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ABSTRACT |
Wittenberg A.F.; Laing C.J.; Rosenblum D.I.; Radiology, MetroHealth Medical Center, Cleveland, OH.
Address correspondence to A.F. Wittenberg (aaronwittenberg{at}yahoo.com)
Background: The aging patient population and the increased use of cross sectional imaging have resulted in an increased number of renal masses being incidentally discovered. Cross sectional evaluation and subsequent Bosniak classification of thesemasses play a pivotal role in patient management, often deciding whether or not surgical intervention is required. Many of these smaller masses can now be treated effectively and non-invasively with percutaneous radiofrequency ablation (RFA). It is important that Radiologists be able to identify those patients with renal masses that may benefit from percutaneous RFA and become familiar with the post-operative appearance of previously ablated lesions. We will address the role of cross-sectional imaging in the evaluation of renal masses, selection of appropriate patients for RFA, RFA procedure planning and follow-up of previously ablated lesions.
Key Issues: This exhibit will address the selection of candidates for percutaneous renal tumor RFA. Cross sectional imaging is needed to characterize the surgical nature of renal lesions and to determine the safest pathway to approach the lesion during ablation. Technically difficult cases will be reviewed, such as those requiring the use of saline or air to mobilize adjacent structures such as bowel loops or ureter. Follow up of RFA patients requires evaluation for residual tumor enhancement on CT or MRI images which are obtained 1, 3, 6, 12, and 24 months after the procedure. We will review the post-operative appearance of successfully ablated masses as well as those demonstrating recurrence or incomplete ablation. The absence of enhancement in the region of the tumor bed is consistent with successful coagulation necrosis. Should residual enhancement be detected, the patient would require an additional RFA treatment session.
Format: The format will be a power point presentation. This will include text, pre-procedure, intra-procedure, and post-procedure imaging, as well as video clips which will detail the finer technical points of renal tumor RFA.
Teaching Points: The viewer should learn the following: 1. The role of cross sectional imaging in selection and follow up of renal tumor RFA patients. 2. The proper technique for conducting percutaneous image-guided RFA of renal tumors. 3. Potential challenges of renal tumor RFA and how to overcome them.
E341. Use of MR Subtraction Technique to Evaluate for Residual Renal Tumor following Radiofrequency Ablation
Pinchouck M.J.; Shah R.R.; Rosenblum D.I.; Department of Radiology, MetroHealth Medical Center, Cleveland, OH.
Address correspondence to M.J. Pinchouck (mjpincho{at}hotmail.com)
Background: Radiofrequency ablation (RFA) is a method of local tissue ablation, which utilizes both frictional heating and ionic agitation to cause cell death. Percutaneous RFA is performed by placement of a needle electrode into tissue under ultrasound, CT or MR guidance. Once in place, the non-insulated tip is heated in a controlled manner to, ultimately, result in coagulative necrosis of tumors. The benefits of percutaneous RFA include treatment of tumors in patients with renal insufficiency, solitary kidney, or who are poor surgical candidates. Patients avoid the morbidity and mortality associated with nephrectomy or nephron-sparing surgery.
Key Issues: One of the major criteria used to evaluate the success or failure of RFA on follow-up imaging is the absence or presence of enhancement within the lesion. Enhancement has been evaluated with both iodine contrast enhanced CT and gadolinium enhanced MR. Initially, the thermal ablation zone can appear hypointense, isointense or hyperintense to surrounding renal parenchyma on MR imaging. The ablation zone can continue to have a variable appearance over several months. Thin rim enhancement, normally noted following RFA, tends to gradually fade with time. Qualitative assessment of enhancing vs. non-enhancing tissue can be difficult against the variable appearance of the ablation zone. Using a post-processing technique to subtract the non-enhanced T1 weighted MR images from the enhanced T1 weighted images improves conspicuity of residual tumor following RFA.
Format: This presentation is a didactic review of renal RFA with imaging examples of pre-RFA renal masses and MR follow-up performed at MetroHealth Medical Center in Cleveland, Ohio.
Teaching Points: 1. Review the technique of renal RFA. 2. Illustrate the MR appearance of post-ablation renal masses, with and without residual tumor. 3. Demonstrate the use of MR subtraction to improve the conspicuity of post-ablation enhancement and reader confidence in the visual assessment of residual tumor.
E344. Magnetic Resonance guided Focused Ultrasound Surgery (MRgFUS) with Rapid Interleaved Technique: Initial Experience for the Treatment of Uterine Fibroids
Holland G.A.1; Hananel A.2; Briggs M.H.3; Dick A.B.3; Bruno R.3; 1. Radiology, Lahey Clinic, Burlington, MA; 2. Clinical Applications, InSightec, Tirat Carmel, Israel; 3. Gynecology, Lahey Clinic, Burlington, MA.
Address correspondence to G.A. Holland (george.a.holland{at}lahey.org)
Objective: MRgFUS is a technique that uses MRI to target, and control the noninvasive ultrasound thermal ablation of uterine fibroids. The purpose of this study was to evaluate a rapid manual interleaved MRgFUS (iMRgFUS) treatment of uterine fibroids that permits treatments to be done in less time or treatment of larger fibroids than the prior reported technique of MRgFUS.
Materials and Methods: 14 pre or perimenopausal adult women with symptomatic fibroids were treated with the rapid iMRgFUS. Enrolment required symptomatic uterine fibroids scoring a minimum of 18 on a symptom severity questionnaire. Gynecological examination and prior MRI confirmed a definitive diagnosis of symptomatic uterine fibroids. Treatments were with conscious sedation on an ExAblate 2000 (InSightec, Tirat Carmel, Israel) integrated into a 1.5 Tesla MR scanner (GE Healthcare, Waukesha, WI). T2 weighted images were performed in 3 cardinal imaging planes (4,000–7,000/95–102 msec TR/TE). The treatment was manually plotted on the FSE images with fibroid(s) divided into 2 to 5 separate non-overlapping regions. The intersonication cooling time was decreased from the default of 90 seconds to the minimum of 45–50 sec's. Each sonication was performed in 14–20 sec's and then monitored with an MR thermal map which are performed with a spoiled gradient echo sequence (TR/TE 27/11–13 msec). The treatments were limited to about 3 hours. Post procedural imaging was performed with dynamically gadolinium enhanced using 3 dimensional spoiled gradient echo images. The research was funded by a grant from InSightec.
Results: iMRgFUS permitted up to 127 sonications in a treatment versus 60–70 sonications with prior technique in a 3-hour treatment. The same sized fibroid could be treated in about 60% of the time as the treatments using the former protocol. There were no serious adverse events in patients treated with the iMRgFUS. All patients had 3 month follow up and 8 patients had 6 month follow up. Twelve of the 14 patients had marked improvements in their symptom scores on the follow up visits. None of the patients treated with iMRgFUS have had alternative forms of treatment to date.
Conclusion: iMRgFUS is an apparently safe method for a more rapid treatment of fibroids. This allows either a shorter duration of a fibroid treatment in 60% of the time previously required or permits the treatment of greater volume of fibroid. Larger studies of iMRgFUS will also need to be tested.
E345. Endovascular Management of Deep Venous Thrombosis
Cura M.A.; El-Merhi F.; Cura A.; Radiology, University of Texas Health Science Center, San Antonio, TX.
Address correspondence to M.A. Cura (marcocura{at}yahoo.com)
Background: Acute deep venous thrombosis (DVT) has an incidence of 250,000 cases per year in the United States. Pulmonary embolism (PE) and thrombus propagation are acute complications of DVT. Post-thrombotic syndrome is a long-term sequela of lower extremity DVT. Although anticoagulation is used to prevent PE and recurrent DVT, anticoagulation is an ineffective treatment to remove thrombus and restore venous patency preserving venous valve function. In the other hand rapid lysis of acute thrombus restores the vessel lumen with the consequent relief of venous outflow obstruction, preservation of valve function and prevention of thrombus propagation.
