood pressures in EnligHTN-I (EnligHTN-III) were 176/96 (174/93) mmHg and 150/83 (155/82) mmHg. Average office

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BP reductions at 24 months for EnligHTN-I (6 months for EnligHTNIII) were −29/13 (−25/7). Average 24-hour ambulatory blood pressure reductions at 24 months for EnligHTN-I (6 months for EnligHTN-III) were −13/7 (−8/2) mmHg. Only the EnligHTN-III 6-month ambulatory diastolic reduction from baseline was not statistically significant. Conclusion: The collective data of these 2 trials demonstrate that the EnligHTN ablation system is safe and effective in the treatment of patients with drug-resistant hypertension with reproducible results in office and ambulatory blood pressure reductions. Complete 24-month results for EnligHTN-I and 6-month results for EnligHTN-III will be presented at the time of the congress.

P-329 Novel method for performing percutaneous transluminal renal angioplasty (PTRA) under non-contrast MRA guidance overlaid on fluoroscopy image Y. Morita1, T. Fukuda1, E. Tateishi1, K. Ozaki1, Y. Sanda1, S. Kanzaki1, M. Higashi1, N. Yamada1, H. Naito1, Y. Iwashima2,, S. Nakamura2, Y. Kawano2; 1Department of Radiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan, 2Division of Hypertension and Nephrology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan Purpose: We implemented a new method for performing percutaneous transluminal renal angioplasty (PTRA) under non-contrast MRA guidance, which was overlaid on intra-procedural fluoroscopy image. Material and Methods: Twelve patients scheduled for PTRA were included. Non-contrast MRA was obtained using respiratory-gated 3D-SSFP proprietary sequence on 3T clinical machine. The preacquired non-contrast MRA image was registered on fluoroscopic image to mark the lumbar vertebrae as landmarks, and the overlaid vasculature on the live fluoroscopic image was used as a roadmap for navigation during PTRA procedures. Results: Using non-contrast MRA, it was possible to clearly visualize the origin and course of renal arteries and detect significant stenosis in all patients. According to the initial aortography, the origin of the renal artery was registered with complete accuracy in 8 patients and the renal artery deviated less than 5 mm in 4 patients. Arteriography using diluted contrast material was performed only twice for initial aortography and final evaluation. Additional contrast injection during catheterization, guidewire manipulation, positioning of balloon catheter, and so on could be omitted using a roadmap. In all cases, PTRA was successful without complications and completed with the volume of contrast media limited to only 12.5 ± 5.0 ml. None of the patients developed contrast-induced nephropathy. Conclusion: The overlay system using non-contrast MRA enabled the completion of PTRA safely with fewer angiographic procedures, thus requiring less amount of iodinated contrast material. This novel technique allows for effectively performing PTRA in patients with chronic kidney disease in whom the use of contrast material needs to be limited.

P-330 Transradial access for сomplex interventions below the diaphragm  S. Kondrashin, V. Koblikov; Interventional Radiology and Angiography, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation Purpose: To evaluate the advantages of transradial catheterisation in the interventional treatment of the liver, pancreas, kidneys and bladder.

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Material and Methods: From 2010, 58 patients (30 males, 28 females; 48–95 years) were operated for tumors of the liver (7), pancreatic head (6) and kidney (10); renal artery stenosis (23); acute haemorrhage from upper gastrointestinal tract (7); kidney (3); bladder (2) and SMA thrombosis (1). For selective chemoembolisation of the liver and pancreas, we used 5-/6-F introducer and 100cm JR4 catheter from the right (7) and left sides (6). For superselective embolisation in 5 cases, we used 3-F 130-cm microcatheter. For renal stenting, we used 0.014-inch wires in patients <175 cm in height from the left (9 cases) and right sides (10) with 6-F introducer and standard 6-F 100-cm JR4 guide. In 4 cases, we used 125cm multipurpose guide catheter; in 5, repeat procedures from opposite approach were required. For embolisation of gastrointestinal haemorrhage, one artery was used twice after 20-h interval. Thirtysix patients (62.1%) required interventions in kidneys. Results: Transradial procedures were successful in 54 cases without complications; in 4 (6.9%), conversion to transfemoral approach was required. In one case, we simultaneously performed embolisation of the left kidney for tumor and stenting of the right renal artery. For renal artery stenting, we used 15 5.5–6.0-mm diameter and 14–18-mm long stents and 9 7.0-mm diameter and 15–19-mm long stents. Procedure time was 25–60 min; radiation exposure time was 3–10 min. Conclusion: Transradial intervention below the diaphragm is technically feasible and safe, significantly improves patient comfort and reduces access site complications.

P-331 Visceral artery aneurysms: management, treatment, and outcome in a tertiary care centre over one decade M.B. Pitton, R. Kloeckner, S. Schotten, E. Dappa, C. Düber; Diagnostic and Interventional Radiology, University of Mainz, Mainz, Germany WITHDRAWN

P-332 Acute adrenal haemorrhage – silent killer or massive murderer? W. Sprenger De Rover, F. Kovacs, J. Kirk, P. Thurley, M. De Nunzio, P.M. Bungay; Radiology, Royal Derby Hospital, Derby, United Kingdom Learning Objectives: Unusual presentations of acute adrenal haemorrhage and differential diagnosis of large retroperitoneal bleeds. We aim to revise the related pathology, expand on technique and our experience as well as provide a pictorial review of the related cases which differ in both anatomy and procedural steps. Tiny branch vessels from the aorta can repeatedly be successfully catheterised and save a life. Background: Unlike the classic presentations, these cases presented with massive retroperitoneal bleeds, which were life threatening not because of the hypoadrenergic effects but rather because of significant blood loss requiring transfusion during resuscitation. Clinical Findings/Procedure: We describe a case series and provide a pictorial review of young patients in different clinical settings presenting with life-threatening adrenal haemorrhages. These were treated successfully by transcatheter embolisation without any related procedural complications. Successful super selective angiographic catheterisation of the related adrenal arteries was performed using a non-adhesive liquid polymer embolic agent (Onyx), occluding both the anterograde and retrograde feeding vessels successfully. No significant related peri-operative vasogenic instability was experienced in any of the cases.

Abstract Book Conclusion: Adrenal haemorrhage should be a part of the differential diagnosis of large retroperitoneal bleeds. Armed with the correct skill set and knowledge, we can save a life and avoid open surgery, with related morbidity and complications, without significant delay.

P-333 Percutaneous CT-guided cryoablation (CRYO) of 112 renal tumours in 102 patients: pearls and pitfalls J. Zhong, S. Burbridge, J. Smith, T.M. Wah; Clinical and Interventional Radiology, St. James’s Institute of Oncology, St. James’s University Hospital, Leeds, United Kingdom Learning Objectives: 1. Pearls and pitfalls of CT-guided CRYO techniques 2. Intra-procedural monitoring of CRYO 3. Post-procedure imaging findings 4. CRYO complications Background: This pictorial illustration aims to present our experience in the CT-guided CRYO and imaging follow-up of 112 renal tumours in 102 patients post CRYO at a tertiary university institution from 2008 to 2013. Clinical Findings/Procedure: We present a pictorial review of CT-guided renal CRYO over a 5-year period. The contents include description of current CT-guided techniques used at our institution to guide renal CRYO treatment, intra-procedural monitoring of the treatment effect and the imaging follow-up to assess renal tumours following CRYO. This review aims to highlight the pearls and pitfalls during treatment, e.g. use of warm pyeloperfusion, hydrodissection and pneumodissection techniques, and intra-procedural monitoring of the treatment effect, e.g. unexpected findings associated with pneumodissection technique; to illustrate the normal expected findings and sequential imaging interval changes longitudinally on both CT and MRI and to describe the classic imaging signs associated with the interval change; to present our renal CRYO complications such as ureteral stricture and superficial ‘frost-bite injury’, early residual disease and local early recurrent disease and to demonstrate the use of contrast-enhanced ultrasound in problem-solving cases when CT/ MRI follow-up is contraindicated. Conclusion: It is important to appreciate the potential pearls and pitfalls during CT-guided CRYO and to recognise various salient features post renal CRYO on imaging. Early recognition of residual/ recurrent disease as well as complications would allow timely clinical management.

P-334 Splenic artery aneurysm: what the interventional radiologist needs to know about various endovascular techniques P. Rigamonti1, U.G. Rossi1, P. Torcia2, A. Cotroneo3, C. Ferro4, F. Melchiorre5, G. Cornalba6, M. Cariati1; 1Radiology and Interventional Radiology, San Carlo Borromeo Hospital, Milan, Italy, 2Radiology and Interventional Radiology, San Giovanni Addolorata Hospital, Rome, Italy, 3Radiology and Interventional Radiology, SS Annunziata Hospital, Chieti, Italy, 4Radiology, IRCCS San Martino, University Hospital, Genoa, Italy, 5Interventional Radiology, AO San Paolo, Milan, Italy, 6Diagnostic and Interventional Radiology, S. Paolo Hospital, Milan, Italy Learning Objectives: To describe the indications and possible endovascular therapies for splenic artery aneurysm exclusion. Background: Splenic artery aneurysm is now being diagnosed with increasing frequency for the routine use of computed tomography, magnetic resonance imaging, and ultrasound. Diagnostic radiology plays a major role in the detection and characterization of splenic artery aneurysms. Advantages in endovascular therapies have allowed interventional radiologists to contribute to the

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management of splenic artery aneurysms. Endovascular procedures have the goal of preventing aneurysm expansion and rupture. This goal is accomplished by excluding the aneurysm from the arterial circulation and pressure. Clinical Findings/Procedure: The purpose of this poster is to illustrate (1) imaging evaluation of splenic artery aneurysm, (2) the possible endovascular therapies [embolization (packing and isolation) and covered stent placement], and (3) advantages and limitations of these three endovascular techniques. Conclusion: Clinical history and imaging characteristics of the splenic artery aneurysm dictates its treatment. Therefore, the treatment should be individualized for the most rapid and efficient endovascular procedure for the patient’s anatomy.

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Catastrophic renal artery aneurysm rupture in a pregnant woman

Retrieval of unraveled detachable coil system using myocardial biopsy forceps

S. Quigley, K. Khanna, I. Renfrew; Radiology, Barts Health NHS Trust, London, United Kingdom

M. Okada1, M. Yasui2, S. Katayama2, N. Matsunaga1; 1Radiology, Yamaguchi University Graduate School of Medicine, Ube, Japan, 2Radiology, Yokuyama Central Hospital, Tokuyama, Japan

We describe a pregnancy-related visceral aneurysm rupture that resulted in haemodynamic shock and foetal loss, its endovascular treatment and the complex management decisions related to the contralateral unruptured aneurysm. We review the aetiology and management of spontaneous visceral aneurysms in pregnancy.

P-336 Delayed presentation of a renal transplant artery pseudoaneurysm: management with transcatheter embolisation using thrombin S. Ameli-Renani1, R. Das1, A. Bagul2, G.J. Munneke1, U. Patel1; 1Radiology, St Georges Hospital NHS Trust, London, United Kingdom, 2Renal Transplant Unit, St Georges Hospital NHS Trust, London, United Kingdom At 4-month follow-up, US of a 47-year-old renal transplant recipient revealed a 3.7-cm transplant artery pseudoaneurysm. Following selective microcatheterisation of pseudoaneurysm sac, flow within it ceased on both angiography and transabdominal US, indicating pseudoaneurysm neck occlusion. Transcatheter embolisation using thrombin was successfully performed.

P-337 Percutaneous CT-guided ethanol sympathicolysis for the treatment of resistant arterial hypertension F. Streitparth1, B. Gebauer1, P. Freyhardt1, P. Nickel2, R.W. Günther 2; 1Department of Radiology, CVK, Charité Universitätsmedizin, Berlin, Germany, 2Department of Nephrology, CVK, Charité Universitätsmedizin, Berlin, Germany We report the case of a 50-year-old man with refractory hypertension and end-stage renal failure who was treated with CT-guided percutaneous periarterial ethanol sympathicolysis. The procedure was painless. The office blood pressure dropped significantly after 1 month.

Percutaneous thrombin embolization of a pancreaticoduodenal artery pseudoaneurysm after failure of endovascular treatment G. Barbiero, M. Battistel, A. Susac, D. Miotto; Department of Medicine, Institute of Radiology, Padua, Italy We present a case of pseudoaneurysm of the pancreatico-duodenal artery in a patient with occlusive lesion of the celiac axis successfully treated with single transabdominal ultrasound-guided injection of thrombin after failed attempts at percutaneous catheterization of the feeding vessel.

Coil unraveled during left renal aneurysmal embolization with balloon-assisted technique. The unraveled coil was cut at the left renal arterial orifice in the abdominal aorta using myocardial biopsy forceps and was safely retrieved.

P-340 Successful management with transcatheter arterial particle embolization in a case of infantile hepatic hemangioendothelioma with consumptive coagulopathy A. Uçar, E. Agolli, A. Sulovari; Interventional Radiology Department, Istanbul University Faculty of Medicine Hospital, Istanbul, Turkey A 7-month-old infant presented with bluish discoloration of the skin of the extremities. Blood test revealed decreased platelet count. We decided to embolize immediately the two hemangioendothelioma lesions in the liver.

P-341 Transcatheter renal arterial embolization for symptomatic autosomal dominant polycystic kidney disease (ADPKD) Y. Ishimaru1, N. Kawaguchi1, H. Miki1, H. Tanaka2, T. Mochizuki2; 1Radiology, Ehime Prefectural Central Hospital, Matsuyama, Ehime, Japan, 2Radiology, Ehime University Graduate School of Medicine, Ehime, Japan Some patients with ADPKD on hemodialysis have serious symptoms due to progressive renal enlargement. We assess the efficacy of transcatheter renal arterial embolization in symptomatic ADPKD with absolute ethanol, NBCA, gelatin sponge, and coils to reduce renal volume.

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Uretero-iliac fistula: a challenge

Analysis of clinical outcome, prognostic factors and associated costs of transjugular intrahepatic portosystemic shunt for the treatment of portal hypertension in liver cirrhosis: comparison between a stent and a stent-graft device

R. Candelari1, M. Rosati2, A. Felicioli2, C. Mincarelli1, P. Boscarato1, M. Fichetti1, E. Paci1; 1SOD Radiologia Interventistica, Az Osp-Univ OORR Torrette, Ancona, Ancona, Italy, 2Scienze Radiologiche, Università Politecnica delle Marche, Ancona, Italy We report a case of an underestimated ureteroarterial fistula between the right ureter and right external iliac artery pseudoaneurysm in a patient presenting with intermittent massive hematuria and underwent nephrectomy; he was then treated successfully with percutaneous endovascular stent graft placement.

TIPS and portal vein intervention P-343 Accuracy of indirect portosystemic gradient measurement as a surrogate to direct measurement S. Tulin-Silver, H.W. Charles, S. Sigal; Radiology, NYU Langone Medical Center, New York, NY, United States of America Purpose: PSG is used not only as a quantitative measurement of the grade of cirrhosis but also as an endpoint and prognostic indicator of technical success and clinical outcome in patients undergoing primary and secondary transjugular intrahepatic portosystemic shunt (TIPS) procedures. We tested the accuracy of indirect measurement of PSG compared with the direct measurement, as a surrogate for the latter. Material and Methods: In 50 patients undergoing primary TIPS creation, wedge (WHVP) and free hepatic (FHVP) vein pressures and portal (PVP) and right atrial (RAP) pressures were measured prior to and immediately following portosystemic stent placement. Results: The pre-TIPS indirectly (iPSG) measured portosystemic gradient (WHVP – FHVP) was compared with the post-TIPS directly measured portosystemic (dPSG) gradient (PVP – RAP). The pre-procedure MELD (model for end-stage liver disease) score was also calculated for all patients, and correlation was sought between the score and PVP and PSG. Conclusion: While there was correlation between WHVP and PVP, there was no significant correlation between iPSG and dPSG. Analysis showed that the MELD score did not affect how well the two sets of measurements (indirect vs. direct) correlated with one another. This could potentially be interpreted as the accuracy of the surrogate (indirect) method. Formulations for the predicted PVP [20.22 + (0.3209) WHVP] and predicted PSG [12.62 + (0.2183) HVG] from WHVP and HVG, respectively, were derivable from the data on scatter plots of reference between the surrogate WHVP and PVP and between HVG and PSG.

T. Rodt1, J. Lauermann1, D.B. Hasdemir1, A. Potthoff 2, S. Marquardt3, C. von Falck1, H.-P. Reiffen4, H. Rosenthal1, F. Wacker1, B. Meyer1; 1Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany, 2Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany, 3Institute for Diagnostic and Interventional Radiologiy, Medizinische Hochschule Hannover, Hannover, Germany, 4Anesthesiology, Hannover Medical School, Hannover, Germany Purpose: To analyse the prognostic factors for the clinical outcome of transjugular intrahepatic portosystemic shunt (TIPS) in portal hypertension due to liver cirrhosis and compare a stent and a stentgraft device with regard to clinical outcome and associated costs. Material and Methods: TIPS interventions of 5 consecutive years in 170 patients with portal hypertension due to liver cirrhosis were reviewed. In all, 47.1% (group1) received a stent (WALLSTENT; Boston Scientific) and 48.8% (group2) received a stent-graft (GORE VIATORR). Technical data, peri-procedural imaging, follow-up ultrasound and clinical data were analysed for prognostic factors of clinical outcome, intergroup differences and associated costs. Results: Technical success was 95.9%. Mean portosystemic gradient decrease following TIPS was 6.9 cmH2O. Long-term primary patency (2 years) was 83.3% (group1) and 93.1% (group2). No significant intergroup mortality difference was found. Kaplan–Meier analysis yielded a probability for 1-year survival of 87.5% (group1) and 90.4% (group2) with costs for TIPS placement and all re-interventions of €8709 (€1449 material) and €9346 (€3932 material), respectively. Liver capsule perforation (5.9%) was associated with significant increase in ICU treatment (MV 5.1 days/2.1 days) and significantly higher mortality (1-year survival 44.4%/91.6%, p=0.001). Child score correlated with 1-year survival (A 100%, B 90% and C 78.9%). Hepatic encephalopathy occurred in 16.6% (group1 13.8%, group2 19.3%), necessitating TIPS reduction in 4.9% and occlusion in 1.8%. Conclusion: Stent and stent-graft enabled successful TIPS placement with good clinical results. Child score and capsule perforation are prognostic parameters for 1-year survival. Primary patency rates are in favour of the stent-graft, whereas the stent was more costeffective to establish comparable clinical results.

P-345 Effect of transjugular intrahepatic portosystemic shunt on renal function B.K. Erly1, M.J. Sands2, W. Carey3, C. Shah2, J. Bullen4, B. Kapoor2; 1School of Medicine, Case Western Reserve University, Cleveland, OH, United States of America, 2Radiology, Cleveland Clinic, Cleveland, OH, United States of America, 3Transplantation Center, Cleveland Clinic, Cleveland, OH, United States of America, 4Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States of America Purpose: Renal dysfunction is a common consequence of decompensated cirrhosis with ascites; the most severe manifestation of this is hepatorenal syndrome. Transjugular intrahepatic portosystemic shunt (TIPS) is used to alleviate the consequences of portal hypertension, including refractory ascites, hydrothorax, and variceal bleeding. TIPS has become increasingly common as covered stents improve long-term patency. The purpose of this study was to examine the effect of TIPS on renal function. Material and Methods: We studied a retrospective cohort of 122 patients receiving first-time TIPS at our institution for any indication

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between 1999 and 2012. Serum creatinine measurements were recorded 0–7 days pre-procedure and compared with measurements at three subsequent time points: 1–2 days post-procedure, 5–12 days post-procedure, and 15–40 days post-procedure. GFR was estimated at each time point using the MDRD equation. Results: Serum creatinine decreased significantly (p<0.05) at 1–2 days post-procedure, and GFR increased significantly at all three time intervals. Patients with the most severe renal impairment experienced the greatest improvement in renal function. In secondary analyses, lower volumes of contrast and greater reductions in portosystemic gradient were associated with significantly greater improvements in renal function at one or more time intervals. Patients with an initial serum ≥1.5mg/dL – an important diagnostic criteria for hepatorenal syndrome – showed the most dramatic improvement in renal function with a mean reduction in creatinine of 0.64 mg/dL at 15–40 days. Conclusion: This study suggests that TIPS is effective in improving renal function in patients with cirrhosis and renal impairment, and is most beneficial to patients with severe renal function impairment.

Liver resection was carried out through median (25%–75% interquartile range) [Me (25%–75%)] = 29 (29–35) days after the preliminary endovascular embolization. Vascular access was performed via antegrade approach through the ileocolic vein in the laparotomic wound in the right iliac region under general anesthesia. For PVE, we used the homogenized hemostatic sponge soaked in 70% ethanol. Results: The duration of the extensive hepatic resections performed without PVE was Me (25%–75%) = 420 (360–540) minutes and after PVE was Me (25%–75%) = 420 (360–420) min, p=0.896. Intraoperative blood loss during the liver resection after PVE was Me (25%–75%) = 500 (300–650) ml and without PVE was Me (25%–75%) = 400 (300–800) ml, p = 0.773. The growth of the hepatic tissue was Me (25%–75%) = 9% (8%–11%). No complications were observed during PVE. Conclusion: PVE enables performing curative liver resection, which, in some cases, is impossible. PVE does not increase intraoperative blood loss and operative time during liver resection.

