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ABSTRACT |
Lee E. W.1; Raman S. S.1; Yu N. C.1; Economou J. S.2; Lu D. S.1 1. UCLA Medical Center, Department of Radiology, Los Angeles, CA; 2. UCLA Medical Center, Department of Surgery, Los Angeles, CA
Address correspondence to E. Lee (EdwardLee{at}mednet.ucla.edu)
Objective: To assess the results of intraoperative radiofrequency ablation (RFA) of unresectable liver metastases of sarcomas in patients.
Materials and Methods: IRB approval was obtained for the study. Between 1999 and 2005, intraoperative RFA was performed in eight patients (mean age: 55.4 years) with 30 surgically unresectable hepatic metastases of sarcomas from the following: gastrointestinal stromal tumors (GIST) of small bowel (17); leiomyosarcoma of ovary (1), stomach (5), and retroperitoneum (1); angiomyoliposarcoma of diaphragm (4); and retroperitoneal paraspinal paraganglioma (2). The lesion size ranged from 0.3 to 7.5 cm. All RFA were performed under intraoperative ultrasound guidance using either clustered cool-tip or expandable electrodes. All patients were followed for a mean of 30.4 months following RFA with CT or MR imaging.
Results: All RFA were performed without any complications. The mean survival time was 57.4 ± 9.9 months and mean disease free survival was 15.2 months. No local recurrence at the RFA site was noted throughout the follow-up periods (the local tumor control rate of 100%).
Conclusion: Intraoperative radiofrequency ablation was a safe and effective modality for local treatment in patients with unresectable liver metastases from sarcomas.
E465. Percutaneous Parathyroid Ethanol Ablation in Patients with Multiple Endocrine Neoplasia Type 1
Veldman M.; Reading C.; Farrell M.; Charboneau W. J.; Mullan B. Mayo Clinic, Rochester, MN
Address correspondence to M. Veldman (veldman.mark{at}mayo.edu)
Background: Multiple endocrine neoplasia type 1 (MEN 1) is an uncommon complex genetic disorder. Patients with MEN 1 often develop overactivity of the parathyroid, pancreas, and pituitary glands. 95% of these patients develop hyperparathyroidism involving all parathyroid tissue. Surgical treatment usually involves a subtotal parathyroidectomy with 3.5 of the 4 glands removed. A subset of these patients then develops hyperparathyroidism from re-enlargement of the remaining half gland. Reoperation in these patients carries an increased risk of permanent hypoparathyroidism and recurrent laryngeal nerve damage due to scar formation in the operative bed.
Key Issues: Percutaneous ultrasound-guided ethanol ablation is a safe and effective way to control serum calcium levels in postoperative MEN 1 patients with recurrent hyperparathyroidism. This exhibit will address: 1. Localization of parathyroid adenomas using nuclear medicine parathyroid scans and ultrasound scanning. 2. Techniques used for percutaneous ethanol ablation. 3. In 18 MEN 1 patients treated with ethanol ablation, the average elevated serum calcium levels of 10.5 mg/dL dropped to normal limits of 9.4 mg/dL following ablation. Clinical and laboratory immediate and long-term follow-up of patients after ablation will be presented.
Format: This exhibit will be a didactic presentation of MEN 1 patients with hyperparathyroidism who were treated by percutaneous ethanol ablation.
Teaching Points: The viewer should learn the following: 1. Percutaneous ethanol ablation of residual and recurrent parathyroid tissue in MEN 1 patients is an effective technique to control recurrent hypercalcemia. 2. Ethanol ablation is a safe procedure. 3. Ethanol ablation is less invasive and less expensive than re-operative neck surgery, and is an excellent alternative to re-operation.
E466. CT-guided Percutanous Cryoablation of Kidney Tumors: Retrospective Analysis of 42 Patients
Brinkman M.; Johnson B.; Waldrop D.; Brady T.; Rashid T. University of Illinois College of Medicine at Peoria, Peoria, IL
Address correspondence to M. Brinkman (mikalabrinkman{at}yahoo.com)
Objective: The goal of this study is to assess the efficacy and safety of percutaneous cryoablation in patients who have undergone CT-guided percutaneous cryoablation (PC) for treatment of renal tumors. The end points measured include the change in tumor size and tumor recurrence rate on follow-up imaging studies and major and minor complications
Materials and Methods: 42 people (21 men and 21 women, average age = 73.7 years) are included in this retrospective analysis. All were seen by a urologist and interventional radiologist prior to the procedure and felt to be poor surgical candidates (n = 40) or refused surgery (n = 2). All underwent PC for 44 tumors, ranging in size from 1 to 11 cm. Two tumors were angiomyolipomas. The others were suspicious for renal cell carcinoma. Four of the tumors were embolized with metallic coils prior to PC. The procedures were all performed under conscious sedation with CT guidance. 2.4-mm diameter cryoprobes were used in all cases. In 2 cases, catheter mounted balloons placed percutaneously into the abdominal cavity were used to displace and protect adjacent loops of bowel. CT and MRIs obtained prior to and after PC were reviewed and tumor measurements and enhancement patterns recorded (i.e. no enhancement, linear enhancement, nodular enhancement.)
Results: The 42 patients underwent regular follow-up imaging an average of 3.4 times with a mean follow up period of 8.3 months (range 3 to 40 months.) 54% of the 143 follow-up imaging evaluations were done using CT. The remainder was done using MRI. In all patients studied, tumor size decreased or remained stable. At the time of the first follow-up, 57.1% of tumors showed no significant enhancement. In those that had visible enhancement patterns at the first follow-up, all but one were characterized as "thin and smooth" and resolved on further follow-up. The patient with suspicious enhancement (i.e., nodular) underwent repeat PC. Biopsy showed only granulation tissue, however. Minor complications occurred in 8%. All were managed conservatively with the exception of a large pleural effusion which required drainage. Three major complications occurred: myocardial infarction, respiratory failure and bleeding form thermal injury to the colon. All were treated and recovered. One death occurred 4 days after PC from complications of renal hemorrhage.
Conclusion: Renal cryoablation is a safe and effective alternative method of treatment of renal tumors in patients who are poor surgical candidates.