Key Issues: Anatomy of the deep veins and vena cava are described. Clinical conditions leading to DVT are reviewed. Treatment options for DVT and the use of catheter-directed pharmacological and mechanical lysis of acute venous thrombus are discussed as well as the need for the treatment of underlying venous stenosis.
Format: This exhibit presents patients with DVT, who were treated by direct catheter pharmacological and mechanical thrombolysis in a didactic format and reviews the venographic findings, technique of the different treatment options, indications and contraindications for catheter-directed pharmacological and mechanical thrombolysis.
Teaching Points: Learn about conditions that may predispose to venous thrombosis. Learn the acute and chronic complication of DVT. Learn the various treatment options for DVT. Understand the used and describe the technique of catheter directed pharmacological and mechanical lysis in the treatment of DVT and the need for treatment of the underlying venous conditions that may affect venous flow return and predispose to venous stasis. Learn the contraindications for venous thrombolysis.
E346. Treatment of Superficial Venous Insufficiency with Endovenous Laser: Indications, Techniques, Complications, and Clinical Outcomes
Gandhi R.T.1; Rosenblatt M.2,3; 1. Radiology, UCLA Medical Center, Los Angeles, CA; 2. Interventional Radiology, Connecticut Image Guided Surgery, Milford, CT; 3. Radiology, Yale University Medical Center, New Haven, CT.
Address correspondence to R.T. Gandhi (ripgandhi{at}hotmail.com)
Background: Superficial venous insufficiency of the lower extremities is the most common venous disease, occurring in 10–15% of men and 20–25% of women. Patients with symptomatic varicose veins typically present with leg fatigue, leg heaviness, generalized or focal pain, and restlessness, all worsening as the day progresses. The most common cause of this disease is valvular dysfunction in the greater saphe-nous vein, which results in the formation of varicosities and associated symptoms. The traditional treatment of this disease is surgical ligation and removal or "stripping" of the greater saphenous vein. Disadvantages of surgical treatment include invasiveness, requirement for general anesthesia, significant post-operative pain, and prolonged recovery period. Furthermore, surgical treatment is not free from recurrence.
Key Issues: Endovenous laser therapy (EVLT) is a new technique that utilizes laser energy to thermally obliterate refluxing veins by causing endothelial denudation and collagen contraction. Several clinical trials have demonstrated that EVLT is very effective in the treatment of refluxing varicose veins with results that are comparable or superior to other treatment modalities, including surgical stripping and sclerotherapy. Complications, such as cutaneous thermal injury, have been minimal. Retreatment of EVLT failures with the same modality has been effective and durable. In this educational exhibit, we describe the techniques, complications, and evidence based clinical outcomes of this innovative procedure.
Format: The current educational exhibit will be in didactic format. Organization: The proposed exhibit will involve description of the following: 1. Superficial venous insufficiency pathology 2. Conventional surgical stripping versus endovenous laser therapy 3. Endovenous laser device 4. Technical considerations 5. Criteria for patient selection 6. Contraindications 7. Complications 8. Review of literature 9. Clinical outcomes with short term and long term results 10. Treatment failures
Teaching Points: 1. To review the pathophysiology and symptomatology of superficial venous insufficiency. 2. To discuss the technical considerations necessary for performing endovenous laser treatment of refluxing varicose veins of the lower extremity. 3. To describe the indications, complications, and clinical outcomes of this procedure.
E347. Inferior Vena Caval Filters: Complications and Management of Complications
Santeler S.; Van Ha T.G.; Lorenz J.M.; Funaki B.S.; Javier C.; Radiology, The University of Chicago, Chicago, IL.
Address correspondence to S. Santeler (scott.santeler{at}uchospitals.edu)
Background: Inferior vena caval filters have been shown to be effective in the prevention of pulmonary embolism (PE), with low morbidity and mortality associated with their implantations. However, complications do occur. Awareness of complications is helpful in avoiding them and if they do occur, early management can lead to better outcomes. With the advent of retrievable IVC filters, there are complications that are unique to these new devices during their implantations and retrievals.
Key Issues: We will use radiographs and CT scans from actual cases in our archive over the last six years to illustrate procedural complications and well as complications of indwelling filters. Both the permanent and retrievable filters will be discussed. These complications include crossed filter legs preventing proper deployment, filter placement in incorrect position, caval thrombosis, new DVT, strut fracture, filter migration to the heart, IVC penetration, and pulmonary embolism. Complications associated with the removal of retrievable filters will be illustrated and discussed. We will then and illustrate and discuss management of these complications including percutaneous techniques to uncross tangled filter legs, fibrinolysis for caval thrombosis, and retrieval of migrated filters. In cases where percutaneous techniques prove not feasible, surgical options will be discussed.
Format: The exhibit will be an electronic presentation with both didactic and interactive components. The presentation will be case-based. At the end of each section, there will be questions with multiple choice answers for the reader to enhance the learning experience.
Teaching Points: After reviewing the exhibit, the readers will be able to discuss 1. Complications of IVC filter implantations, including procedural complications and long term complications. 2. Complications associated with implantation and removal of retrievable filters. 3. Management of these complications by medical, surgical and percutaneous techniques.
E348. Retrievable IVC Filters: Experience at a Single Level One Urban Trauma Center
Ray, Jr. C.E.1,2; Cothren C.C.3,4; Moore E.E.3,4; 1. Radiology, Denver Health Medical Center, Denver, CO; 2. Radiology, University of Colorado Health Sciences Center, Denver, CO; 3. Surgery, Denver Health Medical Center, Denver, CO; 4. Surgery, University of Colorado Health Sciences Center, Denver, CO.
Address correspondence to C.E. Ray, Jr. (cray{at}dhha.org)
Objective: Purpose: To report our large experience with outcomes of two commercially available retrievable IVC filters.
Materials and Methods: The medical records of all patients receiving retrievable IVC filters between 2001–2005 were reviewed. Type of filter placed, indications for placement, attempted retrievals or repositionings, and patient outcomes were evaluated.
Results: A total of 117 retrievable filters were placed. There were 70 attempts at repositioning or retrievals; there were 5 unsuccessful retrievals (7%) due to technical problems, and 5 filters (7%) were left in place due to thrombus superimposed on the filter. Two filters (2%) that had been placed at the bedside under ultrasound were malpositioned in the right iliac vein; no other complications were noted. In all patients, 17 filters (22%) were converted to permanent devices for medical indications, and 17 patients (22%) died with the filter in place. Another 17 patients (22%) were transferred to long-term facilities with the filter in place, and 10 patients (13%) were lost to follow-up. 76 filters (65%) were placed for PE PROPHYLAXIS in patients who could not receive the standard DVT prophylaxis at our hospital (low-molecular weight heparin). Multitrauma patients represented the majority (89%) of these patients. Of those filters placed for prophylaxis, 40 (53%) were successfully removed; 14 patients (18%) were transferred to other hospitals or long-term facilities before filter removal, 13 patients (17%) died before filter removal, and 7 patient (9%) were lost to follow-up. 6 patients (8%) had unsuccessful retrievals.
Conclusion: Retrievable IVC filters can be placed with high success and low complication rates. A significant number of filters will be converted to permanent devices, due to changing clinical needs, technical issues, or losing patients to follow-up.