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P-348

Embolization of percutaneous transhepatic portal venous access tract with N-butyl cyanoacrylate

Extrahepatic portal vein puncture with hemorrhage in the transjugular intrahepatic portosystemic shunt: treatment with covered stent

J.H. Won; Radiology, Ajou University School of Medicine, Suwon, Korea Purpose: The purpose of this study is to evaluate the safety and feasibility of NBCA embolization for percutaneous transhepatic portal venous access tract and to establish the appropriate technique. Material and Methods: From June 2007 to August 2013, 40 consecutive patients underwent 42 percutaneous transhepatic portal venous intervention procedures for various reasons. After the procedure was completed, sheath dilator was inserted through introducer sheath and NBCA-lipiodol mixture in 1:1 or 1:2 ratio was injected via the introducer sheath using a 1-cc syringe. Sheath was carefully withdrawn while injecting the NBCA-lipiodol mixture under fluoroscopic guidance until embolization was progressed through the skin tract. Results: Immediate hemostasis was successfully achieved in all patients. No perihepatic hematoma was observed on immediate ultrasonography. The size of introducer sheath ranged from 5 Fr to 9 Fr, according to the procedure. The used amount of NBCA-lipiodol mixture ranged from 0.5 cc to 2 cc. In all, 39/40 patients underwent computed tomography imaging at mean interval of 14.9 days after the procedure. Complete embolization of percutaneous access tract was confirmed in all patients. Three patients had underlying bleeding diathesis: two with prolonged PT/aPTT level and one with hemophilia. However, none of these three patients showed evidence of bleeding or decreased Hb/Hct levels after the procedure. Conclusion: Percutaneous transhepatic portal vein access tract embolization with NBCA-lipiodol mixture is feasible and technically safe, even in patients with bleeding diathesis.

P-347 Experience in portal vein embolization for extensive liver resection D. Avdevich, D. Yurlevich, O. Kozak, Z. Labunets, I. Kulinkovich; Interventional Radiology, 9th City Clinic Hospital, Minsk, Belarus Purpose: To evaluate the effectiveness of preoperative endovascular portal vein embolization (PVE) in the treatment of pathological conditions of the liver that require extensive resections of the liver. Material and Methods: During 2010 to 2014, 237 liver resections were performed, 57 of which involved resection of more than 4 segments (extended hemihepatectomy). Thirty patients underwent PVE, and 12 (40%) underwent liver resection.

J.-B. Zhao1, F. Chao1, H.X. Xiaofeng2, Z. Qing-le1, L. Yan-hao1, Y. Chen2; 1Interventional Radiology, Nanfang Hospital, Southern Medical University, Guangzhou, China, 2Interventional Radiology, Nanfang Hospital, Guangzhou, China Purpose: To evaluate the use of covered stent in the treatment of hemorrhage resulting from extrahepatic portal vein puncture in the transjugular intrahepatic portosystemic shunt (TIPS). Material and Methods: Seven cases presented with abdominal hemorrhage in TIPS resulting from extrahepatic portal vein puncture. All shunts were created with covered stent (Fluency stentgrafts; Bard Corp). The pressures of portal vein were measured pre- and post-TIPS. The patients were followed-up to evaluate the medium-term effects. Results: Abdominal hemorrhage resulting from extrahepatic portal vein puncture was diagnosed by contrast material extravasation to lesser omentum. Nine covered stents were implanted, following which abdominal hemorrhage resolved in all cases. The covered stents varied from 6 to 8 mm in diameter and 6 to 8 cm in length. Portal vein pressure decreased from 3.50 to 2.20 KPa (t = 10.42, P = 0.000). During follow-up (6–25 months; average, 13 months), ultrasound indicated the patency of the shunt in 6 cases; 1 case had restenosis in the hepatic vein, which was corrected with bare stent placement after 8 months. Conclusion: Covered stent implantation was effective in the treatment of abdominal hemorrhage resulting from extrahepatic portal vein puncture in TIPS. Medium-term effects on follow-up were satisfactory; however, long-term effects are unknown.

P-349 Long-term outcome of percutaneous interventions for portal vein stenosis after pediatric living donor liver transplantation R. Imamine, T. Shibata, M. Yabuta, K. Shinozuka, H. Isoda, K. Togashi; Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan Purpose: To retrospectively evaluate the long-term outcomes of percutaneous intervention for portal vein stenosis after pediatric living donor liver transplantation. Material and Methods: Between October 1997 and August 2013, 47 patients (22 boys, 25 girls; median age, 2 years) who had undergone

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living donor liver transplantation were confirmed to have portal vein stenosis at portography with or without manometry, and underwent percutaneous interventions, including balloon angioplasty with or without stent placement. Technical success, clinical success, laboratory findings, patency rates, stent placement, and major complications were evaluated. Follow-up duration after the initial balloon angioplasty ranged from 8 days to 166 months (mean, 109 months). Results: Technical success was achieved in 77 of 78 sessions (98.7%) and in 46 of 47 patients (97.9%), and clinical success was achieved in 40 of 47 patients (85.1%). Platelet counts, aspartate aminotransferase levels, and alanine aminotransferase levels improved significantly. At 1, 3, 5, and 10 years after the balloon angioplasty, the rates of primary patency were 80%, 76%, 73%, and 67%, respectively, and the rates of primary-assisted patency were 100%, 100%, 100%, and 96%, respectively. Of the three patients with stent placement, two had no recurrent portal vein stenosis after the stent placement but one developed stent thrombosis. Two major complications, severe asthma attack and portal vein thrombosis subsequent to balloon angioplasty, were noted. Conclusion: Balloon angioplasty with or without stent placement was an effective treatment for portal vein stenosis after pediatric living donor liver transplantation.

P-350 Management of Budd–Chiari syndrome: a single-center experience J.B. Hartman1, M. Sands2, W. Carey3, G. Kochhar4, C. Shah5, B. Kapoor2; 1School of Medicine, Case Western Reserve University, Cleveland, OH, United States of America, 2Department of Vascular and Interventional Radiology, The Cleveland Clinic, Cleveland, OH, United States of America, 3Transplantation Center, Cleveland Clinic, Cleveland, OH, United States of America, 4Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, United States of America, 5Radiology, Cleveland Clinic, Cleveland, OH, United States of America Purpose: To retrospectively review the etiology, diagnosis, and management of Budd-Chiari syndrome (BCS) in 48 patients. Material and Methods: From 1997 to 2013, 48 patients (32 females and 16 males, average age 39.2 years, average BMI 28.5) with BCS were retrospectively reviewed. Results: Etiology of BCS included idiopathic disease (n=11), polycythemia vera (n=10), paroxysmal nocturnal hemoglobinuria (n=5), oral contraceptive use (n=5), factor V Leiden (n=4), elevated factor VIII (n=3), prothrombin mutations (n=2), IVC webs (n=2), iatrogenic (n=2), and autoimmune disease (n=4). Twenty-one patients presented with ascites. Other presentations included abdominal pain (n=13), lower extremity swelling (n=6), anorexia/nausea (n=4), venous thromboembolism (n=3), and upper gastrointestinal hemorrhage (n=1). Ten patients underwent transjugular intrahepatic portosystemic shunt (TIPS); 6, angioplasty; 4, surgical shunts; 3, liver transplant; and 25 were treated conservatively with medical management. Elevated bilirubin (OR=3.3, p=0.086) and aPTT (OR=1.16, p=0.060) trended toward increased odds of receiving TIPS. Patients were followed up for an average of 51 months following BCS diagnosis. Four patients died an average of 54 months following diagnosis; of these patients, 1 underwent TIPS and 3 received no intervention. The 10 patients who underwent TIPS were followed up for an average of 45 months. During follow-up, none of the 10 patients who underwent TIPS experienced bleeding esophageal varices vs. 4/25 patients with conservative management. Three of 10 patients who underwent TIPS experienced recurrent ascites. Conclusion: BCS patients may likely be female and overweight and have ascites, abdominal pain, and idiopathic disease or polycythemia vera. Post-TIPS outcomes appear favorable.

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P-351 Percutaneous transhepatic variceal embolization followed by partial splenic embolization for acute esophagogastric variceal massive hemorrhage X. Duan, X.-W. Han, J. Ren; Department of Interventional Radiology, The First Affiliated Hospital, Zhengzhou University, Zhengzhou, China Purpose: To evaluate the feasibility of a new strategy of percutaneous transhepatic variceal embolization (PTVE) followed by partial splenic embolization (PSE; PTVE-PSE) for acute esophagogastric variceal massive hemorrhage in patients with cirrhosis. Material and Methods: Sixty-five cirrhosis patients with acute variceal massive hemorrhage were retrospectively studied, including 31 cases in PTVE-PSE group and 34 cases in PTVE group. Rebleeding rate, survival rate, postoperative complications, duration of hospitalization after PTVE, and outcome were evaluated in the two groups. Peripheral blood cell counts and hemoglobin levels before and at 1 week and 6, 12, and 24 months after the interventional procedures were analyzed. Results: The 6-, 12-, and 24-month cumulative rebleeding rates after interventional procedures in the PTVE-PSE and PTVE groups were 3.2%, 6.7%, and 13.3% and 20.6%, 36.7%, and 53.6%, respectively, and all differences were statistically significant between the two groups (all P<0.01). The cases of fever and abdominal pain were more in the PTVE-PSE group than in the PTVE group (P<0.05). The cases of ascites and portal hypertensive gastropathy were more in the PTVE group than in the PTVE-PSE group (P<0.05). There were significant differences in peripheral blood cell counts and hemoglobin levels between the two groups at 1 week and 6, 12, and 24 months (all P<0.01). Conclusion: PTVE is an effective method for treatment of active variceal massive bleeding in patients with cirrhosis. PTVE-PSE can not only ensure the long-term efficacy in alleviating hypersplenism but also prevent rebleeding and maintain hepatic reserve.

P-352 Safety and mid-term efficacy of PTFE-covered portosystemic shunts (TIPS) in children S. Lombardo Galera, L. Zurera Tendero, J.J. Espejo Herrero, M. Canis López, J. Garcia Revillo; Interventional Radiology Unit, Hospital Reina Sofia, Cordoba, Spain Purpose: To analyse retrospectively the safety and mid-term efficacy of PTFE-covered TIPS in children. Material and Methods: We present 12 children with an average age of 9 years (2–16 years) and an average weight of 30 kg (11–60 kg) who received Viatorr PTFE-covered endoprostheses for upper gastrointestinal bleeding (UGB) caused by medically or endoscopically uncontrollable varices. Three patients had chronic portal thrombosis with cavernomatosis (two of them after liver transplantation). The recurrence of UGB, associated complications and permeability were assessed with Doppler ultrasound sequentially or up to transplantation. Results: In all patients, a single endoprosthesis was implanted in a single session with no associated mortality. The mean initial transhepatic gradient was 15 mmHg (3–21 mmHg), which dropped to 7 mmHg (1–12 mmHg) after TIPS implant. Immediate complications observed were mild encephalopathy in one patient and a girl with portal cavernomatosis suffered acute occlusion of TIPS. Dysfunction of TIPS were observed in four children at 7, 9, 12 and 54 months (two stenosis and two thrombosis – one of them with portal cavernomatosis) but UGB recurred only in three of them (primary patency: 67%). All stenosis/occlussions were resolved with coaxial endoprostheses. Four patients received transplants at 7, 9, 10 and 17 months, with permeability of TIPS observed. In the other eight

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patients, permeability was demonstrated with Doppler ultrasound during a mean follow-up period of 18 months (5–55 months). Conclusion: Our results indicate Viatorr PTFE-covered endoprostheses are feasible, safe and permeable (67%) for the treatment of UGB due to gastro-oesophageal varices, and can be good even in patients with portal cavernomatosis.

P-353 Single-centre experience of extending indications for percutaneous intra-portal islet auto-transplantation (PIPIAT) after pancreatic surgery to prevent diabetes: feasibility, technical aspects, complications and clinical outcome G. Agostini1, M. Venturini2, L. Piemonti3, G. Balzano4, F. De Cobelli2, A. Del Maschio2; 1Radiology, San Raffaele Hospital, Milan, Italy, 2Radiology, VitaSalute University, San Raffaele Hospital, Milan, Italy, 3Internal Medicine, Vita-Salute University, San Raffaele Hospital, Milan, Italy, 4Pancreatic Surgery, San Raffaele Hospital, Milan, Italy Purpose: Percutaneous islet allo-transplantation, needing immunosuppression, is a traditional less invasive alternative to surgical pancreas transplantation for brittle type 1 diabetes, while PIPIAT, not needing immunosuppression, is usually performed after pancreatic surgery for chronic pancreatitis to prevent diabetes. Our aim was to assess the feasibility, technical aspects, complications and clinical outcomes of PIPIAT following pancreatic surgery not only for chronic pancreatitis but also for benign and malignant nodules. Material and Methods: From 2008 to 2012, 41 patients were enrolled for PIPIAT 24/48 hours after pancreatic surgery (total pancreatectomy or distal pancreatectomy for benign/borderline neoplasms of pancreatic body/neck). PIPIAT was performed using a combined US- and fluoroscopy-guided technique (4-F catheter); portography PIPIAT feasibility, complications, median follow-up and metabolic (insulin independence rate, graft function based on β-score and marker of islet function) and oncologic (malignant and metastatic diseases) outcomes were recorded. Results: PIPIAT was not performed in 7/41 patients (4 for inadequate islet mass, 2 for hemodynamic instability and 1 for islet culture contamination), while it was successfully performed in 34/34 patients. PIPIAT-related complications occurred in 8 patients (23.5%): 3 bleedings (2 requiring transfusions), 1 partial portal thrombosis and 1 sepsis. Median follow-up duration was 546 days. Insulin independence was achieved in 15/34 patients (44%), partial graft function in 16/34 patients (47%) and no function in 3/34 patients (6%). Seventeen patients had malignancy; none of them developed liver metastases during follow-up. Conclusion: PIPIAT, performed under combined US and fluoroscopy guidance and not requiring immunosuppression is feasible, with a relatively low complication rate and a better metabolic outcome than allo-transplantation.

P-354 Single-center experience with complex percutaneous portosystemic shunt creation in the setting of hepatic or portomesenteric vein thrombosis Z.L. Bercu, S. Sheth, R. Blue, E. Kim, R. Patel, F.S. Nowakowski, R.A. Lookstein, A.M. Fischman; Division of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America Purpose: To review a single-center experience in complex percutaneous portosystemic shunt creation for portal hypertension complications in the setting of portal or hepatic vein thrombosis. Material and Methods: An IRB-approved retrospective study was performed in 204 patients with complications of portal hypertension

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who underwent percutaneous portosystemic shunting between November 2008 and September 2013 at a single tertiary care center in a major metropolitan hospital. Records were reviewed for demographics, technique, technical success, and clinical results at followup. Clinical results were assessed at 30- and 90-day intervals. Results: Seventeen patients had significant clot burden either in the hepatic or portomesenteric veins, preventing conventional transjugular intrahepatic portosystemic shunt (TIPS) placement. Percutaneous shunting was unsuccessful in 9 patients, whereas 8 patients underwent successful shunt creation. Five patients were female. Primary access was transsplenic (n=2), transhepatic (n=5), or transjugular (n=1). Shunts placed were right portal vein (RPV) to right hepatic vein (RHV) (n=3), RPV to inferior vena cava (IVC) (n=2), main portal vein to RHV (n=1), splenic vein to RHV (n=1), and superior mesenteric vein to IVC (n=1). Average pre-shunt Child–Pugh and Model for End-Stage Liver Disease (MELD) scores were 10.4 and 20.4, respectively. The 30-day mortality was 25%. Three patients underwent shunt revision. All patients experienced reduced ascites. No patient developed significant encephalopathy or post-shunt bleeding. One patient experienced transient post-shunt acute renal failure. Conclusion: Complex percutaneous portosystemic shunting may be performed in the setting of significant portal or hepatic venous thrombosis. Immediate technical success was 47.1%. Reduced survival and shunt patency may be related to an overall more morbid population.

P-355 Three-dimensional volume flow measurements in transjugular intrahepatic portosystemic shunts in patients referred to interventional radiology for shunt evaluation and/or revision P. Novelli, S. Pinter, O. Kripfgans, B. Fowlkes, J. Rubin; Interventional Radiology, University of Michigan, Ann Arbor, MI, United States of America Purpose: The purpose of this prospective study was to evaluate three-dimensional volume flow measurements in transjugular intrahepatic portosystemic shunts in patients referred to interventional radiology for shunt evaluation and/or revision. Material and Methods: This was a prospective study including 17 patients (5 females, 12 males) referred to IR for the evaluation of TIPS status. Fifteen patients had an abnormal ultrasound suggesting TIPS dysfunction. Ten patients had clinical signs and symptoms of weight gain, ascites, and/or hydrothorax. Five patients with abnormal ultrasound findings were asymptomatic. A GE LogiQ 9 ultrasound system (4D3CL; 2.0–5.0 MHz) was used to acquire multi-volume respiratory-gated 3D color Doppler data sets to assess pre- and post-revision volume flow. Volume flow was compared to reference measurements of pre- and post-revision portosystemic pressure gradient measured during direct venography. Pre- and post-revision flows were compared to determine predictability. Results: Revisions consisting of balloon angioplasty alone or the placement of additional stent were necessary in 12 patients. Revisions were deemed necessary on the basis of the venographic appearance of the stent. No revision was necessary in 5 patients despite an abnormal ultrasound. Results showed a negative correlation between pre- and post-revision shunt blood low and portosystemic pressure gradient; an increase in shunt blood flow corresponded with a decrease in pressure gradient. We noted a pre-revision volume flow threshold developing at approximately 1300 ml/min, below which a revision was needed. Conclusion: Volume flow may provide a more sensitive noninvasive tool than standard pulsed wave Doppler for evaluating TIPS function.

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P-356 Transjugular intrahepatic portosystemic shunt (TIPS) versus balloon-occluded retrograde transvenous obliteration (BRTO) for the treatment of gastric varix D.Y. Lee1, S.J. Lee2, M.D. Kim1, Y.H. Kim3, J.Y. Won4, S.I. Park1, I.J. Kim2, Y. Yoon5; 1Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea, 2Radiology, Severance Hospital, Seoul, Korea, 3Radiology, Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea, 4Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea, 5Radiology, National Medical Center, Seoul, Korea Purpose: To compare the re-bleeding rate and overall survival of TIPS with BRTO for the treatment of gastric varix. Material and Methods: A total of 135 cirrhotic patients underwent endovascular treatment for gastric varices between 2005 and 2012. BRTO was performed in 86 patients, and TIPS in 49. The mean age of the patients was 58.5 years. The mean follow-up period was 735 days. Technical success, re-bleeding rate, cause and site of re-bleeding, overall survival, and clinical findings (encephalopathy and ascites) were evaluated. Statistical analysis was performed. Results: Re-bleeding rate in the TIPS group (28.6%, 14/49) was significantly higher than that in the BRTO group (9.3%, 8/86; p=0.005). The location of re-bleeding was identified through endoscopic exam; gastric varix (n=7), esophageal varix, both esophageal and gastric varix (n=4), and unknown origin (n=5). Mean overall survival in the BRTO group (2309.7 ± 199.5 days) was significantly longer than that in the TIPS group (1272.5 ± 177.7 days; p=0.041). Encephalopathy developed in 28.5% in the TIPS group after procedure. Aggravation of ascites was found in 4% in the TIPS group and 15% in the BRTO group. Conclusion: BRTO was found to be more effective than TIPS in controlling gastric variceal bleeding. Furthermore, the BRTO group showed a significantly longer survival than the TIPS group.

P-357 BRTO for gastric varices – advanced techniques and in-depth ideas to overcome anatomical difficulties and lack of required devices M. Horikawa1, M. Yamamoto2, K. Yamada2, T. Kaji2, K.J. Kolbeck3, K. Farsad3, F.S. Keller4, J.A. Kaufman3; 1Dotter Interventional Institute, Oregon Health & Science University, Portland, OR, United States of America, 2Radiology, National Defense Medical College, Tokorozawa, Japan, 3Dotter Interventional Institute, Oregon Health & Science University Hospital, Portland, OR, United States of America, 4Department of Vascular and Interventional Radiology, Oregon Health Sciences University, Dotter Interventional Institute, Portland, OR, United States of America Learning Objectives: To learn how to overcome technical difficulties in performing BRTO for gastric varices. Background: The BRTO procedure has developed in the past 20 years, especially in Asia. Recently, it has been more widely regarded as an effective management for gastric varices instead of or sometimes in addition to the TIPS procedure. However, there are still difficulties in achieving technical success due to anatomical challenges or lack of certain devices, especially well-manufactured balloon catheters. Clinical Findings/Procedure: We demonstrate various methods to overcome the anatomical difficulties and limitations regarding the availability of devices or clinical backgrounds. For anatomical challenges:

Abstract Book 1. Utilize a double coaxial balloon catheter system. 2. Use a well-trackable microballoon catheter. 3. Use foam sclerosing agents and changing the patient’s body position. For limitations of device availability and clinical backgrounds: 1. Evaluate with CO2 injection and treatment with various foam sclerosing agents. 2. Seal the retrograde tract with glue or vascular plugs to prevent pulmonary embolism. 3. Combine BRTO with TIPS, especially to prevent an exacerbation of esophageal varices. Conclusion: There are several ways to achieve technical success with BRTO in spite of the various difficulties. IR physicians must have various types of keys in their pockets to open the door to success.