E467. The Curved Needle: From Biopsies to Ablations
Drasin T.; Raman S.; Anaya C.; Min J.; Lu D. David Geffen School of Medicine at UCLA, Los Angeles, CA
Address correspondence to T. Drasin (tdrasin{at}ucla.edu)
Background: Over the last 25 years, image guided interventions have come to play a key role in the diagnosis and management of disease. Many techniques have been developed to enable percutaneous needle access to deep structures within the body using ultrasound, CT, or MRI guidance. However, some targets are still not directly accessible. In such instances, one may consider the curved needle strategy. Approaching a target with a curved needle can enable the operator to avoid sensitive structures, sample different parts of a lesion through the same guide needle, and compensate for suboptimal positioning of a guide needle.
Key Issues: Applications of this technique in the literature for fine needle aspiration biopsy and drainages will be reviewed. We will also describe our experience using this strategy not only for fine needle aspirations but also for core biopsies using spring-loaded devices, and for ethanol injection therapy and radiofrequency ablation of liver masses. We will demonstrate how customized curves can be generated from conventional straight needles, spring-loaded biopsy devices, and ablation electrodes. Cases illustrated will include coaxial core biopsies of otherwise inaccessible targets and of lesions where sampling yield was enhanced. For liver tumor ablations, cases illustrated will include utilization of the curved needle to better access difficult lesions for ethanol injection therapy as well as radiofrequency ablation. Guidance for the curved needle by CT, ultrasound, and MRI will also be demonstrated.
Format: In a didactic format–(1) Brief review of the literature describing indications, advantages, and reported applications of the curved needle technique will be presented. (2) Video presentation of how custom curves may be created in biopsy needles, spring-loaded biopsy devices, and in radiofrequency ablation electrodes. (3) Fine needle aspiration and spring loaded core biopsy device case demonstrations using CT and MRI guidance. (4) Ethanol ablation case demonstrations using CT and MRI guidance (5) Radiofrequency ablation case demonstrations using ultrasound guidance
Teaching Points: 1. How curved needle technique may be applied with CT, ultrasound, and MRI guidance. 2. The process of custom curving a spring loaded core biopsy device. 3. How a custom curved needle may be utilized for liver tumor ablation applications.
E468. Fluoroscopically Guided Balloon Dilation for Upper Gastrointestinal Tract Stricture: Comprehensive Review
Shin J.; Song H. Asan Medical Center, Seoul, South Korea
Address correspondence to J. Shin (jhshin{at}amc.seoul.kr)
Background: A variety of clinical situations are amenable to balloon dilation in upper gastrointestinal tract strictures. The purpose of this exhibit is to review our experience in fluoroscopically guided balloon dilation of several types of upper gastrointestinal tract strictures including gastric outlet obstruction, duodenal obstruction, anastomotic stricture after total gastrectomy and anastomotic stricture after Ivor-Lewis operation.
Key Issues: Clinical and diagnostic imaging features and balloon dilation protocol will be presented according to each type of strictures. Complications and their management, and long-term results will be addressed through example cases and reference to related literature. Specific emphasis will be placed on the technical aspects, complications, and long-term results of the fluoroscopically guided balloon dilation in comparison with endoscopically guided balloon dilation based on the literature review.
Format: This exhibit will be shown in a didactic manner with radiographic images and clinically relevant findings.
Teaching Points: 1. To review the indications of balloon dilation for the management of various upper gastrointestinal tract strictures. 2. To be familiar with balloon dilation protocol according to each type of upper gastrointestinal tract strictures. 3. To understand complications and long-term results of balloon dilation for the management of various strictures.
E469. Balloon-occluded Retrograde Transvenous Obliteration for Hepatic Encephalopathy
Honda M.; Hashimoto T.; Seino N.; Gokan T. Showa University Hospital, Tokyo, Japan
Address correspondence to M. Honda (hondamin{at}med.showa-u.ac.jp)
Objective: Balloon-occluded retrograde transvenous obliteration (B-RTO) was originally introduced for treatment of gastric varices with gastrorenal shunt. Another indication of B-RTO is hepatic encephalopathy due to portosystemic shunt. The purpose of this study is to evaluate the clinical efficacy of B-RTO for hepatic encephalopathy, and to describe technical problems and complications experienced during this procedure.
Materials and Methods: From November 1994 through August 2006, we performed B-RTO in 12 patients (6 men and 6 women; range, 53–83 years; mean age, 66.3 years) with hepatic encephalopathy. Hepatic encephalopathy and gastric varices with gastrorenal shunt were seen in 5 patients. Hepatic encephalopathy were associated with portal hypertension as a result of hepatitis C viral liver cirrhosis in 7 patients, alcoholic liver cirrhosis in 3 patients, both in 1 patient, and primary biliary cirrhosis in 1 patient. Child-Pugh class was B in 7 patients and C in 5 patients. 2 patients had hepatocellular carcinoma. Gastrorenal shunts were seen in 6 patients. Splenorenal shunt was seen in 1 patient. Shunt tracts drained into the gonadal vein were seen in 3 patients. 14 procedures were performed for these patients. Transfemoral approach was used in 4 procedures, transjugular approach in 7 procedures, and both approaches were used in 3 procedures. 3 patients underwent dual balloon-occluded embolotherapy using both methods of transjugular intrahepatic portosystemic shunt (TIPS) and B-RTO. Coil embolization was performed in 4 patients followed by B-RTO. After balloon-occluded retrograde venography, the sclerosant (ethanolamine oleate: EO) was injected into the shunt tracts during balloon occlusion. The maximum dose of EO at 5% was 20 ml/day. Follow-up CT was used to assess whether the shunt tracts were thrombosed.
Results: Technical success was achieved in all 12 patients. Follow-up CT after the procedure revealed thrombosed shunt tracts. Hepatic encephalopathy was improved in all 12 patients. Three sessions of B-RTO were needed in 1 patient, because collateral flow was shown on follow-up CT images. Although extravasation of contrast media was seen in 1 patient, no significant sequela was observed.
Conclusion: B-RTO is a safe and effective method of treatment for patients with hepatic encephalopathy due to portosystemic shunt.
E470. Percutaneous Nephrostomy Catheter Placement On-call: Techniques, Indications and Complications
Regalado S.; Thuong V.; Lorenz J.; Vinokur O.; Zangan S.; Knuttinen G.; Funaki B. University of Chicago Hospitals, Chicago, IL
Address correspondence to S. Regalado (sidreg3{at}yahoo.com)
Background: Percutaneous nephrostomy (PCN) catheter placement is a safe procedure with a high technical success rate. The safety and efficacy of this procedure using a variety of different imaging modalities including various combinations of CT, fluoroscopy and ultrasound has been described and validated in the medical literature over many years. The primary indication for PCN catheter placement on an emergent basis is to relieve pyonephrosis, which can be defined as an obstructed and infected renal collecting system. If hydronephrosis is present without a clinical suspicion for pyonephrosis, PCN catheter placement can be performed on the next procedure day. PCN catheter placement is the initial treatment of choice in managing patients with suspected pyonephrosis at our institution. The purpose of this presentation is to review the most important clinical aspects regarding the emergent placement of PCN catheters. Differences between emergent and routine catheter placement will be emphasized.
