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ABSTRACT |
Wednesday, May 3, 1:30 PM-3:30 PM
Abstracts 198-207
Moderators: R. Torrance Andrews, MD and Thuong G. Van Ha, MD
1:30 PM
Keynote Address: Arterial Plaque Excision: Old Dog or New Trick?
Thuong G. Van Ha, MD, University of Chicago, Chicago, IL
1:50 PM
198. Reduced Physician Radiation Exposure during Coronary Angiography With New Radiation Protection Technique
Magram M.Y.*; Radiology, University of Maryland Medical Center, Baltimore, MD.
Address correspondence to M.Y. Magram (mmagram{at}umm.edu)
Objective: A new technique of physician radiation protection during coronary angiography was evaluated in order to assess the associated reduction in physician radiation exposure compared to conventional methods.
Materials and Methods: This new technique consisted of using a body length floor mounted lead plastic panel to reduce exposure during all cine angiography and most fluoroscopy along with an extension bar attached to the table which allowed manual movement of the table for panning. A lead apron, thyroid shield, eye glasses and face mask were used in both techniques but a ceiling mounted shield was used in the conventional technique. Radiation dosimetry badges measured radiation exposure in 25 cases using the new technique and in 25 cases using conventional protection. All 50 angiograms were performed by the author using the femoral approach. Radiation badges were placed outside and inside the face mask, outside and inside the thyroid shield, on the right and left arm, outside and inside the lead apron and on the right and left leg. Radiation exposure was measured using conventional shielding and was compared with exposure and percent reduction in exposure using the new technique.
Results: A new technique of physician radiation protection showed a reduced exposure of the head, arms and legs of approximately 90% compared to the conventional technique. Exposure of the thyroid and torso (under the lead apron) was minimal with both techniques.
Conclusion: Enhanced physician radiation protection during coronary angiography is readily achievable with this new technique.
199. The Diagnosis and Treatment of PostTraumatic Arteriovenous Fistulae: A 25 Year Single Institution Experience
Kobak J.A.1*; Sclafani S.J.1,2; Herskowitz M.1,2; 1. Radiology, State University of New York Downstate Medical Center, Brooklyn, NY; 2. Radiology, Kings County Hospital Center, Brooklyn, NY.
Address correspondence to J.A. Kobak (jeffrey.kobak{at}nychhc.org)
Objective: The authors conducted a 25 year retrospective single institution review of arteriovenous fistulae (AVF) resulting from external trauma.
Materials and Methods: Patients were prospectively identified at the time of arteriography and subsequently reviewed. This analysis included mechanism of injury, modality for diagnosis, patterns and features of the vascular abnormalities and method of treatment. Because of the duration of this study, both analog and digital angiography were employed. The injuries were classified according to location, shape, flow dynamics and the presence or absence of false aneurysm. Finally, the methods and outcomes of treatments were reviewed in detailed.
Results: One hundred eighteen traumatic AVF were seen in 108 patients. Typically the diagnosis was made radiologically; clinical findings were either absent or unrecognized prior to angiography. Mechanisms of injury included gunshot wound (72 AVF), stab wounds (24 AVF), blunt trauma (8 AVF), fall from a height (3 AVF), iatrogenic causes (2 AVF) and unspecified (8 AVF). Common locations were the extremities (n = 47), the neck (n = 19), hepatic vessels (n = 13), and subclavian vessels (n = 12). About half of the AVFs were associated with false aneurysm. The most common pathophysiologic variant showed proximal and distal flow of both artery and vein with incompetent distal venous valves. Other variants included fistulae between proximal artery and vein without distal arterial or venous flow; continued antegrade arterial flow with or without distal venous flow; and retrograde arterial flow through collaterals with proximal arterial thrombosis. Half of the AVF had retrograde flow contributions from distal collaterals. Treatments included embolization in 61 of the patients. Embolic agents included coils (47), microcoils (3), gelfoam (9), PVA (3) that were mostly successful with few complications. Surgical repair was performed in 34 patients with conduit AVF. Nine were observed. Recently, five AVF of vital conduits were treated nonoperatively by stent-grafts with excellent short and mid-term results.
Conclusion: Angiography is an excellent method of diagnosing traumatic AVFs. However, diagnosis and treatment of chronic AVF is extremely difficult and requires several unusual techniques. Embolization is effective in managing AVF of expendable vessels. Stent grafts are an attractive alternative to surgery for AVF of vital conduit vessels, particularly chronic AVF.