P-358 Cost analysis of portal vein embolisation (PVE) embolic agents: a single-centre experience of embolic agents and operative techniques in PVE A. Walker, C. Hay, J. Gordon-Smith; Radiology, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom Learning Objectives: Single-centre review of practice over 4 years (65 patients) of portal vein embolisation comparing both embolic agents used and operative techniques. Measured endpoints for this study included degree of contra-lateral liver lobe hypertrophy, procedure time, procedure dose and cost. This study aims to act as an educational tool concerning the different embolic options available for portal vein embolisation and to highlight, through our experience, the benefits of each agent. Background: PVE is a well-recognised technique to facilitatiate contra-lateral liver lobe hypertrophy as a bridge to hemi-hepatectomy. Our hepato-biliary centre experiences a high volume of PVE workload. PVE may be successfully accomplished with a variety of embolic agents. There is a variety of operator preference in their use either alone or in combination. The literature provides conflicting reports of improved hypertrophy with different agents. Each agent has its inherent handling characteristics and costs. Clinical Findings/Procedure: We reviewed over 60 cases performed at our centre over a 4-year period by 5 consultant radiologists. We have retrospectively collated techniques (approach) and embolic agents used for each procedure from operative notes and departmental stock IT system. We examined a variety of outcomes, including procedure time, procedure radiation dose, resultant contra-lateral liver lobe hypertrophy and cost. Conclusion: Retrospective review of work in our practice highlighted the variability of technique and choice of embolic agents within our unit. Although no difference in outcomes has yet been demonstrated, there is significant variability in cost related to the type of embolic agent used.

P-359 Is there still a role for parallel transjugular intrahepatic portosystemic shunt (TIPS)? P. Rigamonti1, U.G. Rossi1, C. Ferro2, G. Cornalba3, M. Cariati1; 1Radiology and Interventional Radiology, San Carlo Borromeo Hospital, Milan, Italy, 2Radiology, IRCCS San Martino, University Hospital, Genoa, Italy, 3Diagnostic and Interventional Radiology, S. Paolo Hospital, Milan, Italy Learning Objectives: To describe the indications and technical aspects of parallel shunts in patients with chronic total occlusion of transjugular intrahepatic portosystemic shunt (TIPS).

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Background: Despite advances in medical management and clinical and imaging follow-up, the major disadvantage of TIPS is still its poor long-term patency. Therefore, secondary interventional procedures for treating TIPS occlusion are necessitated. However, these procedures can fail in case of chronic total occlusion of TIPS. Clinical Findings/Procedure: The purpose of this poster is to illustrate the indications and technical aspects of parallel shunts in patients with chronic total occlusion of TIPS. Conclusion: Patients with chronic total occlusion of TIPS and clinical findings of portal hypertension are candidate for parallel shunts, when all other recanalization procedures have failed.

P-360 IVUS-guided direct intrahepatic portocaval shunt (DIPS): from the original to the current state M. Horikawa1, B.D. Petersen1, K. Farsad2, K.J. Kolbeck 2, F.S. Keller 3, J.A. Kaufman2; 1Dotter Interventional Institute, Oregon Health & Science University, Portland, OR, United States of America, 2Dotter Interventional Institute, Oregon Health & Science University Hospital, Portland, OR, United States of America, 3Department of Vascular and Interventional Radiology, Oregon Health Sciences University, Dotter Interventional Institute, Portland, OR, United States of America Learning Objectives: To learn the techniques and required devices for direct intrahepatic portocaval shunt (DIPS), comparing the feasibility of the original method first reported in 2001 with the current method. Background: The TIPS procedure is still one of the most difficult and potentially invasive procedures among the various procedures of interventional radiology. The causes of the major complication or failure of TIPS are mainly due to the relatively “blind” puncture, while IVUS-guided DIPS enables performing the puncture under real-time guidance. The IVUS-guided DIPS procedure itself has developed since the original method was published in 2001; especially, the appearance of a new type of IVUS dramatically changed the feasibility. Clinical Findings/Procedure: We demonstrate IVUS-guided DIPS from the following viewpoints. 1. Procedures and devices, including the types of IVUS 2. Keys and pitfalls during the procedure 3. Effectiveness and safety, with long-term data 4. Advance methods and techniques related to DIPS and possible combinations with other interventional procedures Conclusion: Although IVUS-guided DIPS requires interventional radiology physicians to be familiar with the maneuver, after mastering the procedure, they can create effective portosystemic shunts safely under real-time guidance.

P-361 Portal vein targeting technologies during transjugular intrahepatic portosystemic shunt (TIPS) placement C.N. Weber1, T.W.I. Clark2; 1Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States of America, 2Radiology Department, Penn Presbyterian Medical Center, Philadelphia, PA, United States of America Learning Objectives: 1. To become familiar with several portal vein (PV) targeting technologies. 2. To understand advantages/disadvantages of each. 3. To understand which technologies are currently used in humans. Background: During TIPS placement, the most time-consuming and dangerous step is PV access. We provide an update on a number of emerging imaging modalities for assisting the interventional radiologist in PV targeting.

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Clinical Findings/Procedure: 1. Ultrasound: a) Transabdominal – currently used in humans, combines transjugular and transhepatic approaches, often successful with one needle pass. b) Transabdominal 3D – not commonly used; has shown feasibility in humans. c) Intravascular – not commonly used; has shown feasibility in humans. d) Endoscopic – intrahepatic portosystemic shunts have been placed in animal models. No human studies reported. 2. Cone-beam CT: fuses cross-sectional imaging (often acquired in the IR suite) with fluoroscopy. It has been utilized with challenging TIPS placement in cases of altered/distorted anatomy (i.e., polycystic liver disease, transplants). 3. MRI: both MRI and MR fluoroscopy hybrid systems have demonstrated feasibility for TIPS placement in animal models and humans, requiring 2–3 needle passes. 4. Electromagnetic tracking: cross-sectional imaging obtained with fiducial markers is registered with software; catheter/wire sensors are fused to the imaging. TIPS have been placed in animals with 1–2 needle passes. Respiratory-gated image registration is feasible. No human studies have been reported. 5. Fluoroscopic triangulation: software provides navigation derived from multiple angled portograms. It has shown feasibility in humans for reducing the number of needle passes. Conclusion: Several PV targeting technologies have demonstrated feasibility for TIPS placement, increasing efficiency and minimizing procedural risks.

P-362 Transjugular intrahepatic portosystemic shunt (TIPS): CT planning, ultrasound and fluoroscopy guidance P. Rigamonti1, U.G. Rossi1, A. Rampoldi2, G. Cornalba3, M. Cariati1; 1Radiology and Interventional Radiology, San Carlo Borromeo Hospital, Milan, Italy, 2Interventional Radiology, Ospedale Niguarda, Milan, Italy, 3Diagnostic and Interventional Radiology, S. Paolo Hospital, Milan, Italy Learning Objectives: To describe the steps of the transjugular intrahepatic portosystemic shunt (TIPS) from CT planning to ultrasound and fluoroscopy guidance. Background: Various methods have been described to perform TIPS. Pre-treatment CT planning with MIP and VRT reconstruction images is essential for the inclusion criteria of the procedure. Fluoroscopy and digital subtraction angiography (DSA) guidance has undergone continuous technical modifications with possible vascular maps (overlay, road map). The introduction of ultrasound guidance in portal vein puncture eliminates the “blind” part of the procedure. All these modifications have improved the safety and effectiveness of the procedure. Clinical Findings/Procedure: The purpose of this poster is to illustrate all passages necessary to improve the TIPS procedure, with particular emphasis on the following: i) pre-treatment CT planning with vascular reconstructions, ii) high-resolution fluoroscopy and DSA guidance and iii) ultrasound guidance in portal vein puncture. Conclusion: The use of CT vascular reconstructions as pre-procedural planning, ultrasound guidance to access the portal vein, and fluoroscopy reduces the procedure time and the number of attempts at portal vein puncture, thereby making TIPS safer and more effective.

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P-366

Transjugular intrahepatic portosystemic shunt: enhanced targeting in portal vein access

Balloon-occluded retrograde transvenous obliteration of esophageal varices via the azygos vein

D. Wells1, R. Gupta1, M. Smith1, K. Kondo1, C.E. Ray, Jr.2, J. Durham1, M. Gipson1; 1Radiology, University of Colorado, Aurora, CO, United States of America, 2Radiology, University of Illinois at Chicago, Chicago, IL, United States of America

Y. Tamura1, O. Ikeda1, S. Inoue1, Y. Nakasone1, Y. Yamashita1, T. Shono2, T. Kounoe2, Y. Sasaki2; 1Diagnostic Radiology, Kumamoto University Graduate School of Medical and Pharmaceutical Sciences, Kumamoto, Japan, 2Gastroenterology and Hepatology, Kumamoto University Graduate School of Medical and Pharmaceutical Sciences, Kumamoto, Japan

Learning Objectives: 1. To review the clinical indications for performing transjugular intrahepatic portosystemic shunts (TIPSs). 2. To review the current image-guidance and access techniques utilized for the TIPS procedure. 3. To discuss the benefits, limitations, and risks of available techniques for enhanced portal branch targeting. Background: By creating a direct channel between the hepatic and intrahepatic portal vein, TIPS creation controls portal hypertensive complications. The most technically demanding step of the procedure is gaining access from the hepatic vein to an intrahepatic portal vein branch. Accurate imaging of the portal system is therefore key to the technical success of the procedure. Various techniques have been developed to make this blind procedure more targeted. Understanding image-guidance techniques during TIPS creation, as well as their advantages and drawbacks, is essential. Clinical Findings/Procedure: Direct and indirect visualization methods may guide needle placement from the hepatic vein into the portal system; indirect visualization methods are more common. Indirect imaging of the portal venous system is performed with negative contrast CO2 via trans-sinusoidal flow, transabdominal puncture of a portal branch or paraumbilical collateral, or splenic arteriography with delayed imaging. Guidewires can be placed either in or near the portal venous target to aid in fluoroscopic guidance. Direct, real-time imaging of the hepatic veins, portal veins, and TIPS needle can be achieved with an intravascular ultrasound probe placed in the retrohepatic cava. Conclusion: New techniques and devices available to interventional radiologists to perform the TIPS procedure. Treatment practices should be evidence-based, aiming to minimize avoidable patient risks and exposures.

P-364 A case of gastric varix successfully treated with balloonoccluded retrograde transvenous obliteration (B-RTO) via the left pericardiacophrenic vein R. Morita1, T. Hasegawa2, W. Sakai2; 1Radiology, Obihiro-Kosei General Hospital, Obihiro City, Japan, 2Radiology, Sapporo-Kosei General Hospital, Sapporo City, Japan A 76-year-old woman with liver cirrhosis was admitted to our hospital for gastric varix. CT revealed that the only draining vein was the left pericardiacophrenic vein. B-RTO was successfully performed via the left pericardiacophrenic vein, which was approached from the left subclavian vein.

A 35-year-old man underwent endoscopic injection sclerotherapy for esophageal varices and Hassab operation for gastric varices. Hematemesis occured, the bleeding source being the para-esophageal vein draining into the azygos vein. He underwent balloonoccluded retrograde transvenous obliteration via the azygos vein for esophageal varices.

P-367 Balloon-occluded retrograde transvenous obliteration of gastric varix with multiple draining veins performed with temporal occlusion of the pericardiacophrenic vein with a micro-balloon T. Yamagami1, R. Yoshimatsu1, M. Iida2, N. Tanitame2, C. Ono2, K. Kajiwara1, K. Waki3, K. Tsuji3, K. Awai1; 1Diagnostic Radiology, Institute and Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan, 2Radiology, Hiroshima City Asa Hospital, Hiroshima, Japan, 3Gastroenterology, Hiroshima City Asa Hospital, Hiroshima, Japan We successfully performed balloon-occluded retrograde transvenous obliteration for a gastric varix that drained into the gastro-renal shunt, left pericardiacophrenic vein, and several other collateral veins. While injecting sclerotic agents, the left pericardiacophrenic vein was temporarily occluded using a micro-balloon catheter.

P-368 Spontaneous hemoperitoneum due to the rupture of the paraumbilical vein varix successfully treated with balloonoccluded retrograde transvenous obliteration R. Morita1, T. Hasegawa2, W. Sakai2; 1Radiology, Obihiro-Kosei General Hospital, Obihiro City, Japan, 2Radiology, Sapporo-Kosei General Hospital, Sapporo City, Japan A 69-year-old man with liver cirrhosis was admitted to our hospital with abdominal distention and pain. CT revealed hemoperitoneum and rupture of the paraumbilical vein varix. Balloon-occluded retrograde transvenous obliteration was successfully performed via the left femoral vein.

P-369 TIPSS revision by direct stent-graft puncture using percutaneous transhepatic approach

P-365

E.M. Aldulaigan, S.A. Qazi, M. AL Moaiqel; Interventional Radiology, Medical Imaging, King Abdulaziz Medical City, National Gaurd Hospital, Riyadh, Saudi Arabia

Balloon-occluded retrograde transvenous obliteration for gastric varices without gastrorenal/gastrocaval shunt M. Maruno, H. Kiyosue, S. Tanoue, S. Matsumoto, H. Mori; Radiology, Oita University Faculty of Medicine, Yufu, Japan Balloon-occluded retrograde transvenous obliteration (B-RTO) is usually indicated for gastric varices with apparent gastorenal/gastrocaval shunt. However, there are some cases without gastrorenal/ gastrocaval shunt. For such cases, we present a B-RTO technique via the pericardiophrenic vein and internal throracic vein.

A 67-year-old male with cryptogenic cirrhosis and occluded TIPSS presented with refractory acsites. Successful TIPSS revision was performed using direct percutaneous transhepatic puncture of the stent-graft after failure of conventional approach. Ultrasound at 6-month follow-up confirmed a patent stent-graft.

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P-370

P-372

Transjugular intrahepatic portosystemic shunt for portal stent occlusion

Pathological findings of enhancing nodules in postcryoablation site of renal cell carcinomas and results of repeat cryoablation

M. Okada1, Y. Nakashima2, T. Ishikawa3, K. Sakamoto4, N. Matsunaga1; 1Radiology, Yamaguchi University Graduate School of Medicine, Ube, Japan, 2Radiology, Yamagugi Grand Hospital, Hofu, Japan, 31st Internal Medicine, Yamaguchi University Graduate School of Medicine, Ube, Japan, 42nd Surgery, Yamaguchi University Graduate School of Medicine, Ube, Japan Portal stent occluded two years after placement for life-threatening variceal bleeding. Under fluoroscopic guidance using the gun-sight technique, TIPS was created with two goose-neck snares placed in the accessory hepatic vein via the transfemoral approach and occluded stent via the transileocecal approach.

Urinary tract intervention P-371 Multicenter experience of the newly designed covered metallic ureteral stent for malignant ureteral occlusion: comparison with double J stent insertion H.H. Chung1, M.D. Kim2, J.Y. Won2, J.H. Won3, S.B. Cho4, T.-S. Seo5, S.W. Park6, B.C. Kang7; 1Radiology, Korea University Ansan Hospital, Ansan, Korea, 2Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea, 3Radiology, Ajou University School of Medicine, Suwon, Korea, 4Radiology, Korea University Anam Hospital, Seoul, Korea, 5Radiology, Korea University Guro Hospital, Seoul, Korea, 6Radiology, Konkuk University Hospital, Seoul, Korea, 7Radiology, Mokdong Hospital, Ewha Woman University, College of Medicine, Seoul, Korea Purpose: This study was designed to evaluate the effectiveness of the newly designed covered metallic stent (CMS) for malignant ureteral obstruction by comparing with double J stent (DJS). Material and Methods: CMSs were placed for malignant ureteral obstruction caused by various types of cancers for 42 ureters in 32 patients from 7 institutes. Retrospective data were collected for DJSs, which included 72 malignant ureteral occlusions in 56 patients: 27 DJSs were placed percutaneously and 45 were cystoscopically inserted. Technical failure of the CMS group was compared with that of the radiologically inserted DJS group. The primary patency of the CMS group was compared with the assisted primary patency of the DJS group. Results: The technical failure of the CMS group is lower than that of the radiologically inserted DJS group [0 % (0/42) vs. 25.9 % (7/27); p = 0.002]. The primary patency of the CMS group is better than the assisted primary patency of the DJS group (p = 0.012). The primary patency of the CMSs is 100%, 94.5%, 74.7%, 70.3%, 65.3%, 65.3%, and 65.3% at 1, 3, 6, 9, 12, 18, and 24 months, respectively. The assisted primary patency of the DJSs is 78.6%, 75.1%, 59.1%, 48.7%, 38.7%, and 37.8% at 1, 3, 6, 9, 12, and 18 months, respectively. No serious complications were noted in the CMS group. Migration of the metallic stent occurred in one patient (2.3%). Conclusion: CMS placement for malignant ureteral obstruction is superior to DJS placement in terms of technical success and patency.

K. Shimizu1, T. Mogami2, K. Michimoto1, Y. Kameoka1, T. Tokashiki1, N. Kurata1, J. Harada1; 1Radiology, Jikei University, Kashiwa Hospital, Chiba, Japan, 2Radiology, Tokyo Denatal College, Ichikawa General Hospital, Chiba, Japan Purpose: To investigate the pathological findings of enhancing nodule (EN) in post-cryoablation site of renal cell carcinomas (RCC) and the effectiveness of repeat cryoablation. Material and Methods: From September 2011 to December 2013, 55 patients with T1a RCC underwent percutaneous cryoablation. Follow-up contrast-enhanced CT (CECT) was performed at 1, 3, 6 and 12 months after cryoablation. Seven cases had ENs in post-cryoablation site. Percutaneous CT-guided biopsy was performed in cases with EN, which did not resolve spontaneously for more than 6 months, and repeat cryoablation was performed for cases which had pathologically viable lesions. Results: CT-guided percutaneous biopsy was performed in 5 of 7 ENs which did not resolved spontaneously for more than 6 months. Viable clear cell carcinomas were pathologically diagnosed in all 5 cases. All lesions showed strong enhancing effect in the arterial phase of CECT. Complete ablation was obtained by repeat cryoablation in all 5 cases. No patient showed evidence of recurrence during the mean follow-up period of 5.2 months. Spontaneous resolution of EN was observed in 2 cases. In 1 case, EN, which observed on first follow-up CECT, decreased in size at 6 months and disappeared completely at 18 months. In another case, EN resolved at 6 months. Conclusion: Even in EN observed on first follow-up CECT, spontaneous resolution is expected. Strong enhancing lesions in the arterial phase of CECT which are continuously observed more than 6 months should be suspected as incomplete ablation. Repeat cryoablation for these lesions is effective.

P-373 Safety and yield of real-time ultrasound-guided percutaneous renal biopsy using an automatic 16-gauge Tru-cut needle in 372 consecutive native kidneys J.R. Fortuño, A. Alguersuari, E. Criado, J.F. Falco-Fages, A. Mateos, S. De Lamo, E. Garcia; Interventional Radiology, UDIAT-CD. Corporacio Parc Tauli, Sabadell, Spain Purpose: To review the diagnostic yield and rate of complications for US-guided percutaneous renal biopsy using automatic 16-G needles in 372 consecutive native kidneys. To evaluate the efficacy of percutaneous treatment with embolization in major complications. To assess the correlation between certain factors (e.g., age, renal function, blood pressure before the procedure) and major complications. Material and Methods: We reviewed 372 consecutive renal biopsies obtained from native kidneys using automatic 16-G 1.9-mm side-notch (Tru-Cut) needles under real-time US guidance. We calculated the diagnostic yield using the number of biopsies with a complete histological report, including inmunofluorescence evaluation when needed, and the rate of minor (managed with observation) and major (managed with intervention) complications. We evaluated the efficacy of endovascular treatment to manage active bleeding and major complications.

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We used Fisher’s test to evaluate the correlation between the occurrence of major complications, patient age, renal function, and blood pressure before the procedure. Results: Biopsies yielded enough material to establish a complete diagnosis in 345/372 cases (92.75%). Complications were detected in 43/372 biopsies (11.5%); of these, 11 (2.95%) were major and 32 (8.6%) were minor. Nine patients with severe active bleeding were successfully treated with arteriography and superselective embolization. We found no cases of nephrectomy or death. We found no correlation between major complications and the items reviewed. Conclusion: The efficacy and safety of percutaneous renal biopsy using an automatic 16-G needle make it a good alternative for obtaining histological specimens. Major complications can be managed using percutaneous approach. We did not find any predictive factor for major complications.

P-374 Short-, medium-, and long-term outcomes of prostatic arterial embolization for patients with benign prostatic hyperplasia refractory to medical therapy: 600 cases

Abstract Book Material and Methods: Between January 2002 and June 2013, 37 male patients (mean age, 36 years) had post-traumatic high flow priapism. All patients underwent bilateral pudendal artery catheterization with consequent super-selective arterial embolisation of the arteriovenous fistula site. In all patients, Gelfoam was used as the embolic material. Clinical and ultrasound follow-up was performed in all patients. Results: All 37 patients had complete detumescence after a maximum of 2 days from embolization. Three patients had relapse and underwent a second arterial embolization. None of them had complications, and all returned to normal sexual function and remained symptom-free thereafter (mean follow-up duration, 18 months). Conclusion: Super-selective arterial Gelfoam embolisation for posttraumatic high flow priapism is a safe and efficient therapeutic procedure with long-term effect of penile detumescence and preservation of erectile function.