Key Issues: A combination of photographs, radiographic images and computer-generated images will be used to illustrate the steps used in placement of PCN catheters. Techniques used in placement of PCN catheters on an emergent basis will be discussed, including single needle and double needle puncture methods. Indications, contraindications, and catheter management will be addressed. Complications including the risk of sepsis, hemorrhage, and inadvertent bowel puncture will be reviewed. Management of these complications will be addressed. Differences between emergent and nonemergent placement of PCN catheters will also be compared.
Format: An interactive PowerPoint presentation with a combination of actual photographs, radiographic images and computer-generated images will be used to illustrate the most important clinical aspects of emergent PCN catheter placement. The exhibit will be interactive as the participant will be able to choose which aspect of PCN catheter he/she would like to review. The viewer will be able to choose the order and the speed at which he/she would like to complete the exhibit.
Teaching Points: 1. A general overview of PCN catheter placement. 2. Differences regarding PCN catheter placement during routine and emergent situations. 3. Indications and contraindications for emergent PCN catheter placement. 4. Techniques used for emergent PCN catheter placement. 5. Catheter management. 6. Complications of emergent PCN catheter placement and their management.
E471. Uterine Artery Embolization (UAE): How we do it?
Cura M.2; Alejandro C.1; Guzman K.2; Marco G.2 1. University of Buenos Aires, Buenos Aires, Argentina; 2. University of Texas Health Science Center, Dallas, TX; 3. UTHSCSA, San Antonio, TX
Address correspondence to M. Cura (marcocura{at}yahoo.com)
Background: Uterine fibroids are common tumors of the female pelvis. Uterine Artery Embolization (UAE) is an effective treatment of symptomatic uterine leiomyoma in the appropriate candidates, reducing or eliminating leiomyoma related symptoms of bleeding, bulk, and/or pain.
Key Issues: This exhibit will describe the indications and contraindications for UAE, illustrate how patients are selected and how preprocedure diagnostic imaging may help interventionalists select patients and patients understand what to expect from the procedure. Describe the technique, tips and tricks, and relevant vascular anatomy, and post procedure management and imaging.
Format: Uterine artery embolization procedures, preembolization imaging, and post UAE management and imaging will be illustrated in a didactic format.
Teaching Points: Learn the indications and contraindication of UAE. Understand how preprocedure imaging helps in patient selection. Learn the technique (unilateral vs. bilateral access, tips and tricks to catheterize the ipsilateral iliac artery, embolic agents, avoiding and solving uterine artery spasm, angiographic end points, etc). Learn possible complications and how to prevent them. Learn about postprocedure management and imaging.
E472. Transarterial Embolization for Massive Hemoptysis in Patients with Coal Worker's Pneumoconiosis: An 11-year Experience
Lee S.; Hahn S.; Choi B. St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
Address correspondence to S. Lee (leesangh{at}catholic.ac.kr)
Objective: To evaluate immediate and long-term efficacy of transarterial embolization (TAE) for control of massive hemoptysis in patients with coal worker's pneumoconiosis (CWP) and to clarify the factors influencing the rebleeding.
Materials and Methods: This study included 34 CWP patients with massive hemoptysis who were treated with 47 TAE sessions during the recent 11 years. Immediate (within 1 month) and long-term (1 month to 11 years, mean: 37 months) outcomes were evaluated retrospectively. The relationships between the frequency of rebleeding and type of CWP, angiographic findings, and presence of tuberculosis were evaluated.
Results: Initial success rate was 91.2% (31/34). In 23 patients (68%), hemoptysis did not recur on long-term follow-up. In eight patients who received repeated procedures for recurrent hemoptysis, bleeding was discovered in nonbronchial systemic artery (n = 13) and bronchial artery (n = 7). The frequency of recurrent hemoptysis was higher in cases with complicated pneumoconiosis than simple type (p = 0.029). There was no statistical difference between rebleeding and angiographic findings or presence of tuberculosis.
Conclusion: TAE is an effective treatment modality for controlling massive hemoptysis in patients with CWP. However, many nonbronchial systemic collaterals contributed in causing the recurrent hemoptysis. Furthermore, complicated type CWP suggest a high probability of rebleeding, and extra care must be put into the embolization procedure
E473. Bleeding of Malignant Neck Cancer after Radiotherapy: Value of Transarterial Embolization
Chen Y.; Lee Y.; Lo Y.; Chen J.; Shen W. China Medical University Hospital, Taichung, Taiwan
Address correspondence to Y. Chen (jeonhc{at}uci.edu)
Objective: This study aimed to evaluate the role of transarterial embolization (TAE) for treatment of tumor bleeding in malignant neck cancer after radiation therapy.
Materials and Methods: In a period of four years, seventeen patients of pathologically proven malignant neck cancers, including six tongue cancers, four buccal cancers, three nasopharyngeal cancers, one tonsilar cancer, one palatal cancer, and one oral cancer, were studied. All these patients were male. Age ranged from 32 to 92 years old. Fourteen patients received only radiotherapy due to advanced cancer stages. Three patients had an operation first followed by palliative radiotherapy. Angiography for detecting tumor bleeding was performed by inserting a catheter in the common carotid artery (CCA) of the suspicious side followed by further progress of the catheter into the external carotid artery (ECA). The contrast agent used for CCA angiography was 12 ml injected at a rate of 4–6 ml/sec. For ECA angiography, it was 6 ml injected at a rate of 2 ml/sec. Once the bleeding site or heavily stained tumor region was found, embolization of the affected vessel(s) was performed using either gelform sponge (or cubes), microcoils, or both combined. All patients were followed up for two months after TAE to evaluate if there was any rebleeding.