E349. Imaging Findings of Rupture, Impending Rupture, and Contained Rupture of Abdominal Aortic Aneurysms
Schwartz S.A.; Taljanovic M.S.; Smyth S.H.; O'brien M.J.; Rogers L.F.; Radiology, University of Arizona Health Sciences Center, Tucson, AZ.
Address correspondence to S.A. Schwartz (ltaylor{at}radiology.arizona.edu)
Background: With the increasing utilization of cross-sectional imaging for a variety of medical and surgical conditions affecting the abdomen and pelvis, familiarity with the imaging features of aneurysm rupture, as well as with the findings suspicious for impending or contained aneurysm rupture, is critical for all radiologists. This pictorial essay reviews the imaging findings of rupture of abdominal aortic aneurysms and of complicated aneurysms.
Teaching Points: Prompt detection of abdominal aortic aneurysms rupture is critical, as survival is improved by emergent surgery. Identification of impending or contained rupture is equally as important, as these patients are at risk for frank rupture but can generally benefit from a more thorough preoperative assessment, followed by urgent surgery.
E350. Acute Aortic Syndrome: Evolution from Intramural Hematoma to Aortic Dissection
Nguyen T.T.; Radiology, University of California, Davis, Sacramento, CA.
Background: Acute chest pain syndrome is often attributable to aortic diseases. The most common etiology of acute aortic syndrome is aortic dissection. Other processes which should be considered in patients presenting with acute aortic syndrome include intramural hematoma (IMH) and penetrating atherosclerotic ulcers. With advances in imaging, these processes are increasingly being identified as the cause of acute chest pain using CT, MRI, angiography, and TEE. The overlap between these three processes and their relationship to one another remains controversial. There is no consensus on whether these are distinct entities or evolution of a single disease process.
Key Issues: A case is presented involving a 65 year-old woman with history of chronic obstructive pulmonary disease, hypertension, and hypertrophic cardiomyopathy who presented with left-sided chest pain radiating to the back. Imaging in this patient using CT angiography and MR angiography demonstrates the evolution of a normal aorta to intramural hematoma without flap to penetrating aortic ulcers and finally, to the development of a Type B aortic dissection.
Format: PowerPoint didactic presentation describing the anatomy and pathophysiology of diseases of the aorta related to the acute aortic syndrome. The presentation will illustrate the progression from normal aorta, to intramural hematoma, to penetrating aortic ulcers, to frank dissection.
Teaching Points: 1) Understand the etiology of Acute Aortic Syndrome 2) Learn the differences between Intramural hematoma, penetrating aortic ulcers, and aortic dissection 3) Understand the various imaging techniques for studying intramural hematoma.
E351. MRA versus CTA of the Lower Extremities: Which to Choose?
Jain M.1; Katz D.S.1; Pinto M.H.1; Hines G.1; Garrisi W.2; Hon M.1; 1. Radiology Department, Winthrop-University Hospital, Mineola, NY; 2. Radiology Department, Upstate Medical University, Syracuse, NY.
Address correspondence to M. Jain (mjain{at}winthrop.org)
Background: For first-line diagnosis, clinicians often turn to non-invasive angiographic techniques to evaluate for lower extremity arterial disease. For years now, MRangiography has become the preferred non-invasive imaging test. However, although numerous technical advances have improved the quality of MR angiograms, technical challenges remain, especially for imaging the calves. In the past few years, with the advent of multidetector CT scanners, CT angiography of the lower extremity arteries has proven to be a robust, easily performed, and rapid test for imaging of atherosclerosis and its complications in the legs. It is now uncertain in some patients as to which examination is preferable, as both tests may have artifacts and other limitations compared with conventional angiography.
Key Issues: The purpose of this exhibit is to provide a review of both CT angiography and MR angiography of the lower extremities, the preferred situations for their use based on the current literature, and to show examples to compare and contrast the two imaging tests.
Format: Didactic format, with review of the literature in some detail, focusing on this topic, with selected CTA and MRA examples demonstrated.
Teaching Points: To review the current status of MRA and CTA of the lower extremities. To overview the arguments for the use of MRA versus CTA, when imaging patients with known or suspected atherosclerotic disease. To demonstrate examples of the utility of CTA and MRA for imaging the lower extremity arteries.
E352. 64-Channel Multi-detector Row CT Angiography of Lower Extremity Arterial Inflow and Runoff: Initial Experience
Bell M.L.1; Ayala R.1; Levin J.M.1,2; 1. Diagnostic Radiology, St. Luke's Medical Center, Milwaukee, WI; 2. Radiology, Milwaukee Radiologists Limited, Milwaukee, WI.
Address correspondence to M.L. Bell (matthewlbell{at}hotmail.com)
Background: 64-channel MDCT has made tremendous impact upon the diagnosis and treatment of lower extremity peripheral vascular disease. 64-channel MDCT offers superior spatial and temporal resolution, is an accurate and reproducible technique, is noninvasive, and is less expensive than conventional angiography. CTA provides an accurate analysis of the vessel lumen, as well as a unique window into the morphologic analysis and pathophysiology of vascular disease. The cross sectional capabilities more clearly demonstrate the normal anatomic relationship of the pelvic viscera and appendicular skeleton in relationship to the lower extremity vasculature. This type of specific information is critical to the surgeon or interventionalist in planning treatment strategies. At our institution, 64-channel MDCT has become the preferred means of assessing lower extremity arterial inflow and runoff.
Key Issues: State-of-the-art 64-channel MDCT provides sub-millimeter data acquisition with the ability of isotropic rendering. Images may be viewed in any desired plane with resolution equal to the plane of initial acquisition. This allows for improved multi-planar reformations as well as three dimensional imaging. The diagnostic and treatment planning value of 3-D reconstructions and interactive reformatting for image analysis of 64-channel MDCT angiography will be demonstrated. Multiplanar reformation, volume rendering, maximum intensity projection, and curved planar reformation techniques will be described, illustrated, compared and contrasted. There will also be correlation with digital subtraction angiography. Issues including asymmetric disease, venous opacification, extensive mural calcification and imaging of small vessels including the internal iliac and popliteocrural arteries will be addressed.
Format: Didactic with interactive features demonstrating 3-D reconstruction techniques. The organizational structure includes all formats of 3D CT angiography analysis techniques including: multiplanar reformations, volume rendering, maximum intensity projections and curved planar reformations. The utility of endoluminal navigational techniques will also be demonstrated.
Teaching Points: The value of 64-channel MDCT angiography in assessment of lower extremity arterial inflow and runoff. An appreciation of 3-D reconstruction techniques of MDCT angiography.
E353. Outflow Embolic Protection Devices in the Non-carotid Circulation: Feasibility and Safety
Suri R.1; Wholey M.1; Cura M.1; Postoak D.1; Toursarkissian B.2; 1. Interventional Radiology, University of Texas Health Sciences Center, San Antonio, TX; 2. Vascular Surgery, University of Texas Health Sciences Center, San Antonio, TX.
Address correspondence to R. Suri (suri{at}uthscsa.edu)
Background: A variety of outflow protection devices have emerged for preventing distal embolization during arterial interventions. Multicenter randomized trials have documented the value of outflow protection devices in preventing embolic complications in carotid interventions (SAPPHIRE) and in coronary saphenous vein graft interventions (SAFER trial). The role of protection devices in the non-carotid and non-coronary circulation is an emerging field.