P-376 Accordion sign in the transplant ureter: ramifications during balloon dilation of strictures J.S. Kriegshauser1, S.G. Naidu1, Y.-H. Chang2, E.A. Huettl1; 1Radiology, Mayo Clinic Hospital, Phoenix, AZ, United States of America, 2Biostatistics, Mayo CLinic Arizona, Scottsdale, AZ, United States of America

J.M. Pisco, L. Campos Pinheiro, T. Bilhim, H. Rio Tinto, M. Duarte, J.A. Pereira, A.G. Oliveira, L. Fernandes; Interventional Radiology, Saint Louis Hospital, Lisbon, Portugal Purpose: To evaluate the short-, medium-, and long-term clinical outcomes of PAE in 600 patients with BPH and moderate-to-severe lower urinary tract symptoms (LUTS) refractory to medical therapy. Material and Methods: Patients were evaluated before and at 1, 3, 6 months after the procedure and every 6 months thereafter. Nonspherical polyvinyl alcohol (PVA) particles (420 patients), Bead Block (102 patients), Embospheres (40 patients), or Embozene (38 patients) were used. Technical failure was considered when none of the prostatic arteries could be embolized. Clinical success was considered when there was reduction in the total IPSS score of at least 25% and to ≤15, reduction of Qol by at least 1 point or to ≤3, and no need of any other treatment. Results: The mean follow-up was 26.3 months; PSS/Qol improvement was 10.6 ± 7.8/1.2 ± 0.9 points; IIEF increase was 1.7 ± 7.1 points; PV reduction was 17 ± 31.4 mL); PSA reduction was 2.3 ± 4.8 ng/mL; Qmax improvement was 4.5 ± 5.2 mL/s; and PVR reduction was 32.3 ± 96.3 mL. There were 10 technical failures. In the 549 control patients, there were 20.6% clinical failures. Cumulative rate of clinical success at short term was 89.7% (at 3 months); at medium term, 78.3%; and at long term, 74.1%. Major complications were bladder wall ischemia and an uncomfortable perineal pain. There was no sexual dysfunction or incontinence. PAE was an outpatient procedure in all patients. Conclusion: PAE is a safe, well-tolerated, and efficient outpatient procedure; it is an alternative to surgery with good short-, medium-, and long-term results.

Purpose: To demonstrate the accordion sign within the transplant ureter and evaluate its ramifications during balloon dilation of strictures. Material and Methods: A retrospective electronic chart and imaging review included demographic characteristics, procedure reports, and complications of 28 renal transplant patients having ureteral strictures treated with percutaneous balloon dilation reported in our transplant nephrology database over an 8-year period. The accordion sign was deemed present or absent on the basis of an imaging review, and was defined as present when a tortuous ureter became kinked and irregular when foreshortened after the placement of a wire or a catheter. Procedure-related urine leaks were categorized as occurring at the stricture if within 2 cm; otherwise, they were categorized as away from the stricture. Results: The accordion sign was associated with a significantly higher occurrence of leaks away from the stricture (P=0.001) but not at the stricture (P=0.34). Conclusion: The accordion sign is an important consideration when performing balloon dilation procedures on transplant ureteral strictures, given the increased risk of leak away from the stricture. Its presence should prompt additional care during wire and catheter manipulations.

P-377 The safety and efficacy of prostatic arterial embolization with Bead Block for patients with refractory benign prostatic hyperplasia – a pilot study

P-375 Super-selective arterial embolisation for post-traumatic high flow priapism: a multi-centre review U.G. Rossi1, P. Rigamonti1, A. Rampoldi2, G. de Caro3, G. Cornalba4, M. Cariati1; 1Radiology and Interventional Radiology, San Carlo Borromeo Hospital, Milan, Italy, 2Interventional Radiology, Ospedale Niguarda, Milan, Italy, 3Radiology and Interventional Radiology, Galliera Hospital, Genoa, Italy, 4Diagnostic and Interventional Radiology, S. Paolo Hospital, Milan, Italy Purpose: To describe the feasibility, safety and effectiveness of super-selective arterial embolisation for post-traumatic high flow priapism.

J.M. Pisco, T. Bilhim, H. Rio Tinto, L. Campos Pinheiro, J.A. Pereira, L. Fernandes, M. Duarte, A.G. Oliveira; Interventional Radiology, Saint Louis Hospital, Lisbon, Portugal Purpose: To evaluate the clinical outcome of patients with refractory benign prostatic hyperplasia (BPH) who underwent prostatic arterial embolization (PAE) with Bead Block. Material and Methods: Twenty-four patients with BPH refractory to medical therapy for at least 6 months underwent PAE with 300– 500-μm Bead Block between October 2012 and July 2013. Procedure and fluoroscopy times, radiation dose, pain score were evaluated. The following were evaluated: International Prostate Symptoms Score (IPSS), Quality of life (Qol), and Erectile Function (IIEF); prostate

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volume (PV); PSA; peak urinary flow rate (Qmax); and post-void volume (PVR). Technical success was considered if at least one of the prostatic arteries was embolized. Clinical success was considered when IPSS was reduced by at least 25% and ≤15, Qol reduced by at least one point or ≤3, and no need for any other treatment. Results: Mean follow-up was 7.8 months; procedure time, 84.5 min; fluoroscopy time, 21.3 min; procedure pain score, 2.8; radiation, 2050 dGcm2; PV reduction, 21.2 ± 32.5mL/s; PSA reduction, 2.1 ± 4.1 ng/ mL (28.3 %); IPSS/Qol improvement, 10.2 ± 9.72/1.52 ± 1.02 points (34.5%/23.1%); IIEF improvement, 1.25 ± 5.14 (18.6%); and Qmax improvement, 4.1 ± 6.3 mL/s. There were 2 initial clinical failures. The remaining 21 control patients improved. There were 3 minor complications – 2 inguinal hematomas and 1 UTI – and no major complications. Conclusion: PAE with Bead Block for patients with BPH refractory to medical therapy is a safe procedure with low morbidity as well as very good short-term outcome.

P-378 Ureterial rendezvous: technique and results M. Corona1, C. Zini1, P. Lucatelli1, A. D’Adamo1, G.P. Ricciuti2, F.M. Salvatori1; 1Department of Radiological Sciences, Sapienza Università di Roma, Rome, Italy, 2Urology, Sapienza University of Rome, Rome, Italy Purpose: To describe and evaluate the feasibility of the rendezvous procedure for re-establishing ureteral continuity in case of iatrogenic lesions of the ureter. Material and Methods: From May 2005 to January 2014, 12 patients (5 males, 7 females; mean age, 56±16 years; range, 30–82 years) were referred to our department because of an iatrogenic ureteral lesion caused by prostatectomy (N=2), gynecological surgery (N=4), right colectomy (N=1), and rectum/anus resection (N=5). Including two bilateral injuries, 8 right ureteral lesions and 2 left ureteral lesions were present in our population. The treatment involved a combined percutaneous anterograde and cystoscopic retrograde approach in order to realign the ureter; double J stent was subsequently indwelled. Double stents were changed every 6 months until complete restoration of the ureter. Results: Realignment was successful in all cases (100%), and the initial nephrostomy was removed after a mean time of 5.8 days. Restitutio ad integrum was achieved in the ureter after 4 double J stents (N=3) and 3 double J stents (N=2); five patients had permanent maintenance of double J after 2 double J stents (N=2) and 1 double J stent (N=3). No surgical reconstruction of the ureter was necessary. No major complications related to the technique were observed. All patients were able to complete the adequate oncological therapies. Conclusion: Combined endoscopic–radiological rendezvous technique could be a valid option in an iatrogenic ureteral lesion, especially in oncological patients, thus avoiding an open operation.

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P-379 Retrograde ureteral catheterization following cystectomy in patients with an ileal conduit: technique and outcome S. Ilyas1, N. Shaida1, B. Koo2, A. Winterbottom2; 1Radiology Department, Addenbrooke’s Hospital NHS Trust, Cambridge, United Kingdom, 2Radiology, Addenbrookes Hospital, Cambridge, United Kingdom Learning Objectives: 1. Recognition of complications after cystectomy and urinary diversion: uretero-ileal anastomosis, stricture and fistula formation, and renal calculi. 2. Retrograde cannulation of ureters via the ileal conduit with retrograde stent insertion with or without balloon dilatation. 3. Combined antegrade approach: reserved for challenging cases. Background: Complications after cystectomy and urinary diversion include leakage at the uretero-ileal anastomosis, stricture and fistula formation, or renal calculi. Historically, these were treated with open surgery; however, over the past decade, there has been a move towards less invasive endourological techniques as these patients may not be appropriate operative candidates. Clinical Findings/Procedure: Indications for intervention in these patients include urospesis, elevated creatinine level, and loin pain with associated hydronephrosis. We describe our techniques of retrograde ureteric stent placement via the ileal conduit and report our success rate based on a combination of resolving symptoms and signs in the absence of surgical intervention or the need for longterm nephrostomy. Where retrograde ureteric cannulation is challenging, a combined antegrade approach is required. Urosepsis or anastomotic leaks may warrant a two-stage procedure with the insertion of a nephrostomy tube initially. Conclusion: Complications following urinary diversion are common and, if technically feasible, should be treated under fluoroscopic guidance in patients with multiple co-morbidites. Retrograde catheters draining directly into the stoma bag are better tolerated than antegrade catheters, and are associated with reduced complications.

P-380 Transplant kidney ureteral strictures: when and how to intervene D.A. Valenti1, R. Van der Wal1, K. Ho2, T. Cabrera1, C.I. Torres2, P.P. Rao2, K. Muchantef1, P. Delli Fraine1, A. Bessissow1, M. Anidjar3, J. Tchervenkov 2, L.-M.N.J. Boucher 2; 1Radiology, McGill University, Montreal, QC, Canada, 2Department of Radiology, McGill University Health Center, Montreal, QC, Canada, 3Department of Urology, McGill University Health Center, Montreal, QC, Canada Learning Objectives: 1. Understand when nephrostomy drainage is indicated in kidney transplants 2. Review basic technique of drainage 3. Review the technique of ureteral dilation 4. Discuss decision process concerning double-J stents and other drainage options Background: Ureteral strictures occur in 2%–9% of renal transplants, often due to ureteral ischemia. Strictures may be more common with increased ureter length, donor age, male donors, and retransplantation. At least two-thirds of strictures occur at the ureterovesical junction (UVJ). Ureteral stricutures can be managed percutaneously in almost all cases. Clinical Findings/Procedure: Nephrostomy drainage is the first step; technique will be reviewed. It is usually diffiult to cannulate UVJ cystoscopically in transplants, so antegrade drainage is required.

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At the time of initial drainage, attempts can be made to cross the ureteral stricture. If unsuccessful, a repeat attempt usually works. Once through the stricture, intravesical position is confirmed with contrast. Techniques to cross the stricure will be outlined. Dilation of the ureter is the next step – starting with standard balloons, sometimes using cutting balloons. A double-J stent is placed. Sizing wil be discussed. After a waiting period, the double-J stent is removed. The patient is monitored clinically, bochemically, and ultrasonographically. If obstruction recurs, drainage is performed again. Stategies to deal with recurrent strictures will be outlined. Conclusion: Transplant ureteral stricture occurs in 2%–9% of transplants, and is a common problem in major transplant centres. Appropriate management is critical for organ preservation. A multidisciplinary approach yields the best results. In almost all cases, the strictures are successfully treated percutaneously.

Abstract Book

P-384 Urethral recanalization after traumatic transection using the rendezvous approach and a radiofrequency guidewire C.R. Weiss1, A. Borowski1, J.P. Gearhart2, S.E. Mitchell1; 1The Russell H. Morgan Department of Radiology and Radiologic Science, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America, 2Urology/Pediatric Urology, Johns Hopkins University School of Medicine, Baltimore, MD, United States of America A 5-year-old boy with complete urethral transection underwent multiple failed attempts to recanalize his urethra from above. Using a cystoscope as a target, and a guidecatheter/RF generating guidewire (PowerWire™ RF Guidewire; Baylis) from below, we safely recanalized his urethra.

Venous intervention and IVC filters

P-381 Bilateral ureteric balloons for the treatment of ureteric leak J. Patel, K. Patatas, E.D. Lehmann; Interventional Radiology, Northwick Park Hospital, London, United Kingdom Post-operative urinary leaks are challenging and are associated with significant morbidity. We report the successful conservative management of a persistent urinary leak despite diversion by bilateral large-bore nephrostomies using percutaneous antegrade angioplasty balloon catheters to provide temporary bilateral ureteric occlusion.

P-385 3D computer modeling of the Celect IVC filter for clinical simulation J.D. Dowell1, M. Schickel2, S. Ghadiali2; 1Radiology, The Ohio State University, Columbus, OH, United States of America, 2Biomedical Engineering, The Ohio State University, Columbus, OH, United States of America WITHDRAWN

P-386

P-382 Inadvertent insertion of a ureteric stent into the inferior vena cava (IVC) I.U. Din, R. Davis, P. Kumar; Interventional Radiology, University Hospital Aintree, Liverpool, United Kingdom A nephrostogram in a post-operative patient demonstrated a distal uretero-colic fistula. Antegrade wire access to the bladder failed with subsequent retrograde stent placement. A CT abdomen performed for sepsis revealed that the stent was within IVC. The stent was successfully removed.

P-383 Percutaneous treatment of a postoperative ureteralaneurysmal sac fistula created after abdominal aortic rupture surgery V.D. Souftas1, P. Korodimos2, M. Kosmidou1, A. Mpantis2, G. Georgiadis1, P. Prassopoulos1; 1Radiology, University Hospital of Alexandroupolis, Alexandroupolis, Greece, 2Radiology and Medical Imaging, University Hospital, Alexandroupolis, Greece Ureteral-aneurysmal sac fistula formation following surgery for ruptured abdominal aorta aneurysm is a rare complication. Successful interventional treatment of an ureteral-aneurysmal sac fistula is presented by means of percutaneous nephrostomy, antegrade stenting and ureteral angioplasty, using cutting balloon and ballooning.

A single-incision technique for placement of the chemoports in the medial pocket after making the vertical incision via the axillary vein T.-S. Seo1, M.G. Song1, Y.H. Kim2, S.B. Cho2, H.H. Chung3, S.H. Lee3; 1Radiology, Korea University Guro Hospital, Seoul, Korea, 2Radiology, Korea University Anam Hospital, Seoul, Korea, 3Radiology, Korea University Ansan Hospital, Ansan, Korea Purpose: To evaluate the technical feasibility and safety of a singleincision technique for the placement of chemoports in the medial pocket after making the vertical incision via the axillary vein. Material and Methods: Ports were placed in 425 patients between May 2012 and August 2013 using a single-incision technique via the axillary vein after making the vertical incision and medial pocket. Patients included 281 men and 144 women with a mean age of 59.4 years. Ports were placed via the left and right axillary veins in 334 and 91 patients, respectively, after making a single vertical incision without subcutaneous tunneling and pocket medial side incision. Axillary vein punctures were directed medially at the incision site under ultrasound guidance. We retrospectively reviewed the success rates, problems, duration, and immediate and delayed complications of the procedure. Results: All single-incision port placements were technically successful. Problems occurring during the procedure included advancement of the wire or catheter into an unintended vein (n=59), kinking at the cuff–catheter junction (n=10), bleeding via the puncture tract (n=5), bending of the peel-away sheath (n=3), and puncture of the axillary artery (n=3). All technical problems were overcome with additional manipulation. The only immediate complication was puncture site hematoma in two patients. Conclusion: The single-incision technique for placement of the chemoports in the medial pocket after making the vertical incision via the axillary vein was a feasible and safe procedure with high technical success and low risk of complications.

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SS/FC/HL/HTS/CM Posters

S357

P-387

P-389

Balloon-occluded retrograde transvenous obliteration using sodium tetradecyl sulfate foam: intermediate-term result

Phlebographic classification of anatomic variants in the right spermatic vein confluence: 23 years of work

Y.H. Kim1, S.H. Kim1, Y.H.D. Kim2, C.S. Kim1; 1Radiology, Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea, 2Radiology, Dongsan Medical Center, Daegu, Korea

S. Pieri, A. Paolo, M. Domenico; Cardioscienze, Az Osp S.Camillo Forlanini, Rome, Italy

Purpose: To evaluate the clinical efficacy and intermediate-term result of BRTO using sodium tetradecyl sulfate (STS) foam as an alternative sclerosing agent. Material and Methods: From April 2011 to January 2013, we performed a prospective study in 24 consecutive patients with gastric varices. BRTO was performed with STS foam as new sclerosing agent. STS foam was made using a combination of 3% STS:contrast:air in a 1:1:2 ratio. Sclerosing time was one and half hour in all patients. To evaluate clinical efficacy, we obtained CT scans at 7 days, 3 months, and 1 year after BRTO. Results: The overall mean dose of STS used was 240 mg (range, 60–300 mg) with a mean total volume of sclerosant mixture of 31.6 mL (range, 16–48 mL). Technical success rate was achieved in 22 patients (91.7%), and clinical success was achieved in all patients who received BRTO (100%). In all patients, follow-up contrastenhanced CT scans showed complete obliteration of GV without any short- and intermediate-term recurrence. No major complication occurred in any patient. Conclusion: BRTO utilizing STS foam for sclerotherapy appears to be effective and safe in obliterating GV bleeding with good intermediate-term results.

P-388 Fluoroscopy-guided endovenous sclerotherapy into varicose tributaries using a microcatheter followed by endovenous laser ablation for incompetent saphenous vein: comparison between liquid and foam sclerotherapy S.W. Park1, I.S. Chang1, J.H. Oh2; 1Radiology, Konkuk University Hospital, Konkuk University School of Medicine, Seoul, Korea, 2Radiology, Kyung Hee University Medical Center, Seoul, Korea Purpose: To compare the efficacy and adverse effects of treatment with endovenous foam (EFS) or liquid sclerotherapy (ELS) using a microcatheter for varicose tributaries prior to endovenous laser ablation (EVLA) for incompetent saphenous vein. Material and Methods: From July 2005 to September 2011, patients with venous reflux in the great (GSV) and small saphenous veins (SSV) were enrolled. Foam or liquid sclerosant was injected through a microcatheter just before EVLA. Patients were evaluated for technical success, clinical success, and procedure-related complications during the procedure and follow-up visits. Results: A total of 512 limbs were included; 466 limbs (GSV, 355; SSV, 111) were managed using EFS and EVLA (FG), and 46 limbs (GSV, 37; SSV, 9) were treated by ELS and EVLA (LG). FG and LG showed complete closure in 96.6% vs 100% of the cases at 1-month follow-up and all (100%) at further follow-up (p>0.05). Varicose tributaries demonstrated complete sclerosis in 86% with FG and in 71.8% with LG (p=0.018). Bruising (79.0% in FG vs 73.2% in LG, p>0.05), pain or tenderness (68.4% in FG vs 51.2% in LG, p=0.03), and hyperpigmentation (54.2% in FG vs 46.2% in LG, p>0.05) were noted. Conclusion: EFS using a microcatheter is more effective than ELS for eliminating remnant varicose tributaries. However, EFS is more commonly associated with local complications such as pain or tenderness than ELS. Furthermore, both techniques seem to prolong the duration of hyperpigmentation along with higher costs.

Purpose: Male varicocele is a clinical dysfunction caused by pathological venous reflux. Knowledge of anatomic variants of the spermatic vein confluence is fundamental for the technical success of the percutaneous treatment. Material and Methods: From a retrospective review of 5,885 patients treated percutaneously between 1988 and 2011, we extrapolated the phlebographic images of patients with incontinence of the spermatic vein only. The indication for treatment was the presence of pain in the right inguinal region and absence of a history of trauma and/or seminal fluid alterations. Phlebography had been performed with transbrachial approach. Selective catheterization of the internal spermatic vein was performed to assess the radiological characteristics of the vessels prior to sclerosis. Results: There were 180 cases of incontinence of only the right internal spermatic vein (3.06%). In the first group of patients (14 cases, 7.8%), the right spermatic vein drained exclusively into the renal vein. In the second group (42 patients, 23.4%) the vein drained into both the renal vein and inferior vena cava, with one branch showing functional predominance. In most patients (124 cases, 65%), the internal spermatic vein drained into the inferior cava vein. Visualization of the incontinence was limited to the initial 5–10 cm of the vein in 26 cases. Conclusion: Interventional treatment is one of the therapeutic options for male varicocele. Interventional radiologists must have a thorough knowledge of the anatomic variants of the right spermatic vein confluence to be able to perform the procedure within a reasonable amount time and reduce radiation exposure.