Results: Obvious extravasation of contrast agent indicating bleeding was found in five patients. Ten patients only showed tumor vessels with heavily tumor stain. No definite bleeding point was detected. Two patients, one nasopharyngeal cancer and one palatal cancer showed a pseudoaneurysm arising from the right internal carotid artery and left external carotid artery, respectively. TAE was performed in all these seventeen patients with a catheter inserted in branches of ECA in thirteen patients, ECA in three patients, and ICA in one patient. Embolization material used included gelform sponge or cubes in nine patients, microcoil or coil in six patients, and gelform cubes plus microcoils in two patients. No procedure-related complication was identified. All patients showed dramatic improvement of clinical condition without further bleeding. After two months of follow-up, no patients had problem of rebleeding.
Conclusion: Transarterial embolization is a safe and effective procedure for treating bleeding of malignant neck cancer after radiation therapy. In patients with only heavy tumor stain but without definite bleeding point, TAE is also effective in stopping the bleeding and improving patients' clinical condition.
E474. Systemic and Pulmonary Arteries Embolization with Ethylene Vinyl Alcohol Copolymer "ONYX" in Patients with Hemoptysis
Khalil A.; Muriel F.; Tassart M.; Parrot A.; Carette M. AP-HP Tenon Hospital, Paris, France
Address correspondence to A. Khalil (antoine_khalil{at}yahoo.fr)
Objective: To evaluate the feasibility and to determine the indication of embolization of systemic and pulmonary arteries in hemoptysis with Onyx.
Materials and Methods: Prospectively collected clinical charts and radiological reports of patients referred to the respiratory intensive care unit for hemoptysis during a 6 month period (April 2006 to July 2006) were analyzed. Patients treated with Onyx were obtained for review. Neither institutional review board approval nor patient consent was required for this retrospective study.
Results: Of the 42 patients (25 men, 16 women; mean age, 57 years) treated with endovascular manner during this period, 7 patients (16%) were treated with Onyx. Indications were for hemoptysis of pulmonary (n = 3) or systemic (n = 4) arterial origin. Anatomical lesions were pulmonary artery aneurysms (n = 2; one pulmonary artery aneurysm with small neck, and one patient needing anticoagulation therapy), abrupt pulmonary artery interruption (n = 1; unstable catheter), aneurysm of left internal thoracic artery (n = 1) in a patient with invasive aspergillosis, dangerous large ectopic bronchial artery (n = 1) arising from the right subclavian artery, opacification of bronchial artery responsible of bleeding through small anastomosis network (n = 1), this patient had surgical ligation of bronchial arteries, and dangerous anastomosis between bronchial artery and right coronary artery. In all cases hemoptysis was controlled.
Conclusion: The embolization with Onyx of hemoptysis of pulmonary or systemic arterial origin is feasible. The indications have to be discussed more; however, onyx is helpful in treating patients with pulmonary artery aneurysm with small neck, dangerous systemic arteries, and embolization of large systemic arteries through small anastomosis.
E475. Percutaneous Partial Splenic Embolization for Thrombocytopenia Following Liver Transplantation
Amesur N. B.; Zajko A. B.; Fontes P.; Sharma V. University of Pittsburgh Medical Center, Pittsburgh, PA
Address correspondence to N. Amesur (amesurnb{at}upmc.edu)
Objective: Patients who present with thrombocytopenia after liver transplantation (LT) are at high surgical risk for splenectomy. We herein describe our experience in 6 such patients who were successfully treated with percutaneous partial splenic embolization (PSE).
Materials and Methods: Six LT patients who failed medical management for thrombocytopenia were referred for PSE. All patients were pretreated with pneumovax and given prophylactic intravenous antibiotics. They underwent PSE using a combination of 100–300 micron (µ) and 300–500 (µ) particles of EMBS (Biosphere Medical, Rockland, MA). Selective PSE was performed via microcatheters mainly into the mid and lower pole branches to avoid any diaphragmatic irritation from possible infarction of the upper pole.
Results: The average platelet count in the 6 patients prior to the procedure was 27. Average platelet counts at 1, 4, 8, and 12 weeks were 253, 293, 259, and 257. One patient developed moderate infarction of the spleen with a large volume of liquefaction which required percutaneous catheter drainage. The patient recovered uneventfully with a final platelet count of approximately 400. Our first patient required two PSE treatments to see a significant improvement in platelet count but we believe this was due to inadequate initial embolization.
Conclusion: PSE following LT with EMBS appears to provide a safe and successful alternative to surgical splenectomy in this high risk surgical group that is already immunosuppressed.
E476. Premature Atherosclerotic Lesions of the Carotid Vessels in HIV-positive Patients Treated with HAART
Cristofaro M.; Busi Rizzi E.; Schininà V.; Cicalini S.; Petrosillo N.; Bibbolino C. INMI IRCCS L Spallanzani, Rome, Italy
Address correspondence to M. Cristofaro (mcristofar{at}sirm.org)
Objective: The prognosis of HIV infection has improved dramatically since the advent of highly active antiretroviral therapy (HAART). However, HAART therapies in HIV infected patients are often associated with lipodystrophy syndrome and metabolic disorders. Lipid disorders may contribute to the premature development of atherosclerosis. The aim of our study was to evaluate prevalence and incidence of early epiaortic vessels atheroscerotic lesions in patient HIV+ treated with protease inhibitors versus HIV-.
Materials and Methods: In the period 2001–2005, 200 HIV+ patients and 135 HIV- patients undergoing US of the neck region for lymphonodal or thyroid examination at the National Institute for Infectious Disease "L. Spallanzani" in Rome were also subjected to Doppler US of epiaortic vessels. Atherogenic plaques were defined as a thickening of the intima-media > or = 1.2 mm. Each subject was evaluated for heavy smoke, hypertension (PA > 80–120 Hg), high cholesterol level (>200 mg/gl), high lipid level (>200 mg/dl), high glucose level (>110 mg/dl), duration of PI treatment (only HIV positive). Differences among patients were evaluated by Chi square test or Fisher exact test for qualitative variables Kruskall-Wallis test was performed to compare continuous variables. A p value <0.001 was considered statistically significant.
Results: Of the 335 enrolled patients, 200 were HIV+ treated with HAART, and 135 HIV- controls. The median treatment period was 5 years, and all patients had been in therapy for at least 12 months. HIV+ were more frequently cigarette smokers in comparison to HIV- (<0.0001). HIV+ had a significantly higher prevalence of hypertriglyceridemia. The IMT mean value was significantly higher in HIV+ patients than HIV- (0.98 mm and 0.74 mm, respectively; p = 0.000). Moreover, in 59 (27.8%) of HIV+ an atherosclerotic plaque was evidenced, compared with 3/135 (2.3%) of controls (p < 0.0001).