200. Complications and Intra-procedural Adverse Events Due to Embolic Protection Devices During Protected Carotid Interventions
Suri R.1*; Wholey M.1; Toursarkissian B.2; Postoak D.1; Cura M.1; 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)
Objective: Outflow embolic protection devices during carotid artery stenting (CAS) protect the cerebral circulation by capturing clinically significant debris. However, use of these devices increases procedural time and carries the risk of intra-procedural adverse events and potential complications. The aim of this study was to evaluate and classify the adverse events of these embolic protection devices during carotid interventions.
Materials and Methods: 75 protected CAS procedures were analyzed for variables related to the embolic protection device. Technical success of embolic device deployment and retrieval, with or without adjunctive procedures was documented. Adjunctive procedures included use of buddy wires or angioplasty to facilitate filter deployment and neck maneuvers or catheter interventions to facilitate removal. The filter was assessed for visible debris in each case. Adverse events related to the filter device were classified into two categories (I) minor adverse events that resolved with appropriate management and (II) major adverse events that persisted despite appropriate endovascular management and caused morbidity (stroke, hospitalization or surgical intervention).
Results: The filter deployment was technically successful in 96%. Adjunctive procedures to facilitate filter deployment included use of buddy wires (13%) or pre-filter deployment angioplasty (5%). Adjunctive procedures to facilitate filter removal included neck position maneuvers (40%) or adjunctive catheter interventions (4%). Visible debris was present in 13% of filters. Minor adverse events included filter related carotid artery spasm in 27% (resolved with IA nitroglycerin); transient neurological deficits (yawning and mental sluggishness) in 1%; and slow/absent ICA flow due to large embolic burden in the filter in 3% (resolved with aspiration/filter removal). Major adverse event occurred in 1 procedure with a flow limiting ICA dissection with no neurological sequelae.
Conclusion: The use of embolic protection devices is safe and feasible during CAS. Awareness of device related adverse events and their appropriate management avoids potential complications.
201. Endovascular Management of Post-Biopsy Arterial Injuries in Renal Transplant Patients
Ferral H.*; Urbina I.K.; Pillai A.; Behrens G.; Alonzo M.; Patel N.H.; Interventional Radiology, Rush Medical Center, Chicago, IL.
Address correspondence to H. Ferral (hferral{at}rushradiology.org)
Objective: Describe our experience in the management of post-biopsy vascular injuries in kidney transplants.
Materials and Methods: Retrospective study. A total of 124 ultrasound guided percutaneous biopsies were performed in 63 kidney transplants from January 15, 2003 to January 15, 2005. Twenty-six diagnostic arteriograms were performed in 23 patients (17 men/6 women; mean age 45 ± 5.6 years) who underwent percutaneous biopsy of the kidney transplant. Indications for arteriography were: renal failure with increasing creatinine (n = 15), AV fistula (n = 3), hypertension (n = 3), renal artery stenosis (n = 3) renal artery occlusion (n = 1) decreased blood flow on Doppler study (n = 1). The records of patients who underwent embolization of vascular injuries were reviewed and data analyzed.
Results: The incidence of post-biopsy vascular injury was 6.5% (8/124). Seven AVFs and one PSA were treated. AVFs were super-selectively embolized with coils (n = 1), and microcoils (n = 6); the PSA with direct thrombin injection (n = 1). The technical success rate was 100%. The mean serum creatinine was 3.7 mg/dl (range 2.7-8.1 mg/dl) before arteriogram, 2.9 mg/dl (range 2.7-7.3 mg/dl) 24 hr post embolization and 3.2 mg/dL at 4 months post embolization. No major complications were encountered.
Conclusion: Post-biopsy vascular injuries in renal transplant patients are managed effectively using superselective embolization. Kidney function is not improved in these patients but a stabilizing effect was identified.
202. The Effect of Uterine Artery Embolization on the Largest Uterine Fibroids: Evaluation of Imaging and Clinical Response
Nikolaidis P.; Shah S.; Chrisman H.B.; Pyrros A.T.; Vogelzang R.L.; Hammond N.A.; Ryu R.; Miller F.H.; Omary R.A.; Department of Radiology, Northwestern University, Feinberg School of Medicine, Chicago, IL.