P-390 Pulmonary arteriovenous malformations: percutaneous embolisation using Amplatzer Plug IV A. Balderi, A. Antonietti, F. Pedrazzini, C. Vinay, D. Sortino, E. Peano, M. Grosso; Radiology, Ospedale Santa Croce e Carle, Cuneo, Italy Purpose: The aim of our study was to illustrate the benefits of percutaneous treatment with embolisation of high-flow pulmonary arteriovenous malformations (PAVMs) in patients with hereditary haemorrhagic telangiectasia (HHT; Rendu–Osler–Weber disease) using Amplatzer Plug IV. Material and Methods: From December 2001 to July 2013, we embolized 277 PAVMs in 114 procedures performed on 89 patients, all referred by the ‘HHT Foundation international centre in Crema’, and enrolled in a screening programme of HHT families. All patients underwent clinical evaluation, contrast-enhanced ultrasound (CEUS) and spiral computed tomography (CT). Fifty-four of 277 PAVMs (19%) were treated using Amplatzer Plug IV (from April 2010 to July 2013). Results: All 54 embolisations using Amplatzer Plug IV were performed without difficulty, obtaining the immediate exclusions of PAVMs. One patient developed hemiparesis, which resolved in 12 hours. At the 6-month spiral-CT follow-up, we demonstrated the complete exclusion of treated PAVMs from the circulation. Conclusion: Percutaneous embolisation has recently become the initial treatment option in PAVMs owing to its good results and minimal invasiveness compared with thoracotomy. From 2009, Amplatzer Plug IV is available that can be deployed using 4- or 5-French catheters. This device seems to be time- and cost-efficient compared with coils, having the same level of invasiveness.

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P-391 Recurrent postsurgical varicocele embolization: anatomic reasons for surgical failure K. Pyra, T. Jargiełło, M. Szczerbo-Trojanowska, M. Sojka; Department of Interventional Radiology and Neuroradiology, Medical Univeristy in Lublin, Lublin, Poland Purpose: The formation or pre-existence of collateral gonadal veins in varicocele patients has been reported as the main cause of surgical treatment failure. We aim to describe the venographic findings in patients with post-surgical recurrent varicoceles and to assess the efficacy of the following minimally invasive endovascular treatment. Material and Methods: Thirty-three males with failed surgical treatment of left-sided varicocele were examined between 2006 and 2013 using retrograde venography to assess the anatomy of varicoceledraining veins before attempting transcatheter embolization. Anatomic variants of gonadal veins were categorized according to the classification modified for the purpose of the present study. We used 3% polidocanol as the embolic agent together with pushable fibered coils. Results: In 31 (93%) of 33 patients, venography demonstrated the incompetence of the gonadal vein or veins draining varicoceles after failed surgical treatment. The most frequent venographic finding was gonadal vein duplication in 66% cases (39% in its mid-portion). Embolization was technically successful in all 31 patients. No major complications were observed. Conclusion: Retrograde varicocele embolization may be superior to surgery because of its ability to detect gonadal vein variants. In our study group, transcatheter embolization with 3% polidocanol and fibered coils allowed successful, minimally invasive treatment of postsurgical varicoceles.

P-392 Retrospective review of 367 implantations of Option retrievable inferior vena cava filter at a single healthcare system W. Wang1, T. An2, E.K. Moon2; 1Interventional Radiology, Cleveland Clinic/Imaging Institute, Cleveland, OH, United States of America, 2Section of Interventional Radiology, Cleveland Clinic, Cleveland, OH, United States of America WITHDRAWN

P-393 A simplified algorithmic approach for the treatment of chronic Budd–Chiari syndrome: review of 75 cases S. Punamiya; Diagnostic Radiology, Tan Tock Seng Hospital, Singapore, Singapore Learning Objectives: To describe the use of a simplified algorithmic approach for the treatment of patients with chronic Budd– Chiari syndrome. Background: Budd–Chiari syndrome (BCS) is a complex disorder with various interventional treatment options, including the recanalisation of the hepatic veins and inferior vena cava and transjugular intrahepatic portosystemic shunts. The obstructive hepatocaval segment would vary in morphology, age and length; depending on this pathoanatomy and patient’s symptomatology, an appropriate procedure is chosen. An algorithmic approach is useful when such variability is encountered. Clinical Findings/Procedure: Seventy-five consecutive patients with symptomatic chronic BCS were considered for interventional treatment. The stepwise treatment strategy involved (1) restoration of normal physiological hepatic venous outflow by IVC and/or hepatic vein angioplasty and stenting and (2) creation of a portosystemic shunt when venous recanalisation is deemed to fail or has not

Abstract Book improved patient’s condition. Depending on the extent of occlusive disease, procedures performed included hepatic vein recanalisation, IVC recanalisation, complex hepatocaval stenting, TIPS and combined IVC stenting with TIPS. A simplified algorithmic approach is described using these treatment options in a systematic manner. Conclusion: BCS is a complex disorder with variable treatment options that depends largely on the morphology of venous outflow obstruction. An excellent clinical outcome is obtained with the use of this simplified approach.

P-394 Lower extremity deep venous thrombosis in the pediatric patient – state of the art C.E. Ray, Jr.1, M.-G. Knuttinen1, R.C. Gaba1, J. Minocha1, J.T. Bui1, S. Vedantham2, N. Goldenberg3, J. Durham4; 1Radiology, University of Illinois at Chicago, Chicago, IL, United States of America, 2Radiology, Mallinckrodt Institute of Radiology, St Louis, MO, United States of America, 3All Children’s Research Institute, Johns Hopkins School of Medicine, Tampa, FL, United States of America, 4Radiology, University of Colorado, Aurora, CO, United States of America Learning Objectives: 1. To understand the incidence and proposed etiologies of lower extremity deep venous thrombosis (LEDVT) in the pediatric population. 2. To understand the current treatment methodologies used in the treatment of LEDVT in children. 3. To summarize the ongoing research (particularly clinical trials) for pediatric LEDVT. Background: Deep venous thrombosis is more commonly observed in the adult population, but is not infrequently seen in the pediatric population. In the pediatric population, LEDVT is more typically associated with coagulation disorders or other underlying predisposing factors than it is in the adult population. In addition, postthrombotic syndrome clearly occurs with significant (approximately 25%) frequency and life impact in pediatric patients. Clinical Findings/Procedure: Diagnostic and treatment algorithms are not as well defined in the pediatric population as they are in the adult population. This is in part due to the relative paucity of significant data, particularly level 1 data, specific to the pediatric population. Given the long anticipated life span of this population and the risk of life-long complications from post-thrombotic syndrome, therapeutic protocols for pediatric patients with LEDVT should be clearly developed and prioritized. This poster will review the current evidence available for the treatment of LEDVT in children as well as discuss any on-going clinical trials addressing this disease process. Conclusion: Understanding the current status of LEDVT treatment in the pediatric population is vital to any interventionalist who may be consulted regarding thrombolysis procedures for these patients.

P-395 Is there a path through? Innovative use of Outback re-entry device to treat venous obstruction A. Parthipun1, K.N. Katsanos2, N. Karunanithy1; 1Interventional Radiology, Guy’s and St. Thomas’ NHS Foundation Trust, London, United Kingdom, 2Interventional Radiology, Guy’s and St. Thomas’ Hospitals, London, United Kingdom Inflated balloon was used as a target for Outback re-entry device to cross venous iliac occlusion when conventional endovascular technique failed. Push–pull tehnique with burst angioplasty balloon containing the guidewire was withdrawn from IJV access. Primary stenting was performed.

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P-396 Sharp recanalization of the inferior vena cava in Budd–Chiari syndrome E.M. Aldulaigan, S.A. Qazi, M. AL Moaiqel; Interventional Radiology, Medical Imaging, King Abdulaziz Medical City, National Gaurd Hospital, Riyadh, Saudi Arabia A 35-year-old female with refractory ascites having APD, SLE, and Budd–Chiari syndrome (IVC web), was referred for TJLBx; short segment suprahepatic IVC occlusion was found. Routine techniques failed. Sharp needle recanalization and stenting was performed. US at 18-month follow-up showed no ascites.

P-397 Successful treatment of duodenal varices combining transvenous balloon occlusion and endoscopic injection sclerotherapy O. Ikeda1, Y. Tamura2, Y. Nakasone1, S. Inoue2, T. Shono3, T. Kounoe3, Y. Sasaki3, Y. Yamashita1; 1Diagnostic Radiology, Kumamoto University Graduate School of Life Sciences, Kumamoto, Japan, 2Diagnostic Radiology, Kumamoto University Hospital, Kumamoto, Japan, 3Gastroenterology and Hepatology, Kumamoto University Graduate School of Life Sciences, Kumamoto, Japan This patient underwent endoscopic variceal ligation for esophageal varices. He developed melena due to ruptured duodenal varices at the inferior pancreaticoduodenal vein, which drained into the superior mesenteric vein. He then underwent transvenous balloon occlusion and endoscopic injection sclerotherapy.

SS/FC/HL/HTS/CM Posters

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S360

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Author Index SS/FC/HL/HTS/CM

Glasgow, UK

September 13-17

CIRSE 2014 PART 4 Author Index

List of all abstract authors with presentation numbers Please note that bold numbers indicate presenting authors and P-numbers stand for poster presentations.

Cardiovascular and Interventional Radiological Society of Europe

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S362

A Abdel-Rehim, M. Abo, D. Abraham, M. Abraham, R. Acosta Ruiz, V. Acunas, B. Adam, A. Adams, B. Adovasio, R. Affonso, B.B. Agazzi, R. Agolli, E. Agostini, G. Agriantonis, D. Aherne, T.M. Ahmed, I.

901.1 P-241 P-89 P-91 3105.2 P-14, P-48, P-105 2505.3, 3105.5 P-1 P-131 607.5, P-171, P-324 2208.3, P-225 P-88, P-340 P-263, P-353 3006.6, P-238 P-297 P-107, P-286, P-287, P-307, P-309 Ahuja, C. 2206.3, P-45 Airoldi, A. 2208.3 Aitken, E.L. P-83 Akata, S. P-112 Åkesson, M. 1802.3 Akgul, A. P-111 Akgul, E. P-182 Akhtar, M.R. P-42 Akinci, D. P-27 Akiyoshi, T. P-128 Aksungur, E. P-182 Aktas, A.R. P-41 Al Moaiqel, M. P-369, P-396 Alago, W. 3005.4 Al-Amari, S. P-222 Alberghini, F. P-28, P-138, P-161 Alberti, N. P-242 Albino, V. 1506.5 Albrecht, T. 2205.7 Aldulaigan, E.M. P-369, P-396 Alguersuari, A. P-84, P-160, P-373 Ali, M.M. P-238 Alishev, N. P-14, P-48, P-105 Alisky, J. P-245 Al-Lamki, S. P-289 Allen, W. P-149 Allevi, F. P-206 Almeida, P.A.M.S. 3203.3 Alnafisee, S.S. P-258, P-304 Al-Obaydi, W. 1406.5, P-153, P-315 Aloj, L. P-221 Alonso-Burgos, A. 1408.5 Alpagut, U.I. P-14, P-48 Alsafi, A. 1407.1, P-129, P-270, P-278 Amaral, J. 1406.1, P-98 Ameli-Renani, S. 3107.4, P-133, P-166, P-310, P-336 Amin, A. 3006.5 Ammar, T. P-211 Amouyal, G. 3005.5, 3106.6 Amthauer, H. P-218 An, S.W. P-20, P-21 An, T. P-392 Andhare, A. P-44, P-234 Andic, C. P-82, P-295, P-305 Andrašina, T. P-25, P-187 Andresen, R. P-254, P-301

CIRSE

Andrews, J.C. Anidjar, M. Anil, G. Antonella, F. Antonic, Z. Antonietti, A. Antonios, T.F. Antonuccio, E.G.M. Anzidei, M. Aoki, K. Appel, E. Arablinskiy, A. Arai, Y. Arashiro, M. Arena, U. Arepally, A. Argiro’, R. Armijo Astrain, J.E. Armstrong, T. Arsava, E.M. Arslan, B. Arya, R. Aryafar, Hamarz Aryafar, Hamed Asal, G. Asatiani, G. Atar, E. Avdevich, D. Avsenik, J. Awad, A.S. Awai, K. Azizi, M. Azrumelashvili, T. Azzeroni, R.

Abstract Book

1506.4 P-380 P-54 3005.3 P-139 P-240, P-390 902.1 3007.1, P-193 2306.3, 2306.4, P-35 P-97 3008.5 P-233 P-17, P-243, P-285 P-154 2208.3 202.3, 1406.3, 3104.6 1505.1, P-35 P-118, P-130 P-248 1005.4 P-38 P-37 P-33 P-33 P-31 P-283 1407.6, 1702.3, 2605.2 P-347 P-119 P-165 P-34, P-367 607.6, P-322 1405.4 P-319

B Baba, Y. Baek, J.H. Bagul, A. Bahoura, L. Baijal, S.S. Bakare, V.N. Baker, R. Balamurugan, R. Balázs, T. Balderi, A. Bale, R. Ballet, S. Balli, T.H. Balm, R. Balzano, G. Banavali, S. Bandi, R. Banerjee, A. Barbiero, G. Barburoglu, M. Barlas, A. Barnacle, A.M. Barral, F.G. Barrufet, M. Bartal, G. Bartels, M. Bartholomé, E.J. Bartling, S. Bartoli, J.-M.

P-241 P-266, P-273 P-336 3104.4 P-252 3005.1, 3007.6, P-44, P-234 P-318 1406.5 P-317 P-240, P-390 203.1, P-65 3007.3 P-182 3107.1, 3107.3, P-5 P-353 P-234 P-260 3006.3 P-338 P-14, P-48 3005.4 2504.4, P-50 3106.5, 3106.6 P-101 2605.3, 2704.4 P-282 3008.4 3008.5 2305.3

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Basile, A. Battistel, M. Battistuzzi, J.B. Baxter, B. Bayramoglu, Z. Bažík, R. Beckett, D. Behne, A. Bellemann, N. Belli, A.-M. Bellobuono, A. Benenati, J.F. Bengtsson, J. Beomonte Zobel, B. Bercu, Z.L. Bérczi, V. Beregi, J.-P. Bergerat, J.P. Berk Ergun, S. Bernard, V. Berntzen, D.T. Bertaccini, L. Bertini, M.J. Beschorner, U. Bessissow, A. Bessoud, B. Bester, L. Besting, A. Beumer, M. Beyer, L.P. Bezzi, M. Bhargava, B. Bhat, R. Bicen, F. Bicknell, C. Biegler, P. Bilbao, J.I. Bilhim, T. Bing, F. Binkert, C.A. Biondi Zoccai, G. Bipat, S. Birchall, D. Birgi, E. Bize, P.E. Blitz, L. Blue, R. Blümmel, J. Bodini, F.C. Bollen, T.L. Bonafé, A. Boni, F. Bonomo, L. Boronat, A. Borowski, A. Bosanquet, D.C. Boscarato, P. Bose, A. Bosiers, M. Bossalini, M. Bouanane, M.

1802.1 P-338 P-222 P-89 P-105 P-317 P-185 2205.7 P-143 607.4, 1805.3, P-175, P-176 3007.2 P-306 3008.3 3005.6, P-250, P-256 P-198, P-354 1705.3, 2602.1, P-66, P-259 1801.1 P-49 P-212 P-25 3007.5 2306.3, 2306.4, 2306.5 3006.3 607.2, P-291 P-127, P-380 P-251 P-236 2208.4 P-231 2306.6 1505.1, 1804.2, 3005.3, P-35 3008.2 P-261 P-105 1407.1, 1407.4, P-278 P-306 1001.4 2305.5, P-109, P-374, P-377 P-271 3301.4 2205.7 2205.5, 2205.6, P-302 P-142 P-316 904.4 3006.5 P-354 P-144 P-284 1703.1 905.4 2306.3, 2306.4, 2306.5, P-35, P-169 3007.1, P-193 3005.5, P-100 P-384 3107.5 P-342 P-89 607.2, P-291 P-284 3008.6

Boucher, L.-M.N.J. Boucherie, J.-C. Boudny, J. Boulin, M. Bouman, C.S.C. Bouwman, A. Bouzagrou, M. Bouziane, T. Bovio, G. Boyarintsev, M.I. Boyd, D. Bozkaya, H. Brambilla, G. Brambilla, S. Branera, J. Brant-Zawadzki, M. Brasseur, P. Brat, H. Bratby, M. Braun, S. Brauner, J. Bravo Rey, I. Breen, D.J. Brekkan, E. Brennan, P. Bretelle, F. Brichaux, J.-C. Brodmann, M. Brody, L.A. Brountzos, E. Brown, K.T. Brown, M. Bruening, R. Bruners, P. Bruno, R. Bruyère, P.-J. Bryant, T.J. Buckley, J. Budjan, J. Buecker, A. Buell, H. Bui, J.T. Bullen, J. Bungay, P.M. Buquicchio, M.G. Burbridge, S. Burgmans, M.C. Burnes, J.P. Burney, K. Burrel, M. Buy, X. Byun, S.S.

P-26, P-127, P-380 3005.5 P-25 P-144 3107.3 2306.1, P-228 2305.2 P-61 P-86, P-121 P-141 P-91 P-215 1405.3 P-24 P-84, P-160 P-89 P-55 P-61 2602.2 P-55 3108.5 1506.2 2501.2, P-248 3105.2 1005.1, P-257 P-186 P-51 607.2, 1003.5, P-291, P-293 3005.4 101.4 3005.4 3105.5 P-231 2208.4, P-145 2208.3 P-200 P-90, P-248, P-321 P-172 3008.5 1408.3, 2502.1, 3106.1, 3106.2, P-195 P-89 P-59, P-159, P-245, P-274, P-281, P-394 P-345 3006.2, P-332 P-178 P-333 1408.1, 1505.3 102.4, 2504.2 P-166 P-101 303.2, 2207.2, P-222, P-242 P-12, P-116, P-117

C Cabrera, J. Cabrera, T. Cahill, A.M. Camerano, F. Cameron, P. Campbell, J. Campeggi, A.

S363

SS/FC/HL/HTS/CM Author Index

CIRSE 2014

1408.5 P-26, P-127, P-380 103.3, 1406.2 P-121 2305.1 3104.4 3008.6

Campos Pinheiro, L. P-374, P-377 Candelari, R. P-342 Candito, D.F. P-7, P-24 Canis López, M. 1506.2, P-352 Cannavale, A. 1405.2, 2208.3, 3107.2, P-32 Caporali, C. 2208.3 Carata, L. 3005.3 Cardoso, I. P-320 Carey, W. P-345, P-350 Cariati, M. P-6, P-7, P-11, P-24, P-28, P-102, P-138, P-155, P-161, P-206, P-334, P-359, P-362, P-375 Carli, D. 2207.3 Carling, U. 3007.5 Carmody, E. P-304 Carnevale, F.C. 1004.2, 2901.1 Carr, J.C. P-191 Carrafiello, G. 1405.1, 1704.1, 3105.1, P-23, P-78, P-229, P-326 Carroll, T. P-191 Caruso, S. 2208.1, 2208.2 Catalano, C. 2306.3, 2306.4, 2306.5, P-35, P-169 Catena, V. P-242 Catoen, S. 3007.3 Cavalcante, R.N. 607.5, P-171, P-324 Cazejust, J. P-251 Cazzato, R.L. 303.2, 2207.2, 3005.6, P-222, P-242, P-250, P-256 Celtikci, P. P-316 Cengiz, Ş.L. P-214 Cereatti, F. 1405.2 Cervera Araez, A. P-85 Cevener, M. 1506.1, P-31, P-227 Chadha, M. 2206.3, P-45 Chakraverty, S. P-261 Challacombe, B. 3105.5 Chalmers, N. 301.2 Chan, A. 2205.4 Chan, S.X.J.M. 2205.1, P-299 Chandramohan, S. P-16 Chang, I.S. P-388 Chang, Y.-H. P-376 Chao, C. 3108.6 Chao, F. P-348 Charles, H.W. P-343 Chatturjee, N. P-191 Chaudhuri, A. P-135 Chavan, A. 2603.3 Cheguirim, M. P-60 Chen, A.T. P-38 Chen, C.C.-C. P-99 Chen, Y. P-348 Chernyshov, S.D. P-136 Chiaradia, M. 3008.6 Chiaravalloti, A. P-207, P-208, P-209, P-210 Chiba, K. P-17 Childs, L. P-8 Ching, K. P-260 Chiu, K.W.H. P-188 Chng, S.P. 2205.1, P-299 Cho, S.B. P-371, P-386

Choi, B.G. Choi, Y.H. Cholley, B.P. Chong, T.T. Chopra, R. Chovanec, V. Chrisman, H. Chua, S.Y.B. Chun, H.J. Chung, E. Chung, H.H. Chung, J.W. Chung, R. Chung, Y.E. Ciampi Dopazo, J.J.

P-18 P-272 3005.5 2205.1 2902.4 P-79 P-267 2205.1, P-299 3104.2, 3104.5, P-18 3104.2, 3104.5 P-371, P-386 2305.4, 3104.2, 3104.5, P-146, P-262 P-3, P-133, P-310 P-219

P-108 P-111 P-215 P-169 1405.2, 3107.2, P-32 2305.5 3106.4 301.6, P-361 101.1, 3303.4 P-75 1408.1 2206.4, P-224, P-244 3106.4 1408.2, P-197 3108.4 P-206 2206.6 P-191, P-267 P-150 2208.3 P-167 P-190, P-194 2205.5, 2205.6, 3107.1, P-302 Connolly, B. 1406.1 Conrad, B.A. 3107.5 Constant, M.J. 3108.2 Contegiacomo, A. P-193 Contractor, S.G. P-120 Cooper, S. P-26 Corelli, S. 2208.6 Cornalba, G. 1405.3, P-15, P-28, P-206, P-319, P-334, P-359, P-362, P-375 Cornelis, F. 2305.2, 3108.4 Corona, M. 1405.2, 1505.1, 3107.2, P-32, P-378 Corot, C. 3007.3 Correia, M. 1408.2 Cosimelli, M. P-237 Cossu, G. P-150 Costa, A. P-125, P-197, P-269 Costalat, V. 905.4 Cotroneo, A. P-334 Cousin, F. P-200 Cousins, C. P-265 Cova, M.A. P-131 Covey, A.M. 3005.4 Coyne, J. P-90, P-185, P-248, P-321 Crespi, S. 3007.2 Cil, B.E. Cinar, C. Ciolina, F. Cirelli, C. Cirurgião, F. Clark, N. Clark, T.W.I. Cleveland, T.J. Cliffe, H. Coenraad, M. Coffin, A. Cohen, A.M. Coimbra, E. Coleman, J. Colletti, G. Collettini, F. Collins, J.D. Colombo, M. Colopi, S. Colucci, F. Comans, E. Conijn, A.P.