Conclusion: Our data show a high frequency of epiaortic vessels atherosclerotic lesions, either early (intima media-thickening) or late (atheromatous plaque), in HIV-infected patients on PI treatment compared to HIV negative patients. In conclusion, follow-up Doppler US carotid vessel studies of HIV- positive patients on PI treatment should be conducted in order to ascertain if early carotid vessel lesions have a fast progression to more severe changes, and to provide evidence for a switch to other therapeutic options.
E477. TIPS Creation and Revision with Stent Grafts: How We Do It?
Cura M.2; Alejandro C.1; Rajeev S.2 1. University of Buenos Aires, Buenos Aires, Argentina; 2. University of Texas Health Science Center at San Antonio, San Antonio, TX
Address correspondence to M. Cura (marcocura{at}yahoo.com)
Background: TIPS are an effective method of treatment to control the complications of portal hypertension; however shunt dysfunction is common. Some shunts may remain patent, whereas others develop stenoses and thromboses. 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. The use of a covered stent graft for TIPS creation have demonstrated improved patency compared to bare stents TIPS. This exhibit reviews the benefits and technique of TIPS creation and revision with stent graft.
Key Issues: This exhibit will describe the benefit and downsides of creating and revising TIPS with the Viatorr stent graft. The relevant anatomy (IVC, hepatic vein, portal vein, and its branches) and the technique of creating and revising TIPS with covered stents are described. Extending the covered segment of the stent graft from the portal vein puncture to the HV/IVC junction address the common causes of bare stent dysfunction (biliary-TIPS fistulas, miofibroblast proliferation of the parenchymal track and hepatic vein stenosis).
Format: This exhibit presents patients with portal hypertension in whom TIPS were created or revised with stent graft in a didactic format and reviews the venographic and hemodynamic findings, technique (tips and tricks of creating and revising TIPS with stent grafts), complications and how to solve them and post procedure patient management and follow up.
Teaching Points: Review the indications and benefits of creating and revising TIPS with stent graft. Learn the technique of creating and revising TIPS with stent graft. Understand the possible complications and downsides of stent graft TIPS.
E478. Endoleaks: Classification, Incidence, Diagnosis, and Treatment
Patel P. J.; Bova D.; Posniak H.; Borge M. A.; Demos T. Loyola University Medical Center, Maywood, IL
Address correspondence to P. Patel (paragpatelmd{at}gmail.com)
Background: Endovascular stent-grafts have been used to treat aortic aneurysms for more than ten years. The goal of therapy is total exclusion of the aneurysm sac. Endoleak is a major cause of complications that result in failure of the endograft. When an endoleak is present, the aneurysm sac remains pressurized or under endotension and is at continued risk for rupture. Endoleaks can be accurately diagnosed and classified with CT angiography. Additionally, many can be treated percutaneously. Endoleaks occur at the proximal or distal attachment site (Type I) due to a lack of seal between the endograft and the arterial wall or from retrograde flow from an excluded artery into the aneurysm sac (type II). A hole in the graft material (type III) or bleeding through porous graft material (type IV) also leads to an endoleak.
Key Issues: Angiography and CT are essential to the follow-up of patients with stent-grafts. Characteristic abnormalities shown by computed tomography and angiography will be illustrated. Specifically, type I endoleaks associated with aortic dissection or graft defects (type III) will be presented. Type II endoleaks from various sources including lumbar, inferior mesenteric, and an accessory renal artery will also be shown. Clinical presentation and treatment will be discussed and demonstrated.
Format: This interactive didactic exhibit will be presented in a PowerPoint format. The exhibit will be divided into clinical, imaging, and treatment sections. The imaging section will be organized based on type of endoleak and include treatment options.
Teaching Points: The goal of this exhibit is to illustrate and discuss the diagnosis, classification, presentation, and treatment of endoleaks complicating endovascular stent grafts used to treat aortic aneurysms.
E479. 64-slice MDCT Angiography of the Abdominal and Lower Extremity Arteries: Efficacy of Determining Scan Delay by Test Injection Technique at Knee Level
Nakaya Y.; Kim T.; Hori M.; Onishi H.; Osuga K.; Mikami K.; Tatsumi M.; Higashihara H.; Maeda N.; Tomoda K.; Nakamura H. Department of Radiology, Osaka University Graduate School of Medicine, Suita City, Japan
Address correspondence to Y. Nakaya (y-nakaya{at}radiol.med.osaka-u.ac.jp)
Objective: The purpose of this study was to evaluate the efficacy of determining scan delay by test injection technique at knee level for 64-slice MDCT angiography (CTA) of the abdominal and lower extremity arteries.
Materials and Methods: This study included 58 patients (52–89 years; mean, 71 years) who were referred for CTA of the abdominal and lower extremity arteries. CT examination was performed with a 64-slice MDCT scanner (LightSpeed VCT, GE Healthcare). For the test injection, low dose (10 mA) serial CT scan (10-mm collimation) was performed at a level of knee joint after injection of 12 ml contrast material (300 mg/ml) at a rate of 3 ml/s followed by saline flush. Time-density curves for the bilateral popliteal arteries were obtained, and the time to peak enhancement elapsed from the contrast material injection was calculated and applied to scan delay time for CTA. When the times to peak enhancement differ between the right and left, the later one was applied. After the injection of 80 ml contrast material at a rate of 3 ml/s followed by saline flush, CT scan was started in the craniocaudal direction with a rotation speed of 0.4 s/rot, detector coverage of 40 mm, a detector configuration of 0.625 mm x 64, and a pitch of 1.375:1. Scan time for CTA was about 10 sec. CTA image of each patient was evaluated for visualization of arteries and venous overlap.
Results: At test injection, time density curves for the popliteal arteries were obtained in 56 of the 58 patients. For the remaining two cases, time density curves were not available because of occlusion of the bilateral popliteal arteries and they were excluded from further discussion. The delay time of CTA for the 56 patients ranged between 20 and 50 sec (mean 33 sec). The differences in time to peak enhancement at test injection between bilateral popliteal arteries were 0–20 sec (mean 2.6 sec). CT scan did not overtake the contrast material flow in any of the 56 cases. CTA images in 54 of the 56 cases were of good quality, while those in the remaining two cases with delayed arrival time of contrast material to the popliteal arteries showed prominent enhancement of abdominal veins, disturbing evaluation of abdominal arteries. Even in these two cases, iliac and lower extremity arteries were clearly depicted without venous overlap.