Key Issues: Occlusive and nonocclusive distal embolic protection devices have been proven to have a beneficial role in the carotid circulation. There is a documented risk of distal embolization in non-carotid and non-coronary arterial interventions with a potential of increased procedural morbidity. Cholesterol embolization during renal intervention is associated with peripheral infarcts and worsening renal failure, and athero/thromboembolism during infrainguinal interventions could be complicated with outflow occlusions and absence of distal flow. As outflow protection devices prevent these distal emboli, they have a potential role in noncarotid interventions. However, these protection devices have a minor risk of complications, hence their potential use would be dictated by the individual case characteristics.
Format: The established role and potential complications of protection devices in the carotid circulation shall be discussed, to help in assessing the safety of these devices in the non-carotid circulation. Features of the currently available occlusive and nonocclusive distal embolic protection devices, their mechanisms of deployment and device retrieval and their differing characteristics shall be discussed, to assess the feasibility of their use in the non-carotid circulation. Based on available literature, indications for their potential use in the non-carotid circulation shall be discussed.
Teaching Points: To understand the differing characteristics of outflow embolic protection devices, to understand their potential complications, and to evaluate their potential role in the non-carotid circulation.
E354. Optimized Protocols for Vascular CT Angiography (CTA)
Streeter J.1; Rybicki F.J.1; Lell M.M.2; Ersoy H.1; Bae K.T.3; 1. Cardiovascular Imaging Section, Brigham and Women's Hospital, Boston, MA; 2. Radiology, Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany; 3. Radiology, Washington University, St. Louis, MO
Address correspondence to J. Streeter (jstreeter{at}partners.org)
Background: In vascular CT angiography (CTA), differences in the speed of image acquisition between 16- and 64-slice MDCT technology has necessitated the development of protocols to optimize the delivery of iodinated contrast media.
Key Issues: Detailed vascular CTA protocols are presented for 16- and 64-slice scanners from all major CT vendors. While the principles of contrast delivery do not vary, scan delay, bolus tracking, and other acquisition and reconstruction parameters vary according to individual platforms. Understanding the relationships between contrast media injection parameters (total volume, iodine concentration, flow rate, total iodine dose, iodine delivery rate, and duration of injection) are important in the implementation of efficient protocols. The speed offered by 16- and 64-slice MDCT, in comparison with earlier scanners, enables superior arterial and/or parenchymal enhancement with a smaller total volume and total iodine dose. However, the speed of current scanners enables the user to acquire CT data faster than the physiologic distribution of the contrast media. This pitfall and methods to avoid it are detailed.
Format: Didactic. Essential differences among MDCT scanners for vascular CTA are highlighted. Parameters are reviewed individually, particularly when there is significant variation among vendors. Imaging pitfalls are described with respect to physiology, mathematical models, and imaging illustrations.
Teaching Points: 1. Vascular CTA protocols optimized for 16- and 64-slice MDCT. 2. Differences between different CT platforms for vascular CTA 3. Principles of MDCT contrast dose optimization.
E355. Covered Stents: Extra-Aortic Applications as Primary Therapy for Arterial Trauma and Aneurysms
Midkiff B.D.; Ahn S.H.; Lambiase R.E.; Soares G.M.; Murphy T.P.; Diagnostic Imaging, Rhode Island Hospital/Brown Medical School, Providence, RI.
Address correspondence to B.D. Midkiff (bmidkiff{at}lifespan.org)
Objective: To report the use of covered stents as primary therapy for extra-aortic peripheral arterial trauma and aneurysms in lieu of traditional open surgical repair.
Materials and Methods: We performed a retrospective review of a cohort of patients who were treated with covered stents for arterial traumatic injury and aneurysms, excluding aortic pathology, from September 2002 to September 2005. Patient demographic information was collected. Etiology and type of arterial disease, diagnostic imaging, and interventional procedures were reviewed. Patient charts and the Interventional Radiology database (Hi-IQ) were reviewed for patient outcome, including complications, recurrence of disease, and need for surgical intervention.
Results: Twelve patients were treated percutaneously with covered stents. Five were treated with Viabahn and seven with Wallgraft devices respectively. Peripheral arter-ies treated included common carotid (n = 1), internal carotid (n = 2), subclavian (n = 2), hepatic (n = 1), renal (n = 1), iliac (n = 3), femoral (n = 1) and superior gluteal (n = 1) arteries. Arterial diseases were comprised of active extravasation including a carotid blowout (n = 3), aneurysms (n = 3), traumatic avulsions (n = 2), iatrogenic pseudoaneurysms (n = 3), and prophylaxis for carotid blowout (n = 1). Technical success was achieved in twelve of twelve patients (100%). One patient required surgical explantation of the covered stent and open repair of a mycotic pseudoaneurysm. In this case, the stent was placed as a temporizing measure for 24 hours with full intention of removal and definitive resection of the diseased segment. No patients required additional or unplanned peripheral or surgical interventions. One patient had a change in mental status related to sedation. One patient required intubation during the procedure.
Conclusion: Our initial experience with covered stents as primary treatment for extra-aortic arterial trauma and aneurysms was favorable with 100% technical success rate and excellent short-term results. In selected patients this approach may obviate the need for surgery.
E356. Vascular Disorders of the Hand: High-resolution Three-dimensional Contrast-enhanced MR Angiography Assessment
Abdel Razek A.1; Saad E.2; Soliman N.1; Abou Elatta H.1; 1. Diagnostic Radiology, Mansoura University Hospital, Mansoura, DK, Egypt; 2. Vascular Surgery, Mansoura University Hospital, Mansoura, DK, Egypt.
Address correspondence to A. Abdel Razek (arazek{at}mans.eun.eg)
Objective: To assess the usefulness of high-resolution contrast enhanced MR angiography in vascular disorders of the upper limb.
Materials and Methods: Three-dimensional contrast enhanced MR angiography (CE-MRA) was performed for 34 hands in 31 patients (17 M, 14F mean age 34ys) with clinically suspected vascular disorders of the hand. This study was conducted on 1.5 tesla MR unit (Symphony-Siemens). Bolus of gadolinium-DTPA was injected in the forearm (0.2 mmol/kg at rate of 2 ml/sec followed by 20ml saline flush at the same rate). Images acquired in coronal plane using dedicated surface coil. The first acquisition served as, a mask, which was subtracted from the second acquisition, the contrast run. Conventional angiography was done for 21 hands within 2–7 days after CE-MRA.
Results: All CE-MRA examinations were technically adequate for analysis with high signal noise ratio. Vessel anatomy & stenotic areas detected with CE-MRA correlated well with those on conventional angiography. No vascular abnormality could be detected in 2 patients. In vasculitis (n = 12), multiple stenotic or occluded regions involving the digital arteries and arch of the hands. In Burger disease (n = 4), there was corrugated vessel with corkscrew collaterals. Multiple occluded vessels were seen in emboli (n = 3). Raynouds disease (n = 3) showed gradual narrowing & tapering of proper digital arteries with capillary congestion. Steal syndrome of the hand (n = 3) was seen in patients with forearm dialysis graft. Vascular supply of the arterio-venous malformation (n = 2). Various types of hemangiomas (n = 3) and aneurysm (n = 2) can be easily diagnosed with CE-MRA.
Conclusion: These preliminary results indicated that high resolution three dimensional contrast enhanced-MR angiography is a promising diagnostic imaging modality for assessment of vascular disorders of the hand as it creates arterial map similar to that provided with conventional angiography.
E357. Use of 16-slice CT Angiography in the Imaging of Patients with Takayasu's Arteritis
Gulati G.S.; Sharma S.; Jagia P.; Seth S.; Kothari S.S.; Saxena A.; Cardiac Radiology, All India Institute of Medical Sciences, New Delhi, Delhi, India.