S364

Criado, E. Crippa, M. Cruise, G.M. Cunha, R.S. Cura, M.A. Cwikiel, W. Czerny, C.

CIRSE

P-84, P-160, P-373 P-15 3108.2 P-134 P-239 3008.3 P-53

D D’Adamo, A.

1405.2, 1505.1, 3107.2, P-32, P-378 Dagli, M. 1405.5, 3108.6 Dahlman, P. 3105.2 Dahmane, M. P-11, P-86, P-155 Daly, C. P-91 Damm, R. P-218 D‘Angelo, R. 1506.5, P-221 Dappa, E. P-331 Darcy, M. 304.4 Darzi, A. P-278 Das, M. 3201.2 Das, R. 607.4, P-3, P-133, P-175, P-176, P-310, P-336 Davis, R. P-382 De Amorim, J.E. P-324 De Baère, T. 1001.2, 1805.4, 2207.4, 2306.2, 3005.2 De Bazelaire, C. 2206.4, P-224, P-244 De Beule, T. P-196, P-253 De Blas, I. 607.3, P-96 De Boo, D.W. 2305.1 De Caro, G. P-375 De Chiara, M. 1405.1 De Cobelli, F. P-150, P-263, P-353 De Coster, J. P-114 De Fina, B. P-324 De Gregorio, M.A. 607.3, 1004.3, 3006.3, P-96, P-279 De Jong, M.C. P-228 De Kerviler, E. 2206.4, P-224, P-244 De La Taille, A. 3008.6 De Lamo, S. P-373 De Margerie, C. P-244 De Nunzio, M. P-332 De Paoli, L. P-131 De Parades, V. 2305.3 De Santis, M. 2208.3 Déan, C. P-100 Defreyne, L. 904.3, 3008.4 Degirmenci, B. P-41 Deitrick, G. 3104.1 Del Maschio, A. P-150, P-263, P-353 Delli Fraine, P. P-127, P-380 Deloose, K. 607.2, P-291 Demarco, F.J. 3006.3 Dematteo, R.P. 3005.4 De’Medici, L. P-167 Deng, G. P-67 Deniz, S. P-288, P-305 Denys, A. 202.6, P-144 Deschamps, F. 303.3, 2207.4, 2306.2, 3005.2 Desgrandchamps, F. 2206.4 Desgranges, P. 3201.1, P-296 Deutschmann, H.A. P-293

Deux, J.-F. P-296 Di Maira, T. 2208.3 Diamantopoulos, A. 1505.5, 2205.2, P-287, P-289, P-303, P-307, P-309 Diaz, C.A. P-13 Diaz, O. P-89 Diaz-Cartelle, J. P-325 Diehl, S. 3008.5 Dietz, U. 2205.7 Din, I.U. P-286, P-382 Dionísio, T. P-63 Dixon, J. 607.7, P-80 Dmytriw, A. P-95 Dodds, K. 1406.2 Dollinger, M. 2306.6 Domenico, M. P-389 Donati, T. P-15 Dorenberg, E.J. 3007.5 Dörfler, A. 905.1 Dorr, A. P-293 Dósa, E. P-259 Dowell, J.D. P-385 Dravid, V.S. P-174 Du Preez, H. P-42 Duan, X. P-351 Duarte, H. P-63 Duarte, M. 2305.5, P-109, P-374, P-377 Düber, C. 3104.3, P-331 Dudeck, O. 3108.5, P-76 Dueland, S. 3007.5 Duka, E. P-229, P-326 Dupuy, D.E. 2701.3 Durham, J. P-43, P-132, P-363, P-394 Durmaz, H.A. P-212, P-316 Dyer, J. P-90, P-321

E Edwin, B. 3007.5 Efstathopoulos, E.P. 2704.2 Egan, T. P-77 Eichhorn, W. 3104.3 Eichler, K. P-53 Eide, N.A. 3007.5 Eker, H.E. P-82 Eker, O. 905.4, 2207.2 Eldergasch, O. 2603.3 Eller, P. P-293 Emerson, S. 3104.4 Enescu, I. P-271 Engelhorn, T. 905.1 Erbahceci Salik, A. P-27, P-111 Eren, S. P-189 Ergun, O. P-212, P-316 Erly, B.K. P-345 Eschenbach, G. 2205.7 Escudero, P. P-13 Espejo Herrero, J.J. 1506.2, P-352 Esteban Hernández, E. P-85, P-108 Ettles D.F. 1003.2 Evans, D. P-211

C RSE

Abstract Book

F Fabre, T. Facchini, F.R. Fadin, B.V. Fagiuoli, S. Faiella, E. Falco-Fages, J.F. Fallon, M. Fan, F. Fan, N. Fanelli, F. Fanello, G. Farhat, Z. Farsad, K. Faughnan, M. Fedele, C. Felicioli, A. Fernandes, L.

2207.2 3006.3 P-136 2208.3 3005.6, P-250, P-256 P-84, P-160, P-373 303.1 2205.4 3005.4 101.2, 1405.2, 2208.3, 3107.2, P-32 1405.2 1406.1 2206.3, P-357, P-360 P-103 P-238 P-342 2305.5, P-109, P-374, P-377

Fernández-Parra, R. P-279 Fernandez-Tresguerres, B. 607.1, P-294 Fernando, R. P-201 Ferrer-Puchol, M.D. P-85, P-108 Ferro, C. P-11, P-86, P-102, P-121, P-155, P-334, P-359 Fesenko, D.V. P-235 Fichetti, M. P-342 Fierens, J.J. 3008.4 Figueroa, N.C. P-318 Filatov, M. P-141 Fina, B.D. 607.5, P-171 Fiocca, F. 1405.2 Fiore, F. 1506.5, P-221 Fiorina, I. 2208.3 Fischman, A.M. 2208.6, 3104.6, P-89, P-198, P-354 Fleming, C.J. 1506.4 Flett, M. P-261 Flood, K. P-75 Floridi, C. 1405.1, 1704.1, 3105.1, P-78, P-229, P-326 Flowers, D. P-90, P-248, P-321 Foley, P. 2305.1 Fontana, F. 1405.1, 3105.1 Forde, C. P-149 Forjaz, M. 2305.5 Forrer, F. 204.2 Fortuño, J.R. P-84, P-160, P-373 Fotheringham, T. P-87 Fotiadis, N.I. P-201 Foukal, J. P-187 Fourneau, I. P-253 Fournier, D. P-61 Fowlkes, B. P-355 Francois, O. P-114 Frans, F. 2205.6 Frauenfelder, T. 3107.6 Freire, G.M.G. 607.5, P-171 Frey, G. P-232 Freyhardt, P. P-337 Friend, C.J. P-260 Fries, P. 1408.3

Fuchs, J. Fugazzola, C. Fujisawa, H. Fujisawa, S. Fukuda, T. Fukuyama, N. Fumoto, K. Funaki, B.S. Funatsu, T. Funovics, M.A. Furukawa, A.

P-282 P-23, P-229 P-46 3005.4 P-329 P-47 P-246 1408.4 P-112 2603.1 P-246

G Gaba, R.C.

S365

SS/FC/HL/HTS/CM Author Index

CIRSE 2014

P-59, P-159, P-245, P-274, P-281, P-394 Gahlot, P. P-54 Gaikwad, K.U. P-44, P-234 Gailloud, P. P-89 Gal, G. 905.3 Gala, K.B. 3005.1, 3007.6, P-44, P-152, P-234 Galasso, R. 1506.5, P-221 Galastri, F.L. 607.5, P-171, P-324 Gandhi, R.T. P-318 Gandini, R. P-207, P-208, P-209, P-210 Gangi, A. 203.4, 303.2, 903.1, P-49, P-271 Garbajs, M. 3007.4 Garcia, A.R. 3005.4 Garcia, E. P-373 Garcia, M.J. 3006.5, 3006.6, P-238 Garcia Alba, C. P-251 García Oliver, E. P-85 Garcia Revillo, J. P-352 Garnon, J. 2501.4, P-49, P-271 Gary, T. P-293 Gasparini, D. 3005.3 Gavier-Widén, D. 3008.3 Gavrilovic, V. P-260 Gawlitza, M. P-282 Gazzera, C. 3005.3 Gearhart, J.P. P-384 Gebauer, B. 103.4, 2206.6, P-337 Geboes, K. 3008.4 Gedikoglu, M. P-82, P-288, P-295 Gemmete, J.J. P-64, P-106 Generalov, M.I. P-136 George, D. 3104.4 Georghiou, G. P-10 Georgiades, C.S. 2206.1, 2206.2, P-10 Georgiadis, G. P-383 Georgountzos, V. P-124 Geschwind, J.-F.H. 1001.3, 3202.3 Ghadiali, S. P-385 Ghouri, M.A. P-142 Giantonio, B. 3104.1 Gibbs, R.G. 1407.1, 1407.4 Gilbert, C.W. 3008.1 Gilbert, P. P-103 Gill, A. P-151 Gillams, A. 1804.1, 2701.4 Gimenez, J.M. P-247 Ginsburg, M. 1408.4 Gioppo, A. P-319 Gipson, M. P-43, P-132, P-363

Giroux, M.-F. Giuliani, S. Giulianotti, P. Giurazza, F. Given, M.F. Gizewski, E.R. Gkoutzios, P. Glenck, M.J. Gnutzmann, D. Gobara, H. Gockner, T.L. Goel, M. Goffette, P.P. Gögebakan, Ö. Gogna, A. Goh, G.S. Gohel, M. Gok, M. Gökmen, E. Gola, G. Goldberg, D.J. Goldberg, N. Goldenberg, N. Goldin, D. Golfieri, R. Golli, M. Golzarian, J. Gómez, F.M. Gonçalves, B. Gonen, M. Gonsalves, M. Gonzalez, W. Goo, D.E. Goodman, M. Gorący, J. Gordon, A. Gordon-Smith, J. Goshima, S. Gouttefangeas, C. Goverde, P. Gozlek, E. Graif, A. Grams, A.E. Grasso, R.F. Greenberg, J. Grenier, N. Griauzde, J. Grilli, C.J. Grimme, F.A.B. Groesdonk, H. Grosso, M. Gudmundsson, M.T. Guedes Pinto, E. Guerra, A. Guiness, R. Guitart, J. Guiu, B. Gulati, G.S. Gulia, A. Günther, R.W. Guo, J.-H. Gupta, A. Gupta, R. Gupta, Y. Gurajala, R.K.R.

P-103 P-167 P-159 3005.6, P-250, P-256 3006.4, P-19 P-213 P-287, P-307 3107.6 P-143 P-241 P-143 3007.6 3008.4 2205.7 2205.1, P-299 2502.2 P-313 P-215 P-214 P-86, P-121 1406.2 2605.1, 3202.2 P-394 3104.4 2208.3, P-237 P-60, P-62 1004.4, P-100 P-101 3203.3, P-63 3005.4 P-133, P-310 3007.3 P-81, P-180 1407.6, 2605.2 P-217 3107.5 P-276, P-358 P-177 3202.4 P-2, P-290, P-292 P-41 P-238 P-213 3005.3, 3005.6, P-242, P-250, P-256 P-132 2305.2 P-64, P-106 3006.6, P-238 P-2, P-292 P-195 P-240, P-390 P-33 P-125, P-197, P-269 3007.1, P-193 P-312 P-101 P-144 3008.2 3005.1, P-234 P-337 1406.4 P-40, P-174 P-43, P-132, P-363 P-289 P-151

Gurdal, C. Güzel, A.B. Guzelmansur, I. Guzman, A.K. Györke, T.

P-212 P-182 P-82 1406.2 P-66

H Ha, E.J. Haage, P. Habib, N. Hacking, N.

P-266, P-273 1802.4 1405.4, P-74, P-283 202.2, P-90, P-248, P-321 Haen, S.P. 3202.4 Haeussler, S.M. P-56 Hag Mohamed Ali, B. 3106.6 Häggman, M. 3105.2 Hagino, R. P-89 Hall, M.J. 3006.3 Hamady, M.S. 104.4, 1407.1, 1407.4, P-129, P-270, P-278 Hamaguchi, S. P-17, P-285 Hamanaka, Y. P-246 Hamilton, C.R. 2505.4 Hammond, C.J. P-75 Hampton, T. P-211 Han, X.-W. P-22, P-36, P-202, P-351 Han, Y.H. P-255 Hänninen, E.L. 2205.7 Harada, J. P-372 Harris, M. 202.1, 1004.1, P-90, P-321 Hartman, J.B. P-350 Hartmann, H. 2205.7 Hartung, M.P. 2207.5 Harzallah, W. P-60, P-62 Hasdemir, D.B. 2208.5, P-344 Hasegawa, T. P-364, P-368 Hashimoto, K. P-285 Hashizume, N. P-46 Hashizume, T. P-104 Haskal, Z.J. 2703.2 Hassan, M.R. 1408.6 Hatipoglu, E. P-288, P-305 Hatten, Jr., H.P. 2207.1 Haugvik, S.P. 3007.5 Haumonté, J.-B. P-186 Hausegger, K.A. 305.1, 1003.6, P-204 Hay, C. P-276, P-358 Hayashi, A. P-92, P-140 Hayashi, H. P-264 He, S.-C. P-67 Heck, D. P-89 Heister, D. P-69 Hekimoglu, B. P-212, P-316 Helmy, A.E. 1405.6 Henkes, H. 1005.2 Hennessy, M. P-16 Henroteaux, D. P-200 Heverhagen, J. 3108.2 Heye, S. 3008.4, P-196, P-253 Heye, T. 1505.4 Hieb, R.A. P-70 Higashi, M. P-329 Higashi, Y. P-92 Higashihara, H. P-92, P-226

S366

Higashiura, W. Hilliard, N. Hirata, M. Hirose, T. Hirota, S. Hlavsa, J. Hmida, B. Ho, K. Hoffmann, R.-T. Hohenwalter, E.J. Hohl, C. Holden, A. Hollenbeck, C. Hoppe, U. Hori, Y. Horikawa, M. Hoshiai, S. Houston, J.G. Hu, C. Huang, D. Hubsh, J.-P. Huettl, E.A. Hui, W.Y.J. Hukuoka, Y. Hung, S.-W. Huppert, P.E. Hur, S. Husainy, M.A. Hüttl, K. Hynes, N.

CIRSE

P-154 P-313 P-47 P-246 P-241 P-25 P-60, P-62 P-26, P-380 P-56 P-70 2703.1 301.5, 3201.3 3007.3 P-325 P-92 P-357, P-360 P-183 P-261 1406.3 P-211, P-314 3005.5 P-376 2205.4 3008.1 P-99 304.1 2305.4, P-220, P-262 P-314 P-259 1407.5

I Iavarone, M. Idoguchi, K. Ierardi, A.M. Iezzi, R. Iida, M. Ikeda, O. Ilyas, S. Imamine, R. Inaba, M. Ingram, L.M. Inoue, A. Inoue, M. Inoue, S. Ip, V. Iraha, T. Irani, F.G. Ireland, H.M. Iseri, T. Isfort, P. Ishii, H. Ishikawa, M. Ishikawa, T. Ishimaru, Y. Islim, F. Isoda, H. Ito, N. Iwashima, Y. Izzo, F.

Abstract Book

J Jackson, A.J. Jackson, R. Jae, H.J. Jaffer, O.S. Jagia, P. Jagoda, P. Jahnke, T. Jain, D. Jain, V. Jakobs, T.F. James, K. Janu, A. Januszewicz, M. Jargiełło, T. Jazaeri, O. Jenkins, M. Jens, S. Jeon, C.H. Jeromel, M. John, P.R. Joo, S.-M. Juhn, J.R. Jung, D.C. Jung, E.-M. Jürgens, J.

P-83 1703.4, P-72 2305.4, P-146, P-220, P-262 P-308 3008.2 3106.1, 3106.2 1701.3 P-252 P-252 2601.2 P-172 3005.1, 3007.6, P-44, P-152, P-234 P-323 P-391 P-132 1407.1 2205.5, 2205.6, P-298, P-302 P-20, P-21 P-205 1406.1, P-98 2305.6 P-181 P-168 2306.6 2306.2, 3108.5

K 3007.2 P-140 1405.1, 1704.1, 3105.1, P-23, P-229, P-326 3007.1, P-193 P-367 P-39, P-241, P-280, P-366, P-397 P-163, P-265, P-313, P-379 P-349 P-147 P-90, P-321 P-97 P-122, P-128 P-39, P-280, P-366, P-397 2205.4 P-154 2205.1, P-299 P-276 P-140 2208.4, P-145 P-243 P-34 P-370 P-341 P-27, P-111 P-349 P-145 P-329 1506.5

Kably, I.M. P-247 Kachramanoglou, C. P-211 Kaji, T. P-357 Kajiwara, K. P-34, P-367 Kala, O. P-187 Kalina, I. P-66 Kallur, K.G. 1506.6 Kameoka, Y. P-372 Kamusella, P. P-254, P-301 Kanasaki, S. P-246 Kanematsu, M. P-177 Kang, B. P-262 Kang, B.C. P-371 Kang, T.W. 3105.3 Kang, U.R. P-179 Kang, Y.J. P-73 Kantarci, M. P-189 Kanzaki, S. P-329 Kapoor, A.K. P-252 Kapoor, B. P-345, P-350 Kaposi, P.N. P-66 Karakitsios, I. P-192 Kargi, A. 1506.1, P-31, P-227 Karlstam, E. 3008.3 Karnabatidis, D. 1505.5, 2205.2, 2702.1, P-303 Karrow, J. P-59 Karunanithy, N. P-287, P-307, P-309, P-395 Karuppasamy, K. P-151 Karydas, G. P-124 Kashef, E. 1407.1, P-129, P-270 Kasprzak, P. P-292

C RSE

Kasthuri, R. Katayama, N. Katayama, S. Katoh, M. Katsanos, K.N.

Katsargyris, A. Katzen, B.T. Kau, T. Kauczor, H.-U. Kaufman, C. Kaufman, J.A. Kavcic, P. Kavnoudias, H. Kawada, H. Kawaguchi, N. Kawai, N. Kawai, T. Kawanaka, K. Kawano, Y. Kayan, M. Kazemier, G. Kee, S. Keeling, A. Kehagias, E. Kehoe, S. Keller, F.S. Keller, M.S. Keluth Chavan, V. Kemeny, N.E. Kennedy, A.S. Kenny, L.M. Keskin, S. Kessel, D.O. Ketsakin, Y. Keussen, I. Khairutdinov, Y. Khametov, R.Z. Khan, N. Khandelwal, A.H. Khanna, K. Kharoti, Y. Khin, P.M. Khira, H.G. Khouri Chalouhi, C. Khurana, N. Kichikawa, K. Kieselbach, D. Kikuchi, K. Kim, C.S. Kim, C.W. Kim, E. Kim, E.-Y. Kim, G.M. Kim, H. Kim, H.-C. Kim, H.-H. Kim, H.O. Kim, I.J.

607.7, P-80, P-83 P-140 P-339 301.4, P-195 301.1, 1505.5, 2205.2, 3105.5, P-107, P-287, P-289, P-303, P-307, P-309, P-395 1407.2, 1407.3, 2503.1, P-300 P-318 P-204 P-143 P-162, P-199 2206.3, P-199, P-357, P-360 3007.4 2305.1 P-177 P-47, P-341 P-93 P-104 P-39 P-329 P-41 2306.1 1302.2 3006.4, P-19 P-326 P-91 P-357, P-360 1406.2 P-38 3005.4 P-236 1805.1, 2701.2 P-214 2502.3, P-75 P-296 304.2, 3008.3 P-173, P-233 P-235 P-42 P-252 P-8, P-77, P-87, P-308, P-335 2206.3 P-299 P-68 P-15, P-206 P-38 3008.1, P-203 2205.3 P-154 P-179, P-387 3104.2 2208.6, 3104.6, P-89, P-198, P-354 P-156, P-158 3104.2, 3104.5, P-220 P-179 2305.4, P-220, P-262 P-272 P-73, P-94 P-168, P-170, P-219, P-356

Kim, J.D. Kim, J.H. Kim, J.K. Kim, M.D. Kim, P.S. Kim, S.H. Kim, S.J. Kim, S.W. Kim, T.-H. Kim, T.Y. Kim, W.B. Kim, Y.H. Kim, Y.H.D. Kim, Y.I. Kim, Y.J. Kim, Y.-J. Kim, Y.T. Kimbiris, G. King, D. Kingsmore, D.B. Kinney, T.B. Kinoshita, T. Kircher, A. Kirk, A.J.B. Kirk, J. Kirmi, O. Kishimoto, K. Kisza, P. Kitrou, P.M. Kiyosue, H. Klimstra, D.S. Klingele, M. Kloeckner, R. Klucznik, R. Knuttinen, M.-G. Kobeiter, H. Koblikov, V. Koc, O. Koca, N. Koch, U. Kochhar, G. Kock, G.-A. Koelemay, M.J.W. Kolbeck, K.J. Kon, Y. Kondo, H. Kondo, K. Kondrashin, S. Konishi, T. Koo, B. Korodimos, P. Kortes, N. Korzeniowski, K. Kosiek, O. Kosmidou, M. Kossuth, I. Koulia, K.S. Kounoe, T. Kovacevic, V.