Conclusion: Test injection technique at knee level was useful for determining scan delay for 64-slice MDCT angiography of the abdominal and lower extremity arteries in cases without occlusion of the bilateral popliteal arteries.
E480. Assessment of Vascular Disorders of the Lower Extremity with Contrast Enhanced MR Angiography
Abdel Razek A.; Saad E.; Megahed A. Mansoura Faculty of Medicine, Mansoura, Egypt
Address correspondence to A. Abdel Razek (arazek{at}mans.eun.eg)
Background: Ischemic changes of the lower limb commonly duet atherosclerotic disease but it may be due to no atherosclerotic disease. Atherosclerotic occlusive and nonatherosclerotic disease usually affect the lower limb extremity. CE-MRA is a useful noninvasive imaging modality used for treatment planning of peripheral arterial occlusive disease and nonatherosclerotic disorders of the lower extremity as well as for assessment of patency and surveillance of bypass graft.
Key Issues: Multistation contrast-enhanced MR angiography (CE-MRA) for the lower extremity usually performed on high field MR unit with phased array coil. In peripheral arterial occlusive disease, CE-MRA can detect location, degree and length of stenosis as well as collaterals, inflow and outflow vessels that are essential for decision of treatment. Also, it can detect stenosis, occlusion or pseudoaneurysm of bypass arterial graft. In nonatherosclerotic disease, it diagnosed aneurysm, vasculitis and Burger's disease. It created a preoperative map to manage traumatic injury and classify vascular malformations.
Format: The exhibit is didactic in format presenting the technique for contrast MR angiography of the lower extremity followed by clinical application of CE-MRA in atherosclerotic occlusive, bypass arterial graft and nonatherosclerotic vascular diseases.
Teaching Points: 1) To review technique for contrast-enhanced MR angiography (CE-MRA) of lower limb extremity. 2) To illustrate the information needed for decision of treatment of atherosclerotic diseases. 3) To review its role in surveillance of bypass arterial. 4) To review nonatherosclerotic lower limb arterial vascular disease.
E481. Superselective Intraarterial Chemotherapy for Advanced Maxillary Sinus Cancer: Assessment of Drug Distribution using CT Arteriography
Iida E.; Okada M.; Furukawa M.; Matsunaga N. Yamaguchi University School of Medicine, Ube, Japan
Address correspondence to E. Iida (iida76223{at}yahoo.co.jp)
Objective: To evaluate the relationship between drug distribution and tumor response for intraarterial chemotherapy of advanced maxillary sinus cancer.
Materials and Methods: The feeding arteries and their territories of the advanced maxillary sinus cancer were identified by superselective intra-arterial CT arteriography in nine patients. Cisplatin was infused into these feeding arteries other than the internal carotid artery, and sodium thiosulfate was administered intravenously for systemic drug neutralization. After the superselective intra-arterial chemotherapy with concomitant radiation therapy, the relationship between tumor response and the drug distribution was evaluated.
Results: Multiple feeding arteries were identified in eight of nine patients. A main feeding artery was the internal maxillary artery, and other feeding arteries were the facial artery, the transverse facial artery and the ophthalmic artery via the internal carotid artery. Drug distribution could be evaluated by superselective intra-arterial CT arteriography in eight of nine patients. Immediate response rate was 100%. Complete response without local recurrence was achieved in three patients with sufficient drug distribution, and partial response and complete response with local recurrence were seen in five patients with drug distribution defect. Residual tumors and a local recurrent tumor were only seen in the drug distribution defects.
Conclusion: Drug distribution should be correctly evaluated by superselective intra-arterial CT arteriography to predict tumor response to the intra-arterial chemotherapy for advanced maxillary sinus cancer.
E482. Complications of Femoral Artery Access
Partin R.; Kelly T. Monmouth Medical Center, Long Branch, NJ
Address correspondence to R. Partin (richusf{at}yahoo.com)
Background: Complications related to femoral artery access for angiographic procedures are becoming increasingly more common as a result of larger bore catheters, longer procedures, and periprocedural anticoagulation. Complications including pseudoaneurysm, arteriovenous fistula, hematoma, and arterial obstruction have seen their reported incidences increase in recent years from approximately 0.5% to 5.0%. The complication rate is highly dependent on the site of arterial puncture and the duration of compression. High or low puncture sites increase the risk of complications. Direct manual compression for at least 15 minutes is the traditional method for achieving hemostasis upon removal of the sheath.
Key Issues: Schematic representations are shown of the CFA puncture technique and selected complications. Pseudoaneurysm is displayed by ultrasound, MRI, MRA, and CT. AV fistula is displayed by angiogram and MRA. Hematoma is displayed by CT. CFA thrombosis is displayed by angiogram. Dissection is displayed by angiogram.
Format: The format is generally that of a pictorial essay. Introductory material is presented describing the effects of puncture site and length of time of compression on the overall rate of complications. The issue of puncture site is depicted graphically. Various complications, including pseudoaneurysm, AV fistula, hematoma, thrombosis, and embolism are discussed in detail. Included are pathophysiology; individual incidences; imaging strategies, findings, and examples; and management.
Teaching Points: Complication rates of femoral artery access are highly dependent on the site of arterial puncture and the duration of compression used to achieve hemostasis. Pseudoaneurysm occurs relatively commonly, particularly with a low puncture. A swirling pattern is seen with to-and-fro flow on Doppler examination. Treatment options include ultrasound-guided compression and thrombin injection. Arteriovenous fistula occurs rarely, usually resulting from a low puncture, where the femoral vein lies posterior to the femoral artery. Findings include increased diastolic flow in the artery on Doppler examination and early draining vein on angiography. Retroperitoneal hematoma is usually a result of a high puncture. It can be clinically silent and a low threshold should be used in evaluating for it with CT. Occlusive injuries, including thrombosis, embolism, and dissection can be variously treated with lysis, stenting or surgery.
E483. Portal Bilopathy: Not Always an Insignificant Lesion
Runyan B.; Walser E. M.; Bridges M.; Stockland A.; McKinney J.; Paz-Fumagalli R. Mayo Clinic, Jacksonville, FL
Address correspondence to B. Runyan (runyan.brandon{at}mayo.edu)
Objective: Portal bilopathy (PB) is a pattern of segmental biliary obstruction due to compression from collateral veins which form in response to chronic portal vein occlusion (PVO). While this obstruction rarely causes jaundice or cholangitis, we report five cases of common bile duct obstruction secondary to PB which required portosystemic shunt creation, biliary stenting, or pancreatic head resection. Our purpose is to illustrate the patterns of portal collateral formation and the pathophysiology of symptomatic bile duct obstruction secondary to chronic PVO.