Address correspondence to G.S. Gulati (gulatigurpreet{at}rediffmail.com)
Objective: To describe the imaging spectrum of Takayasu's Arteritis (TA) on multidetector CT angiography (MDCTA) with 16-slice technology, and compare the results with digital subtraction angiography (DSA).
Materials and Methods: Forty patients with clinically established TA underwent MDCTA. Of these, 21 patients had DSA. MDCTA of thoraco-abdominal aorta was performed (120 kv/130 mAs/0.5 sec tube rotation time; collimation: 0.75 mm; table feed/rotation = 15 mm, slice thickness = 1.5 mm), after iv injection of 100 ml non-ionic contrast (iohexol) and 40 ml saline at 3.5 ml/s. Scan delay was set by bolus tracking over the aortic arch. Axial and reconstructed multi-planar and maximum intensity projection images were reviewed for analysis. Intra-arterial DSA was done by the standard technique, with pigtail catheter injections being made in the thoracic and abdominal aorta using iohexol contrast. MDCTA and DSA images were interpreted separately by two vascular radiologists. Site and nature of involvement, branch vessel disease, and calcification and reformation of occluded renal arteries were analyzed with both techniques. MDCTA was also used to assess vessel wall thickness and pulmonary artery (PA) involvement.
Results: All patients [34 females; age range: 10–50 (mean 22) yrs] completed both the examinations. MDCTA images were diagnostic in all cases. Descending thoracic and abdominal aorta were most frequently involved (74% each). Left subclavian artery was more often involved than right (53% vs. 21%). Carotid involvement was equal on either side. Bilateral renal involvement was seen in 37% of cases, left being more commonly diseased. Iliac arteries were the least affected (11%). Stenotic lesions predominated (84%) over dilatation (26%) and dissecting aneurysms (32%). On MDCTA, the aortic wall thickness was 3.1+/- 2.9 mm. PA involvement was seen in 21%. In 21 patients who underwent both the techniques, for all lesions, the sensitivity and negative predictive value of MDCTA were 100% each. Presence of minimal disease (wall thickening) caused false positives on MDCTA. MDCTA demonstrated a small dissecting aneurysm and calcification in 3 cases each that were missed on DSA. Renal artery reformation beyond occlusion was better seen with MDCTA than DSA (70% vs. 20%).
Conclusion: MDCTA reliably displays the spectrum of vascular lesions in TA. Compared to DSA, it can detect minimal disease (increased wall thickness), as well as better visualize reformation of blocked renal arteries, presence of calcification & small aneurysms.
E358. Ehlers Danlos Syndrome Type IV: Imaging Findings
Zilocchi M.1,2; Macedo T.A.1; Oderich G.S.1; Vrtiska T.; Stanson A.W.1; Zatschkowitsch N.2; Biondetti P.R.2; 1. Diagnostic Radiology, Mayo Clinic, Rochester, MN; 2. Radiology, IRCCS Ospedale Maggiore di Milano, Milano, Italy.
Address correspondence to M. Zilocchi (massimo.zilocchi{at}gmail.com)
Objective: Ehlers-Danlos Syndrome (EDS) type IV is an autosomal dominant disorder characterized by fragility of medium-sized and large arteries due to defects in the type III collagen. Our purpose was to review imaging findings in patients with EDS type IV diagnosis.
Materials and Methods: Review of the radiology, surgery and genetics database over the last 30 years identified 32 patients (15 male and 17 female) with EDS-IV. The diagnosis was confirmed with lab tests in 23 patients and based on clinical findings only in 9 patients. Imaging studies were available for 27 patients (11 male and 16 female). A vascular radiologist and a neuroradiologist reviewed a total of 185 exams including: 88 CT, 22 MR, 59 US and 16 angiograms.
Results: The mean age at time of diagnosis was 30.8±13 years. Vascular abnormalities were found in 20 patients including: 12 arterial ectasias (2 thoracic aorta, 2 pulmonary arteries, 2 visceral and 6 iliac and lower extremity), 42 aneurysms (13 head and neck, 3 thoracic aorta, 14 abdominal aorta and visceral arteries, 12 iliac and lower extremity), 1 splenic vein aneurysm, 22 arterial dissections (3 head and neck, 4 thoracic aorta, 11 abdominal aorta and branches, 4 iliac arteries), 8 arterial occlusion (2 head and neck, 2 visceral, 4 iliacs); 1 carotid-cavernous sinus fistula and 1 enlargement of the cavernous sinus. Vascular complications was found in 9 patients and included 11 infarcts (5 chronic cerebral infarcts, 2 splenic and 4 renal) and 8 hemorrhages (2 spleen, 2 liver, 1 lung, 1 groin, 1 internal mammary artery and 1 of the inferior epigastric) 4 of these were related to procedures (1 liver biopsy, 1 coil embolization, 1 stent placement and 1 cholecystectomy). Extravascular findings included: 1 diverticulitis, 1 partial colectomy because of the rupture of a diverticulum, 1 pancreatitis, 4 cavernous hemangiomas, 1 cholecystitis, 1 sclerosing colangitis and 1 hemangioma in a lumbar vertebrae.
Conclusion: EDS type IV is a rare connective tissue disorder affecting the vascular system. The most common findings include arterial aneurysms and ectasias followed by arterial dissections and occlusions. Life threatening complications include hemorrhage and infarcts.
E359. Acute Traumatic Rupture of the Abdominal Aorta. Diagnosis and Treatment
Tisnado J.; Sydnor M.K.; Murphy T.P.; Radiology/Vascular & Interventional, MCV Hospitals/VCU Medical Center, Richmond, VA.
Address correspondence to J. Tisnado (jtisnado{at}vcu.edu)
Objective: Acute traumatic rupture of the thoracic aorta (ATRTA) is well described and well known. However, acute traumatic rupture of the abdominal aorta (ATRAA) has not received literature attention. ATRAA is much less common than ATRTA but is very serious. We describe the diagnostic and therapeutic aspects of this rare injury, being seen with increasing frequency in this era of high speed, aggressive driving, and violent behavior.
Materials and Methods: We have studied many patients with ATRAA secondary to severe blunt trauma to the abdomen and pelvis, particularly lap belt injuries. In some emergency room patients, the diagnosis was missed until few days later, which could jeopardize their definitive management. We describe the noninvasive diagnostic imaging and angiographic features. With the advent of stent grafting, this management can, in certain instances, be applied to this potentially lethal condition. Children are prone to sustain ATRAA.
Results: An accurate diagnosis was made, as rapidly as possible, with noninvasive imaging: CT, CTA, MRI, MRA, and DSA. Open aortic graft insertion and stent grafting was performed successfully in our patients. Serious complications (intraabdominal or pelvic bleeding, visceral or lower extremity ischemia, or death) were not recorded.
Conclusion: ATRAA is a rare entity which could be fatal if a prompt diagnosis and therapy is not established. This injury is seen with increasing frequency in this era of high speed and impaired and aggressive driving. Children are prone to this injury. An awareness need of this potentially lethal injury, easily missed clinically, prompted this poster.
E360. Endovascular Management of Acute, Severe Gastrointestinal Bleeding
Ferral H.1; Pillai A.1; Behrens G.1; Lopera J.2; Alonzo M.1; Patel N.H.1; 1. Interventional Radiology, RUSH Medical Center, Chicago, IL; 2. Interventional Radiology, UT Southwestern Medical Center, Dallas, TX.
Address correspondence to H. Ferral (hferral{at}rushradiology.org)
Background: A few years ago, the management of acute, severe gastrointestinal bleeding was primarily surgical. In the past, the angiographic evaluation of the bleeding patient was useful only to localize the bleeding site and if embolization was attempted, the embolic agent would be deposited in relatively large intestinal branches, resulting in a high incidence of post-embolization mesenteric ischemia.