S367

SS/FC/HL/HTS/CM Author Index

CIRSE 2014

2305.4, P-220 P-12, P-116, P-117, P-158, P-223 3104.2, 3104.5, P-73, P-94 P-168, P-170, P-219, P-356, P-371 3006.3 P-73, P-94, P-179, P-387 P-146 P-255 P-158 P-266 P-266 3104.2, 3104.5, P-179, P-356, P-386, P-387 P-387 P-146 P-81 P-20, P-21 P-73, P-94 3006.6, P-238 2207.5 P-83 3301.3 P-147 1505.4 2701.1 P-315, P-332 1407.4 P-92, P-226 P-120 3105.5, P-287, P-303, P-307 904.1, P-216, P-365 3005.4 P-195 3104.3, P-331 P-89 P-59, P-159, P-245, P-274, P-281, P-394 2702.2, 3008.6, 3201.1, P-296 P-330 P-214 P-295 P-231 P-350 P-230 2205.5, 2205.6, 3107.1, P-298, P-302 2206.3, P-357, P-360 P-17 P-177 P-43, P-132, P-363 P-330 P-183 P-163, P-313, P-379 P-383 P-143 P-4, P-323 2306.2 P-383 P-217 3303.1 P-366, P-397 P-139

Kovacs, F. Kovalenko, I.B. Kozák, L.R. Kozak, O. Kraitchman, D.L. Krajina, A. Kranzhoefer, N. Kravchenko, E. Kriegshauser, J.S. Kripfgans, O. Krishnamurthy, G. Krokidis, M. Kubota, T. Kucher, N. Kuhelj, D. Kuhl, C. Kulinkovich, I. Kulkarni, S.S. Kumar, A. Kumar, N.S. Kumar, P. Kumar, S. Kumita, S. Kuntelia, K. Kuo, S.S. Kuo, W.T. Kurata, N. Kurokawa, S. Kushihashi, T. Kuwayama, D. Kwak, B.K. Kwon, D.I. Kwon, D.S. Kwon, J.H. Kwon, S.H. Kyriakou, Y.

3006.2, P-315, P-332 P-141 P-66 P-347 1406.3 P-79 3106.1, 3106.2 P-173 P-376 P-355 1406.2 1505.5, 3203.2, P-265 P-154 1302.1 3007.4 2208.4 P-347 3005.1, 3007.6, P-44, P-152, P-234 3005.1, 3007.6, P-44, P-120, P-152, P-234 P-54 P-382 1702.4, 3008.2, P-40 3105.4, P-115, P-148, P-264 P-113 P-89 3006.3 P-372 P-203 P-46 P-132 P-29, P-311 3104.2, 3104.5 1704.3 P-255 P-30, P-275 3108.5

L La Torre, M.F. P-193 Laborda, A. 607.3, P-96, P-279 Labunets, Z. P-347 Lachat, M.L. 3107.6 Ladjevardi, S. 3105.2 Laganà, D. P-23 Lagerveld, B. P-230 Lahuerta, C. P-279 Lai, J. P-89 Lakshminarayan, R. P-188 Lammer, J. 1801.4 Lanciego, C. P-108 Lange, A. P-55 Lange, C. 2205.7 Langhoff, R. 607.1, P-294 Lanza, E. 1405.3 Larrivée, S. P-103 Lasserre, A.-S. 2305.2 Lastoria, S. P-221 Lauermann, J. 2208.5, P-344 Lauwers, K. P-2, P-290 Lawler, L.P. 104.3 Le, N. P-192 Lea, S. P-286

Leahy, A.L. Lebras, Y. Lechareas, S. Lee, C.K. Lee, D.M. Lee, D.Y.

3006.4, P-297 2305.2 P-124 P-12, P-116, P-117 P-304 P-168, P-170, P-219, P-356 Lee, H.G. P-18 Lee, J. P-267 Lee, J.H. P-266 Lee, J.M. P-81, P-110 Lee, J.T. P-170 Lee, K.-H. 2305.6, 3104.2, 3104.5 Lee, K.T. 2205.4 Lee, M. 2305.4, P-146 Lee, M.J. 902.2, 3006.4, P-19, P-258, P-268, P-297, P-304, P-327 Lee, M.S. P-262 Lee, R.J. P-304 Lee, S.H. P-386 Lee, S.J. P-168, P-170, P-219, P-356 Lee, W.-H. P-81, P-180 Legemate, D.A. 2205.6, 3107.3, P-5 Lehmann, E.D. P-381 Lencioni, R. 901.3 Leonardi, A. 2306.4 Lessne, M. 2206.1, 2206.2 Leung, D. 3006.5, 3006.6, P-238 Leung, T. 2205.4 Levent, A. P-189 Levy, J. 1405.5 Levy, J.R. 3006.3 Lewandowski, M. P-217 Lewandowski, R.J. 204.4, P-191 Lewis, S.C. 3104.6 Leyva Vásquez-Caicedo, M. P-118, P-130 Li, P. 2207.6 Li, T.-F. P-22, P-202 Li, Z. P-22 Li, Z.-M. P-36 Lie, K. 3006.6, P-238 Lightfoot, C. P-95 Lim, Y.S. P-18 Lin, Y.-T. P-99 Lindsay, A. P-274 Lions, C. 1702.2 Lo, G.C. 2208.6 Lo, H.G.R. 2205.1, P-299 Loftus, I. 3107.4 Lohle, P.N.M. 2207.3 Lombardo Galera, S. 1506.2, P-352 Lönn, L.B. 2503.2 Lönnemark, M. 3105.2 Looby, S. P-257 Lookstein, R.A. 2208.6, 3006.5, 3104.6, P-198, P-354 Lopez-Benitez, R. 3108.2 Loreni, G. P-207, P-208, P-209, P-210 Lorenzen, O. P-301 Louis, G. 2305.3 Low, D.E. P-8, P-77, P-87 Luca, A. 2208.1, 2208.2, 2208.3

S368

Lucatelli, P. Lucchina, N. Luedtke, C. Lumia, D. Luong, E. Luppi, G. Lutat, C. Lutjeboer, J. Lyon, S.M.

CIRSE

1405.2, 3107.2, P-32, P-378 P-23, P-229 P-301 P-23 P-89 3005.6, P-250, P-256 3108.3 1505.3 2305.1

M Maatouk, M. P-60, P-62 Macchi, E. 3105.1 Macdonald, S. 1702.1 Machado Carvalho, A. P-63 Machi, P. 905.4 Maciag, R. P-4, P-323 Macias, N.G. P-101 Madarang, E. P-89 Maeda, N. P-92, P-226 Magnusson, A. 3105.2 Mahalingam, S. P-166 Mailli, L. P-133, P-310 Makuuchi, H. P-17 Maleux, G.A. 3008.4, P-100, P-196, P-253 Malige, S. 1506.6 Malik, H.Z. 901.2 Malliwal, R.S. P-87 Malý, R. P-79 Manninen, H.I. 2602.4 Manova-Todorova, K. 3005.4 Mansbridge, C. P-248 Mantagui, F. P-224 Manyonda, I. 607.4, 1705.1, P-175 Manzi, M.G. 2702.3 Mao, H.-Q. 1406.3 Marashi, K.B. P-239 Marcia, S. P-58 Marini, S. P-58 Marinkovic, V. P-164 Markus, H.S. 305.4 Marquardt, S. 2208.5, P-344 Marquering, H.A. P-298 Marquez, C. 2206.3 Martin, D.F. 1703.2 Martin, R.C.G. 1704.3 Martin III, C. P-151 Martinetti, L. 3007.2 Maruno, M. P-365 Maruzzelli, L. 2208.1, 2208.2 Marzocchi, G. 2208.3 Masada, T. 3008.1 Massmann, A. 1408.3, 3106.1, 3106.2 Mateos, A. P-373 Matsumoto, S. P-365 Matsunaga, N. P-339, P-370 Matsunari, K. P-46 Matsuoka, T. P-140 Matyash, Y.S. P-235 Matzko, M. 1505.2, 1705.4, 2902.2 Mauri, G. 1405.3 May, M.D. 607.5, P-171

Mayer, J. Mayer, J.-F. Maystrenko, D.N. Mazor, M. Mbalisike, E. McCartney, E. McCluskey, K.M. McEniff, N. McGarry, J.G. McGarry, M.K. McGrath, F. McHugh, S. McIntosh, A. McKinney, J.M. McLarty, J. Mclennan, G. McLucas, B. McPherson, S.J. McWilliams, R.G. Mechel, J. Meeks, M. Mehta, S. Meijer, S. Meijerink, M.R.

3008.6, 3201.1, P-296 3007.3 P-136 P-325 P-53 607.7, P-80 P-260 103.1 P-257 P-238 3006.4 3006.4, P-297 1406.2 P-232 2206.3 P-151 1505.6 302.2, P-75 2503.3 P-143 P-296 3007.6 2306.1, P-190, P-228 2306.1, P-190, P-194, P-228 Melchiorre, F. 1405.3, P-15, P-28, P-206, P-319, P-334 Meler, J.D. P-239 Meloni, M.F. 3005.3 Melzer, A. 2902.1, P-192 Mendez Montero, J.V. P-118, P-130 Meng, Z. 1704.4 Menu, Y. P-251 Mercurio, S. 3005.6, P-250, P-256 Meria, P. 2206.4 Messina, M.D.L. 607.5, P-171 Met, R. 2205.6 Meyer, B.C. 2208.5, P-344 Meyer, D.-R. 2205.7 Meyer, G. 3106.5 Mezzolla, C.L. 3005.3 Michelozzi, C. 1405.3 Michieletti, E. P-284 Michimoto, K. P-372 Mick, R. 1405.5 Mie, K. P-140 Miele, V. P-167, P-178 Mihajlovic, M. P-164 Mikala, G. P-66 Miki, H. P-341 Miki, I. 3105.4 Miller, F. P-191 Minami, M. P-183 Minami, T. P-241 Mincarelli, C. P-342 Mindjuk, I. 1505.2 Mine, T. 3105.4, P-115, P-148, P-264 Mingazzini, P. P-138 Minko, P. P-195 Minocha, J. P-59, P-159, P-245, P-274, P-281, P-394 Miotto, D. P-338 Miraglia, R. 2208.1, 2208.2 Mirza, M. P-268 Misaki, S. P-97

C RSE

Abstract Book

Mismetti, P. 3106.5 Mitchell, S.E. P-384 Miyairi, T. P-17 Mizandari, M. 1405.4, P-74, P-283 Mnari, W. P-60, P-62 Moche, M. P-282 Mochizuki, T. P-47, P-341 Modrzejewski, A. P-217 Mogami, T. P-372 Mohanty, S. 3008.2 Möhner, B. P-300 Mohnike, K. P-218 Mojibian, H.R. P-162 Mokrane, T. 1702.2 Mokry, T. P-143 Molina, H. P-267 Moloney, F. P-172 Mondschein, J.I. 1405.5, 3104.1, 3108.6 Moneley, D. 3006.4, P-297 Monge, M. 607.6, P-322 Mongiat-Artus, P. 2206.4 Montagna, B. 3005.3 Montañá, X. P-101 Montauban Van Swijndregt, A. P-230 Montechiari, M. P-15, P-206 Montesinos García, P. P-85 Monzon, L. 1407.4, P-129 Moon, E.K. P-392 Moramarco, L.P. 2208.3 Moran, T. 1406.3 Morelli, F. P-263 Morgan, R.A. 2603.4, 3107.4, P-3, P-133, P-310 Morgan Bates, K. P-135 Mori, H. P-216, P-365 Mori, K. P-183 Mori, S. P-97 Morii, E. P-92 Morimoto, R. P-147 Morita, R. P-364, P-368 Morita, S. P-243 Morita, Y. P-329 Morosetti, D. P-207, P-208, P-209, P-210 Morshedi, M.M. P-33 Mosconi, C. 2208.3 Moss, J.G. 201.1, 607.7, 902.4, P-71, P-80 Motta-Leal-Filho, J.M. 607.5, P-171, P-324 Moyle, H. P-89 Mpantis, A. P-383 Muchantef, K. P-26, P-380 Müller-Hülsbeck, S. 1003.1, 1801.2 Mulligan, M. P-70 Mullins, L. P-149 Munneke, G.J. P-310, P-336 Muradi, A. P-140 Murakami, K. P-285 Murakami, Y. P-97 Murata, K. P-97 Murata, S. 3105.4, P-115, P-148, P-264 Murphy, J. P-172 Murray, T.É. P-327

Murshed, A.S. Muto, M. Myochin, K.

1408.6 903.2 P-203

N Na, H.-S. Nadkarni, N.D. Naidu, S.G. Naito, H. Nakagwa, H. Nakajima, Y. Nakamura, M. Nakamura, S. Nakanote, K. Nakashima, Y. Nakasone, Y.

2208.4, P-145 P-174 P-376 P-329 P-203 P-17, P-285 P-92, P-226 P-329 P-33 P-370 P-39, P-280, P-366, P-397 Nakatsuka, S. P-122 Nani, R. 2208.3, P-225 Napoli, A. 303.4, 2306.3, 2306.4, 2306.5, 2902.3, P-35, P-169 Narayanan, G. P-247 Nassef, A.A. P-68, P-165 Nasser, F. 607.5, P-171, P-324 Naughton, P. 3006.4, P-297 Neilson, J.C. 2207.5 Nemes, B. P-259 Nemsadze, G. P-283 Nene, P. P-37 Nestola, M. 3007.1 Newton, I. P-69 Nguyen, B. P-89 Nguyen, T. 3008.5 Nicholson, A.A. P-75 Nicholson, P.J. P-172 Nickel, P. P-337 Nicolini, A.F. 3007.2 Nie, C.-H. 2206.5, 3105.6 Niedermayer, M. P-204 Nielsen, K. 2306.1, P-190, P-194, P-228 Niessen, C. 2306.6 Niessen, H.W. 2306.1 Nieuwenhuis, M.B.B. 2205.6 Nihayah, S.M. P-98 Nishikawa, H. P-104 Nishimaki, H. P-17 Nishiofuku, H. 3008.1 Nitta, N. P-97 Noce, V. 2306.5 Noda, Y. P-177 Noto, A. 3005.3 Novelli, L. 3008.6 Novelli, P. P-355 Nowakowski, F.S. 2208.6, 3104.6, P-198, P-354 Nuredini, D. 3007.4

O Obmann, S.-M. Ogawa, Y. Oguzkurt, L.

S369

SS/FC/HL/HTS/CM Author Index

CIRSE 2014

P-204 P-17, P-285 1802.2, P-82, P-288, P-295, P-305

Oh, J.H. Oh, J.S. Oh, J.Y. Ohara, R. O’Hare, A. Ohashi, F. Ohm, J. Ohno, Y. Ohta, K. Oikonomou, K. Okada, M. Okada, T. Okamoto, D. Okolo, P. Okuno, Y. Oldhafer, K.J. Oliva, V.L. Oliveira, A.G. Olson, E. Ono, C. Ono, Y. Onozawa, S. Oran, I. Orsi, F. Osterhues, S. Osuga, K. O’Sullivan, G.J. Ota, S. Otaka, J. Otani, H. Ott, C. Ott, I. Otto, G. Ou, Y.-C. Oz, N. Ozaki, K. Ozdogan, M. Oztekin, S.

P-30, P-275, P-388 P-18 P-137 P-183 P-257 P-92 P-110 P-112 P-104 1407.2, 1407.3, P-300 P-339, P-370 P-140 P-243 P-247 P-52, P-57 P-231 P-103 2305.5, P-374, P-377 P-69 P-367 P-92, P-147, P-226 3105.4, P-115, P-148, P-264 P-215 1804.4, P-250 2208.4 P-92, P-226, P-241 1302.4 P-97, P-246 P-112 P-97 902.3 P-325 3104.3 P-99 1506.1, P-31 P-329 1506.1, P-31, P-227 P-31

P Pabon-Ramos, W.M. 3106.3, P-123 Paci, E. P-342 Pagoni, M. P-124 Pal, S. P-276 Palena, L.M. 2702.4 Palla, C. 2306.3, 2306.4, 2306.5, P-169 Palmisano, A. P-263 Palussière, J. 303.2, 2207.2, P-222, P-242 Panek, J. P-25 Pantelidou, M. 3105.5 Pantos, A. P-277 Paolo, A. 3006.1, P-178, P-389 Paprottka, P.M. P-56 Park, H.S. P-266, P-273 Park, J.H. P-12, P-116, P-117 Park, J.-H. P-156 Park, J.S. P-146 Park, S.I. P-168, P-170, P-219, P-356 Park, S.J. 302.4 Park, S.W. P-30, P-275, P-371, P-388

Park, Y. Parra, D.A. Parthipun, A.

P-168 1406.1 P-107, P-287, P-289, P-307, P-309, P-395 Pasupathy, S. 2205.1, P-299 Patatas, K. P-381 Patel, A. 2205.1, P-299 Patel, J. P-381 Patel, J.V. P-75 Patel, P.A. P-50 Patel, P.J. P-70 Patel, R. 2208.6, 3104.6, P-89, P-198, P-354 Patel, U. P-336 Patil, P. 3007.6 Patil, S.S. 3005.1, 3007.6, P-44, P-152, P-234 Patil, V.V. P-198 Patrone, L. P-86 Paul, J. 607.7, P-80 Paulo, G. 2704.3, P-320 Paz-Fumagalli, R. P-232 Peano, E. P-390 Pech, M. 102.1, P-218 Peck, W. P-89 Pecoraro, F. 3107.6 Pedicini, V. 1405.3 Pedraza De Leistl, M. P-300 Pedrazzini, F. P-240, P-390 Peeters, P. 607.2, P-291 Pelage, J.-P. 1705.2 Pellerin, O. 2305.3, 2503.4, 2601.3, 3005.5, 3106.5, 3106.6, P-100 Penha, D. P-125, P-197, P-269 Pennington, B. P-236, P-237 Pennycooke, K.A. P-19, P-258, P-268 Penzkofer, T. 2208.4, P-145 Peregrin, J.H. 201.2 Pereira, H. 607.6, P-322 Pereira, J.A. 2305.5, P-109, P-374, P-377 Pereira, P.L. 901.4, 1301.1, 3202.4 Pereira, S. P-320 Pereira, T. P-184 Perendreu, J. P-84, P-160 Perera, A.H. 1407.4 Perez, J.T. P-222 Petersen, B.D. P-360 Petersen, T.-O. P-282 Petitpierre, F. 2305.2 Petrillo, M. 1405.1, 3105.1, P-78, P-229, P-326 Petrocelli, F. P-86, P-102, P-121, P-155, P-161 Petrovic, B. P-139 Petrovic, L.M. 3005.4 Pfammatter, T. 2603.2, 3107.6 Phillips-Hughes, J. 3203.4 Piacentino, F. 1405.1, P-78, P-326 Piana, G. 1001.1 Piemonti, L. P-353 Pierami Neto, R.J. P-232 Pieri, S. 3006.1, P-178, P-389 Pilger, E. 607.2, P-291, P-293 Pillon, S. P-167

S370

CIRSE

Pinheiro Oliveira, M.L. 607.5, P-171 Pinter, S. P-355 Piracchio, R. 3005.5 Piras, E. P-58 Pisco, J.M. 2305.5, P-109, P-374, P-377 Pitton, M.B. 3104.3, P-331 Planer, D. 1407.6 Poewe, W. P-213 Poggi, G. 3005.3 Pohl, T. P-144 Politi, M.A. P-6 Pollock, G. 3006.2, P-315 Polnaya, A.M. 3005.1, 3007.6, P-44, P-152, P-234 Poonawala, H. P-45 Popovic, P. 3007.4, P-119 Poretti, D. 1405.3 Porfiri, A. P-35 Portugal, P. P-184 Posa, A. 3007.1 Posso, I.D.P. 607.5, P-171 Poston, G.J. 2601.1 Potthoff, A. 2208.5, P-344 Poulou, L. P-124 Pozzi-Mucelli, F. P-131 Pozzi Mucelli, R. P-131 Prabhudesai, S.G. P-309 Pradella, M. 1505.4 Prassopoulos, P. P-383 Prevoo, W. 3105.1, P-78 Probst, T. 3106.2 Protto, S.M. P-204 Ptohis, N. 3301.1, P-124 Pua, U. P-9 Puippe, G. 3107.6 Punamiya, S. 1406.6, P-126, P-393 Puppala, S. P-1, P-75 Puri, A. 3005.1, P-234 Pwint, M.K. 2205.1 Pyra, K. P-391

Q Qanadli, S.D. Qazi, S.A. Qing-Le, Z. Quaretti, P. Quarfordt, S. Quek, L.H.H. Quencer, K. Quigley, S.