Objective: While uterine artery embolization (UAE) has been proven safe and effective for the treatment of most symptomatic uterine fibroids, its exact role and indication in the setting of large fibroids is still controversial. The purpose of this study is to assess the clinical and volumetric response to UAE of the largest fibroids encountered in a high volume single center practice.
Materials and Methods: Six hundred females referred for UAE for treatment of symptomatic fibroids between 2002 and 2005 with pre- and post procedure MRI examinations were retrospectively reviewed. Indications included menorrhagia and/or bulk symptoms. Pelvic MR (including multiplanar T2-FSE and pre/post gadolinium fat-saturated GRE sequences) was obtained prior and following UAE. Review of MRI studies included measuring the size and location of dominant fibroids, and overall uterine volumes prior and post UAE. The largest 5% of these volumes (31 patients) prior to UAE were then selected for further analysis. We determined outcomes via clinical response and percent reduction of dominant fibroid and overall uterine volume. Patients were prospectively followed for clinical response at 1, 6 and 12 months following UAE.
Results: The 31 patients (top 5%) had a mean pre-UAE uterine volume of 1605 cc (SD +/-620), with longest dimension range of 16-25cm. Of these 31 patients, 28 (90%) showed successful response to embolization by size criteria, with a mean uterine volume reduction of 44%. These results correlated with clinical response.
Conclusion: Large volume fibroids can be successfully embolized with response rates similar to historic fibroid controls.
2:40 PM
203. Balloon Angioplasty and Stenting for Budd-Chiari Syndrome: Mid-term Results
Gulati G.S.*; Chakravarty S.K.; Acharya S.K.; Sharma S.; Cardiac Radiology, All India Institute of Medical Sciences, New Delhi, Delhi, India.
Address correspondence to G.S. Gulati (gulatigurpreet{at}rediffmail.com)
Objective: To study the mid-term outcome of interventional therapy for Budd-Chiari syndrome (BCS) in a cohort of patients with suitable anatomy.
Materials and Methods: Sixty-one consecutive patients were referred for therapy of suspected BCS. Diagnosis was established based upon color Doppler sonography and contrast venography (in selected cases). Forty-five patients with suitable anatomy were considered for percutaneous interventions. Detailed baseline clinical assessment was performed for all patients. A combination of transfemoral, transjugular and transhepatic approaches was used during the intervention. Technical success was defined as disappearance of collaterals and reduction of pressure gradient across the stenosis/occlusion (less than 5 mm Hg). All patients received post-procedure anticoagulation continued during follow-up. Follow-up included clinical examination and color Doppler sonography at 1 week, 1 and 3 months, and then 6 monthly intervals, and contrast venography at 1 year.
Results: Of the 45 patients [28 males; mean age, 27 years (range
14-55 years); 23 (51%) with underlying hypercoagulable state], percutaneous
intervention was techni-cally successful in 36 patients (80%) [inferior vena
cava: 16/20 (80%); hepatic vein: 17/21 (81%) and combined: 
(75%)].
Except 1 patient (needle puncture), all other occlusions were recanalized with
soft/hard end of guidewire. None of the patients with IVC stenosis/occlusion
required stents, while 11 patients with hepatic vein obstruction needed stent
(balloon-mounted: 10; self-expanding: 1) placement. The pressure gradient
improved from 20+/-8 mm Hg to 8+/-3 mm Hg for the IVC, and from 25+/-10 mm Hg
to 7+/-2 mm Hg for the hepatic vein following the intervention. Complications
(7) included hemoperitoneum (3), subcapsular liver hematoma (2), neck hematoma
(1) and pneumothorax (1). All except pneumothorax (that necessitated chest
tube drainage) resolved spontaneously following reversal of post-procedural
anticoagulation. Mean follow-up period was 11 months (range 2-22 months).
Restenosis occurred in one hepatic vein stent and was successfully redilated.
Clinical patency (cure or improvement of symptomatology and clinical tests)
was seen in 34/36 (94%) patients. Minor bleeds that occurred in 4 patients
resolved following adjustment of anticoagulation dosage.
Conclusion: Angioplasty and stent placement is a safe and effective treatment in patients with BCS having suitable anatomy.