Key Issues: The recent development of lower profile angiographic catheters, microcatheters and new embolization agents has allowed the interventional radiologist to perform super-selective catheterization and embolization of small intestinal branches with a lower risk of post-embolization mesenteric ischemia, resulting in fewer patients requiring surgery.
Teaching Points: The purpose of this exhibit is to illustrate the endovascular techniques currently available for the management of severe, acute upper and lower gastrointestinal bleeding. The approach to different conditions including Mallory Weiss tears, aneurysms, pseudoaneurysms, hemobilia, tumors and inflammatory conditions will be reviewed. Angiographic anatomy, outcomes and complications will be discussed.
E361. "Initial Experience with 64-slice CT Angiography for the Evaluation of Gastrointestinal Bleeding"
Tobias T.; Laing C.; Radiology, Metrohealth Medical Center, Cleveland, OH.
Address correspondence to T. Tobias (linutian{at}hotmail.com)
Background: Gastrointestinal bleeding accounts for 300,000 hospital admissions per year, carrying a significant mortality rate of 10%. Rapid, accurate diagnosis is imperative as these patients require a multidisciplinary approach amongst gastroenterologists, surgeons, and radiologists to determine the most appropriate management of the patient. The advent and growing availability of multi-detector CT angiography has introduced a promising new tool that has the advantages of being quick (no bowel prep required), noninvasive, and sensitive, while also providing a roadmap prior to catheter-directed therapy. This is in contrast to the long imaging time and poor anatomic detail of tagged RBC-scans, or the invasiveness and personnel demands of conventional angiography.
Key Issues: The classic CTA findings for both upper and lower GI bleeds will be addressed. In addition, the scanning protocol on our Philips 64-slice scanner will be explained.
Format: This will be a didactic presentation first discussing the current diagnosis and treatment algorithm for GI bleeding at our institution. We discuss the advantages and disadvantages of current imaging exams for GI bleeding, what CTA brings to the table, and how it changes (and improves) patient management. A pictorial case review of our eight initial patients will be presented.
Teaching Points: The viewer will learn about the etiology, standard diagnosis, and management of GI bleeding. We will then discuss how CTA for GI bleeding is performed at our institution, its imaging characteristics, the advantages over current imaging modalities, and most importantly, its affect upon patient management.
E362. Causes of Transjugular Intrahepatic Portosystemic Shunt Failures
Cura M.A.; El-Merhi F.; Suri R.; Postoak D.; Wholey M.; Radiology, University of Texas Health Science Center, San Antonio, TX.
Address correspondence to M.A. Cura (Curam{at}uthscsa.edu)
Background: Transjugular intrahepatic portosystemic shunt (TIPS) creation is an effective method to control portal hypertension. TIPS have demonstrated limited and unpredictable patency. In nearly all cases of rebleeding or recurrent ascites after TIPS creation, there is shunt stenosis or occlusion. Recurrent portal hypertension with stenoses greater than 50% develop in 25%–50% of cases 6–12 months after TIPS creation.
Key Issues: Excluding early shunt failure secondary to technical failure such as stent shortening or migration, causes of TIPS dysfunction include bile related, bile non related and hepatic vein stenosis. Bile is thrombogenic and delays tract healing by inhibition of smooth muscle proliferation. In acute thrombosis and recurrent occlusion, biliary-TIPS fistulas should be suspected. Later non thrombogenic parenchymal tract stenosis, due to myofibro-blast proliferation which growths through the stent mesh into the shunt lumen, may represent a fibrotic healing response to the trauma of shunt creation. Hepatic vein stenosis or intimal hyperplasia of the hepatic vein occurring months to a year after TIPS creation is mainly caused by shear stress from increased blood flow circulation.
Format: This educational exhibit presents patients who after having TIPS creation presented because of recurrent symptoms of portal hypertension or abnormal ultrasound Doppler surveillance of the TIPS and reviews the venografic findings and the technique for TIPS revascularization including revision with stent graft.
Teaching Points: Understand the causes of TIPS failure. Learn the Technique of TIPS revisions. Understand how stent-grafts treat and prevent causes of shunt failure of bare stents.
E363. Liver cell transplantation. State-of-the-art
Tisnado J.; Murphy T.P.; Prasad U.R.; Fisher R.A.; Sydnor M.K.; Leung D.A.; Komorowski D.J.; Radiology/Vascular & Interventional, MCV Hospitals/VCU Medical Center, Richmond, VA.
Address correspondence to J. Tisnado (jtisnado{at}vcu.edu)
Objective: Orthotopic liver transplantation (OLT) is the definitive method for fulminant, acute and chronic liver failure. The availability of organs is limited. A "bridge" is needed until a liver is found. There are 10,000 patients waiting for a liver in USA. Many of them die waiting. Recently, right lobe living donor transplantation (RLLDT) has become popular and the pool of organs has increased 10-fold. However, the need of organs is still critical. One method to keep patients with fulminant failure alive, being developed in our institution, is liver cell transplantation (LCT), i.e., the injection of hepatocytes from donor livers into the recipient's liver.
Materials and Methods: LCT provides function until a liver is available, or improves liver function in patients too sick to tolerate OLT or RLLDT, patients with an expected mortality of 100% in 24 hours. The hepatocytes (200 to 1,000 million) are harvested, cultured, frozen and stored. Thereafter, the cells are infused in the spleen or liver by catheterization of the splenic artery or the portal vein. Thereafter, the hepatocytes colonize in the splenic pulp or hepatic sinusoids.
Results: We have done LCT in 20 patients. Therefore, we present our very encouraging experience. We emphasize this exciting new method to "bridge" the interval between OLT or RLLDT.
Conclusion: The interventional radiologist must be available at all times to catheterize the splenic artery or portal vein for LCT. These procedures are required on a short notice during the day or night. The future of liver cell transplantation is exciting.
E364. Transluminal Drainage of Postsurgical Pararectal Collections Communicating with the Lower GI
Cozzi G.1; Salvetti M.1; Fornari S.2; Sporeni M.2; Zilocchi M.2; Vannelli A.3; Severini A.; 1. Diagnostic Imaging, Istituto Nazionale Tumori, Milan, Italy; 2. Radiologic Science Institute, Università degli Studi, Milan, Italy; 3. Department of Surgery, Colo-Rectal Unit, Istituto Nazionale Tumori, Milan, Italy.
Address correspondence to G. Cozzi (guido.cozzi{at}istitutotumori.mi.it)
Objective: To describe an easy and safe procedure to drain collections originating from anastomotic fistulas in patients who underwent rectal resection with colorectal or coloendoanal anastomosis.
Materials and Methods: When a pararectal collection is suspected, a water-soluble contrast enema is performed with the patient laying on a lateral side. Several serial digital images (up to 4/sec) are acquired in order to identify the precise origin and course of the fistulous tract. If the collection is confirmed a torque control catheter is inserted through the anus into the rectum. Under fluoroscopic control, the tip is advanced close to the site of origin of the fistula: a guidewire is inserted into the catheter and positioned into the collection, across the anastomotic rent. A 12/14F sump catheter is then advanced on the guidewire into the collection, fixed to the skin of the thigh with strips and connected to a collection bag. The catheter allows aspiration of fluids, flushing with saline and/or antibiotics and radiographic control of the collection, until its complete healing. The catheter is eventually removed when the dimensions of the collection clash with the diameter of the locking loop of the catheter itself. In absence of clinical symptoms, a radiographic control is performed within a week after removal of the catheter. In the last 16 years about 300 with pararectal postsurgical collections were treated with transluminal drainage.