1701.4 P-369, P-396 P-348 2208.3 P-89 P-9 P-162, P-199 P-77, P-87, P-308, P-335

R Raatschen, H.-J. Radaelli, A. Radak, D. Radeleff, B.A. Rahmouni, A. Ramamurthy, S. Ramiro Gandía, R. Rammensee, H.-G. Rampoldi, A. Rand, E. Rand, T.

3108.3 3008.6 P-139 204.3, P-143 3201.1 2205.1, P-299 P-85, P-108 3202.4 2208.3, P-362, P-375 1406.2 1003.4, 1801.3

Rao, P.P. Raoul, J.-L. Rashid, H. Ratnam, L. Raupach, J. Rawf, F. Ray, Jr., C.E.

P-26, P-127, P-380 1001.1 P-211 P-310 104.2, P-79 P-278 P-43, P-59, P-132, P-159, P-245, P-274, P-281, P-363, P-394 Raz, S. 1407.6 Razavi, M.K. P-149 Razvi, S. P-142 Redaelli Spreafico, C. P-7, P-24 Reed, I. P-77 Reekers, J.A. 201.4, 2205.5, 2205.6, P-5, P-298, P-302 Reeves, A. P-89 Rega, L. 2208.3 Reganati, P. P-6 Rehani, M. 2704.1 Reich, S. 3104.4 Reiffen, H.-P. 2208.5, P-344 Reijnen, M. P-2, P-292 Reimer, P. 2505.2 Reimerink, J. P-5 Reinhardt, S. P-144 Reis, C. 3008.5 Reiser, M.F. P-56 Rek, M. P-79 Ren, J. 3008.1, P-351 Ren, K. P-36 Renc, O. P-79 Rendon, R. P-95 Renfrew, I. P-335 Renzulli, M. 2208.3 Resch, T. 2503.2 Resnick, S. P-267 Ressurreição, J. P-184 Resta, E.C. P-7, P-24 Rhim, H. 3105.3, 3202.1 Ricciuti, G.P. P-378 Richman, K. P-69 Ricke, J. 2306.2, 3108.5, P-218 Rieder, C. 3108.3 Rigamonti, P. P-6, P-7, P-28, P-102, P-138, P-155, P-161, P-334, P-359, P-362, P-375 Rilling, W.S. P-70 Ringe, K.I. 3108.3 Rio Tinto, H. 1408.2, 2305.5, P-109, P-374, P-377 Riquelme Bareiro, C. 905.4 Ritchie, M. 607.7, P-71, P-80 Robert, P. 3007.3 Roberto, E. P-240 Roberton, B. P-201 Roberts, A.C. 3301.2 Robertson, I. 1701.1, 2505.1 Robertson, J.P. 2205.1, P-299 Robic, C. 3007.3 Rocha, R.D. 607.5, P-171 Rodriguez, R. 2206.1, 2206.2 Rodt, T. 2208.5, P-344 Roebuck, D.J. P-50

C RSE

Abstract Book

Roi, D. Romin, Y. Ronot, M. Rosati, M. Rose, E. Rosenthal, H. Rosignuolo, M. Røsok, B. Rossi, B. Rossi, U.G.

Rostam, A. Rousseau, H. Rowinski, O. Ruales, F.L. Ruberte Thiele, R.A.

3107.5 3005.4 901.1 P-342 P-267 2208.5, P-344 1505.1 3007.5 P-284 P-6, P-7, P-11, P-24, P-28, P-86, P-102, P-138, P-155, P-161, P-206, P-334, P-359, P-362, P-375 3106.2 1702.2 P-4, P-323 P-13

3106.3 Rubin, J. P-355 Rudarakanchana, N. 1407.1, 1407.4 Rudas, G. P-66 Rusovic, S. P-164 Ryan, A.G. 903.3 Ryan, M. 1703.3 Rychik, J. 1406.2

S Sabharwal, T.

302.3, P-107, P-287, P-289 Sacks, J.D. P-239 Sagic, D. P-139 Saguchi, T. P-112 Sailer, A.M.H. 3201.4 Saint Lebes, B. 1702.2 Saito, K. P-112 Sakai, W. P-364, P-368 Sakamoto, K. P-370 Sakurai, K. P-177 Salahi, M. P-159 Salem, R. 202.5, 2601.4, P-60, P-62, P-191, P-267 Salvatori, E. P-207, P-208, P-209, P-210 Salvatori, F.M. 1405.2, 3107.2, P-32, P-378 Samuels, S.L. P-306 Sanamandra, S.K. P-299 Sanchez, O. 3106.5 Sanchez Ballestin, M. 607.3, 1004.3, P-96 Sanda, H. P-93 Sanda, Y. P-329 Sandner, T.A. P-56 Sands, M.J. P-151, P-345, P-350 Sangiovanni, A. 3007.2 Sangro, B. P-236 Santos, J. P-320 Santos Martín, E. P-260 Sapoval, M.R. 201.3, 607.6, 2305.3, 3005.5, 3106.5, 3106.6, P-100, P-322 Sarkadi, H. P-259 Sartori, S. 3005.3

Sasaki, Y. Satake, M. Sato, F. Sato, M. Sato, T. Sato, Y. Saunders, D. Savin, M. Scemama, U. Scepanovic, M. Schaapman, J. Schäfers, H.-J. Scheer, F. Scheffer, H.J.

P-366, P-397 P-148 P-147 P-93 3008.1 P-241 P-1 3104.4 P-186 P-164 1408.1 P-195 P-254, P-301 2306.1, P-190, P-194, P-228 Scheinert, D. 607.2, 2205.2, P-291 Schepis, F. 2208.3 Schernthaner, M.B. P-306 Schickel, M. P-385 Schmid, A. 902.3 Schmieder, R.E. 902.3 Schmitt, A. P-144 Schmitz, A. P-143 Schmitz-Rode, T. 2208.4, P-145 Schmuck, B. 2603.3 Schneider, G.K. 1408.3, 3106.2 Schnorr, B. 2205.7 Schönberg, S. 3008.5 Schotten, S. P-331 Schreiber, N. 2206.6 Schroe, H. P-290 Schroth, G. 305.2, 1005.3 Schullian, P. P-65 Schulte, K.-L. 607.1, 607.2, P-291, P-294 Schulz, B. P-53 Schulz, N. 3108.5 Schürmann, K. 104.1 Scott, P. P-188 Sedrak, L. 3106.4 See, T.C. 1405.6 Seidel, R. 1408.3 Seidensticker, M. 3108.5, P-218 Seidensticker, R. P-218 Seiji, K. P-147 Sella, D. P-232 Sellers, M. 1704.3 Semaan, E. P-191, P-267 Sennfält, K. P-236, P-237 Seo, T.-S. P-30, P-371, P-386 Seong, N.J. P-20, P-21 Seror, O. 1804.3 Serrano, C. P-279 Sessa, B. P-178 Setser, R. P-151 Settembrini, A. P-138 Shah, C. P-345, P-350 Shaida, N. 1405.6, P-163, P-265, P-379 Shaikh, M.S. P-268 Shaikh, S. P-19, P-258 Sharif, F. P-149 Sharma, S. 1702.4, 3008.2 Shaw, A. P-107 Shaw, R. P-71 Shaygi, B. P-312 Shehata, I.A. P-165

S371

SS/FC/HL/HTS/CM Author Index

CIRSE 2014

Sherman, I. Sherstobitov, V.E. Sheth, S. Shetty, N.S.

P-286 P-136 P-354 3005.1, 3007.6, P-44, P-152, P-234 Shibamoto, Y. P-104 Shibata, T. P-349 Shiigai, M. P-183 Shim, H.J. P-29, P-311 Shimada, R. P-216 Shimizu, K. P-372 Shimohira, M. P-104 Shin, J.H. P-156, P-158 Shin, J.S. P-29, P-311 Shinozuka, K. P-349 Shirroi, B. 3007.6 Shivalingappa, S.S. 1506.6 Shlansky-Goldberg, R. 1405.5 Shoenfeld, R.B. 2703.3 Shong, Y.K. P-266 Shono, T. P-366, P-397 Shrikande, S. 3007.6 Shui, S. P-202 Siablis, D. 1505.5, P-303 Sibert, A. 901.1 Sidhu, P. P-211, P-314 Sielezneff, I. 2305.3 Sierre, S. 2703.4 Sigal, S. P-343 Silverberg, D. 1407.6 Silverman, D. 2605.2 Simonetti, G. P-207, P-208, P-209, P-210 Simoni, E. 3006.5 Singh, J. 1406.3 Singh, R. 1406.5 Sista, A.K. 3006.3 Sit, S.P. P-89 Slovacek, L. P-79 Smith, J. P-333 Smith, M. P-43, P-132, P-363 Smith, P.G. P-38 So, Y.H. 2305.4, P-272 Soares, J.T. P-184 Sofocleous, C.T. 203.2, 3005.4 Sofue, K. P-140 Sojka, M. P-391 Solbiati, L. 3005.3 Solomon, S.B. 3005.4, 3108.4 Solovov, V.A. P-235, P-249 Somani, B. P-90, P-321 Somma, F. 1506.5, P-221 Sommer, C.M. P-143 Sone, M. P-243 Song, D. P-81 Song, H. P-199 Song, H.-Y. P-156 Song, M.G. P-386 Song, S.-Y. P-137 Song, Y. P-181 Soni, J. P-38 Sonoda, A. P-97 Soo, Y. 2205.4 Sortino, D. P-240, P-390 Soteriou, M. P-10 Souftas, V.D. P-383

Soukas, P. Soulen, M.C. Soulez, G. Sousa, M.J. Soussan, J. Spence, L. Spiliopoulos, S.

3006.5 1405.5, 3104.1, 3108.6 2504.1, P-103 P-63 P-186 P-172 1505.5, 2205.2, 2602.3, P-303 Sprenger De Rover, W. 1406.5, 3006.2, P-153, P-315, P-332 Srimathveeravalli, G. 3108.4 Stabuc, M. 3007.4 Stacul, F. 3005.3 Stampfl, U. P-143 Stang, A. P-231 Staunton, P. 3006.4 Stavropoulos, S.W. 1405.5, 3104.1, 3108.6 Stavrou, G.A. P-231 Stedman, B. P-248 Stiepani, H. 2205.7 Stockland, A. 1506.4 Stoneham, M.D. 3303.3 Streit, S. 3108.5 Streitparth, F. P-337 Strobl, F.F. P-56 Stroeder, J. P-195 Stroszczynski, C. 2306.6 Stuart, R.C. 202.4 Subbanna, I. 1506.6 Sudheendra, D. 1405.5, 3108.6 Sugawara, S. P-243 Sugihara, F. 3105.4, P-115, P-148, P-264 Sugimoto, K. P-140 Sullivan, C.M. 3107.5 Sullivan, M. 2501.3 Sulovari, A. P-88, P-340 Sultan, M. 1407.5 Sultan, S. 1407.5 Sun, J.-H. 2206.5, 3105.6 Susac, A. P-338 Syal, A. P-174 Szczerbo-Trojanowska, M. 101.3, P-391 Szeberin, Z. 2602.1

T Taberner López, E. Tacher, V. Tachibana, M. Tacke, J. Tahir, O. Takahashi, S. Takara, H. Takase, K. Takayama, K. Takes, M. Tamaki, W. Tamura, Y. Tan, B.S. Tan, G.W.L. Tan, L. Tan, S.G.

P-85 3201.1 P-112 2205.3, 2501.1 P-238 P-147 P-154 P-147 P-203 1505.4 P-154 P-39, P-280, P-366, P-397 2205.1, P-299 P-9 P-54 2205.1, P-299

S372

Tan, Z. Tanahashi, Y. Tanaka, F. Tanaka, H. Tanaka, K. Tanaka, T. Tancredi, T. Tanitame, N. Tanoue, S. Tantawi, S. Tarkhanov, A. Tasse, J. Tateishi, E. Tay, K.-H. Tchervenkov, J. Tec, C.T. Teigen, C. Teitelbaum, U. Teixidor Vinas, M. Temple, M. Teng, G.-J. Tepe, G. Texeira Jr., F. Thakur, M.

2205.1 P-177 P-93 P-47, P-341 P-92, P-226 304.3, 3008.1 P-61 P-367 P-216, P-365 P-103 P-136 P-38 P-329 2205.1, P-299 P-380 P-299 P-89 1405.5, 3104.1 P-50, P-176 1406.1 1406.4, 2207.6, P-67 301.3 P-242 3005.1, 3007.6, P-44, P-152, P-234 Thanaratnam, P. P-19 Thanaratnam, P.N. P-304 Thenint, M.A. P-49, P-271 Thérasse, É. P-103 Thomas, R. 2603.3 Thomas, R.H. P-270 Thompson, M. 3107.4 Thomson, K.R. 1302.3, 2305.1 Thornton, J. P-257 Thurley, P. 3006.2, P-332 Togashi, K. P-349 Tokashiki, T. P-372 Tokuuye, K. P-112 Tomimatsu, H. P-243 Tomiyama, N. P-92, P-226 Tomozawa, Y. P-97 Too, C.W. 2205.1, P-299 Toonsi, F.A. P-26 Torcia, P. P-28, P-161, P-334 Torres, C.I. P-26, P-127, P-380 Tramarin, M. 1405.3 Travassos, F.B. P-324 Travis, S. P-153 Trerotola, S.O. 1405.5 Tricaud, E. 2305.2 Triolo, M. 3007.2 Trumm, C.G. 1505.4, P-56 Tselikas, L. 2306.2 Tsetis, D.K. 1701.2, P-326 Tsioufis, C. P-328 Tsoumakidou, G. P-49, P-271 Tsuji, K. P-367 Tsukada, J. P-128 Tsurkan, V. P-233 Tsygankova, O. P-173 Tuite, D. P-172 Tulin-Silver, S. P-343 Turba, U.C. P-38 Turk, A.S. 905.2 Turkekul, M. 3005.4 Tutton, S.M. 903.4, 2207.5, P-70 Tuzzolino, F. 2208.1, 2208.2 Twine, C.P. 3107.5

CIRSE

Abstract Book

U Úbeda Morant, N. Uberoi, R. Uçar, A. Uchikawa, Y. Uder, M. Ueda, T. Ueshima, E. Uggetti, C. Ugurlucan, M. Uhde, K. Unal, D. Unlu, N. Unver, K. Urbano, J. Ürünsak, I. Uthoff, H. Utili, A.

P-85 904.2 P-88, P-340 P-183 902.3 3105.4, P-148, P-264 P-140 P-6 P-14, P-48 2306.2 P-288, P-305 P-41 3006.3 1408.5 P-182 P-306 P-121

V Vadlamudi, V. Vahl, A. Vakiani, E. Válek, V. Valenti, D.A. Valle, J.W. Van Beek, S.C. Van Cutsem, E. Van Delden, O.M. Van Den Eynde, M. Van Den Tol, P.

P-64 3107.3, P-5 3005.4 1704.2, P-25, P-187 P-26, P-127, P-380 204.1 3107.1, 3107.3, P-5 3008.4 302.1 3008.4 2306.1, P-190, P-194, P-228 Van Der Wal, R. P-380 Van Deun, W. P-196 Van Erkel, A.R. 1408.1, 1505.3 Van Ha, T.G. 1408.4 Van Houten, D. 3104.1 Van Kuijk, C. 2306.1, P-194, P-228 Van Overhagen, H. 103.2, 1003.3 Van Rijswijk, C.S.P. 1408.1 Van Strijen, M.J.L. 203.3 Van Tilborg, A.A. 2306.1, P-190, P-194, P-228 Van Waesberghe, J.H. P-194 Vari, A. 1505.1, 3303.2 Vasani, R. 1408.4 Vaudon, E. 3007.3 Vedantham, S. P-394 Velayutham, P. P-44, P-234 Veloso Gomes, F. 1408.2 Venturini, M. P-150, P-263, P-353 Verhoeven, E. 1407.2, 1407.3, 2503.1, P-300 Vermassen, F.E. P-290 Vidal, V. 2305.3 Vieveen, J.M. 2306.1, P-228 Vilares Morgado, P. 3203.1 Vilgrain, V. 901.1 Villa, C. P-225 Villa, E. 2208.3 Vilvendhan, R. P-37 Vinay, C. P-240, P-390 Vizzari, F.A. P-23, P-229 Vizzini, G. 2208.1, 2208.2

C RSE

Vizzutti, F. 2208.3 Vogl, T.J. P-53 Vogt, L. 3107.3 Von Falck, C. 2208.5, P-344 Von Seydewitz, C.-U. P-231 Voorhees III, W.D. 1505.6 Vorontsov, I. P-173 Vorwerk, D. 305.3 Vozdvizhenskiy, M.O. P-235 Vranckx, J. P-196, P-253 Vulev, I.P. P-317

W Wacker, F. Wada, T. Wagenpfeil, S. Wagner, H.-J. Wah, T.M. Waki, K. Waldenberger, P. Walker, A. Wang, T.-H. Wang, W. Wasan, H. Wassal, I.Y. Watanabe, K. Watanabe, S. Watkins, K.T. Weber, C.N. Weber, J.R. Weber-Donat, G. Wei, Q. Weiss, C.R. Weissenbacher, A. Weller, A. Wells, A. Wells, D.

2208.5, 3108.3, P-344 P-203 P-195 2502.4 P-333 P-367 2504.3 P-358 1406.3 P-392 P-236 P-165 P-46 P-97 1704.3 P-361 P-204 3005.5 3108.1 1406.3, P-384 P-204 3107.4 P-261 P-43, P-132, P-245, P-363 Wendremaire, M. P-144 Werk, M. 2205.7 Whitaker, L. P-89 Whitaker, S. P-153 White, H. P-153 White, R.D. 3107.5, P-261 White, S.B. 2207.5, P-70 Widenmeyer, M. 3202.4 Widmann, G. P-65 Wiggermann, P. 2306.6, P-254 Wigmore, S.J. 901.2 Wilkins, C.J. P-211 Wilkinson, J. 1805.2 Wilkmann, C. 2208.4, P-145 Williams, D.M. P-106 Williams, I.M. 3107.5 Winterbottom, A. P-379 Wirth, G.M. 3104.3 Wisselink, W. 3107.3, P-5 Wissgott, C. P-254, P-301 Wlderk, A. P-32 Wohlgemuth, W.A. 102.3 Wojtaszek, M. P-4, P-323 Wolfgang, R. 1407.2, 1407.3, P-300 Wolosker, N. P-324 Wolterbeek, R. 1408.1

SS/FC/HL/HTS/CM Author Index

CIRSE 2014

Won, J.H. Won, J.Y.

Wong, L. Woo, Y.N. Wood, A.M. Wörns, M.A. Worthley, S.G. Wrigley, C. Wu, G. Wu, O. Wu, Y. Wybranski, C. Wyffels, E.

P-346, P-371 3104.2, 3104.5, P-168, P-170, P-219, P-356, P-371 2205.4 P-20, P-21 3107.5 3104.3 P-328 3006.6, P-238 P-36 607.7, P-80 3108.2 3108.5 P-325

X Xhepa, G. Xiao, J. Xiao, X. Xiaofeng, H.X.

1405.1 P-37 P-192 P-348

Y Yabuta, M. Yadav, R. Yamada, E. Yamada, K. Yamada, N. Yamada, T. Yamagami, T. Yamaguchi, H. Yamaguchi, M. Yamakado, K. Yamamoto, M. Yamashita, Y. Yang, C.-K. Yang, J. Yang, S.B. Yan-Hao, L. Yasui, D. Yasui, M. Yasumoto, T. Yasutani, T. Yeong, K. Yildirim, G. Yildiz, A. Yilmaz, O. Yilmaz, S. Yim, N.Y. Yokoyama, K. Yoon, C.J. Yoon, J. Yoon, S.C. Yoon, Y. Yoshimatsu, R. Yu, S.C.-H. Yuce, I. Yunaiyama, D. Yurlevich, D.

P-349 P-40 P-154 P-357 P-329 P-285 P-34, P-367 3105.4, P-115, P-264 P-140 P-241 P-357 P-39, P-280, P-366, P-397 P-99 3108.1 P-81, P-180 P-348 3105.4, P-148, P-264 P-339 P-241 P-154 P-54 P-88, P-105 1506.1, P-31, P-227 P-41 1506.1, P-31, P-227 P-73, P-94 P-39 P-20, P-21 P-120 P-81 P-168, P-170, P-219, P-356 P-34, P-367 1506.3, 2205.4 P-189 P-112 P-347

Z Zaccagna, F. Zahed, A. Zak, P. Zangos, S. Zealley, I. Zech, C.J. Zeile, M. Zeleňák, K. Zeller, T. Zende, U. Zhang, Y.-L. Zhang, Y.W. Zhao, J.-B. Zheng, S.-S. Zhong, J. Zhou, G.-H. Zhou, T.-Y. Zhu, H.-D. Zia, A. Ziade, C. Zini, C. Zou, W. Zrig, A. Zrig, M. Zurera Tendero, L. Zvavanjanja, R.C. Zwiebel, B.

2306.3, 2306.5, P-169 P-72 P-79 P-53 P-261 1505.4 P-231 102.2 607.2, P-291 P-44 2206.5, 3105.6 P-157 P-348 2206.5, 3105.6 P-333 2206.5, 3105.6 2206.5, 3105.6 1406.4, P-67 P-270, P-278 P-222 P-378 2205.4 P-60, P-62 P-60, P-62 1506.2, P-352 3106.4 P-89

S373