204. Interventional Treatment of Budd-Chiari Syndrome: "Through and Through" Technique from Different Approaches for Patients with Completely Occluded Hepatic vein/IVC
Zu M.1*; Xu H.1; Gu Y.1; Li G.,; Zhang Q.1; Wei N.; S Sun S.2; 1. Medical Imaging and Interventional Radiology, Xuzhou Medical College, Xuzhou, Jiangsu, China; 2. Radiology, University of Iowa Health Care, Iowa City, IA.
Address correspondence to M. Zu (cjr.zumaoheng{at}vip.163.com)
Objective: To introduced a new method, "through and through technique," for crossing over a guide wire through a completely occluded hepatic vein/IVC to treat Budd-Chiari syndrome, to determine the clinical value of the technique.
Materials and Methods: Fifty-two consecutive patients with completely occluded hepatic vein/IVC secondary to Budd-Chiari syndrome, underwent venous recanalization procedure by using "through and through technique." Through right internal jugular approach a wire was advanced through the occluded IVC and snared out through femoral vein were performed in 43 patients. Through percutaneous transhepatic approach a guide-wire was crossed over tightly occluded hepatic vein and snared out through jugular vein were conducted in 8 patients. From accessory hepatic venous approach the wire was snared out through femoral vein was performed in one patient. Balloon angioplasties and stent placements were conducted in all patients.
Results: Accesses were obtained successfully by using "through and through technique" in all 52 patients. Balloon angioplasties and stent placements were successful in those patients. Average time used for the procedure was shorter compared with that of using traditional approach. There were no complications in this group of patients.
Conclusion: "Through and through technique" can be a relative easy, safe and practical method in complicated venous recanalization procedure. The access provided by this technique is reliable and makes placement of balloon/stent through a tight stenosis/occlusion easier.
205. Interventional Management of Hepatic Pseudoaneurysm
Sun S.*; Jamil M.; Jain V.; Mimura H.; Golzarian J.; Radiology, University of Iowa Health Care, Iowa City, IA.
Address correspondence to S. Sun (siliang-sun{at}uiowa.edu)
Objective: To report a group of patients with intra-hepatic artery pseudoaneurysm secondary to different etiologies and assess the outcomes and safety of trans-catheter arterial embolization.
Materials and Methods: 35 consecutive patients with hemobilia (8 patients) and intra-peritoneal bleeding (27 patients) caused by hepatic artery pseudoaneurysm underwent trans-arterial embolization. The data was collected retrospectively. The etiologies of HAP included iatrogenic injury in 16 patients (liver surgery in 2, laparoscopic cholecystectomy in 6, open cholecystectomy in 2, trans-hepatic liver biopsy in 2, percutaneous biliary tube placement in 3, and liver abscess drain placement in 1), Trauma in 10 patients (blunt injury in 7 and penetrating injury in 3), pancreatitis in 4 (acute in 2 and chronic in 2), hepatoma bleeding in 4, and spontaneous rupture of intra-hepatic true aneurysms in 1. Hepatic arteriography and embolization were performed emergently in 27 patients, 8 patients underwent relatively elective intervention. 2.9 F micro-catheter was used in all patients for super-selective embolization. Microcoils were used as embolic agent in all patients. Additional gelfoam slurry was used in 20 patients. Post embolization follow-up included clinical evaluation and laboratory tests immediate post procedure and duration of hospital stay, and imaging study at 1 month.
Results: 33 patients underwent successful diagnostic hepatic arteriography and embolization (94%). We were unable to super-selectively catheterize the bleeding arteries due to severe spasm in two patients. 25 patients had the HAP arising from right hepatic artery, 7 from left hepatic artery, and 3 from cystic artery. The artery distal and proximal to HAP was embolized with micro-coils in 23 patients, the neck of HAP was embolized with coils in 4, the artery proximal to HAP was embolized with coils after delivery of gelfoam slurry into the artery in 6 patients. 32 patients were stable without transfusion. 3 patients died of multi-organ failure within 30 days. There was no hepatic infarction and hepatic failure encountered in this group of patients within 30 days post procedure.
Conclusion: HAP is not as rare as reported in the literature with commonest cause being iatrogenic. Due to its high fatality, trans-catheter embolization should be performed emergently without delay. Transcatheter embolization is an effective and safe method for the treatment of HAP.
206. Transcatheter Embolization of Surgical Portocaval Shunts after Orthotopic Split or Pediatric Liver Transplantation in Adults
Stockland A.H.1*; Walser E.M.3; Steers J.L.2; Rosser B.G.3; 1. Radiology, Mayo Clinic Jacksonville, Jacksonville, FL; 2. Surgery, Mayo Clinic Jacksonville, Jacksonville, FL; 3. Medicine, Mayo Clinic Jacksonville, Jacksonville, FL.