Results: Transluminal drainage alone or in association with temporary colostomy and/or parenteral nutrition allowed the healing of the collections and the closure of the fistulas in the 77.9% of the patients followed-up in this series. The mean healing time was 11.9 days. No procedure-related complications developed.
Conclusion: Anastomotic fistulas are a frequent complication in patients who underwent colorectal or coloendoanal anastomosis for adenocarcinoma of the rectum. The clinical course of these fistulas may be asymptomatic and generally no treatment is necessary but in some cases pararectal collections may develop. In the present series transluminal drainage appeared to be a safe and well tolerated technique that contributed to the healing of the collections reducing the need of surgical reintervention.
E365. Pulmonary Artery Pseudoaneurysm: Etiology, Presentation, Diagnosis and Treatment
Lafita V.S.1; Borge M.1; Demos T.1; Radiology, Loyola University Health Center, Maywood, IL.
Address correspondence to V.S. Lafita (vlafita{at}lumc.edu)
Background: Pulmonary artery aneurysms are uncommon and associated with high mortality. Left untreated, these lesions can progressively enlarge, rupture and lead to exsanguination and death. Most occur in patients with cardiovascular disease, but other etiologies are infectious, iatrogenic, traumatic, congenital, and neoplastic. Presentation ranges from acute severe hemorrhage to lesions without hemorrhage that enlarge for days, months or years. Most patients have abnormalities on imaging studies that can lead to early diagnosis and treatment. Embolization is a treatment of choice, especially when there is major hemorrhage. Thus the radiologist is in a position to contribute to both timely diagnosis and treatment.
Key Issues: Most patients have history of indwelling pulmonary artery catheters or have undergone procedures involving the pulmonary arteries, blunt or penetrating trauma, or an infection. Most present with abnormalities on radiographs or CT. Radiographs may show focal lung consolidation, a solitary pulmonary nodule, or early consolidation evolving to a well-defined nodule or mass. There may or may not be hemorrhagic pleural fluid. CT is more definitive when there is central enhancement within a hematoma or focal lung consolidation. Other findings include an enhancing mass contiguous with a pulmonary artery, partial thrombosis of a dilated pulmonary artery, and an enhancing nodule with a low attenuation halo. Definitive diagnosis is usually made by angiography that confirms the diagnosis, demonstrates the pathologic anatomy, and provides a roadmap for treatment by embolization.
Format: This didactic exhibit has clinical, etiologic, imaging, and treatment sections. Clinical presentation and imaging findings will be illustrated by patients with pseudoaneurysms due to penetrating trauma, blunt trauma, iatrogenic causes related to a pulmonary catheter and complicating right heart catheterization, and endocarditis. Interventional treatment options for embolization will be discussed and illustrated in two patients. The exhibit will be interactive and in the PowerPoint format.
Teaching Points: The goal of the exhibit is to review the clinical presentation and imaging finding that suggest and confirm the diagnosis on chest radiographs, CT, and angiography. Treatment options will be discussed. The radiologist is in a key position to both diagnosis and treat pulmonary artery pseudoaneurysms.
E366. Noninvasive 64-slice CT Imaging of Complex Lesion Stenting Techniques in Coronary Arteries
Pugliese F.1; Cademartiri F.1; van Mieghem C.2; Martinoli C.3; deFeyter P.J.2; Krestin G.P.1; 1. Department of Radiology, Erasmus Medical Center, Rotterdam, Netherlands; 2. Department of Cardiology, Erasmus Medical Center, Rotterdam, Netherlands; 3. Cattedra R di Radiologia, University of Genoa, Genoa, Italy.
Address correspondence to F. Pugliese (francesca.pugliese{at}libero.it)
Background: An accurate noninvasive coronary imaging tool is highly desirable for the follow-up of patients after percutaneous coronary revascularization with stent placement. Imaging the in-stent coronary lumen with CT is more challenging than imaging the native coronary artery lumen, basically because of high density artifacts secondary to the metallic stent struts. The increased restenosis rates associated with complex lesions compared to simple lesions makes some knowledge of the stenting technique used and subsequent CT imaging issues mandatory.
Key Issues: Although recently introduced drug-eluting stents have reduced the occurrence of restenosis, still this phenomenon occurs in up to 20% of patients with complex lesion characteristics. Reliable clinical interpretation of CT data for the assessment of in-stent restenosis or more subtle degrees of neo-intimal hyperplasia requires knowledge of the stent configurations (and related artifacts) at bifurcation points.
Format: CT examples of applied techniques such as provisional stenting, T, Y, culotte and crush stenting are provided with schematic explanations to the purpose of helping the interpretation of the reshaped bifurcation anatomy and evaluating the technical outcome of the procedure.
Teaching Points: The reader will be made familiar with the major complex lesion stenting techniques in light of the associated 64-slice CT stent configurations. Clues about how to overcome metal related artifacts and assess vulnerability to the development of restenosis will be dealt with according to the bifurcation technique used and technical outcome.
E367. Image-Guided Interventions in Morbidly Obese Patients: A Guide to Limitations and Technical Difficulties and What Can Possibly be Done
Uppot R.N.; Hahn P.F.; Sahani D.V.; Gervais D.A.; Mueller P.R.; Division of Abdominal Imaging; Department of Radiology, Massachusetts General Hospital, Boston, MA.
Address correspondence to R.N. Uppot (ruppot{at}partners.org)
Background: Increasingly, interventional radiologists are asked to perform minimally invasive interventions in obese patients. Obese patients present unique challenges to image guided interventions including. 1. Challenges in the ability to acquire adequate imaging. 2. Challenges to adequately sedate the patient for the procedure. 3. Technical difficulties associated with performing minimally invasive interventions with equipment (wires and catheters) designed for normal-sized adult. 4. Increased risk to the technologist and radiologist when moving/positioning large patients. 5. Increased risk for post procedure infections and poor wound healing.
Key Issues: Minimally invasive procedures can be performed by understanding: 1. Weight limits of CT and angio/fluoroscopy equipment. 2. Limitations of tissue penetration with ultrasound, and x-ray and what can be done to maximize image quality. 3. Choices in catheter and wires available including lengths widths, stiffness. 4. Choice of access routes.
Format: Didactic. Organizational structure Temporally: 1. Obese Patient Intervention Consulted. 2. Best modality for patient weight? 3. Techniques to maximize image quality for that modality? 4. Which catheters/wires? 5. Which access routes? 6. Technical challenges - Possible practical solutions.
Teaching Points: 1.To define limitations in the ability to acquire adequate images in obese patients and discuss technical difficulties encountered. 2. To define risks involved in image-guided interventions to the patient, the technologist/nurse, and the radiologist. 3. To discuss solutions including choice of imaging modality and offer technical alternatives.
E368. Minimally Invasive Imaging Guided Procedures: A Practical Update of Routine and Novel Body Interventional Procedures
Grimm J.; Matcuk G.R.; Broumandi D.D.; Facchini D.; Palmer S.L.; Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA.
Address correspondence to J. Grimm (drgrimmy{at}yahoo.com)
Background: Most radiology practices provide imaging guided minimally invasive procedures as an important part of their clinical service. Computed tomography (CT) and ultrasound (US) guide the majority of these biopsy and drainage procedures. With catheter and needle advancements, minimally invasive procedures are becoming easier and safer to perform in daily practice. One of the benefits of these advancements is that more patients will avoid invasive surgical procedures. Because CT and US guided procedures have become routine, referring physicians expect higher diagnostic and therapeutic yields, with lower patient complications. By streamlining routine procedures, introducing new approaches to well established procedures and developing novel procedures, radiologists can continue to expand their clinical practices.