Materials and Methods: Five cases of PB were evaluated and treated. In all patients, the biliary obstruction caused jaundice and/or pruritus. Two patients underwent transhepatic or endoscopic biliary drainage and stent placement. One of these patients initially had TIPS performed in an attempt to shrink the offending periportal collaterals, but had stent placement later when the biliary obstruction failed to resolve. Three patients had pancreatic head resection for suspected neoplasm. Retrospective review of the images and the histopathology showed that the biliary obstruction in these cases was due to PB and not malignancy. Ten additional cases of portal cavernoma without biliary symptoms were reviewed and compared with the 5 patients with symptoms.
Results: PVO with cavernous transformation may cause extraluminal biliary compressions. The majority of patients are asymptomatic but we found that severe biliary obstruction can occur and be mistaken for malignancy. Intraluminal ultrasound is helpful to visualize the extrinsic veins compressing the bile duct. MRI or CT shows a collar of dilated veins in the area of obstruction without identifiable mass. Patients who develop symptomatic PB are unique in that the PVO in these patients extends into the mesenteric veins whereas asymptomatic patients are more prone to occlusion of the main portal vein only. Although some patients had TIPS, there was no significant change in the biliary ductal obstruction after reduction of the portal pressure.
Conclusion: Symptomatic PB from chronic PVO rarely occurs and is more prevalent in patients whose PVO extends into the mesenteric veins. Decreasing portal hypertension is ineffective for this form of obstruction and metal stents or biloenteric drainage are necessary in such cases. Cross-sectional imaging and endoluminal ultrasound can help establish the correct diagnosis in PB patients suspected of malignant biliary obstruction.
E484. 64 slice MDCT/CTA of the Renal Arteries: Principles, Techniques, and Clinical Applications
Fishman E. K.; Horton K. M.; Kawamoto S.; Johnson P. T. Johns Hopkins School of Medicine, Baltimore, MD
Address correspondence to E. Fishman (efishman{at}jhmi.edu)
Background: CT of the renal arteries became feasible following the implementation of helical CT technology. The advent of multidetector row CT scanning has had a significant impact on study design and expanded study applications. An improved temporal resolution has implications for the contrast infusion and data acquisition protocols. Furthermore, volumetric datasets with isotropic resolution provide a detailed assessment of the renal arteries, expanding diagnostic capacity and clinical applications. The focus of this exhibit is study design and indications fro 64-slice MDCT of the renal arteries.
Key Issues: The purpose of this exhibit is to review techniques to optimize evaluation of the renal arteries with 64-MDCT and to demonstrate the range of clinical applications for 64-MDCT of the renal arteries.
Format: The exhibit is organized as follows: (1) data acquisition-contrast volume and delivery rates, contrast delivery and timing of data acquisition, selection of acquisition phases (2) data processing-role of multiplanar reconstruction, 3D volume rendering and maximum intensity projection, (3) Clinical applications: renal artery stenosis (RAS), fibromuscular dysplasia (FMD), renal artery aneurysms (RAA), renal donor evaluation and renal allograft follow up, renal tumor assessment and staging.
Teaching Points: 1. Optimization of scanning protocols for evaluation of the renal arteries. 2. Understanding the role of postprocessing of axial isotropic datasets into 3D displays for analysis of the renal arteries 3. Comprehension of the key clinical applications for 64-MDCT of the renal arteries, ranging from assessment of renal donors to detection of pathology such as RAS, FMD and RAA.
E485. MDCT and 3D CTA of Splanchnic Artery Aneurysms
Horton K. M.; Smith C.; Fishman E. K. Johns Hopkins School of Medicine, Baltimore, MD
Address correspondence to K. Horton (kmhorton{at}jhmi.edu)
Background: Splanchnic artery aneurysms are rare, with an incidence of 0.01–0.2% in routine autopsies. These are most commonly identified in the splenic, hepatic, superior mesenteric and celiac artery, but pancreatic and gastroduodenal aneurysms have been reported. Rupture of a splanchnic artery aneurysm is associated with a high rate of morbidity and mortality. Autopsy statistics suggest that asymptomatic cases remain undiagnosed and, therefore, splanchnic artery aneurysms may be more common than previously suspected.
Key Issues: This exhibit will focus on the use of multidetector CT and 3D imaging in the detection and management of patients with both symptomatic and asymptomatic splanchnic artery aneurysms.
Format: Didactic format as follows: (1) Introduction (2) MDCT data acquisition and post processing (3) Review and images of splanchnic artery aneurysms organized by anatomic location.
Teaching Points: 1. Splanchnic artery aneurysms are rare but can be clinically significant especially in the setting of rupture, with a high associated morbidity and mortality. 2. CT angiography with 3D rendering allows visualization of the aorta and its branches, which may facilitate identification of splanchnic artery aneurysms with greater frequency in symptomatic and in asymptomatic patients. 3. Treatment depends on the medical condition of the patient, in addition to the location, type, and the size of the aneurysm, all of which must be carefully evaluated when a splanchnic artery aneurysm is identified.
E486. The Evolving Role of the CTA of the Extremities Following Trauma: Current Concepts and Clinical Applications
Fishman E. K.; Horton K. M.; Johnson P. T. Johns Hopkins School of Medicine, Baltimore, MD
Address correspondence to E. Fishman (efishman{at}jhmi.edu)
Background: CT has become a crucial component for identification of vascular injury in the trauma patient. Current MDCT acquisition protocols must be optimized, and the indications for CT vs. angiography vs. surgery should be understood.
Key Issues: The goals of this exhibit include definition of the role of 64-MDCT for evaluation of vascular injury following trauma, review of scanning protocols and image reconstruction techniques necessary to evaluate the arterial map of the extremities, and illustration of a wide spectrum of vascular injuries, with a discussion of how CT helps to rapidly triage patients.
Format: This is a didactic presentation organized into 2 major sections: (1) How to optimize study acquisition protocols and data processing, with a discussion of the value of the 3D postprocessing for image display and analysis. (2) Clinical case studies organized by anatomic location (upper and lower extremities, chest and pelvis), and how CTA provides key information for patient triage. Potential pitfalls will be addressed.