Address correspondence to A.H. Stockland (stockland.andrew{at}mayo.edu)
Objective: To evaluate whether percutaneous closure of surgical portocaval shunts created during liver transplantation can correct encephalopathy and promote maturation of pediatric or split liver transplants in adults.
Materials and Methods: During split or pediatric donor liver transplantation, surgeons may create portocaval shunts from the recipient portal vein to the vena cava using vein grafts. This shunt is created to divert some portal flow away from the small allograft and avoid excessive portal venous inflow to an immature liver and perhaps avoid hepatic artery thrombosis. With time, however, these shunts may degrade liver function or hinder graft hypertrophy. We evaluated 6 patients who received split (n = 2) or pediatric (n = 4) donor livers and required shunt occlusion due to encephalopathy (n = 3), failed hepatic size maturation (n = 2), or hepatic failure (n = 1). Embolization of the shunts was attempted 4 days to 1099 days post transplantation (mean 596 days). All patients were male and the average age was 53.7 years. All patients had transjugular venous access and embolization using balloon occlusion (n = 1), balloon occlusion, IVC filter and endovascular coils (n = 1), endovascular coils alone (n = 2), a combination of coils and IVC filters (n = 1) and a homemade stent occlusion device (n = 1).
Results: The prolonged balloon occlusion method failed in one patient who went on to surgical closure but died 10 days later from sepsis and liver failure. Another patient failed balloon occlusion but the shunt was successfully closed later with coils supported by an IVC filter. The remaining 4 patients had successful shunt occlusion at the first attempt. The remaining 5 patients are alive with adequate liver function. Encephalopathy in all 3 patients cleared and the 2 patients with liver dysfunction and lack of graft maturation experienced improved liver function and graft hypertrophy. Post shunt occlusion, portal flow improved, both angiographically and by follow up ultrasound imaging.
Conclusion: Surgical portocaval shunts for split or pediatric liver transplants in adults may lead to poor graft maturation, encephalopathy or liver dysfunction. These shunts can be occluded percutaneously, but may require IVC filters, large coils or stent occlusion devices to effect closure due to the large size and rapid flow through these shunts. Successful closure leads to resolution of encephalopathy and promotes improved graft function and maturation.
207. Interventional Management of Acute Pulmonary Embolism
Wang F.1*; Zhang Z.1; Jing D.1; Huang W.1; Lang Z.1; Ma J.1; Sun S.2; 1. Radiology, The First Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, China; 2. Radiology, University of Iowa Health Care, Iowa City, IA.
Address correspondence to F. Wang (cjr.wangfeng{at}vip.163.com)
Objective: To assess the effectiveness and safety of pulmonary embolectomy/thrombectomy through different interventional techniques for treatment of acute massive pulmonary embolism.
Materials and Methods: 38 consecutive patients with acute massive PE, diagnosed by CT scan or pulmonary angiography, underwent mechanical thrombus fragmentation, catheter aspiration thrombectomy, and catheter directed thrombolyses with Urokinase or tPA (alone or combination of the techniques). Following sequential steps was ob-served during the therapy: mechanical fragmentation with pig-tail catheter initially, followed by suction thrombectomy, then pharmatheutical thrombolysis if residual clot remained. All patients were under critical condition with hemodynamical impairment before the therapy. Pre and post procedural clinical symptoms, PaO2 and PAPm parameters, and pulmonary arteriogram were used as the modalities to evaluate the efficacy and safety of the procedure. Paired t test was used to determine the statistical significance.
Results: 36 patients survived and showed significant clinical improvement (p < 0.05). Pulmonary angiograms revealed complete recanalization of pulmonary artery with no evidence of residual emboli/thrombi in 30 patients, and partial recanalization in 6 patients. Significant improvement of PaPm and PaO2 parameters were observed in all 36 patients (p < 0.05). Two patients who had failed procedures died two days after procedure. There was no other procedure related complications.
Conclusion: Pulmonary embolectomy/thrombectomy through interventional techniques is a reliable and effective procedure for treatment of acute massive pulmonary embolism. Best results can be achieved when different techniques were used in combination during the treatment.
* Will present paper
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