Key Issues: This educational exhibit reviews in detail the indications for minimally invasive body interventional procedures and demonstrates the appropriate techniques for each procedure. The techniques presented include patient positioning, how to choose the appropriate approach, needle and catheter selection and peri-procedure patient care. Some of the specific procedures featured include: intra-thoracic and intra-abdominal abscess drainage, superficial and deep seroma drainage, pericardial effusion drainage, and biopsy of intrathoracic and intraabdominal masses, both deep and superficial.
Format: This exhibit is based on an educational video format. Each procedure will be covered step by step in a video manual style. All aspects of the procedure will be addressed, from beginning to end. These minimally invasive imaging guided procedures will be divided into two categories, biopsy and drainage, with each procedure demonstrated in a separate instructional video. A brief overview will also be presented to allow the viewer to select and review the procedures that are most important to their individual practice.
Teaching Points: After reviewing this exhibit the viewer will: 1. Know the indicationsfor minimally invasive imaging guided procedures 2. Understand the techniques for imaging guided procedures and be able to modify these techniques to individual and technically challenging cases. 3. Be more confident in performing minimally invasive imaging guided procedures and teaching these techniques to residents and fellow staff
E369. Rendu-Osler-Weber's syndrome: Radiological features of Multiple Organ (Diagnosis and Therapeutic)
Carette M.F.; Tassart M.; Korzec J.; Marsault C.; Khalil A.; Radiology, APHP Tenon Hospital, Paris, France.
Address correspondence to A. Khalil (antoine_khalil{at}yahoo.fr)
Key Issues: Pictorial review based on our experience of the follow-up in our multidisciplinary consultation for hereditary hemorrhagic telengiectasia (HHT) in 98 patients. Rendu-Osler-Weber's syndrome or HHT is a multiple organ involvement. It is an autosomal dominant disorder with high penetration, characterized by epistaxis, mucocutaneous telangiectases, and visceral arteriovenous malformations (AVM). The gene study is fundamental for patient and family screening such as a clinical exam, chest x-ray, abdominal color Doppler sonography. The angioarchitecture of pulmonary AVM is studied by unenhanced multidetector CT, however, all others explorations (liver, digestive bowels, brain, spinal cord) need contrast media administrations. MR angiography is helpful for central nervous system screening, and also for pulmonary AVM, liver and pelvic. The knowledge of multiple organ involvement, the mechanism, the radiological findings are fundamental to correctly treat these patients.
Format: Didactic format. Organizational structure by organ involvement.
Teaching Points: 1: Hereditary Hemorrhagic Telengiectasia (HHT) genotype and their related clinical involvement. 2: Diagnosis criteria of pulmonary arteriovenous malformations and their therapeutics. 3: Diagnosis criteria of liver involvement and the therapeutic options in HHT. 4: Mechanisms and radiological findings of central nervous system in HHT.
E370. Diagnosis and Management of Back Pain with Fluoroscopy-guided Interventions
Chong-Han C.H.1,2; Orth R.C.1,2; Wong W.1,2; 1. Radiology, UCSD Medical Center, San Diego, CA; 2. Radiology, Veterans Affairs San Diego Healthcare System, La Jolla, CA.
Address correspondence to C.H. Chong-Han (c_chonghan{at}yahoo.com)
Background: Back pain is the second most common complaint faced by primary care physicians with an estimated 80% of people experiencing back pain in their lifetime. The economic and social burdens of back pain include significant direct health care costs, loss of productivity, and decrease in quality of life. Accurate diagnosis of back pain and effective treatment is important in controlling costs and improving outcome for patients.
Key Issues: There are many causes of back pain. Pain can be diskogenic in origin stemming from herniated nucleus pulposus or degenerative disc. Myofascial pain may be a result of strained muscles or tendonitis. Spinal stenosis can lead to pain and radiculopathy. Osteoarthritis of the facet joints or sacro-iliac joints may produce focal pain. Fractures, inflammatory or rheumatologic diseases, and infiltrative diseases such as infection or neoplasm can also contribute to back pain. Using a combination of history, physical exam, and imaging findings the radiologist can differentiate the different causes of back pain and provide directed treatment.
Format: Our exhibit will focus on diagnosis and treatment of the common causes of back pain using case scenarios. Video clips and photos will used to illustrate basic spinal diagnoses and interventional procedures. Interventional topics will include image-guided epidural steroid injection, facet and sacro-iliac joint injections and nerve blocks, spinal biopsies, diskogram technique, radio-frequency ablation, vertebroplasty, and kyphoplasty.
Teaching Points: Understanding the different etiologies of back pain and providing image-guided treatments is vital for radiologists participating in the care and management of patients experiencing spinal pain.
E371. The Role of Interventional Radiology in the Transplanted Kidney
Tisnado J.; Sydnor M.K.; Prasad U.R.; 1. Radiology/Vascular & Interventional, MCV Hospitals/VCU Medical Center, Richmond, VA.
Address correspondence to J. Tisnado (jtisnado{at}vcu.edu)
Objective: Renal transplantation, the definitive management for end stage renal disease, is effective, safe, and widespread. As more transplants are done, more associated problems and complications are found. We are pioneers in renal transplantation in the USA and the world; therefore, we have a vast experience on the topic.
Materials and Methods: Few comprehensive reviews are available. We review our experience of most complications including (A) vascular, (B) non-vascular, and (C) others: PTA of renal artery stenoses, stenting of renal arteries, arterial and venous thrombolysis, placement of filters in the IVC and iliac veins, embolization of AVFs due to kidney biopsy, management of lymphoceles, and other collections. Percutaneous nephrostomy, internal and external urinary drainage, dilatation of pelvic and ureteral strictures, stenting of ureters, drainage of fluid collections, needle aspiration and core biopsies, and other complications.
Results: All procedures are successful in managing the minor and major complications of renal transplantation.
Conclusion: Interventional radiologists (IR) are the most important members of the team managing renal transplant complications. The procedures are simple, quick, safe and effective and cost-effective as well. Surgery must be avoided, if possible. The IRs are available 24 hours a day, 7 days a week. Every effort must be made to salvage a transplanted organ.
E372. Core Biopsy vs. Fine Needle Aspiration Cytology (FNAC) of Thyroid Nodules: A Review of Technical Success and Complications
Kapoor B.; Panu A.; Shenouda M.; Berscheid B.; Panu N.; Medical Imaging, Saskatoon Health Region, Saskatoon, SK, Canada.
Address correspondence to B. Kapoor (bkapoo{at}yahoo.com)
Objective: Object: Core biopsy vs. fine needle aspiration cytology (FNAC) of thyroid nodules: a review of technical success and complications
Materials and Methods: Material, methods and Procedures: A total of 161 biopsies were performed in 154 patients (median age, 50 years; age range, 20–87 years) as an outpatient procedure under direct US guidance as either core-needle or FNAC.
Results: Results: Histological specimens were diagnostic in 85% of
core needle biopsies, compared with 57% for the FNAC aspirates. The
significance of the results was tested using a two way contingency table. Core
needle biopsy was significantly more successful in diagnosis than FNAC
(Pearson and 
-square = 5.58, p < 0.02, df = 1). As determined
by the odds ratio, core needle biopsy is 4.2 times more likely for successful
diagnosis than FNAC (95% c.i. 1.11 to 14.98). There was one complication
encountered with core biopsy where the patient had a transient vasovagal
reaction with a drop in blood pressure and responded immediately to
conservative management. No other complications were noted.
Conclusion: US-guided core-needle biopsy of the thyroid nodules is a safe outpatient procedure with a higher diagnostic yield than FNAC.
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