Teaching Points: 1. Understand the important role of CTA for the evaluation of vascular trauma. 2. Define the techniques of CT acquisition and data display and analysis that are crucial for study optimization. 3. Understand the appropriate clinical applications for CT angiography in the trauma patient regarding vascular injury. 4. Recognize which patients should bypass CT and go directly to the OR for surgery. 5. Understand the advantages of noninvasive imaging.
E487. Evaluation of the IVC: Spectrum of Disease Using 64 MDCT and 3D Imaging
Fishman E. K.; Sheth S. Johns Hopkins, Baltimore, MD
Address correspondence to E. Fishman (efishman{at}jhmi.edu)
Background: The IVC is involved in a number of disease processes ranging from renal cell carcinoma to hepatoma to Budd Chiari syndrome as well as primary IVC sarcomas. The use of 64-slice CT and 3D imaging allows a more accurate staging of extent of disease. The exhibit will focus on this and its role in patient management.
Key Issues: 1. IVC involvement vs. pseudolesions. 2. IVC tumor involvement and definition of extent. 3. potential pitfalls in imaging normal anatomic variations of the IVC in trauma.
Format: Didactic with interactive mode as well as vodcasts and use of podcasts.
Teaching Points: 1. IVC appearance in disease. 2. How to optimize visualization of IVC pathology. 3. Role of 3DC VRT in IVC. 4. Imaging range of pathologies that involve the IVC.
E488. Vascular Pathology in Loeys-Dietz Syndrome: The Role of 64-row MDCT with 3D Rendering for Vascular Screening and Detection of Vascular Abnormalities
Fishman E. K.; Johnson P. T. Johns Hopkins School of Medicine, Baltimore, MD
Address correspondence to E. Fishman (efishman{at}jhmi.edu)
Background: Loeys-Dietz syndrome (LDS) is a newly identified genetic syndrome similar in phenotype to Marfan syndrome (MFS) and Ehlers Danlos type IV (vascular Ehlers Danlos, EDS-IV). However, the vascular lesions, including aneurysms throughout the arterial system and arterial dissection, occur at younger ages and rupture at a smaller diameter than that associated with other syndromes. Cognizance of the vascular pathology and potential complications in these patients is essential for radiologists, who play an integral role in diagnosis and guiding management. MDCT with CT angiography is ideal for screening these patients.
Key Issues: The goal of this computer-based exhibit is to define the genetic alterations and phenotypic manifestations of Loeys Dietz syndrome, to discuss the important differences in complications and surgical indications as compared to MFS and EDS-IV, and to demonstrate the vascular pathology associated using 64-MDCT with 3D rendering.
Format: This is a didactic presentation organized as follows: (1) genetics of LDS, (2) phenotypic manifestations, with emphasis on vascular pathology and the differences from MFS and EDS-IV, (3) Use of 64-MDCT to screen for vascular pathology, (4) Imaging findings (arterial tortuosity and aneurysms) presented by anatomic location, including the aorta, coronary, carotid and mesenteric arteries.
Teaching Points: 1. Understand the role of CTA in the evaluation of patients with LDS. 2. Recognize the various components of LDS, from the genetic to the imaging perspective. 3. Learn the role of noninvasive imaging, like CTA, for screening at-risk populations. 4. Understand the appearance of aneurysms and vessel ectasia in LDS, as well as the complications and surgical indications.
E489. Interventional Procedure under CT-fluoroscopy Combined with C-arm: Application in Lumbar Discography
Kim H.; Lee S.; Chung D. Gimpo Airport Wooridul Spine Hospital, Seoul, South Korea
Address correspondence to H. Kim (jradikim{at}empal.com)
Background: Lumbar discography is usually performed under C-arm control, but we often cannot avoid neural or vascular injury because of limitation of showing anatomic detail. We specially designed an operating room for CT-fluoroscopy combined with C-arm equipment in interventional procedures to make the good use of advantages of multimodality control.
Key Issues: From Jan. 2006 to Aug. 2006, 14 patients with 30 levels discography performed under CT-fluoroscopy guidance and C-arm assistance. We designed an operating room for the purpose of minimally invasive spinal operation and interventional procedure with CT-fluoroscopy and C-arm. CT was 10 slice MDCT with interventional options. We extended the distance between gantry and patient table for introducing C-arm (about 1 m). We could easily localize a proper access route to the disc and an exiting nerve root and ganglion and vessels on the way to the annulus for puncture using CT-fluoroscopy.
Format: We performed a double needle technique to avoid infection, insert 18-G guiding needle first between facet joint and annulus, and then inserting a 22-G second needle to the center of nucleus pulposus. We injected contrast media to the nucleus pulposus under C-arm, checking patient's response during annular puncture, opening pressure, and increment of contrast media from 0.5 to 2.5 cc under real-time C-arm image. After the procedure, we directly performed postdiscography CT scan in the same room.
Teaching Points: Lumbar discography under CT-fluoroscopy control combined with C-arm is a favorable method for safety, easy access, and minimization of patient discomfort.
E490. Complications Due to Cerebral Embolic Protection Devices
Suri R.; Wholey M.; Postoak D.; Cura M. University of Texas Health Sciences Center San Antonio, San Antonio, TX
Address correspondence to R. Suri (suri{at}uthscsa.edu)
Background: Outflow embolic protection devices are used during carotid interventions, though their role is still controversial. They enjoy the benefit of preventing neuroembolic complications; however, the use of these devices increases procedural time with associated increased risk of adverse events.
Key Issues: Procedural adverse events specific to embolic protection devices may be classified into (I) minor adverse events (resolve with appropriate management), and (II) major adverse events (persist despite appropriate management and cause morbidity). Minor adverse events may occur during device deployment (technical failure, or use of adjunctive procedures), stent/PTA (device migration, pseudo-occlusion, arterial spasm responsive to nitroglycerine, transient neurological deficits), or device retrieval. Major adverse events may be related to intraprocedural events (proximal device migration, arterial spasm refractory to nitroglycerine, flow-limiting dissection, persistent neurological deficits) or device retrieval. Knowledge of techniques to avoid and appropriately manage these adverse events is essential.
Format: The aim of this exhibit is to compare and contrast embolic protection devices, clarify their role with evidence based literature, classify device related adverse events, and present a pictorial essay of these potential complications with their appropriate management.
Teaching Points: 1. Compare and contrast various embolic protection devices. 2. Pictorially depict and classify procedural adverse events due to embolic protection devices during carotid interventions. 3. Understand techniques to avoid and appropriately manage these adverse events.
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